Lie Still (23 page)

“No, sir. I’m off of her service as of this morning.” Again, a silence. “I saw a man in her clinic two weeks ago. He had a redo lumbar spine fusion before I came on service. And now 166

DAVID FARRIS

he’s worse than before the operation. I know, like everyone else, that bad outcomes happen. Especially in neurosurgery. It’s all a matter of percentages. X percent of our patients will get worse.

And when someone dies or lives in pain we all tell ourselves it could not have been helped. I’m feeling like it could have been helped.”

His look was hateful. “Like you could help.”

“No, sir. But maybe you could improve the odds for these patients.”

A long pause. “Why, Dr. Ishmail, do you think . . . what possessed Dr. Lyle to tell you—a mere resident, if you’ll pardon me—of this
inability
of hers?”

My ice was thinning out. Still, I knew I needed to keep the personal separate from the professional, keep our superiors focused on the real issue. “Like I said, she was in a weak-ened state. She’s been stressed a lot lately. Mr. Coles died, then this inquiry got going. Dr. Lyle hid it all, but she’s been really affected.”

He stared at me. “And you know this.”

“Yes, sir.”

“You’ve been calling her ‘Mimi.’ Are you on familiar terms?”

“Well, sir. We spent a lot of time together. It was just me.

I was the only resident on the service.”

“You saw her every day.”

“Well, nearly so. It’s a busy service. We always had several patients.”

“What is your relationship?”

I hesitated. “Sir. With all due respect, that is probably not relevant to the question.”

“Your relationship—how you might have come to know certain things—is not irrelevant.”

“Well, sir, it’s—”

“Because your credibility is not going to be impeccable, no matter what.”

“Her word versus mine.”

“Yes, and she’s a professor.”

I rubbed my eyes. I thought. “She told me. She told me LIE STILL

167

exactly what I’ve told you. She was upset about the Coles case. That’s all there is to say.”

He stared at me, hard. He took a huge breath.

“And when I go to Dr. Lyle—Mimi—and ask her about this—I will, of course, have to get her version—if I ask her about getting lost in the head, what do you imagine she’ll say?”

I thought. “Within the logical bounds of possibilities, sir, she could, as an honest physician, ask for appropriate help.

For the good of her patients. But more likely, I suppose, she’ll just flat-out deny it, then ask who said so.”

“And surely you’re not hoping that could be kept secret.”

“I know that would be asking too much.”

“And it would be unfair to her. One gets to know the source of one’s accusations. Also it would be fully impossible.”

“Yes, sir.”

“So when she finds out it’s you . . . ?”

“I don’t know. I’m sure it will be unpleasant.”

He waited a second, then said, “Are you going to be able to stand up to the process? Have you any idea what’s going to happen?”

“I’ll do what I have to.”

He turned his chair to look out his window. There was a long silence. Without turning back to me he said, “Dr. Ishmail, you know, do you not, that Dr. Lyle is an Associate Professor of the University of Arizona?”

“Yes, sir.”

“That she is on track for promotion to full Professor within a year?”

“No sir, I didn’t know that, but if—”

“That she is well respected by her colleagues around the country? The world’s best academic neurosurgeons?”

“Yes, sir, or, I mean, if you say so. But with all due respect, sir—”

“She is. And, you also know that our little ad hoc group has answered Dr. Miekle’s
damnable
letter. Her outcome in the Coles case, however regrettable, was to have been expected given the patient’s disease state. The man had suf-168

DAVID FARRIS

fered a massive stroke going in and no surgeon in the world was going to make that better.”

I was silent. He turned back to me. He said, “Keep in mind, Dr. Ishmail, it will not help Mr. Coles, nor Ms.

McKenzie—nor you—to be going around spreading stories about a faculty member.”

I nodded slightly.

“I don’t know where this . . .
maelstrom
got started—this goddamn anesthesiologist’s letter and all this. A tempest in a goddamn teapot.” He said “goddamn” as I imagined an angry Creator might. “It gets to be impossible to control.

People want to gossip like old ninnies.”

I said nothing.

“It will not help anyone for you to contribute to this . . .

this defamation. This character assassination.” Apparently Mimi’s reputation was to be our concern. “So . . .” He closed his eyes and took a deep breath. “I thank you for your concern. For your coming here.”

Dismissal.

“Yes, sir. Er, you’re welcome.”

He stood up. “I’ll give this some thought. Believe me, I will.”

I nodded.

“I know where I can find you if I need to.”

We shook hands. I drove home in the dusk knowing I had started a wildfire behind me, with little reason to hope that what I had done would help Miriam Lyle’s patients, and knowing just as surely that I had done only the bare minimum.

10

Hundreds of weekends ago Adrienne sent me to one of her
favorite stops on the Western Acute Tour of the High Plains:
Hoacham, Nebraska. Hoacham is the “Scenic Hub of Agriculture for the Republican Valley,” population 5,952, considerably more when there’s a cattle auction.

On my first stint in that Quiet Little ER Where Nothing
Ever Happens, I came upon a telling example of innate medical talent, or maybe lack thereof.

The nurse rousted me out just after midnight. An itinerant
Salvadoran farm worker was found in a roadside ditch with
four small stab wounds at the base of his neck. If you picture
a slender knife entering flesh, then leaving, you realize the
visible slit in the skin is only a point on a line. The tip of the
blade might have angled just about anywhere, and it could
have reached many inches deep. And the base of the neck,
anatomically, is tiger country.

The one farthest to the right apparently went down into
his chest. When I parted the skin edges, I had the distinct impression I saw lung moving. Whether that was correct or just
overwrought fantasy, his right lung was down, so I put in a
chest tube to suck it back to attention while the nurses
squeezed in enough fluids to get his blood pressure up into
human ranges. This allowed him to begin to wake up, which
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allowed us to see that he was drunk beyond recognition. It
also provided enough driving force to reopen from the inside
one of the stab wounds in the left neck that had partly clot-ted shut; it started pumping out bright red blood.

Every time I tried to part the edges to find the pumper, the
hole filled before I could see a thing. It seemed to be coming
from well below the skin and sub-Q; it was definitely coming fast. I needed help. I pushed a finger into the hole and
asked the nurses, “Who’s on call for surgery?” They looked
at each other.

I clarified the question: “Whom do you call when you
need a surgeon?”

“Whoever you want.”

It occurred to me to mention my mother—or my father—

but I restrained myself. “Who’s on call?”

“Well, we don’t really have a call schedule or anything
like that.” I’m sure I just blinked back at them stupidly. “You
just call who you want,” one said.

I blinked. “Okay. What are my choices?”

“Well, there are two surgeons in town. Dr. Yates has done
a surgery residency and Dr. Latta has not, but—” she looked
over her shoulder as if the wrong person might hear “—Dr.

Latta is the better surgeon.”

It took a few seconds to digest that. If the ER nurses were
willing to impugn the one despite his far superior credentials, that was an exceptional bit of intelligence. “One has
done five or six years of residency, but the other one is better?” She nodded emphatically. “No contest,” I said. “Get
the better surgeon, please.” I smiled, picturing Dad traips-ing out of our house in the middle of the night.

I stood there pressing on the poor guy’s neck, trying to
figure if I was pressing too hard and cutting off flow to one
side of his brain or not hard enough and letting his entire
blood volume squirt down into his left chest cavity where I
wouldn’t know about it until it was way too late.

Fortunately, Dr. Latta did not live far away and was apparently sober. An old-style GP just like Dad who had evi-dently been doing surgery since before there were
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residencies, he had glowing silver hair and the smiling un-flappability of a doc who has survived probably four
decades of bleeding drunks.

He eschewed gloves and essentially dove into the wound
with two long sterile Q-tips to see what he could see.

Which was nothing. Every time he parted the skin edges
the hole immediately welled up with more lipstick-red
blood. After three such tries he looked up at me and said,

“Vertebral artery.”

The vertebral artery is one of four that feeds the brain.

“That’s not good,” I said.

“But, don’t you think so?”

“Hmm-mmm?” I replied. I was wondering why the devil he
was asking me.

“Don’t you think that’s probably what it is?” he went on.

“Comes up off the subclavian right under there.”

“Yeah, I guess so. So what do we do?” I was praying we
would not be opening the man’s chest in my ER.

“Punt. It’s fourth and thirty-four.” Fortunately I had
grown up with football as metaphor for life. “Fly him to Lincoln. They’ll fix him.”

And that was that. I kept a finger in the dike for another
half hour waiting for the helicopter. We gave him two units
of blood, switched out my finger for one of the flight nurse’s,
and said
adios
.

When our nurse called for follow-up, the trauma surgeon
in Lincoln, a Dr. Karlgaard, confirmed as correct Dr. Latta’s
diagnosis-by-presumption. He had opened the area, found
the severed ends of the vertebral artery, and, to keep any
tension off the repair, sewn in a short segment of the guy’s
leg vein. He said, “Count it. It’s a win.”

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

The Book of Mimi,
in an ideal world, would have been finished.

Immediately after returning from Tucson and Dr. Bullock’s light socket, I resumed being a faux–vascular surgeon, again doing well the job of the supplicant. By Day Three of that rotation, however, the arrogance and bombast of my new boss had me missing Mimi at every level, even the professional. After his third casual reminder that he had, you know, trained at Harvard, I almost said, “Isn’t that in Ohio?”

The hours wore on. I heard nothing from Drs. Bullock, Kellogg, or Lyle about my report to Dr. Bullock on Mimi’s

“3-D Problem.”

On Day Four, though, the end began. In afternoon clinic, still talking over my shoulder to a kindly local “dirt farmer”

unfortunate enough to have a tobacco-induced stricture of the artery that fed his left leg, I opened the door from the exam room and was face-to-face with Doug Goodbout.

“Hello, Dr. Goodbout,” I said, closing the door.

“Good afternoon, Dr. Ishmail. I act today in my role as Vice-Chairman of Surgery.” His breathiness was in full force. “Our Chief, Dr. Hebert, is not yet returned from the nation’s capital, where he has gone to testify to a congres-sional subcommittee on the role of the County Hospital System in Arizona. As you know, we are the only state not participating in the federal Medicaid program.”

“Yes, sir.”

“My task here is rather unpleasant, I fear. Could we find an empty exam room?”

“Of course,” I said. A patient was just leaving the room two doors down, so we went in there. He closed the door.

He clasped his hands in front of himself and sighed. “I must ask you for a specimen of your own urine,” he said.

“What?” I asked. “Is this some kind of sick joke?” though I knew Doug Goodbout would never participate in any kind of joke, sick, healthy, or indeterminate.

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“I’m afraid not. Dr. Ishmail, there has been an assertion from a highly credible source that you have been—and possibly are—using illicit drugs.”

I was spinning. “Maybe I should see a lawyer first. I mean, this is a pretty serious accusation. I have nothing to hide, but—”

“I hate to be the one to remind you of this,” he interrupted,

“but your employment contract with the universitly does specifically allow for spot checks when the supervising authority has any legitimate reason to suspect such activities.

Actually, the same is true of all public employees, including myself.”

“And who’s the supervising authority here?” I was pretty sure he was right. I was trying like hell to remember how fast cocaine and its metabolites were cleared.

“There are potentially several here, actually. The Department Chairman, the Residency Director, the Committee on Graduate Medical Education—any could make the request.

In this case, the matter was brought before the GME Committee Chairman. She called the Residency Director and me—acting for the Chair of Surgery. We all agreed a spot check needed to be done expeditiously. The matter will of course come before the full GME Committee.”

“Who—or what—is the credible source?” I asked, though I knew very well. It had been over two weeks since we had done the coke in the canyon, and I should have been clean.