Lie Still (9 page)

I asked, “Ruining your day, Dr. Levov?”

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“It’s ‘LeFleur,’ Ishmail. Levov is the heart surgeon, and anybody who’s been through the three divorces he has wouldn’t let a little thing like a code in an elevator ruin his day.”

I smiled. “You know, Doctor, I’ve always wondered, what is that little plastic thing you guys wear around your necks?”

The nurse was now smiling.

“Actually, it’s a stethoscope—custom molded.” He put the blue glop of plastic at the end of his piece of tubing into his left ear. “It’s becoming an antique,” he went on, “what with all our electronics going beep, beep, beep, we hardly need to listen to the patient anymore. But I’d still rather listen to a steady lub-dub than to a putz surgeon.”

“Gee, thanks.”

“Not you, Ishmail, you’re still a human being. But just wait till you’re out. Busy practice, wife, three or four kids, couple of mortgages. Office full of whiny old ladies and your nurse’s period is two weeks late. Then we’ll see how nice and respectful you are to your copilots of the OR.”

I said, “Yes, Doctor,” using the very official sounding tone of voice that all the nurses use to mean “Fuck you, Doctor.”

Everyone smiled, even Dr. LeFleur.

With a collective grunt we began the parade of stop and go with only a little whining from the anesthesiologist.

Halfway there two of the infusion pumps began to emit piercing alarm tones for no apparent reason. Dr. LeFleur cursed them but urged the procession onward, vowing to pitch them off the roof after the case.

Mr. Coles’s ICP was about 16 with occasional bumps up to 30. Not good, but not awful. Living in the borderlands.

I helped with the return parade, safely tucking in Keith back in the ICU. I found Ms. Roberts on the pay phone in the hallway outside the ICU waiting room. She was crying.

“. . . I know you do . . . I know you do . . . Daddy loves you too. . . .” She looked up only long enough to acknowledge me waiting for her. “Daddy’s going to be fine, Daddy’s going to be fine. I love you, punkin’. Now let me talk to Ma . . .” She covered the phone and looked at me. “What LIE STILL

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was the pressure?” Then immediately back to the mouthpiece, “Helen, one of the doctors is here, just hold for a second. . . . That’s what I need to find out,” then back to me, a pleading look.

“The pressure was okay; not normal, but not terrible.” I patted her arm. “If it bumps up we should be able to get it back down. Just knowing what it is, we’ll know better where to keep his blood pressure, too.”

“So what now?”

“Wait.”

“I hate waiting.”

“Yes, we all do.”

“But if that’s what’s best for Keith . . .”

“Yeah, that’s what’s best for Keith. You finish your call.

I’ll come find you if anything changes.”

Keith Coles’s ICP and blood pressure bounced around for two days. He got morphine and sodium thiopental to keep his nervous system barely idling, he got mannitol to carry water and salt out via the kidneys, and he got intermittently hyperventilated when his ICP shot up. He did not wake up, though. I hoped that was from the thiopental and morphine and not the brain injury.

No one liked the waiting. Mimi was noticeably surly and snappish. Not completely antisocial toward me, but decidedly asocial. Which was convenient anyway; her bedside nastiness toward the afflicted had well chilled my ardor. A few nights of sleeping at home was entirely welcome at that point.

On Keith’s own Day Three we took him back to the OR.

Clipping an aneurysm deep in the brain is, I am told, probably the most nerve-wracking operation in all of medicine. The exposure is lousy, the room to maneuver nonexistent, the margin for error exactly zero. You’re trying to get a titanium clip across the base of a sack growing from the arteries that feed the brain. The usual mental image is that of a berry hanging on a stalk, but in reality the base of the beast is almost never that discrete; the aneurysm is just a bulge, 62

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frequently lying between two perfectly good arteries that the patient is going to need. Worst of all, the aneurysm walls are incredibly weak—the arterial tissue was not meant to stretch that far. That’s why they bleed in the first place.

Sometimes the damn thing bursts open just by being exposed. It can explode when touched during the dissection or clip application. If it does, you’re all completely fucked: Surgeons must try to get the clip deep in a hole, perfectly applied to something they can’t see, while counting down the seconds until all the patient’s blood is on the floor. Anesthesiologists jump around yelling for blood to transfuse while trying to decide if they should raise the blood pressure to feed the brain or lower it so the surgeon has a chance to see.

The nurses are trying to do twelve things at once while wondering if the whole thing is their fault. Of course the patient—well, the patient. If control can be regained somehow, he might still be okay. If there is no quick control, the surgeon might have to clip off the arteries feeding the aneurysm and hope the backup blood supply to the brain is adequate.

If the backup supply is weak, the patient has the biggest stroke imaginable and will be either dead or nearly so.

When the case started, Mimi was already mildly pissed off.

We were listed as an 11:00 A.M. start, which was not a bad time considering we had only booked the case two days before, but the first case in the room, a hysterectomy, had gone long because of some screwup that should have been minor but apparently, in their hands, wasn’t. We didn’t even get Mr. Coles into the OR until 1:15. I’d paged Mimi at 10:30 to let her know about the delay. All she said was, “Goddamn gynecologists,” using the soft “g” in the word. She probably learned it from Ian McWhorten at Mayo’s.

Things started off okay. From what I could tell, the anesthetic induction and the arterial line and all the anesthesia futzing around went fine. Mimi had me shave the guy’s head, and I did the sterile prep under minor but continual criticisms from the circulating nurse. We then put his head in the Mayfield head holder. A big stainless steel C-clamp, LIE STILL

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with two opposable halves, it reaches up and around the middle of the head. It grabs the head via three stainless steel

“points” about the size and shape of the end of a pencil, but much sharper. These are pressed into the scalp, two from one side and one from the other. The clamp is then tightened like a vise until the points are firmly into the skull. The whole assembly is then attached with large hand-bolts to the surgical table to provide absolute stability to the head for as long as needed.

Just as we were about to press the things into the skin, Charlie Ryan, the anesthesiologist, said, “Wait a sec, sorry,”

and pushed some drug into the IV. “Gotta be a little deeper for this,” he added. We ratcheted together the two halves of the C-clamp and the points sank home. Blood trickled from each. The beep-beep of Keith’s pulse quickened. The anesthesiologist stared at the blood pressure trace on the monitor. It went from 105 over 60 to 155 over 100. He turned a dial on the anesthesia machine. We tightened all the clamps between the Mayfield and the table, and Mimi gave the thing a gentle but firm rock. The whole table bounced slightly. Mr.

Coles’s head was effectively bolted to the table. We went to scrub.

As we washed our hands and arms she did not seem nervous. She was humming softly to herself. Neither of us said anything until nearly the entire five minutes of scrubbing had gone by. Finally she turned and whispered, “You really have a great cock,” hit the water switch with her knee, and headed into the OR with her poker face intact.

She pressed two fingers into the bony nubs at the ends of the skull, then drew a sickle-shaped purple line across his naked scalp with a sterile felt-tip pen. She laid the scalpel onto the far end of the line, took a long breath, pressed the blade through the skin, and drew it sharply along the prescribed arc cleanly to the other end. The two skin edges fell slightly open and then, after an odd pause, began to ooze purplish-red blood.

“Clips,” she said. The scrub nurse laid into her opened 64

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palm a stainless steel pliers-like clamp with a blue plastic clip loaded on the end. These clips are like barrels missing a few staves. The clamp holds them open so they can be fitted over open skin edges, then released. The clips contract down and press shut the bleeding points, stopping the ooze.

She peeled the skin back from the skull and its lining layers, buzzed a few bleeding points with the cautery, and called for the drill. She bored, with a brace and bit little different from the ones in my grandfather’s workshop, five one-eighth-inch holes around the perimeter of the open space.

“Can you do dot-to-dots?” she asked me.

I’m sure I looked stupid.

She handed me the saw. “This is an ultrafast rotary saw. It goes through bone like a hot knife through butter. If you can control yourself, you can connect the dots.” She put the tip through the nearest hole. “This deep.”

I reached for the handle. The saw had a long, thick, cum-bersome power cord. It was driven by high-pressure nitrogen and controlled by a foot pedal. I plowed from A to B to C to D to E. My lines between dots wavered a bit, but I realized the defect would have zero functional importance and would exist only under the skin, where it would never be seen.

With the saucer-shaped segment of skull passed off to the nurse, we were looking at the dura, a tough, fibrous sheath with the appearance and feel of the cover of a well-used baseball. Mimi incised it with a scalpel, then cut a smaller version of her earlier sickle curve with a small scissors and pealed it back to expose the brain.

She stripped away thin filmy sheets of membrane and electrically obliterated the tiny blood vessels belonging to them. This freed up the underlying brain lobes to be eased out of her way.

That’s where I came in. My job in an operation like this was to hold retractors, though only temporarily. Once into the brain, she would bend thin strips of stainless steel like long spatulas to conform to certain curves, gently lay them under lobes, and lift. I then held them there until she could get the LIE STILL

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rod on the other end of the retractor clamped into the support frame, this latter being far more reliable than a resident.

When she handed me the first retractor she made her expectation clear: “Hold this. Like a rock.” I believe residents have a “freeze” reflex. I could not have moved if I had wanted to.

Having filled the available space with retractors, we began to advance them. She would lock my hands onto one, loosen its clamp, take it from me, give it another incremen-tal lift, nod for me to grasp and hold, then reattach it. By alternating between the table clamp and the resident, she was able to slowly advance her retractors and open up a view into a deep recess under the brain.

Once the primary exposure was accomplished and secured, the nurses swung in an operating microscope the size of small backhoe. The working end of the thing is can-tilevered out from a heavy base. Once it was in approximate position a huge sterile plastic bag was put over it from the business end toward the base unit. Through it we could work the knobs and turn the dials, all the time staying sterile. Rub-berized rings in the bag fit over the lenses of the scope so the bag wouldn’t interfere with the light transmission.

“Oh hell,” she said. “I’m contaminated!” Apparently she had accidentally brushed her hand against the scope; she was holding out her left hand for the nurse to pull off the glove. I had not seen her touch anything outside the invisible bound-ary of sterility. “Let’s change the bag, too,” she said.

The nurse said, “You didn’t contaminate the bag, though, if you just touched the lens.”

“I just want it changed.”

“These are expensive.”

“Less than wound sepsis.”

The nurse was rolling the bag off the microscope.

“Waste,” she mumbled.

After the false start, Mimi got the scope the way she wanted it, and we sat down again, her eyes pressed to the main scope with me at the teaching head, 90 degrees to her right.

Brain, under binocular 4X magnification, looks like noth-66

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ing else. The lobules of neurons, for all the power and holi-ness we imagine they contain, are smooth wet bumps; yel-lowish pink, cheesy, slightly dirty. Every groove between lobules has two tiny blood vessels snaking through, the vein somber, purple, thin-walled, fragile; the artery smaller but more muscled and a cheerier red. With each heartbeat the artery and even the brain substance itself pulsate and expand, giving the view in the lens a surging rhythm. The first time I sat in on brain surgery I found it unsettling. Very soon, though, like the rocking motion of a boat, you get accus-tomed to it. You only become aware of your new sense when you are totally unnerved as it slows or stops.

Twenty-four hours later Keith Coles was effectively dead.

5

Since Henry, since escaping Arizona with my hide and little
else, my personal life, for all the reasons I am here to tell,
has been static, at best. I live in a rented two-bedroom house
in the town where I grew up, within walking distance of my
parents. My mother cooks me dinner more often than I cook
my own, though hospital cafeterias and roadhouse diners
outnumber the two combined.

If I have a unique talent it is driving. Driving for distance.

During the extended dependency of college, medical school,
internship, and residency, one is always short on money.

Early in college I learned from a fellow Nebraska-to-Boston
vagabond how to compensate with youthful exuberance. He
and I would drive nonstop tag-team from Cambridge to Lincoln—his home—and back again, all to spend a few break
days with family.

When he was in Europe one quarter I did the trek alone,
grabbing a few hours sleep in the cramped backseat of my
car. It became my routine mode of travel. Sure, I’m a little
bleary-eyed and zombielike when I arrive, having spent fifteen to thirty hours at seventy-plus miles per hour, but being
able and willing to put my head down and get someplace far
away has proven a useful skill, especially since returning
West, where the deserts are vast between the oases.