Excavations

I am not a surgeon, not even in fantasy. Nor have I any expertise or interest in the technology that makes modern surgery possible. Yet two months ago, I watched for a week as heart surgeons plied their trade. I watched because my daughter had had heart surgery as an infant and the doubt and mystery surrounding that operation wouldn't leave me. I watched because opening the body and touching the heart, a notion once unthinkable to me, had become personal.

According to their surgeons, heart patients do not die; they get killed--sometimes by the misdiagnoses of internists; sometimes by cardiologists doing fibrillation tests or by residents who don't recognize signs of imminent death in time to prevent it. But most often, the killer is identified as the surgeon himself: "I killed one on the table today." "I must have killed 50 patients during my residency." Such talk reflects more than the brutal flippancy of those who spend their days cutting into the damaged organs of dying people; it carries an edge of guilt and, even more, a tacit assumption that death is, somehow, always preventable. It indicates, besides professional paranoia, an unhealthy disrespect for death. In the world that surgeons inhabit, death has become unnatural.

There was a time not so long ago when heart surgeons killed most of the people upon whom they operated. The technology of heart-lung machines, the drug mixtures by which anesthesiologists manipulate blood pressure and pulse rate, the cooling techniques by which fibrillation is controlled without exhausting the heart's electrochemical balance, all these were insufficiently advanced to prevent recurrent death on the operating table. Desperately ill people hoped that the long shot would come in for them and, of course, the odds won.

There is a story told about one of the first cardiac surgeons, a man whom the IRS took to court for back taxes. A colleague called as a character witness by the defense supposedly remarked as he and the surgeon walked out of the courtroom, "John, you're just like Al Capone. You killed all those people and they can only get you for income-tax evasion." But that has changed. Heart surgery, with all its frightful aspects, is routine and has little more risk than a gall-bladder operation.

The surgeons I watched belong to a generation for whom death is the exception, and so it comes as a shock when, as I enter the hospital the first day with one of the surgeons, he is already being paged, an hour before he is scheduled to operate. By the time we reach the doctors' changing room, we hear that the day's first patient has arrested while being transported to surgery. He is dying or already dead.

Before we push through the swinging doors that separate the operating area from the rest of the hospital, covers must be pulled over shoes, a cap tied over hair and a mask placed over nose and mouth. The surgeon does this quickly and rushes on. But in a world where bypasses are finely stitched and secured with delicate knots, I cannot manage the shoelace-thick ties at the back of the cap and the mask. Seconds pass as I fumble, losing first one end and then the other, time enough to destroy an oxygen-depleted brain. Properly clothed at last, I hurry to the final pair of doors, push a button beside the long steel scrub sink and am admitted to the operating room.

The man, surrounded by masked figures, lies naked on the table, his arms outstretched to either side, hands cupped, fingers loosely curled. His heart has been shocked back to feeble activity, but his blood pressure falters and will not climb to an acceptable level. Two surgeons are in the room, one watching the monitors that hang above the operating area. The other cuts into the right thigh and feeds a catheter through the artery toward the heart. At the end of the catheter is a balloon that, once inside, will be alternately inflated and deflated, displacing some of the blood the heart has wearied of pumping. When at last the catheter is in place and the balloon is doing its work, the blood pressure stabilizes, though still at a perilous level. There is nothing else to do. The patient will stay alive with the help of this support system; without it, he will die.

The surgeons stand aside while nurses prepare the patient for transport to the intensive-care unit. One of the surgeons is tall, at least 6'5", and stooped. The other stands straight but is still a head shorter. There is no exhilaration that the dead has been raised, only the weight of defeat and the first effort to assign blame. The short surgeon is frustrated beyond endurance, not only because it is his patient but also because, like many surgeons, he is incapable of enduring much frustration.

Nurses and orderlies, three to a side, slowly lift the naked man from the operating table as technicians keep tubes and electronic leads from tangling. The man is heavy and his weight sags against his attendants as they struggle to keep his body straight. At last, he is settled on the gurney and is wheeled, with his machines and drip bottles, to intensive care.

"What the hell kind of hospital kills people in the goddamned corridors?" the short surgeon cries out. The tall surgeon shrugs but doesn't look up.

"Dehydrated," the short man says, his voice only slightly lower and his left hand twisting the back of his cap. "Degoddamnedhydrated. You know why? I'll bet you goddamned anything they gave the guy an enema last night. Had to make sure the plumbing was clean as a whistle, and they killed him. You make it three months with a heart all shot to hell, and then what a hell of a note. You get killed by a goddamned enema." He starts to pace. Nurses and orderlies, preparing for the next patient, move around him without slowing.

The tall surgeon raises his head, then slowly straightens the rest of his body, as though awakening. "A nice old guy," he says softly. He shakes his head.

The other man stops in front of him, not speaking for a moment. "I got a Pacemaker," he says. "What's coming up for you?"

The tall surgeon stretches. "A bypass. A big scar, too--probably an aneurysm. We're done with this one. Might as well get on with it." It is eight A.M. and both men seem tired, wary of a day and a week that begin so badly.

For one who does not live there, who has not come to accept its narrow world as "real," the strangest thing about an operating room is not the blood or the smell of burning flesh that the electric scalpels produce but the way day after day you can stand side by side with six to a dozen people, share the most intimate of rituals and yet never see or know more than two or three inches of their faces. The intern, whose smooth skin at the corners of his eyes declares his youth, I can recognize by the nervous swallowing that bobs his Adam's apple as he tries to anticipate the surgeon's next move. But if he were unmasked, I would not know him. An economy of movement identifies the surgeon's assistant, whether in suturing a wound or in the rare blinking of his eyes. In the operating room, he is always calm. I cannot imagine him running for a bus or pushing his way through a supermarket.

But most remarkable are the nurses, who in the machinery of surgery--alternating as scrub nurse presiding at high table--are interchangeable parts but who after a few hours, the most casual observer can distinguish immediately. One sways above the surgeons as she hands out clamps and retractors from the instrument table that covers the patient's lower body, moving with an easy grace that has its own choreography. Another darts. Her short arms always seem fully extended as she snatches, unerringly, the requested instrument. A third, heavier than the others, moves deliberately, rarely bending, never darting. She moves with her feet and hands rather than with her body and, despite her size, seems almost to disappear from the proceedings, because her movements are so nondescript.

The woman resident does not move like a nurse. She works in the narrow limits of a chest, never reaches the length of an instrument table, never bends to anticipate the next tool to be required of her. She works up and down, like a bricklayer or a carpenter--like a surgeon--probing the same opening, always returning to the same confinement. Unlike the imperturbable surgeon's assistant, she likes to grimace. Little things: pushing at her mask with outstretched lip and blowing at the sweat sliding down around her nose, or wrinkling her forehead to adjust the glasses she has taped in place. Even with her mask, it is evident that she smiles easily and often. A part of her job, in addition to opening the chest, is to bring a new joke every day. And she does, usually telling it after she has pushed the saber saw the length of the breastbone and worked the retracting clamp into place, while, still a little breathless from her effort, she watches the surgeon examine the damage. Her jokes are oddly pristine, the kind you can tell your mother, yet she always seems a little embarrassed. A blush creeps out from the edges of her mask as she talks, and she laughs lightly at the punch line. Then she returns to cauterizing bleeders with the electric scalpel.

•

Ten years ago, my wife and I gave our daughter to such people. The surgeon came to us in a stylish suit, with the proper show of pastel cuff. He examined his cuticles, checking the manicure beneath bright fluorescent lights, and told us the odds, like Nick the (continued on page 136) Excavations (continued from page 104) Greek in George Plimpton's clothing. We, too, watched his hands as he told us terrible things about our child. They were beautiful, soft, with long, delicate fingers. He watched them with a parent's pride. Then he looked up, an easy, confident smile on his face. "We beat the odds every day," he said. "We'll give it our best shot." His gaze dropped back to his hands. He moved and talked and smiled like a professional athlete, a man absorbed in his own body. Curling thumb and forefinger into a circle, he said softly, "It's no bigger than that, you know. The size of a walnut." The four of us looked down at those fingers, at the nut-sized hole, in silence.

•

A heart is not an appendix or a gall bladder. Despite a growing sophistication in such matters and the gradual reorientation of our sense of life and self, the heart remains the essence of us. We may redefine life and death as statements about our brains, even grow used to talk of transplants and pumps, but our everyday language gives us away. A change of heart is still a more significant event than a change of mind. Even the sloppiness of expression when we say we "feel"--a function relegated to the heart--when to say we "think" would seem more appropriate involves a clear weighing of priorities. We value the one more than the other.

The brain may be the neurological center directing our rational lives, but we have placed our feelings far away from the head, locked in the deeper security of the chest. Brain injuries are terrifying precisely because that organ seems so helpless, a kind of cranial pudding that, for all its supposed ability to control and order, is itself so shapeless. Merely to touch it is to destroy a part of us, kill some function if not the whole being. Although we describe some people as strong-minded, we never refer to the brain as strong. But we do speak of strong--even stout--hearts, and if the brain is amorphous in our thoughts, the heart has been simplified to a shape that every childish hand can inscribe. And this form that we display so casually is only a token, an outward sign of what is most intimately and securely us.

When I was a child, all rural Baptist churches had the same picture hanging on the front wall, placed to one side of the pulpit. In it, Jesus, romantically depicted in white robe and highlighted hair, stood knocking at a door. The door was oak, bound with heavy metal bands, and at the top, rather than squaring off in the modern fashion, it curved. I was told that the picture showed Jesus knocking at a person's heart, my heart, waiting for it to be opened. The explanation always brought a sad word for those who would never respond, and there came a rush of fear or, rather, twin fears: one the fear of the heart exposed--a thought that always caused me to pull my arms in tightly against my chest--and the other, somehow worse, the fear of never being opened, of never being known.

•

In the operating room, the second patient lies naked, blotched by reddish-yellow disinfectant wherever an incision is to be made. Beside his head, an anesthesiologist probes with a hypodermic needle until he locates the jugular. But the patient is dehydrated, and the vein slips away from the needle. The anesthesiologist turns the head, adjusting tubes that run to nose and mouth. He continues to probe, massaging the neck until he again locates and holds the vein. This time, the needle penetrates, and blood rises dark and heavy. The anesthesiologist removes the filled plastic cartridge and inserts a tube, but the vein falters, the needle slips and he must begin again. A nurse, her head between the patient's feet, lifts the legs to increase the blood pressure. At last, with the needle in place, the anesthesiologist reinserts the metal tube, then a larger plastic one through which he feeds a catheter down into the heart, where it will monitor pressure inside the chambers. He watches the monitor as the catheter enters the ventricle, waiting for the lines to settle into their proper pattern on the screen. When he is content that the heart has accepted this intrusion, he busies himself with the tubes and clamps and drip stands that will allow him to administer drugs as the monitor demands.

Two nurses, one on each side of the operating table, are at work. One wraps the patient's feet and ankles in toweling and gauze. The other, who keeps her wedding ring pinned to her operating gown, shaves the pubic hair and then primly lifts the penis by its foreskin while she swabs the area with disinfectant and finally inserts a catheter.

After the anesthesiologist has arranged all his tubes and drip stands, he raises a sheet, separating the patient's head from what is about to take place below, and, as though that were not sufficient, tapes the eyes closed with clear-plastic tape. At last, he repositions the monitors, adjusts the stool and settles down for the vigil ahead.

The tall surgeon has left the operating room and now, on another floor in a closet-sized room, threads into a viewer the catheterization film the cardiologists have made of dye released inside the heart. He darkens the room and switches on the machine. At first, Africalike, the shadow heart throbs; then, as the dye appears, the blackness divides, cut through by chalkish streams and rivulets that twist across the heaving terrain, not with the geographical grace of terrestrial rivers but with a severe angularity that thickens and narrows in ugly, awkward branches, resembling less the waterways of the Congo or the Nile than newly plucked insect legs strung in a twitching chain. Here and there, the streams terminate abruptly, dammed by blockages that disrupt their flow. The surgeon stops the film, memorizing where the grafts should go, identifying the regions most devastated by the lack of oxygen, and lingers over a large dead space, blank on the screen, where a heart attack has left its mark. As the film moves once more, the pale outline of the heart throbs back to life, dilating and expanding, the tributaries clearly charted on its surface as it clinches and releases.

On the way back to the operating room, the surgeon stops to reassure the family. They stand apart from other families, edging out into the corridor, shyly inviting recognition. As he talks, they smile and nod nervously, as though the most important thing is to be agreeable.

•

We waited in the hospital's halls and waiting rooms during our daughter's operation. Our stomachs were knotted; our heads throbbed with an ache that we knew was there for the duration. We watched the movements of doctors and nurses and listened to the meaningless calls of the P.A. system, fearfully expecting some sign. We were powerless amid the mystery and secrecy of the place. Everything was a hieroglyph, a message concealed in the jangle of doctor calls or on the faces of the staff. Something terrifying was taking place and was being hidden from us. We paced the corridors or hunkered down in vinyl chairs, blotting out everything until only the fear remained. Somewhere in that building, unspeakable things were happening to our daughter, and we were ignorant but witting accomplices.

•

After talking briefly with the family, the surgeon goes back to the locker room and returns the white coat he wears whenever he ventures into the hospital halls. Before entering the operating area, he again dons cap, shoe covers and mask. Outside the last door, he scrubs, all the while bantering with other surgeons who will be working in the surrounding rooms.

He enters the operating room holding his hands, arms bent at the elbows, in front of him, as though about to surrender. A nurse helps him into an operating gown and then starts the rubber gloves over his hands. After he has worked the gloves into place, wriggling his fingers, testing, he circles the table, avoiding any physical contact as he exchanges greetings and inspects the body.

A senior resident, the young woman who likes to smile, bends over the patient. His chest, yellowed with disinfectant, has been covered with a sheet of clear plastic, the kind used to seal food in refrigerator dishes. She slices through the plastic as she begins the long incision that runs from the base of the neck to the stomach. She cuts a layer at a time, working with an electric scalpel that sizzles and crackles, sending out the heavy smell of singed tallow. A small green pad, the kind used to scour Teflon-coated pots and pans, has been stuck to the patient's abdomen; and from time to time, the resident scrapes her scalpel across that rough surface, cleaning away the burned flesh. As each layer gives way--the skin, the thick ivory heaps of fat--she catches up the bleeders, burning them shut. It is an archaeological dig, accomplished by burning rather than by digging, and as the cut deepens, the strata of the body rising on either side, the chest continues to rise and fall, responding to this assault with an occasional tremor but, for the most part, absorbing it without complaint. There is little blood and it seems at times more like cutting through the fabric of a chair or the plastic layers of a doll than what it is.

But with the thigh, which the surgeon has opened in search of a usable vein, there can be no such illusion. This is real flesh, sliced by a real knife and producing real blood. The foot-long incision gapes; skin and muscle hang limp and ugly in their powerlessness. In contrast to the subdued yellows and ivories of the chest, this wound shows the garish reds and purples of raw meat. And rather than the neat trenchlike incision being carved into the chest, here a hole stretches from the upper thigh to the knee, resuming below the knee for another six or seven inches.

When the prospecting is concluded and the vein lies exposed, the surgeon lifts it with long forceps and gently snips it free from the surrounding tissue. The opening is then packed with a sponge dressing to collect the blood. If the vein is itself too damaged or is insufficient for the number of bypasses needed, the other thigh may be opened. But this vein is adequate, and the surgeon carries it away from the patient to a well-lighted table, where he can prepare the grafts, suturing any leaks and side veins. He bends like a jeweler over his worktable, intent on the minutiae of his craft. When at last all the sutures are in place, he straightens. He lifts his hands, flexing his fingers, and then takes the vein once more, lifting it from the bowl of saline in which he is continually rinsing it. He clamps one end and injects solution into the other, inflating the length of vein. Where he has tied off side veins, thick white bumps rise, rough on the surface. He checks the sutures for leaks, the rest of the vein for weaknesses.

At the main table, the resident has reached the breastbone. The first time, and to a surprising extent every time, this event brings its own peculiar mix of sensations. It is that moment from childhood fantasies of buried treasure when the shovel strikes the box and the thrill of impending discovery runs high. And it is, too, a moment of violation, the work of grave robbers who have carved their way into some pharaoh's tomb and now stand before the last unbroken seal. What the patient has contained for 70 years, has nourished and protected but has never seen--never will see--is about to come to light. The resident taps on the bone with her knuckle, gauging its thickness. "Some old people have really thick breastbones," she says. She speaks, interprets, only when the surgeon is away from the table; but, like most of the other people who work in this room, she both enjoys and needs to explain what is taking place. "Not always, but sometimes, they're gnarled and hard to cut. Sometimes, though, they are spongy."

The resident's green robes are blood-splattered now. She calls for the saw, one very much like a carpenter's saber saw, and begins the cut from top to bottom. The bone is tough and the work proceeds slowly, straining her arms and causing sweat to glisten on her face. Her lower lip juts out as she blows the sweat away from her mouth. She leans into the saw with all her weight, lifting the chest with her effort as the saw cuts through the eight-inch length of bone. After sealing the last bleeders that bubble from the fat along the cut, she calls for a spreading clamp. It also seems like a thing from a carpenter's kit, a bulky stainless-steel contraption that attaches to either side of the broken breastbone. It cranks at the end, levering the chest apart, separating the halves of the sternum until the chest opens like a clumsy satchel.

Below the bone, only soft tissue remains; but even here, a person is a creature of layers. The lungs are partially exposed, pushed up against the clamp, not nearly so perfectly shaped as they appear in anatomical drawings. But the heart, between the lungs, is still concealed by the pericardium, the thick, lumpy membrane that surrounds the heart and swells and trembles with every pulse beat. This cut, so much easier than all that have preceded it, will be irrevocable. Once opened, the pericardium will not be closed again. Instead, fluids will drain into the chest cavity, then out through plastic tubes, and the healing heart will settle directly behind the sternum. No longer muffled by the membranous sack, the beating heart will turn the breastbone into a sounding board, declaring its presence more assertively than ever.

The resident works wax into the raw, porous edges of the split bone. Beside her, the physician's assistant suctions debris from the chest cavity. The rest of the staff take their places as the pericardium is cut open, slowly, gently, not only because of its toughness but also because of the frantic lurching of the thing inside.

All other activity in the room ceases as the heart comes into view. The anesthesiologist, rising on his stool, peers over the patient's head. The tall surgeon, head and shoulders taller than the resident, watches from behind her. Poised above the instrument table, the scrub nurse looks on. Another nurse stands on tiptoe opposite the physician's assistant. Even the profusionist who operates the heart-lung machine looks momentarily toward the organ now doing her work.

The heart is large, twice the size of the surgeon's hand, the pink muscle obscured by thick streaks of yellow fat that pour down from the aorta like the overflow of a candle. It thrashes like a cornered beast, convulsing with every beat as though desperate to escape.

When the edges of the pericardium have been sewn to the layer of muscle above the halves of breastbone, it forms a milky lining of the sort found in jewelry boxes and caskets. Suctioned of all fluid, the membrane has a pristine quality that belies its age and the heart's violent wrenching.

All Americans born in the past 50 years have grown up seeing hearts--or, rather, representations of hearts--in the clear plastic people, complete with internal organs, that stand in museums of natural science and in the multipaged, see-through construct-a-person illustrations contained in tenth-grade biology texts. Any surprise in the heart's appearance has to do with its individuality, the consequence of its own particular life and labor. Between the thick streaks of yellow fat that mark its decline, the muscle shows tough and purplish, and where that muscle has been broken or destroyed, the scars and aneurysms show a dead fish-belly white, marking old traumas and future catastrophes.

The surprise is the power, the enormous strength of this engine that drives our bodies. The steady, reassuring thump we hear as we drift into sleep is only the remote evidence of what is at work within us. When we at last confront it, its pounding is wilder, more terrifying than anything ever foreshadowed by that faint, familiar beat.

•

The surgeon takes over now, and as he touches the heart, it reacts with tremors and convulsions. Its rhythm broken, it jerks away from each indignity. He slips his hand cautiously behind, searching the hidden surface for the dead spot he saw in the catheterization film and gauging the dimensions of the aneurysm. When he pulls his hand free, he shows the size with his forefinger and thumb three inches apart, and shakes his head.

He calls for a clamp and settles the heart back into the chest cavity. Slowly, its erratic twitching subsides and blends into the regular upheaval of its beating. The aorta, more like a radiator hose than an artery, rises from the heart a thick trunk of leathery white, larded with lumpy streaks of yellow. The surgeon pinches off one side (continued on page 142)Excavations(continued from page 138) with a long, curved clamp, then divides the leg vein into two seven-inch sections--one for the front bypass, the other for the back. With a tiny needle locked in forceps, he laces the end of each section around the small incisions he has snipped into the clamped artery wall. For the moment, he leaves the veins stretched across the heart, lying pale and curled on its surface.

The patient will be connected to the heart-lung machine by two clear-plastic tubes. One is inserted through an incision into the right atrium and will carry blood to the machine. As it is slipped into the heart, blood surges up to the clamp. The surgeon swiftly laces the tube in place, but before all the sutures are secured, a jet of blood springs up, staining his mask and the slit of face that shows above it. Holding the needle, he waits while a nurse removes his glasses. As she cleans the lenses, he completes the suturing, blinking, owllike, against the light. A trickle of blood crawls from the bridge of his nose down to the top of his mask.

A second tube, also clamped, is inserted above the vein graft into the aorta. Here, too, blood leaps up until its passage is blocked; but this time, the sutures hold immediately and there is only a slight seeping of red around the incision.

While the profusionist readies the heartlung machine, a gleaming console of stainless steel and clear plastic, the surgeon checks and rechecks the sutures. Satisfied, he bends over the tube jutting from the aorta. Eyes close to the plastic, he calls for a pair of forceps and begins to tap against the tube. He stops, examines the plastic once more, then taps again. "Got to save his memory," he says as he continues to thump away at minuscule air pockets that, if they elude him, will go to the brain and cause strokes. "Every bubble's a year." He hesitates, then taps one more time. "That one looked like 1954."

He calls instructions to the profusionist and begins releasing the clamp above the atrium. With a surge, blood moves up the tube, working its way to the machine. The profusionist turns knobs and adjusts controls. Next the clamp is removed from the aorta line providing return passage for the blood that is now detoured around heart and lungs. This blood, cooled by the machine, lowers the patient's body temperature to 30 degrees Celsius. Next, the aorta is clamped between the heart and the blood return line, removing the heart's old burden but denying it food and oxygen as well.

To preserve the muscle's life and function, a cold solution containing potassium and lidocaine is injected through the blocked aorta. At four degrees Celsius, it cools the heart to ten to 12 degrees Celsius. Overhead, the monitors record the erratic tremors of the detached organ as the cold slows its last frantic efforts to beat. Before this procedure was introduced, the bypassed heart exhausted itself, depleting its electrolytic composition with the result that, when reconnected, it responded sluggishly, only gradually recharging itself, like a run-down battery.

As the solution cools the muscle, the heart fibrillates, bouncing the straightened line on the monitor. For a while, the fidgeting continues. Reluctant to surrender, the heart still jumps at the surgeon's touch, but its power is only latent now. It moves nothing, is itself moved, whimsically, as the surgeon lifts and turns, exposing the dead tissue of the aneurysm. Finally elevated on a pillow of sponges, it juts, bottom up, from its cavity, revealing the sausage-shaped protrusion where dead tissue has bloated out like the rupture on an old tire. The surgeon cuts, using a steel scalpel, around the whitened scar tissue. He works his way along the edge of the aneurysm until a two-and-a-half-inch hole opens directly into the heart's interior, revealing beneath the lights the rubbery mitral valve, for the first time in 70 years immobile and discovered.

The aneurysm lies in a bright metal pan, neither muscle nor fat but parchment-colored and leathery, strangely offensive in its blatant deadness. In cutting it from the heart wall, the surgeon has left a thin rim of this tough dead tissue, and now he makes a seam with green thread, pulling tightly so that the scar is drawn into a long, puckered line, joining on the underside living muscle from both sides of the incision. As he weaves in more and more sutures, a green web forms, firmly anchoring the repair.

The surgeon's height forces him to work bent in compromise to the rest of his team. Now he straightens, twisting his neck and wriggling his shoulders. Stooping again, he tilts the heart, carefully inspecting the sutures, then lowers it back into place. The mended hole has greatly shortened one side of the organ, twisting it oddly below the gaudy seam. "Not pretty," he says. "He's traded one funny heart for another." He frets with his fingers, pale in the thin gloves, along the wound, trusting them more than his eyes. If the repaired heart fails after the heart-lung machine has been shut down and the blood pushes back into these chambers, the rupture will be here, along this line.

The surgeon turns almost reluctantly to the grafts, connecting the veins to each of five coronary artery branches. He is joined now by the short surgeon, whose work across the hall has been completed. The shorter man finds a riser and climbs up on the opposite side of the patient. There are four of them now. The resident works on the leg, joined by the physician's assistant, who had, until pushed aside by the short surgeon, been assisting with the graft. Now it is this recent arrival who lifts the free end of the vein being stitched into place.

Above them, the scrub nurse bobs and weaves over rows of scalpels and forceps and sutures, handing out new ones, taking back the old to deposit in shiny pans. From a distance, all of this might look reverential: the three doctors and the assistant bowed under the bright lights, the scrub nurse bent over the patient's lower body. Except for the sigh of the respirator, the clicking of monitors and the rustle of nurses renewing supplies, the room is quiet. Occasionally, one of the doctors calls for an instrument, but his voice carries only a few feet. The room, apart from the black-tile floor, is ivory-colored, and beneath the intense lights, the green uniforms and dazzling-red sponges seem surrealistic, the stainless-steel surfaces mirroring and distorting from every side. But this is no celebration of ancient mystery. It is a concentrated effort to make routine that which ultimately refuses to become business as usual.

As the surgeons suture the last grafts into place, securing the dead-looking vein to arteries on the stilled heart, they have all become seamstresses, an assembly line of stitchers and cutters, plying their needles on heart and leg with the dexterity of craftsmen, while the scrub nurse prepares the sutures, removing them from sterile packages and fitting them into needle holders or, when business slows, cleans dirtied forceps and clamps as though polishing household silver.

The anesthesiologist, still seated, watches; but all the while, he alternately pushes downward against the stool on which he is sitting and then releases. He is doing isometrics. Beside him, irrelevant, a trickle of blood works its way slowly from the patient's nose and down his cheek. The profusionist looks toward neither patient nor doctors but tends her machine. She is very thin, with skin as pale as skim milk. Her fingers are also thin, with long, curving nails polished in a shade that exactly matches the dark crimson of the blood-filled plastic hoses.

•

When all the sutures are in place, inspected and reinspected, when all the sponges have been wrung out and their contents suctioned away, it is time for the blood bypassing through the machine to be returned to the heart. All pretense of routine passes away. For the past hour, the work has been intricate, demanding, but with issues of life and death postponed: A heart disconnected cannot fail. The test of patient and surgeon comes when the organ is called upon to do what it hasn't since its first fetal beat: start from a dead stop.

Instructions pass between surgeon and profusionist. Peripheral movement ceases. As when the pericardium was opened, everyone is again pulled toward the center. The anesthesiologist has drawn more samples for the lab, readjusted drip tubes and now sits ready for the chemical fine-tuning that will be required when the heart is working again. His features are contorted, his head back so that neck muscles are taut, mouth stretched wide, as though about to scream. After a few seconds, he relaxes, then contorts his face again. The scrub nurse quietly realigns her wares, and the supply nurses move to where they can see the monitors.

When the warm blood re-enters the coronary arteries, the reaction is immediate and violent. The heart leaps, twisting in a lopsided seizure, straining at the green threads. It contracts into a fist of muscle, releases with abandon and clinches again. "They always want to beat," the tall surgeon says.

A thin jet of blood spurts up from the spot where a graft is attached to the heart. It leaps two feet above the table, driven by tremendous pressure. The tall surgeon blocks it with his hand and calls for a suture. The short surgeon quickly catches up the vein, now inflated pink with blood, and holds it with forceps while another suture is put into place. Leaning over the patient, he cracks his head on the overhead light. "Damn it," he says, "every time I start to grow...."

The first suture does not stop the leak. Another is tied in place. The bleeding stops. For the outsider, the jet of blood seems urgent, visible evidence of what has, all along, been at stake. But for those on the surgical team, it is merely a nuisance involving an amount of blood trivial in comparison to that squeezed from sponges and suctioned into the machine for recirculation; less blood than stains their clothing. For them, the drama focuses on thread, especially the web of stitching where the aneurysm was. As the machine is shut down, the tubes are removed from the aorta and the atrium, and the holes they leave behind are drawn closed so quickly by the threads stitched into place when the operation began that only a thin line of blood escapes the sealed incisions. The tall surgeon intently watches the stitches while the short man calls out pressures from the monitor.

When the repairs hold, absorbing the wrenching force of the heartbeat, the anesthesiologist takes over. The monitor dictates his pace, calling for this drug or that as the pressure levels fluctuate. Only the profusionist shows no interest. Oblivious to the change in events, she is absorbed in cleaning her stained machine. The short surgeon continues reading the monitor, though now everyone is watching for himself. He bounces on his toes when the pressure rises; his voice deepens in anger when it falls. He is like a little boy who needs to go to the bathroom. The numbers begin to fall, and the anesthesiologist moves among the drip stands, adjusting clamps, checking bottles. As he varies the flow of drugs into the blood stream, his expression does not change, but his eyes flick constantly between monitors and medications. He never looks at the patient. The nurses are silent, unmoving.

The tall surgeon, still standing beside the open chest but now turned, eyes uplifted to the monitor, softly names a drug. The anesthesiologist, busy over yet another clamp, does not look up. He answers affirmatively, then curtly gives an amount. Another is named. Another affirmation, another quantity identified. The pressure continues to fall. "What about increasing it?" the tall man asks. The anesthesiologist does not answer. He seems annoyed with the distraction, even with the patient. He is shutting out everything but the monitors and the paraphernalia of his trade.

The short surgeon, still bouncing in agitation, still calling out the numbers, turns from the monitor to the anesthesiologist. "Goddamn it, you're killing him!" he cries. He is genuinely angry and steps toward the drip stands as though he wants to fight. "Get it right!" he is nearly screaming. This is not his patient--he has been in the room only for the past 30 minutes--and he gives no specific instructions. But he cannot contain himself, must throw himself at something or someone. He is ignored.

The numbers begin to climb once more, and the short surgeon returns to his announcements, now a partisan sportscaster when the favorite has taken the lead. "That got it," the tall doctor says. The anesthesiologist does not answer but, arms folded on his chest, watches the monitor, shunning his doubters.

As the heart stabilizes, people drift back to their work once more. Having called the race, the short surgeon departs for his office. Around the operating room, green-robed figures fill garbage bags with the debris of surgery. The resident returns to stitching the leg wound, but the chest is left open as the tall surgeon, who has slumped onto a nearby stool, waits. He looks at the patient, turning so that for the first time since the operation began, he can take in the entire person. Then he closes his eyes. The heart throbs regularly, strongly against the now-stained backdrop of the pericardium, driving yellow lung tissue against the chest retractor. The surgeon at last rises from his stool. The anesthesiologist looks over to him. "A good job," the surgeon says.

The anesthesiologist nods noncommittally.

"Let's close it up, then," and he turns, reluctantly, back to the patient. He closes the retractor, lowering the two halves of uplifted chest until the broken bone lies once more in place. The retractor is removed and the resident takes over. With large curved hooks, she pushes wire through both pieces of sternum, a length of wire every inch from top to bottom, and then, with pliers, twists the ends together as though repairing a fence, the strain obvious in her arms and face, until the halves of bone have been rejoined, laced together like a football. The twisted wire is bent over flat against the bone, little veins of silver along the rough, bleached surface of the sternum.

Drainage tubes are inserted, protruding from slits below the bone. At last, flesh pulled back into place, all wounds are sealed on chest and leg, by thread and then by wide metal staples, seaming the patient in a bright metallic line. The surgeon watches, giving occasional directions, as the resident finishes. He leans against the table, conserving energy for the next operation. Nurses gather the last of the garbage--of which there has been an incredible amount--and clean the patient, removing from room and body all traces of blood. The anesthesiologist removes the curtain, returning the head to the rest of the body.

From the operating room, the surgeon goes to the doctors' dressing room and exchanges bloodied operating greens for clean clothes topped with a long white jacket. Then he walks out into the corridors, where Muzak plays tirelessly, where brass plaques declare the generosity of the local upper class and candy-stripers with innocent smiles rush about in pink-and-white pinafores. He makes his way to the waiting room, where the family, a wife and two middle-aged daughters, stands huddled. When they see him, they move eagerly, but then they slow, suddenly reluctant. "He's fine," he says quickly. His tone is positive, confident. "He's doing even better than we expected." The women relax, slide into relief after the long wait. Old suspicions give way to gratitude. Husband and father is alive. Suddenly, they are eager to be amused. They laugh when the surgeon says, "He'll be yelling for food in a few hours." That reminds them of their own hunger and, still smiling, they make their way toward the elevator and the snack bar.

•

After 15 hours, the surgeon came down the hall toward us. We watched his face for any evidence of the news he brought and moved toward him awkwardly on leaden legs. His mouth was set in a professional line, a line we knew was meant to inspire confidence, to set the laity at ease. It did neither. He strode purposefully toward us, still not speaking, but a faint smile of recognition touched his mouth. He had found the right people.

"How is she?" my wife demanded.

"That is rather difficult to say," he replied. He was evasive, sly. "They are watching her in the recovery room. We'll know more when she wakes up."

"What do you think right now?" I asked. "Do you think her heart has been fixed? Will she live?"

"Oh, I think the heart will be fine. I'm very happy with what we've done."

"Then she will live, or," anticipating his cautiousness, "you expect her to?"

"Yes, I expect her to live," but his words were guarded.

"Can we see her?" my wife asked.

"She will be down soon," he said, almost frowning. "But let the nurses get her comfortable first. There will be a lot of tubes, and you'll be unnecessarily upset." He tried to move us out of the hall.

But he was too late. She was wheeled from the elevator, drip stands banging, catheters slapping and the tubes from her chest dripping red into plastic bottles. But she was there, her color already pinker, and, although her eyes were closed and she did not move, we knew she was alive, and we rushed to her, crowding between orderlies to touch her and to look across at each other and laugh. She had come back.

•

I observed surgery for six days. On the last day, the patient I had seen on the first day returned to the operating room. He had held on all week, his blood pressure eventually steadying to the point where the balloon could be removed from his heart. And so, on Friday, the orderlies took him for surgery once more. This time his heart was more damaged than before. They gave him a new mitral valve, a pig valve--rather than an artificial one--and a quadruple bypass. When the old valve had been cut away and lay in a silver pan, the surgeon passed it to me.

"Feel that," he said. It was tough, lined with grit, like a chicken's craw. Then, since I was scrubbed and gloved, "Feel this." The wall of the heart was thick and rubbery, still pliant and resilient. The surgeon arranged the overhead light, focusing it on the incision, all the while holding the stilled heart in his hand at an angle that directed the light through the hole he had cut, illuminating the chamber below. At last, he lowered the heart back onto the sponges and began to sew. "That's it," he said. "Now you've seen the cockles and touched the quick."

When it was done and the chest had been closed, I lingered, watching as the patient was cleaned and lifted to the gurney. He looked very old, the flesh on his legs and sides deeply wrinkled, hanging in thick folds. But his color was changing even as I watched. No longer a blue-gray, it already showed the first touch of pink.

"We were powerless amid the mystery and secrecy of the place. Everything was a hieroglyph."

"The fidgeting continues. Reluctant to surrender, the heart still jumps at the surgeon's touch."