by Allen Wyler
“You sure you want to go through with surgery?” Alex asked the patient that afternoon. He sat next to the patient’s bed, explaining one final time all the things to expect the next morning, secretly hoping the patient or his wife had enough second thoughts to cancel. “We did shut down a lot of arteries, but we couldn’t get all of them. This is still a very tough, risky surgery. Never forget, you have the option of delaying. We can easily do the very same thing in a few weeks to shut more of them down. In fact, we can do it several more times before going through with the actual surgery. How does that sound to you?”
“Doc, I know you mean well and all, but the thing is, I just can’t live knowing that time bomb’s still in there,” he said, pointing at his left temple.
Alex placed a reassuring hand on the patient’s shoulder. “There’s nothing wrong with cancelling. We can always see what today’s treatment does over time. Maybe we got more than we thought and you can avoid the surgery entirely,” he said hopefully, but he knew that was a lie.
“I want it out, Doc.”
Martin’s words echoed in his head. “He’ll end up going to someone like Cramer if you don’t do it.”
Alex handed him the consent and a pen.
He lay on his side staring at the glowing digits as they passed midnight and continued on toward one o’clock.
Just be careful. Stay cautious and you’ll get him through this intact. Now isn’t the time to get squirrelly.
Alex prayed to God to watch over him, to get his patient through surgery intact.
Unable to sleep, Alex arose at 5:00 a.m. Bleary-eyed, Lisa dragged herself out of bed to make a bowl of oatmeal and raisins topped with brown sugar, the way he liked it. For some reason the oatmeal seemed to stay with him longer than dry cereal, and he didn’t want the grease from bacon and eggs in his stomach. He wasn’t sure when—or if—he’d get a chance to eat anything else, because this was the kind of case that, once started, wouldn’t allow him to take a break.
“Comforting to see you here,” Alex told Cole in the lounge after a quick trip to the waiting room for final words with the family. Family members he’d never met before sat with the patient’s wife in a small prayer room off the surgery waiting area, the room already stuffy and warm. The family looked at him with awe, as if he were a god. He wanted to assure them he wasn’t, that he could only do his best. On the other hand, this wasn’t the time to cast even one seed of doubt. Today, more than any day in his practice, he needed all the positive energy he could muster.
“Big case,” Cole said before sipping his coffee, a half-eaten donut in hand.
“Biggest of my career,” Alex muttered, then left to change into fresh scrubs. Today would test just how good—or bad—he really was. As he paused to think about that, a rush of guilt and shame overcame him. Is that what this is all about? A test of my ability? Is this really all about me?
Shit!
His gut butterflies intensified.
Why not let Cramer do it? Why do I have to be the one?
Because I’m better than they are. His chances are better with me.
“Skin knife,” Alex said as he eyed the clock, noting the start time: 7:31 a.m. He pressed the scalpel blade into the scalp, officially beginning the case. The initial cut bled more briskly than normal, causing Alex to work slowly and meticulously to control the loss. Every inch of skin he opened took more time than normal. Since blood loss was cumulative, every drop that left the patient became part of the final tally. Let too much slip by and the patient would need a transfusion. With each transfusion came the risk of a reaction. The significance of this abnormal scalp bleeding dawned on him: even the scalp vessels—which usually had no connection with the brain’s blood supply—contributed to the AVM. This staggering realization caused him to pause. Back out? Just close up and tell the patient I can’t do it?
Just pay more attention to every move. Be meticulous. You’ll get through.
Steve Stein—who wasn’t on his rotation, but who Alex had requested assist him—stood on his right, dutifully sucking the blood and irrigation fluid, keeping the surgical field clean.
9:45 a.m. Alex continue struggling to open the dura. Excessive oozing from all the tissues made progress agonizingly slow. Typically he had a craniotomy open and ready to go in thirty minutes or less, but they were now two hours and fifteen minutes into the case, and he hadn’t reached the hard part. He consoled himself by thinking that every vessel coagulated, even the tiniest, was one less he had to deal with. He remained haunted by the reality that this much bleeding this early in the case was a very bad sign.
Stay calm.
“Bob, we’re losing more blood than I anticipated. Let’s send off a red-top for an additional type and hold. Just in case.” As an afterthought, he turned to Chuck. “Why don’t you see if we can get one of those doohickeys in that the vascular guys use. The device that recycles irrigated blood. Know what I’m talking about?”
“Roger that, sir. I was about to suggest that.”
The sick feeling in the depths of Alex’s gut grew more intense.
10:30 a.m. “Chuck and Ethyl, why don’t you guys get some replacements in here so you can take a break.” This wasn’t a question. He purposely wanted to spin them out early for a rest, because it was now painfully apparent the case would take much longer than expected, certainly much longer than his typical tumor case. With the opening completed, he was struggling to discern arteries from veins because, unlike the normal condition in which veins carried blood with less oxygen, these veins carried oxygen-rich blood directly from the arteries. Clip a thin-walled vein under a full head of arterial blood pressure and it could burst, creating a hemorrhage that might be impossible to control. This was the reason all arteries feeding to the lesion had to be closed down first. Now he had to resort to meticulously tracking each vessel back to its origin before slipping a spring-load clip around it. Veins drain to the midline whereas arteries originate from the base of the brain. Each time he passed the jaws of a clamp over a vessel, his heart pounded with anxiety. Would it burst? And each time he did close down a vessel, others seemed to appear or get larger. It appeared that the embolization on Tuesday had accomplished very little. He was sweating now, drops rolling down his chest, soaking the elastic of his shorts.
“Roger that, sir.”
Alex glanced at Steve. “Get another resident in and take a break for lunch.”
Steve seemed hesitant. “What about you?”
“I’ll have someone bring me in a carton of chocolate milk and a straw.”
“Call the lounge and see who’s free,” Steve said to the circulator. “Anyone will do.”
2:02 p.m. Shit! Alex blinked away a drop of sweat that stung his right eye. He peeked at the twenty-four-hour wall clock. Oatmeal long gone, his stomach growled. He was seeing initial signs of clotting problems from the patient receiving so many transfused units of blood. Cole had resorted to ordering fresh plasma and platelets from the blood bank, and word just came back that the bank was running dangerously low. They had to control the bleeding. Break the bank and they’d be out of luck.
“Hey Ethyl, put in a page for Gene Roux,” Alex said.
Cole glanced over the drape and nodded approval. If you ever need a hematologist, Gene’s your man. Morbidly obese or not, Alex wanted to see him waddle through the door. Immediately, he felt a wave of guilt for ridiculing the fat man’s love of maple bars and sugary coffee. He wanted to apologize to someone.
“You call?”
Alex glanced up from the surgical field, sending a sharp stab of pain through his neck. Gene Roux stood just inside the OR doors dressed in green scrubs.
“Boy, am I glad to see you. We got a serious problem.”
Now starved and dog-tired, Alex plodded on without any sign of progress. Every artery he clipped seemed to enlarge the smaller neighboring ones. There was no way he could stop and close the case now and no way to predict how much longer it might take before the malformation w
ould be obliterated. He now appreciated why Garrison refused the case. The first wave of panic hit with a dizzying impact, forcing him to stop and take some deep breaths to calm himself. He closed his eyes and willed his mind to not succumb to the terror flirting with him. Every one of the muscles down his spine ached. The palms of both hands were cramping. In a perverse way, he welcomed the discomfort as a form of penance for bringing this unfortunate patient to surgery, believing that if he suffered enough, perhaps the patient would somehow make it through this.
4:10 p.m. “Doctor Cutter, we’re rotating out now. Joyce will replace me and Troy will replace Ethyl. Good luck.” With that, Chuck stepped off the platform for the overhead table, allowing Troy to take his place. Alex had worked with Troy only once before and had decided that, like Chuck, he’d been well trained in the Navy.
“Thanks, Chuck, Ethyl. Appreciate your help.”
He glanced at the clock and realized that both techs had stayed beyond their normal three o’clock end of shift, probably in hopes the case might be finished by now. Not even close. Alex was continually fighting an overwhelming feeling of despair from the creeping knowledge that the case had gotten away from him and that nothing good would come of it. Never before had he been faced with this situation, and he didn’t know how to handle it other than to keep on keeping on. He wanted to plead with Chuck or Ethyl—touchstones of normalcy—to stay but felt guilty for even entertaining the thought.
“Before you go, could you call over to the clinic and ask Garrison to come over? Then call my wife and tell her I’m not coming home in the foreseeable future. Certainly not for dinner.”
“Doctor Cutter? Clinic says Doctor Majors is tied up and can’t come.”
Fucking Garrison. He’d never known Garrison to refuse a partner, especially if he was in trouble. It was, after all, one of the reasons he lived in scrubs. Does he know I’m in trouble? Has to. The whole fucking hospital knows. He could see pity in everyone’s eyes, even staff who entered for various reasons. They knew he was in over his head.
He straightened his spine and rotated his head, working out kinks, stretching sore muscles. The additional pound and a half from the loupes strapped to his forehead was killing him after so many hours, producing the neck ache from hell. Even the bridge of his nose hurt from the pressure of their feet.
5:03 p.m. Alex’s left hand had developed a tremor. No matter how hard he tried to suppress it, it didn’t ease up. So far Stein hadn’t mentioned it, but Alex knew everyone in the room noticed it as the first obvious sign of his mental defeat. A sense of despair was beating him down now. Don’t give up. You can’t anyway. You’re in this to the end. Be defeatist and the case will go tits up before you know it. Hell, it already has.
He recognized his lightheaded tremulousness as symptoms of hypoglycemia. He asked the circulator, “Can someone please bring me another chocolate milk?” An hour earlier, the circulator had snaked a straw in from the side of his mask so he could drink a small carton of milk. He’d had nothing else since the morning oatmeal and felt famished, although the thought of eating made him nauseous. He inhaled deeply and pressed on, amazed at being able to garner the strength to do so. There was no alternative.
Why did Garrison refuse to come? His anger toward Garrison pushed him on.
“Hey Alex, want a break? I just finished my last case.”
Surprise! Jason Braddock, one of his partners, stood to Alex’s right, peering at the exposed AVM. A mirage? He couldn’t believe his eyes. “Aw man, would you do that? I’d love to be able to get down on the couch for five, ten minutes and maybe eat something.”
“Go ahead, get it ready to babysit. I’ll scrub in.”
Alex hurried downstairs to the prayer room filled with warm, stale air that smelled of strong coffee and body odor. It was littered with newspapers, empty Styrofoam cups, and plastic food containers. Two young kids played on the floor with primary color toys, every seat occupied by adults of various ages. The wife stared at him the moment he entered. “You look beat, Doc Cutter.”
Her words almost brought tears to his eyes. Rather than ask for word about her husband, she seemed focused on his well-being.
“One of my partners spelled me so I could come give you an update in person.” Several times during the afternoon he had asked the circulator to call down with a progress report.
He palm-wiped his facial stubble. “This is taking much longer than I anticipated, but I will get him through surgery. Can’t lie to you: we’re in serious trouble with continual oozing. Have been for hours now, but I have a good hematologist working with me. I will bring him though this no matter how much longer it takes.” Surprisingly, he felt inspired by his own word.
“We’re praying for you, Doc.”
“Good. I need all the help I can get. Just want you to know I’m not giving up. I’ll be here with him until this is over.”
Her eyes glistened with moisture. “I know you will. You’re a good doc. We have all the faith in you. But if something happens … well, we know we did the right thing. He said he didn’t want to live knowing that time bomb was ticking inside his brain. You’re the only one who tried to help him. God bless you, Doc Cutter.”
That’s because I wasn’t as smart as those others.
Ashamed, still fighting back tears, Alex shut the door behind him, relieved to escape the eyes of these people who trusted him blindly. The patient would die from this operation, he knew. Killed by Alex’s own hubris.
The cafeteria closed at 7:00 p.m., leaving the vending machine in the alcove next to the surgeon’s lounge as his only choice for food. Alex stopped at his locker for change, found enough to buy a Hershey bar. He scarfed down the cloying, sweet chocolate while lying flat on his back on a couch in the lounge. His five minutes had blown past in a blink, and he was relishing the break way too much to return right away. A change into fresh, dry scrubs perked him up slightly. He closed his locker and spun the lock but remained standing with his fingers on the combination knob.
I don’t want to go back.
His physical discomfort seemed amplified by the shame and guilt of thinking such a thought.
What if I just walked out of the hospital? Just went home?
What kind of person even thinks such things?
Slowly, he trudged the empty hall back toward the OR, the chocolate making his hunger worse. Every muscle in his back and shoulders ached from hours of sitting tensely on the stool, his fatigue almost overwhelming. His spirits lowered with each step as the OR doors grew larger, but his feet continued forward, as if of their own accord. Then he was poking his head through the doors saying, “I’ll scrub back in now. Thanks.”
At the sink, water running over his hands, he lathered up Betadine. In a few minutes he’d be gowned and gloved. He knew he wouldn’t see this hall again until the case was finished. By now, the other ORs along the long, empty hall were dark and silent, the day’s schedule finished long ago, the rooms already cleaned and ready for the start of a new day.
“Thought we were never getting out of there,” Cole said as he and Alex pushed the gurney to the empty recovery room. The hospital kept one nurse on duty to monitor the patient until Cole deemed him sufficiently awake from anesthesia to transfer him from the recovery room to the neuro ICU.
“He’s going to bleed into that resection cavity,” Alex predicted. In spite of his faith in Gene Roux’s skills as a hematologist, the clotted edges of the brain would give way within the next twelve hours. “I guarantee it. Probably sometime early this morning.” And that would be the end of it.
They continued on in silence, moving slowly up the hall.
Finally, Alex said, “I can’t find the words to thank you for sticking with me on this. Without you and Steve I never could’ve made it through.”
Cole patted Alex on the shoulder. “Go talk with the family. I’ll finish up the paper work. Go home; get some rest. Seriously. You look like two-day-old dog shit.”
Alex veered off from C
ole to take the stairs down to the prayer room. The hall clock showed 11:05 p.m.
“I’m on my way home,” Alex said over the car phone. “Do me a favor, draw a tub of hot water. All I want to do is soak.” Neither Alex nor Lisa usually took baths.
“Want something to eat?”
In spite of an empty stomach, the thought of food made him nauseous. “No, I’m good. A glass of wine might help.”
Alex hung up the car phone and continued driving along deserted Central Avenue.
The call came at 3:13, waking him from fitful sleep. Alex knew its significance before even picking up the phone. “Cutter here.”
“Your AVM just blew his pupils and is non-responsive to deep pain,” the on-call resident said, using doctor-speak for dilated pupils that wouldn’t constrict when a light was shined in them, a very dismal neurologic sign.
“Order a CT, I’m on my way.”
“Already ordered. The staff’s getting him ready as we speak.” Moving a patient in that condition required several nurses and a respiratory therapist to breath him while off the respirator.
“Oh, you poor man,” the patient’s wife said, tears streaming down her face. She hugged Alex as he wrapped his arms around her, unable to hold back his own tears. The rest of the family sat silently, heads bowed in prayer. “I know you did everything you could. You did your very best. This is what he and God wanted.”