Chapter 16 The Fishmonger's Valve

Mabel Ortega had my wrist in a fishmonger's grip.

"Your mother would've told me a terrible joke right now," she said.

She was sixty-four and she'd stood behind the haddock counter at Ortega's on Wharf Street for forty of those years, and her hands had not been soft for a day of it. She lay on the pre-op gurney in a paper hat, her gray braid tucked under it and an IV in the back of her hand, and she didn't take her eyes off me.

"She would," I said. "She'd have told you the one about the octopus."

"I never heard the one about the octopus."

"An octopus walks into a bar," I said, "and asks the bartender for a drink. The bartender says, 'Sorry, we don't serve your kind.' The octopus says, 'That's fine. I've got eight arms. I'll just hold up the place.'"

Mabel gave me a long, flat stare, the one she gave customers who asked whether the fish was fresh. Then she laughed so hard the anesthetist had to put a hand on her monitor leads.

"That's awful," she said. "That's the worst thing I ever heard. Helen would've loved it."

"She did. She told it at your counter years ago, and you gave her a free piece of cod to stop."

"I remember." Her grip on my wrist loosened. Her eyes were wet. "I remember you. You were this high and you used to stand on the crate by the scale."

There was another joke, one that was older and better and Helen's alone, and that one stayed where it was. Some things you keep in your own pocket.

I hadn't answered Rhys either. On Saturday, on the bench, Pippa had come running back from the fish shack with a lobster-claw story before I'd found a single word, and he had stood up and taken Admiral and the driftwood and walked the twins back to the car without another word. His question was in my pocket too. I'd left it there all weekend.

"See you on the other side, Mabel," I said.

"Don't you drop me, Margot Fairley."

"I never drop anyone."

---

The observation gallery above OR 4 held twenty-two people. By seven-fifteen it held thirty-one.

I saw them from the scrub room through the gap in the door: residents crammed along the rail, fellows standing on the step behind them, two medical students on the floor because there was nowhere else.

Word had gone around the sixth floor over the weekend. The Swiss stitch. The poisoner ex. The first one in Bramport. People who had never cared about aortic valves had decided to care this morning.

In the middle of the front row, arms folded across his chest, was Trent Kemp.

He'd taken the seat beside the intercom. When I came through the doors with my hands up and dripping, he leaned forward and pressed the button, and his voice came down into the OR warm and friendly and amplified.

"Watch closely, everyone," he said to the gallery. "You're about to see why we replace valves."

Someone up there laughed. Someone else shushed them.

I didn't look up. I put my arms into the gown the circulating nurse held for me and turned for her to tie it, and then my hands into the gloves, left, right, and then I turned around and there was Rosa.

Rosa Ibarra had been scrubbing cardiac cases at St. Ansel for fourteen years. She was forty-one, with the shoulders of a woman who swam in the harbor in January for fun and the most unbothered face I had ever seen on a human being.

On my first day she'd checked my loupes, then my hands, asked me which needle holder I liked, and never asked me anything else. I'd decided by lunchtime that I would follow her into a burning building.

"Morning, Dr. Fairley."

"Morning, Rosa. Leaflet set?"

She touched the instruments on her back table with one gloved finger, already laid out, already in order: the fine forceps, the curved scissors, the sizers in their row. Everything where my hand would look for it, in the order my hand would look.

"Leaflet set," Rosa said.

I stepped up to the table.

---

I don't remember much of the opening. I never do. Skin, sternum, the saw, the retractor, the pericardium opened and hitched out of the way. Then Mabel's heart was there under the lights. Big, from years of working too hard. Beating.

"Going on bypass," said the perfusionist.

The heart slowed, then stopped, then lay still in its cradle while the machine breathed and pumped for her. I opened the aorta and looked in.

Mabel's aortic valve was a mess. Three leaflets, but two of them had thickened and curled at the edges like old leather, and the third had a tear along its free margin from years of blood hammering through a gap it couldn't close.

Every beat, a little of what her heart pushed out had fallen back. For years. Kemp had seen this valve on an echo in February, written *replacement*, and told her she might not wake up.

I began to hum.

I'm told it's annoying. Lorenz used to say other surgeons swore in the OR and I hummed. Most of the time I don't know I'm doing it, and that morning I couldn't have told you the tune. Rosa told me afterward it was "the lobster one," which isn't a song, so I don't know what she meant.

I trimmed the thickened margins back to healthy tissue. I measured. Rosa put the sizer in my hand before I'd turned my wrist. I took a small patch of Mabel's own pericardium, cut it to shape, a curved piece the color of a shell's inside, and began to sew it in to rebuild the torn leaflet.

Small bites. Even spacing. Ten stitches, twenty, thirty. You can't rush a valve. You can only be exact.

I asked for the fine forceps and they were there. I asked for the 6-0 and it was there. I put out my hand for the next sizer and it was in my palm, and it was the right one, and so was the one after. Every instrument came the instant I wanted it, in the order I wanted it, as if Rosa were reading the inside of my head.

I didn't think about it at the time. You don't. You only notice an instrument tray when it's wrong.

"Testing," I said.

We filled the root with saline under pressure and watched. The three leaflets came together in the middle and held. A drop of saline seeped at one corner and stopped.

I closed the aorta. We took her off the cross-clamp. Her heart lay quiet for six seconds, which is always too long, and then gave one fat clumsy beat, and another, and then found its rhythm on its own and went on.

"Echo," I said.

The anesthetist already had the probe down. On the screen the valve opened and shut, opened and shut, gray-white, crisp. The wide flame of blue and orange that had sprayed backwards into her heart on the February scan was gone. A thin wisp, almost nothing, flickered at the edge and faded.

"Trace," said the anesthetist. "Trace regurg. That's a competent valve."

Somewhere above us, a person started clapping.

You don't clap in a gallery. It's not a theater, whatever we call it. But one of the residents in the front row had started, and then a medical student on the floor, and then the whole gallery was applauding, a muffled roar through the glass, thirty people in blue on their feet. Someone whooped. A fellow pressed his palms flat to the window.

I looked up, finally.

Trent Kemp was still in the seat beside the intercom. He was the only person in the front row sitting down. The residents on either side of him were clapping over his head, and one of them glanced down at him and then quickly away.

He leaned forward and pressed the button.

"Let's see how it looks in two years," he said. The speaker put his voice into the room a beat late, tinny and too loud. "Repairs fail. Write that down."

Nobody laughed this time. Nobody wrote anything down. The applause didn't stop. At the back, whoever had whooped did it again, longer.

The circulating nurse looked at me. I nodded. She reached over to the wall panel and turned the intercom down to nothing.

Kemp's lips went on moving behind the glass for a second, to no one. Then he took his finger off the button, stood, pushed past the residents along the rail, and left. The door swung shut on thirty people still clapping.

"He'll miss the best part," Rosa said, without looking up from her count.

"Closing," I said.

---

Mabel's family were in the sixth-floor family room when I came out at noon, still in my scrub cap. There were nine of them. I'd been told there would be two.

Her son came at me first, a big man in a fish-market jacket that brought the whole smell of Wharf Street into the room with him, brine and ice and diesel. He hugged me off the floor.

Then her daughter Leonie, who was my age and had her mother's braid and her mother's grip, put her arms around both of us. Behind them were two cousins, a brother-in-law, three grandchildren under ten and an old man in a flat cap who turned out to be Mabel's father and kept saying "Is she done? Is she done?" until someone told him yes.

"She's done," I said, into the son's jacket. "She's in recovery. It went well. Very well. Her new valve is her old valve, only better. She'll be sore for a while, and then she'll be back behind the counter yelling at you."

Leonie started to cry. The son put me down.

"Dr. Kemp told her she'd die," he said. "In February. He said a new valve, a pig one, and she might not wake up, and she should get her affairs in order. She went home and wrote out who gets the shop."

"Well," I said. "She can tear that up."

"Cod," said Leonie, wiping her face with the heel of her hand. "Best cod in Bramport. For life. You come to the counter, you don't pay. Ever. Swordfish when we have it."

"That's a bribe," I said. "I'll accept it."

The old man in the flat cap shook my hand and then forgot to let go of it. He told me he'd sold my mother her first lobster when she was twenty. She'd asked him how to tell if it was a boy or a girl, and he'd told her, and she'd laughed so hard she dropped it.

I'd never heard that story. I stood in the family room with my scrub cap in my hand and listened to the whole thing.

On my way back down the corridor a resident caught me at the elevators. She was one of the front-row ones, a second-year with a bitten pen behind her ear and a notebook already open.

"Dr. Fairley. Sorry. The margin trim. How do you know where to stop?"

"You look for where the tissue stops lying to you," I said. "Thickened leaflet is stiff and white and pretends it's fine. Healthy leaflet is thin enough to see the light through. You cut back until you can see the light."

She wrote it down word for word, which made me feel about a hundred years old.

"Dr. Kemp's telling everyone it won't last," she said, not looking up. "He was saying it at the elevators. Two years, and she'll need a valve anyway."

"Dr. Kemp may be right," I said. "Ask me in two years. Ask Mabel. She'll be at her counter on Wharf Street, and she'll sell you a haddock while you wait."

---

Rosa was still at the scrub sink when I went back through the suite at one to check the OR was clear. She'd been in since before six. Most of the team had gone to lunch. The room beyond the window was empty, the lights off, the table stripped.

I started washing my hands beside her out of habit.

"Thank you," I said. "This morning. That was the cleanest tray I've ever worked off."

Rosa took her time. She finished peeling off one glove, inside out, and dropped it in the hamper. She started on the other. Her face was its usual face, unbothered, but she was watching the window into the dark OR and not me.

"It wasn't clean at six o'clock," she said.

I turned off the tap.

"I came in at five-fifty to check my set. I always check my set." She peeled the second glove off slowly, finger by finger.

"The leaflet instruments were out of order. Not much. Two sizers swapped. The fine forceps on the wrong side. Your 6-0 under the 5-0, where you'd grab the wrong one if you were moving fast and trusting the tray." The second glove followed the first. "Somebody who knew what they were doing. Somebody who knew what you'd reach for, and when."

The water dripped from my hands into the steel sink.

"I put it back," Rosa said. "I didn't say anything this morning. You didn't need it in your head going in.

"Someone moved your instrument tray last night."