“That’s not going to happen,” Grant said. “I’m very good at what I do. Which website were you on?”
“AVM survivors’ network or something like that.”
“She was obsessing about whether she’ll ever be allowed to exercise,” Michael said. “I had to take away her computer.”
“We’ll talk about all those things later,” Grant said.
“But what if I end up on the wrong side of the percentages?” Alison said. “Someone has to. There are people behind those numbers.”
“I could go through the chances of getting every complication,” Grant said, “but that isn’t going to make you feel any better. Right now, the best thing to do is focus on the surgery and recovery.” The room felt stuffy all of a sudden. He hoped he’d said enough to get her off this topic. He couldn’t take any more talk about complications and message boards.
“Okay,” Alison said. Grant could hear by the pitch of her voice that she was trying not to cry. If he didn’t change the topic, he’d never get her under anesthesia.
“Did Vik come to see you yet?” Grant asked.
Alison nodded. “He asked me all sorts of questions and looked in my mouth. Something about making sure it would be safe.”
“Great, then all we need to do is get the consent signed and we’re good to go.”
Grant grabbed her chart from the nurses’ station and opened up to the informed consent page as he walked back to the bedside.
“So, this is when I tell you about the procedure you’re having, the alternatives and the possible risks. I think we’ve been through all this already. You know this isn’t a straightforward surgery and there’s always a risk of bleeding, infection, and a small risk of stroke. Having said that, I got my reputation for a reason. My patients do exceedingly well.”
Over the years, he’d shortened the informed consent discussion considerably. Some may think he sounded conceited when he bragged about his skills, but for the most part, his confidence put his patients at ease. In this case, a lot of what he was saying was an act. Alison’s AVM was so large and in such a difficult location that he wasn’t at all sure she was going to do well, but he had to pretend. Usually he felt a sense of ease while the patients signed consent, a feeling that he could handle anything that came his way, but today felt different. Today, the pep talk was more for him than for her. He would have to do his best to forget who his patient was and hope his years of training and experience served him well.
Grant cleared his throat and handed Alison the clipboard. “I just need your John Hancock right here,” he said, pointing at the line for her to sign.
“How will we know if the surgery was a success?” she asked.
“I’ll know how much I was able to resect, but we’ll keep you sedated for most of the day. Give your brain time to rest before we take out the breathing tube. We’ll also carefully monitor your vital signs to make sure there aren’t any fluctuations.”
“Okay, I think I’ve heard enough,” Alison said while she signed her name on the line. “Any more talk and I’m going to rip up this form and walk out of here.” A small part of Grant hoped she would do exactly that. Maybe he’d agreed to take on her case too easily. He should have encouraged them to get another opinion after they wrote off the guy at the Cleveland Clinic.
“Let’s do this,” Michael said.
Grant took the clipboard back and patted Alison’s leg. “I’m going to take good care of you.” He could still feel his heart rate racing and now there was a whooshing sound in his ears that he’d never noticed before. As he was placing the chart back on the rack at the nurses’ station, he heard Michael calling his name from across the room.
“Grant, are we doing the right thing here?” Michael asked.
“We don’t want to have any regrets,” Alison added.
“Absolutely,” Grant said, walking away toward the OR entrance. “You’re in good hands.” He held his ID up to the card reader and entered through the double doors.
When Grant reached his usual room, everyone was busy preparing for the case. The scrub nurse counted instruments on the sterile tray, while Wendy reviewed the schedule on the computer, and Vik programmed the anesthesia machine.
“Dr. Kaplan, we’ll be ready to start in ten minutes,” Wendy said.
“I have a stellar team,” Grant said, doing his best to seem relaxed. “What would I do without all of you?”
When he went to the hallway to grab a cup of water, Vik followed him. Grant filled his cup from the cooler and drank it down in three big gulps.
“I wanted to check in with you,” Vik said.
“What do you mean?”
“See how you’re feeling about this whole thing. This is a big deal.”
“You mean the fact that my sister-in-law has an AVM the size of Texas?”
“I meant your decision to perform the operation,” Vik said. “It’s not too late to change your mind you know.”
“I can’t do that. I’m the best person to do this. How could I forgive myself if I sent her away and she had a bad outcome? I really have no choice.”
“There’s always a choice,” Vik said.
“What are you saying, Vik? That I should call it off?”
“Not necessarily. I just want to make sure you’ve considered all the possibilities. What if you go ahead and she still doesn’t do well? Have you considered that?”
“I can’t think that way. Right now, I just need to stay focused and get her through the surgery.”
“I hear you,” Vik said. “You know I’ve always got your back.”
One of the transporters wheeled Alison past them and she gave them both a nervous smile. As the gurney rolled through the OR doors, Grant and Vik both followed behind.
“Don’t worry,” Grant said. “I have everything under control.”
Though Grant understood Vik was only trying to look out for him, the last thing Grant needed today were doubts. He did his best to put the conversation out of his mind so he could focus on performing the most flawless surgery of his career.
After Wendy got Alison situated on the table, Grant walked to the sink in the hall. Before starting his scrub, he placed two fingers on his neck to check his pulse. It still felt a bit fast, but now that things were moving in the right direction he had calmed down a bit.
He set the timer next to the sink for five minutes, and turned on the water with the foot pedal. Wetting a sterile scrub brush, he cleaned under his nails and then squirted soap into his hands, rubbing his hands together and spreading the lather all of the way up to his elbows. The scrub sink was the closest Grant got to a house of worship, using this time to center himself and clear his mind. He worked through the surgery step by step in his mind, envisioning the entire thing from the first incision to the closing staples. At the end, he took a moment to hope that Alison would come through the surgery intact and healthy. Some might call this a prayer, but since Grant didn’t subscribe to religion, he would never put that label on it. Today he almost wished that he did have faith, but he had to believe that even an atheist surgeon deserved a little divine attention in this extraordinary situation.
As he rinsed the soap off his hands and forearms, he pictured the water washing his sins down the drain. He lifted his foot off the pedal, pushed open the OR door with his back and stepped into the embrace of his blue sterile gown and gloves. Wendy tied his mask behind his neck and fit his plastic goggles over his eyes.
Vik had already administered sedatives through Alison’s IV and intubated her. With her arms strapped to the arm boards at shoulder height in a T shape, she looked like the angels Sadie used to make in the backyard on a snow day.
“Okay team, let’s do this. It’s definitely a Getz and Gilberto kind of day,” he said to Wendy. She gave him the side eye as she turned on the music, knowing full well this album was reserved for only the toughest of cases. Hopefully, the bossa nova music would keep him positive and focused for today’s crucial operation.
> A blue sheet extended upwards from Alison’s upper lip, separating his surgical field from the rest of her body. When he stepped to his side of the sheet, he saw that his chief resident, Matt, had already shaved the left side of Alison’s head and positioned her in the headrest and skull clamp for cranial stabilization. When Grant looked down, he noticed a pile of blond hair on the floor.
The lights over the operating table seemed much brighter today. Grant wasn’t sure if that was because they had just replaced the old fluorescent bulbs with LED lights or whether it was an effect of the Adderall. When he tried to focus, he noticed his heart rate now felt irregular, the beats either too close together or too far apart. He couldn’t take his pulse in his neck because he couldn’t touch anything but the sterile field, so he took a few deep breaths to try to break the unsettling rhythm.
“You okay?” Vik gave him a look of concern over the curtain.
“We’re all ready to go,” Matt said.
“I’m fine,” Grant said. He asked for a scalpel and made the first incision along Alison’s left temple and then over and behind her ear, trying to camouflage the incision in her hairline so that no one would ever notice the scar.
“Time of first incision is 7:04 AM,” Wendy said as she typed that information into the electronic chart. “On-time start Dr. Kaplan.”
“Close enough.” After he pulled the scalp flap over the top of her head, he passed the bone saw to Matt. Though Grant had done this more times than he cared to count, he couldn’t bring himself to cut Alison’s skull. When Matt rested the blade on top of the shiny bone, and turned on the switch, the whirring noise began. Grant knew this was the same noise he’d heard during every craniotomy, but this time it sounded different: louder, higher pitched and much more irritating. When the noise shot straight to his auditory cortex and jangled his brain cells, he wanted to plug his ears with his fingers to make it stop. The familiar burnt smell of bone dust filled the air. It usually didn’t bother him, but today he could feel it coating his nostrils and mouth, making him queasy. Swallowing his saliva, he willed the nausea to go away so he could concentrate on the surgery. Finally, Matt finished cutting through the skull and removed a segment of the parietal bone to expose the dura.
“Good job, Matt,” Grant said. Every time he spoke, or even just exhaled, he felt the heat collecting under his mask. He wondered how he ever managed to breathe in this thing without suffocating. The room felt like it was at least eighty-five degrees, sweat dampening his scrub cap. “I’ll take over from here.” Maybe if he was operating, he’d be able to clear his mind of diversions: the heat and the noise and his irregular heartbeat.
Usually Grant would need to peel back the dura before he got a sense of what he was dealing with, but now he could see the reddish discoloration of the parietal lobe even through the thick, white membrane. The dura pulsated with each beep of the anesthesia machine. Grant asked for a scalpel and sliced through the dura, taking special care not to nick the AVM or the brain tissue, and then folded it back on itself to expose the surgical field.
“Wow,” Matt said. “That’s a whopper.”
Grant had decided not to tell Matt about his relationship to Alison. The chief resident was known for following the rules at all costs and making sure all the more junior residents did the same. The situation was already complicated enough without getting into a conversation with his subordinate about the ethics of taking on his sister-in-law as a patient. As the attending, Grant could pull rank and shut the conversation down, but he would rather not have to play that card.
“It sure is,” Grant said. The malformation looked even bigger and angrier than it had on the MRI scan. The bright red arteries and maroon veins crisscrossed over each other in haphazard ways, forming tangles and gangly knots. It reminded Grant of the puzzles Sadie used to do on the airplane, the ones where she had to keep her eyes on one squiggly line as it meandered over others, tracing the same line to the finish without straying off course. He tried to track the path of a dilated vein as it intersected several arteries until it disappeared deep in the brain tissue, and then when he tried to track another one, he started getting lightheaded. This wasn’t going be an easy case. He wasn’t sure how much of the malformation he would be able to resect without causing serious deficits.
“How are we going to approach this?” Matt asked. The heat inside Grant’s mask now felt stifling, and his breathing was shallow and rapid. No matter how many times he breathed, he couldn’t force air down into his lungs. The edge of his scrub hat was sopping wet and he could feel the sweat trickling down the side of his face and threatening to drip into the surgical field. “The Girl from Ipanema,” which Grant usually found uniquely beautiful, now sounded haunting and ominous. Something was very wrong.
“She’s holding stable over here.” Vik tried to make eye contact with Grant.
“Thanks.” Grant avoided looking up, afraid that Vik would be onto him the instant their eyes met.
“Is everything on track, Dr. Kaplan?” Wendy reached around from behind him to dab his forehead with a towel.
“Yeah, all good.” When Grant asked for the forceps and tried to lift the delicate arachnoid membrane from the surface of the parietal lobe, his fingers began to tingle. No matter how he adjusted, he couldn’t maintain a confident grip on the instrument. As his heart threatened to pound through his sternum, he knew he had to get out of this room before he passed out on the operating room floor.
“I need to step out,” he mumbled as he walked toward the door, his feet moving in slow motion.
“Dr. Kaplan?” Wendy followed him into the hall.
“I need a minute,” he said. “Tell Matt to keep going.”
Grant ripped off his gown and gloves and dumped them in the hall trashcan before staggering to the locker room. He sat down on the bench and bent over so his head hung below his knees, trying to get his breathing under control and his heart rate back down. Peeling off his scrub cap, he grabbed a towel from the pile on the bench and dried the sweat from his hair. What was wrong with him? He’d had his fair share of challenging cases, but nothing like this had ever happened before. He had to get back in there before everyone started to get worried. Matt was an excellent chief resident, but not good enough to handle this case on his own. He sat up and took a few deep breaths.
Grant stood up, opened his locker, and reached into the pocket of his pants. He found the yellow envelope and tipped a few Oxy tablets into his mouth. He had never taken it at work before, usually reserving the opioid to help him come down at the end of the day, but today was not a typical day. He had to do something to calm himself down and this was the only way he knew how. Stretching his legs onto the wooden bench, he decided to lay down for just a few seconds until the medicine took effect.
When he opened his eyes, he felt much better. The tingling in his fingertips had subsided and his heart rate had returned to normal. The Oxy must have done the trick. He walked back to the sink outside his OR and scrubbed up again, realizing immediately by the look of fear in Wendy’s eyes that something had gone seriously wrong while he’d been out. In his absence, the perfect order of his OR had fallen apart: the music had stopped, the cardiac monitor galloped, and the staff were all yelling. Blood-soaked gauze pads covered one of the steel Mayo stands. The clock on the wall read 8:37. He couldn’t have been gone for half an hour.
“We called you over the PA several times, Dr. Kaplan,” Wendy said. What the hell was she talking about? He hadn’t heard any overhead pages. How long had he been in the locker room?
Once his gown was tied, Grant retook his position at Alison’s head.
“What the fuck, Matt?” he said.
“Dr. Kaplan, I don’t know how this happened.” Matt’s breathing was ragged and panicky. “I can’t stop the bleeding.”
When Grant looked down at the surgical field, he couldn’t see anything through the sea of blood. This was his worst nightmare. In the month since Alison and Michael had shown up in his offi
ce, he had run through the steps of this operation over and over in his head, but he had never allowed himself to imagine that things would go this wrong, that he would be standing where he was right now. He now pictured Alison confined to a wheelchair, her once toned body slack and pudgy, and the horrified look on Cynthia’s face when he told her what had happened. He tried to regroup before his thoughts pulled him under.
“Matt, I’ll take over from here,” Grant said. “I think Dr. Shin needs an assistant in the next room.” Cal already had an assigned resident, but if Grant was going to get this operation back on track, he needed to remove all unnecessary distractions. He tried to suction away the blood, but the more he sucked out, the more seemed to accumulate. He couldn’t see what the hell was going on. Grabbing the Bovie device from the scrub nurse, he began cauterizing all of the possible bleeders.
“I’m sorry, Dr. Kaplan.” Matt stepped back. “I did my best.”
“Put on the Herbie Hancock, Wendy,” Grant said. He needed some funkier jazz to center his energy and bring everyone’s focus back to the task at hand. As the synthesizer sounds of “Chameleon,” filled the room, the staff began bobbing their heads in rhythm with the beat. It was that kind of song. He looked back down at Alison’s brain and took a deep breath. Let’s do this, he thought.
The bleeding had slowed down and Grant could now get a sense of what was happening. It looked like Matt had nicked one of the dilated veins in the AVM. Venous bleeding was not usually this brisk, but because these veins were in direct communication with arteries, they were under higher pressure. Grant bovied the vein and then used a suture to close the hole, temporary fixes until he could resect as much of the AVM as possible. Now that the energy in the room had come back down to normal, Grant felt a lot better. He settled into his ergonomic chair, allowed Wendy to adjust his magnifying goggles over his eyes, and let the sounds of Herbie Hancock put him in the zone.
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