Lie Still (8 page)

No one doubted that she saw well the good and only wanted more data before writing the paper. Everyone knew the pirate’s motivation—his written output had dwindled to nil in the last few years along with his speaker’s stipends.

But he routinely took night call in the chairman’s place in the rotation, and he had a defense, however mealymouthed.

Nothing happened. Mimi’s only honorable choice was to resign. From there she ended up with a nice job in an academic backwater, reputation marred by an unfinished fellowship.

By the end of the tale Mimi’s hands were shaking. I went to pour the last of our dinnertime bottle of wine into her glass. She stared at me and said very quietly, “There is nothing worse than powerlessness.”

Maricopa days and nights obviously acquired a dramatically different flavor. Extraordinary things became the norm.

Some of them actually involved patient care.

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something to be learned. On that rotation two extraordinary cases—one bad, one good—showed me how an individual surgeon might make a difference. I called them the Cases of Extraordinary Teaching.

The first came in my third week on Neurosurgery. It was superficially starting out the same as any other week of residency: I was up way too early in the morning, bleary eyed, and tired after a too-short weekend. The only difference was the secret source of my weariness.

The neurosurgeons at the Maricopa Medical Branch ro-tate on and off call at 9:00 A.M.: If a case hits the ER at 8:30

on a Monday morning, it belongs to the guy who had the weekend duty. Unless he can pass it to someone else, sometimes by pleading the recipient’s greater expertise is needed, sometimes by begging, sometimes by just a sleazy exit out of town. The costs to the giver’s reputation are predictable if not meaningful; repercussions are generally only dealt downward on the totem pole.

Keith Coles was a truly unfortunate person at least twice over. During a morning jog along one of the city’s many irrigation canals, he collapsed. At the age of thirty-nine. Another runner found him, help was called, and he ended up in the UAMMB emergency room. The ER doc recognized the signs of stroke, got him some IV fluids, got him intubated, pharmacologically paralyzed, and mildly hyperventilated—

state-of-the-art treatment then. The CAT scan showed a grape-sized blood clot in the deep substance of the brain in front of the thalamus and free blood in the fluid around the brain. Mr. Coles had blown an aneurysm.

Mimi and I were rounding at seven forty-five or so, struggling to muster the energy needed to appear as if we had spent the weekend in our respective homes reading medical journals, when Dr. Leonard Babcock, one of the more aged neurosurgeons on the faculty, paged her. I heard only a couple of polite conversation fillers and then some nonspecific grunts from Madame Lyle. After hanging up she said, “He said the ER called him with an aneurysm, and would I like the case. Lazy prick.”

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“Dr. Lyle, you are a diversely skilled individual,” I chided her.

“This morning I can barely walk,” she said and closed her eyes and formed her lips into a kissing posture.

“You’re bad,” I mumbled.

We found Mr. Coles in the ER just as the nurse was packing up his belongings to get him shipped off to the ICU. He had two big plastic tubes sticking out of his nose, one on each side. The ventilator was breathing for him through one; his stomach was being drained through the other. Each had blood drying around it. IV fluids were running in both arms; clearish urine was draining from his bladder catheter.

His wife was there, propped up on an ER stool, draped uncomfortably over the chrome side rail of the gurney, holding one of his hands and brushing back his hair while talking to him quietly. She dabbed a bloody washcloth at his nose. Mimi introduced herself and me. Though the woman’s eyes looked like they had been on fire, she stood and shook both our hands, then rubbed her eyes with the heels of her palms.

Mimi looked at the man’s wristband, then said to the woman, “Is it Mrs. Coles?”

“Roberts. Abbie Roberts, but I am his wife.” I lowered the side rail so his wife could get closer to him. He obviously wasn’t going to be thrashing around.

“Ms. Roberts, I don’t know how much the Emergency physician has told you . . .”

She broke in, “That he might have had a stroke . . .” and began a stuttering sniffle.

“Technically I suppose that’s true, Mrs. Roberts. Has he been in good health before today?”

“Yes. Jogged almost every day.” I found her a new tissue.

“Never in the hospital before?”

“Not since we’ve . . . not since I’ve known him. Thirteen years.”

“Has he been on any medications?”

“No. Well, sometimes aspirin.”

“How much?”

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“Maybe a couple, a few times a week. Could that be what . . .”

“No, no. Very unlikely.”

“Because I told him he should be using Tylenol. He said it didn’t work as well.”

As she spoke Mimi was doing her physical exam. The man was paralyzed with drugs, so there wasn’t much to examine. Even if he had been awake in there, he couldn’t have responded. “Had he been complaining of headaches? In the last few days?”

“No. He took the aspirin for his knee. He said men were supposed to take aspirin every day anyway. Isn’t that so?”

Mimi was looking at his pupils with her penlight. “Mrs.

Roberts, I think we can cut to the chase a bit. It appears, from the presentation, the sudden onset, the location of the bleed, his age, and all, that most likely your husband has ruptured a berry aneurysm, probably at the junction of the internal carotid artery and the anterior communicating artery. That’s the usual spot. We will get a cerebral angiogram, of course . . .”

“What is that?”

“. . . to delineate the exact spot of the bleed and try to see the aneurysm.”

“I’m sorry. What is that?”

“What?”

“The cerebral something. A test, I guess.” Mimi was silent. Ms. Roberts repeated herself, “A cerebral angie-something.”

There was a pause. “Angiogram,” Mimi said, patronizing.

“I’m sorry, Doctor. I don’t know all these terms. But if you could . . .”

“No, of course you don’t. You wouldn’t. You let us worry about these technical things.”

“But I’ll need to know . . .”

“Well, we’ll see. We’ll need to get the angio today. This morning actually. It’s a dye study—X-rays of the head.

With these things it’s best to let the brain recover somewhat. Cool off a couple of days. Stabilize. But there’s also 56

DAVID FARRIS

the risk of re-bleeds. We can’t wait too long. We generally go in at about day two or three to clip the aneurysm. It can be very touchy surgery but our success rate is pretty good.”

It was obvious to me Ms. Roberts had not processed much of that. I was used to imperious professors but Abbie had not done the time. Mimi’s peremptory attitude would turn Abbie’s emotional shock into a turtlelike disappearance.

I said, “The angiogram is a dye study. They inject an io-dine contrast—people call it a dye—into the arteries so the X-rays can show what they look like, and frequently it will show if there’s leaking—bleeding—too.”

Ms. Roberts nodded, but Mimi shot me a withering You’re-wasting-my-time-again look.

The thought flashed through my mind,
Fuck it. Maybe I
don’t want to be a surgeon.
I gave Abbie another tissue.

She asked Mimi, “But what do you think his chances are?

I mean . . .”

“He should make it.”

“But will he be . . . He wouldn’t want to be . . .” She was sobbing too hard to finish. Mimi motioned to me we would leave.

Ms. Roberts said, “But he’s never even been sick.”

Mimi said, “We’ll talk more later.”

At the nurse’s station she rattled off some orders for me to write: Admit to ICU. Neuro protocol vital signs. Nothing by mouth. Consent for cerebral angiography. Consent for a pressure-monitoring bolt in the skull. Stop the hyperventila-tion. She seemed agitated but said only, “I’ll be in my office,” and left.

I found the forms for the consents and wrote for the new ventilator settings. I caught up with Mr. Coles and his wife as the ER nurse was pushing the stretcher out the automatic doors. The nurse was saying, “This is her specialty . . . ,” but stopped when I came in.

I offered Ms. Roberts an apologetic smile. “Maybe I can fill in a few of the blank spots,” I said. She mustered a small smile in return.

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lowed carpet, up the ramp between buildings, and into the elevator, I explained to Ms. Roberts the procedure involved for an angiogram and what we expected to find. I said Dr.

Lyle also wanted her consent for us to put into Keith’s head what we call a bolt—a device that screws into a small hole in the skull, through which we thread a thin catheter to measure the intracranial pressure, or ICP. “Because the brain is within a closed space,” I said, “any swelling—

edema—of injured brain would raise the pressure inside the skull. If the pressure gets too high it can interfere with or even stop the blood flow to the brain.” I looked over my shoulder to see her face. She was staring. I wasn’t certain she had heard me.

“And then what do you do?” she asked.

“Then?”

“If the pressure gets too high and there’s no blood flow.”

“The plan, what we try to do, is know how the pressure is going. We can lower it, usually, with certain drugs or hyperventilation, for brief periods. Hyperventilation lowers the carbon dioxide in the blood, and the blood vessels in the brain constrict down. That lowers the pressure in the head.

Blood can actually flow in better. Protects the perfusion pressure.”

“Perfusion pressure. Blood pressure to the brain?”

“Pretty much. Yeah.”

“So the blood pressure can’t be too low?”

“That’s part of it. The blood pressure has to be a certain amount greater than the pressure inside the skull or the blood flow will be too low. Or stop.”

“So you’re looking at the pressure difference.”

“Uh-huh.”

“And drugs can control it.”

“Usually.”

“And if they can’t?”

“The injury to the brain extends.”

She blinked. “More brain cells die.”

“Uh-huh.” I was not being medically eloquent but we had resumed communicating.

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“Could the whole brain die?”

“Not really. I mean it can, in the most extreme cases, usually through herniation, where the lower parts of the brain get squeezed down into the hole at the base of the skull, the foramen magnum, and all the blood flow around there stops.”

“And then he would be brain dead?”

“Yeah, that can happen. Or even just . . . dead.” “Expired”

came to mind but we were beyond the usual euphemistic niceties. “That part of the brain controls the heart to a certain extent. But that’s not what will happen here. That usually only happens in the severe injuries, the really bad head traumas.”

“So what’s going to happen in Keith’s case?” I offered a sympathetic frown. She went on, “I mean, the most likely things. What could happen.”

“The cortex, the outer layer”—I was gesturing over the top of my head—“is the most vulnerable, the most sensitive.”

“But that’s the most important, isn’t it?”

“Well, the deeper parts control basic life functions. They keep us alive.”

“But the cortex, the outer . . . the vulnerable part, that’s where we think and feel, right?”

“Well, right.”

“So if Keith loses his cortex, what would he want with basic life functions?”

I nodded. “Well, I guess most people would see it that way.”

There was a pause. She said, “He would see it that way. If his cortex is dead I want him off the machines.”

“We think we can avoid that,” I said. It was all I could say, though I was not sure it was true.

In the ICU she read over the consents and looked up at me, tearful. “Of course I’ll sign them. You’ve been kind to explain, but, really, how would I know?”

After a silence I looked her in the eye and said, “We’re going to be doing everything that can be done. We’ll give him the best chances. He’s in the best of hands.”

I meant it. I did not know better.

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*

*

*

Mimi was scribbling furiously on a yellow legal pad when I got to her office. I sat silently on the couch there and went through my note cards on the various patients admitted over the weekend: A pair of three-hundred-pound Hawaiians who had been drunk, sharing a large motorcycle, and turned in front of an even larger truck. A three-year-old admitted with an infection of her ventriculo-peritoneal shunt.

Mimi said from out of nowhere, “You know, if she wants to assume the care of her husband it’s fucking fine with me. Four years of college, four years of medical school.

Six years of residency, two years of fellowship. You’d think just once someone would be willing to take my word for something.”

After a deep breath I ventured, “Well, I went through some of the stuff in detail with Mrs. Coles—Roberts, I mean. She’s really pretty sharp. And scared, of course.”

“Don’t let her run you around. You’re the doctor.”

I bit my lip—the proper response of a junior resident.

Maybe she was showing me what it took to be a surgeon.

Maybe I wouldn’t make it.

In those days ICP bolts were done in the OR, not the ICU.

This meant someone—someone low on the totem pole—

had to move Mr. Coles’s bed, monitors, IV pumps, ventilator, drainage bags, and body, as a unit, down some halls, around some corners, through some doors, into and out of an elevator, and dock them softly against an OR table. Hallways, corners, and elevators have a surprising ability to reach out and disconnect the critically ill from their life-support devices.

I was in the ICU when the OR team came for Mr. Coles.

A tall, quiet OR nurse and an anesthesiologist I thought I recognized, an elfin man with spindly fingers and a naso-whiny Brooklyn accent, unusual in the desert. He was grumbling to the nurse something about “. . . the loser’s gonna code in the elevator.” She barely nodded.