The Patient

by Michael Palmer

  Jessie ran her fingertips over the folds of Sara’s cerebral cortex.

  “We’re going to do a rapid imaging sequence with contrast,” she said. “Have the IV gadolinium ready.” She shut off her microphone. “My mother’s more interested in how I spend my nights. Or should I say how I don’t spend my nights. She thinks I never date.”

  “I guess that means she’s not wrong all the time.”

  “Hey, watch it. I date, and you know it.”

  “Example?”

  “That lawyer from Toronto. The one I met when I went to Cancun. I even flew up to Canada for a couple of weekends with him. Remember?”

  “Jess, I hate to tell you this, but that was almost two years ago.”

  “I’ve been busy. Gadolinium in, please. Besides, all he talked about was how much opportunity there would be for me in Canada. When I suggested he might like Boston, I thought he was going to have a seizure. Look, look, there it is, Em. Great pictures, Ted. Perfect. Just think of all those chemists who called gadolinium a useless rare earth element. Surely someone should have known that a hundred years later we were going to invent magnetic resonance imaging and it would be the perfect contrast material. That just goes to show you—never discount anything. Byron, ten minutes and I’m going to want her to start waking up. Em, you get her goggles on while I expose this beast. Holly, how about something mellow—maybe that Irish harp CD. We’re going to get this sucker. We’re going to get every bit of it.”

  Mapping by MRI was the key. Mapping tumor. Mapping functioning brain. Superimposing the two. Melting one with ultrasound. Leaving the other intact.

  Speed was also important. Although brain swelling was generally well controlled during surgery, it was always a concern. The more the swelling, the more the blurring between thinking tissue and tumor. Jessie hummed along with the harp as she worked, melting obvious tumor with the ultrasonic selector as Emily helped suction out the resultant debris. Soon, the obvious tumor was markedly depleted. The general anesthesia had been turned off. Sara Devereau, her brain widely exposed, was awake.

  Now we see who’s a warrior, Jessie said to herself.

  “Sara, it’s me. Everything’s going great. Can you hear me?”

  “I can,” Sara replied hoarsely.

  “Remember, you’re in that frame. You can’t move.”

  “Can’t … move.”

  “Open your eyes, please, and think about what you’re seeing. Don’t say anything unless I ask you to. Just think it.”

  Functional magnetic resonance—another miracle—was based on detecting the chemical change in hemoglobin where thinking brain was using extra energy and drawing extra oxygen from the blood. Jessie had been around for much of the development of the technique, but it still astonished her. Amazing, she thought as she worked.… Amazing … amazing … amazing.… And the geek shall inherit the earth.… That’s it, sweet baby … just keep thinking … just keep thinking.

  Jessie watched the map of Sara’s functional gray matter develop on the monitor screen. Moments later, the radiologist superimposed the tumor on it. Then, as quickly as possible, Jessie began melting cancer cells once more, all the while getting closer and closer to thinking brain.

  “What do you see, Sar? Tell me what the guy’s doing?”

  “Ski-ing.”

  “And now?”

  “Run-ning.”

  “She’s starting to swell,” Jessie whispered. “Jesus, is she swelling. Byron, please give her fifty of mannitol.”

  “Fifty going in.”

  “What do you see, Sar? Talk to me. Talk to me.”

  “M … ma …”

  Jessie felt her aggressive approach to the resection begin to blunt.

  “Em, there’s too much swelling. Everything’s shifting, getting distorted. Byron, give her some steroids. Make it ten of Decadron.”

  “Ten in.”

  “Easy, Jess. You can only do what you can do,” Emily said.

  “Sara, what do you see? Sara? Em, suck here. Right here.”

  God, I’m too deep. I know I am.

  Jessie was far less emotional in the operating room than she was in the rest of her world. But even at her coolest, she was not the ice cube some surgeons were. With the reality of a partial or complete loss of communication for her patient on the line, Jessie knew she was tightening up like a heated bowstring. The sudden swelling and the intertwining of normal and abnormal cells had made further surgery impractical, if not impossible. Maybe she had gotten enough already, she reasoned. Maybe Sara’s own immune system could take care of whatever was left behind.

  I don’t think I can go any further.

  “Sara, it’s Jess. Tell me what you see.… Say something.… Anything.… Come on, baby, say something.”

  The best Sara could muster was a guttural groan.

  “Em, I don’t know,” Jessie said. “I’m right there. I’m right at speech pathways. Maybe in them already. It’s like the tumor’s just melted into brain.”

  “You want to stop?”

  “I … I don’t know.”

  This was it—the moment she had prayed would never come. She had allowed herself to hope for an operation that was perfectly clean—everything crystal clear and well defined. No overwhelming scarring, no dangerous swelling, no wrenching decisions. She surveyed the edema distorting Sara’s brain. If anything, it had gotten a little worse. Too soon, she told herself. It was still too soon to tell if the mannitol and Decadron would reduce the swelling. But as things stood, there was still some definition of structure—not much, but some. If she waited for the treatment to work and instead the swelling worsened, the chances of avoiding critical speech areas, and probably other structures as well, would be even slimmer than they already were. The bowstring tightened.

  The only safe thing to do, she decided, was to stop.

  Before she could voice that decision to Emily, the door to the OR pushed open and a man strode in wearing scrubs and a mask, but no covering over his rippling brown hair nor his spit-polished wing tips.… Gilbride.

  “Jessie, where’s Skip Porter?” he asked with not so much as an acknowledgment that there was brain surgery going on, let alone on a former patient of his.

  Jerk

  “Skip? He had some emergency oral surgery yesterday. I think he went to have it checked before coming in today. He usually only works afternoons on Mondays anyway.”

  “Well, I need him. The president of Cybermed was at the meeting this morning. He’s in my office right now and he wants a look at ARTIE.”

  Jessie looked down into Sara’s incision. The swelling was no better, but thank God, no worse.

  “The prototype from yesterday has been taken apart,” she said through clenched teeth. “ARTIE-Two should be around.”

  “Well, it isn’t. I looked all over the lab and I can’t find it. Cybermed has the clout to make ARTIE number one in the area of intraoperative robotics. And here I can’t even produce the damn thing.”

  Beneath her mask, Jessie calmed herself with a lengthy exhale.

  “Did you look in the cabinet over the central sink? That’s where we always keep both ARTIEs locked up.”

  “No, I … The cabinet with the combination lock?”

  “Exactly. You had us set the combination for your birthday, remember?”

  “Oh … yes. It’s been a while since I … since I needed to do any work in that lab. I’ll go check. Carry on.”

  Gilbride turned and was gone. Just like that. Not a word about Sara Devereau. Jessie wondered how much of the conversation Sara had heard, and whether it registered that the surgeon who had done her first two operations had breezed in and out without even acknowledging that she was on the table.

  Jessie felt the bowstring relax. Her shoulders sagged comfortably. The tightness in her jaw vanished. Gilbride had just saved her from making a decision she would have regretted for the rest of her life. There was still tumor in Sara’s brain—too much tumor for Jessie to believe her body could fight
for long.

  Fearless.

  In the heat of the moment, with her friend on the table, swelling distorting the anatomy, and faced with a tumor among the most difficult she had encountered, Jessie had lost her objectivity. She had forgotten her promise to her friend and to herself.

  Fearless.

  “Ted, I want a new set of images of this sucker,” she heard herself say. “Everybody, this is the captain speaking. I want you all to just hunker down and let your honeys know you might be late for dinner. We’re going to be at this for a few more hours.”

  CHAPTER 6

  BOSTON’S FLEET CENTER WAS A NEAR SELLOUT. Pacing about the carpeted VIP room, Marci Sheprow could hear the crowd, like the white noise of the ocean. Both were sounds familiar to her. She had spent the first nine of her eighteen years living at home with her parents on Cape Cod. The next eight she had lived, essentially, in a Houston gymnasium, training with several dozen other gymnastics hopefuls. But unlike the others, Marci had made it to the pinnacle of her sport. Two Olympic golds and a bronze. She was back living on the Cape now, more often than before, anyway. And when the time came, maybe after college, she planned to take a piece of the millions she had already banked and buy a place near her parents.

  She had no intention of competing in the Olympics again, but every time she said that, her coach and parents just smiled. They knew as well as she did that there was little about competitive gymnastics she didn’t love. And now she was riding a wave of incredible popularity, especially in New England.

  “Hey, babe, what gives?”

  Shasheen Standon, Marci’s closest friend on the U.S. team, was eating a pear, and offered a bite.

  “No, thanks. My stomach’s a little queasy, and I’ve got a little bit of a headache.”

  “It must be a virus. It sure can’t be nerves. You ain’t got none of those.”

  “Come on. You of all people know that’s just b.s.”

  Marci was famous on the team and in the press for her calm, almost blissful demeanor when she performed. She was approachable, though—not like those Russian and Romanian ice maidens. Still, her routines were described in the New York Times as “breathtakingly daring.” “The whole package,” another writer gushed.

  “You know,” Shasheen said, “now that you mention it, you don’t look that great. Remember, this is only an exhibition. Maybe you should pack it in tonight. Let us second stringers have center stage.”

  Marci punched her friend lightly on the arm.

  “A team gold and an individual silver on the uneven bars. Some second stringer you are. I may cut back on my routine, but I can’t back out. I’m local. Do you have any idea how many family and friends I have out there? You stayed at my house last night. You know.”

  “That was a pretty wild scene, that’s for sure, especially that Uncle Jerry of yours. Well, just go easy. Leave out some of the crazy Sheprow moves.”

  “Maybe. Maybe I will.”

  Marci bent over and effortlessly touched the carpet with her palms. At five foot five she was on the tall side for a gymnast, but she was remarkably lithe and the strongest girl on the team. She was also 100 percent athlete, totally in tune with her body. And tonight, she simply didn’t feel right. She went up on her toes and snapped her hands across her body, then up toward the ceiling. To the casual observer, she would have looked lightning quick. But she knew that she was unnaturally aware of her right leg when she flexed at the ankle, and that her right arm felt slightly sluggish as well. They had been on tour for more than a month, with shows sometimes three nights in a row. Maybe she was just wearing down.

  Across the room, Shasheen was entertaining several of the girls and coaches with one of her stories. Marci smiled. Talk about loose.

  “Five minutes,” the promoter called into the room. “Five minutes, everyone. Marci, that deal with the governor’s going to happen at intermission. I told his people you felt uncomfortable being singled out, but they reminded me that you’re the only one on the team from Massachusetts, and that the small print in our contract says we have to cooperate with this sort of thing. It’s just a plaque of some kind. Your folks’ll love it.”

  “Viva Sheprow,” Shasheen cheered with her typical sly edge.

  The others laughed and applauded. At one time or another, everyone on the team had had differences with the others, but by and large they had stuck together pretty well. Marci bowed to the group and nodded to the promoter that she was okay about the plaque. She pulled on her warm-up jacket and tried, unsuccessfully, to shake the strange leaden feeling from her right arm. Finally she zipped up and followed the others out to the arena.

  As Marci had anticipated, there were few empty seats in the house—probably the biggest crowd they had drawn on the entire tour. Through the playing of the national anthem and the introduction of the team, Marci tested her muscles—fingers, hands, arms, shoulders, neck, legs. Better, she thought. Everything felt better. She went up on her toes again. No real problem. Well, maybe a little weirdness.

  What in the hell is going on?

  She was scheduled to perform on the balance beam and uneven bars, as well as the vault. Then she and two others were to do a series of synchronized tumbling passes. Maybe she could beg off that.

  “You okay, Marse?” Shasheen asked.

  “Huh? Oh, yeah. I’m okay, I guess.”

  “What did you say?”

  “I said I’m okay.”

  “Marci, you’re not speaking right.”

  “I’m okay.”

  Her words sounded fine now. This was like the flu, she thought, or some kind of sugar thing. She typically wouldn’t eat for hours before a competition, and even though this was only an exhibition, she should never have had a frappe and sandwich. The loudspeaker announcer called the eight of them to their places. Shasheen was starting on the uneven bars. Marci would be vaulting.

  “Knock ’em dead,” Shasheen said, giving her a thumbs-up as she headed across the arena.

  “Yeah,” Marci whispered to no one. “You, too.”

  She followed a teammate toward the head of the runway leading to the vault horse. Her individual gold medal was on the balance beam, but of all the events, vault was the most natural and automatic for her. Again, her right arm and leg seemed heavy. She felt confused and, for the first time, frightened.

  Knock ‘em dead.

  Marci watched her teammate do an adequate vault, then heard her own name reverberate through the vast arena.

  Mom, something’s wrong with me. What should I do?

  Marci looked to her left, where her parents, sister, relatives, and friends took up most of three rows. Barbara Sheprow, with her flaming red hair and the white suit she had bought for the occasion, beamed at her and pumped both fists in the air.

  Mama?

  Marci suddenly became aware that the entire Fleet Center had become eerily silent. Everyone was watching her … waiting. She hadn’t even begun going through the mental prep to vault.

  She turned toward the runway, shaking her hand and contracting the muscles in her arm. If she waited any longer, there was no telling what she would feel like.

  You can do it. There are no judges. Just do a decent vault. Nothing special. Go for it.

  The silence in the arena was replaced by a nervous buzz.

  It had to be now.

  Marci rose on her toes and began her sprint toward the horse, arms pumping. She knew her speed was down, but it was too late now. She could pull it off. Even feeling lousy, she could pull it off.

  A step before the take-off ramp, her right leg seemed to disappear. When she planted it, there was almost nothing there. She was airborne, but not nearly high enough to complete a vault. Panicked, she reached out reflexively for the horse, but her right arm failed her completely. She did an awkward, clumsy turn in the air and fell heavily on the horse. Air exploded from her lungs. She toppled forward helplessly. Her consciousness began to fade. The last sound Marci heard before blacking out was the cracking
of bone in her wrist.

  CHAPTER 7

  “JESSIE, DEL MURPHY HERE. ARE YOU FREE TO MEET ME in the ER?”

  It was just after nine when Jessie answered the page from Murphy, the neurologist on call. She was taking a short break in her office, but for much of the past five hours she had been in the neurosurgical ICU. Sara Devereau had shown no signs of regaining consciousness following what had turned into a ten-hour battle to remove enough tumor from her brain to give her a chance at a cure. Jessie had a dreadful sensation that her friend was not going to awaken with intact neurologic function if, in fact, she woke up at all.

  “I can be down in just a few minutes,” she said. “What do you have?”

  “I have Marci Sheprow.”

  “The gymnast?”

  “She blacked out during an exhibition at the Fleet Center tonight, fell, and broke her wrist. The fracture’s been set and casted by Bill Shea. But he didn’t like her story of passing out, and called me. I’ve gone over her. She’s stable, but she’s got some neurologic findings, and I just got a look at her MRI.”

  “I don’t like the sound of that.”

  “Probably not as bad as it could have been. Come on down.”

  Jessie splashed some cold water on her face and made another quick stop in the unit. Sara, her eyes taped shut, was hooked to a ventilator by a clear polystyrene tube that ran up her nose, down the back of her throat, and between her vocal cords. In addition, the usual array of catheters, monitor cables, and other tubes were connected to her.

  “She looks so peaceful,” Barry Devereau said.

  “She is, in a way. Certainly, she’s in no pain.”

  “But there’s a battle going on.”

  “There’s a battle going on, all right,” Jessie echoed flatly. “I don’t expect there to be any change tonight, Barry.”

  “I’m going to stay just the same. I have someone with the kids.”

  “The nurses’ll take good care of you. I’m backing up the residents and covering for all private cases tonight. I take calls from home, but at night I can get back here in no time at all.”