A Step Beyond (9 page)

“When?”

“As soon as we are sure of the diagnosis. Time is of the essence. A burst appendix can be fatal.”

“Do you have the proper equipment?”

“Of course,” Endicott replied with a false smile. He was wondering how he would conduct the diagnosis without an X-ray or an ultrasound machine.

E
ndicott and Nelson were standing in front of the high-definition waiting for Dr. Cain to silence the men surrounding him. When he finally succeeded, he smiled briefly at the camera.

“Good morning,” he said. “You may already know some of the doctors here.”

The camera swiveled past Cain’s silver curls and focused upon a panel of doctors. Seated at the center, an elderly man lifted his graying head and, with his index finger, pushed back on a pair of wire-framed glasses until they settled into the red indentations that marked each side of his nose. Cain introduced him as Dr. Lear.

“Good morning, Dr. Endicott. I had hoped our next meeting would have been under more pleasant circumstances,” Dr. Lear said, articulating each word with crisp precision. “In order to minimize the delay, I will pause between questions to allow you to respond. Of course, we will be unable to respond to any questions you may have until several minutes later. They tell me the delay is nearly twelve minutes. I understand you are used to this sort of disorientating dialogue, but I assure you my colleagues and I are not, so please bear with us.” He paused to look down at a sheet of paper. “The white blood-cell count was slightly higher than I would have expected. Over eighteen thousand.”

“Eighteen thousand, five hundred, and sixty-two,” Endicott clarified.

“The elevated count and the shift to the left could indicate a perforated appendix. Under the circumstance we must assume the worst. Commence intravenous hydration and start the patient on Mefoxin immediately. Any evidence of albuminuria in the urine?” He paused.

“None.”

“Did you check for Rovsing’s sign?” He paused again.

“I’m sorry. I’m not familiar with the technique.”

“The level of amylase in the urine was normal, which rules out acute pancreatitis,” piped in a younger doctor, seated to the left of center. Dr. Lear peered over the top of his glasses, his eyebrows lowered in disapproval. After several uncomfortable seconds he continued.

“Appendicitis can be easily confused with several other disorders, and without a barium enema or ultrasonography the diagnosis can be tricky. Do you feel confident he is not suffering from a severe case of gastroenteritis?” He paused, and while he waited he arranged the lab results on the table in front of him.

“As you have said, without the appropriate equipment it is difficult to make an accurate diagnosis,” Endicott replied. “I am as certain as I can be.”

Lear went on to discuss many of the complications that could arise and had just finished describing the procedures for a perforated appendix when Endicott could hear his own voice over the high-definition saying, “Yes, I am.”

He watched the doctors as they listened to him respond to their questions. Intermixed with his replies a tape of the Earth-side dialogue was being played quietly in the background so that the physicians were able to associate the answer with the question.

Dr. Lear turned to the camera. “Rovsing’s sign occurs when pressure is applied to the lower left side of the abdomen and pain is felt on the lower right. The symptom does not always present itself, but when it does there is a high probability the cause is appendicitis.”

“There was no indication of pain,” Endicott responded.

“As I was saying,” Lear continued, “it will be impossible for us to assist you directly with the operation owing to the time delay; however, the medical assistance program should be able to guide you through any complications that might arise.” He glanced at a paper that had been passed to him. “I have just been informed that if you have any further questions, you must ask them now.”

“What should I look for if it turns out not to be the appendix?” Endicott asked.

Slides of an appendectomy appeared on the high-definition while Endicott and Nelson waited restlessly for a response. As the slides advanced in slow motion, the recorded voice of an elderly woman explained the various aspects of the operation. Thin layers of oblique muscles, crisscrossing, were being pulled back with curved, spoonlike utensils. Behind the muscles was a confusion of organs, dominated by a reddish mass the voice of the elderly woman referred to as the cecum. The bloody organ was being pulled up and out of the wound when suddenly it disappeared and was replaced by the crisp image of Dr. Lear.

“In the event the appendix does not appear to be infected, examine the small bowel for enteritis or Meckel’s diverticulitis. The lymph nodes should also be examined for mesenteric adenitis. The simulation will explore each of these possibilities. If indeed nothing is found to be wrong, the appendectomy should still be conducted.”

There was a pause.

“Good luck.” Dr. Lear’s warm smile had been digitized and torn apart bit by bit, then mathematically reconstructed after oscillating, single file, through space. The smile conveyed confidence in Endicott or was at least meant to convey confidence. Endicott could not be certain. The camera swiveled and focused on Cain. His smile seemed forced, which for Cain was unusual.

“Best of luck, gentlemen,” he said.

Endicott wondered just how much luck he would require. As part of his training for the mission he had performed several surgical procedures, including an appendectomy, but he was not a surgeon. His understanding of medical matters was mostly academic. He glanced at Nelson and saw that he appeared to be waiting for instructions. Normally, Nelson would be giving orders in a crisis of this magnitude. He seemed uncomfortable, or perhaps he was just nervous. Endicott glanced at his watch in order to collect his thoughts.

“We should get him started on the antibiotics,” he said upon looking up.

T
he compartment was too small to be a proper operating room. There was barely enough space for the EKG machine or for Lieutenant Colonel Carter, who was standing nervously in front of the machine with his back to the patient. His responsibilities were to monitor the life-support readouts and enter information dictated by Endicott into the computer. He purposely did not turn around. His skin was still damp with cold sweat and his stomach tight. He had seen the scalpel make a vertical slice across Brunnet’s bare abdomen, leaving a trail of red dots that grew into pools of blood until a sponge swept them away. That was all he could bear to watch. In an attempt to force the image from his mind, he concentrated on the steady pulse of the EKG. He was beginning to think of other things when he heard, or thought he heard, the sound of flesh pulling apart. He closed his eyes and swallowed hard. He wanted to close his ears to stop the sound, and desperately fought the urge to clasp his hands over them. He heard Endicott say something, but his voice was distant. Then silently and without warning came the smell. At first he was uncertain. So he sniffed a little bit deeper. The odor was sweet and slightly pungent. As it slowly expanded into his lungs, he realized that it was intestinal gases. The gases had grown foul inside the wound. He began to gag.

Endicott looked up to see Carter’s back hastily retreat through the portal. He then looked across the table at Nelson, who with a blood-soaked sponge in hand was about to go after him.

“It’s not unusual. Some fresh air and he’ll be all right,” Endicott said. Tom Nelson looked uncertainly at the portal.

“I need you here,” Endicott said. As their eyes met, they heard the sound of Carter vomiting in the next room.

They quickly returned their attention to the body on the table. Towels were draped over the abdomen to form the boundaries of a rectangle outside the wound. The skin was pulled back, revealing a thin layer of red oblique muscles. The lower portion of the opening was filling with blood.

“Sponge,” Endicott said.

Nelson carefully pressed a sponge against the blood.

“Hemostat,” Endicott said.

Wiping the perspiration from his brow as he placed the sponge in the sink, Nelson hesitated at the sight of several clamps of various sizes. He chose a medium-sized one and handed it to Endicott.

“Sponge.”

Nelson wiped the blood clear.

“Don’t wipe. Press,” Endicott instructed. “Wiping the sponge across the vessel may increase the hemorrhaging.”

Endicott located the severed vessel and quickly clamped it shut.

“Hold this,” Endicott said, presenting the end of the hemostat to Nelson. They heard Carter quietly enter the room to resume his vigilance at the life-support monitors.

“Ligature.”

“What?” Nelson asked, his voice strained.

“The thread.”

“Thread,” Nelson repeated as he placed it in Endicott’s hand.

“We are going to tie off the vessel to stop the bleeding. Listen carefully; although the simulation made this look easy, it can be somewhat tricky the first time you try it. I want you to hold the hemostat straight up while I pass the ligature around behind it. You will then lower the handle and raise the tip so that I can tie a knot around the vessel. When I say ‘off,’ remove the hemostat. With the scissors cut the thread at the points I indicate. Take care not to cut or touch anything other than the thread. Are you ready?”

“Ready,” Nelson replied, attempting to sound more confident than he actually felt.

“OK, lift the hemostat.”

Nelson obeyed and held the clamp perpendicular to the body, allowing Endicott to pass the thread behind it.

“Pull up slightly so that I can get the thread around the vessel.”

As Nelson pulled, the clamp slipped off the vessel and blood spurted from the severed tip.

“Damn,” Nelson said.

“Sponge,” Endicott ordered. “Quick.”

Endicott took the sponge and dipped it into the wound. “Blood pressure.”

“One-thirty over eighty,” responded Carter.

“Good,” Endicott replied. “Let’s try it again. Hemostat.” Nelson handed the hemostat over and watched as Endicott clamped the vessel shut at a spot slightly farther back than he had the first time.

“OK, hold this here,” Endicott said, offering the clamp. “Do not put too much tension on the blood vessel. Pull back gently. That’s good.”

Endicott tightened the thread around the vessel. He looked up and smiled triumphantly. “Off.”

Nelson released the clamp and, when he was sure the knot would hold, breathed a sigh of relief.

“Cut the ends with the scissors.” Endicott held the two ends of the ligature apart. They formed a giant V. “Not so close.”

“Where then?” Nelson asked.

“A centimeter up from the knot. It may come undone if you cut too close, and the ends may get in the way of the scalpel if you cut too far.”

Nelson, taking a deep breath, bent over the body and clipped the thread.

“And now,” Endicott said, “the external obliques.”

Without turning around, Carter spoke. “The computer says to split the external oblique muscle in the direction of its fibers, then split the internal obliques, and then split the transversus abdominis. What the hell is that?”

“Another muscle group.”

Carter returned his attention to the EKG. He was thankful that he did not have to look at the open wound and decided the cartoonlike depiction on the screen before him was not so bad. It was the smell that troubled him the most.

Endicott separated the internal obliques with the retractors and saw that his hands were shaking. He paused to breathe deeply.

“Everything OK?” Nelson asked.

“Everything is fine.” Endicott looked at his hands. They were steady now. He waited a few more seconds before proceeding.

“When will we be done here?” Nelson asked.

“Fifteen minutes, maybe longer.”

“How much longer?”

“Depends upon what we find behind the cecum. If the appendix is not the culprit, then we’ll have to search elsewhere. It is difficult to estimate the unknown.”

Endicott split the transversus abdominis; he instructed Nelson on how to secure the muscle group; then he delicately lifted the cecum out of the wound, revealing the appendix. The inflamed protrusion was immersed in a turbid pool of white pus, leaving little doubt in the minds of the two men hovering above the tiny organ that it was responsible for Brunnet’s condition. Endicott slowly extracted the pus with the hand-operated suction. Once he had the immediate area cleared, he lifted the appendix to examine it. The flesh on the underside near the tip was shredded.

“Not good,” he said. “It’s perforated. Hemostat.”

Endicott lifted the burst appendix from the abdomen and clamped it shut at its base. The organ turned pale. He inserted the suction into the cavity and sucked the remaining pus into the clear device. After irrigating the wound, he cleansed the surrounding area with a sponge treated with a topical antibiotic. He severed the appendix, handed it to Nelson, and motioned for him to enclose it within the sterile container on the counter.

Nelson wasn’t sure what Endicott meant, so he stood there without moving, the bloody specimen in the palm of his hand.

“Place it in that container there,” Endicott said.

“You plan to keep it?”

“They want to examine it back on Earth.”

Endicott bent down near the open cavity and sewed the stump closed. He handed Nelson the needle. With the appendix successfully removed and tied off, Endicott was beginning to relax. “Ease up slowly on the retractor.” He gently pushed the abdominal contents into the cavity. The muscles fell neatly into place. He left an opening in the skin so that the wound could be easily drained if an infection developed.

“That should be it for now,” Endicott said, suppressing his relief. “I’ll remain with him for a while. There’s no reason for you two to stay.”

“Congratulations,” Nelson said, and extended his hand. Carter had already left the room.

N
elson was reviewing the daily activity sheet as he sipped his morning coffee. The workload had been reduced to compensate for Brunnet’s absence during his recovery, but to a much greater degree than Nelson had expected. It was obvious that the mission planners didn’t want to tax them. But it was also obvious that the planners didn’t want them idle either. Nelson considered this and decided to approve the activities.