Cutting for Stone - Abraham Verghese [157]
I served the patient his Johnny Walker, which he downed in one gulp.
I loved assisting Ghosh. Ever since he treated me as if I were old enough to learn and understand, I took my role very seriously. I was thrilled to have Cooper there watching.
Ghosh, on the patient's right, rooted with his thumb and index finger at the top right of the scrotum, just where it joined the body. “You feel all the wiry things—lymph vessels, arteries, nerves, and whatnot? Well, the vas deferens is in that lot, and with practice you can tell it apart from all the other wires. It has the largest wall-to-lumen ratio of any tubular structure in the body, believe it or not. Here it is. A whiplike structure. Put your finger behind mine.”
Cooper rooted around, and said, “Got it. The vas. Yup.”
“Now, push the vas forward from the back with the tip of your index finger, fix it like this against the pulp of your finger so that it doesn't slip away.”
Ghosh's instructions to Cooper were similar to what he said to me when I assisted him. He loved to teach, and in Cooper, he had the kind of student he deserved. If he dazzled Cooper with his polished delivery, it was because he'd practiced it on me. Practicing medicine and teaching medicine were completely connected for Ghosh. When there was no one to instruct, he suffered. But that was rare. He would happily teach a probationer, or even a family member—whoever happened to be around.
“I use Adrenalin with my local anesthetic to keep the bleeding minimal. And don't be stingy.” He emptied a five-cc syringe of local into the tissue that his index finger pushed forward. “Any less than that and he'll have pain and the balls will go to the armpit. You'll have to call a chest surgeon to bring them down. Now … see how my index finger still has the vas stretched over it? I make a tiny cut in the scrotal skin. I keep pushing on the vas, pushing it forward … and … there! When I can see it in the wound, I use an Allis to grab the vas.”
He pulled out a short length of pale, white, wormlike tissue. “I put a mosquito clip here and here … and then I cut between the clips. I remove a two-centimeter segment. Ideally you'd send it to pathology. That way if his wife gets pregnant a year from now, you can show the patient the pathology report and he'll know it's not because you didn't do your job but because a third party did his job better. I don't send it to pathology for the simple reason that we don't have a pathologist. But for a while, there was a pathologist at the American Embassy clinic in Beirut. I'd do the vasectomies for the American staff and send him these little pieces I cut out. The man did the pathology for all the American embassies in East and West Africa. He kept sending back reports that my specimens were inadequate: though he thought he saw some uroepi -thelial tissue, he couldn't be certain it was the vas. ‘It's the vas,’ I wrote to him each time. ‘What other uroepithelial tissue could I have cut out? Call it the vas.’ But he kept complaining: ‘Cannot be certain. Not enough tissue.’ It was starting to annoy me, you know? So finally, I sent him a pair of sheep's balls. I put them in formalin and sent them off in the same diplomatic pouch. With a note: ‘Is this enough tissue?’ Never had a problem with him after that.”
Cooper hee-hawed, his mask sucking in and out.
“Now, I tie off the cut ends with catgut. And then I tell the patient, ‘No communication with wife allowed for the next ninety days.’ “
Ghosh turned to face the patient, and repeated the sentence. The patient nodded. “Okay, you can communicate, say ‘Good morning, darling,’ and all that, but no sex for three months.” The patient grinned. “Okay, you can have sex, but you must wear a condom.”
“I use interruptus,” the patient said, speaking for the first time in a heavy East European accent.
“You use what? Interruptus? Pull and pray? Good God, man! No wonder you have five kids! It's noble of you to try to get off the train at an earlier station, but it's unreliable.