Lie Still (15 page)

“Can I see her?”

“Not for a while. When she comes out of recovery.”

“But she gonna be okay?”

“It certainly looks that way. Dr. Lyle did a wonderful—”

“That surgeon lady? I still ain’t seen her. If she thinks I ain’t worth talking to then Lord have mercy.”

“That is absolutely not the case,” I said. “It’s been a very busy day. She has a lot of patients. I know you’ll get to meet Dr. Lyle on rounds this evening.” I paused, wondering if it was wise to veer again toward full disclosure, but decided with good news it couldn’t hurt. “I think you should know that Dr. Lyle didn’t meet with you ahead of time because she was in the OR suite whipping them up into a frenzy to get 106

DAVID FARRIS

Darla’s operation started before anything else could happen in there. She made us all break a few rules. She upset some people. They don’t like having their plans changed suddenly.

None of us does. But it may have made a big difference for Darla.”

I think she thought I was feeding her a line.

I found Mimi in her office. I asked her how often she threw fits at the OR control desk.

“About once a year or so,” she said. “Whenever I get an otherwise salvageable person with an isolated epidural or even a subdural. And this was a little kid. With babies and kids I get especially pissy.”

“Because they’re harder to manage?”

“No. For basic trauma stuff like this kids are no harder.

Easier in some ways. They bounce out of the hospital in three days. The ones who do well.”

“Do you think thirteen minutes to get to the OR is a magic number?”

“Only to the OR staff. If you say fifteen, people think you’re saying ‘about a quarter hour,’ which could just as well be a half hour, which could be three quarters of an hour, which could be an hour. If you say thirteen minutes, people believe you mean thirteen minutes.”

“But I’ve never seen that kind of push from a surgeon before.”

“I’m perfectly happy to play nice for meningiomas. I’ll even wait my turn at night for VP shunt revisions. But I had a man arrest and subsequently die from an epidural while waiting for the next available OR team. It happens with epidurals. I realized then that that man needed me to be drilling on his skull more than anything else, more than anesthesia, more than sterile technique. Did five or ten minutes make the difference for that little girl, what was her name?”

“Darla.”

“Darla. Did shaving a few minutes make any difference? I don’t know. If they don’t die maybe you could have gone slower. You never know. Unless you run like the wind and LIE STILL

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they die anyway. Then you know you weren’t any good. You know you didn’t make any difference.”

As I walked out she said to my back, “And I will not be irrelevant.” I turned but she had turned her face back into her work.

7

Walter Bryant’s warning about his bleak future as a surgeon
was easily dispatched with a dose of naive optimism. The
one who really should have given me pause, though, was Joe
Baltz, a man who never said a word to me.

We met on the shiny new Monday starting my medical
school Surgery rotation at the San Diego VA. At the start of
rounds the interns were dividing up the patients on the service among us hopeless students. We were to “follow” patients as if they were our own, doing as much of the work
for them as we could before seeking the sage counsel of our
superiors—practicing for internship. We started at the pinnacle of acuity—the ICU. When they sneeringly asked for a
volunteer, I stepped up first, green and transparent as a
tropical sea. I wanted the full experience. I was going to be
a surgeon. I won Mr. Baltz.

He was most of my workload and my emotional albatross for the next five weeks. He had come in with some
blood in his stool and was found to have a plum-sized cancer in his transverse colon. The resection was a complete
success and probably cured him of his cancer. Unfortunately, for years he had been intoxicating his liver by “tipping the jar” with greater vigor than anyone knew. Going
into the operation his liver was still functional, but, unbeLIE STILL

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known to his doctors, had zero reserve capacity. In the
stress of recovering, it made the unilateral hepatic decision
to check out.

While I had read about the consequences of liver failure,
I was, as I had come to expect as the norm for a medical student seeing organ failure for the first time, unprepared for
the reality. Chemical wastes run rampant. Everything turns
a greenish yellow.

For reasons unknown to anyone, without a functional
liver the kidneys shut down, too. Mr. Baltz required daily
dialysis to stay alive.

Without a liver one of the worst accumulated toxins is am-monia. As the level rises the patient is pushed into a coma.

Comas are graded on a scale of 15 down to 3, 15 being

“normal”— awake and knowing who, when, and where you
are—and 3 being neurologically indistinguishable from a
chair. Mr. Baltz was a 3.

Not surprisingly, the immune system practically runs and
hides. The patient is a setup for major infections. Napalm-like antibiotics are given every few hours to prevent this.

These kill off all the usual suspects, the staph, strep, and
E.

coli.
But, with the normal competition gone, the unusually
hard-to-kill stuff get to have their own chance to shine. Mr.

Baltz was widely septic with one such bug,
Pseudomonas aeruginosa,
the day I took him on—sixteen days after his operation—and stayed that way until he died.

Pseudomonas, not surprisingly, smells bad. It also turns
pus a sort of lime green. Mr. Baltz had green ooze at every
unnatural body orifice we had made for him—his surgical
incision, his tracheostomy, his chest tube, abdominal drain
sites, and dialysis catheters.

The antibiotics we use on pseudomonas only fight the
bugs to a standoff. They definitely, however, kill kidneys.

While kidneys will recover from hepatic failure alone, we
were pretty sure Mr. Baltz—should he survive—was ensured
lifelong dialysis from all the “mycins” we poured in.

From Day One of my tenure I thought he should be allowed to die. I grumbled on rounds. I grumbled to Mary
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DAVID FARRIS

Ellen. On about Day Eight I spoke up: “Why are we doing
this?”

Walter Bryant blinked at me, then gave only a paternal
smile. “You’re new here, aren’t you?”

The interns laughed. I scowled.

“We’re doing this,” he said, “because it’s what we do.”

I scowled harder.

He made a sweeping motion around the ICU. “Intensive
care. We fight sepsis. We fill in for the organs that have failed.

We replace all the missing elements.”

I said, “But this man is dead.”

He said, “He’s not dead till we say he’s dead.”

I said, “I vote he’s dead.”

“Medical students don’t get votes, Doctor,” said a
pimple-faced intern.

“Then don’t call me Doctor.”

He did a melodramatic version of looking shocked. “It’s
considered a sign of respect.”

“Well, it also carries a certain responsibility,” I said.

“And if I don’t even get a vote, I don’t want anyone to think
I have any responsibility.”

“Lighten up, man. You take this shit way too seriously.”

I blinked at him, then looked over at Mr. Baltz.

Dr. Bryant said, “Each of this man’s problems is recoverable. We’re giving him a chance.”

“What about his kidneys?” I asked.

“You don’t know they won’t recover. And he could live
forever on dialysis.”

“Total liver failure is recoverable?”

“In theory, it can be.”

“In what proportion of cases?”

“Oh, it won’t happen. It’s less than one percent.”

I said nothing. We moved on to the next patient.

When I complained to Mary Ellen, she was, of course,
sympathetic toward the patient and me. She said, though,

“Remember why you’re there.”

“To help the man?”

“No, they’re the ones doing that. Or trying to. You’re
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there to learn how to be an intern. Help if you can, but don’t
make it too hard on yourself. The patient has the disease.”

I looked for something—anything—to do. When I saw his
wife I gently brought up the idea of withdrawing care. She
was more than receptive, she was grateful. “He’s hating
every bit of this,” she said.

“You know that?” I was expecting her to recount an earlier conversation.

“He tells me,” she said.

I looked at her.

“When I’m praying I feel him there.”

Next morning on rounds I reported her reaction. “You
know his family is suffering,” I said.

“They don’t realize he could still live,” Dr Bryant said.

We repeated our earlier argument. Dr. Bryant again
ended by disavowing any hope for success: “Do I believe
he’s going to live? Not for a second.”

“Then why are we flogging him? They’re in real pain.”

“Because we don’t
know
he’s going to die.”

“Seems to me we do,” I said with self-assurance, though
I felt like a schoolboy expecting a beating for being right at
the wrong time.

“But we can’t prove it,” he said, again moving on toward
the next unfortunate.

My only recourse was to spend more time talking to Mr.

Baltz’s wife and daughters. I explained medical details and let
them voice their frustrations. They seemed to appreciate the
time and it made me feel like I was doing something.

Each day at rounds, when we got to Mr. Baltz, my contribution was an update for the team on the emotional state
of the man’s family. The intern told me to knock it off. I ignored him.

It took another month for Joe Baltz’s heart to quit, too, so
we could pronounce him dead. Not once did his coma score
budge off of 3.

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T H E B O O K O F M I M I , C H A P T E R F I V E

Even as Mimi and I imagined we did everything for The Cause, suffering, even in bed, the imagined slings and arrows of Drs. Miekle, Ryan, Kellogg, and Bullock with the grace of martyrs, patient care went on. And on. Our siege-state mentality was often superseded by the numbing repetition of all-consuming crises and the bone-bending hours of clinical neurosurgery.

We had a night in that stretch when three head traumas each needed surgery. The first was a routine clot on the brain from a head conk. We were near the end of it when a call came for Numbers Two and Three, arriving simultaneously from the same wrecked pickup. This was slightly unusual because it wasn’t yet 2:00 A.M., so the bars were still open and people shouldn’t have been on the road. Mimi said to me, “Put this guy’s head back together,” told the scrub nurse,

“Watch him,” meaning me, and broke scrub for the ER. By the time we finished the identical operation on Number Two and put a pressure bolt in Number Three, it was time for morning rounds, which we began with the usual walking breakfast of donuts and bad coffee.

The investigation of the Coles case and Mimi’s abilities took an interesting twist before completion. Mimi was told, completely off the record, that Marshall Bullock, the Chair of Neurosurgery, had been forced to form an ad hoc Committee of Three to review the facts and make the final call.

Academic tradition says that any question of fitness for a faculty member belongs solely to the chair, but because of the nature of the department structure—split across two campuses less than two hours apart by high-speed freeway—he had largely turned it over to Joe Kellogg, the local vice-chair.

Dr. Kellogg related his findings to Dr. Bullock, Mimi was told, then phoned Ted Miekle in the Anesthesiology Department and told him he had found nothing to be concerned about. Dr. Miekle then apparently made enough of a row about the whole thing being a whitewash that Drs. Bullock LIE STILL

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and Kellogg had to agree to bring in an “objective” third person to go through it with the two of them and prepare a written report. They invited a neurosurgeon who was said to be

“well-respected” to fly in from Seattle.

When word of this reached the residents, speculation ran wild among them. One evening at The Longhorn, our version of a student commons, I witnessed a memorable deliberation.

That night there were members of the usual bunch: repre-sentatives of future surgeons, radiologists, internists, anesthesiologists, et cetera. No one had heard of the neurosurgeon from Seattle, so there was a rumor-based, fact-free argument about just how impartial this third party might or might not be. The most important unknowns to the debaters were his marital status and the likelihood he had bedded Mimi, or vice versa, at some convention of brain surgeons. I kept my mouth shut.

One wag pointed out that such a coupling, had it occurred, would not by itself guarantee either a favorable or unfavorable review. He pointed out that her degree of bedtime willingness and expertise might have colored their ultimate parting in any number of unpredictable ways. It occurred to me that
his
talents were more likely to be a limiting factor than hers, but I kept my mouth shut tighter still. “The only thing I think we can guarantee,” he said, “is that the facial expressions around the committee table would be really interesting to watch.” To this I agreed wholeheartedly but silently, maintaining my mask of disinterest by keeping my face in my beer.