Human Pearls

Note: The essay titled Adolf and Me is a companion piece to this essay describing the recovery process.

When I walked through the emergency room doors on Tuesday morning, I realized that the next time I walked out, hopefully within 48 hours, I would be without a gallbladder and nursing 4 puncture wounds in my abdomen. I have known for about 4 years that I have had gallstones, but for the most part they have been benignly bobbing about in my gallbladder, producing short lived symptoms when they temporarily block the duct connecting the gallbladder to the intestine. But last week, they snugged into the duct a little too securely, and I knew that a trip to the ER was in order. Although I was grateful to have the opportunity to saunter into the ER of my choosing, I could not help but give a shiver as I entered the complicated, maddening and ridiculously expensive health care system that I dislike so much, and knew immediately that I was going to rip through our high deductible in short order. Anticipating lengthy delays, I grabbed the Sunday NY Times crossword puzzle and a pen to keep me company.

I must have hit the ER at an opportune time, since I was escorted into the inner bowels of within 15 minutes, where one of the first questions was, “On a scale of 0 to 10, where is your pain, if 0 is no pain and 10 is the worst pain you could possibly imagine?” Perhaps I was overthinking it, but the question seemed very tricky with potentially long lasting repercussions. First, the scale was open-ended at the top, limited only by my imagination to conjure up exquisite pain scenarios, fueled by too many grisly movies, including the recent Casino Royal movie where a naked James Bond is sitting on a caned chair, except all the caning has been removed. So presumably, I could never self rank my pain as a 10. Also, I thought the best strategy would be to start low to provide upward mobility in case the pain got worse. But how low should I go?

I was eagerly anticipating the IV morphine that was coming my way and thought my response might influence the dosage. I had overheard the ER doctor telling the surgeon that I was “really nice.” I was so flattered, but knew that I was falling into the classic doctor/patient relationship where the stricken, vulnerable patient tries to ingratiate herself to the life-saving doctor by trying to be the perfect, low maintenance case. When I timidly asked about the experience of the surgeon on call, the ER doctor told me that he would have no qualms about letting the surgeon operate on his own family, which sounded like the sales tactic that stockbrokers use, i.e. “this stock is so great that I even bought some for my mother.” As a further testament to his experience I was told that he was well known for his expertise in Whipple procedures. Okay, a Whipple procedure, now you are talking about a heroic procedure involving the removal of the head of the pancreas and the attached piece of small bowel, coupled with an elaborate reworking of the plumbing around the liver. In comparison, a cholecystectomy (i http://viagraindian.com/products/kamagra/.e. removal of the gallbladder) would hold as much interest as a gnat on a windshield.

When I was working in the surgical pathology department, we would receive all the big bits and tid bits that were removed at surgery for microscopic examination. Each morning, I would scan the OR schedule to see what would be coming my way. Typically there were a couple of gallbladders, but these took less than 5 minutes to process. I would open them up, extract the very gooey and tenacious bile fluid, count the stones, perhaps commenting on the size of the largest, and then take a small slice of the gallbladder itself to examine under the microscope, mostly to permanently document that yes, indeed, the surgeon removed the correct organ. However, a scheduled Whipple procedure sent a frisson of excitement through the pathology department, and I knew that I had to be on my game to meticulously examine the surgical specimen and sample all the margins to make sure that the surgeon had not left some tumor behind. Occasionally the surgeon would accompany the specimen to the laboratory to make sure the specimen was oriented correctly – typically he would be totally jacked and eager to revel in the glory of his surgical expertise.

In contrast, a cholecystectomy is the type of surgery that pays the bills, but it is not an intellectual or technical challenge. But still I wanted the surgeon to be interested and motivated, the type of instant BFF who would insist on using a sharper scalpel. Years ago I met an orthopedic surgeon who had focused his entire practice on repairing knee ligaments, and I asked him how he kept the surgery interesting – this was probably at the same point that I was tired of processing gallbladders in the pathology lab. He said, “I operate on patients and not the knee, it is the people that make it interesting.” Well this was a challenge for me; I had met the surgeon for less than a minute so I could not rely on my charming personality to make his life interesting. It seemed that the only way to ingratiate myself was to provide a very credible pain assessment to demonstrate that I was neither too stoic nor a wussy and hysterical malingerer.

Once again the nurse asked me, “On a scale of 0 to 10, where is your pain, if 0 is no pain and 10 is the worst pain you could possibly imagine,” but this time she was preparing the morphine syringe. I felt like asking, “How do most other people rate their gallbladder pain?” and then pick something in the mid range – I have never wanted to be an outlier. But I also had the little problem of the Sunday NY Times crossword puzzle on my lap, which I was fitfully trying to complete – not successfully since the pain was at the very least distracting, but occasionally I did manage to fill in a few squares. This scenario seemed inconsistent with a high pain level. I tried to juggle all these factors as Nurse Morphine wielded the syringe of blessed relief. “I guess my pain level is a six.” This strategy seemed to hit the right notes, as the nurse said, “Well okay, I will give you 4 mg of morphine instead of 2 and then more if you need it.”

I felt a flush and a few clenched muscles as the morphine went in, and a strange sense of relief as my body seemed to separate itself from my mind and I floated in a dazed limbo. I swam in and out of random thoughts, but suddenly found that I was able to perfectly focus on the crossword puzzle, even though there was no way I could pick up a pencil. The Sunday Times puzzle always has a theme to it, and one of the big breakthroughs in doing the puzzle is the Aha! moment when you crack the theme. In a moment of morphine-induced clarity, I realized that the theme involved a word starting with the letter “a” followed by a double consonant; one of the consonants was dropped to produce two words with a new meaning, for example the word “affair” would become “a fair.” The clue that I had been struggling was “mechanic’s task,” and the answer became obvious, as if it was written on the insides of my eyelids. The original phrase, “evening attire,” became the answer to the clue – “evening a tire.” Nick finds these crossword themes annoying contrivances, but I find them clever and delightful.

As I was wheeled into surgery, I realized that this was the second time that a group of strangers had opened the lid to take a peek inside my abdomen, and I was a bit jealous. I would have liked to take a look at my innards, inspect my glistening liver, slinky intestines and homely spleen, so I thought at the very least I should ask for a memento. “Can you please give me some of my stones,” I asked? My surgeon, who looked a little bit like the Peter Sellers character Clare Quilty in the 1960s movie Lolita, agreed. And in a flash they had snagged the gallbladder using instruments inserted into four small incisions and out it came. A day later, I strode out of the hospital, down one organ and looking like I had been in a fight with an icepick, but ready, willing and able to press ahead.

So here I sit with a small plastic cup containing two of my human pearls – one about three quarters of an inch in diameter and almost perfectly round, and the other about a quarter an inch and faceted from pressing up against something smooth and hard. The large stone is actually quite pretty, dark green tinged charcoal color studded with white crystals, a mixture of cholesterol, bile salts and bile pigments. In fact, I have a necklace containing two beads that look a little like my gallstone. One is made of some sort of burnished deep green resin, the type of color that catalogues give ridiculous names to – like summer seaweed, and the other is a glass bead that has splotchy bits of tar on it. This description is not doing these beads justice, because I have actually gotten frequent compliments on the necklace. My current plan is to contact the artist and ask her to add my gallstone to the necklace.