Brains

by Jaq Wright

  He hoped Tucker was up to it. He had been an admirable resident, working harder than everyone else, plus having better hands and smarts. Overbridge had been pleased when he went to Lenox Hill, although Mt. Sinai would have been closer to both his apartment and Our Lady.

  Our Lady of Salubrious Penitence. He smiled. He had gone there to poke them all in the eye. And himself. He was sure to have been the next Chair at Columbia's Neurological Institute of New York. Before Lake. Before Monique. Before Pierre. What an arrogant fool I had been. So, penitence at Our Lady of Salubrious Penitence. Founded in 1886 as a sanatorium for “working” women with tuberculosis or advanced syphilis, the nuns had been certain that the Love of God was heavily peppered with Divine Justice for the whores of Manhattan. He felt cursed himself, every day. It had been too far to walk up from SoHo, and so he would walk a mile or so north from his loft, then catch a cab the rest of the way, and the reverse in the evenings. Then he found increasing comfort in walking EXACTLY a mile, and it became clear that the only reasonable thing was to find a place at the proper distance. Exactly. It was better to leave SoHo anyway. Too many distractions, too many ghosts. He had been wrong, however, to think he could escape the ghosts. So, he quieted them by meticulous attention to detail. If he were perfect enough in his routine, they would leave him alone. Or at least be quieter. Less condemning.

  Banking had always been the family's plan. His father and his father's fathers before him had been bankers, and were quietly rich in the understated way of the Boston Brahmin. He had rebelled, but only mildly, going west to Berkeley instead of staying at Harvard. There he studied Economics and co-eds, planning all the while to eventually return to Harvard for business school. Then came Vietnam. And the first ghosts.

  He had been an exceptional marksman. He went to Southeast Asia as a well-trained killer. And kill he did. One hundred and thirty-three souls, if people really have souls. Seventy-eight shot in the head. The Brain. How many brains would he have to repair to make up for those seventy-eight? He had saved seventy-eight, and they still haunted him. He had saved seven hundred and eighty, and they still haunted him. Then seventy-eight hundred. Now over twice that. Seventeen thousand, two hundred and thirty-three saves. There had been some deaths, naturally, but they did not haunt him. Except for Lake, the only man he had killed neither by design nor by fate's hand, but by something less forgivable. Negligence.

  ◆◆◆

  The banging stopped, and he was taken out of the scanner. He could see Tucker through the glass of the control room, looking intently at the monitor.

  “Kindly ask Dr. Tucker to come look at the films with me in Emergency,” he was talking to the nurse wheeling him back. “I need to know where we stand.”

  Where he stood was actually lying on a stretcher, with a clot the size of a fist in the right side of his brain. Jack showed him the films. “The fact that you are awake and talking tells us that most if not all of that volume must be the aneurysm. Anyone with a sudden clot that large would be dead, or at least paralyzed on half of his body.”

  Overbridge grimaced. “Clearly. That aneurysm itself must be at least eight centimeters. You, Dr. Tucker, are in for an exciting night. I wish I could be awake to watch.”

  Irrespective of who the patient was, Jack had the same speech. “The risks of surgery include infection, bleeding, brain injury, and death. Your other options are . . .”

  Overbridge interrupted, “You and I both know that the only option is death. Anything else is a fairy tale or a miracle, and I don't believe in either one. Get me to surgery as soon as is possible, if you don't mind.”

  ◆◆◆

  The operating room was ready, so Jack headed upstairs. He was a little nervous. After all, this was not only Dr. Overbridge, but it was also a really big, leaking aneurysm, which he did not have the luxury of investigating more thoroughly. Plus, it was Friday night, and he was tired.

  He grabbed his iPod from the locker, slammed the door, and headed down the hall to operating room South-3.

  When Jack got to the OR, things were in their usual chaotic state, preparing for an after-hours case. A large room, twenty by thirty feet, it had been recently renovated, and was completely up-to-date, including video cameras mounted in the surgeons’ headlights so as to be able to record the entire procedure. The on-call surgery staff was bustling around, getting everything set up. The patient was not yet in the room.

  “Who do we have for anesthesia?”

  “Hi Dr. Tucker,” responded a pleasant woman in a Mickey Mouse scrub cap. “We have Dr. Franz tonight. He’s in pre-op getting the patient.”

  “Ah, Alice! I can't tell you how happy I am to see you. You never know who you're going to get on the weekend. And Paul, too? I must have won the lottery.”

  “Don't get too excited, Dr. Tucker.” She looked around. They were alone. “Your scrub tech is Jeremy.”

  “Jeremy? I don't know Jeremy.”

  “You wouldn't. He usually works Ortho. I'm not sure he's done a Neuro case since he got here.”

  Jack groaned. “Perfect.” Jeremy walked through the door and gowned up.

  “Jack Tucker. Pleased to meet you. Maybe we should go over the instruments I'm likely to use.” He put on gloves, and started going through the two-hundred-piece instrument set, indicating which ones he wanted to have available. Jack told Jeremy the name of each instrument, and he kept nodding and saying “got it,” but Jack could tell this was going to be a long one.

  “Don't worry,” Jeremy assured him, “I was in the army, I can handle anything.”

  Jack was not convinced. He plugged in his iPod, and chose his OR playlist. “The greatest hits of the ‘30’s, ‘40’s, ‘50’s, ‘60’s, ‘70’s, ‘80’s ‘90’s, and Today,” he announced.

  Paul Franz pushed open the OR door, and wheeled in the patient. “’Evening, Jack. This one looks interesting.”

  Dr. Overbridge was calling to him. “Yes, sir?” Jack asked.

  “Can you tell me your plan? Your precise plan? I need to know the details.”

  “Actually, Dr. Overbridge, what you need to know is that I am faced with an eight centimeter leaking aneurysm, and that I will have to see what it looks like when I get in. The last thing you need is for me to be constrained by a speculative plan based on insufficient information. You made a big effort to get here to be here with ME in MY OR, so now trust me to do my work. We’ll talk after, and I’ll give you the play by play.”

  Halfway through his little speech, Jack could tell that his patient had stopped listening, and appeared to be counting the ceiling tiles. Or maybe the little holes IN the ceiling tiles. Or maybe the molecules of oxygen in the air. Counting something, that was certain.

  Just before going out to scrub, Jack shot Cathy a text to let her know he was starting a leaking aneurysm, and had no idea when he would be home. Thank goodness tomorrow was Saturday, and he was NOT on call. It was already after ten.

  Things started out fine. Jack incised the scalp, exposing the skull, and cut out a good-sized rectangle of bone, setting it aside to be plated back in at the end. The aneurysm was a giant, pulsating mass with a wall as thin as tissue paper. Jeremy was pushing in to look. “Wow, that's a big one. What's the plan?”

  “Well, on the far side of that throbbing mass is the aneurysm's neck, probably no more than a quarter of an inch across, coming off of a vital artery not much bigger. If I can clamp the neck, we'll be golden. If I miss, or rupture the thing, we'll have a bloody mess, and I probably won’t be able to stop it fast enough to save anything resembling the essence of Dr. Overbridge here. If I accidentally clamp the artery itself instead of the aneurysm neck, then he'll have a major, possibly fatal, stroke. Also, I can't put enough pressure on the mass to move it so I can see. I'll have to do it by feel.”

  Jack got it exposed as well as he could, then went over and stared intently at the thirty-year-old angios. After a few minutes, Jeremy cleared his throat, “Er, Doc, are you going to do some surgery here?”
/>
  Jack turned slowly and looked at Jeremy. “The neck should be coming off the vessel in the same place where it always was. If you will kindly shut up, I am trying to get the position fixed in my mind so I can do this thing.” He turned back to the films, and stared and stared, trying to remove all words from his mind, and just become one with the three-dimensional anatomy of his patient’s brain. When he felt that his mental picture was perfect, he moved back into place at the operating table. He said a little prayer, and then, with one motion, he gently pushed the aneurysm forward, and slipped a long curved clamp along the side and around to what he hoped was the neck, and ratcheted the jaws together. It felt okay, but there was only one way to know. He opened the mass, suctioned out the blood, and as the wall collapsed he could see that his clamp was very nearly perfectly placed. He adjusted it slightly, applied the permanent clip, and stepped back, sweating.

  For the next several minutes, he simply stared into the cavity where the aneurysm had been. Just to reassure himself that the clip was holding, and that there was not any other bleeding. He zapped a few minor oozing points with his bipolar cautery, dabbed gently here and there with cotton sponges. Just watching. Appropriately, Tom Petty was playing on the speakers. The waiting IS the hardest part.

  ◆◆◆

  It was after two when he crept into his house. He went to the guest bathroom and took a warm shower to relax himself, then quietly climbed the stairs and slipped in bed next to Cathy. He was not sure whether she really woke up – she just twined her arms and legs around him and resumed her soft snoring. She had been a little embarrassed when he first had told her she snored, but it truly did not bother him at all, it was just soft and soothing. As he had told her, “I like it when you snore, because then I know you’re there.”

  He was too wired to sleep, just lying there for what seemed like hours, but it was in reality just a few minutes, motionless, enjoying the feel of Cathy breathing beside him.

  Chapter 18

  Saturday, October 22

  New York

  Jack woke up to the sound of his phone at a few minutes after seven. He was cranky. “NOT ON CALL,” he wanted to shout. But he knew it would be about Overbridge. He had told the ICU nurses that he would be taking calls over the weekend for that patient only.

  “Hi Dr. Tucker. Just wanted to give you the update. Your patient in 643, Overbridge, has been stable. Dr. Kelly has kept him snowed and hyperventilated to make sure his intracranial pressure stayed okay. Vitals are all stable. Do you want to try and wean him this morning?”

  “Yeah, go ahead and let him wake up. I’ll be over around ten. See if you can have him ready to extubate by then.”

  Jack made his signature goat cheese, havarti and mushroom omelets, with his mother’s secret ingredient, corn flakes, added for texture. Cathy was a big fan.

  “How long will you be at the hospital this morning?”

  “Not long. I just want to make sure he is neurologically intact once we get him off the blower, then I should be good to go. What’s on the docket for today?”

  Newlywed or not, Cathy had figured out that ‘not long’ to a neurosurgeon with a fresh post-op in the Neuro ICU meant somewhere between an hour and a half and six hours.

  “I was going to get my hair done at two, but there is a message that they had a cancellation, so I think I’ll go now. Let’s just see when we’re both done.”

  They walked together to Gino’s. “Let me know what’s happening,” she said. “I want to go to the flea market on the West Side later if we have time.” She gave him a peck and darted into the salon. He continued down Madison towards the hospital.

  When Jack arrived at the ICU, the Intensivist on duty was waiting. He was a large, round, smiling man from Louisiana and had some unpronounceable Cajun name, so was called “Bubba” by one and all. “He's ready to go, breathing fine, just waiting for you,” he reported.

  Jack looked at the monitors and checked the ventilator. Bubba was impatient. “Hey, Jack, he's cool. I'm pulling the tube.” He cut the straps securing the endotracheal breathing tube, deflated the balloon that was holding a seal in the windpipe, and smoothly drew out the tube.

  Dr. Overbridge coughed a couple of times, then looked at Jack. “It would appear that I am alive, so I congratulate you on a successful conclusion. I would like to have the pressure bolt removed, and then leave the hospital at once.”

  Jack looked at him quizzically. “I would prefer that you stay and remain monitored for at least twenty-four hours here in the ICU. I don't need to tell you the risks we run if your pressure goes up, or if you were to re-bleed. I doubt you would let any of your patients leave twelve hours after the repair of a giant leaking brain aneurysm.”

  “Certainly not. They would not be able to adequately comprehend all of the potential risks. I, on the other hand, understand them perfectly, and choose to go. Also, I would like to verify that you have not contacted anyone at Our Lady of Salubrious Penitence regarding this episode. I do not authorize you to discuss my case with anyone. Anyone.”

  “I haven't yet, but it seems like we should let them know you will not be at work on Monday.”

  “That is not your affair, Dr. Tucker. I will take action if you violate my confidence. Not one word. To anyone. Now kindly remove my bolt and IV, and sign my discharge.”

  “No, I think you should stay.”

  “Fine, I'll sign out Against Medical Advice. And yes, I know my insurance might refuse the bill. Please have the papers brought up at once. Don't worry, I'll pay if BlueCross balks. I am most grateful for your skill and service. Truly I am.”

  “I could hold you on an involuntary commitment.”

  “It would never stand. I'm lucid, and I am obviously aware of my risks.”

  Fine, Jack thought, Let the crazy old goat have his way.

  He watched while the pressure bolt and IV were removed, then followed Dr. Overbridge down to the lobby and watched him get into a cab.

  Overbridge rolled down the window. “One more thing, if you don't mind.”

  “Yes?”

  “Would you and your lovely new bride care to meet me for dinner this coming Friday? Perhaps the New York Athletic Club at seven?”

  “Uh, I'll check with Cathy, but I suppose that would be okay.”

  “Very well. Call me to confirm.” He rattled off a phone number, which Jack wrote on his hand.

  Jack stared as the cab drove off, then turned and walked home.

  ◆◆◆

  After Overbridge left Lenox Hill, he directed the cabby to turn up Fifth and head north. He stared to the side, counting the doorways as they passed. After a few blocks, he spotted a street vendor. “Pull over, please.” He unrolled the window, waved a twenty, and called to the man presiding over a large table of knitted hats and scarfs.

  “A black knit cap, please.”

  The man obediently brought over the item. “Ten bucks.”

  Overbridge handed him the twenty. “Keep it.” They drove on north. He next had the cab stop in front of a drug store on 94th. He called over to a teenager. “Young man – would you be interested in making forty dollars for ten minutes' work?”

  The kid was interested.

  “Please go into the drug store and get me two sets of eyebrow tweezers and a package of super glue. Here's fifty dollars, you can keep the change.”

  He shrugged, grabbed the fifty, and was back in more like five minutes, carrying a small paper bag. “Thank you,” Overbridge said, taking the bag. The taxi continued uptown.

  After two hundred and forty-three doorways had passed, they arrived at his apartment. He paid the cabby, took five steps to the door, six more into the lobby, nodded to the doorman, eight more steps to the elevator, up, and then four more to his apartment. He went to the mirror, and checked his appearance. He took off the new watch cap. The large incision was closed with skin staples, and had nothing to hide it on his bald pate. There were orange traces of the betadine prep solution around the ears and fo
rehead.

  He called his attorney, gave him instructions on what he required, then called the corner grocer, who sent a delivery order of bread, cheese, and smoked salmon. He was starving. He was also in searing pain. Although the brain itself is not sensitive, having a piece of bone sawed out of the skull is excruciating. He had no pain pills, other than Advil, which he did not wish to take due to risk of bleeding, and Tylenol. That would have to do. He ate, and then arranged himself seated in a high-backed chair, not wanting to lie down and invite brain swelling. After recording a new message on his answering machine, he fell into a fitful sleep.

  ◆◆◆

  Santiago glanced at his watch. Almost noon. Family number four had not made an appearance, but family three had set up, a couple of hours earlier, in exactly the same chairs as the day before. Okay, then, he thought, Family Three, you are the winners on the Price is Right. He had heard the father, Miguel, tell the mother, Marta, that they should take Jorge to the resort’s evening Fiesta at six. Santiago had room service send up fish tacos for lunch, and made reservations of his own for the Fiesta. He then settled in to watch and listen, keeping notes of anything that might be useful.