Lie Still (11 page)

“I went and studied the scans just like she had done, turned my head a little this way and so . . .” Dr. Kellogg smiled.

“Then I came and sat down at the teaching head again.

She said, ‘Now look at the patient. Which side am I approaching from?’

“I looked and looked, and I must say that once the drapes are over the guy and the skull is open you really can’t tell front from back or left from right. Damnedest feeling. Like being lost in the woods. I got up again and went around to the anesthesia side of the drapes. Dr. Ryan lifted up the drapes a little, and I could just see the guy’s chin. He had a short beard, and I mentally pictured the rest of the head and how it had to be lying and yeah, we were coming in from the left, just above and in front of the ear. I told her, ‘We’re coming in from the left.’ She said, ‘And this is the head?’ We all kind of laughed.”

“Nervously,” he suggested.

“Yeah. Nervously.”

“Whose idea was it to call in Dr. Adams?”

Mines everywhere. I had to think a second. “I guess it was hers—Dr. Lyle’s. I didn’t really pay that much attention to it. I remember Mimi—Dr. Lyle—saying, ‘Oh, okay, call him!’ Kind of exasperated.”

“ ‘Call
him
’? Not ‘call Dr. Adams’?”

“Yeah. Just ‘call him.’ ”

“How did they know who to call?”

“I don’t know.”

“Dr. Adams’s name hadn’t been mentioned?”

“Well, it must have been, I guess. I guess I just didn’t hear it. But I’m sure she just said ‘call him.’ ”

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“It wasn’t at the insistence, or the suggestion, of Dr.

Ryan?”

“I don’t remember that as such. There was some grumbling going back and forth across the ether screen between the anesthesiologist and the scrub nurse. Nobody was too happy by then. Anesthesiologists must hate slow surgeons as much as surgeons hate slow anesthesiologists.” Dr. Kellogg nodded. “This case was dragging on forever and people were getting pretty stressed. I remember another anesthesiologist came in to give Dr. Ryan a break, and they were whispering and shaking their heads. Then Dr. Ryan said something to his partner—louder—about ‘needing help again.’ ”

“Did you think Dr. Lyle noticed any of that going on?”

“It was all really tense. I figured she at least heard the comment about help, but she didn’t show it.”

“Who was the other anesthesiologist?”

“I don’t really remember. I think it might have been Dr.

Koehler.” I leaned over to look at the anesthesia record.

“There’s no mention of a break,” he said, waving his hand over the chart.

“It was probably Dr. Koehler,” I said. “Whoever it was wasn’t there but about twenty minutes.”

“I’ll look into it. One of the other people present during the case reported to me that Dr. Lyle finally asked for help from Dr. Adams only at the insistence of Charlie Ryan.”

I just looked blank. “I don’t remember it that way.”

“You understand what I’m being asked to decide,” he continued.

I nodded. “I think so.”

“Part of a surgeon’s skill set is knowing his—or her—limitations. None of us is as good an aneurysm surgeon as we’d like to be. Each case is different and there aren’t enough cases—thank the good Lord—for anybody to get what you would call a whole lot of practice. I’m supposed to get some idea of Dr. Lyle’s level of insight into her own abilities. Somebody must think I can do miracles. You and Dr. Ryan were the only other doctors present for the majority of the case.”

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“But . . . what I don’t get, is, this was one case. As I understand aneurysm operations, they can go from bad to awful at any time. The way it’s been explained to me, the things lie about dead center in the head. The exposure is never good. They burst if you, you know, disturb their invisible force fields, or whatever. When they do burst you’re totaled.”

“Well, not always,” he said. “There are things one does.

Sometimes they work. This aneurysm didn’t burst, though.

Correct?”

“No. I mean, yes, it did not burst.”

“Did not . . . spring a big leak at any point?”

“No. And wouldn’t that be in the Op Report?”

“It should be, if it happened.”

“Well, it didn’t happen. Unless I was asleep on my stool when it did.”

He nodded. “If it did, the screaming—well, actually it’s not screaming, it’s the, I don’t know, the lightning flashing around the room. Crisis management. It certainly would have awakened you and half the OR staff in the lounge.”

I smiled. “But, sir, if the outcomes are rarely as good as you’d like, and, like you said, each one is different, how does this case mean so much?”

“Well, Malcolm, you hit the nail on the head. Dr. Lyle is a fine surgeon. I am proud to have her here at Maricopa. So I will tell you the party line, same as I’m telling Dr. Lyle: We take any peri-operative death seriously.”

“Well, of course,” I said.

“And this one generated a formal complaint from Dr.

Miekle, Head of Anesthesia, to both Marshall Bullock and me. Which we will answer.”

I nodded.

“Marshall has asked me to do all the legwork. We go asking a lot of questions, wasting a lot of time, it seems to me, to find out all over again that aneurysms do poorly.”

“Yes, sir.”

“It is a bit baffling how it could have gone on so long,” he said to himself. “One thing noted on the anesthesia record,”

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DAVID FARRIS

he went on, “was ‘0020: Dr. E. Adams called to help!’

There’s an exclamation point.” He looked up at me. “Plain-tiffs’ attorneys adore little things like exclamation points around some problem. Then: ‘0105: Dr. Adams here.’ Then

‘0155: Clip on.’ Surgery end time is given as 0240. Patient in the ICU at 0310. Seem right to you?”

“Yeah. I guess so. I don’t watch the clock.”

“Could you tell me what happened? When Dr. Adams arrived, I mean. What was said?”

“Well, like I said, Dr. Lyle said, ‘Oh, all right, call him!’

She was exasperated. When she said that, it felt like everybody relaxed, the nurses and the anesthesiologist anyway.

Mimi was pretty wound up, but seemed sort of resigned by then.

“So we’re kind of sitting on our hands, you know, waiting for Dr. Adams to get there, once in a while sucking the blood out of the wound but mostly just keeping it covered and waiting. So about a half hour later he kind of slowly ambles in, holding a mask over his nose and mouth with one hand”—I slowed my speech way down—“sets his briefcase on the floor,”—Dr. Kellogg was smiling at this—“and looks over the scans on the viewbox while tying up his mask.

Doesn’t say much, except he drawls out, ‘Howdy, everybody.’ I’m wondering if this guy’s for real.”

“He’s very real. Seen him do it,” he said. “Defusing bombs.”

“What?”

“Defusing bombs. Nobody feels like yelling anymore when he’s sauntering around saying ‘Howdy.’ ”

“Well, he kind of shuffles over to the table and peeks through my side of the microscope for a minute, nods to me, mumbles, ‘Howdy,’ shuffles back to the viewbox and studies the scans, then looks at the scrub nurse. I swear she was grinning behind her mask. She says, ‘Eight browns?’ He says,

‘Yyyepp, like always,’ and shuffles out to the scrub sink.

“When he came back I got up. Dr. Lyle took my seat and he moved to her seat. I was pretty beat, so I didn’t exactly follow what he did, but he loosened and refixed the retrac-LIE STILL

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tors a few times, looked through the scope, moved the retractor again, moved the scope. He just went in and found it.

Clipped it. Took about thirty, forty minutes, I guess.”

“Did he say anything?”

“He said, after the clip was on, something about it being in a tough spot, easy to miss. Maybe he was just being nice, though.”

“He’s like that.”

“Then he got up and left. Said, ‘Thanks for callin’ me.’ It was really kind of incredible. I even looked over at Dr. Ryan.

He was kind of nodding. I said to him real quietly, ‘Who was that masked man?’ ”

“Indeed.” Dr. Kellogg rubbed his eyes. “Did you . . . Have you talked with any of the people who were there since the operation? Dr. Ryan? Any of the nurses?”

“You mean about the case?”

“Yes.”

“No. I guess not. I mean, I’ve run into them. One of the nurses asked me how the guy was doing. That sort of thing.

After he died one of the other residents asked me what happened. I said, ‘Hey. Some patients die.’ Bad disease—bad outcome.”

“It is a bad disease.”

“I read in the text that something like seventy percent die.

Is that right?”

“It may be. About half don’t even make it to the hospital.

But of those who do, most survive.”

“But all gorked out?”

“No. Some, for sure. Nursing homes and bedsores. But most survivors are more or less functional. One of our car-diologists here is an aneurysm survivor.”

“Practicing?”

“Came back after rehab. Took most of a year, but now he’s bright and busy as ever. It can be done.”

“Well, like I said, there’s been some head shaking among the residents and nurses and folks, but I haven’t hashed through any details with any of them.”

“Well, if you could, don’t bring it up for a week or so. I’d 80

DAVID FARRIS

like to complete my round of questions first. In fact, please don’t discuss this case with anyone, other than the usual sorts of things you’ve already mentioned.”

“I think I understand.”

He looked at me. “I imagine you do. They tell me you’re one of the better surgery residents,” he said. “Real talent.”

“I don’t know about that. It’s kind of you to say so, though.”

“Going to stick it out in general surgery?”

“Planning to.”

“Surgery of the stool-forming organs?” I just smiled. It was an old joke. “Thought of a subspecialty fellowship?

Cardiac? Vascular?”

“I’ve kind of thought about cardiac, but I don’t know if I’ll be able to swallow another two years. Plus, my dad is expecting me to take over his practice back in Nebraska.”

“Well, from what I hear you’ll do very well.”

“Thank you.”

“One last thing.”

“Yes, sir.”

“I was in Tucson in meetings last Thursday. Was there a Morbidity and Mortality—M & M—presentation?”

“Yes, sir. I presented it.”

“What was the gist of the discussion?”

“I presented it as an acute aneurysm, obvious high risk going in, difficult exposure, protracted surgery, Dr. Lyle got Dr. Adams to help. They got it clipped. Unfortunate outcome.”

“What was given as the ultimate cause of death?”

“Diffuse cerebral infarction, massive reperfusion edema, brain swelling leading to herniation and ultimately no blood flow.”

“The usual final pathway. Was there an autopsy?”

“No, sir, but the CT scan twenty-four hours post-op pretty strongly suggested the picture. The whole brain was massively congested.”

“What about the discussion from the faculty, the other surgeons there?”

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“Really not much. One asked how long the dura was open.”

“What did you say?”

“I told him I thought it was about six hours. I hadn’t checked the times. There were a couple of murmurs from the back.”

“It was ten and three quarters.”

“Yeah. I should have checked, I guess. Anyway there was very little discussion.”

“Was Dr. Adams there?”

“I think so, yeah.”

“Dr. Miekle?”

“I didn’t see him.”

He rose and shook my hand. “Thank you, Malcolm. I don’t expect we’ll have to bother you any more about this.”

In the receptionist’s room sat Dr. Ryan, apparently awaiting his turn to meet with Dr. Kellogg. I was momentarily frozen, standing in front of him. He cocked his head back, slapped shut the magazine he’d been reading, and said,

“Time of your life, eh, kid?” He was smiling from only one side of his mouth.

“Isn’t that from a movie?”

“Yeah, I suppose.”

“Why do I have the feeling I’m stepping into a tar pit or something?”

“You’re already in it up to your nuts, son. And the party’s just beginning—I’m coming in after you.” He stepped past me, into the inner office.

My enthusiasm for spending nights with Miriam Lyle had been considerably deflated, first by her nastiness toward Abbie Roberts, then by an instinctual sense that I’d aided and abetted a crime of some kind. When we weren’t working at the hospital all night, I slept at home.

After my session with Dr. Kellogg, though, Mimi, naturally, was dying to know every word of the encounter. She maintained an air of unworried detachment, though. This, of course, made me want to recite the whole thing in detail, 82

DAVID FARRIS

to get her responses, but I, too, restrained myself. As a result, it hung in the air like fog until the end of morning clinic, when we could reconstruct over lunch, one piece at a time, the details of the conversation. She acknowledged that I had no choice but to respond to the questions as I had and told me flat out that the whole thing would blow over, that there was no “meat in the burger.” She said, “I don’t know what they would expect. Outcomes are lousy in aneurysms.”

“That’s what I said. I mean, I said that was what I understood to be true.”

“It is!” She was going to vent a bit.

“I don’t know,” I said, “how they make all this stink over a single case.”

“Charlie Ryan.”

“The anesthesiologist?”

“Yes.”

“I thought it was the chairman. I thought he sent some nasty-gram that started this shit.”

“That may have been, but I promise you it started with Charlie Ryan. He’s such a prick.” I smiled—ever the dutiful audience. “He’s a card-carrying misogynist.”

“What’s he got against women?”

“Who knows. Probably thinks we all should be home doing the laundry and folding his underwear.”

“Barefoot and pregnant.”

“And grateful,” she said. “I’ve heard, also, that he’s a bit of a closet racist.”

I raised one eyebrow. The resident’s job is to be the shill.

“Goddamn gas-passers. Sit on their fat asses reading
The
Wall Street Journal
while we struggle with patients’ problems so we can serve them their cases on a fucking silver platter.” She was starting to roll. “We make decisions, do the tests, plan the operations. They do a simple anesthetic, collect a fat fee. Some of them do their best to make it look hard, take all fucking day to get a case going, take all fucking night to wake somebody up. Can’t get lines in. Patients bucking, puking, disoriented. Blood pressures all over the LIE STILL