by Robin Cook
Mannerheim caught the silent rebuke and cursed the nurse under his breath. “Women,” he muttered. To Mannerheim, nurses were becoming more and more a pain in the ass.
Mannerheim burst into the OR like a bull into the ring. The congenial atmosphere changed instantly. Darlene Cooper handed him a sterile towel. Drying one hand, then the other, and working down his forearms, Mannerheim bent over to look at the opening in Lisa Marino’s skull.
“God damn it, Newman,” snarled Mannerheim, “when are you going to learn to do a decent craniotomy? If I’ve told you once, I’ve told you a thousand times to bevel the edges more. Christ! This is a mess.”
Under the drapes Lisa felt a new surge of fear. Something had gone wrong with her operation.
“I . . .” began Newman.
“I don’t want to hear a single excuse. Either you do it properly or you’ll be looking for another job. I got some Japs coming in here and what are they going to think when they see this?”
Nancy Donovan was standing at his side to take the towel, but Mannerheim preferred to throw it on the floor. He liked to create havoc and, like a child, demanded total attention wherever he was. And he got it. He was considered technically one of the best neurosurgeons in the country, if not the fastest. In his own terms he said, “Once you get into the head, there’s no time to pussyfoot around.” And with his encyclopedic knowledge of the intricacies of human neuroanatomy, he was superbly efficient.
Darlene Cooper held open the special brown rubber gloves that Mannerheim demanded. As he thrust in his hands, he looked into her eyes.
“Ahhh,” he cooed, as if he were experiencing orgastic pleasure from inserting his hands. “Baby, you’re fabulous.”
Darlene Cooper avoided looking into Mannerheim’s gray-blue eyes, as she handed him a damp towel to wipe off the powder on the gloves. She was accustomed to his comments, and from experience she knew that the best defense was to ignore him.
Positioning himself at the head of the table with Newman on his right and Lowry on his left, Mannerheim looked down on the semi-transparent dura covering Lisa’s brain. Newman had carefully placed sutures through partial thickness of the dura and had anchored them to the edge of the craniotomy site. These sutures held the dura tightly up to the inner surface of the skull.
“All right, let’s get this show on the road,” said Mannerheim. “Dural hook and scalpel.”
The instruments were slapped into Mannerheim’s hand.
“Easy, baby,” said Mannerheim. “We’re not on TV. I don’t want to feel pain each time I ask for an instrument.”
He bent over and deftly tented up the dura with the hook. With the knife he made a small opening. A pinkish gray mound of naked brain could be seen through the hole.
Once under way, Mannerheim became completely professional. His relatively small hands moved with economical deliberation, his prominent eyes never wavering from his patient. He was a physical person with extraordinary eye-hand control. The fact that he was short, five-foot-seven-inches, was a constant source of irritation to him. He felt he’d been cheated of the extra five inches to match his intellectual height, but he kept in excellent condition and looked much younger than his sixty-one years.
With small scissors and cottonoid strips, which he inserted between the dura and the brain for protection, Mannerheim opened up the covering over Lisa’s brain to the extent of the bony window. Using his index finger he gently palpated Lisa’s temporal lobe. With his experience the slightest abnormality could be detected. For Mannerheim, this intimate interaction between himself and a live pulsating human brain was the apotheosis of his existence. During many operations, the sheer excitement made him sexually erect.
“Now let’s have the stimulator and the EEG leads,” he said.
Dr. Newman and Dr. Lowry wrestled with the profusion of tiny wires. Nancy Donovan, as his circulating nurse, took the appropriate leads when the doctors handed them to her and plugged them into the nearby electrical consoles. Dr. Newman carefully placed the wick electrodes in two parallel rows. One along the middle of the temporal lobe and the other above the Sylvian vein. The flexible electrodes with the silver balls went under the brain. Nancy Donovan threw a switch and an EEG screen next to the cardiac monitor came alive with fluorescent blips tracing erratic lines.
Dr. Harata and Dr. Nagamoto entered the OR. Mannerheim was pleased not so much because the visitors might learn something, but because he loved an audience.
“Now look,” said Mannerheim, gesturing, “there’s a lot of bullshit in the literature about whether you should take the superior part of the temporal lobe out during a temporal lobectomy. Some doctors fear it might affect the patient’s speech. The answer is, test it.”
With an electrical stimulator in his hand like an orchestral baton, Mannerheim motioned to Dr. Ranade, who bent down and lifted up the drape. “Lisa,” he called.
Lisa opened her eyes. They reflected the bewilderment from the conversation she’d been overhearing.
“Lisa,” said Dr. Ranade. “I want you to recite as many nursery rhymes as you can.”
Lisa complied, hoping that by helping the whole affair would soon be over. She started to speak, but as she did so Dr. Mannerheim touched the surface of her brain with the stimulator. In mid-word her speech stopped. She knew what she wanted to say, but couldn’t. At the same time she had a mental image of a person walking through a door.
Noting the interruption in Lisa’s speech, Mannerheim said, “There’s your answer! We don’t take the superior temporal gyrus on this patient.”
The heads of the Japanese visitors bobbed in understanding.
“Now for the more interesting part of this exercise,” said Mannerheim, taking one of the two depth electrodes he’d gotten from Gibson Memorial Hospital. “By the way, someone call X ray. I want a shot of these electrodes so we’ll know later where they were.”
The rigid needle electrodes were both recording and stimulating instruments. Prior to having them sterilized, Mannerheim had marked off a point on the electrodes four centimeters from the needle tip. With a small metal ruler he measured four centimeters from the front edge of the temporal lobe. Holding the electrode at right angles to the surface of the brain, Mannerheim pushed it in blindly and easily to the four-centimeter mark. The brain tissues afforded minimal resistance. He took the second electrode and inserted it two centimeters posterior to the first. Each electrode stuck out about five centimeters from the surface of the brain.
Fortunately, Kenneth Robbins, the Chief Neuroradiology X-ray technician, arrived at that moment. If he had been late Mannerheim would have thrown one of his celebrated fits. Since the operating room was outfitted to facilitate X ray, the chief technician needed only a few minutes to take the two shots.
“Now,” said Mannerheim, glancing up at the clock and realizing he was going to have to speed things up. “Let’s stimulate the depth electrodes and see if we can generate some epileptic brain waves. It’s been my experience that if we can, then the chances of the lobectomy helping the seizure disorder are just about one hundred percent.”
The doctors regrouped around the patient. “Dr. Ranade,” said Mannerheim. “I want you to ask the patient to describe what she feels and thinks after the stimulus.”
Dr. Ranade nodded, then disappeared under the edge of the drapes. When he reappeared he indicated to Mannerheim to proceed.
For Lisa the stimulus was like a bomb blast without sound or pain. After a blank period that could have been a fraction of a second or an hour, a kaleidoscope of images merged into the face of Dr. Ranade at the end of a long tunnel. She didn’t recognize Dr. Ranade nor did she know where she was. All she was aware of was the terrible smell that heralded her seizures. It terrified her.
“What did you feel?” asked Dr. Ranade.
“Help me,” cried Lisa. She tried to move but felt the restraints. She knew the seizure was coming. “Help me.”
“Lisa,” said Dr. Ranade, becoming alarmed, “Lisa,
everything is all right. Just relax.”
“Help me,” cried Lisa as she lost control of her mind. The fixation of her head held, as did the leather strap at her waist. All her strength concentrated into her right arm, which she pulled with enormous force and suddenness. The wrist restraint snapped and her free arm arched up through the drapes.
Mannerheim was mesmerized by the abnormal recordings on the EEG when he saw Lisa’s hand out of the corner of his eye. If he had only reacted faster he might have been able to avoid the incident. As it was, he was so startled that for a moment he was incapable of reacting. Lisa’s hand, flailing wildly to free her body imprisoned by the OR table, hit the protruding electrodes and drove them straight into her brain.
Philips was on the phone with a pediatrician named George Rees when Robbins knocked and opened the door. Philips waved the technician into his office while he finished his conversation. Rees was inquiring about a skull X ray on a two-year-old male child who was supposed to have fallen down stairs. Martin had to tell the pediatrician that he suspected child abuse because of the old rib fractures he’d seen on the patient’s chest X ray. It was sticky business, and Philips was glad to hang up.
“What have you got?” Philips asked Robbins, swinging around on his seat. Robbins was the Chief Neuroradiology technician whom Philips had recruited, and there was a special rapport between the two men.
“Just the localization films you asked me to do for Mannerheim.”
Philips nodded as Robbins snapped them up on Philips’ viewer. Normally the chief technician didn’t leave the department to take X rays, but Philips had asked him to attend personally to Mannerheim just to avoid any trouble.
Lisa Marino’s operative X rays lit up on the screen. The lateral film showed a polyhedral lucency where the bone flap had been cut. Within this sharply defined area were the bright white silhouettes of the numerous electrodes. The long needle-like depth electrodes Mannerheim had pushed into Lisa Marino’s temporal lobe were the most apparent, and it was the position of these instruments that interested Philips. With his foot, Philips activated the motor on a wall-sized X ray viewer called an alternator. As long as he held his foot on the pedal, the screen in front of him changed. The unit could be loaded with any number of films for him to read. Philips kept the machine running until he found the screen containing Lisa Marino’s previous X rays.
By comparing the new films with the old, Philips could determine the exact location of the deep electrodes.
“Gees,” said Philips. “You take beautiful X rays. If I could clone you, half of my problems would be over.”
Robbins shrugged as if he didn’t care, but the compliment pleased him. Philips was a demanding but appreciative boss.
Martin used a finely calibrated ruler to measure distances associated with minute blood vessels on the older X rays. With his knowledge of the anatomy of the brain and the usual location of these blood vessels, he could form in his mind a three-dimensional image of the area he was interested in. Translating this information to the new films gave him the position of the tips of the electrodes.
“Amazing,” said Philips, leaning back. “Those electrodes are positioned perfectly. Mannerheim is fantastic. If only his judgment equaled his technical skill.”
“Do you want me to take these films back to the OR?” asked Robbins.
Philips shook his head. “No, I’ll take them myself. I want to talk to Mannerheim. I’m going to take some of these older films as well. The position of this posterior cerebral artery bothers me a little.” Philips picked up the X rays and headed for the door.
Although the situation in OR #21 had returned to a semblance of normality, Mannerheim was furious about the accident. Even the presence of the foreign visitors did not temper his anger. Newman and Lowry suffered the greatest abuse. It was as if Mannerheim felt they had deliberately schemed to cause the problem.
He had started the temporal lobectomy as soon as Ranade had inducted Lisa under general endotracheal anesthesia. There had been a panic immediately after Lisa’s seizure, although everyone acted superbly. Mannerheim had succeeded in grabbing Lisa’s flailing hand before any more damage had been done. Ranade, the real hero, had reacted instantly, injecting a sleep dose of one hundred and fifty milligrams of thiopental IV, followed by a muscle paralyzer called d-tubocurarine. These drugs had not only put Lisa to sleep, but had also terminated the seizure. Within only a few minutes Ranade had placed the endotracheal tube, started the nitrous oxide, and positioned his monitoring devices.
Meanwhile, Newman had extracted the two inadvertently deeply embedded electrodes while Lowry removed the other surface electrodes. Lowry also had placed moist cottonoid over the exposed brain before covering the site with a sterile towel. The patient had been redraped and the doctors regowned and gloved. Everything had returned to normal except Mannerheim’s mood.
“Shit,” said Mannerheim, straightening up to relieve the tension in his back. “Lowry, if you’d rather do something else when you grow up, tell me. Otherwise hold the retractors so I can see.” From Lowry’s position the resident could not see what he was doing.
The door to the OR opened, and Philips entered, carrying the X rays.
“Watch out,” whispered Nancy Donovan. “Napoleon is in a foul mood.”
“Thanks for the warning,” said an exasperated Philips. It irritated him that everyone tolerated Mannerheim’s adolescent personality, no matter how good a surgeon he was. He put the X rays up on the viewer, aware that Mannerheim had seen him. Five minutes passed before Philips realized that Mannerheim was deliberately ignoring him.
“Dr. Mannerheim,” Martin called over the sound of the cardiac monitor.
All eyes turned as Mannerheim straightened up, shifting his head so that the beam of his miner-like head lamp fell directly on the radiologist’s face.
“Perhaps you don’t realize that we are doing brain surgery here and maybe you shouldn’t interrupt,” Mannerheim said with controlled fury.
“You ordered localization X rays,” said Philips calmly, “and I feel it is my duty to provide the information.”
“Consider your duty done,” said Mannerheim, looking back into his expanding incision.
Philips’ real concern was not the electrodes’ positions, because he knew they were perfect. It was the orientation of the posterior or hippocampal electrode in relation to the formidable posterior cerebral artery. “There’s something else,” said Martin. “I . . .”
Mannerheim’s head shot up. The beam of light from his head strafed the wall, then the ceiling, while his voice lashed out like a whip. “Dr. Philips, would you mind taking yourself and your X rays out of here so that we can finish the operation? When we need your help, we’ll ask for it.”
Then in a normal voice, he asked the scrub nurse for some bayonet forceps and went back to work.
Martin calmly took his X rays down and left the OR. Changing back to his street clothes in the locker room, he tried not to think too much; it was easier on his mood. Heading back to Radiology, he allowed himself to ponder about the conflict in his sense of responsibility that the incident evoked. Dealing with Mannerheim called on resources he never imagined he’d need as a radiologist. He hadn’t resolved anything when he arrived back at the department.
“They are ready for you in the angiography room,” said Helen Walker when he reached his office. She stood up and followed him inside. Helen was an extremely gracious thirty-eight-year-old black woman from Queens who had been Philips’ secretary for five years. They had a wonderful working relationship. It terrorized Philips to think of her ever leaving, because like any good secretary she was instrumental in running Philips’ day-to-day life. Even Philips’ current wardrobe was the result of her efforts. He would have still been wearing the same boxy clothes he’d worn in college if Helen hadn’t teased him into meeting her in Bloomingdale’s one Saturday afternoon. The result had been a new Philips, and the contemporary fitted clothes suited his athletic body.
Helen stood behind him reading a steady stream of messages she felt obligated to tell him. Dr. Rees had called asking about the CAT scan on his patient, the X ray unit in the second angiography room had been fixed and was functioning normally, the emergency room called saying that they were expecting a severe head injury that was going to need an emergency CAT scan. It was endless and it was routine. Philips told her to handle everything, which was what she’d planned to do anyway, and she disappeared back to her desk.
Philips removed his white coat and put on the lead apron he wore during certain X-ray procedures to protect himself from the radiation. The bib of the apron was distinguished by a faded Superman monogram, which had resisted all attempts at removal. It had been drawn there in jest two years previously by the neuroradiology fellows. Knowing the gesture had been made out of respect, Martin had not been annoyed.
As he was about to leave, his eyes swept across the surface of his desk for a reassuring glimpse of the program cassette, just to make certain he hadn’t fantasized Michaels’ news. Not seeing it, Martin walked over to shuffle through the more recent layers of debris. He found the cassette under Mannerheim’s X rays. Philips started to leave, but again stopped. He picked up the cassette and Lisa Marino’s latest lateral skull X ray. Yelling through the open door for Helen to tell the angio room he’d be right there, he walked over to his worktable.
He took off his lead apron and draped it over a chair. He stared at the computed prototype, wondering if it would really work. The he held up Lisa Marino’s operative X ray to the light that came from the banks of viewing screens. He wasn’t interested in the electrode silhouettes and his mind eliminated them. What interested Philips was what the computer would say about the craniotomy. Philips knew they had not included the procedure in the program.