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that group of patients—probably the majority portion—who actually did well despite a poor draw on the assignment of her brain surgeon.
Suddenly things began to pick up. There was a flurry of activity in the hole and Mimi mumbled, “Now we’re getting somewhere.” BB-sized chunks of tofu-like tumor began parading out. Within forty-five minutes she was satisfied that she had it all. I had no way of knowing.
She looked at me, stupidly victorious, and, attempting humor, uttered one of the trite phrases of medicine: “Even a blind pig finds an acorn now and again.”
I lied my smiling approval.
Just when she said “Let’s pack up and go home,” something unexpected broke open. Bright red blood began to pour from the nose. Mimi muttered, “Oh, for fuck’s sake,”
then shouted, “Clip. No, cautery. No suction. No. Not ‘no, suction.’ No, there is no—no fucking suction!” The suction had stopped. We were unable to evacuate the work area.
Through the scope I got a highly magnified view of the headwaters of the red stream running down the plastic drapes. It was a kaleidoscopic gush that looked like a clear mountain brook running over a spring of molten cherry candy. The clear stuff was cerebrospinal fluid, sig-nifying we’d torn through one extra layer. This meant Susan would be at risk for a chronic leak of brain fluid out her nose.
I was of course useless, frozen in my role of ignorant supplicant. Mimi was apoplectic until the scrub nurse got a new tip on the sucker and we could see tissue again. She laid into the electrocautery, changing my view to highly magnified, swirling brain smoke. I held the sucker. She ultimately put a tiny titanium clip on the bleeding source, a point I guessed to be an artery, hopefully of the tiny, insignificant type, which she referred to as “that little prick.”
She gently laid in a strip of a white, bioactive gauze that was supposed to stop bleeding from outside of the source, something our physiology professors in La Jolla had said was impossible. When it appeared to have worked, she LIE STILL
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packed a wad of Styrofoam-like stuff in the gap where the tumor had been.
While sitting and waiting, making sure the bleeding didn’t start up again, she told Dr. Denny, the anesthesiologist, he would need to put in a lumbar drain before we left the room. This would help the hole in the lining of the brain heal by keeping the cerebrospinal fluid from flowing through it out the patient’s nose. Mimi’s tone was peremptory. Dr. Denny didn’t look up. He barely nodded.
Away from the table, Mimi allowed herself a quick, self-congratulatory grin as she pulled off her paper gown and latex gloves and stuffed them in the trash with a small flourish.
The ENT team trundled in and put Susan McKenzie’s nose back together. One of the OR nurses, the anesthesiology resident, and I, the wordless zombie witnesses, wheeled Ms. McKenzie to her ICU cubicle. When the physical part of the delivery was complete and the life support functions were being methodically assumed by the ICU nurses, I went to the desk and hid my face in the chart. I carefully lettered the “Brief Op Note” that memorializes the collected labors until the transcriptionist can type out the verbose spoken version. I followed that with a comprehensive set of orders—everything I could think of, from ventilator settings to a laxative if needed. Unfortunately I was too good at it. Having done it hundreds of times it took no more than ten minutes. I’d wanted it to take longer.
Under proper resident protocol I would have paged Dr.
Lyle and asked where and when she wanted to start rounds on her other patients. I couldn’t. I just went and saw them, wrote progress notes, and updated orders. For one Pilgrim in Pain, I acquiesced to his wish to be discharged. He was angered that being in the hospital for back pain meant he’d be getting fewer narcotics than at home.
Just as I was finishing, Mimi walked onto the ward, looking just as she always did, as if the day had been routine. I avoided eye contact.
“Go home, Dr. Lyle,” I said. “I’ll take care of rounds.” It 146
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was what an overreaching resident would have said to show off broad shoulders, but I honestly did not want her around. When she answered by taking a chair next to mine, I gave her a succinct status report on each of our half-dozen patients.
She smiled. I was afraid she was thinking of celebrating her “victory” by having me for dinner again. Unfortunately all I could come up with were exactly the same things I would have said had I been creating cover for a later ren-dezvous and clandestine fucking, something that would have been beyond even the most testosterone-soaked imagination at that point.
“Go home,” I said again. “I’ll page you if anything comes up.”
“I am tired,” she finally allowed. Then the way she looked as she said “I’ll see you for morning rounds” told me she wanted to see me for morning rounds and no sooner.
When she was gone I finished the charting on the last of our patients. Then I went home and threw a few things in a duffel. I got in my car and drove east out of the Valley of the Sun.
9
On my first Friday night, years ago, in the Quiet Little ER
Where Nothing Ever Happens of St. Petersburg, Nebraska, I got two maxims from one case. The first: Be careful where you put your head.
We received a guy who’d been pouring some kind of rocket fuel into the open carburetor of his old pickup, trying to get it to turn over and buck. The ensuing fireball took all the hair off his face, eyebrows included, and left his cheeks and lips raw and blistering and on the verge of shedding very many layers of skin, some of them only partially formed at the moment of their death. His left hand was just as bad.
My surgical training had been truncated before I got to the Burn Unit rotation, so I lacked experience. I’d done my homework, though, reading the textbooks and studying the pictures. I knew to slather the raw parts with a standard concoction of antibiotics and silver salts that would stop the Chinese army, were they in bacterial form, then wrap thickly with soft cotton and ship the whole package to a Burn Unit where the resident experts could graft and grow him some new skin.
The hard part, though, was his airway. Anyone who has ever done a CPR course knows airway comes first. Anyone who has put his face into that kind of heat may have inhaled 148
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enough hot gases to have scorched his throat and trachea to the temperature of the exhaust pipe on a hot rod. Significant swelling there can close down his breathing passage, which would be particularly bad in the back of an ambulance halfway between Hooker and Lincoln. He would die. Standard treatment, according to the books, would be to put him down with drugs and pass a breathing tube to keep open his airway.
Easy to read—or write—considerably harder to do. This gentleman weighed about 280 and lacked any visible neck.
His mouth looked relatively small. While I was sure I could figure out what drugs and how much to use to get him to be still, at the time I was not at all sure I could get a view of his larynx and get a tube in. That is a mechanical skill we practice on plastic mannequins, none of which has the anatomy I expected in him, that of a bull elk in rut. If I failed there he would die unless I did an emergency tracheotomy—something I had never done before—and if I failed there he also would die.
They say good judgment is based on experience; experience is based on bad judgment. To date I had made no judgments, good or bad, regarding potentially burned airways.
I sweated and procrastinated for a good ten minutes before the sign lit up over my head with Maxim Number Two: You can call for help.
The senior doc in the Burn Unit in Lincoln, when I answered in the negative each of his questions about labored breathing, coughing, hoarseness, and throat pain, was quite reassuring. He said the man would “probably” make it just fine to Lincoln. We packed him into the ambulance and said,
“See ya.”
I called the next morning to see if “probably” had been good enough in his case. Better to pester Lincoln immediately than be surprised by the subpoena in six months. Fortune had smiled on all of us: Mr. Fireball would live to get that dang truck going yet.
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T H E B O O K O F M I M I , C H A P T E R S E V E N
Flight from Phoenix and Mimi, of course, solved little and made many things worse. I knew when I started the car and left town that simply failing to show up for morning rounds could be tantamount to quitting the residency. Short of vomiting up whole organs, one’s physical presence is always expected. Still I felt I had no choice. Theoretical consequences were as nothing in the face of the reality of Susan McKenzie.
In my Datsun in the evening sun I sprinted east. On the edge of the suburbs my pager chirped. A woman’s voice asked me to call the Maricopa operator. I turned the pager off, something I’d never done before. I crossed the Salt River dust plain twice to get to the highway up into the mountains.
My strength was exhausted. Maybe it was the McKenzie case or the Coles case, maybe the long hours of emotionally demanding medicine mixed with long hours of an emotionally demanding relationship at the edge of disrepute. In more normal times I would have conferred with Mary Ellen, but I’d made her counsel off limits to myself.
I passed the Tonto National Forest. I passed Globe. I ascended the Mogollon Rim in the gloaming. I found Interstate 40 at Holbrook and lowered my head for the distance.
There is little traffic across the high desert. Excessive speeds are the norm. I focused on my drive, refusing to examine all internal signals to slow down and think about what I was doing. Trepidation was for the timid.
I slept a few hours at a rest stop between Gallup and Al-buquerque. Just past Las Vegas, New Mexico, the sun climbed above the flat, stiff bed of the Great Plains, screaming all the way. I hurried through a drive-in for a late-morning meal in Colorado Springs. Once my head is down, food, gas, and peeing are like speed bumps.
It was night again when I got to Hooker. I went by Dad’s office. It was dark but for the small light over the sign—his
“shingle”—“Nicholas Ishmail, MD, Physician and Surgeon.” I walked from my car and stood and peered in the 150
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window at his desk. Neat stacks of journals and charts and correspondence awaited his attention there.
I drove to our house. Even nothing-towns like Hooker have beautiful old houses. Ours was built in 1910 by a successful merchant and had survived with minimal tinkering by its few owners.
When I walked into the kitchen, Mom dropped her dish towel and almost ran to hug me. “Malcolm! What are you doing home? Why didn’t you call?”
“Uh, Mom, kind of a spur-of-the-moment thing.”
“Are you in trouble?”
“No. Not really. I mean yes, a little. But I think I can handle it. I came home to think about it. Maybe talk it over with Dad.”
“Medical trouble?”
“Yeah. Residency trouble.”
“Have you eaten? Did you sleep this time?”
“Yeah, some of each.”
“Not enough of either, I’m sure. I’ll get you some dinner. Your father’s in the living room. But you’ll have to tell me, too.”
Dad was staring at a crossword, pen in hand. He raised his head to show he knew someone had entered, but did not look up at first. When he did he blinked and slowly let a smile build.
“Malcolm. Home from the war already?”
“Seems so.”
“I didn’t know it was over.”
“It might be. For me.”
He sat up in his chair. “Sit down.” He waited.
“Tell me again how you handle it when you get into an operation over your head.”
He frowned. “I know you didn’t come all this way for a bedtime story.”
“I’m AWOL.”
“They aren’t kind to deserters, Malcolm. I’m surprised you got as far as Gallup without some horseback posse getting you roped and hung.”
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“I’ve got a real dilemma, Dad.”
“And you think an old country doctor can help?”
“I think you can.”
He bit his lip but smiled slightly. “You want a drink?”
“Yeah. Yes, please. I’m pretty wound up. I get that way when I do these drives. I’ll get it. You want one, too?”
“Yes, please.”
“Scotch?”
“Sure.” I poured two drinks. He said, “Every surgeon gets himself into jams. You know that.”
“I know I do, but tell me again what you do.” I said.
“I get help. It’s not that hard.”
“But where is the point when you say to yourself . . . what does it take to say ‘I can’t do this’?”
He rubbed an eye. “Okay. Here’s one you haven’t heard before. Last year I was going in for a simple abdominal hysterectomy. Fibroids. Bleeding and painful. Simple. I did what you’re supposed to, though, I looked and felt all around and lo and behold the poor woman had a lump in her descending colon. You know I’ve done hundreds of bowel operations, probably dozens of partial colectomies. But she’d not been worked up for cancer. I don’t do surgical oncology anymore.
It all gets sent to Lincoln or Denver. But I was facing a woman, in the flesh, anesthetized, with her belly open.”
“Who is there to come help you in Hooker?”
“You know, Malc, we got phones here a couple of years back. I got her covered up, broke scrub, and got on the phone. The guy in Lincoln I send cancer patients to was off fishing or something, but I had a nice chat with the man covering for him. He told me what biopsies she would need for staging and to go ahead and do a wide resection with a primary anastomosis. Of course I could sew two ends of a colon together. It’s basic surgery. I suspect even you have mastered that by now.”
“Yes, Dad.”
“But when I was doing this kind of work I would never have done a primary anastomosis for a cancer patient.
Everybody got a colostomy. But times change.
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“I went out and told her husband what I thought we should do. He agreed, of course. And she got what she needed—two fairly simple operations at one go-round. She didn’t need a second admission, a second anesthetic, a second incision, any of that.”
“And she did okay?”
“Cured of both problems. Not every surprise cancer is such a happy case, though. I’ve also had to close up and send patients on down the road by ambulance. That’s more hum-bling. Not sure I told you about each of those.” He drank.
“So those guys in Lincoln aren’t thinking you should be quitting surgery altogether.”
“They think I do okay. When you call another doctor for help—if you’ve been careful up to that point—not been stupid in thinking you can do an operation you have no business doing, or burned an anatomic bridge inside the patient before you realized what you were up against—a good surgeon, a good doctor, will help. There’s no judgment—it’s about the patient. Sure, you’ll be explaining step-by-step how you got to where you are, but if your logic is sound you get the patient taken care of and you can still live with yourself.”
I said, “Of course.”
“Your pride isn’t worth a gnat on your ass compared to the patient’s well-being.”
“I know that.”
“And your pride will be ultimately better off with healthy patients, anyway.”
“I know that, too.”
“I know you know that. But you asked me.”
“Yes. But what . . . ,” I said, “what if you can’t do an operation you are supposedly trained to do?”
“Well, now, that’s a totally different ball game. I’m sure you’re not talking about yourself, because you’re not finished training, yet.”
“No, it’s my Attending.”
“Your current Attending? What service are you on?”
“Neuro.”
“A neurosurgeon.”
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“Yes.”
There was a silence. “What can’t he do?” he asked.
“She. She can’t find her way around deep inside the brain.”
“Malcolm, think about what you’re saying.”
“Dad, I have thought about it. I have thought about nothing else for the past week and a half. She gets lost. That’s what she told me. Her words. She told me it’s always been this way. She does her homework. Studies the scans. Sits and thinks and tries and tries and I guess just nothing comes.
She can’t, in her mind, put one slice on top of the other and make it look like brain, see it from different angles.”
“That’s not . . . She’s a trained neurosurgeon, for God’s sake.”
“Dad. I’ve seen it. I didn’t know what it was at first, but I’ve seen it.”
Another pause. “Give me a case.”
“She’s been known to open the wrong side of the head or start a laminectomy at the wrong level, though I haven’t seen that myself.”
“Carelessness. Unacceptable, but just simple human care-lessness. Not some deep flaw.”
“Yes, I know. But the deep flaw is there. It first came up in an aneurysm case. Supposedly fairly routine for an aneurysm. Anterior communicating artery. I scrubbed and held hooks till she got them all bolted to the table. Then I sat for hours blinking into the microscope. Dad, she was lost. I didn’t realize it at the time, but it went on for hours. She had the dura open for over ten hours. And they say that’s not her record. There was even an inquiry over this case.” I told him about Mr. Coles’s death and Drs. Miekle, Ryan, Kellogg, and Bullock. “In the end they just said, ‘Bad disease, bad outcome. What do you expect?’ Then, after her exoneration, in a moment of, I guess, uninhibited self-awareness, she told me she gets lost and it’s always been that way.”
He rubbed his face. “She told you this?”
“Yes, Dad.” I looked away. “She was feeling vulnerable.
Weak for a moment.”
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He stared at me. “She trusts you.”
“Yes, Dad.”
I was afraid he would want to know why, but he stuck to the clinical issue. “She needs to get a second surgeon. Someone to help her.”
