The Best American Nonrequired Reading 2011

by Dave Eggers

  On the operating table Dr. Brede's patients bled considerably—the face-lift in particular was bloody, as it involved deep lacerations in both the face and the scalp—but nothing out of the ordinary—nothing that Dr. Brede couldn't stanch with routine medical intervention. But this!—this mysterious evidence of bloodstains, inside the latex gloves!—he couldn't comprehend. There had to be a deficiency in the rubber gloves.

  He would ask his nurse-receptionist Chloe to complain to the supplier—to demand that the entire box of defective gloves be replaced. It wouldn't be the first time that medical suppliers had tried to foist defective merchandise on Lucas Brede in recent years; with the worsening of the U.S. economy there'd been a discernible decrease in quality and in business ethics.... Lucas hadn't wanted to credit rumors he'd been hearing recently about malpractice settlements certain of his cosmetic surgeon-colleagues had been forced to make, suggesting that medical ethics, too, in some quarters, had become compromised.

  In desperate times, desperate measures. Whoever had said that, it had not been Hippocrates.

  In the mirror above the sink the familiar face confronted him—a hesitant smile dimpling the left cheek, a narrowing of the eyes as if seeing Lucas Brede at such close quarters he couldn't somehow believe what he was seeing.

  Is this me? Or who I've become?

  He was Lucas Brede, MD. He was forty-six years old. He was a "plastic" surgeon—his specialty was rhinoplasty. He took pride in his work—in some aspects of his work—and, rare in his profession, he hadn't yet been sued for malpractice. For the past eight years he'd rented an office suite on the first-floor, rear level of Weirlands, a sprawling glass, granite, and stucco medical center set back from a private road on an elegantly landscaped hillside on the outskirts of Hazelton-on-Hudson, Dutchess County, New York. In this late winter season of dark pelting rains—the worsening economic crisis, foreclosures of properties across the nation, "domestic ruin"—and thousands of miles away beyond the U.S. border a spurious and interminable "war to protect freedom" in its sixth year—Lucas Brede and the other physicians-residents at Weirlands were but marginally affected. Most of their patients were affluent, and if the ship of state was sinking, they were of the class destined to float free.

  In addition, Dr. Brede's patients were almost exclusively female, and vitally, one might say passionately, devoted to their own well-being: faces, bodies, "lifestyles." They were the wives, ex-wives, or widows of rich men; some were the daughters of rich men; a significant fraction were professional women in high-paying jobs—determined to retain their youthfulness and air of confidence in a ruthlessly competitive marketplace.

  Occasionally Lucas happened to see photographs of his patients in the local Hazleton paper, or in New York Times society pages—glamorous clothes, dazzling smiles, invariably looking much younger than their ages—and felt a stir of pride. That face is one of mine.

  He liked them, on the whole. And they liked him—they were devoted to him. For all were attractive women, or had been: their well-being depended upon such attractiveness, maintained in perpetuity.

  Already in their early forties the blond, fair-skinned women were past the bloom of their beauty and wore dark glasses indoors, expensive moisturizers, and thick creams at night. No cosmetic procedure could quite assuage their anxiety, that they were looking their age. Lucas couldn't imagine any husband—any man—embracing one of these women in the night; they must insist upon sleeping alone, as they'd slept alone as girls. (Lucas's wife now slept apart from him. But not because she wanted to preserve her beauty.) His patients were nervous women who laughed eagerly. Or they were edgy women who rarely laughed, fearing laugh lines in their faces. Their eyes watered—they'd had LASIK eye surgery, their tear ducts had been destroyed. Botox injections and face-lifts had left their faces tautly smooth, in some cases flawless as masks. But their necks!—their necks were far more difficult to "lift." And their hands, and the flaccid flesh of their upper arms. In their wish to appear younger than their ages, as beautiful as they'd once been, or more beautiful— what they were not—they were childlike, desperate. The more Dr. Brede injected gelatinous liquids into their skin—collagen, Botox, Restylane, Formula X—the more eager they were for more drastic treatments: chemical peels, dermabrasion, cosmetic surgery. They feared hairfine wrinkles as one might fear melanomas. They feared soft, crepey flesh beneath their eyes; they feared the slackening of jowls, jawlines as in another part of the world one might fear leprosy.

  To assuage their skittishness, for they were hypersensitive to pain, Dr. Brede provided them with small, hard, rubber balls to grip when he injected their faces with his long, transparent needles; he gave them mildly narcotizing creams to rub into their skin before arriving at his office; he gave them tranquilizers, or, occasionally, placebos; it amused him, and sometimes annoyed him, that his patients reacted to pain so disproportionately—sometimes, before he'd actually pushed the needle into their faces. The most delicate procedure was the injection of Botox, Restylane, or Formula X into the patient's forehead where, if Dr. Brede was not exceedingly careful, the needle struck bone, and gave every evidence of being genuinely painful. (Dr. Brede had never injected himself with any of these solutions so had no idea what they felt like, nor did he have any inclination to experiment.) His patients were devoted to him, but they were uneasy and emotional, like children—who could be angry with children?

  He wanted to assure them My touch is magic! I bring you mercy.

  He liked—loved—his work—his practice at Weirlands—but there were times when the prospect of doing what he was doing forever filled him with sick terror.

  Leave then. Quit. Do another kind of medicine. Can't you?

  His wife hadn't understood. There'd been a willful opacity in her pose of righteousness. He'd tried to explain to her—to a degree—but she hadn't understood. He needed to take on more patients—he needed to convince his patients to upscale their treatment—in the aftermath of this fiscal year that had been so devastating for all. Lucas wanted only to keep his finances—his investments—as they were, without losing more money; he'd had to deceive his wife about certain of these investments, of which she knew virtually nothing. Audrey's signature was easy to come by—trustingly she signed legal and financial documents without reading them closely, or at all; so trustingly, Lucas sometimes skirted the nuisance of involving her and signed her signature—her large, schoolgirl hand—himself. Certain of his financial problems, he'd confided in no one, for there was no one in whom he could confide. Nor could he share his more exciting, hopeful news—that he'd been experimenting with an original gelatinous substance that resembled Botox chemically but was much cheaper. There was a marginal risk of allergic reactions and chemical "burning"—he knew, and was hypercautious. This magical substance, to which he'd given the name Formula X, Dr. Brede could prepare in his own "lab" in his office suite and be spared the prohibitively high prices the Botox manufacturers demanded.

  One day, maybe, Lucas Brede would perfect and patent Formula X and enter into a lucrative deal with a pharmaceutical company—though making money in itself wasn't his intention.

  "I'm going in."

  So matter-of-factly the neurosurgeon spoke, you would not have thought him boastful.

  Lucas Brede had entered medical school intending to be a neurosurgeon. Except the training was too arduous, expensive. Except his fellow students—ninety percent of them Jews, from the Metropolitan New York region—were too ambitious, too ruthless, and too smart. Except his instructors showed shockingly little interest in Lucas Brede—as if he were but one of many hundreds of med students, indistinguishable from the rest. As in the Darwinian nightmare struggle for existence, Lucas Brede hadn't quite survived, he'd been devoured by his fierce competitors, he'd been the runt of the litter.

  How fascinated he'd been as a medical student, and then an intern, and finally a resident at the Hudson Neurosurgical Institute in Riverdale, New York—how envious—observing with what confidence t
he most revered neurosurgeons dared to open up the human skull and touch the brain—the living brain. He was eager to emulate them—eager to be accepted by this elite tribe of elders—even as in his more realistic moments he knew he couldn't bear it, the very thought of it left him faint, dazed—an incision into the skull, a drilling open of a hole into the skull to expose the living brain.

  Vividly he remembered certain episodes in his two-year residency at the Institute. Memories he'd never shared with anyone, still less with the woman he married, whose high opinion of Lucas Brede he could not risk sullying.

  Ten-, twelve-hour days. Days indistinguishable from nights. He'd assisted at operations—from one to three operations a day, six days a week. He'd interviewed patients, he'd prepped patients. He'd examined CT scans. Once confronted with a CT scan he'd stared and stared at the dense-knotted tangle of wormy arteries and veins amid the sponge-like substance that was the brain, and all that he'd learned of the brain seemed to dissolve like vapor. Here was a malevolent life-form—a thing of unfathomable strangeness. He'd tasted panic like black bile in his mouth. For more than twenty-four hours he'd gone without sleeping and in his state of exhaustion, laced with caffeine and amphetamines, he'd been both over-excited and lethargic—his thoughts careened like pinballs, or drifted and floated beyond his comprehension. Somehow he was confusing the brain-picture illuminated before him with a picture of his own brain.... What he was failing to see was a brainstem glioma, a sinister malignancy like a serpent twined about the patients brainstem and all but invisible to inexpert eyes. "Ordinarily these tumors are inoperable," the neurosurgeon said,"—but I'm going in." Lucas shivered. Never would he have the courage to utter such words. Never would he have such faith in himself. Going in.

  Not that he dreaded the possibility of irrevocably maiming or killing a patient so much as he dreaded the public nature of such failure, the terrible judgment of others.

  He hadn't failed his residency, explicitly. In some ways he'd performed very well. But he'd known, and everyone around him had known, that he would never be a neurosurgeon. A shameful thing had happened when he assisted in his first trepanation, or craniectomy—he'd been the one to drill open the skull—this was the skull of a living person, a middle-aged man being prepped for surgery—handed a heavy power drill and bluntly told, "Go to it." By this time in his residency he'd observed numerous craniectomies—he'd observed numerous brain surgeries. He knew that the human skull is one of the most durable of all natural substances, a bone hard as mineral; to penetrate it you need serious drills, saws, brute force. In the dissection lab in medical school he'd experimented with such drilling, but in this case the head was a living head, the brain encased in the skull was a living brain and this fact filled him with horror, as well as the fact that he knew the patient, he'd interviewed the patient, and had gotten along very well with the anxious man. Now, as in a ghoulish comic-book torture, this man had been placed in a sitting position, clamped into position; mercifully, for the resident obliged to drill a hole in his head, he'd been rolled beneath the instrument table and was virtually invisible beneath a sterile covering and towels. All that Lucas was confronted with was the back of the man's head, upon which, in an orange marking pen, the neurosurgeon had drawn the pattern of the opening Lucas was to drill. "Go to if—the older man repeated. The patient's scalp had been cut, blood had flowed freely and was wiped away, now a flap of the scalp was retracted and the skull—the bone—exposed. Calmly—he was sure he exuded calm—Lucas pressed the power drill against the bone—but couldn't seem to squeeze the trigger until urged impatiently, "Go on." Blindly then he squeezed—jerked at—the trigger; there was a high-pitched whining noise; slowly the point of the drill turned, horribly cutting into the skull. Lucas's eyes so flooded with tears, he couldn't see clearly. Blindly he held the drill in place; the instrument was heavy and clumsy in his icy hands and seemed to be pulsing with its own, interior life. How hard the human skull was, and adamant—but the stainless steel drill was more powerful—a mixture of bone-shavings and blood flew from the skull—a flurry of bloodied shavings—the drill ceased abruptly when the point penetrated the skull, to prevent it from piercing the dura mater just beyond, a dark-pink, rubbery membrane threaded with blood vessels and nerves. Lucas smelled burned bone and flesh—he'd been breathing bone-dust—he began to gag, lightheaded with nausea. But there was no time to pause for recovery—he had to drill three more holes into the skull, in a trapezoid pattern, first with the large drill and then with a smaller, more precise drill. The smell of burned bone and flesh was overwhelming, hideous—he held his breath not wanting to breathe it in—now with a plier-like instrument pulling and prying at the skull—panting, desperate—turning the holes into a single opening. He thought This isn't real. None of this is real yet how ingenious, the "skull" oozed blood, now the single hideous hole in the skull was stuffed with surgical sponges immediately soaked with blood. Then he was speaking to someone—he was speaking calmly and matter-of-factly—the procedure was completed and the next stage of the surgery was now to begin—he was certain that this was so, he'd done all that was required of him and he'd done it without making a single error, yet somehow the tile floor tilted upward, rose to meet him—as all stared the young residents knees buckled—the nerve-skeleton that bore him aloft and prevented him from dissolving into a puddle of helpless flesh on the floor collapsed, shriveled, and was gone.

  It was fatigue. Caffeine, speed. The pressure of his work. The eyes of the others. Dazed and not seeming to know where he was at first—in the corridor outside the OR—not wanting to ask what had happened only if the patient was all right, if he'd completed the craniectomy satisfactorily, and he'd been assured yes, he had.

  Nineteen years he'd been a cosmetic surgeon in Hazelton-on-Hudson, New York. Eight years since he'd moved his practice to prestigious Weirlands at the outskirts of town. As a suburban physician Dr. Brede avoided all surgeries involving pathologies and all surgeries except the most familiar and routine, and high-paying—face-lifts were the most lucrative and the most reliable. The procedure was ghastly as a sadist's fantasy and horribly bloody when the facial skin-mask was "lifted" and "stretched"—"stapled" to the scalp—but no one had ever died of a face-lift—at least not one of Dr. Brede's patients. One of these operations was very like another as most human faces, attractive or otherwise, beneath the skin-mask, are very like one another.

  Of course he knew—and he resented—that in the pantheon of physicians and surgeons Dr. Lucas Brede's life's work was considered trivial, contemptible. And he himself trivial, contemptible. He knew, and tried not to know. He tried not to be bitter. Thinking I wouldfeel this way myself, about myself. If my life had gone otherwise.

  In this season of dark-pelting rains. Snow swirling like sticky clumps of mucus out of a sheet-metal sky. His four-fifteen patient Mrs. Druidd, in whose sallow, sagging face he'd been injecting Formula X slowly, carefully—wiping away blood with sterile gauzepads—an itchy film of perspiration on his face—began to be restless, skittish. On her previous visit to Dr. Brede, just before Christmas, Mrs. Druidd had had a chemical peeling; now, follow-up injections to plump out lines and wrinkles in her face, much of this routine except Dr. Brede was substituting his own Formula X for Restylane—a substitution that was entirely ethical, he believed, in the way that substituting generic drugs for pricey brand-name drugs was ethical—but the mild tranquilizer he'd given her didn't seem to be effective, and with each injection she seemed to be feeling more pain. "Squeeze the balls. Both balls"—Dr. Brede advised. His manner was calm, kindly. If he was deeply annoyed, you would never have guessed so from his affable smile.

  "Oh! That hurts."

  Mrs. Druidd had never spoken so petulantly to Dr. Brede—this was a surprise. Lucas saw to his alarm that there were deep bruises in the woman's face, where he'd been injecting Formula X; collagen and Restylane caused bruising too, but nothing like this. And that weltlike mark on one side of the woman's mouth, he knew wouldn't
fade readily.

  Three to five days was the usual estimate for bruising following injections. Very likely it might be more than a week this time.

  Mrs. Druidd asked if this was something new he was injecting into her face—"It feels different. It stings and burns."

  Lucas hesitated just a moment before assuring her, this was the identical treatment she'd had numerous times in his office.

  "I don't remember it stinging so and burning. I'm afraid to see what I look like..."

  The woman was fifty-seven years old, what did she expect? A miracle? Even with the lurid bruising, the effect of Dr. Brede's treatments over the past several years gave Mrs. Druidd the appearance of a woman of thirty-five, perhaps—if you didn't look too closely at the small, damp, fanatic eyes.

  Here was a rich man's wife, or ex-wife. Dr. Brede had seen Mrs. Druidd's photograph in the Hazelton paper, he was sure. Chairwoman of the Friends of the Hazleton Public Library. Chairwoman of the Hazleton Medical Clinic's annual Spring Fling. With her dramatic dark hair and flawless-seeming face Mrs. Druidd managed to hold her own with women of her daughter's generation. Her sessions with Dr. Brede, that had more often the air of custom and ritual, usually went more smoothly.

  Dr. Brede had no choice but to bring the hand mirror to Mrs. Druidd's face. This was a part of the ritual, he could hardly avoid it. At first Mrs. Druidd drew in her breath sharply, as if she'd been slapped—then she touched her tender, wounded skin—unexpectedly she laughed—"Well! It felt worse than this! I suppose I deserve it—after all." She paused, with a rueful sort of flirtatiousness. "How long will this awful bruising last, Doctor?"

  Even now, the woman yearned to trust Dr. Brede, for women yearn to trust men—all women, all men. And Dr. Brede wanted to believe that certainly, yes, he was a man worthy of a woman's trust.