David Johansen was never my patient, but I remember him well. His story was legend to every doctor and nurse and medical student who worked at Stanford Hospital during his two-year admission, which began with a three-month stay in the ICU, followed by nine months in the TCU and almost a year on rehab. He was in bad shape. His motorbike had run headlong into a parked car on El Camino Real, catapulting him into the middle of a busy intersection. Speed – of both the chemical and kinetic variety – was involved. Roy Cohen, Stanford’s chairman of surgery at the time, described David’s internal injuries as “too numerous to count.” No one knows how many vehicles ran over him before traffic finally ground to a halt, but the first California patrolman to arrive at the scene reported that the truck trailer whose wheel rested on David’s right knee was loaded with six junked cars.
By the time they got the poor fellow to the ER, his right leg was coal black, swollen to the size of a log. Six weeks later he awoke from a coma to discover that his leg and speech and control of bowel and bladder were gone forever. A rehab nurse taught him to type with two fingers. The day before his discharge to a nursing home for what would in all likelihood be a life-long habitation, he typed “A Farewell Note to My Stanford Family,” a rambling, poetic commentary on his life among us. Most memorable was the following paragraph: “In that wreck I lost four things: my leg, my voice, my bike, and my girl. The one I miss the most is my bike.”
David proved the exception. In the house of surgery, amputation inhabits what most of us would consider the darkest room. Doctors are meant to heal, take away sickness, but the joy of healing is lost when this taking away carries with it an arm or a leg. Surrendering a nonessential organ – a ruptured spleen, an infected appendix, a stone-laden gallbladder – brings little grief. Even the loss of a cancerous kidney or lung strikes a happy bargain with death. But the patient who loses a limb, however necessary the surgery, will never be the same, inside or out. Even when chronic infection has reduced an extremity to a festering, cumbersome mess, amputation brings with it a devastating sense of loss, so much so that many Vietnam veterans suffered years of agony rather than surrender a mutilated arm or leg to the surgeon’s knife. During my orthopedic elective in medical school, the chairman advised his residents to start their patients on antidepressants two weeks before an amputation, hoping to blunt the despair that often followed – a despair on occasion so severe it led to suicide.
* * *
I never suffered an amputation, but I did have a near miss, as attested by an ugly, bone-deep scar on my right heel, the stigma of a broken hip when I was five years old. The general practitioner who wrapped a plaster cast from my armpits to the soles of my feet did his best, but his best was too tight. It shut off the blood supply to my heel, suffocating the tissues until they rotted away. The medical term is pressure necrosis. If the wrong bacteria had infected my dead flesh, the resulting gangrene could have cost me a foot, perhaps a leg. Thus, all things considered, I have nothing to complain about. Or do I? This has always bothered me: my father was six-foot-two, yet I never made it to five-eleven, thanks to an early growth spurt that petered out when I was only twelve. And another thing: my legs are too short. Were they proportional to my trunk, I would be the same height as my father. Did that broken bone stunt my growth, robbing me of my father’s imposing statue and blighting my life – especially the courtships of my youth – with a pedestrian five-foot-ten frame? I’m embarrassed to admit that this notion still disturbs me, even as I enter my seventh decade.
* * *
In the darkest corner of amputation’s dark room there lives an obscure operation, a procedure rarely performed but nonetheless horrific, an unspeakable mutilation of the human body. The name – hemicorporectomy – tells its own story: in Latin, hemi means “half,” corpor means “body,” ectomy means “excision.” The surgeon, hoping to cure a pernicious cancer or infection, severs the spine just above the pelvis and removes the pelvic bones with all their contents and appendages – the colon, rectum, bladder, hips, legs, external and internal genitalia – then wraps the remaining organs in an enormous skin flap. A mutilation known in medical vernacular as eggcup surgery, since any victim who survives the ordeal must spend the remainder of his or her life perched in a padded receptacle that resembles nothing in the world so much as a giant eggcup.
I never met a patient who underwent hemicorporectomy, but everyone at Stanford Hospital during my era came to know George H., who not only ended up in an eggcup but did so by his own volition. His story began during childhood when a car ran over him, crushing his legs and spine and injuring his brain. His legs became spastic and paralyzed, drawn up behind his back in a state of rigid disfigurement so profound he could neither lie on his back nor sit in a chair, but had to spend his life chest-down on a gurney. By the time he was thirty, pressure necrosis had caused weeping bed sores that covered both mangled legs. Not that this handicap kept George confined to his room. Thanks to a large-wheeled gurney, plus powerful hands that spun those wheels like windmills, he was able to scoot himself all over Stanford Hospital. In the cafeteria they moved tables to create an aisle wide enough for his gurney, and here he befriended everyone he met.
At first it seemed strange – talking to a man who lay chest-down on a gurney, resting his chin on one hand and gesturing with the other while his twisted, back-drawn legs formed a towering lump under the sheet. Yet day by day George became less a disfigured patient and more an ordinary person; no different, in any substantial way, from those who sat around him. Well-educated, with a mellow base voice so much like Paul Harvey’s new acquaintances often commented on the resemblance, he read the New York Times from cover to cover every morning and knew current events down to the last detail. And there was something more: an open face, iron-grey hair, bushy eyebrows, a warm smile and a gentle, measured tempo to his speech that brought peace wherever he went. His one idiosyncrasy was an aversion to conflict of any sort. Several times during the Nixon/Watergate hearings – they seemed to go on forever, one venomous debate after another – I saw George abruptly wheel himself away from a table whenever Nixon supporters and detractors began shouting at each other.
During a three-month hospital admission for a chronic infection, George got bad news from Doctor Chase, the chairman of plastic surgery. Osteomyelitis had destroyed the bones in George’s left leg; surgery was the only option. Even more disturbing, the infection had spread so far up the femur a standard amputation would have left behind a festering core of antibiotic-resistant bacteria in the marrow of the femoral head, and thus, for any hope of a cure, Doctor Chase would have to perform a disarticulation of the hip. This operation, also known by the unnerving titles “hindquarter amputation” and “hemipelvectomy,” would involve complete excision of the leg and hip, leaving no trace of a stump, but only the smooth curve of the pelvis itself.
George consented. What else could he do? Following surgery, he disappeared from the halls of Stanford Hospital for almost a week. The next time I saw him, he was parked on his gurney beside the pharmacy counter, chatting eagerly with an intern and two nurses. The lump formed under the sheet by the remaining twisted leg was half its former size.
“Good grief, George,” the intern said as I approached, “you been doing speed or something?” Indeed, George was more animated than I had ever seen him. Propped on both elbows, his face aglow, he talked with boisterous energy, denying even a twinge of pain. (Nonsense, of course – the massive wound was closed with 120 stitches.) The surgery had gone splendidly, so splendidly George had hatched a scheme: he would persuade Doctor Chase to disarticulate his other hip.
“Jesus, George,” the intern said, “that’s a nasty piece of surgery.” The rest of us nodded. We felt embarrassed. George was obviously manic, irrational. Perhaps decades of unrelenting illness had finally taken their toll. The intern said, “Maybe you could just get a regular amputation.” The nurses and I murmured our assent.
“Not in a million years,” George said, pounding his fist on the gurney. “Rehab says they can’t fit me in a wheelchair long as that stump keeps getting in the way. I’ve put up with that stinking leg for almost twenty-five years. I want the whole goddamn thing off.”
We all stood silent, staring at the floor. I had never seen George upset, never heard him curse. Surely it was the medication, the stress of surgery. At that moment, four normal people – the two nurses, the intern and I – shared a deep but helpless pity for the cripple who lay before.
At first Doctor Case wouldn’t consider disarticulating a leg that posed no threat to the patient’s life, but George harassed the poor man for months, until finally Case sent him off to a psychiatrist, promising they would schedule surgery if George proved to be of sound mind. The psychiatry department had a lot of experience in such matters, since their faculty had examined candidates for the trans-gender surgery Stanford so famously pioneered. After three sessions, the therapist declared George officially sane. Case, true to his word, put him on the schedule.
The next chapter in George’s story came from Freddie Tinsdale, a classmate of mine and an intern on the plastic surgery team that performed the second operation. The procedure went without a hitch. George woke from anesthesia cheerful as a new mother, refused his morphine, then violated his post-op diet by mooching a slice of apple pie from his roommate. The next morning he wheeled himself down to rehab on his old gurney, where his smooth, legless pelvis was fitted for a special seat. That evening Tinsdale discovered George giving himself a bed bath. The nursing aides were meant to do that, but George had persuaded rehab to install parallel bars above his bed, and now, unencumbered by those useless legs, he could support the weight of his body with one ape-strong arm. Tinsdale pulled back the bed curtain to discover a naked legless man dangling from a bar while he soaped his armpits.
On the fourth post-op day, an even stranger thing happened. Late in the afternoon, the charge nurse on George’s ward paged the plastics team, so Tinsdale, along with his resident and medical student, wandered up to find out what she wanted. Nothing much, the nurse said, just . . . well . . . somehow, George had disappeared. After lunch he had rolled down to rehab on his gurney, eager to try out his new custom-made wheelchair, but the clerk on the rehab ward swore George had departed hours before. Calls all over the hospital – to the cafeteria, the ER, the ICU, the admissions desk, another to rehab – had turned up no sign of George.
How peculiar: a legless man gone missing. The nurse sat at the ward desk, staring up at the intern and resident and medical student. They stood in a circle staring down at her. The hallway was silent except for the overhead speaker, which sounded almost constantly: “Doctor Vinney, STAT to SICU . . . Orderly with a wheelchair, Ward East 1A . . . Blood bank tech, call extension 511 . . . ”
Then, suddenly, all eyes were on the overhead speaker.
The plastics team ran down three flights of stairs, into the basement where two page operators sat huddled in a cubicle. The team crowded around the doorway. There was George, microphone in hand, perched in his new eggcup, mounted in his new wheelchair. A set of earphones embraced his head. He leaned into the microphone and flipped a switch on the panel in front of him.
The voice was unmistakable: “Doctor Coursey, STAT to the ENT clinic.” Finally George looked up and saw the doctors standing shoulder-to-shoulder in the doorway. He smiled, his face glowing with pride. He took off the earphones, flipped off the switch and shouted, “My first job.” He clapped his hands. Tears streamed down his cheeks. “I’ve been on the payroll almost three hours!”
The senior resident on the plastic service was upset because the skin flap on the right side of George’s pelvis was held in place by 120 four-day-old stitches, every stitch bearing the weight of his torso. “Jesus, George,” he said, “Get out of that chair. Your wound . . . you want to rip that thing open?” Then the resident went after the switchboard manager, but she insisted it wasn’t her fault.
“How was I to know?” she said. “He’d been pestering me for weeks, rolling down here every day on his gurney, and I kept telling him I’d hire him soon as he could get in a wheelchair. Then he disappears for a few days. Next thing I know he’s bragging about his new wheelchair and asking when he can go to work. He didn’t say a thing about surgery. One of the girls was out on maternity leave, the backup broke her ankle at Tahoe. It only took me a few minutes to show him how to work the board.”
George was retired on the spot, but a week or two later Doctor Chase signed the release for him to go back to work. It was George’s first job, and he was still at it five years later when I finished my fellowship at Walter Reed and returned to Stanford for a visit. He continued to live in an eggcup. Every morning he dangled first by one arm, then the other, bathing his half body as it hung suspended over the tub, then swung himself around his apartment on overhead bars and settled into his padded wheelchair.
For decades he’d cherished a fantasy – not the fantasy of walking on his own legs but the simple triumph of bathing himself and earning his bread. At work his voice was distinctive, a deep, soothing bass that put his listeners at ease. And he was a smart man, knew every nurse and doctor in the building, knew their routines, their hiding places – including, alas, the residents’ on-call rooms, where his inside knowledge and dogged persistence interrupted many trysts.
I envy the man. I don’t envy his eggcup, but I would give anything to own what’s in his heart.