Tell Me Where It Hurts: A Day of Humor, Healing and Hope in My Life as an Animal Surgeon

First Chapter

2:47 A.M.
WAKE-UP CALL

This might seem strange, coming from an Englishman, but sometimes emergency surgery in the middle of the night can play out like a synopsis of a perfect season for the Boston Red Sox. The beginning may be predictably crappy, slow, and discombobulated until a rhythm develops and momentum builds leaving you stricken with that familiar glimmer of hope. When it comes to the final stretch, everyone accepts that there may be failure, there may be disappointment, but the struggle is always gritty and memorable, and occasionally, if you are really lucky, something magical will happen.

My beginning came half an hour earlier with a phone call reeling me in from a cozy dreamless void. “Hello,” I said, two disjointed syllables caught in a sticky web at the back of my throat. “This is Dr. Keene, one of the new surgical residents. We haven’t met but I’ve got a dog, a ten-year-old spayed female German shepherd; she’s bloated and... like...well...I need you to come in for the surgery. Sorry.” All I heard was sound, not words I could interpret, my brain dormant on my pillow. “Hello, are you still there?” “Yeah, sure, I’m listening,” I croaked, wiping a palm across my face. “What time is it?” She told me and dove into her apology.“I really hate to disturb you but, like, my backup’s not answering his pager and, like, I didn’t know what else to do.” Her words surfed through me—a Valley Girl inflection—and sluggish gray matter dug out a memory of a recent departmental memo—“Be sure to welcome our first-year surgery resident, Dr. Sarah Keene, from the University of California, Davis.” I came awake, sat up in bed, and told my wife to go back to sleep. “No problem, Dr. Keene. Tell me about your GDV.” As a new surgery resident, Dr. Keene may know all about GDV, an acronym that stands for gastric dilatation and volvulus, commonly referred to, with a satisfying rustic flavor, as “bloat.” But more than likely, at this stage in her training, her understanding is primarily academic, words and phrases in a textbook, disease as bullets of information in shocking fluorescent pink highlights. She will be a year out from veterinary school, a year in which she will probably have diagnosed and managed several cases of GDV. She knows all about this bizarre anatomical aberration and the inevitable, rampant pathology it will incite. She even knows exactly what needs to be done. But, until now, until tonight, she has never been the one who actually picks up a scalpel and makes the cure happen. Tonight, for the first time in her professional career, she is the surgeon on call, and not surprisingly, she is in need of some help. GDV is a true veterinary surgical emergency. It typically occurs in deep-chested dogs like German shepherds, Great Danes, and standard poodles but, on occasion, I’ve even seen it in breeds as small as dachshunds. No one is entirely sure why it happens, but oftentimes the animal eats a large meal, gets some exercise, and an hour or so later the problems begin. Fermented gas starts to accumulate in the distended stomach, and for whatever reason the entire organ twists around and flips over on its long axis. The effect is catastrophic. The twist blocks off the esophagus, so despite the poor creature’s desire to throw up and rid itself of all that food and gas, nothing will budge. The stomach expands unchecked, destroying its own blood supply, driving into the chest and squashing the lungs and the blood flow back to the heart. There is no absolute timetable for how long an animal can survive in this state, but dogs can die in a matter of hours. As soon as the diagnosis is made, the clock is ticking. “She got into a full bag of kibble around seven. Owner took her for a walk before bed. He could hear the dog trying to vomit unsuccessfully around midnight and drove her all the way up from the Cape. She looks ready to explode. Classic double-bubble on abdominal X-rays.” I had been waiting for this description, the twisted, distended stomach looking like the silhouette of a giant heavyweight’s boxing glove on an X-ray. It tells me her diagnosis is correct. “Is she stable?” I asked. “Not really,” said Dr. Keene. “Her pressures are through the floor and we’re having a hell of a time just finding a decent vein, let alone placing a catheter.” My feet were swinging out of the bed and I began to fumble for clean clothes. “Do your best. Try to pass a stomach tube. I’ll be there as fast as I can.” Angell Animal Medical Center, part of the Massachusetts Society for the Prevention of Cruelty to Animals, is located in the eclectic and increasingly gentrified Boston neighborhood of Jamaica Plain. There are no world rankings of veterinary hospital size, but at 185,000 square feet I imagine Angell is one of the larger ones, with over seventy veterinarians serving nearly fifty thousand dogs, cats, and exotic pets every year. After ten years on staff as a surgeon, I know that those nasty rumors about Boston traffic are all subterfuge because at three in the morning, an easy commute is rewarded with my pick from one of the primo parking spots close to the front door. It is January in New England. There are a couple of inches of snow on the ground, a miniature version of the Andes has been plowed against the perimeter wall, and today’s high will be only ten below. I walk across the salted asphalt like a geriatric with a bad case of hemorrhoids, poised to slip on the black ice. Despite the hour, my sleepiness is starting to burn off like fog on an imaginary sunny morning as I enter this five-story brick building and head toward the nonsterile surgical prep area. The corridors are empty, floors polished, phones silent, and pagers dead. I have entered an antiseptic ghost town and I like the way it feels. It reminds me of being a kid again, of breaking into the neighbor’s backyard in order to steal the ripe apples taunting me from their tree. The mission is covert, even risky—all but guaranteeing the rewards will make it worthwhile. Cutting through the radiology department, I catch a glimpse of my reflection in the glass window outside the MRI unit. The man I see looks unfamiliar. He has piggy eyes, a pillow-crease scar across his left cheek, and a jaunty case of bed head. Thank goodness my patients never judge me on my appearance. My patient lies splayed across a large gurney, nervous nails clawing for purchase on the stainless steel surface. She is a big girl, obviously not lacking for love in the calorie department. Her darting chocolate eyes scream in fear of her strange situation and the changes taking place in her body, but as I enter the room and approach, her broad and bushy tail offers me a couple of friendly beats. I like German shepherds. I grew up with one as a kid, but this gesture strikes me as both uncharacteristic and, at the same time, utterly endearing. Until this moment I have been dealing with an anonymous and remote animal reduced to a list of diseases, conditions, problems, and deformities. Suddenly everything has changed. This animal has a name and a personality. This animal has become my patient. This is the moment when I begin to care. I pat her head and run my hand across a soft velvety ear, over her chest and down to the enormous, unyielding abnormality that is her drum-tight abdomen. “Hi, sweetheart. You hanging in there?” For me, all my patients are “sweethearts” until proven otherwise, whether they are male or female, cute and cuddly Himalayan kittens or a slobbering and stoic 250 pounds of bullmastiff. Holding a needle and syringe, Dr. Keene, a short, shiny-faced woman with blond hair in a ponytail, turns to me. She can be no more than twenty-five. I wonder if at forty-three I’m getting a little long in the tooth for this game. She glares through sparkly green contacts as though she thought I had been addressing her. I introduce myself, offer my hand, and assure her that I was speaking to our patient. “This is Sage,” she says, trying to apply an oxygen mask to the dog’s snout. “I’m Sarah, and this is Dan.” She gestures to a technician I have never met before, although this is not surprising given the hour. For most of us working in a busy animal hospital, being on call for surgical emergencies every other night, every other weekend, is simply not sustainable for more than a couple of years. Nocturnal surgical emergencies are a rite of passage, an inherent requisite in any decent residency program, a privilege to be endured and enjoyed. But now, nearly fifteen years after the completion of my training, my midnight forays into the OR are limited to the one week in every month that I am available as backup to the residents. Dan juts a square chin in my direction and gives me a casual “ ’sup.” He has a pierced right eyebrow and lower lip with colorful sleeves of tattoos running down his arms in perfect contrast to the sallow vampire skin of his face. In different surroundings he might attract attention, but here, working the overnight, he can relax, setting up the EKG leads, sorting out the pulse oximeter, and adjusting the intravenous fluids with an experienced hand. There is a small shaved square on Sage’s flank where an attempt has been made to release the trapped and expanding gas in the dog’s stomach by directly puncturing the organ with a large bore needle. I touch the small red bull’s-eye in the center of the bald spot. The skin is impossibly taut. Clearly the attempt failed. “No luck with a tube?” I ask, although I know the question is redundant. If they had successfully passed a stomach tube, the preferred method of decompression, there would have been no need to try to use a needle. Dr. Keene shakes her head. “I’m afraid not,” she says. “She’s in bad shape. Heart rate’s two twenty with occasional VPCs. Her color looks like shit.” I’m not surprised. The shock to Sage’s circulation has convinced her heart that she is running an endless sprint. This effect combined with the absorption of toxic by-products via the damaged stomach can produce runs of abnormal and ineffective heartbeats called VPCs or ventricular premature contractions. Heard over a heart monitor, VPCs make the beat of a frenetic African tribal dance sound like the chord changes of a funeral march. They can be disastrous in their own right. Sage’s tail beats a message of thanks as I relieve her of the oxygen mask and lift an upper lip to inspect her gums. Healthy, vibrant pink tissue signifying normal peripheral blood flow has been replaced by an ugly, muddy purple. “How much intravenous fluid has she had?” “This is her fourth liter,” says Dr. Keene. “It took forever to find a vein. Isn’t that right, Dan?” Dan nods. Sage’s color looks awful. I imagine someone shoving an overinflated beach ball under my rib cage. I know I wouldn’t be faring as well. “You’re absolutely right,” I say. “She looks like crap. You’re certain Sage got into the kibble around seven?” “According to the owner she did. Why?” “Because she’s acting like she’s near the end, like her stomach has been distended for so long it’s going to die. It’s all very well trying to get her stable for surgery, but if her stomach dies, she dies. I don’t think we have any more time to dick around. Start a lidocaine drip, give her some intravenous antibiotics, and knock her down. The faster we get this thing untwisted the better. I’m going to get changed into scrubs.” “Before I forget,” says Dr. Keene, “the owner is waiting up front. He insisted on meeting with you before you get started.” Inwardly I groan. Don’t get me wrong, good client communication lies at the heart of great veterinary care. There is enormous satisfaction in getting pet owners involved, explaining exactly what it is we are doing, why we are doing it, and making sure they are part of the decision-making process. But right now, with Sage fading fast, every minute lost is a minute closer to a patient who never wakes up from anesthesia. I just want to get going, to give this dog a measure of relief. Perhaps Sage’s owner doesn’t understand the gravity of the situation. I imagine myself walking into a time trap, forced to engage in idle banter with a belligerent owner about whether I really know what I am doing, how many of these things I have done before, committing to verbal assurances that I will be the one performing the operation and not my resident. “Okay,” I say, “if I’m not back in five minutes get scrubbed in, drape her off, and start setting up. If I’m not back in ten, page me to the OR, stat.” I hand comb my hair on the way to the vast waiting room, preparing myself for combat with some sort of aggressive middle-aged lawyer type, who, despite the hour, has turned up perfectly coiffed in an immaculate pinstriped suit. But the only person I see is an old man of at least seventy, sitting in a corner, head slightly bowed with one liver-spotted hand tightly clasped in the other. He is bundled up like a snowman, frail skin swaddled in a cap, scarf, and overcoat. “Mr. Hartman?” My mind and body rapidly decelerate as I approach. The old man looks up, offering an apologetic expression that changes into a wince as he gets to his feet with difficulty. My nose detects the faint, menthol aroma of Bengay. “Hi, Mr. Hartman, please don’t get up on my account. I understand Dr. Keene has explained that your dog is seriously ill and in need of emergency surgery, so I thought I should introduce myself. I’m Sage’s surgeon. I will be the one operating on her this morning.” Tired, frightened eyes search mine as he extends a cold hand. “I’m so very sorry getting you out of bed,” he says. “It was my daughter, you see. She’s a doctor.” I assume he means a doctor of humans. I am pleased to hear him refrain from saying a “real” doctor. MDs appreciate better than most that a hierarchy exists in a referral hospital—student, intern, resident, attending. She probably provoked this insight. “She said to make sure to get a surgeon who is on staff, someone with more experience. Not a resident, she said. To be honest, it doesn’t bother me. I just don’t want to lose her, that’s all. Sage is all I’ve got.” There is a tremor in his voice that he cannot fight down. He is holding it together but only just, proud, helpless, and completely vulnerable, tethered by that wonderful and inconceivably powerful bond to the animal in his life. The passion for his canine companion pours from him, washing away any residual traces of my sleep deprivation, replacing them in an instant with the awesome responsibility I have to this man and his best friend. “You think I’m doing the right thing, don’t you? I mean bringing her here, having the operation?” “Of course,” I say. “No question about it. There’s a good chance that we can correct the problem. Things might get a little rough in the postoperative period, but nothing we haven’t seen before, nothing we can’t handle. Believe me I wouldn’t be standing here ready to perform surgery if I didn’t have your animal’s best interests at heart.” For a moment he studies his hands, wringing them, working the thick and knotty joints and knuckles before adding, “Tell me I’m not being selfish? You see, my daughter, she means well, but she keeps reminding me that Sage is ten, after all.” I shake my head. “Not at all, Mr. Hartman. You’re doing exactly the right thing. You’re taking the best possible care of the animal you love.” I can see that he is still not convinced. “And if she were your dog? Would you put her through surgery, given her age?” How many times have I been asked this question? It is the yardstick against which so many owners measure and weigh the difficult decisions they must make. This is the point at which the veterinarian has the unique opportunity, through a combination of experience, knowledge, and personal opinion, to totally influence a decision. It is a burden we must accept and use wisely. Fortunately, in this case, I can answer honestly and without bias. “Absolutely. Sage seems like a great dog. Any animal prepared to beat me up with her tail, feeling as sick as she does, is definitely worth saving.” He tries his best to stifle a smile. It works but he cannot catch the tear. “She’s all I’ve got since my wife died. Sage helped me through the darkest hours of my life.” I swallow hard, trying not to get sucked in, unable to resist the allure of this gentle old man. He is a character out of a James Herriot novel, a cliché widower clinging to the last tangible link to the love he has lost. But the truth is these people are everywhere. Sixty-three percent of all homes in the United States have a pet. That’s more than 69 million people. It may be a cat, a bird, a ferret, or a guinea pig, but the chances are high that when someone close to you dies, a pet will be there to pick up the slack. Pets devour the loneliness. They give us purpose, responsibility, a reason for getting up in the morning, and a reason to look to the future. They ground us, help us escape the grief, make us laugh, and take full advantage of our weakness by exploiting our furniture, our beds, and our refrigerator. We wouldn’t have it any other way. Pets are our seat belts on the emotional roller coaster of life—they can be trusted, they keep us safe, and they sure do smooth out the ride. “I can’t tell you how much that dog means to me,” says Mr. Hartman, and I see the deep pools of suffering in his eyes. I try to defend myself from his grief. I need to focus on my job. “Believe me, Mr. Hartman,” I say, pursing my lips into a smile, “it shows. I know the problem. My father had a shepherd when I was growing up. They’re one-man dogs. They bond tight, like superglue, and never let go.” His smile begins to win his emotional battle. He raises a hand and gives my shoulder a gentle squeeze. “Just do your best. I know you will.” “Doing my best is the easy part,” I say. “Sage needs to do hers.” “She will,” says Mr. Hartman, watching me go. “She’s a strong girl. She won’t let us down.” The golden iodine-stained skin yields easily to the scalpel, weeping the familiar tiny tears of blood to reveal a pure, white, fatty shellac below. I don’t have to deliberate. I don’t have to ask. I don’t have to think. My hands are on autopilot as they gently work their way into Sage’s abdomen. I am not a natural-born surgeon. I was not blessed with what some like to call good hands. Thankfully surgery is a skill that can be learned. It is a bit like playing the piano. If we possess the desire and the diligence to practice long enough and hard enough, eventually we can make progress, eight of our ten thumbs might even disappear, and most of the time we end up hitting the right notes and playing a decent tune. Shortly after graduation, when we make our first sortie into the operating room, we quickly appreciate that our Rachmaninoff solo at Carnegie Hall might have to wait until we have mastered “Chopsticks” on the out of tune upright at Grandma’s house. Neophyte surgeons have to shout and scream at their hands, ordering them to the appropriate places, struggling to find the right touch and pressure, fumbling to select and handle the correct instrument. Only with time and practice can we begin to whisper and, occasionally, not to speak at all. The hands learn to dance, to move without effort, without hesitation, without waste. Work becomes seamless, slick, economical, and productive. I am wearing blue scrubs, a sterile gown, and powdered size seven-and-a-half latex surgical gloves. Blue paper bootees cover my sneakers, my hair is trapped inside a disposable bouffant cap, and most of my face is hidden behind a paper mask affording me the pleasure of sniffing my own hideous morning breath for the foreseeable future. Dr. Keene peers on tiptoe through the green window of the sterile drape covering our anesthetized patient only to recoil as the bloated stomach bursts through the raw edges of my calculated slash. Paper masks can hide only so much. With my gesture toward the distended organ, a polite “please, be my guest,” she televises the emotions playing behind her eyes—a flash of excitement followed by the lingering betrayal of apprehension—so together we squeeze our gloved hands into the impossibly tight space between Sage’s stomach and the abdominal wall, watching them disappear into pink tissue and the vat of red paint that is free and pooled blood. “Get a good love handle of stomach in your right hand, and pull up on it as you push down with your left, here,” I say, ensuring her grasp is appropriate and correctly positioned. Dr. Keene begins to grunt, to strain, and I know that with every breath Sage takes, the abdominal wall is cinching down tight on her forearms, replacing her hands with cramped and useless stumps. A full minute passes and nothing has happened. “Fuck it!” she curses, retrieving her lifeless fingers. “There’s no way I can do it. You’re going to have to take over.” I study her over the rim of my mask. Given their interminable workload, even the most angelic of surgery residents might occasionally cuss like a character on The Sopranos, but in this circumstance, I know the outburst is borne of insecurity and a fear of failing her patient. I have no doubt that she can do this. I need to reassure her that I am here as a safety net and a few first-time jitters do not constitute a fall. “Don’t beat yourself up,” I say. “Your natural instinct is to be too gentle, too cautious. You’re worried the stomach is going to rip.” I focus on finding the right tone with no trace of condescension. “Think of it this way, if you don’t correct the torsion, Sage will be dead. If the stomach rips, because it’s damaged, it was going to rip anyway. At least she dies trying. You’ve got nothing to lose.” Dr. Keene takes a deep breath and lets it out, causing her mask to flutter. Slowly she begins to nod. Shaking the blood down to her fingers, she resumes her position, hands grappling with the enormous stomach, and once again I ensure that everything is correct. Within seconds her frustration has liberated all the greater force and vigor she requires, and with a sloppy and wonderfully satisfying whoosh of finality, this great big muscular balloon flops back into its anatomically correct position. The green contacts beam with the satisfaction of her achievement, a triumph trumpeted by Sage herself as the dog is relieved of the kind of belch that would satiate the toilet humor of any eleven- year-old boy. “Fantastic,” I say. “Dan, if you’d be so kind as to pass the stomach tube.” I reach into the abdominal cavity and already there is more room to spare. Down by the diaphragm I can feel the esophagus as the wide-bore rubber tube slips by my fingers. Suddenly a column of liquid food and gas pours from the tube and into a collection bucket, instantly searing our nostrils with the pungent aroma of fermented dog kibble. “Thanks,” says Dr. Keene. “I mean, like, for making me keep going.” “Not a problem,” I reply. “It’s like I always say. Surgery is meant to be difficult, but the more you struggle, the more you learn.” Her professionally plucked eyebrows knit over her mask in an expression that says, “Okay, Grandpa, no need to get all philosophical on me.” She recovers and says, “So, now what?” My hands begin fishing through the blood and small intestines. “Time to check out Mr. Spleen.” I locate the large meaty boomerang of an organ located adjacent to the stomach. It is entirely purple black in color. “What do you think?” I ask. Dr. Keene does exactly as I had hoped, feeling for the arterial supply to the spleen and palpating for a pulse between her fingers. She takes her time moving from one vessel to the next before concluding, “Nothing. I feel no pulses. The spleen is dead.” I repeat her examination for myself and agree with her conclusion. Unfortunately the spleen is tightly tethered to the stomach, so wherever the stomach goes, the spleen must try to follow. In the case of a GDV, the result can be damage and obstruction to the spleen’s blood flow, followed by the organ’s death. Fortunately, Sage can afford to lose her spleen. “Dan, I’ll take an LDS.” Dr. Keene smiles behind her mask at the mention of another three-letter acronym. It is contagious and for a second, as we wait for the instrument, I bask in the memory of those early days as a surgical resident where everything was new and every sterile instrument was like opening a present at Christmas. LDS stands for Ligation and Divide Stapler, a surgical device that looks and handles a little bit like a gun. It has a barrel, cartridge, a grip, and a trigger, which fires metal clips that seal off a blood vessel just before a razor-sharp blade slices the vessel in two. It also comes powered by a carbon dioxide gas canister so that each “shot” makes a satisfying noise like a sound suppressor on a handgun. I don’t care whether it is soft-tissue surgery or orthopedics, surgeons love toys. In minutes, with the instrument in semiautomatic fire in her hands, I feed Dr. Keene the appropriate vessels and the dead spleen is out of Sage’s body. “Okay,” I say. “Now let’s go back to the stomach and see how it looks.” Her hand sweeps back a stray loop of bowel, I grab at the main body of the stomach, pulling it free of the blood and into the bright light of the surgical lamps. Dr. Keene senses my hesitation. “What is it?” For a moment I say nothing, taking my time, changing the position of my hands, feeling the tissue as it slips between my fingers, noting its color and its texture. I can almost feel Mr. Hartman’s hand on my shoulder. “I don’t like what I see. This area,” I point to the junction of the stomach and the esophagus, “its color, that purple congestion with maybe a hint of gray. It might not be viable.” Dr. Keene is staring at me. “So why not simply staple it off?” She makes her question feel like a casual invitation, one I can take or leave. I wish it were that simple. Dogs and cats don’t read textbooks in which line drawings, flow charts, and photographs reduce disease to black and white. Surgery is replete with everything in between, forcing surgeons to make quick, vital decisions based on experience, instinct, and faith. Mistakes are inevitable and their results are indelible. In my opinion dexterity and touch can take a surgeon only so far. Learning to make the right decisions is the art in this science. I like to believe that my decision is objective, emotionally detached from patient and client alike. But in my peripheral vision, I can see a dog who still manages to say hello with a stomach about to burst and an old man reduced to tears at the thought of losing his closest friend. If this job came with tunnel vision our clinical judgment would be so much clearer. “Here are Sage’s three options as I see them,” I say. “One, we take our chances, staple off as much stomach as we dare, and pray that nothing breaks down.” Dr. Keene nods her approval. “Two, we seal off the end of the esophagus, seal off the end of the stomach, put a feeding tube into her small intestine, put a tube into Sage’s throat and down her esophagus to suck off her own saliva because it has nowhere else to go, let the stomach decide whether it lives or dies, and come back in a few days to see if we can put her back together again.” “Wow,” she says, her eyebrows performing a fine impersonation of the “golden arches.” “Have you ever tried to do that?” “No,” I said. “And I hope I never will. But in theory it is possible. I just don’t know if I could put an animal through all that surgery when the risk of failure is so high.” She appears relieved. “So what’s option three?” I sigh. “We call it a day. I scrub out and speak to Mr. Hartman right now. Explain our predicament. It might be better to let Sage die in her sleep than to have to wake her up and succumb to a slow and painful death when her stomach perforates because I made the wrong decision.” Suddenly I notice the beat of the heart monitor filling the silence and it sounds deafening. “What do you think Mr. Hartman will want to do?” I meet her stare. I know the answer. “The right thing. Whatever that may be.” For a full minute neither of us speaks. My relationship with animal and owner is entirely superficial and only minutes old, yet I hold two lives in the balance—one physically and one emotionally. Who am I to make the call? “Dan, get me a GIA, and I’m going to need at least three or four cartridges.” I read agreement and relief in Dr. Keene’s eyes. The Gastrointestinal Anastamosis Stapler chomps its way across the area of devitalized stomach, sealing and separating the good from the bad as it goes. I let Dr. Keene do most of the work. She may fire the device, but I am the one defining the line of demarcation. I am the one selecting healthy tissue from dead tissue. The responsibility for this part of the procedure is mine alone. “Let’s oversew the staple line,” I say, “and then you can get on with the pexy.” “Sure,” says Dr. Keene, asking Dan for some suture material. “But I’ve only done one before now.” Crow’s feet gently land at the corners of my eyes. “Well, you know what they say. ‘See one, do one, teach one.’ ” The resident loads her needle driver and picks up a Debakey forcep from her table. She tuts, making a nice job of rolling her wrists as she passes the suture through the stomach wall. “What idiot made that one up?” The term pexy means the surgical fixation of an organ. In this case a gastropexy is essential to prevent Sage’s stomach from performing somersaults in the future. Rather than relying on the strength of synthetic suture material alone to hold the organ in place, a chunky flap of the outer stomach wall is created and fixed to the muscular lining of the abdominal wall for added security. I make Dr. Keene feel for the slip, the physical separation between the inner and outer layers of the stomach, because this is the natural plane she must define, physically separate, and exploit. I watch as she traces the margins of the flap with the point of her scissors. I approve her design and let her get to work. In my mind I am still deliberating over the merits of my gamble when I hear a curse and look down to see dark brown fluid spewing from a rent in the stomach lining where Dr. Keene has been cutting with her scissors. “I’m so sorry,” she says, fumbling with sponges, trying to mop up the contamination flooding our sterile surgical field. “I thought I was dissecting in the right place. My scissors went straight into the lumen.” It would have been so easy to snatch the instruments from her hands and take over, an arrogant misogynistic surgeon justified in shooing his resident aside. After all, the last thing my patient needed right now was a case of peritonitis because of her heavy-handed technique. But what would Dr. Keene gain from the experience? How would she learn from her mistake? “It’s okay, Sarah. It’s done. Let’s fix the problem, flush half a dozen liters of sterile saline through her abdomen, change gloves, change instruments, and get out. Do you think the mucosa is viable?” I peer down at the tiny rip she has made. It is relatively small and the tissue appears to be healthy. “Yes,” she says, but without conviction. “Look. Do you want to finish this? You’ll be much faster than me.” I shake my head. “No way,” I say. “You need to get used to operating at this time of the morning. And besides, I’m useless before my first cup of coffee. I’d only screw up.” Her eyes roll up and say, “Yeah, right,” but her hands are already placing some stay sutures to reduce the risk of further spillage. Fifteen more minutes and with the click of the last staple bringing the edges of the skin incision into perfect apposition I return to the waiting room to speak to Mr. Hartman. He is still sitting where I first saw him, staring at the floor, working his hands, chewing on his lower lip as he gently rocks back and forth. Obviously he’s been keeping vigil for the past hour. I make it to the bench beside him before he has time to try to get to his feet. “Everything went well,” I say, but already I can see he is searching my eyes for the caveat. I tell him exactly what we found, about how we deflated the stomach and fixed it in place to prevent it from twisting in the future. I tell him about the spleen and how Sage will be absolutely fine without it. He hangs on every word, every intonation, reading more in the expressions on my face than the words falling from my mouth. I feel like he can hear, but he is not listening because he knows I am keeping something back. “My biggest concern is the stomach wall and whether it will live or die. There’s no way to know for sure. I had to make a judgment call, a difficult one, but one that I believe is correct. The next twenty-four hours will be critical.” He lets out a deep breath, hanging his head. He has allowed himself to hope, flooded by the relief that Sage is alive and still in the fight and in doing so a levy inside him has burst. Emotional and physical exhaustion are taking their toll. He looks like he may collapse. “You need to get home and get some rest. Do you have to drive all the way back to the Cape?” I noticed on Sage’s record an address in Orleans, Cape Cod, at least an hour and a half drive given the wintry conditions. “My daughter offered to put me up. She lives in Wellesley.” “Great,” I say. “Let’s give her a wake-up call and let her know you’ll be on your way. It might be better if you take a cab. Sage and I need you in good shape for visiting hours later today.” He smiles, more with his eyes than his lips, nodding his understanding that he must be patient. I make sure we have his daughter’s phone number in Sage’s computer record, promising to call if anything changes as we part company. As I watch him go, my mind silences a tumult of ugly, undisclosed statistics. Mortality rates for GDV can be as high as 60 percent and factors associated with a higher chance of death include abnormal heart rhythms, extremely high pulse rates, the need to cut out part of the stomach, and the removal of the spleen. In short, Sage had checked off almost every negative prognostic factor for survival and yet I still decided to give her the benefit of my doubt. Should I have been more blunt, more cynical in my synopsis of the surgery, stacking the odds against success? Should I have used the word die more often, more emphatically? And even if I had, who would have been the beneficiary? Not Mr. Hartman and certainly not poor old Sage. Sometimes, early on in our careers, veterinarians tend to err on the side of caution when looking into their clinical crystal ball, seeking the safe refuge of a negative prognosis. If the animal died, the outcome was sadly inevitable. If the animal lives, the doctor has worked a miracle. I have made a huge decision—either a moment of flitting genius or enduring miscalculation—and like it or not, a stranger and his best friend are coming along for the ride. It is too late now. I may wonder if I have taken my final look at a stomach that should never have seen the light of day, but the verdict is already in. I just hope I read the decision correctly—sentenced to life, and not death by lethal injection.