Brian knew that Jack’s machine-gun speech and litany of complaints meant only that he was scared stiff. Andrew, apparently appreciating the same thing, put his hand reassuringly on Jack’s shoulder. Brian knew his assessment was right when Jack made no attempt to move it away.
“Good morning, everyone.”
Carolyn Jessup entered from the women’s lounge and took command of the room instantly. She wore a paper hair-covering and mask, loose scrubs, and tennis sneakers, and looked as engaging in that outfit as she did in her lecture suit. Her first stop was at Jack’s side.
“Have you been behaving, Jack?” she asked.
“Complaining, but behaving. You look very mysterious, with just your eyes showing like that.”
Brian groaned inwardly. Suddenly, Black Jack Holbrook, the man whose glare set 270-pound linemen onto their bellies for twenty push-ups, was a puppy dog.
“All women look alluring and mysterious in this getup,” Jessup said. “That’s why there’s such a clamor for jobs in the OR. Before we begin, do you have any questions?”
“None, except what am I doing here?”
“Without these pictures, we’re just about blindfolded in trying to figure out what to do to help you.”
“As long as one of the choices isn’t surgery.”
Brian had discussed with Jessup the aftermath of Jack’s catastrophic post-op course.
“He’d probably be willing to go along with just about anything,” Brian told her that first night, “except repeat bypass.”
The expression in Jessup’s eyes was knowing.
“We’ll see,” she said.
Now, she bent down to whisper a few words of encouragement and then crossed over to the scrub nurse, who helped her glove and gown.
Let the games begin, Brian thought, noting how small and frail his father looked, sandwiched as he was between the table and the massive fluoroscopic camera.
Gloved, gowned, and masked, Carolyn approached the table, polled the console nurse and each person in the room with her eyes to ensure they were ready, and began. Her movements were economical and assured. Her skill at inserting the large-bore guide needles into the femoral artery and vein was unerring.
“Brian, I’ve sent for his old films from Suburban,” she said, threading the long catheters up without breaking tempo. “They should be here later today.”
“It’s been about four years since he was done last, so I’m not certain how much help the films will be. You know, I don’t think I’ve ever seen an arterial catheter quite like that.”
“That’s very observant of you. It’s a prototype from Ward-Dunlop, the surgical supply people. We’ve been working on the development of this catheter with them for three years. Right now, we’re one of several institutions evaluating it. It’s all we use here.”
“I can see why. It looks like a definite improvement over the one that we were using.”
“It is. In another year or so, we expect every cath lab in the country to be using them. Hey, Jack, are you still with me?”
“I’m with you.… But I’d rather be with you in Hawaii.”
Jack’s speech had slowed and thickened. His eyes were closed. The pre-op medication had kicked in right on schedule.
“Good,” Jessup said. “If anything hurts or bothers you, just shout out.”
“I will.”
“Now, Jack, I want you to know that I’ve asked another doctor to stop by and look at these arteries of yours with me.”
“Fine by me. Whatever you say.”
“His name is Dr. Randa. He’s the chief of the surgical unit here at BHI.”
“No surgery,” Jack managed.
“I understand that’s how you feel, Jack,” she said with, it seemed to Brian, a hint of flirtatiousness in her voice, “and right now I’m not suggesting anything. Just a consult. He’s just going to look at the films and say hello. Okay?”
“If … you … say … so.”
Brian was pleased to hear his father capitulate so easily, although he was well aware of the role sedation was playing in Jessup’s small victory. He was also elated that Laj Randa was being called in on the case, even though he had once heard the surgeon described as two velvet hands on a 130-pound asshole.
As Jessup advanced the catheters into Jack’s heart, she checked their position by shooting in a small burst of X-ray opaque dye and turning on the X-ray camera for short exposures using a toe pedal on the floor. Brian was not surprised that she checked much less frequently than most operators. She performed the pressure measurements and brief injections of the chambers on the right side of the heart, then turned her attention to the more important left side, and Jack’s coronary arteries in particular.
“Okay,” she said. “Let’s start with the right coronary. Left anterior oblique view, please, Andrew.”
The tech adjusted the position of the huge camera to the first of what would be eight different views, and Carolyn Jessup did the first injection of dye. In between glances at the EKG monitor and at his father, Brian studied Jack’s coronary arteries on the video display. With each injection, the arterial tree lit up bright white against the pulsating gray of the heart itself. Although the main vessels followed a similar pathway from patient to patient, the overall pattern of the arteries was actually as unique and individual as fingerprints.
Jack’s vessels were as bad as Brian had feared. There were arteriosclerotic plaques blocking portions of nearly every artery that mattered. Two of the grafts from his previous surgery appeared to have closed. For three decades of marriage, Jack and Shirley Holbrook had drunk and smoked to excess. After her death from alcohol-induced jaundice and kidney failure, Jack had stopped drinking altogether. He stopped smoking a year or two after that, but much cigarette-related damage had already been done.
After the final injection of the left coronary—the so-called Widowmaker Artery, Brian whistled softly through his teeth and looked away. Jessup turned from the table to face him.
“Not a pretty picture,” she said softly.
Jessup was withdrawing the catheters when the door to the men’s locker room burst open, and Laj Randa strode into the cath lab, followed at a respectful distance by two of his fellows. The surgical chief was no more than five feet four, with café-au-lait skin, a short black beard, and piercing dark eyes. He wore a royal blue silk turban and had a steel bracelet on his right wrist. A Sikh, Brian thought. Mystical, deeply religious, persecuted in the Punjab of northern India for centuries. He had trained with a Sikh during his fellowship. The man was as determined, as opinionated and intense, as anyone he had ever known. If Randa was equally fervent, the hair beneath his turban had never been cut, and most of his beard was actually rolled up tightly beneath his chin.
“So, Carolyn,” Randa said, breezing past Brian, “this man is how old?”
His accent was a mix of British and Indian.
“Sixty-three. He—”
“And who did his previous surgery?”
“Steve Clarkin at Suburban did a quintuple bypass six years ago,” Brian said.
Randa stopped short and turned slowly to Brian, who towered over him.
“And you are?”
“Jack’s son, Brian Holbrook. I’m a—”
Randa had already turned away.
“Carolyn, could you have your nurse run the film for me.”
Jessup nodded to the control-room nurse, who could hear everything they were saying. Surely Randa knew that, too, Brian thought. He could have simply asked the nurse himself. A 130-pound asshole. Whoever had made that assessment obviously knew what he was talking about.
Moments later, Jack’s catheterization began to replay on the monitor.
“See,” Randa said to his sycophants, “only three grafts are left open and one of them is nearly closed. Typical result for Clarkin.”
The remark was inappropriate under any circumstances, but doubly so in the presence of Clarkin’s patient. Jessup, obviously used to the surgeon, seemed unf
azed.
“So,” Randa said as soon as the screen went dark, “are you planning on treating this man with your magic juicer?”
“Laj, let’s not get into this here.”
“I read an article about your drug in the Boston Herald. The Herald! Why not the National Enquirer?”
“I don’t know where the lay press is getting its information about Vasclear,” Jessup said patiently.
“Obviously someone is feeding it to them. I don’t like getting my medical information through the tabloids. From the beginning of science, methods have evolved to inform the scientific community of a new discovery. They do not include the Boston Herald.”
“I’ve got half a dozen academic papers on the drug accepted or already published in very prestigious journals. The FDA has thousands of pages of our research documentation and dozens of our angiograms. Now please, Laj. Let’s discuss this someplace else. As for your question about this patient, our double-blind research protocol bars anyone from Vasclear treatment who has had bypass surgery, so Mr. Holbrook doesn’t qualify.”
“Whatever you say.”
Randa walked past her to the table. Brian could see Jack’s eyes open, then close. He was awake and very much aware.
“I am Dr. Randa,” the surgical chief said, not bothering to shake Jack’s hand or even to ensure that he was awake. “Your arteriograms show a great deal of arteriosclerotic blockage throughout the arteries of your heart. You would benefit from bypass surgery as soon as possible. Dr. Jessup will go over the details with you and set up a time. I would suggest if there is an opening in my schedule, that you have the procedure done before you go home. Otherwise, you should be at bed rest until something can be arranged. One of my fellows will be up to see you later today. Good day, Carolyn.”
“Thanks for coming down,” she said as he was heading out the door.
Brian went immediately to his father.
“You okay?” he asked.
“No surgery,” Jack said.
“We’ll do our best. But listen, Pop, I don’t want to lose you, and the girls would be devastated. I’ll do my best to protect you from surgery, but whatever it takes, I’m going to recommend, including a repeat bypass. I need your promise that you’ll go along with that. Jack?”
There was a prolonged silence.
“I don’t like that guy,” Jack said finally.
“You don’t have to like him, Jack,” Jessup said. “You just have to believe us that he’s one of the very best in the world at what he does.”
She motioned Brian across the room and out of Jack’s earshot.
“Randa’s an absolute boor, I know,” she said. “But trust me, he really is a wizard in the OR. Lately, he’s even more unbearable than usual because of our research. I can’t believe he isn’t feeling very threatened by the Vasclear results we’ve been getting.”
“If what I’ve been hearing is correct, I understand why. He’d be like a blacksmith watching a Model T Ford rumbling up the road. Dr. Jessup, about putting Jack on Vasclear—”
The cardiologist shook her head.
“I’m sorry, Brian. In almost three years of research we haven’t broken protocol once. Not once. The only thing I can promise you is that I’ll mention the situation to Dr. Art Weber, the project director from Newbury Pharmaceuticals. But you know, even if he said yes, which is doubtful, Jack would have to be randomized into the study like every other patient. That gives him only a thirty-three percent chance of getting into the maximum-treatment group and an equal chance of getting placebo.”
“I understand, but please, do what you can. If we really push, there’s a possibility we could talk Jack into surgery. He’s taken to you like no other doctor he’s ever had. But if we can manage him with medications alone, we really owe it to him to try that.”
“Well, we might be able to buy some time by juggling his meds. I have a few ideas that might help the situation, especially after seeing his pressures on this cath. And I will speak with Dr. Weber, I promise you that. But I’d have to say that as things stand, surgery is my recommendation.”
“Okay. I’m not arguing. But I need time to think and to discuss this with Jack. I haven’t seen many patients go through the hell he did after surgery. We nearly lost him.”
“I know.”
“Well, thank you. There’s no need for you to wait around here. I’ll stay with my dad until he gets back upstairs.”
Jessup smiled at him enigmatically.
“Actually,” she said, “there is a reason for me to wait around. Come back into the lab.”
Brian followed her back into the cath lab, where Jack had been transferred from the table to his gurney.
“How’re you doing, Pop?”
“That wasn’t much fun, if that’s what you mean. What was that guy—some sort of Arab?”
“Indian. He doesn’t have much of a bedside manner.”
Carolyn Jessup cut in, speaking to the staff.
“If all of you could repair to the dressing rooms for a couple of minutes, I’d like to speak to these two gentlemen alone. Thank you.” She waited until the doors had closed, then took a plain white envelope out of her pocket and handed it to Jack. “Dr. Pickard, the chief of this hospital, had this brought to me just before I came down here. It was delivered to his office late this morning. He sends his regrets that he can’t be here to do this personally. But I’m glad I’m here in his place. Go ahead, Jack, open it.”
His hands a bit shaky, Jack tore open the envelope and extracted a small, wallet-sized card. He stared at it for half a minute at least, then said softly, “Oh, my God.” He looked up at Jessup. “This is for real?” She nodded. “Carolyn, this is going to do more for me than any operation or any pill ever could.… Here, son.”
He passed the card through the side rail of his gurney. It wasn’t until Brian had it in his grasp that he realized what it was.
COMMONWEALTH OF MASSACHUSETTS
BOARD OF REGISTRATION IN MEDICINE
David Connolly, Governor
ISSUES THIS LICENSE TO
Brian’s name and address followed. There was an addendum printed at the bottom that the license was provisional, but that made no difference. Brian stared at the card, afraid that if he tried to speak he’d end up crying.
“You start here as a postdoc fellow next Monday,” Jessup said. “Tuesday morning you’ll be assisting me here in the cath lab. Pass that test and you’ll be doing caths by yourself within the month. Just promise us all one thing.”
“Anything,” Brian said. “Anything at all.”
“Promise us you won’t show up the faculty with any more diagnoses like that thyroid storm.”
Angus “Mac” MacLanahan had always prided himself on having a good attitude about life. As a machinist in Glasgow, then later, after immigrating to the States, as a mechanic fixing the upper crust’s Jaguars, he had always been upbeat—content with his lot, but willing and anxious to do what he could to improve it. Now, every step was an effort as he trudged up the hill from the clinic to an empty apartment, battling the consuming sadness that came from no longer being healthy.
It had been great for him for a long time. He was a gentle bull, known for his strength and stamina. They had made him chief mechanic at Back Bay Jag. He had an angel of a wife and three terrific kids. Then Mary had gotten the bad news about the lump in her breast, and everything seemed to go sour—her surgery, the doctors appointments, the horrible, poisonous chemotherapy, and still, ultimately, the bone pain, weight loss, and at last, the merciful end.
It wasn’t six months after Mary’s death that Mac had his first episode of chest pain. He was working under a hood when the pain hit—an ill-defined burning pressure that started beneath his breastbone, but seemed to be everywhere in the top half of his body at once—his shoulders, his neck, his jaws, his ears. Deep down inside, he knew it was his ticker. But his mind wouldn’t accept it. He simply got a glass of water, sat down, wiped the sweat from his forehead and fa
ce, and breathed slowly until the pain let up.
He told no one about the episode—not his sons, not his coworkers, not his doctor. And for a couple of months, he paced himself and took a break the moment he sensed the fearsome ache coming on. But finally, his tongue loosened by a pint or two at The Tartan, he made the mistake of mentioning the symptoms to his friend, Marty Anderson. The very next day, with Marty at his side, he was at his doctor’s office.
Now, two years later, he wondered whether or not he should have just said the hell with it and let them cut on him.
The walk to his apartment was just five blocks, but Mac was only at the 7-Eleven store and he had already had to stop three times. The doctor at the clinic, a woman who looked to be in her teens, had brought in a dietician to go over the low-salt diet for the umpteenth time, and had bumped up the fluid pills to two twice a day. Mac reminded her that he already kept a bottle by the bed to pee in the three or four times he had to go each night, but the doctor just laughed and assured him that the ankle swelling and shortness of breath would be better if he would eat fewer chips and drink less beer.
“Why not just give me the black pill,” Mac had responded, only half in jest.
He shuffled into the 7-Eleven and picked up some milk, ketchup, a package of vanilla sandwich cookies, and a small bag of Doritos. The effort left him panting.
“You all right?” the man behind the cash register asked.
“I’m okay,” Mac managed. “Just a little … winded is all.”
“You sure?”
“I’ll be fine in … just a minute.… Here.”
He paid the clerk and forced himself to stop leaning on the glass countertop. Then he shuffled from the store.
“You sure you don’t want me to call someone?” the man called after him.
A block and a half, Mac told himself. He was hardly at his best, but hell, he could walk on broken glass for a block and a half if he had to. If he didn’t improve soon, though, he was going to have to make some decisions about living alone. But a home was unthinkable, and he had no desire to become a burden to either of his kids. Maybe Dr. Babyface was right, he told himself. Maybe the change in fluid medicine would help.
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