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New Fiction: The Heartbroken Work of a Staggering Liver

Introduction

In my mind, medicine and narration are intertwined. I understand nearly everything–from how a medication might work, to the course of an untreated disease–as a story. Perhaps that’s why I see literature and medicine as being woven of the same cloth. I know I understand a particular area of clinical medicine well when I can tell stories within that area. Once upon a time, in the fourth decade of life, there was a heart who had collected too much cholesterol along his coronary arteries… What is physiology but the protagonist, pathology but the antagonist? Organs are characters; drugs and interventions plot twists. Of course, the most important characters are the patients, nurses, and physicians. The most important plots are their lives. But every so often, I like to use the speculative fiction muscles, tell stories from the perspectives that have no voice.

Here’s a short bit told by a liver I dissected during a second year autopsy elective. The bald medical student is, perhaps obviously, myself. The blonds are a classmate I briefly dated and her new beau.

The names and details of the story are fabricated. No identifying patient information exists in this story. Though the pathological conditions described are real and the narrative was inspired by multiple real-life events, the narrated course of events is purely a work of fiction.

Creative Commons License

This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License.

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THE HEARTBROKEN WORK OF A STAGGERING LIVER

There is just no easy, delicate, or otherwise endearing way to say that I am a dead man’s liver lying on cold autopsy tray. Doesn’t mean I’m not beautiful in death, even with white grotesques grown into me, even with my staggering size. Look at me. I am dark red like a gem. I’ve sleek lines as if pleasingly designed. Firm, heavy. Slide your fingers across me. Velvety. I’m velvety for all my raw substance. For so long I’ve been silent while the brain talks, still while the heart beats. But I’ve got words like blood, like bile percolating through me.

The pathologists call this class Man in a Pan. But the man is gone, and I’m dead but not yet gone. Tomorrow I will be cremated with the rest of the body. I don’t mind. Better to burn than soak in embalming chemicals I can’t metabolize. An ironic purgatory that would be. Like keeping the lungs in air they couldn’t move, the heart in blood it couldn’t propel.

So I count myself lucky, and I lie on this table. Three medical students—dressed in thin white polyester gowns and purple gloves—pore over us with grave expressions, as if we are holy scripture. They don’t have a clue. Not about the how the man who died or who that man was.

So who was he? I wish I could say. I knew him intimately, knew him not at all. I metabolized the nutrients from every bite of food he swallowed, deactivated every drop of ethanol he drank, pulled the iron from his damaged red blood cells and made it into bile, assembled for him countless complex enzymes. But other than that…I know almost nothing.  Other organs would know more, but I was always too busy cleaning and building, building and cleaning.

Before today I’ve witnessed light only once. Twenty two years ago, the skin near my lower boarder opened. Gloved hands entered and cut out my gall bladder. The stones inside the bladder crunched like gravel when the surgeon rubbed it between thumb and forefinger.

This morning, they cut me out of my abdomen. Nothing gruesome about it. That surprised me. As she worked, the pathologist told a technician about hurriedly undressing and then redressing her six year old son so he wouldn’t miss a school play. As she peeled back my body’s skin and unfolded ribs that had been broken by CPR, I decided I was undergoing something similar to that impatient undressing. Hurry up now, little guy. We have to get this fat off of you or we’re going to be late. Here we go. Off with that fascia.

Later, other pathologists came into the room. They began talking over my case:  Mr. Roberto Gaspar—a 74 year old Hispanic male retired biology teacher—arrived in the emergency department yesterday evening with mild chest pain and bouts of dizziness. Three hours prior, he fainted and hit his head on the carpeted floor. Nothing broken or even bruised, but it scared him. For the past two months he endured increasing fatigue, abdominal pain, trouble moving his bowels, dark stools. Five years ago, he’d survived a minor heart attack.

Sitting up on the ED gurney with grimacing expression, Mr. Gaspar appeared pale and distressed. He stammered when speaking. Both his hands trembled. His heart was beating fast.

A blood test revealed elevated enzymes released by damaged heart cells, but the levels weren’t high enough to indicate a heart attack in the past two weeks. His EKG was abnormal, so the physician admitted him to the ICU and gave him medication that stabilized his irregular heartbeats. Mr. Gaspar tested positive for blood in his stool. More samples were sent for tests, but before they came back his heart entered a deadly rhythm. A code was called, CPR began. One rib broken. They shocked him. He regained normal cardiac rhythm; gasped in pain for long minutes; tried to tell the nurses that he didn’t want to be shocked again but found it difficult, nearly impossible to speak. Ten minutes later he entered another arrhythmia. A second code. More CPR. Two ribs broken. Shocked him again. They pronounced him dead shortly after 11PM.

His daughter and her husband arrived at the hospital an hour later, unaware that he had passed away when they were driving over from Oakland.

Death within 24 hours of admission to a hospital requires an autopsy. So here the pathologists were. After discussing the story above, they focused on maters pathophysiological—causes of arrhythmia, death, blood in the stool…but nothing about what he had been like, what he had looked like, whom he had loved or hated. Pathophysiology.

But then—in a lull of technical discussion—a pathologist wondered if he had been Portuguese. Gaspar was apparently a common enough Portuguese name. The pathologist in question was of Portuguese decent, had a cousin living near the Little Portugal neighborhood of San Jose. And did the other doctors know the Portuguese had been living in Northern California for centuries? It was true. They left the volcanic islands of the Azores aboard whaling ships, living for a time in New England, before trading Atlantic waves for Pacific blue and settling around San Francisco. Perhaps Mr. Gaspar was descended from one of these settlers. Perhaps Mr. Gaspar and the pathologist in question were related to each other. Pause.

And that was it for the historical trivia and the conjecture about Mr. Gaspar. For the rest of the morning and afternoon, there were nothing but recitations of the past medical history, past surgical history, findings that confirmed or refuted past diagnoses. The doctors waited on some microscopic examination. The results came back. They had a diagnosis. They moved on to the next cadaver, the next case.

A technician wheeled me and the other organs upstairs into a smaller lab. There were windows on the far wall, brilliant California daylight shining in. It dazzled me. I’ve never witnessed daylight. It was like…like…an intoxicant I was not obliged to metabolize. Even now it makes me both giddy…and more acutely sad know that tomorrow I will become ash.

There is another problem with the sunshine: one of the med students leaning over me is bald and the daylight shines unpleasantly off of his scalp. He’s a stocky fellow, black goatee, head like a cue ball. Looks like he was headed for a convention for boxing referees, got lost, ended up in medical school. I don’t like the way he keeps grimacing at me as if trying to ignore the other two med students. They’re more pleasing. Tall, fair. They examine the organs, stand closely together, brush against each other as if by accident. They’re secretly taken with each other. It’s endearing. It makes me wonder about Mr. Gaspar. He had a daughter, but did he have a wife? Or perhaps an ill-fated romance? Perhaps after years of estrangement, his daughter found him. Perhaps he called his daughter from the ICU and she came driving over the bay to be with him.

You might be surprised to discover a liver with a romantic streak. I’ve been in this external world for hours only and already I’ve heard the phrases “listen to your heart” and “get it off your chest.” Perhaps it is the heart you think is romantic and poetic. Please, no. Don’t listen to the heart. He’s got nothing but tda-d’da to say, over and over again. Tda-d’da tda-d’da tda-d’da tda-d’da. The only time he said something different, we died.

The only hearts worth listening to are the broken ones.

Let me tell you something about livers. We’re organs of the ragged and the new: master artisans of enzymes, garbage men of the bloodstream. New treasures and old trash, that’s our love. Consider this fact: livers are the only irreplaceable organs. Can’t breathe? The ventilator can take over. Heart acting sluggish? Not a problem if we catch it early; it’s only a pump. Kidneys not filtering? The eggheads invented a hemodialysis for you. No stomach or bowel? They’ll push the pre-digested metabolites right into your veins. No brain? Not really necessary for a living body. (And, really, you should have known that last fact. This morning, one of the pathologists spoke at length about an entire American city where people without brains may live and work for years. But, likely, you’ve already heard of Washington DC.) But if your liver should fail…. Well, there’s no machine to take our place. You get a transplanted liver or you die. Simple as that. We’re the essentially human component.

If organs could became people, we would become what a pathologist this morning called a “hipster.” It seems there are a lot of them in San Francisco. Although, I think we would be less sarcastic. But, yes, brilliant and deliberately run down. Beatnik, bohemian. That’s us.

I don’t think any of my med students are hipsters. The blonds seemed too done up; she’s wearing rouge, he hair product. And Cue-ball, well, him in skinny jeans. Ha. Right.

I’m starting to worry for my med students. They keep looking back to me, remarking on my peculiarities. But the cause of death lies elsewhere. I’d tell them, if I could. Looking on with arms folded is the pathology professor. He’s waiting, smiling. He knows that I am his decoy. But a striking decoy. I have a bit of swagger and strange beauty in my dysfunction. Hipster, remember.

I’m half again as large as a healthy liver. On cross-section, I am bright bloody red inscribed with tan reticular lines. As a younger organ, I was respectably brown.

Now my underside has been partially sliced; my one-centimeter flaps lay pressed together like pages. The students flip through me as if I were a book. Each time they stop on the pages of my pale grotesques, my three metastases of colorectal carcinoma. Each is a tight, knobby knot of white. Something frightening in their geometry makes me think of hunger and blindness. My largest tumor has a black rotting center. The cancer outgrew its own blood supply.  The pathologists described this dark center as ‘necrotic.’ I think that’s a very evocative word. It almost hurts to think of that cracking –khr- sound in the center of the word, sharp as the cancer in the center of me. Necrotic, necrosis, necrotic…

It’s the grotesques that hypnotize the med students. Fascination with the abominations. They try to keep their faces calm, but you can see the tightness underneath. They can’t hear the cancers muttering in their guttural nightmare language about hunger and immortality. The driving wish of cancer is to live forever. That’s why cancer refuses to stop growing when the body hands it tiny chemical suicide commands. That’s why cancer tears through the body. It kills in an attempt to live forever. Ironic, no? The med students have found the original lesion in the colon. They know portal veins drain blood from the intestines to me, carrying nutrients leached from food…and malignant cells loosed from tumors.

Across the room, the pathology professor clears his throat. He walks to the table side and asks for their diagnosis. What killed the patient?

The students stare at me. No one speaks for a longtime. They look at each other, knowing that they haven’t a clue about what’s going on. Whoever opens their mouth first is going to reveal their collective ignorance. Seems like a familiar situation to them. It’s a contest of who can stand the silence the longest. Cue-ball is going to lose. I can tell; his scalp is flushing pink. It’s a pleasant shade, actually. Reminds me of the smooth sheen of the diaphragm muscle that lay above me for so long.

The professor asks again for the cause of death. Cue-ball cracks and starts talking about the cancer in the colon that must have bled into the stool and then metastasized. He gestures toward me, as if my pale grotesques weren’t obvious to anyone within a hundred feet. “And the cancer must have…” Cue-ball says before looking at the heart, who is free of cancer, and then at the blonds. They don’t know how cancer killed the patient. But all of them look sure that cancer caused the death…that’s what metastatic cancer does, after all. Isn’t it?

The professor smiles. Trap sprung. He directs their attention to the heart. The pathologists have cut open each chamber so as to make him a collection of flaps, like some complicated garment. The poor organ. He’s still muttering tda-d’da gotta get back to tda-d’da tda-d’da tda-d’da. Gotta get back. Tda-d’da. The pitiful, confused bastard.

The professor wants an analysis of the heart. What’s wrong?

Silence.

Time for professorial leading questions. Didn’t the patient die of an arrhythmia? Yes, he did. Isn’t the heart a little too large, a little dilated? Yes, it is. And wasn’t the liver too large and bright red with blood? Indeed, I am. How are those connected?

He-blond gets it. “Right-sided heart failure?” he answers and asks at the same time. The professor nods. The right side of the heart wasn’t moving blood out of the liver, out of me, fast enough so I became congested with blood.

The students nod.

So what about the arrhythmia?

The students stop nodding.

The pathologists sighs, holds up the ragged heart, who is still muttering. Tda-d’da tda-d’da. The professor moves through the folds of muscle until he comes to a patch of pale tissue. A scar it turns out, from Mr. Gaspar’s first heart attack five years ago. She-blonde remembers aloud that cardiac scar tissue can cause arrhythmias. For the first time, the professor smiles. He complements her, and then indicates another patch of gray in the heart; this one smaller and almost yellow. It’s a newly forming scar from an unnoticed or ‘silent’ heart attack the patient sustained about twenty days ago. In all probability, the forming scar set off the fatal arrhythmia. But what was the relationship between the cancer, the silent heart attack, and the arrhythmia?

All eyes back to me. Then the blonds look at each other and Cue-ball scowls. The professor clears his throat. Now all the students look at each other. “The colorectal cancer was bleeding for a long time,” says Cue-ball. “So he was losing blood in the stool for a long time. Maybe he was anemic.” That’s nice. I’m glad Cue-ball finally said something worthwhile.

He-blond jumps in. “And if the patient was anemic, that would have caused his heart to race and made it more susceptible to heart attacks and arrhythmias.”

The pathologist points to me and casts out his pearl of wisdom.

My grotesques and I are impressive. It is hard not stare. This led the students to commit the cognitive crime of “anchoring” or “focalism.” They were trying to explain the whole picture in light of its most striking feature. But Mr. Gaspar had not died of liver failure. They knew that, but my grotesques were so much more interesting than the heart (it is not a surprise) that they had misjudged his pathology. This ‘anchoring’ was a vital part of the broader ‘confirmation bias,’ in which a physician searches for evidence to support a favored diagnosis but not evidence that might refute that diagnosis.

The med students nod, impressed. The professor takes a moment to savor a point driven home. Then, with a curt nod, he ends the class. They pull off their gloves and gowns and leave. The professor heads back down to the basement lab.

I am left alone with the other organs. My grotesques mutter about immortality, the intestines groan, the heart stutters out his remembered rhythms. But I’m quiet, thinking about our story and Mr. Gaspar’s story. They both stem from the question: How did Roberto Gaspar die?

I think about the students and what they will remember: cognition errors, pathophysiology, a story written by the organs not by the man. How Roberto Gaspar died. But what of his last night? Did he sleep, or toss and turn? Did he wake early and call his daughter and say that he had been thinking of her mother? Was the daughter scared by the strain in his voice, unsettled because she too had been thinking of her mother? Did Roberto go to the church? We are going to be cremated. That’s less common for Catholics, so perhaps he wasn’t very religious. Doesn’t mean he didn’t light a candle for the memory of his dead wife. His lost wife?

On his way home, did he wonder how he had gotten so old? His muscles so much weaker than they had been. His heart was scared from the attack five years earlier. Part of his bowels had been removed fifteen years ago when they found a small cancerous lesion. Then there was his painful hip, his sore back, his fatigue. All his lost abilities. Did he think back to his young self and marvel at how he had never once suspected that he would eventually become this disabled? Did his chest hurt before he fainted at home?

This was the story the students would never know; worse, I would never know.  How Roberto Gaspar died.

Inside, I feel something both sharp and hollow. It seems in death we do not know ourselves.  I haven’t much longer. Maybe twenty hours. Maybe ten. It’s not a pleasant feeling, this sharp hollowness, but it does make this striking world around me more striking, the bright daylight brighter.

Comments

12 Responses to “New Fiction: The Heartbroken Work of a Staggering Liver”

  • Yay new fiction! I really liked this. You should do a collection of medically-inspired short stories like this. I dig your fantasy stuff, but I also really enjoy this kind of writing a lot, and I would eat up more of it!

    • 🙂 Oh good. I thought this would be so weird no one (but me) would be that into it. I may or may not have one or two of these organ based stories hanging around…

  • Rachel Marie-Emil

    9:04 am Sep-14-2011

    Reply

    I adored it, Blake! Such an interesting point of view. I agree with Vivienne on the collection and hope to see more of this. 🙂 Great work!

    • Thank you kindly! I’ve got another told from the PoV of the brain’s glia (i.e. the part of the brain that is not neurons). It’s even weirder 😉

  • i stared at this for a long time, because there are so many ways to read it:

    “The only hearts worth listening to are the broken ones.”

    i’ve been staring at my screen, just thinking. i’d like to see the other one you mention, if you’re sharing.

  • Wow and oh my. I’m reading this on the backside of finishing Spellwright. I appreciate authors whose work makes my mind shift enough to give me a new perspective..perhaps to break the paradigm. This piece is brilliant. Thank you.

  • […] tour (hello from Dallas, btw), I’m publishing another organ-based magic realism story. As with The Heartbreaking Work of a Staggering Liver, this is an experimental bit of fiction that helped me to explore the close relationship I […]

  • Hello again! Recognize me despite the name change? (Is there any way for me to change my name in the other places I commented to this new name, do you know?)

    You, sir, are very strange and very funny. I laughed out loud at your description of yourself (and again when your scalp turned pink) and at the Washington, DC comment. Thank you very much for sharing! Don’t worry, nothing is too weird for the Internet. 😉

    • I’m afraid I need more of a hint about the name change 🙂 And thank you for the kind words about this story.

      • It was only recently that I left comments on several posts for the first time. I used the same email address but a different name, and I wonder if there’s a way to change my name in the other places to this one so that it’s consistent.

        You’re very welcome.

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