I took a deep breath and listened to the old brag of my heart. I am, I am, I am.
— Sylvia Plath, The Bell Jar
The landscape of theaters must be terrifying for patients, but it’s becoming normal for me. It’s amazing what you can get used to. Life wasn’t always like this.
The first operation that I watch is a heart-lung transplant. I am nineteen years old and still a student nurse. The operation takes so long: over twelve hours. It requires a team of surgeons to behave like a relay team; but instead of a baton, they pass between them a human heart and lungs. I’ve been looking after the patient waiting for the new set of lungs that day: a fourteen-year-old boy named Aaron suffering from cystic fibrosis, who is confined to bed, oxygen tubes inserted into his nose, with a tired, wet cough and sallow gray skin. I help him get ready for the operation. I rub cocoa butter onto his dry knees, take away his Game Boy and swear to guard it with my life. I wet his lips with a small salmon-pink sponge that I dip in sterile water, not wanting to risk the tiniest possibility of him being exposed to any germs.
Aaron’s room glows with lights in the shape of stars and moons surrounding his hospital bed and a journal is hidden under his pillow. There is a small corkboard next to his bed that his stepdad has Blu-tacked to the wall, covered in a mosaic of photographs of him with his friends, every single one of them smiling. It is a common thing for a child’s hospital room to be personalized. Aside from the oxygen piped through the wall and the suction canister with its thick transparent tubing, it could be a typical teenage bedroom.
If the patient ever sees an experienced nurse looking worried, it means they are likely dead already.
We chat almost as if nothing is happening, but when the porters come to help me transfer Aaron to the anaesthetic room, he grabs his mum. “Don’t go before I’m asleep,” he says. He looks at me. “And you will be there the whole time?”
“I’ll be there. You ready?”
He shakes his head no. I nod to the porters anyway and they begin pushing his bed through the doors, out of the ward and down the corridor. One of the porters, a cheerful young woman, whistles continuously. The walls are young-child-friendly and are painted with animals and flowers. Children walk past us pushing IV carts, their parents or a nurse smiling behind them. The porter whistles; Aaron shakes his head again. His mum holds his hand, walking quickly beside the bed. I have one eye on the monitor at the end of Aaron’s bed, which measures the oxygen in his blood. I will it not to drop. “Not now,” I say in my head. “Steady, steady.” I’ve heard stories of children getting worse in broken-down elevators, oxygen running out and full cardiac arrests being badly managed, until an elevator engineer is found. I am anxious, but have already learned the face that nurses know best. I slow my own breathing and movements and focus on portraying an easy-going body language and a soft smile. One of our nursing lecturers, when explaining the benefit of our clinical placements in gaining experience, told us that if the patient ever sees an experienced nurse looking worried, it means they are likely dead already.
Theater is a maze of corridors and trolleys, covered in sterile blue sheets, containing internal defibrillator paddles and difficult airway kits. The theater nurses walk so quickly, their clogs squeaking quietly on the shining floor, their half-done-up theater cloaks billowing out behind them as if they are magicians. There are numerous equipment rooms; in one the nurse kneeling down with her checklist, which she signs off every morning and every night: expiry date, number of sets, date of new batch ordered. There is an autoclave machine in the corner where some equipment is being sterilized; the arterial blood-gas machine that tells the nurse how well the anesthetist is getting on, and whether the patient is being oxygenated or is full of carbon-dioxide gases. The air in the winding, low-lit corridors seems to be thick, holding onto memory like a smell. It tells stories, if you listen hard enough, of the wrong kidney being removed, or the time when the electricity stopped and the generator did not kick in; or the occasion when the patient was defibrillated and the oxygen was not removed, and there was an explosion that sounded like a bomb going off and resulted in the anaesthetic nurse receiving a nasty head injury and admission to intensive care. If walls could talk.
Many of us pass through the operating theater largely without memory. We go to sleep and wake up, without examining too closely what happened in between. Theater nurses see everything. Sometimes funny things: the surgeon and nurse found in the linen cupboard in a state of undress. The men having minor operations who get erections, due to the anaesthetic, and a penis that goes up and down with each movement of the surgeon’s blade, often in time with the music. I work with a surgeon much later on whose scrub trousers fall down during a crucial moment and who happens to be wearing Bart Simpson underwear; a nurse awkwardly attempts to pull them up, while he shouts, “Leave them, leave them alone!”
But theater is also the place where life and death are literally in someone else’s hands. Most of the time everything goes right, but when it goes wrong it is a disaster. The organized, calm, sterile environment can look like a war zone when a patient suddenly deteriorates. Anaesthesiologists do their best to predict which patient groups will be problematic — the obese, smokers, pregnant women, and such — though there are always surprises. There are patients who claim they were awake during the operation and unable to move, a phenomenon explained by the paralysis agent given to them and their lack of reaction to the accompanying sedative. There are patients who react badly to anaesthetic drugs and have a dangerous drop in blood pressure, an occasional cardiac arrest.
I have looked after such patients, who are told post-operatively that things were a little unstable in theater, but the surgeon managed to stabilize them. The language of nursing is sometimes difficult. A heart cell beats in a Petri dish. A single cell. And another person’s heart cell in a Petri dish beats in a different time. Yet if the two touch, they beat in unison. A doctor can explain this with science. But a nurse knows that the language of science is not enough. The nurse in theater translates “your husband / wife / child died three times in there, but today was a good day and, with a large amount of electricity and some chest compressions that probably broke a few ribs, we managed to get them back” into something that we can hear. A strange sort of poetry.
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I try not to think of what can happen in theater, of all that can — and has — gone wrong. I adopt my relaxed-on-the-outside, panicking-on-the-inside pose until we arrive in the anaesthetic room, which is full of reassuring equipment and a very relaxed-looking and smiling anesthetist. “Okay then, Mum. Hi, Aaron.” The anaesthetist introduces herself and keeps eye contact with Aaron, while all the time the operating-department assistant buzzes around in the background, preparing the monitoring and labeling syringes. I stand at the end of the bed, near enough to reach out and pull Aaron’s mum away, if necessary, in the seconds after Aaron has fallen asleep from the gas and air and before she needs to be ushered out. We do not want her to witness the next stage, after a patient is put to sleep: eyes taped shut, head tipped back as far as possible and a tube pushed into his trachea, needles passed into veins, remaining clothing removed. Skin is then painted a muddy copper with Betadine iodine solution until a patient no longer looks human, more like a piece of meat. Ready for the surgeons, of whom in 1800 Lord Thurlow, a Member of Parliament, stated, “There is no more science in surgery than in butchering.” Surgery was considered such a lowly profession that even women were admitted during the Middle Ages, until the 1700s, when surgical training moved into the universities, from which women were barred. Attitudes toward, and public perception of, surgery have moved on a lot more than that of nursing, which at times seems to be heading in the opposite direction.
I am waiting, with my teeth pressed together, for the awful moment between a child being anaesthetized and a parent having to kiss them goodbye and leave them in the hands of strangers. I feel in awe of the anaesthetist, who is cool and calm and reassuring, despite having sole charge of a complicated and high-risk patient.
The next time I go to theater I will watch an operation with a fellow nursing student: Jess. I’ll be impressed with the anaesthetist then, too, in awe of him, until Jess tells me she’s had an affair with him. She will lift her surgical mask up higher and higher during the operation, until I can barely even see her eyes. “What are you doing?” I ask her. “I’ve slept with everyone in here,” she says. “Except the patient.”
Now I walk with Aaron’s mum for a few moments outside the theater, hug her, wish I could say something to help, search inside myself for comforting words.
“That was the worst moment of my life,” she says. “The worst.”
I swear I’ll never underestimate how hard it must be to entrust your child’s life to strangers, no matter how expert they are.
Nurses can be found in the theater corridors of all hospitals with their arms around a relative, reassuring them — or not — that the operation is going well. After we leave the stark white theater corridors, I walk with Aaron’s mum back to the ward, where she begins to cry. I sit with her for a while, without speaking. Eventually she looks at the clock.
“It will be hours and hours,” I say. “All day. You need to fill the time. I’ll head back shortly, to be with Aaron.”
“I’m meeting my sister,” she says. “I’ll try to keep busy.”
I smile at her. I do not tell her what she wants to hear. I have learned that already. The previous week, one of the first babies I’d looked after was going for a relatively straightforward operation to fix a hole in his heart. “He’ll be fine,” I said repeatedly to his parents. But he was not fine. He did not come back from theater. He died on the operating table. I got it very wrong. His parents were distraught and confused. I told the nurse in charge my mistake, and I cried and cried. “They won’t even remember what you told them,” she said. “It wouldn’t make any difference. You did nothing wrong.” But I know that my words were wrong. I can still see his yellow cardigan.
I don’t tell Aaron’s mum that Aaron will be fine. I’d never tell any relative that: I’ve learned my lesson. Because none of us really knows.
“Try and keep busy,” I say. “Time will move very slowly.”
Time is a funny thing. If we are waiting for a relative having an operation, it slows down, until each second becomes a minute, each minute an hour. Yet if we are a patient having an operation, time becomes shorter: we count down from ten, and there is nothing.
I think I’ve never seen anything as beautiful as Aaron’s heart beating in front of my eyes.
The large operating theater is full of people, yet you could hear a pin drop. There is a radio on a shelf high up behind the surgeon’s head, although it is silent. The reassuring sound of music when the operation is going well is absent. The words “Turn the music down” in theater mean that things are not going well — an artery has been nicked, there is a bleed, a drop in blood pressure or a cardiac arrest. But today the lack of music is simply reflective of the enormity of the situation. I am standing on a viewing tower with a clutch of medical students and junior doctors: a large operating theater full of people is standard for interesting or groundbreaking cases, and teaching is common practice during operations. Nowadays operations are filmed and streamed to surgeons around the world, for teaching purposes and for advice from other doctors from various countries: the expert in the details of the procedure, who is based in LA, never needs to leave LA anymore. There are screens displaying everything, but primarily for the people inside the room, and some distance away from the actual surgery. Most faces are studying the screens, watching the hands of the surgeon inside the patient, twisting and turning like a dancer’s hands, moving skillfully around the beating heart in perfect synchronicity. I think I’ve never seen anything as beautiful as Aaron’s heart beating in front of my eyes. Of course I see something even more beautiful, some years later, when I watch the tiniest flickering of my own baby’s heart on an ultrasound screen.
Aaron is at the center of the room. His body is by now a dugout canoe. The surgeon’s hands are inside him. What a strange privilege to place your hands inside a human being, to touch a heart with your fingertips, to become briefly one. I think about that while watching the surgery: how the surgeon and the patient are one, like a mother and her unborn child, sharing the same shell of a body for a time. The room smells of chlorine, bleach and sweat. There is also a strange sharp, biting metallic smell, which might be blood. The walls are clean, but I know that the ECMO machine — the machine that carries the entirety of a person’s circulating blood volume during some operations — once split open, and the walls and ceiling, and staff and equipment were soaked with blood. A horror film.
I shudder and focus on a strand of Aaron’s hair. It reminds me that he is not a carcass being butchered, but a boy obsessed with astronomy, whose battered Game Boy I have locked safely away. The surgeon’s body is completely still above Aaron, his arms and hands the only part of him moving. The other surgeons around the table (I count four in total) are facing him, one of whom has a suction catheter, hoovering up blood around the surgeon’s hands in order that he gets a better view. Another surgeon simply points a large overhead light inside Aaron. There are lights everywhere and it is ridiculously hot, even wearing thin scrubs. But there is never enough light. I look at all the surgery team — most of them men with gray hair, and the occasional woman — and imagine where in his medical career the light-holder is: how you progress from holding the light to suctioning blood, to dancing hands. It must take a lifetime of watching. I am fascinated with surgery, particularly at this tertiary-care teaching hospital where nothing is routine or, if it is, is performed on a child with complex and significant medical needs.
But today it isn’t the surgeon that I am here to watch. Standing next to him a wide-shouldered woman, with thinning hair noticeable at the front of her cap, has her double-gloved hands in front of her body, her fingers starfished, palms down. Below her is a long table of metal instruments, shining diamonds on the stark white ceiling. Every so often the lead surgeon, or one of the assisting surgeons, will say something without lifting their eyes and then she picks up a metal instrument — a scalpel, a stitch, a pair of clamps or arterial forceps — and passes it to them, placing the handle in their hand in the way that you would pass scissors. Sometimes she passes things before the surgeon asks. A look burns between them. She is the scrub nurse. When an instrument is finished with, the scrub nurse turns her head and flicks her eyes to the nurse standing behind her, armed with a plastic tray, who then places that on a table behind the operating table. Nothing is removed from the room. Everything is counted, and counted again. “In case the surgeon accidentally leaves a swab inside a cavity, a scalpel in a lung, a piece of gauze in intestines,” the scrub nurse tells me the following day in her gravelly voice. “But we’ve lost worse. And if things are not going well, my instruments can get thrown and then lost.”
“By the surgeon. Occasionally even at the nurses.” She looks at me and narrows her eyes and smiles. “It’s a very stressful job.”
I have no idea if she is telling the truth, or even if she means the surgeon’s job or hers is stressful, but I am too terrified to ask.
She has something sparky in her eyes that you can only see when close to her. I missed it before. There is a tiny hole on the side of her nose from a nose-ring, and I learn later that she is obsessed with motorbikes. She looks nothing like I imagine a nurse to look. I already know enough to realize that scrub nursing is not for me. Theater nursing has now moved on to mean that nurses work across different areas, including the surgical admissions lounge, main theaters, recovery and day surgery, but at this time scrub nurses remain scrub nurses for a whole career, in the same way that night nurses could simply work nights forever. Now all nurses work days and nights on rotation. I know that I’m not particularly organized, or good at standing still for hours, and the heat of the operating theaters is almost too much to bear. But I watch the heavy hands of that scrub nurse for hours during the operation. The way they are perfectly still, then suddenly purposeful, almost aggressive; then still once more, moving completely differently from the beautiful, delicate hands of the surgeon.
I watch the nurse’s eyes. Imagine all she has seen. Her gaze rests occasionally on the surgery we’ve all come to witness, but then flies around the room, landing on the monitors behind the surgeon, where I see her eyes recording the vital signs; then on the perfusionist (the blood-machine expert) who is wearing a multicolored bandanna, sitting on a stool next to the cardiac-bypass machine, writing frantically on a clipboard. The bypass machine looks futuristic, twisting and turning tubes in a pattern, much like a complicated water-slide at a funfair. The nurse turns her head a fraction and glances at the assistant nurses by the door, at the organ-donation coordinator nurse, holding the box containing another person’s heart and lungs. It is a plain square white box, with the words “Human tissue” written on it. The scrub nurse’s eyes rest on the box for a long time. Then she looks up at the organ-donation coordinator. Something passes between the two. Something that, at the time, I do not quite understand. But I appreciate the importance of what is happening. The room is alive with miracles: of technology, surgical technique, science and luck, alongside the sadness and loss that are recognized by the nurses.
The organ-donation coordinator is the person standing center-court between life and death. Talking to families about donating the organs of a recently deceased loved one, in order that another can live. That Aaron can live. Over the years I listen to many organ-donation coordinators — all of them nurses from various backgrounds specializing in cardiac transplantation, living donors, or all roles related to different types of organ donation. They coordinate the time process between donor and recipient: a twenty-four-hour period during which the call can come at any time. Still, three people die in the UK every day while waiting for an organ. It should be compulsory, unless a person refuses. Opt out, not opt in — like it is in other countries. If a person would accept an organ if they were dying, then they should register as an organ donor themselves. Who would rather die than accept an organ? Nobody should die waiting for a kidney that is buried in the ground, disintegrating.
Aaron is at the center of the room. His body is by now a dugout canoe. The surgeon’s hands are inside him. What a strange privilege to place your hands inside a human being, to touch a heart with your fingertips, to become briefly one.
The heart can beat for seventy-two hours after a person is pronounced brain-dead. The organ-donation coordinator will discuss this with the donor’s family, and try and help them understand that their loved one has died, despite the heart continuing to beat. The nurse will support them if they choose not to donate, or if they want the heart to stop beating completely, after which time it is still possible to donate heart valves. Someone who donates organs might help numerous people: one kidney to a person on dialysis in Southampton, the other kidney to a child in renal failure in Bradford; the liver to a recovering alcoholic in Dunfries; bone, tendons, cartilage, skin, corneas, a pancreas, lungs, heart — all split and delivered to patients who are desperate, and some of whom will die on the waiting list unless they receive a transplant. What greater gift is there than that? There are people, too, who donate a kidney while they are alive, well and simply want to save another life. A level of kindness that I can’t imagine.
It is unusual to see the organ-donation coordinator at the recipient’s end. The medical courier usually delivers the organs after they are put in a bag with a nutrient-rich fluid — which looks like a half-melted Slush Puppie. When a family consents to organ donation (or in the case of many countries, the patient has consented before death), there is a period of time before anything happens: time for tests and goodbyes. The organ-donation coordinator nurse will do everything in her power to make this time less stressful for the family. Organ-donation coordinators in America, for example, sometimes make molds of patient’s hands, and even bring in the family’s pets. The organ-donation coordinator then stays with the donor, caring for the patient after death, being with their family, as they are hollowed out into a shell of bones — parts of them returning to live in another person’s shell.
I stand until I can no longer feel my toes, and the teams — including the scrub nurse — have changed three times. So many long hours. Despite being the most tired I’ve ever felt, I have never felt more awake. My eyes are wide open.
* * *
It is a matter of a few weeks since the operation and Aaron looks like a totally different child. His skin is brighter, the oxygen tubes have vanished and the wet, hacking cough is completely gone. His bedroom is a mess of books and games and cards.
“I love strawberry ice cream,” he says. “I never liked it before but now I could eat it all day. Breakfast, lunch and dinner. And snacks.” Aaron looks at me meaningfully. He is convinced that somehow he has taken on personality characteristics and emotions from his donor. It is the lungs that Aaron needed to treat his cystic fibrosis, though it is the attached heart that he thinks about most.
He is not alone in his belief that the heart houses more than muscle, cells and valves. Professor Bruce Hood, a cognitive neuroscientist at the University of Bristol, tested information about a potential donor and whether it made any difference to recipients. He found an overwhelmingly negative response to the idea of a murderer’s heart. When I first read about it, I wondered if I would accept a murderer’s heart? And afterward, if my feelings about having a murderer’s heart went on to change my personality, would the source of that change be relevant?
Medics are sceptical about most things, including the idea that the heart houses memory, and the evidence supports this: the heart is simply a bunch of nerves, muscles and chemicals. A study of forty-seven heart-transplant patients like Aaron found that although 15 percent of patients felt their personality had changed following transplantation, even that was attributable to having suffered and survived a life-threatening event, and most other information related to the heart housing — or being linked to — emotion is completely anecdotal.
But art, literature and philosophy have been searching for greater meaning about the heart for more than 4,000 years, since ancient Egyptians believed that the heart symbolized truth; after death, they would weigh the heart against a feather of truth, to be eaten by a demon if the scales did not balance, leaving the person’s soul restless for eternity. In this post-truth world, I wonder what will happen to our souls. We have nothing to weigh our hearts against.
Nurses do not explicitly search for meaning, but meaning is part and parcel of their day job. Nurses certainly use the language of the heart. They understand and describe patients as broken-hearted. Many nurses have seen it. And the best nursing comes from the heart, and not from the head.
Aaron gets me to help him write a letter to the mother of the boy who died and gave him his heart. The letter must not go directly, but the organ-donation coordinator is going to find out if the mother wants to read such a letter and, if so, will facilitate the anonymous handover at an appropriate time. Twenty years have passed since I helped Aaron write that letter, but I still remember the lines he wrote, which made me laugh: “Did your son like strawberry ice cream?” And cry: ‘It’s not fair that your son died so I can live. I absolutely promise I will never forget him.”
I think of the look that I noticed passing between the scrub nurse and the organ-donation coordinator. I think about how nursing is sometimes scrubbing in, passing the surgeon instruments and counting the swabs. Sometimes nursing is doing up the ties on the surgeon’s gown, while other days it is handing the surgeon the instrument she or he hasn’t yet asked for. And at other times it is recognizing sadness and loss, and helping a teenage boy write a difficult letter.
At the end of my shift Aaron’s mum tells me that he has always liked strawberry ice cream, but they have avoided dairy food as it increased his symptoms of mucus production.
His mum smiles a thousand smiles. “Aaron can have as much strawberry ice cream as he wants now.”
* * *
Christie Watson was a registered nurse for twenty years before writing full time. Her first novel, Tiny Sunbirds Far Away, won the Costa First Novel Award and her second novel, Where Women Are Kings, was also published to international critical acclaim. Her works have been translated to eighteen languages. She lives in London
Editor: Dana Snitzky