Cutting for Stone (63 page)

Shiva wasn't reading, but reciting word for word from memory. It didn't surprise Hema, but it astonishmed the other physicians at the table. Hema felt proud of Shiva. She was reminded how often she took Shiva's eidetic gift for granted. She knew he could draw the page he was reciting from, reproduce it on a blank piece of paper, beginning and ending each line just as it was on the original, down to the punctuation, the page number, and the staple marks and photocopy smudges.

Shiva, sensing that he had quieted Hema for the moment, addressed Thomas Stone and Deepak, the two surgeons: “May I remind you that the first successful kidney transplant by Joseph Murray involved a dying twin who received a healthy kidney from his identical twin brother?”

Deepak spoke, because it appeared that Thomas Stone was in a state of shock, “Shiva, we also state in the paper,” Deepak said, “that there are ethical and legal implications—”

Shiva interrupted. “Yes, I know. But you also say ‘in all likelihood the first donors will be a parent or sibling, because such a donor has a pure motive and takes on the risk willingly’ “

Deepak and Thomas Stone looked like defendants whose alibi had just been shot down by a surprise witness. The prosecutor was moving in for the kill.

But the attack came from another quarter. Hema said, “Thomas, tell me the truth: in the last four days, given that
this
is your area of interest”—she tapped the paper, her fingers bunched together—”seeing Shiva lie next to his twin, did the thought of this live donor operation not cross your mind?”

If she expected him to squirm and swallow hard, she was in for a surprise: Stone looked steadily at Hema, and after a beat, he nodded almost imperceptibly. “I thought of the Murray twins, yes. I thought of it. But then thinking of all the hazards … I dismissed it. This is much, much harder than removing a kidney. It's never been done.”

“
I
never thought of it!” Vinu Mehta said quietly. “Madam, I
should
have thought of it. Shiva, I thank you. In anyone else with acute hepatitis B, a liver transplant would simply feed the virus. But with a perfect match … Of course, Shiva, the issue is really the risk to you.”

My brother was ready, and he spoke without glancing at his notes, addressing his comments largely to Thomas Stone even though Vinu had asked the question. “Your estimate, Dr. Stone, based on cutting out one or more lobes from patients with liver trauma, is that the risk of death should be less than five percent for me, the donor. The risk of serious complications, such as bile leaks and hemorrhage, you said should be no more than twenty percent in an otherwise healthy donor.” Shiva pushed a single sheet to Deepak and Thomas Stone. “I had my blood drawn last night. All my liver functions came back normal. As you can see, I am not a carrier of hepatitis B or anything like that. I don't drink or take drugs that might damage the liver. I never have.” Shiva waited for Thomas Stone.

“You know that paper of ours better than I do, son,” Stone said. “Unfortunately, those were estimates, a pure guess.” He put his hands on the table. “We don't know how it might really work in humans.”

“And if we fail,” Deepak added gently, since Thomas Stone was finished, “we lose you who walked in here healthy
and we
lose Marion. Not to mention that we won't have a leg to stand on or that our careers could be over. Even if we succeed, we will be heavily criticized.”

If they thought Shiva was done, they didn't know my brother. Hema was seeing her son anew. “I understand your reluctance. I wouldn't think much of you as surgeons if you agreed at once. However, if you
can
do this operation and if it has a reasonable chance, even a ten percent chance of saving Marion's life, and a less than ten percent chance of ending my life, and if you choose
not
to do the operation, then in my opinion, you would have failed Marion, failed Hema and me, failed medical science, failed yourselves. You would have failed my brother not only as his physicians, but as his friend, and as his father. If you
did the
operation and succeeded, you would not only save my brother, but you would have advanced surgery by a decade.
The time is now.”
He looked his father and then Deepak in the eye. “You may never get a chance like this again. If your rivals at Pittsburgh were facing this situation, what would they do? Would they not be bold?”

The prosecution rested. It was time for the other side of the table to respond.

“Bold, yes,” Stone said, breaking the long silence, and speaking in an undertone as if only for himself, “but they wouldn't be operating on their own sons. I'm sorry, Shiva, I can't imagine this.” He pushed back from the table, put his hands on the arms of his chair as if he were thinking of leaving.

“Thomas Stone!” Hema's voice was sharp as a Bard-Parker blade and it nailed him in his seat. “Once before I asked you for something, Thomas,” she said. “It had to do with these boys. You walked away then. But this time if you walk away, neither I nor Ghosh can help these boys.” Stone turned pale. He sat back in the chair. Hema's voice broke. “Thomas, do you think I would want to subject Shiva to a risk he couldn't surmount? Do you think I want to lose my sons?”

When she had composed herself, and after blowing noisily on her kerchief, she said, “Thomas, please dismiss from your head the idea that they are your sons. This is a
surgical
problem and you are in the best position to help them, precisely because they were never
your
sons. They never held you back, they never slowed your research, your career.” There was no rancor in her voice. “Dr. Stone, these are
my
sons. They are a gift given to me. The pain, the heartbreak, if there is to be heartbreak, are all mine—that comes with the gift. I am their mother. Please hear what I say. This has nothing to do with your sons. Make your decision by deciding what you must do for your patient.”

After an eternity, Deepak dragged the yellow pad from Shiva's side of the table and turned to a fresh page. He uncapped his pen and said to Shiva, “Tell me, why are you willing to subject yourself to such a risk?”

Shiva, for once, did not have a ready reply. He closed his eyes and made a steeple of his fingers, as if to shut out their faces. It worried Hema to see him this way. When he opened his eyes, he seemed for the first time since his arrival to be sad. He said, “Marion always thought that I never looked back. He saw me as always acting only for myself. He was right. He would be surprised if I were to risk my life to donate part of my liver. It isn't rational. But … seeing that my brother might die, I have looked back. I have regrets.

“If I was dying, if there was a chance he could save me, Marion would have pushed you to operate. That was his way. I never understood it before because it's irrational. But I understand it now.” He glanced at Hema, then shouldered on.

“I had no reason to think about all this till I got here. But at his bedside … I realized if something happens to him, it happens to me, too. If I love myself, I love him, for we are one. That makes it a risk worth taking for me—it wouldn't be for anyone else, unless they loved him. I am the only one who is a perfect match. I want to do this. I couldn't live with myself if I didn't do this, and I think you wouldn't be able to live with yourselves if you didn't try. This is my destiny. My privilege. And yours.”

Hema, composed till then, pulled Shiva to her and kissed him on the forehead.

Deepak, pen poised, had yet to write a word. He put the pen down.

At that moment it sunk in that they were going to go ahead with what had never been done before.

Shiva said to Deepak, “You said there was a second reason you had initially dismissed the idea of a transplant. What was it?”

Deepak said, “Before he lost consciousness, Marion made me promise not to transfer him. This hospital was special to him. It was more than a place for us foreign medical graduates to train. It welcomed us when other places did not. This is our home.”

Hema sighed and dropped her head into her hands. Just when they had come this far, another obstacle.

“We can do it here,” Thomas Stone said softly. He had listened to Shiva without moving a muscle, and those blue and steady eyes were now shiny and bright. He pushed his chair back and stood up, his movements purposeful. “Surgery is surgery is surgery. We can do it here as well as anywhere if we have the tools and the people. Fortunately, the world's expert in splitting the liver is sitting right next to me,” he said, putting a hand on Deepak's shoulder, “and the tools, many of which he designed, are also here and will need to be sterilized at once. We have a lot to get ready. Hema, at any time if you or Shiva have a change of heart, all you need to do is say so. Shiva, please don't eat or drink anything from this moment on.”

As he walked past Shiva's chair, he clamped his hand on my brother's shoulder, squeezed hard, and then he was gone.

CHAPTER 52
A Pair of Unpaired Organs

A
HELICOPTER FROM BOSTON GENERAL
landed on Our Lady of Perpetual Succour's helipad during the night. It brought special instruments and the key personnel from Boston General's well-oiled liver transplant program. The corridor outside Our Lady's operating suites, normally a desolate stretch where one might find an empty stretcher or a portable X-ray machine parked while the tech took a cigarette break, was now like battalion headquarters at the start of a military campaign. Two large blackboards had been set up, one labeled
DONOR
and the other
RECIPIENT,
each listing what had to be accomplished with a check box next to the task. Our Lady of Perpetual Succour's team with Deepak as lead surgeon would handle the donor (Shiva's) operation, and the Boston General crew with Thomas Stone as lead surgeon would staff the recipient (my) surgery. The Our Lady team wore blue scrubs, while the Boston General crew wore white, and just to be certain, the former had a big
D
(for “donor”) marked on their hats and scrub shirts with a black marker, whereas the latter had an
R.
The adrenaline flow kept these disparate teams in good spirits; one Bronx wag even suggested to his Dorchester counterpart that they could call the teams Crackers and Homeboys. Only Thomas Stone and Deepak Jesudass would be common to both teams, each man assisting the other.

A dry run at midnight with dummy patients in both operating rooms had uncovered a few critical glitches: anesthesia from Boston General needed a better orientation to the setup at Our Lady, and there was need to anoint a “ringmaster” whose job was to be timekeeper, to keep abreast of the activities of both teams, and who was the only person authorized to carry and, most important, record all messages from Team R to Team D and vice versa. Two new blackboards were brought in to be placed
inside
each theater, and tasks to be ticked off written on these. Our Lady of Perpetual Succour was put on diversion, with trauma being rerouted to other hospitals in neighboring boroughs. By
4:00
a.m. it was time for the real thing.

Thomas Stone threw up in the surgeons’ locker room. The Our Lady crew saw this as a bad omen, but the Boston General crew assured their counterparts that a pale, diaphoretic Stone augured a good outcome (though in truth, they had never seen him quite so pale and weak, lying prostrate on the bench, a puke basin at his side).

With so many people from two hospitals involved, it would have been difficult to keep the operation a secret. There were two television crews parked outside Our Lady. Newspaper editors were past the deadline for the morning paper, but they were preparing to weigh in on the ethics of this historic transplant, and now they could wait to see how it went before committing themselves.

Making history or keeping it a secret was the last thing on the surgeons’ minds. Deepak, sitting on a bench separated by a row of lockers from where Stone suffered, tried to block out the sickening sound of his colleague's retching by reviewing a liver atlas.

At
4
:
22
a.m. Shiva was given diazepam and then pentothal, and a tube was passed into his trachea. The donor operation had begun. Thomas Stone and Deepak expected it to take anywhere from four to six hours.

IF THE BEATING HEART
is pure theater, a playful, moody, extroverted organ cavorting in the chest, then the liver, sitting under the diaphragm, is a figurative painting, stolid and silent. The liver produces bile, without which fats are not digested, and the liver stores excess glucose in the form of glycogen. In silence and without outward signs, it detoxifies drugs and chemicals, it manufactures proteins for clotting and for transport, and it clears the body of ammonia, a waste product of metabolism.

The liver's smooth and shiny outer surface is monotonous and unexciting, and apart from a median furrow dividing it into a large right lobe and a smaller left, it has no visible cleavage planes. It is a surprise to find surgeons speak about its eight anatomical “segments”—as if they are discrete, as if they are like sections of an orange. Try pulling these segments apart and you'll have raw surfaces oozing blood and bile and a very dead patient. Still, the idea of segments allows the surgeon to define areas of liver that have a full complement of blood and bile conduits and that are therefore semiautonomous units, subfactories within the factory.

Four families of vessels enter or leave the liver. First, the portal vein, which carries all the venous blood leaving the gut and hauls it to the liver, blood that after a meal is rich in fats and other nutrients for the factory to process. The hepatic artery brings oxygen-rich blood to the liver from the heart via the aorta. The hepatic veins have the task of taking all the spent blood that has filtered through the liver and returning it to the heart via the vena cava. The bile formed by each liver cell gathers in tiny bile tributaries that merge and grow and eventually form the common bile duct that then empties into the duodenum. Excess bile is stored in the gallbladder, which is nothing more than a balloonlike offshoot of the bile duct. In keeping with the liver's chaste and understated demeanor, the gallbladder is tucked out of sight, just under the overhang of the liver.

DEEPAK, STANDING ON THE RIGHT,
made the incision. The first step was to remove Shiva's gallbladder. Then, turning his attention to the stalk of vessels entering the liver
(the porta hepatis),
he dissected out the right hepatic artery, then the right branch of the portal vein and the right biliary duct. To get the right lobe free, he also had to cut through liver tissue and disconnect the hepatic veins at the back where they joined the vena cava—the dark side of the liver, the place where the surgeon might “see God” if there was bleeding. In removing a lobe of the liver for cancer, it is possible to control bleeding by pinching off the stalk of blood vessels in the
porta hepatis
—the Pringle maneuver. But this wasn't an option for Deepak, because it would compromise the function of the lobe they were removing, choke it half to death before giving it to me. There are now ultrasonic and even radio-frequency “dissectors” that make cutting through the liver easier, less bloody. But Deepak, with Thomas Stone as his assistant, had to resort to clamp crushing and “finger fracturing” to break through the liver tissue while avoiding the major blood vessels or bile ducts. Deepak worried about his senior partner: Thomas Stone's mind seemed to wander, something Deepak had never encountered before. Little did Deepak know that Stone was struggling to keep away the image and the memory of his futile efforts to save Sister Mary Joseph Praise, and his dangerous attempts at crushing a baby's skull.

The donor operation went without a hitch. At
9:00
a.m., I was wheeled into the operating room, and at
9
:
30
a.m., just as Shiva's right lobe was coming free, the Boston General team, without Thomas Stone, made a long incision across my middle, below my rib cage but above my belly button. They began mobilizing my liver, cutting away its ligaments and trusses.

Thomas Stone took Shiva's freed right lobe to a side table, where, with hands that were steadier than his insides, he flushed the portal vein with University of Wisconsin solution. Deepak, meanwhile, ensured that there were no bile leaks in the raw edge of what remained of Shiva's liver, which was largely his left lobe. He looked all around for any overlooked bleeders, repeated the sponge and instrument count twice, and then he closed Shiva's belly. In a month, Shiva's liver would regenerate to its previous size.

Now, Thomas Stone and Deepak donned fresh gowns and gloves and came to me to complete the removal of my liver. Because my clotting functions were poor, there were lots of tiny bleeders, particularly behind my liver as they freed it from the diaphragm. I required many units of blood as well as platelets. They carefully identified and preserved my bile duct, the hepatic artery, and the portal vein. It was one in the afternoon when my four-and-a-half-pound companion, which I had sheltered under my rib cage all these years, left me. A gaping cavity under the dome of my right diaphragm, an unnatural void, remained.

Connecting Shiva's liver, or rather his right lobe, was a laborious process. Bleeding had to be meticulously controlled in order to see clearly and for Thomas Stone, with Deepak's assistance, to suture artery to artery, bile duct to bile duct, and vein to vein. The scissors and needle holders were specially designed for microsurgery. Both surgeons wore headlights and magnifying loupes as they manipulated sutures that were finer than a human hair. One advantage of Deepak's decision to give me Shiva's right lobe was that it fit more naturally under the dome of my diaphragm, and its hilum—the place where the vessels entered—was oriented more naturally toward the vena cava. It made the surgeons’ jobs a little easier.

The remnants of the D team took Shiva to the recovery room and then waited in the locker room. Their mood unexpectedly became somber. It was now out of their hands, and that made the tension almost unbearable.

An anxious Hema, with Vinu at her side, watched the clock in the waiting room. At first, she was thankful for her chatty companion, but then even he could not distract her. She kept thinking of Ghosh and wondering if he would have chastised her for letting Shiva take such a risk.
A stone in hand …
or was it “bird”?
Grass is greener …
he would have a maxim for the situation.

Word came from the operating room via the Ringmaster—he called at each stage of the operation—and Hema now wished he wouldn't, because the shrill ring never failed to startle her and made her imagine the worst, only to be told “They have begun” or “The portal vessels have been isolated” when what she wanted to hear is that they were done with Shiva. At last, she did hear those words, and soon she saw Shiva, awake but groggy in the recovery room and wincing in pain. She was giddy with joy, stroking Shiva's hair, and she knew that wherever he was, whatever form his reincarnation had taken, Ghosh, too, was relieved.

Shiva's eyes, coming into focus, asked the question. “Yes,” Hema said. “They're putting your liver lobe into Marion right now. Deepak said the part you donated looked magnificent.”

She wasn't allowed to stay long. Instead of returning to the waiting room, she decided to slip away to the chapel. A solitary stained-glass window allowed in very little light. When the heavy door closed behind her, she had to seek the pew with her hand and ease into the velvet-covered bench. She covered her head respectfully with the tail of her sari. As her eyes adjusted, she got the fright of her life, seeing a figure on its knees near the altar. An apparition! she thought. Then she remembered the prayer chain for Marion, the round-the-clock vigil in this chapel. As her pulse recovered, Hema settled back and observed the veiled head, the scapular falling back, stiff and separate from the pleated tunic. Hema realized that in importuning every deity she could think of, she had somehow neglected to appeal to Sister Mary Joseph Praise. The oversight caused a fierce and silly panic, blood surging up her neck.
Oh, please don't let that be a reason to punish my son.
She wrung her hands, squirmed and chastised herself for forgetting.
Forgive me, Sister, but if you only know how stressful this has been, and if it is not too late, please watch over Marion, please see him through.

She felt the response arrive as distinctly as if it were a voice or a touch: first, a lightness in her forehead, then a calmness in her chest that said she had been heard.
Thank you, thank you,
Hema said.
I promise to keep you updated.

She returned to the waiting room. She was so exhausted that she could only wonder how Stone and Deepak managed to stay upright. From the waiting room window the earth looked as if it were mostly sky and concrete—no real earth to speak of, no manifestation of nature on the ground other than the sun setting in that direction. It was so odd, and yet this was the view her son had known for the last six years.

At
7:00
p.m., Thomas Stone was at her side. He nodded, then smiled, an expression so rare that she knew it had gone well. He said nothing, and she, too, was speechless, tears running down her cheeks. In studying Stone's face, grooved where his magnifying spectacles and lamp had sat, and grooved also from worry and work, she realized with a start how old he had become, how old they had both become, and how if they had nothing else in common, they had this: that they were both still standing after all these years, and that her sons (his, too, at some level, she had to admit) were both alive.

Thomas Stone sat down, or rather fell into the sofa, and he didn't protest when she forced juice and a sandwich on him from Vinu's ice chest of goodies. Stone washed the juice down with a bottle of water and started on a second before life seemed to stir within him. His gaunt face filled out. “Technically, everything has gone well,” he said. “Marion's new liver, Shiva's old lobe, was already making bile before we had even finished the anastomosis.” He smiled again, a shy twist of the corners of his mouth, pride in his voice. The bile, he said, was an excellent sign.

“We had a scare,” he added. “There was a moment when Marion's blood pressure dropped precipitously. No explanation for it. We were ahead on fluid and blood, but still his heart raced to one hundred and eighty beats a minute. We poured fluid in, tried this and that … and just as suddenly, the pressure came back up.” She was about to ask him precisely what time that was, but then she didn't bother, because she knew. She closed her eyes and thanked Sister for her intercession. When she opened them, Thomas Stone was staring at her as if he understood. She felt so close to him, so grateful. She couldn't go so far as to hug him, but she did reach for his hand.

“So, I must leave now,” he said to Hema after a minute. “It will be touch-and-go for a while for Marion, given how sick he was when we started. But at least he has a working liver. His kidneys are still not functioning, and he needs dialysis, but I trust it is just hepatorenal syndrome and the new liver will fix that.” He was holding things back from her. He didn't tell her how, when things had looked so dire in the operating room, hed looked up at the ceiling and prayed not to a God or to spiders, but to Sister Mary Joseph Praise, asking to be redeemed for a lifetime of mistakes.