Cutter's Trial

by Allen Wyler

Then you should know the answer. Then again, this was a prime example of why he chose to work with the most junior residents. “This time you get a free pass. Next time we discuss this you better have the right answer. Chuck, you know what to do?”

  “Nope.” Chuck continued organizing instruments in a stainless steel tray.

  Alex smoothed out the sterile drapes, preparing the area they’d operate in. “First thing is to pack the wound to stop the air leak. Next we drop the patient into the horizontal position and turn them on their left side. Why the left side?”

  Took Lawrence a moment to figure it out. “To keep the air in the atrium?”

  “Bingo. Then what do we do, Bob?”

  He answered without the slightest hesitation. “Use the central line I placed at the start of the case to suck out the air before it can embolize to the lungs or if the patient has a septal heart defect, on to the brain.” A septal heart defect allows blood to short-circuit from the right to left sides of the heart and then up the carotid artery to the brain.

  Alex smiled to himself. Lawrence was actually learning important information before the case began. “I can’t emphasize this next point enough; the most important things to learn in your first year are the complications that can occur in each case you do. Know exactly what can go wrong and how to handle it, and you’ll never be caught flat-footed. Most residents come into a training program with the mindset that good hands make good surgeons, but they’re wrong. Knowing how to stay out of trouble and how to react if you do unfortunately get into trouble is what makes a truly excellent surgeon. Any fool can take a patient to surgery. The trick is getting them through the case with only a scar as evidence of your footprint.”

  Chuck said to Lawrence, “See? Momma didn’t raise no fool.”

  With the patient draped and ready, Alex looked Lawrence in the eye. “Way I do this, the first time we scrub together I show you how I want things done. Then, next case, you do as much as you make me feel comfortable with, etc., etc., until you rotate off my service. Meaning, how much of the case you actually end up doing is determined by your ability. Got it?”

  “Think so.”

  “Ready Chuck?”

  “Roger that, sir.”

  Alex held out his hand. “All right, time to flash the healing steel.”

  Minutes later, the skin from the middle of the neck straight up to the back of the head was being held open with retractors, exposing the white surface of the skull. The cut edges of the skin were crimped with clips to stop blood from oozing during the surgery. The ligament in the middle of the neck that fused together the muscles of both sides contained little blood supply, so it was spread apart with hardly any bleeding. “Ever put in a burr hole?” Alex asked Lawrence.

  “Yes.”

  “With a hand drill?”

  “A what?”

  Alex said to Chuck, “Cushing perforator, please.” He turned back to Lawrence. “You need to know how to open a head without power tools. Archaic as that sounds, you never know when you might find yourself in a situation that forces you to use them. It’s a good skill to know. I’ll do the first one, you do the second.” He felt the cold heft of the stainless steel drill placed securely in his hand, the instrument similar to the brace and bit carpenters use for cutting dowel holes.

  As they were closing, sewing the muscles back together, Alex said to Lawrence, “Got a question for you.” Alex was laying down one-handed knots—a skill he’d perfected during his surgery internship—one knot right after the other as quickly as possible. Chuck loaded the empty needle holders as soon as Alex returned them, rotating between two needle holders, while Lawrence snipped away the excess thread a few millimeters above each knot as soon as Alex finished tying one.

  “What?”

  “What would you say if I told you Humpty Dumpty was pushed?”

  The only sound in the room now was Cole’s boom box. After a moment Lawrence said, “This a joke?”

  Alex kept working, one knot after the other, quickly closing on the skin now. “Just answer the question.”

  Lawrence cut another suture. “It’s a trick question, right?”

  Forceps in his left hand, Alex accepted another needle holder from Chuck. “It’s a question. What’s your answer?” With the forceps holding the edge of skin, he laid in one side of the suture then moved to the opposite side.

  “I don’t know. Can’t think of anything to say, sir.”

  Cole chuckled. “Is it a conspiracy theory question?”

  Alex pushed the needle through the opposite skin edge, jerked the needle from the thread, and started to tie the last knot.

  Lawrence glanced at the wall clock. “You had a muffuletta yet?”

  “No, what’s that?” He decided to let Lawrence off the hook with the Humpty Dumpty question. For now. Last deep skin suture now finished, he had only the top surface of skin to close, which he proceeded to do with staples.

  “It’s a very special sandwich. Started in New Orleans originally, I think. Since we’re fixing to finish up ’bout lunchtime, thought we could run cross the street and get us a couple. What say, you up for it? Can’t live down here without trying one.”

  Lawrence and Alex sat on a weathered, rotting picnic bench ravenously devouring their sandwiches, the bright sun hot against their backs, drying their damp cotton scrub shirts. Alex had never tasted a sandwich with such a flavorful mix of meats, olives, and cheese. He was washing his down with a can of diet Pepsi while Lawrence opted for high-octane Dr. Pepper. Alex watched a ridiculously raised Ford F-100—with fifty megawatts of lights over the cab and confederate flag on the tailgate—park at Shoney’s next door, country music blaring from the open cab windows.

  “Get you a Moon Pie for dessert, you’ll be right at home,” Lawrence said.

  Alex licked his fingers. “I’m so damn stuffed I couldn’t think of possibly eating anything else. What’s a Moon Pie?”

  “Man, you ain’t had you a Pie?” he said with an increasing accent. “What planet y’all from?”

  Alex used a wad of napkins to dry his fingers. “C’mon, let’s go check on our patient. Should be waking up about now.”

  30

  “You’re building quite a reputation,” Linda Brown, Garrison’s nurse, told Alex as they rounded the corner onto 7 West, the neurology and neurosurgery floor.

  “Reputation?” Alex asked, unsure if this was good or bad. “What? With whom?”

  “Among the residents,” she replied with a good-natured lilt.

  He stopped. “Hold on. You can’t just say something like that and not explain it. This good or bad?”

  She smiled at his obvious concern. “They say you like to teach and seem pretty good at it, too.” She hesitated, as if there was more to say but wasn’t sure how to phrase it.

  “Go on, spit it out.”

  “For them it’s good, of course. But you might oughta be a tad cautious.”

  Cautious? Why? “What do you mean? This is a teaching program; that’s my job. I’m glad they regard me in that way. It’s what I’m supposed to do.”

  She glanced down the hall, as if checking who might overhear their conversation. “Keep in mind there are other egos involved. Other faculty. Some of them might see you as a threat. Understand what I’m saying?” Linda was born and raised in Kentucky and spoke with an accent Alex now recognized as noticeably different from those who were natives here. When he first arrived, all accents seemed similar—people saying Ah for I, for example—but he’d since started to develop an ear for the numerous variations. It had so many more nuances than the generic West Coast accent that seemed so normal to him. He wondered if his accent grated on southern ears as much as theirs did on his.

  “Faculty?” Huh. “A threat?”

  “I’m sure you know your coming here had a few negative repercussions on a couple of them. Resident coverage, for one. Reynolds cut Harry Rosen loose. He’s not your greatest fan now. In fact, you might say he’s a tad pissed over it. Once peo
ple start talking, feelings become polarized. There might be some clinic members who come to resent your hold over the residents.”

  Alex massaged the back of his neck and exhaled a long, deep breath. He knew this might happen, at least in theory. Having Linda confirm it made him nervous. Then again, what could Rosen do to him? Probably not much. Unless he had some juice with people like Garrison. But other clinic members? Well, that could become a problem. But Garrison should be on his side, right?

  “Let me ask you, what kind of political pull does Rosen have?”

  “Not much. Fact is, he’s not well liked.”

  Comforting. But still … He glanced up at the acoustic ceiling tiles. Linda had become a trusted source of medical center gossip. On the other hand, he suspected her ears were wired directly to Garrison’s. The ghosts of paranoia seeded by Weiner rose again. Part of him sensed Garrison could be trusted. Another part warned to trust no one. He hated the ambiguity.

  “Thanks for the advice. Now let’s finish rounds.”

  Alex had been back in the office for about a half hour when Garrison knocked at his door. “Got a minute?”

  “Sure. What’s up?”

  Instead of ambling into the office, Garrison remained at the door. “I’m assigning you to cover Tuesday out-clinics. Understand how that works?”

  Alex shook his head. He’d heard the term from the nurses but hadn’t asked for any details. Now, with a practice developing, he was being assigned fewer Any Doctors while simultaneously being integrated into other clinic responsibilities.

  “Two days a week we fly out to towns about a hundred miles or so away. See folks in another doc’s office during their day off. Helps them meet overhead while it gives us a place to see patients. Any patient needs a work-up, we schedule it back here at Baptist or the clinic. Helps drum up business and hold on to our referrals. Also gives those towns some neurosurgical coverage. Everybody wins. Starting tomorrow, you’re scheduled for Tuesdays. Two Clinic Tuesdays, we call ’em ’cause we see patients in one town in the morning and another in the afternoon, then fly back on home. Meet us out at the commercial aviation terminal by 6:30 a.m. That’s the commercial terminal, not the one folks fly in and out of. Know where that is?”

  “At the airport, I suppose.”

  “Yep, except instead of going to the main terminal, you take the side road away from it. There’s signs to help you find it.”

  Alex wasn’t a big fan of small airplanes. “Who’s flying?”

  Garrison smiled. “That would be me. That’s the Cessna I told you about. My partner and I lease it back to the clinic for these out-clinic trips. Say, long as we’re on the subject, you might oughta come out to the Arlington airfield Saturday. I’m flying in an aerobatics competition. Might just get you interested in taking it up. Would love to teach you a few things while we’re in the cockpit Tuesdays. Might as well be doing something during those flights other than mashing hemorrhoids.”

  Fuck!

  Alex opened the chart on his next patient and immediately recognized the name: Bart Jorgensen, the man with the B12 deficiency neuropathy. He’d been practicing long enough now to be seeing long-term return patients, and Bart was one he really looked forward to following. He pushed open the door and stepped in the exam room.

  “Hey, Bart, how you doing?”

  The man grinned broadly. “Just fine, Doc, just fine. Tingling in my feet’s all gone now, and I reckon the sensation’s a hundred percent.” He sounded as happy as his smile was broad.

  Minutes later, exam finished and the patient discharged from his care, Alex dictated a letter summarizing the diagnosis and treatment plan to Bart’s physician. He recommended Bart see him every couple weeks for vitamin B injections. The gastroenterologist had diagnosed and treated chronic gastritis as the cause of the vitamin deficiency, so the case had been amazingly textbook. Four months ago he never would have believed such personal satisfaction could come from diagnosing and treating medical neurological problems outside of surgery. In retrospect, becoming a doctor had always been his only motivation for working so damn hard to enter and graduate med school. As a youngster he’d never considered research as a calling. But all that had changed once his mother’s illness became apparent. No one knew anything about those awful tumors other than they were universally fatal and untreatable. As pleased as he was to be honing his clinical skills, he also yearned to be back working in the lab. He took some satisfaction with the small amount of research he was managing in collaboration with Cell Biology, but it was not nearly what he would prefer. Every day now, it seemed his clinic responsibilities increased, making it more difficult to eke out any time at all in the lab.

  10:12 p.m. Instead of watching television with Lisa, Alex holed up in his study putting finishing touches on his NIH grant application. Tomorrow he’d have Claude FedEx it to Bethesda to make the deadline for the next round of evaluations. Getting his research back on track would be the one missing facet of having the perfect practice: clinical activities, teaching, and research. As more time passed, he also worried about his work becoming trumped by other labs. The previous week, a competitor lab had published a paper in Science claiming two of Alex’s prior findings were valid. If Alex didn’t get his research back on track soon, other researchers would leave him in the scientific dust. He sat back in the chair to massage his aching neck muscles. Although he couldn’t see how, there had to be a way to carve out more lab time.

  31

  “Hey, Jim, how was Bethesda?” Heading back to the office after rounding on the post-op patient, Alex saw Reynolds walking his way from the opposite end of the sky bridge.

  Reynolds stopped and polished his smudged glasses with a tail of his white shirt. “Good trip. Great bunch of guys up there. Think you’d really mesh well with ’em if you have a change of heart. I know you didn’t think much of the idea last time we talked, but I reckon you’ve had time to think on it for a spell now. Offer’s good—just say the word, I could get you in with a nice commission.” Reynolds inspected the lens, but the only difference Alex could see was a new pattern to the smudge.

  “Thanks for the offer, but I just don’t have time for the Reserves.” Well, partly true. Honestly, the hassle didn’t seem worth the few extra dollars. Besides, any extra time should be devoted to research. “Was hoping to run into you so I could tell you about your patient I operated, the cerebellar tumor? Surgery went fine but the tumor’s a lung met. Not a smoker either.” He had less empathy for smokers who developed cancer and felt a twinge of shame for harboring such a prejudice. “We rescanned her and it appears to be the only one, but still, not good for her. Had oncology work her up, and they couldn’t find any other mets either. But you know how that goes; they’re there, sure as hell.”

  Reynolds glanced at his watch as if anxious to be somewhere. “Yep, heard all about it. Thanks again for doing her.”

  Alex’s suspicion gelled: Reynolds hadn’t really needed the extra time to catch his Bethesda flight. The only reason he asked Alex to do the case for him was to evaluate his surgical ability. In all likelihood, he had the residents give him a detailed report. Did he pass the test? He suspected he had.

  “She’s coming into the clinic later today if you want to stop by to see her.”

  Reynolds palmed his thinning comb-over, patting it back in place. “Naw, no need to see her. Only saw her once before. Hell, she probably doesn’t remember my name. Besides, what she needs now is a good oncologist, not a neurosurgeon.” Reynolds seemed to think of something that trumped his pressing engagement. “I mention to you Val’s running for town council?”

  Alex needed a second to realize Val was Reynolds’s wife, Valarie, a certified, grade-A southern belle with newly developed political aspirations. “Don’t remember hearing you mention it.”

  “Yep. Has her a good chance to win, too. Speaking of which, we’re hosting a fundraiser Saturday after next out at the farm in support of the upcoming senate race. Like y’all to come. Be a good ch
ance for Val to get to know your pretty bride better. Can I count on y’all?”

  Uh-oh. Alex scrambled for an acceptable excuse to decline. He hated politics and did everything possible to steer clear of any involvement. More importantly, Reynolds’s invitation seemed nothing more than a weakly disguised solicitation for money. On the other hand, Reynolds was his boss, and there was the old saying about biting the hand …

  “Thanks for asking, but we already have plans for that night,” Alex lied. “Tell you what, how about I make a small contribution to the campaign?” He saw this as the best way to control the monetary damage. “Just let me know where to send the check.”

  “Good man. My girl will drop off the information at your office. Your Republican Party membership current?”

  Shit! Why do people automatically assume doctors are card-carrying Republicans? Admit the truth or spin another little white lie? Months ago, when his world crashed down on him, Alex pondered how men like Waters, Weiner, and Reynolds rose to be leaders in organized neurosurgery. Well, standing here in front of him was a living lesson: men like Reynolds ascended political ladders through active organizational involvement, the same way Alex established his scientific reputation by publishing in journals and presenting at meetings. This simple concept only now came sharply into focus, the corollary being this: leaders promote colleagues who share their attributes and vision, and Alex—certainly this early in his tenure—intended to stay on Reynolds’s good side to avoid another Weiner disaster.

  “Truthfully? It isn’t.” Which, taken literally, wasn’t actually a flat-out lie. “I’ll take care of it right away.”

  Reynolds punched his shoulder. “Good man.” Another glance at his watch. “Wish I had more time to talk, but I’m running late.”

  “Before you go, you know I submitted the grant?”

  “Yep. Claude told me. Glad to hear it.”