by Allen Wyler
Another distant stare settled over her eyes. “We trekked as far as Africa—have I told you this part of the story before?”
He raised a just-a-minute finger, then swallowed. “No.”
“About a month after we left India, we were trekking across Africa,” she said as if it had been a leisurely stroll on a picturesque park trail, “when I saw this incredible woman baking bread in an outside oven fueled by wood scraps. She was making the bread her family would eat that day. We stopped and watched her. Ended up staying in the village overnight, and the next day she showed me every step of how to prepare it.”
Alex opened his small carton of milk. “Remind me again; who was the girl you were with?”
“Oh, just a girlfriend,” she said dismissively. “On my eighteenth birthday we decided to walk around the globe, staying close as possible to the equator.” She blushed. “Silly, huh? But it’s what we both wanted to do at the time. The ultimate adventure.”
“Why?” Steve asked.
With a laugh, she brushed some graying hair away from her bright eyes. Most days her unruly strands remained turbaned under whatever silk scarf matched her colorful sarongs. Other days she opted for shapeless mid-ankle dresses in bold batik prints. She always wore sandals, never shaved her legs, and smelled vaguely of musk and patchouli oil.
“It was either do the trek or have to figure out a way to convince Clem I wouldn’t start premed at Stanford so I could graduate with honors and head off to some prestigious medical school—of his choosing—on the East Coast. I chose the easier path.”
Ah, a new wrinkle to the engrossing life story she parceled out in segments, like today. “Your father expected you to attend medical school?”
“You bet. And believe me, if I’d done it, I would’ve had to ascend to the same lofty heights of recognition as he.” She went back to preparing the hummus.
Alex pulled off a hunk of golden-brown chicken skin to eat. “You sure about that?” He popped the piece of skin into his mouth.
“World-famous hematologists have world-famous expectations for their only child to fulfill. I didn’t want to compete with him, because I knew that’s exactly what would’ve happened. He has this bizarre way of bringing out the worst in me when it comes to these things. In case you haven’t realized it, I’m not a competitive person. Besides, I’m perfectly happy with my life as is.”
He believed her.
“But you ended up in medicine anyway,” Steve said. “Maybe not a physician, but as a researcher.”
She paused, pestle in hand. “Purely happenstance is all, not by intent. I ended up broke in Boston, so I took a job as a lab tech.” A quick shrug, as if this explained everything. “Now I’m here. Wasn’t as if I planned it that way. It’s just the way things were destined, I guess.”
“And your father? How does he accept you not being a doctor?” Alex asked.
Pestle still in hand, she scratched the tip of her nose with the back of her wrist. “He’s too busy with his second wife and new family to worry about me. Besides,” she said with a slight flick of her head, “it’s in the past.”
Ah, another one of her wisdoms: what’s past is past. Move on.
Alex swallowed. “You never mentioned how far you got on this trek.”
She banged the pestle against the crucible rim, knocking off excess hummus. “Never finished making it through Africa.”
Another new episode. Her adventures fascinated him, perhaps because her life had been—and undoubtedly would be—so different from his linear, goal-directed career. “Because?”
Karen blushed and glanced at Steve, as if he were an outsider. Although she insulated herself from most awkward situations with nervous laugher, she now displayed frank embarrassment. “I met this boy …”
“Go on.” He popped another tear of fried chicken skin into his mouth. Lisa harped at him for eating the skin, claiming it to be the unhealthiest part of the chicken. She was probably right, but it tasted too damn good to ignore.
Karen returned to work, probably to avoid eye contact as her blush intensified. “Happened in Israel; he was part of the kibbutz I just mentioned. We became very attached to one another.”
Clearly an understatement. “And?”
“Well, Carrie wouldn’t continue trekking without me, and she realized I wasn’t planning on leaving the kibbutz any time soon, so she flew back home and enrolled at Berkeley. That’s it. End of our ultimate journey.”
“And you?”
Karen poured more olive oil into the bean mash. “His family didn’t approve of me for obvious religious reasons—and I wasn’t going to convert to Judaism—so they gave him an ultimatum. There, family is tighter than love, I guess. Or maybe his love wasn’t as strong as I wanted it to be. Anyway, I ended up in Europe and eventually Boston. I got the job in Beneke’s lab, and you know the rest of the story.”
Alex was about ready to pop the other hunk of chicken skin in his mouth when Art Waters came through the open lab door. “Morning, Karen, Steve, Alex.”
Before anyone could answer, Waters addressed Alex. “We’re on our way to lunch. Why don’t you join us?”
Alex pointed to his brown paper sack and the wrinkled aluminum foil holding the remains of his chicken. “Thanks, but I have mine here.”
“I see that. But Alex, you’re faculty now, not a resident. You need to break bread with us, make an effort to become part of the group. It doesn’t do you any good to stay holed up in your lab every day all day.”
“I drop into the conference room on free afternoons.” The surgeons who weren’t tied up in the OR or otherwise engaged habitually congregated for forty-five minutes or so in the conference room to gossip over coffee.
“I know you do, but I really would like you to start joining us for lunch.” Waters seldom threatened or gave orders, but this sounded like more than a simple wish.
Alex nodded. “Thanks.”
Waters said his goodbyes and left.
After a few moments of silence, Karen said, “He’s right, you know.”
“I know.”
“Why don’t you? You can afford it now; it’s not like you’re still on resident salary.”
Alex set down the chicken leg. “It’s not the money. It’s the time. Now that I have to drive across town to the trauma center for afternoon rounds, I can’t afford to spend an hour talking department politics with them.” As it was, he was already returning to the lab two or three nights a week after heading home for dinner.
“I understand.” Karen paused with a knowing smile, making him believe she did understand. “On the other hand, you’re never going to be one of them if you don’t start playing the role. That’s all it is, you know—role playing.” She turned to Steve, raised her eyebrows a moment before laughing. “You’re going to have to start doing the same thing when you enter med school.”
Alex felt trapped. He was already overcommitted, and his NIH grant had once again been denied funding. He was in serious jeopardy of losing the lab to a full-time researcher, someone with the funds to keep it productively staffed and generating publications rather than just limping along with one lab tech and a catch-as-catch-can investigator. Appetite now ruined, Alex balled the remaining chicken in the foil and tossed it into the trash can. “I better get back to work.”
5
The telephone rang again, rousting Alex from sound, dreamless sleep. “Hello?”
“Doctor Cutter, sorry to call you at this hour, but we got a through-and-through GSW, probably fairly large caliber by the hole it made, maybe .38. Anyway, we’re taking her to the OR now.” We, meaning the chief and a junior resident. Alex recognized the resident’s voice and knew the call came from the trauma center.
“Be right in.” The bedside clock showed 1:37 a.m. For a few beats, he felt an overwhelming urge to snuggle back down in the warm bed and work on dispensing the heavy fatigue that cloaked him endlessly these days. Taking a hundred percent of the trauma center call was the price the senio
r partners exacted for keeping his lab limping along until he could win enough funding to justify devoting a fixed percentage of his time to research.
He hustled through the automatic ER doors at 1:58 a.m. and detoured to the small basement coffee shop—closed this hour of morning—where one wall was lined with vending machines. He slipped three quarters in the coin chute, then made sure the cardboard cup dropped vertically into the serving slot for the jets to squirt in hot chocolate—his reward for being up at this ungodly hour. He drank the tepid liquid while changing into scrubs, then closed and secured the locker before taking the stairs down to the operating rooms.
The skull X-rays looked terrible, the entrance wound obvious by the round, jagged skull defect. A cone-shaped trajectory of bullet and bone fragments expanded from one side to the other through the brain, a chunk of skull blown out the exit wound, radiating spider web cracks from the jagged edges. The two residents were working furiously to prep and drape the patient now that the anesthesiologist had her ready for surgery, which was probably unnecessary from the looks of the skull films. “Want me to scrub?” Alex asked the chief.
The senior resident turned, apparently unaware Alex had entered. “Not unless you feel a burning desire. Pretty straightforward. She’s a goner anyway.”
“Agreed. Tell me what happened.”
“Twenty-eight-year-old black female picked up at Manville Terrace,” he said, naming a low-income housing project nearby. “Story is she bought the gun for her boyfriend as a birthday present. He was in the other room showing his homeys his quick draw when the gun accidently fired. Bullet went through a wall, hit her. She was allegedly watching TV in the next room. That’s all we know. Medics did a scoop and run.”
Alex looked at the junior resident. “What’s her prognosis?” Now eight months into his first clinical year, this rotation on trauma service provided more independent responsibility for the resident than the heavily supervised university rotation.
“Through-and-throughs—especially at this caliber—are universally fatal.”
“Then why bother to waste the taxpayer’s money by operating on her?”
The resident continued assisting his chief while he responded. “Reasonable question. One that’s debated. One argument is that since they’re going to die anyway, why not just put a bandage over the wound and stick them in the corner until they officially die. Guess that’s still done in some places. There’s not as much data on civilian GSWs, so most of what we do is based on military work. But the problem is, civilian wounds are different. Usually military wounds are from higher-velocity bullets or low-velocity frags. Anyway, the current thought is to remove all foreign material from the brain and close the wounds, since no one knows for sure how long the patient’s going to live.”
Alex was impressed. The kid had obviously been studying. “If the patient’s going to die regardless of what we do, why bother operating at all?” he said, referring to bone and bullet fragments as well as in-driven hair and skin.
“Because even though the bullet is probably sterilized from the heat of the blast, it drives skin and hair and other contaminants into the brain. The bone and bullet frags are signposts for where the contamination is. Best to clean out what you can easily get away with and close up the wound. Better to die having been given the best chance rather than to die having done nothing.”
“Very good,” Alex said, truly impressed and proud of the resident’s knowledge. Then to the chief, “I’ll write the operative note.” Recorded in the patient’s chart, the operative note documented vital information such as who was present and what was done. Following surgery the resident would dictate a more complete note for the record, but in the meantime, the handwritten note would let staff know where things stood.
After writing the chart note, Alex spent fifteen minutes perched on a stainless steel stool as he watched the residents work. He decided to watch for perhaps another fifteen minutes before heading home, the accumulative fatigue of three consecutive nights of interrupted sleep weighing down his eyelids as he watched. His mind drifted to the patient, and he wondered what her story was. Divorced, married, widowed? Any children? The family breadwinner? A hooker or a secretary? Sad, the thought of someone losing their mother. Although he identified and empathized with that loss, he felt an unnerving detachment from the pathos playing out before him. He thought about that, too, questioning why he felt so detached from these trauma cases but not the elective ones.
For one thing, in contrast to elective cases, he and the patients weren’t in the OR as a matter of choice. And he certainly could not be held responsible for their ultimately grim outcome. The only reasons to supervise the residents—who were gaining valuable experience by doing the surgery—were to ensure an acceptable level of quality and to satisfy federal and state billing requirements. When Waters had the job—before assigning it to Alex—he would simply drop by the trauma center once a week and sit in the billing office to countersign all the residents’ operative notes and progress notes of patients discharged during the previous week. Once the charts were signed, the bills would be submitted as if Waters had actually provided the service. But the laws had tightened as a result of Medicare reform, making it now a felony to bill for such phantom services. Because the residents weren’t actually licensed neurosurgeons, they could not bill for their services. And neither the university nor the department were eager to leave such a huge chunk of money on the table. Still, over 75 percent of the services billed at the trauma center were never paid.
Wearily, Alex pushed off the stool and caught the eye of the chief resident. “Heading home now. See you for afternoon rounds.”
6
Alex walked into the conference room, poured a cup of coffee, and plunked down in one of the four chairs around the break table. Geoff and Baxter, two full professors, seemed to be enjoying a spirited debate at the table. Baxter routinely had intermittent bouts of blinking as he talked, as if dust had blown in his eyes. Years ago—no one was sure when—one of the residents nicknamed him Baxter Rabbit, and that had been his nickname ever since.
Geoff amused himself playing his coin game, arranging pocket change in ascending size: dimes, pennies, nickels, quarters. It was an annoying habit of his during rounds. His other one was to rock back and forth from the balls to the heels of his feet.
Baxter turned to Alex. “We’re discussing that patient of yours at County, the gunshot wound. How long she been on the respirator now?” Alex had presented the case for the second week in a row during the Monday afternoon Morbidity and Mortality teaching conference.
Alex had to think for a moment, the seemingly indistinguishable days melding into one another. “Two and a half weeks now.”
“Tough problem.” Baxter shook his head sadly. “Had my share of those. Puts you in a lose-lose situation. Administration’s on your back to free up the ICU bed, but her family refuses to take her off the respirator by claiming she’s still alive.”
“In the meantime,” Ogden added, “her hospital bill just keeps growing bigger and bigger. Have any idea what it’s up to now?”
Alex had no idea for sure. “Last time I checked it was past a half a million.”
Baxter blew a long whistle.
“She have insurance?” Ogden asked.
“Nope,” he answered, shaking his head.
“Which means we, the taxpayers, end up paying her bills.”
Alex was sick of the issue. He was caught in the middle—just as Baxter said—between two opposing forces. Although the patient unequivocally met all criteria for being brain dead, her parents refused to let Alex discontinue the respirator. They claimed she was still alive because her heart still beat. It was nonsense.
“Remind me,” Baxter said, “what steps did you use to determine brain death?”
“The usual.” In fact, he had more than enough evidence to indicate her brain was totally devastated. He held up an index finger. “She has a large-caliber through-and-through trajectory.�
�� This meant the brain centers for consciousness had been completely destroyed. The second finger popped up. “There’s no evidence of any function on her neuro exam.” The third finger. “She can’t breathe on her own.” And then the final finger. “She’s had three flat-line EEGs separated by twenty-four hours.”
Baxter used a spoon to stir his coffee. “More than enough evidence.”
“You explained all this to the family?” Ogden asked.
Jesus, give me some credit. “Several times. Their lawyer—a real Al Sharpton type—is claiming we want to kill her because she’s black, that if she were white, we’d have no problem ‘keeping her alive,’” he said, using finger quotes in the air.
Ogden dumped the coins back into his pocket. “Glad she’s your case, not mine.”
Alex wanted to move on to his reason for being here. “I’m applying for AANS membership. May I use you two as references?”
Ogden cocked his head. “You can’t be a member; you haven’t passed your boards yet.” Board certification came from passing both a written and oral examination, and the oral part couldn’t be attempted until the applicant had been in practice for two years.
Geoff dug the coins out of his pocket and started playing with them again. “What’s the hurry? Why not wait until you have more experience under your belt?”
“Because I want—” He stopped short, embarrassed to admit he sought the validation of being board certified.
“He wants to show the world he’s qualified,” Baxter said.
Geoff raised his eyebrows. “You have your eye on Art’s chair?”
The suggestion floored him. “You nuts? Where did that come from?” Alex couldn’t imagine the department without Waters at the helm. He had built it from the ground up, starting when the newly formed medical school consisted of two Quonset huts on the edge of campus. Legend had it that Waters was the second faculty member to be hired, second only to the dean. This would always be Waters’s department.