The Funnel
Volume 57, No. 3, P. 327

Edward Brown was born on a bad night – bad for him, bad for me, and bad for Ames Miller, the pediatric resident in charge of my team. Neither Ames nor I were destined for a minute’s sleep, nor would we sit down, even once, for any purpose other than scribbling notes in dozens of charts as we trotted around Valley Medical Center under summons from the page operator. Despite the tinny acoustics of the overhead speakers, she sounded fetching – throaty, a bit breathless, with a lilting note at the end of each phrase: “Doctor Miller, STAT to the ER . . . Doctor Miller, STAT to peds 1A . . . Doctor Miller . . . Doctor Miller . . . ” It strikes me as poignant that I heard her voice throughout the year of my internship, all the while fantasizing a lovely young woman, yet I never saw her face.

It was April, a warm early spring, and by midnight the ER had plagued my team with three ersatz cases of meningitis. The real problem was a squirrelly ER intern who didn’t know how to test a child for the symptoms of meningeal irritation. Every time a feverish toddler refused to turn his head to look at a set of jiggling keys, the intern diagnosed a stiff neck, and another “Doctor Miller, STAT to the ER” came over the PA system. Ames finally dragged the intern into the cast room and slammed the door.

“Goddamn it, man,” he shouted, “give the kid at least ten seconds. Time it with your watch. And try a rattle or a squeaky toy. A sick kid doesn’t give a shit for a bunch of keys, no matter how loud you jiggle them.”

At two a. m., a premie on a respirator spit out his endotracheal tube. The reinsertion was too tricky for Ames. He made a couple of tries, then spent fifteen minutes coaxing an anesthesia resident out of the OR. By the time they got the tube threaded past the epiglottis and into the soft, pencil-sized trachea, the infant’s face was pitch black, but he pinked up right away, then delighted the nurses with a convulsive meconium bowel movement. Minutes later, while Ames and I were on the peds ward restarting infiltrated IVs, we got paged back to the ER to see an eight-year-old boy who had been poked in the eye with a lighted cigarette. The ophthalmology resident took care of the corneal burn, but Ames had to haggle with a social worker over whether the kid’s father should be charged with child abuse. I ran back up to work on the IVs, but ten minutes later Ames called me on the ward phone.

“For God’s sake, Gamel, I’m trying to keep this poor bastard out of jail, but OB won’t leave me alone. The charge nurse keeps babbling about some newborn with his guts falling out. Get up there and see what’s going on.”

* * *

Edward’s birth caught me in the midst of a soul-searching crisis. During the first few rotations of my internship, working twelve hours on a good day and twenty-four hours on a bad one, I sighed with pleasure at the thought of my chosen career in ophthalmology. The loss of sleep was wearing me down, and yet, in the midst of those frantic days and nights, a longing began to gnaw at me. The life-and-death struggles that drove me to the brink of collapse also gave me something precious, something I didn’t want to give up. In the eyes of the mother of a dying child, there lurks a special depth, a special meaning. When those eyes gaze at the doctors who care for her child, they glow with gratitude and respect. In the surgical ICU, a patient who has just vomited four pints of blood doesn’t ignore the doctor at his bedside. No, he reaches out a desperate hand. The patient cannot speak, he gags on the Sengstaken-Blakemore Occluder thrust down his throat to staunch a massive esophageal hemorrhage, but his eyes say it all: Please help me, doctor. Please don’t let me die.

Night after night, stumbling from ward to ward, I craved those pleading eyes, those hands that grasped my own with a passion known only to the mortally ill. I wanted to give my patients the most precious gifts of all – life. The noblest physician, the surgeon with a knife and the skill to use it, wields a force like no other. His patients never ignore him. But the knife and the skill are not enough. A surgeon must sentence himself to a grueling lifelong struggle, fearing the moment when a slip of his knife or his mind will kill a patient. As I watched my colleagues split an abdomen with a sweep of the scalpel, slicing through skin and fat and muscle to expose a cancerous tumor, I coveted their skills. My affection for the immaculate world of ophthalmology – a world inhabited by phony surgeons, or so it now seemed – had begun to wane. I coveted the true surgeon’s power over life and death, but could I pay the price?

Edward Brown became a special patient. At his bedside, I would discover the secret that decided my fate. Rushing upstairs to the OB ward, I kept prodding my memory for an explanation of the nurse’s absurd phrase – “guts falling out” – but to no avail. After four years of medical school, I still had no clue of the disaster that awaited me.
The mother lay on the OB ward, her eyes closed, her long, dark, disheveled hair still damp from the sweat of her labor. The father sat by her bedside, his face buried in his hands, his shoulders heaving with the rhythmic thrust of his sobs. Edward lay in the delivery room, a small baby with spindly limbs and sunken cheeks. His head was bald except for scattered ringlets of dark hair. His translucent skin showed only the faintest trace of color – an almond tint, perhaps? Or was it the almond shape of his wide-open eyes that hangs in my memory, or the peculiar whiff that caught my nostrils – almonds, again? The child sucked on a pacifier and gazed at the mysterious ceiling above his bassinette. Someone had covered his abdomen with what appeared to be a mound of wet surgical drapes.
The OB nurse scowled at me.

“Dammit all!” she said. “I told that page operator it was really bad, and she should send the resident. Look at this.” She lifted the drapes to expose a glistening, churning mass of intestines, a mass so bulky it dwarfed the infant lying beneath it. I stood astonished, gazing down at the child. “Now you believe me?” She said. “You better get that resident of yours up here STAT!”

“Ok, ok,” I said, rushing for the door. “I’ll get him right now.”

* * *

When I first met Ames Miller, I thought him an idiot. He was short, had a flat head, a square jaw, and almost no neck. At our first morning rounds, a nurse remarked in a whispered aside, “Why does the poor man wear his hair in a flattop?” She was right. The combined effect of his skull and jaw and hair brought the word “blockhead” to the tip of the tongue. But Ames proved himself an intelligent man, though he loved children with what I judged an irrational passion. Infants were his favorite. Not content with the dozens of sick kids heaped upon him every workday, he had a three-year-old son at home, born during his third year of medical school. Six months before we met, his wife had delivered what he described – his face shining with delight – as “another little shitter.” Before rounds, when he traded tales with two nurses who also had infants at home, the topic often drifted to excretory events. One morning, Ames boasted that his sweet new daughter had managed to anoint her curly locks with a whole fistful of stool.

Ames was a second-year resident, far more learned than I in pediatric matters, but he shared my ignorance of a newborn with its guts falling out. Shown Edward’s deformity, he gaped and fled just as I had. The surgical resident on call that night, a well-groomed Syrian named Ahmed, brought the first note of authority to those dismal proceedings. He was slim and poised and spoke with a cultured accent. The OB nurse, angry that we hadn’t summoned a more senior surgeon, stood glowering beside Edward’s bassinette, her jaw set and her arms crossed on her chest.

Ahmed smiled at her, said, “Let’s see what we have here,” then lifted the drapes from Edward’s abdomen. In the first instant, his jaw dropped and his eyebrows shot up, but his face soon regained its mask-like composure. “Oh, my,” he said, gently lowering the drapes. “Congenital gastroschisis – a very bad case.” He paused and blinked a few times.

Ames and I stared at him, waiting for a glimmer of hope, a miracle that might bail us out of this catastrophe.
“Be sure to dose him up with ampicillin.” Ahmed said. “And keep those drapes wet with sterile saline. We don’t want to let him get dried out or infected.”

At last poor Edward had a diagnosis: gastroschisis, a congenital defect in the abdominal wall through which his naked intestines had prolapsed into the outside world. Adding to his troubles, the noose-like constriction of the defect had caused massive congestion, creating a mound twice the size of Edward’s head, while the raw, glistening surface of the swollen bowels offered an appetizing target for bacteria.

Ahmed’s pronouncement disturbed Edward, or so it seemed, for the moment the room fell silent, he began to fret. He balled his tiny fists, screwed his eyes shut and spat out the pacifier, then gave a feeble cry that sounded like the quack of a baby duck. His thin legs stirred beneath the drape-covered mound.

“Oh, doctor,” the nurse said, grasping Ahmed’s arm as he threw his latex gloves into a trash can and headed for the door. “What formula should we feed him? Do you recommend Similac or Enfamil?”

“My god no, you . . . ” Ahmed said, catching himself a hairsbreadth short of adding “you fool.” Even Ames and I had sorted that one out: the last thing Edward’s strangulated intestines needed was a digestive challenge. A bottle of formula would surely finish him off.

“But . . . but doctor,” the nurse said, “what are we going to do?”

“Well, I . . . uh, yes . . . ” Ahmed stammered, holding the door open with one hand. He turned toward the nurse, then paused. His gaze shifted to Edward, who was waving his limbs and giving tiny, quack-like cries. “Draw some blood, run a ‘crit, get a CBC, start an IV with half normal saline.”

“Yes, doctor,” she said, “but then . . . then what?”

Ahmed shook his head. His smooth face and slim body seemed to sag.

“I . . . I don’t know.”

No one spoke. The nurse, Ames, Ahmed and I stood scattered around the delivery room, amid tables and cabinets and the implements of childbirth. We all looked at Edward. We heard his feeble cries. We saw his tiny arms and legs flailing about. I couldn’t know the thoughts of the others, but mine were dark indeed: guard your heart, you foolish man, for that child will soon be dead.

* * *

It was a failure of imagination. Indeed, how could anyone imagine a cure for that deformed child, whose shrunken abdominal cavity, no larger than a tennis ball, could never contain those swollen yet vital organs? Ahmed was poised and bright, learned in the ways of the surgeon. His crestfallen retreat had removed all hope. Edward’s fate seemed no better than that of a death-row inmate, except the moment of his demise – from infection, infarction, or heaven knew what catastrophe – remained unknown. I decided it was time to flee, but Ames beat me to it.

“Wait,” I said as he headed for the door. “Aren’t you going to start an IV?”

“What’s your problem, Gamel? Aren’t you the big IV hot-shot in this hospital?”

The door of the deliver room flapped on its hinges, and he was gone. As his comment suggested, I fancied myself the most skilled phlebotomist among my internship class. Several colleagues, upon hearing tales of my dexterity, had asked me to start an IV or perform a lumbar puncture after their own efforts failed. My special triumph came with scalp-vein IVs, tiny needles threaded into the scalps of infants whose wasted limbs offer no trace of a decent blood vessel. A month before Edward’s arrival, I had earned the nickname “Dracula” by drawing blood from a microscopic vein on the scalp of a three-pound premie, yet I needed – for desperate personal reasons – to stay away from Edward.

I steeled myself. Let’s play a game, I thought – let’s pretend this isn’t a human being. In my mind’s eye, I struggled to transform Edward into an alien life form, a creature so strange and unlovely it could lay no claim on my affections. One-by-one, I wrapped a tourniquet around each of his pathetic limbs. My palpating finger discovered no trace of a vein, but the instant I touched him, he fell silent, as though my squeezing and stroking his flesh brought a primal comfort. His limbs lay still, his eyes opened wide, like the eyes of a child filled with wonder. When I replaced the pacifier between his lips, an eager suck snatched it from my fingers. He gave a flurry of grunts and sucks, then settled into a contented silence.

The time had come. I had no choice: the ritual of the scalp-vein IV must begin. The OB nurse laid an IV tray on the table beside Edward’s bassinette. I took a rubber band from the tray, gently lifted Edward’s head, stretched the band until it circled just above his ears, then snapped it in place. A network of swollen veins raced across his scalp. I peered closely, assisted by a bright overhead light, searching for the plumpest specimen, until – ah yes, there lay a juicy one, a vein the size of a pencil lead running two inches above the rubber band. I grabbed a can of shaving cream, worked a dollop into the hair overlying the chosen vein, shaved the hair from a patch of scalp using a safety razor, then painted the skin with Betadine. Finally, I reached for the butterfly, a needle attached to two wing-like plastic tabs that help anchor it in place.

I steadied my nerves with a slow, deep breath. The chosen vein was no larger than the 21-gauge needle pinched between my thumb and index finger. If I failed, the surgeons would have to perform a cut-down – slice open Edward’s arm or leg in search of a vein large enough to hold the life-sustaining needle. The bloody procedure, stressful even for a healthy newborn, would carry a special risk for Edward. I exchanged an anxious glance with the OB nurse. She braced Edward’s head between her hands. As the needle pierced his translucent skin and threaded its way across his scalp, I took care to enter the diaphanous vein at a shallow angle, lest the sharp tip tear it to shreds. The needle found its mark. Edward’s dark blood flowed into the two specimen vials, and soon an IV bottle was dripping in the half-normal saline that would sustain his life during the coming weeks.

But in the midst of triumph, disaster crept upon me. As I pierced Edward’s flesh, holding my breath to steady my hand, the shield-wall around my heart gave way. Perhaps it was the euphoria brought on by a devilish challenge well-met. Perhaps it was the terrible closeness, my face hovering inches from his doll-like features, from the wide, pale eyes that grew wider still the instant my needle punctured his scalp. His eyes teared, his breathing sputtered, the sucking stopped, but he did not squall, nor did he strain against the nurse’s hands. By the time I had taped the butterfly in place, then taped a clear plastic medicine cup over it to protect against an accidental bump, I was a goner. The brave creature had caught me. In the flash of a moment, it felt as though he were my own child.

* * *

Early the next morning, the surgery service swooped down and stole Edward from me. Fair enough – there was nothing more I could do for him. The hospital’s library contained only a few articles on gastroschisis, and these did little more than speculate on the embryological derangement that brought it about. One author opined, “This defect is the result of obstruction of the omphalomesenteric vessels during development.” Which is to say, the embryonic tissue meant to form the abdominal wall had lost its blood supply, then melted away from lack of oxygen. My spirits sank when I saw pictures of infants with only one or two loops of bowel prolapsing through a tiny umbilical defect. Neat, no problem: slit open the umbilicus, tuck the loops back in, sew up the wound. But, as Ahmed had noted, Edward had a bad case: every inch of his swollen digestive tract lay in a pile beneath those drapes. What on earth could anyone do to save him?

He was transferred to the east nursery, where I looked in on him many times a day, until the word got out that Professor DeVries, Stanford’s world-renowned pediatric surgeon, would soon come to operate on Edward. I questioned Ahmed, then spoke with a classmate who was interning on the Stanford surgery service, but nobody had any idea what the great professor planned to do. I decided he would probably try to cover those bowels with a skin graft – a disturbing thought, since a huge patch of skin would be needed, and the resulting bulbous sack would leave Edward with a hideous lifelong deformity.

I felt terrible. The mental image of that sack revolted me, while the news that DeVries was taking over the case gave me bad vibes. The man was a pompous twit. I had never met him fact-to-face, but he had lectured to my class during our third year of medical school, and on the podium he pranced around like a prima donna, so full of himself he seemed ready to burst. And he was tall, broad-shouldered, revoltingly handsome. Every time he stepped up to the lecture podium, the women in my class sighed and twittered. According to his CV, he had grown up in Iowa, but during a fellowship in pediatric surgery at Oxford University, the snob had acquired a British accent. In his lectures, he kept mentioning his “shedule,” which I later discovered was the British pronunciation of “schedule.” I hated to see Edward cared for by such a vain, self-absorbed man.

The operation took all morning. When I finally rushed up after peds clinic, I found a dozen doctors and nurses lined up at the window of the east nursery. The other bassinettes were filled with premies on respirators, so tiny and wasted they looked like hairless rats. Compared to these creatures, Edward seemed robust, but my god, what was that? Something loomed over him as he lay in the bassinette, something huge and white and bizarre, made of what looked like laminated plastic. It took me several moments to sort out the astounding truth: DeVries had sewn the tip of an enormous funnel into Edward’s abdomen.

Later that night, I returned to the nursery and lifted the wet gauze covering the top of the funnel. There lay Edward’s swollen intestines, but the glistening mass . . . was it – yes! During the few hours since surgery, the mass had already begun to shrink. The swollen loops of bowel were smaller, approaching the size of normal intestines. DeVries had relieved the constriction by stretching the abdominal opening around the broad tip of the funnel, and now the force of gravity was draining the engorged lymph back into Edward’s body.

This was not the end of Edward’s perilous journey. There was still the problem – what seemed to me the insoluble problem – of that tiny abdominal cavity, which could hold only a fraction of the child’s viscera, even when they had shrunk to normal size. I kept my vigil, stopping by several times a day to gaze through the window of the premie ward. Here I saw Edward’s parents. They sat, gowned and gloved and masked, in chairs beside his bassinette, taking turns stroking his cheek or holding his tiny hands. The two of them looked like each other – thin in face and body, with elfin features that left no doubt Edward had come from their loins.

When they gazed at Edward – which the mother did often, the father seldom – their faces showed a quizzical uncertainty. The gadget erupting from their son’s abdomen must have disturbed them, while every day gave opportunity to the bacteria that hungered for those exposed organs, threatening to melt them into a soupy infected hash. And surely the parents must have wondered, as I did, when – if ever – those organs would nestle into his tiny abdomen.

DeVries knew something we didn’t: the tissues of a newborn retain an astounding plasticity. Day by day, then week by week, Edward’s viscera settled deeper into the funnel as his abdomen slowly expanded. On two occasions he spiked a fever, the sign of an occult infection, but each time a change in the antibiotic regimen conquered the invading bacteria. All the while I rooted for the brave child who lay sucking on his pacifier hour after hour, his gaze fixed on the immense white funnel towering above him.

Since Edward had to remain NPO until those intestines were safely sewn inside his abdomen, his only nutrition came through my butterfly IV. The tiny needle, inserted by my hand into a tiny vein, was all that kept him alive. But no IV lasts forever. A nurse on the premie ward told of a visit DeVries made two weeks after I had inserted the IV. Two weeks is the official limit: beyond that milestone, the risk of an infection around the needle begins to soar.

DeVries and Ahmed stood beside Edward’s bassinette, staring down at my scalp-vein IV while the surgical intern laid out the instruments they would use to cut open an arm or leg in search of a new vein. No doubt DeVries noticed the child’s limbs were now more spindly than ever, thanks to the inevitable wasting suffered by anyone who cannot take oral nourishment. The great surgeon hesitated. Moment by moment, as he examined those bony limbs, his eagerness to slice into one of them faded. Then, according to the nurse who told the story, he gingerly untaped the medicine cup shielding my IV and tipped it to one side. The surrounding skin showed the stubble of Edward’s regrowing hair, but there was no redness or discharge to suggest infection.

“Hmm . . . well . . . ” DeVries said, taping the cup back in place. “This looks pretty good. Keep an eye on it. Let me know if you see any puss, but we don’t need to push our luck.” Ahmed gave a sign of relief and began re-packing the instruments.

The story cheered me up. My achievement, a scalp-vein IV of exceptional longevity, had demanded only modest skill, but it bound me to Edward. I was part of his team, a secret sharer in his victory over what I and many others had thought was certain death. Thanks to DeVries’ sleight of hand, an act of conjury more astounding than anything seen on a magician’s stage, the child was climbing out of his coffin. Now, even a coward like me could unleash his affection. Week after shining week, Edward reigned as the hero of Valley Medical Center. Members of he hospital staff came by to watch the miracle unfold. His parents, as they sat beside Edward’s bassinette, smiled at the crowd gathered along the window.

In truth, my visits to the nursery, interludes snatched from my hectic days and nights on the pediatric rotation, had as much to do with me as they did with Edward. The precious child’s fate haunted me, but so did the sheer mechanics of that funnel. How in the hell did DeVries pull it off? In my mind’s eye, I saw his forceps grasp the delicate membranes of Edward’s abdominal wall and stretch them around that stiff plastic cone, taking care not to tear the tissue or trap a friable loop of bowel. A single misplaced stitch could have caused a raging peritonitis. How had that egomaniac acquired such skillful hands? And how did he live – how did he eat and sleep and endure the daily routines of life – knowing that the surgery he had done yesterday or would do tomorrow might fail, spelling the doom of an innocent child? A surgeon – a true surgeon – must endure a lifetime of stress, a career tormented by endless uncertainty.

No – the life of the knife was not for me. Better to steal away into the orderly universe encompassed by the human eye. Blindness was bad enough, but with any luck, I would not have to answer for death.

* * *

I missed Edward’s final victory. It took two months for his viscera to settle into his abdomen, allowing DeVries to close the wound at last, and by then my internship had ended. I was in my first year of ophthalmology residency when word came up to Stanford that Edward had been discharged from the Valley Medical Center. For the next five years I gave him little thought, but then he caught me unawares and crept back into my life. Not the literal Edward, but his spirit.

It happened at the Armed Forces Institute of Pathology in Washington, DC, where I spent a two-year fellowship studying ophthalmic pathology, a rarefied specialty devoted to the histologic study of the eye and its surrounding tissues. I was in the library working on a manuscript when I noticed a copy of The American Journal of Surgery on an adjacent table. The lead article had an intriguing title: “Gastroschisis: the Long-Term Clinical Course of 29 patients.” To my delight, the authors reported that following surgical repair, the majority of patients enjoyed normal lives, indeed lives that could not be distinguished from those of their healthy peers.

I turned the page, and a picture in the article caught my eye. It showed a five-year old child, about the age Edward would have been then. The eyes in the photograph were blacked out to conceal the patient’s identity, but the elfin features and hollow cheeks so closely resembled Edward’s, they gave me a shock. The patient wore only jockey shorts. He had thin limbs and a bony, narrow chest. The shorts were pulled down to reveal an abdominal scar only three or four inches across. So there he stood, a living miracle – a child who could turn somersaults and leap about a playground just like every other kid, with nothing more than a palm-sized scar to mark his horrendous entrance into this world.