Two Thoracotomies 

Angela Tang-Tan

The first time I witness a thorax opened, it is on a twenty-five-gram mouse. Heavier than most because she is gravid. The second time, it’s on a thirty-year-old man. In both, the yielding chest is laid open with scalpel and forceps, and my hand is inside. In both, I search for something invisible, elusive, sliding away from my fingertips.

I open a cage and reach for the mouse. It’s my research year of med school and we’re studying how neurons grow. We’d ordered the two mice online, the same way we order supplies—adding them to checkout just like boxes of slides and bottles of reagent ethanol. The act of procuring these living, breathing animals is as sterile as an operating field.

At first, the two huddle together in a corner, their warm bodies overlapping in the nest of shredded litter they are building in anticipation of their pups. As soon as the lid of the cage comes off, they skitter about to dodge my gloved fingers. Females are usually more difficult to catch than males because they are smaller and faster, but these two are swollen with pregnancy. I root around until my hand closes around the base of a tail. The choice is random. This one, then, will be first.

Her fur is black and glossy, soft as anything I have ever known. The harsh glare of the overhead lamp is reflected within her eyes like twin motes of starlight. I whisk her under the fume hood, into the chamber—a plexiglass container the size of a child’s shoebox—and the lid snaps shut. The gas is already on, hissing quietly through a labyrinth of valves and tubing. Inside, the mouse skitters around this strange new space, her whiskers twitching.

Is she afraid? In sight and in scent, this chamber is not too different from the other cages that have been her home. She cannot know the meaning of the scissors, forceps, and blue drapes laid out on the other side of the plexiglass. Yet, perhaps through some intuition, she perceives that this place is different. She is the first and the chamber is clean, so she does not smell the lingering fear from the ones who came before. I imagine it must be worse for the one to follow.

It doesn’t take long before she begins to sway. Her steps grow crooked, drunken. She falls, then staggers to her feet again. She circles the cage once, twice, pulling herself along on her belly. Then she collapses again, and this time I know she will not rise. The invisible wind rushing through the chamber ruffles her fur into spikes. Her eyes are half-open and dazed. Her hind legs jerk. Claws scrape soundlessly against plexiglass.

She lies utterly still for several minutes, though we wait a little longer, to make sure that she is fully unconscious. Then the animal surgeon removes her from the chamber and places her on the sterile field set up beside it beneath the fume hood. We must keep her alive, but insensate. Her heart must remain beating for long enough to drive clean saline through the brains of her young; only that will ensure a viable tissue harvest.

The surgeon waits a few minutes longer before pinching her hind paws, hard. She does not so much as shudder. Only then does he lay the mouse on her back, spread-eagled, lodging her muzzle into a nose cone, deftly taping each limb to the tabletop. His movements are quick with the ease of experience. The mouse’s belly is white and hairless, stretched taut as the skin of a drum. It pulses rhythmically with her ragged breaths, the beat of her heart. Her nipples are swollen, ready for her brood.

The thoracotomy transpires in a flash. Scissors pierce her chest wall, tearing through hide and sternum with brutal efficiency, unseaming her from chin to diaphragm. In a fraction of a second, her chest is splayed open. Her lungs heave, wet and purple, through a jagged wound speckled with stray pieces of fur. It’s not neat; it doesn’t have to be.

Under the ribs, between the lungs, a heart the size of my fingernail is pried into view with a pair of forceps. The pericardial sac is rosy and shining, like a semiprecious stone. The atria and ventricles quiver as they contract, one after the other, the ageless dance of survival.

A needle pierces the left ventricle, at the base of the heart. The whir of the perfusion machine fills the air as it drives a steady stream of phosphate-buffered saline into the aorta. The mouse’s still-beating heart flutters rhythmically, now pumping saline instead of blood to her brain and across a snarl of umbilical cords to her tiny offspring. We need the tissue we harvest to be clean.

Minutes pass. Watered-down blood bubbles onto the table in an expanding circle. We wait for the blood returning to the mouse’s right atrium to run clear, signaling that the saline has wound its way through the entire circuit of her body, from artery to capillary to vein. Gradually, as her blood drains away, her liver pales from crimson to mauve.

The surgeon widens the incision, and the mass of her uterus is exposed. V-shaped, it resembles a thick string of beads. Each bulge is a fetus; I count seven. One by one, each baby mouse is severed from its siblings and wrenched into the world, a crude approximation of a cesarean section. At fourteen weeks, the fetuses are milky-pale and nearly translucent; their shrimplike eyes have an almost alien sheen.

Beneath my microscope, each fetus’s skull tears apart as easily as the membrane of an egg. Even at this primordial stage, both hemispheres of the brain are developed in perfect miniature. The seat of consciousness is nascent, perhaps dreaming, but I must pluck it apart. I pry along the lateral sulcus to expose the hippocampus, deep within the recesses of the temporal lobe. Each tiny hippocampus goes into a vial of preservative solution. The rest of each mouse fetus is wrapped in paper towels for disposal.

On the operating field next to me, the heart of the mother mouse has gone still at last. Her carcass is spread out in a chaos of blood, viscera, and fur. Her entrails unspool in a tangle of gray. It is science, but it feels like a violation.

A lump rises in my throat, but I swallow it. She died for a good reason, I remind myself. We will learn from her sacrifice. The data we obtain will advance science and help many human patients in the future. We’ll make her life count.
I say it to myself once, twice. I say it with such conviction that I begin to believe it.
Behind me, the other mouse watches and huddles in her cage, awaiting her turn.

The beeper goes off. My resident takes one look and all at once he is striding for the elevator. I am on the first overnight shift of my surgery rotation, several months after my research year has ended. The resident downs the dregs of his Diet Coke while he’s on the move. “Thirty-year-old male, car crash, unconscious, no blood pressure. Arriving in fifteen minutes.” His words tumble out in the space of a single breath. “It’s gonna be bad.”

I scramble to gather my notes and the two of us sprint down to the Emergency Department, where a knot of nurses, emergency medicine doctors, surgery residents, and medical students has formed at the entrance to one of the trauma bays. We are greeted with curt nods. No one speaks above a whisper, and the tension is punctuated only by the clacking of computer keys and the beeping of monitors. The atmosphere is dark and thrumming, like the air before a storm. I watch the residents pull on blue gowns and shoe covers. I quietly do the same. We are expecting to get bloody.

The ambulance bay doors crash open. A burly medic is leaning over the patient, performing chest compressions, each blow reverberating through the gurney’s creaking metal frame. The trauma team springs into motion, slicing off the patient’s clothes, hooking him up to monitors, rapidly assessing his injuries.

The patient is young, bearded, fair-haired, his face pallid in a way that I have never seen. Beneath the seal of the bag-valve mask that is pumping oxygen into his lungs, his mouth is raw and bloody. His head lolls, the whites of his eyes stark beneath half-closed lids, insensible to the world. He is clearly in the midst of dying.

I step in to help the team pull him onto the hospital bed, and at once my gloves and gown are smeared with blood. A circle of blue-gowned figures quickly crowds me from the bedside, and I reflexively stand back so that I am not in the way of anyone more essential. Without seeing, I imagine the steps of intubation, the ultrasound probe pressed hard against his skin, the IV needles snaking into his blood vessels. Commands are shouted; vitals are read out. Minutes pass in a raucous blur. I feel my mind go blank and quiet. Adrenaline narrows my vision to only what is before me.

“Clear!” an emergency medicine doctor calls out. For a fraction of a second, the chest compressions cease. Everyone in the room seems to hold their breath as one. The shock is delivered in silence. I almost expect the man’s body to jolt, but he remains utterly still.

Compressions resume. Minutes pass, and another shock follows, then another. On the monitor screen, the tracing of his heart remains flat and lifeless. The air in the trauma bay grows heavier, though no one mentions it aloud. I can feel it—the shift, the specter of futility creeping in.

“Thoracotomy tray,” the chief trauma surgery resident commands. Her voice rings out like a thunderclap over the commotion, and all heads turn in her direction. Even as a lowly med student just a few days into my surgery rotation, I know that things are desperate when they say those words.

The thoracotomy tray is a brutal affair. Curving forceps, massive scissors designed to rend bone, a formidable retractor with a hand crank—the rib spreader. Each instrument is gunmetal gray and shining with cold promise. My breath catches as I watch the tray whisked into the melee, and I realize: we are about to tear a man open.

The junior resident grabs a scalpel off the tray and slashes a rapid U along the perimeter of the man’s ribs, from one armpit down to the abdomen and back up to the other armpit. It’s as fast as it is ruthless, slicing through skin, fat, and intercostal muscle. He flings down the scalpel and grabs the rongeur—a long-handled instrument with sleek blades the size of garden shears. He plunges the blades into the center of the chest, grips a handle in each fist, and bears down. There is a sharp crack, like a gunshot. The sternum snaps in two and rivulets of blood spring forth. My stomach lurches in reply.

The rib spreader comes next. It is exactly what it sounds like: broad, blunt metal blades wedging the incision open. The hand crank makes a rapid click-click-click with each revolution, ratcheting the edges of the tool apart inch by inch, the cleft yawning open. Bone and connective tissue creak. The ribcage hinges up toward the head until it almost covers the man’s face. The dull anterior edges of his lungs fan outward. In the center, his heart lies in a roiling pool of scarlet, a frightened animal shivering feebly.

The chief resident reaches in and wrests the man’s heart into the brightness of the emergency room. She rips into the pericardium with scissors to reveal the heart muscle itself, her gloved fingers scrambling to clasp the organ in her hand. She squeezes it and then releases. Squeezes and releases, again and again. Her white latex gloves turn black with coagulated blood as she commandeers the left ventricle, trying to force blood out of the heart and into the brain. Behind my mask, my mouth is slack. I have never witnessed an open cardiac massage. It is both brutal and miraculous.

After a few minutes, the chief resident steps back and the second-year takes over. His brow is furrowed deep. A bead of sweat courses down his forehead and slips beneath his mask. In his hands, the heart grows limp. I register that it must be futile if they are allowing the juniors to take a turn for practice.

Then—after how long, I cannot say—the resident turns and motions for me to take his place.

My feet carry me forward. My own heart thrums in the hollow of my throat. There is no time for fear, for reverence. This is something that I will likely never see again, much less participate in. I do not permit myself to hesitate. I place my hands into a nameless stranger’s thoracic cavity, unable to dwell on the intimacy of this act, the magnitude of my trespass. My fingers sink into a morass of congealed blood. I reach for the small creature of his heart and grasp it tight.

Unbidden, the memory of the mouse surfaces: another sterile field, another heart ceasing to beat. A different chest, far more fragile, but forced open in the same way. That body, too, had yielded to us—not to be saved, but so that those of us who go on living could learn.

The man’s heart, a smooth, sinewy knob of muscle, has already fallen utterly still. It is already growing cold in my hand. The emergency medicine attending announces the time of death—11:48 p.m.—and the group pulls back for a moment of silence. I withdraw my trembling, bloodied hands from the dead man’s chest and fold them in front of me. We bow our heads as one.

The trauma bay empties quickly as nurses step away to check on other patients and residents trickle out to write their notes. I find myself alone with the patient. As the medical student on the trauma surgery service, I am tasked with making the body presentable for the family, once they are found and informed.

The room is in catastrophic disarray: everywhere are lengths of discarded tubing, empty saline flushes, gauze pads, medication packaging. The bloodied tools of the thoracotomy tray lay out in the open, and everything, everywhere is wet, all five of the liters of blood that are meant to be in the human body now outside of it. My shoe covers squeak and stick to the ground with each bloodstained step.

The man is utterly exposed, his clothes torn into ribbons by trauma shears. I drape a towel over his genitals and survey the ruin that once was his chest. The arc of his ribs curve outward like the rings of a felled tree. The thoracic cavity gapes open, an unlidded box.

Gingerly, I grasp the piece of ribcage arching up toward his head and hinge it back down into place like a clamshell, folding his chest shut once more. His young face is cold and white as marble, yet the pillow beneath his head is vivid crimson. I fetch a needle driver and a coarse synthetic suture and begin my final task. I have closed skin before, sometimes fascia in the operating room, but I have never encountered an injury so great. The man looks as though he were slashed in two.

I start near his right armpit. The gauge of the thread is thick, the curved needle as long as my pinky finger. I make a row of enormous stitches across to the sternum. I need to yank hard on the suture to pull his ribcage back together. My fingers shake and grow numb from the strain. Little by little, his silent lungs and the shredded meat of his heart are secreted away. It takes several lengths of suture to close the cavernous wound. I manage to give him the barest facsimile of wholeness. It is not deft, not elegant; it doesn’t have to be.

I tie off the last suture, wipe down his body with a wet cloth, and survey what remains. I think of the mouse, pulled at random from a cage. I remember how we taped down her limbs, cracked open her chest, and allowed her heart to beat for just long enough to harvest what we needed from inside her—precious tissue that might one day help scientists treat human disease. This man, too, did not choose to give, but he gave all the same. His last moments were defined by violence, by the trespass of ruthless, seeking hands, first in the desperate hope that his life might still be saved, and then, when that hope failed, in service of educating new and future doctors.

But what was I meant to have learned tonight? When I placed my hands into the sacred dark between a man’s lungs and cradled his heart, what was I meant to grasp? Whatever it was, it slipped away from my gloved fingers.

The trauma bay dissolves around me, a tumult of blood and light. All I see is a man, a human animal, unnamed, unclothed, unraveled: so much wasted life. I remember the second mouse, watching from her cage, waiting her turn. I know that before long, another patient will arrive. Another body, another fate. And once again, I will find myself at their side, still searching for something flickering just beyond my reach.