Examinations Pt 01

The young woman sitting in exam room 2 gripped the edge of the table with white knuckled hands. Directly in front of her, her left foot sat in an emesis basin, blood oozing from the wicked gash across her instep. Her great toe and the two next to it were blanched yellow and blue, since the blood destined for them was now leaking slowly into the basin.

The story she'd given me had to do with an industrial steel storage unit. I didn't believe her for a second. Her remaining foot was covered with light scarring, and her right foot was similarly scarred, as well as missing its little toe.

Her paperwork told me a lot about her, but the most important part of her was yet a mystery, albeit one I intended to unravel shortly. Shelly was 25 years of age, had never delivered a child, and lived on a trust fund from her deceased parents. Her credit was excellent, and she'd used it somewhat frequently in the last few years, for visits concerning her amputated toe as well as a short stay in our psych ward for depression. She did not appear depressed now, however.

Her lovely face was now set in a rictus of pain, certainly. But beneath that was quiet satisfaction, a look of a job accomplished. I knew the look.

Her dark brown hair was swept up in a side-pony, and she was clad in compression-style running shorts. Shelly's more than substantial bust was compressed as well, currently struggling valiantly to be released from a Nike jogbra. Her cleavage reached her supra-sternal notch, pillowing out of the neckline of her bra in delicious pale curves. It appeared to sweep around to her shoulder blades in back, and was obviously naturally gifted. The young woman's dark green eyes were currently closed, and her full lips were curved in a slight smile as she turned her face to the sunshine coming in through the window. She appeared to be about 5'5" tall, and except for her breasts, I would have considered her thin.

"Hello Shelly, I'm Dr. Abrevia. Are you in much pain?"

"No, Doctor. I'm pretty good for now. What's going to happen to my foot?"

"I'm sorry to have to tell you this, Shelly, but due to the level of injury, we're not going to be able to save your forefoot. What I'm going to recommend to you is called a Symes amputation. I will remove the remaining toes, rebuild the bone structure somewhat, and wrap the remaining skin up over the front of your ankle. You will be able to walk almost normally after some rehabilitation. Do you have any questions?"

I watched her face fall after I spoke. I was certain that I had not given her the news she'd hoped for.

She began almost at once, expressing her concern over blood circulation, infection, etc. Shelly was well informed and had obviously done her homework. The near panic in her face swayed me, and I decided to let her off the hook.

I interrupted her heartfelt plea and took her hands in mine.

"Relax, Shelly. You've convinced me. The rest of this conversation must not leave this room, OK?"

"Umm, OK."

A light sheen of sweat had popped out on her face. This sometimes precedes an episode of vomiting, but she said she was fine.

"If you could pick, Shelly, where would you want your leg amputated?"

"Are you making fun of me, Dr. Abrevia? Because it's not funny."

I pulled up the right leg of my surgical scrubs and showed Shelly my Otto Bock C-leg.

"Not kidding, Shelly. I've been where you are."

"Oh my God," she whispered. Her hands stopped trembling and the tears fell freely from her face. I hugged her to me. "I'd like it to be 6 inches below my knee, if that's ok," she said softly.

"I can justify that on my report, Shelly. I'll do a special procedure called a trans-fibular oblation. It involves placing a piece of bone between the tibia and fibula to prevent the ends of the bones pinching together when you use a prosthesis. It's called "Chop-sticking" and it's really painful. That, and myoplasty, neuroplasty, individual vessel ligation, and a special skin closure will make a very nice stump for you."

"I don't want a prosthesis," she said forcefully.

"Your choice, darlin', but I need to make the best stump I can for you, and that's what it takes. It's your choice whether or not to use a prosthesis. My nurse will be in to have you sign some papers, and then we'll get started. In about two hours you'll wake up as a RBK amputee. OK?"

"Dr. Abrevia?"

"You can call me Kate, OK. Shelly?"

"Kate, have you ever heard of an amputee named Jeanne Silver?"

"Long Jeanne Silver?" There aren't many of us who haven't. Why?"

Can you make me... like her? More thin...more, umm, usable?"

I winked at her. "As my lady wishes, so shall it be."

A few minutes later, I met Shelly in the operating room. As my scrub nurse held her foot over the basin, I administered a spinal anesthetic and soon it was over. Shelly had watched via a mirror for most of the surgery, but eventually drifted off to sleep, a smile on her face.

I removed her fibula at the knee joint, and then trimmed the tibia about eight inches from the knee, just to make sure Shelly had enough usable length. I brought the tough Achilles' tendon around the end of the altered Tibia and under and fastened it to the front to form a shield for the amputated bone end, which got an implantable button in the end to make it nice and round. Most of the rest of the muscles were removed to slim the profile of the stump. I took great care to make the final sutures very small to minimize the size of the scar, placed a drain, and bandaged the stump.

Shelly slept about an hour, and I was inspecting my work when she awoke.

"Is it done?" she asked.

"All finished, Shelly. It will be swollen for about a week, and the drain can come out in a couple of days. You can't get it wet until a couple of days after the stitches are out. I have recommended that you remain in the private section of the clinic for a couple of weeks and you'll start rehab as soon as the drain is out."

"I didn't know you had another section of the clinic, Kate."

"It's called my house, actually." I smiled at her. She really was quite beautiful.

"It doesn't hurt at all, Kate."

"That's because of the spinal. It won't wear off for another six hours or so. Try to move your foot. You remember that you only have one now, right?"

Shelly's eyes closed. "Oh yeah...I remember. It makes me really horny, but I can't feel myself." The sheet rustled as she explored her dead torso and lower limbs. "It feels like someone else's body."

"I'm going to start a Morphine drip, Shelly. The spinal will start wearing off in a few hours, and the pain will be intense for a while. This button will let you dose yourself up to a preset level so you will be comfortable, OK? It's important that you not be in pain, so don't hesitate to use it. You won't be on it long enough to cause a problem with dependence, so don't worry about pushing the button. I'll be off work in about three hours and we can talk for a while, if you're up to it."

"I'd like that, Kate."

I turned to leave and she called my name again. I turned. She blew me a kiss, and without thinking, I pantomimed catching it and pressing it to my lips. "Thank you, Kate," she said softly. "More than you'll ever know."

"You're welcome. More than you'll ever know."

I left the clinic and walked down the corridor to the private entrance to my home a little after six in the evening. I lingered in the atrium with a lovely Buddha statue and a Japanese waterfall cascading gently down a series of rocks I'd imported from Japan. The statue was a gift from my brother, Dr. Owen Abrevia, to celebrate the opening of my clinic here several years ago. Shelly was settled into a clinic bed in my living room when I closed the Heavy wooden door behind me. She appeared to be dozing, but her eyes opened when I began to type some notes into the clinic computer mounted to the wall.

"Hi, Doc. I don't know what's in here, but I like it a lot." She waved her arm in the vague direction of the morphine drip.

"Yeah, morphine is the ultimate warm fuzzy. Don't get too used to it, though. I'll be ramping the dose down quickly, so you don't get hooked on it."

"I'm just pulling your chain. I haven't actually used it much so far. I have a really high pain threshold. When I cut my toe...umm, maybe I should change the subject."

"Actually, we do need to chat about that, and the sooner, the better," I said. "I took a huge chance when I agreed to do this surgery, Shelly. Please don't make me regret it."

"Are you kidding? Dr. Abrevia, I think I can say with absolute certainty that you have saved my life! I am totally serious here."

"Go on," I said.

"I have been fascinated with amputees ever since I had a locker next to a LAE in junior high. She touched me with her stump once when I almost backed into her, and I was hooked, not to put too fine a point on it. I don't remember when it went from a spectator thing to wanting to be one, but over the last few years, it's been all consuming. Trying to arrange 'accidents', thinking of how I could get an infection, or nerve damage, or something, anything to become an amputee. I cut my toe off with a wood chisel, and told the doctor I had trapped my foot in a steel door threshold. I'm not sure he believed me, but he took care of it for me, even saying that 'a little toe doesn't really do much'. He was right, though. It didn't really 'do much' for me. I wanted something more disabling, more... 'amputating', I guess. It finally overwhelmed me a few years ago, when my folks died in a car wreck. I went to the hospital to see my Mom. My Dad died instantly, but my Mom lingered for a few days. I was at her side when she died, and, God help me, I was jealous of her, because both of her legs were pinched off in the wreck! That's when I checked into a mental health facility. They helped me get the compulsion down to a dull pain, and helped me get over the conflict I felt over my Mom's injuries and death, but it wasn't long before I was stalking amputees in the mall again. Wow, I don't think I have ever really talked this out before, not even with the shrink."

She went on breathlessly for several more minutes. I felt for her, because I had been there, but it was her story to tell. I recognized the hopelessness, the agony, the overwhelming knowledge that there is something wrong with you, and knowing that it will never be right..."and you'll never be right. And that's when I decided to just do it. I sharpened the flat point shovel I'd purchased years ago but never had the guts to use. I read the manual on the garage door opener, and found out how to disable the down-force sensor and the optical safety system. I programmed the clinic's number into the speed dial on my cell phone. I got a bungee cord from my Dad's camping stuff for a tourniquet. I thought that would seem more believable than just happening to have a two foot length of latex surgical tubing lying around the garage. I put the shovel on my foot and pushed the button. I wanted to take it off high enough that there wouldn't be enough left for a Symes, but the shovel slid on the bones until it hit a flat spot, and then it dug in. the bones were too tough, though, and it didn't go through. The pressure was incredible, but the pain was manageable for a while. I tried to take another try at it by raising the door and dropping it again, but it didn't work any better the second time. So I called and drove myself to the clinic. You know the rest."

While I was catching my breath from the rapid-fire storytelling, Shelly's eyes closed and she slept.

When I walked through the door from the clinic into my apartment about a week later, Shelly was asleep on the living room couch/bed she'd adopted since we'd moved her bed back to the clinic. I checked the counter on the morphine machine drip and saw that Shelly had not used it, for the third day. I filed the information under the 'satisfied' heading in my memory, and went to find dinner in the kitchen. I have meals delivered from the clinic kitchen, which keeps me from cooking, and gives the cooks something to do that's not overseen by the ADA.

I was reading a journal article about implantable pylons used to mount prosthetic limbs, wondering what other cool implements they could 'mount', when I heard a shuffle and turned to find Shelly standing in the doorway on Canadian crutches, her I.V. tagging along beside her.

"Hey there!" I exclaimed, startled by the sight. "How are you feeling today, Shell?"

"I was hungry, and the food smelled great. Can I have some?"

"Absolutely. Have a seat and I'll fill you a plate."

I loaded a small plate of food and sat it on the table, along with a glass of ice water. Shelly ate slowly and carefully, savoring her food, and we talked about nothing in particular.

I was entranced with Shelly's breasts. They seemed to be in constant motion, bobbing and swaying as she moved, breathed, even when she chewed. I can see the reason for the jogbra she'd had on when she'd presented. Her nipples bulged against the thin gown, nodding left and right as she moved. The gas-passer had said something about her "amazing rack" as we scrubbed, but a dirty look from me had shut her down. Shelly seemed nonplussed by them, and I forced myself to look instead at her face, which was nearly as fascinating.

Shelly's deep green eyes were shot through with gold, and her small nose crinkled adorably when she smiled. She used her hands when she talked, and her little voice was soft with just a hint of an accent I didn't recognize.

"Would you mind if I take off my leg, Shelly? It's been a long day, and it's a great leg, but enough is enough."

"Please do, Kate. I'm curious about it anyway. If fact, can I do it for you?"

"Sure. Just pull gently. I'll do the rest." I released the ratcheting keeper from the stud on my silicone sock, and the leg came off in Shelly's hands. She stood it up against the counter beside her and I held up my short stump up to her. She rolled the silicone sock off. She took my stump in her hands as if it were an object to be worshipped.

"It's beautiful, Kate. So soft...where's the scar?"

I lifted my stump and aimed it toward the ceiling. I pointed at a fine white line on the back of the stump. "It's here behind the tip and up a little on the back. See how tiny the suture line is? My brother Owen did the surgery for me, like all the ones before it."

"Other ones?" Shelly's eyebrows lifted high.

"That's a story for another day, I think. Do you need to go to the bathroom before I take your I.V. out?

"I probably should. My Grandma said never to pass up a chance to pee."

She swung easily into the bathroom; her new stump tucked against her other knee for security. I heard splashing noises and then she was out again. I asked her again if she thought she might need the morphine, and she assured me that it was unnecessary. I pulled the butterfly line and taped a cotton ball over the injection site on her hand, and the tucked her into bed. I showered and wrote in my journal a few paragraphs about the day and a few more about the special young woman in my living room.

Saturday morning found me lounging in my PJ's, big mug of coffee in my hands as I sat in the living room and studied the sleeping form of my houseguest. She lay on her back, arms at rest, left on her tummy while the other covered the upper swell of one pillowy breast.

For reasons I have yet to understand, I felt the urge to draw her. I hadn't taken out my sketch pad for years, ever since I made the decision to pursue medicine instead of art. The figure reclining on my couch awakened some lost emotion, I guess, and it only took me a few minutes to round up a large pad and some charcoal.

Moving quietly, being thankful that I was not wearing my backup leg, which tends to squeak when it's cold; I returned to the living room and rejoined my cooling coffee. I skinned my leg off quickly and propped my stump up on the arm of the black leather chair, then placed the sketch pad against the upraised column of my flesh. I worked quickly, conscious of the scratching noises the charcoal made as it swept across the semi-rough page. The image that emerged bore the face and body of my new friend Shelly, but the figure on my pad was almost primal. The woman on the pad looked out at the world with fierce eyes that bore into me with shattering intensity, a hint of a smile on her full lips, as if to say 'I'm the queen of this world, and I don't give a rat's ass what you think about me.' Her corded muscles stood out in animal-like relief against her naked skin. Beside her lay animal-skin clothing, more closely resembling a warrior's girding than a lady's garb. Her left calf was encased in a wrinkled, elephant hide greave and sandal, while a short peg made from a tusk and more elephant skin lay against the stone she reclined upon.

Her mighty breasts rested proudly upon her muscled ribcage, bolstered by amazingly developed abdominal muscles. Her shaven womanhood protruded unashamed from between her thighs, lips fleshy and slightly obscene. Her leg stump rested its tip on the ground, as if daring the viewer to feel the pain it withstood. In the middle distance, a saber-toothed cat lay on its side, watching distractedly as it batted at a large rabbit between its paws.

I sat back, my arm aching, thinking that I had temporarily channeled Frank Frazetta. My lap was full of charcoal dust and my coffee was cold.

I sat the pad down between my chair and a coffee table and stood, stretching. I grabbed my coffee mug and hopped easily to the kitchen. I washed the soot off my hands and arms, grabbed the nearly full hot pot, a bag of bagels and the container of cream cheese with the knife stuck in it and hopped back to the living room.

Shelly was sitting up on the edge of the couch, and looked up as I came into view. Her eyes opened wide and she broke into a smile as I hopped into the room.

"How do you do that?" she giggled.

"Years of practice and design," I quipped, quoting a line from a Mary Chapin Carpenter song.

"How's my girl this morning?" I said.

"I'm in the middle of waking up into a really nice dream, thank you. I looked down at my stump this morning, half afraid it wouldn't be there. Thanks to you, it was."

"Speaking of that, have some coffee and a bagel, and I'll hop next door and get a dressing change and we'll look at my needlework."

I returned shortly, and felt oddly self-conscious as Shelly watched me hop into the living room.

"You make that look graceful and beautiful, Kate. I don't think I'll make it look anything like that," she said, looking down at her breasts with a wrinkled nose.

"You will be able to charge admission, though," I said, and then instantly regretted saying it. "I shouldn't have said that, Shelly. I'm very sorry."

She looked up at me and her face was blank. I thought I had seriously screwed up, and then she broke into hysterical laughter.

She wiped her eyes finally, and said, "My God, somebody who doesn't tiptoe around my tits. I think I could fall for you, lady. But you have to stop apologizing, ok?"

"That's a deal, Shelly. Put your new stump up on the arm of the chair and let me unwrap it, ok?"

"I thought you'd never ask. I can't wait to see it."

"Remember that it's going to be about twice the size it's going to be when it's done. There's going to be a lot of bruising and swelling. The hamburger looking dealy is a vacuum drain enhancer, and I'm going to take the drain out and get rid of it."

I pulled the last gauze pad off, and Shelly looked at her stump with intense interest.

It was about the diameter of the large end of a baseball bat, and still yellow from the antiseptic scrub. A fine suture line ran across the back about 3 inches from the end, and remnants of plasma leakage stained the area. The drain tube ran out of an incision just above the suture line. I swabbed most of the color off and cleaned up the bits of miscellaneous gak clinging to the stump, watching carefully for any pain responses from Shelly, but for all the physical reaction the cleaning got from her, I might as well have been cleaning my own tissue.