Trauma (2 page)

“Let me guess: Leon has no health insurance.”

“Bingo.”

Carrie chuckled and said, “Why am I not surprised?”

It was unusual to see a private patient at Community. Just about every patient was admitted through the emergency department and assigned to resident staff. Dr. Metcalf was known for his philanthropy, and when he rotated through Community he often took on cases he could not handle at White Memorial because of insurance issues.

All the residents looked forward to working with Dr. Metcalf, and Carrie's peers had expressed jealousy more than once. Assisting Dr. Metcalf was the ultimate test of a resident's skill, grace under the most extreme pressure. Dr. Metcalf had earned a reputation for being exacting and demanding, even a bully at times, but his approach paid off. He taught technique, didn't assume total control, and was supremely patient with the less experienced surgeons. Like many world-class surgeons, Dr. Metcalf was sometimes tempestuous and always demanding, but Carrie was willing to take the bitter with the sweet if it helped with her career.

Dr. Nugent put Leon's MRI films up on the viewbox.

“It's most likely a grade three astrocytoma,” he said.

The irregular mass was 1.5 by 2 centimeters in size, located deep in the left temporal lobe and associated with frondlike edema. No doubt this was the cause of Leon's aphasic speech and confused behavior.

“So Dr. Metcalf's scheduled to take this one out tomorrow,” Dr. Nugent said.

“As much as he can, anyway.”

Dr. Nugent agreed.

Carrie was about to ask Dr. Nugent a question when she noticed the time. She was going to be late for the final pre-op consultation with Beth.
Damn.
There were never enough hours in the day.

Carrie made it to Beth's hospital room at four thirty and found the anesthesiologist already there. By the end of Carrie's consult, Beth looked teary-eyed.

“You'll be holding your children again in no time, trust me,” Carrie assured her.

Even with her head newly shaved, Beth was a strikingly beautiful woman, young and vivacious. Despite Carrie's words of comfort, Beth did not look convinced.

“Just make sure I'll be all right, Dr. Bryant,” Beth said. “I have to see my kids grow up.”

At quarter to five, Beth was taken from the patient holding area to OR 15. Carrie had her mask, gown, and head covering already donned, and was in the scrub room, three minutes into her timed five-minute anatomical scrub, when Dr. Michelson showed up.

“How would you feel about doing the Stillwell case on your own?” he asked. “The attending went home for the day, and I got a guy with a brain hemorrhage who's going to be ART if I don't evacuate the clot and decompress the skull.”

Carrie rolled her eyes at Michelson. She was not a big fan of some of the medical slang that was tossed around, and ART, an especially callous term, was an acronym for “approaching room temperature,” a.k.a. dead.

“No problem on Stillwell,” Carrie said. Her heart jumped a little. She had never done an operation without the oversight of an attending or chief resident before.

Quick as the feeling came, Carrie's nerves settled. She was an excellent surgeon with confidence in her abilities, and, if the hospital grapevine were to be believed, the staff's next chief resident. It would certainly be a nice feather in her surgical cap, and helpful in securing a fellowship at the Cleveland Clinic after residency.

“Unfortunately, I'm going to need OR fifteen. Everything else is already booked,” Michelson said.

Carrie nodded. Par for the course at BCH. “Beth can wait,” she said.

“I checked the schedule for you. OR six or nine should be open in a couple of hours.”

Carrie did some quick calculations to make sure she could handle the Stillwell operation and still be rested enough to assist Dr. Metcalf with Leon's operation in the morning.
Three to four hours, tops,
Carrie thought,
and Beth will be back in recovery.

“No problem,” Carrie said. “I'll let you scrub down and save the day.”

“Thanks, Doc Bryant,” Michelson said. “But you're the real lifesaver here. I don't think there's another fourth year I'd trust with this operation.”

“Your faith in me inspires.”

Carrie did not mention the promise she'd made to Beth during her pre-op consultation. Michelson would not have approved. If one thing was certain about surgery, it was that nothing, no matter how routine or simple it seemed, was ever 100 percent guaranteed.

 

CHAPTER 2

Carrie had met Beth again in the preoperative area, this time accompanied by Rosemary, a certified registered nurse anesthetist. While Carrie had never worked with Rosemary before, watching her insert the IV into Beth's arm made Carrie confident in the CRNA's ability. Rosemary gave Beth a light dose of midazolam, which decreased anxiety and would mercifully bring about amnesia. Some things were best not remembered, brain surgery among them.

Once in the OR, Rosemary got Beth connected to the monitors that tracked vitals. She delivered a dose of propofol to induce general anesthesia, followed by a push of succinylcholine to bring on temporary muscle paralysis. From that moment on, the endotracheal tube would do all the breathing for Beth.

Dr. Saleem Badami, originally from Bangalore, India, and a highly regarded intern, was to assist with the operation. This was really a one-person show, so Dr. Badami was there primarily to monitor Beth's neurological status during surgery.

The circulating nurse had painstakingly prepared the necessary equipment, including the Midas Rex drill, which Carrie would use to penetrate the skull and turn the flap. Last on the team was Valerie, a scrub nurse born in Haiti. A longtime vet of BCH, Valerie was one of the best scrub nurses on staff. As usual, Valerie looked in total command of her craft as she prepped her station for the upcoming operation. It was Valerie who had introduced Carrie to the joys of listening to jazz while operating, and over the years the two had grown close.

If there was one drawback to working with Valerie, it was her unwavering commitment to finding Carrie a date. Beneath her surgical cap and scrubs, Carrie had luxurious brown hair down to her shoulders, almond-shaped brown eyes, enviably high cheekbones, and a body toned and muscled from hours of training. All that, combined with her intellect and outgoing personality, and Dr. Carrie Bryant was somebody's total package. Despite Carrie's repeated assurances that she was happily single, Valerie never failed to bring a list of eligible bachelors to surgery.

“His name is James, and he's some hotshot at a biotech startup in Cambridge. My mother knows his family.”

“Thanks for the suggestion,” Carrie said, checking over the equipment, “but today the only man I'm interested in is John Coltrane. Let's fire up the music, please.”

Carrie waited for the first notes from “Out of this World,” the first cut from
Coltrane (Deluxe Edition),
to play before she picked up the scalpel and positioned it for the initial cut. The little stomach jitter that had been kicking around was gone. The first solo flight had to happen to everyone at some point, and today was her day.

You've got this, Doc. You trained hard.

Any and all distractions faded. Lingering thoughts of her ex-boyfriend, Valerie's biotech guy, and tomorrow's surgery with Dr. Metcalf were just ghosts in her consciousness. Her focus was intense. She loved being in the zone; this level of concentration was a rush like no other. Prior to surgery, Carrie had managed sundry pro forma tasks, those checklist items requiring no thought or decision. Following standard procedure, she had used Mayfield pins to secure Beth's head in three fixation points.

It was time to operate.

Carrie made the first scalp incision, expertly cutting the shape of a large semicircle over the crown of Beth's shaved and immobilized skull. She paused to examine her work. It was a fine first cut, and Carrie was pleased with the results. The skin flap was certainly large enough.

The growth was sitting underneath the skull, originating from the meninges, the membrane that covers the brain. It was directly adjacent to the superior sagittal sinus, the major venous channel coursing between the brain's hemispheres. From what Carrie had seen in the MRI, the sinus appeared to be open. This was one of her chief concerns going in. If the tumor were adhering to the sinus, Carrie could do only a partial resection, which would mean Beth would need additional treatment, such as radiation therapy or another surgery.

Why did you make that promise?

It was probably seeing Beth's kids, especially little six-year-old Emily with her sweet toothy smile, that had clouded Carrie's better judgment. If the tumor were free from the sinus, the only treatment Beth would need would be careful follow-up to ensure no recurrence, and perhaps an anticonvulsant medication to reduce the risks of residual seizures.

Surgeons were not, in Carrie's opinion, like normal people. They were more like clutch shooters who took the ball with three seconds left and the basketball game on the line. Difficult times seemed to bring out the best in their cool. Sure, Carrie had sweated for just a bit at the start of the operation, but that was normal. Good, even. She was young, inexperienced, and it was smart for her to be cautious. Things could head south in a flash, but Carrie was not overly concerned. By the fourth year of residency, any surgeon who would cower in a decisive moment had been culled from the herd.

Carrie set to work placing the Raney clips around the margins of the retracted tissue to hold the scalp in place. The slim blue clips were atraumatic, designed to minimize injury and limit both bleeding and tissue damage.

Thirty minutes into surgery.

It took another fifteen minutes for Carrie to set all the clips in place. Now it was time for her to drill. Carrie held the high-speed stylus in her steady right hand and made four expertly placed burr holes on either side of the parasagittal sinus.

“Change the drill, please,” Carrie said.

The circulating nurse handed Carrie a different high-speed pneumatic drill, and she used that one to cut through the skull between the burr holes. Carrie took in a breath as she lifted the bone flap over the dura. She carefully handed the bone flap to Valerie for safekeeping until she was ready to reconstitute the skull after removing the tumor.

Valerie, being Valerie, anticipated Carrie wanting bone wax to control bleeding from the exposed skull margins.

You've got a great team here,
Carrie thought.

Pausing, Carrie examined the dura, a thick membrane that is the outermost of the three layers of the meninges surrounding the brain, for any signs of damage. Using her gloved fingers, she carefully palpated the hard, solid tumor beneath. She judged the location of the growth to be perfect for resection, and then used cotton pledgets to tamp down the margins of the exposed dura.

Carrie was exceedingly careful with the pledgets, because too much traction on the dura might cause tugging on critical veins over the surface of the brain, which could result in bleeding. When the pledgets were properly positioned, Carrie was ready for her next incision, keeping in mind that she would cut one centimeter away from the tumor.

One centimeter. Exact. Precise.

Done. After her perfect cut, Carrie used the coagulator and Gelfoam sponges judiciously to control hemostasis and limit bleeding. And there it was, the tumor, sitting on the top of the brain, pressing down on the cortex that controlled Beth Stillwell's leg and bladder. It was not too big, but it sure was ugly, and more vascular in appearance than she had expected from the MRI image. Thank goodness it was not adherent to the sinus! Carrie could resect it cleanly. Still, the vascular supply was far more complex than she had predicted.

“James is a heck of a lot better-looking than that nasty thing,” Valerie said.

Carrie laughed lightly.

The time was 10:30
P.M
. Beth had been in surgery for two and a half hours, a little bit longer than Carrie had anticipated, but not unusually long.

“Vitals?” Carrie asked.

“Looking fine,” Rosemary said.

One hour and I'll be done,
Carrie estimated.

Working with care, Carrie removed the tumor, along with the adherent patch of excised dura, which would be sent off to pathology for a frozen section. It did not appear malignant by gross inspection. She would want to be sure the margins were clean and there was no evidence of malignancy elsewhere. At this point, Carrie figured she could get to the on-call room by midnight and grab five or so hours of sleep before she needed to be back in the OR by seven o'clock the next morning for surgery with Dr. Metcalf.

Ah, the glorious life of a doctor
. Her dad, an internist at Mass General, had warned Carrie about the rigors of residency, but his description paled in comparison with the real thing.

Carrie paused to examine her work once more. Something was beginning to bother her. The margins of the craniotomy looked to be oozing blood, much more than usual.

“More Gelfoam and four-by-fours.” Carrie's voice sounded calm, but had a noticeable edge.

Valerie complied with speed. As Carrie dabbed away the bleeding, her whole body heated up beneath her surgical scrubs.

“Vitals?”

“Blood pressure stable at one hundred over seventy, normal sinus at ninety.”

What the heck is happening?

Carrie did everything she could to stanch the bleeding, but the oozing persisted. She started to worry.

Why isn't Beth's blood clotting?

Her pre-op labs had showed a normal coagulation profile. She should not be having this problem during surgery.
What is going on? Where is the bleeding coming from?

From the beginning of her residency, Carrie had been taught to think on her feet, but her mind was drawing blanks.