Chapter 5- Peanut in a Box of Worms

Joel Topf summarizes the donation nephrectomy.

Peanut in a Box of Worms.

This is the moment. This is the chapter where Vanessa gives her kidney to Robert. 

The chapter begins with a beat-by-beat explanation of the organ harvest. All the banalities that are glossed over in most medical dramas are examined with poetic beauty. Things we don't usually read or see:

  • The thumb and finger in an exaggerated snap used to open the mouth prior to sliding in the laryngeal blade
  • Sliding the ET tube through the vocal cords. Performing that simple maneuver still ranks as one of the most satisfying things I have ever done.
  • A description of inserting the foley catheter.

But I paused when she described the anesthesiologist listening to the chest for breath sounds. Dr. Grubbs specifies that the anesthesiologist listened to the right lung then the left lung, opposite the correct order of epigrastric region, left lung and finally the right lung. Is the author trying to tell us she has situs inversus? Is this a signal that the anesthesiology team is unconventional? Is this harbinger of future complications? 

But by far the best part of the chapter is the tour of the kidney in biblical and historical views.

It was through the kidneys that God examined the moral worth of man.

She then described how the visual symbol for physicians through the Middle Ages was a man examining the urine with a matula, a glass bottle with a rounded bottom designed to simulate the urinary bladder. Everything fell apart when examining urine replaced the remainder of the physical exam and scammers began exploiting people by claiming to predict the future by examining their urine. This practice of urinalysis became grouped with palm reading. There might be a lesson in here for modern nephrology and its dependence on labs at the exclusion of physical exam.

Dr. Grubbs then reviews the history of transplantation. Twin physicians, Cosmas and Damian supposedly transplanted a leg in Ancient Rome prior to be being martyred for being Christians. I am sorry about their getting beheaded but consider the tale of the successful leg transplant to be fake news.

The transplantation story resumes in the early 1900s as various surgeons defined the surgical procedures needed to attach the blood vessels, ureters and settled on a satisfactory site for the transplanted kidney. However, the transplants all failed in a matter of hours as the science of rejection lagged the surgical skills.

Richard Herrick received the first successful kidney transplant in 1954. The cheat here was that Richard's kidney came from his twin brother Ronald. The fact that they were identical twins allowed success despite the rudimentary immunosuppression of the era.

She concludes the history lesson with a quick review of immunosuppression from whole body radiation in the 1950's to azathioprine, to the breakthrough of cyclosporine in 1976 that finally made transplant a practical reality.

After the history it is back to the OR with a wonderful tick-rock description of a laparoscopic nephrectomy. She describes the precision and order of the nephrectomy team with detail and reverence. She paints a wonderful picture.

The title of the chapter comes from the surgeon, Matt Frank, reaching into her body to grasp the newly freed kidney and pull it out to be given to Robert. 

Reaching. Finding. Grasping. Pulling. He was determined to grasp my slippery kidney before it had a chance to drop down into my right side, at which point he knew finding it would be like finding a peanut in a box of worms—a four-inch kidney in twenty feet of small intestines. But he had it. He exhaled slightly, relieved.

Peanut in a box of worms. Perfect. I think the book works best when Dr. Grubbs mixes narrative with interesting historical perspectives. This chapter is exemplary of her best writing.