Lie Still, page 17
“That’s what eventually got us out of there. After that endless wait they finally called in another surgeon and, bang, it was done. So when we were setting up another patient for a deep-sea expedition—this time a tumor but practically in the same place—I suggested she get another surgeon to scrub at the outset, and she about threw me out of the clinic. The operation . . .” I was talking too loud. “Dad, it was so painful. It was like being stuck in the sand. Wheels turning and nothing happening. I knew she was lost again. I asked her if we should call Dr. Kellogg—the Chief. He had even stopped in the OR earlier to say he was available. She almost killed me.”
“And what happened?”
I described the culmination of the operation. “And after rounds I left for here. No excuses made. I’ll tell them I was dying with the flu and couldn’t get to the phone. It’ll be a black mark against me but I don’t care.” I paused, then said,
“I imagine the patient will be okay. They say most are.”
He nodded and sipped his drink.
“Dad, she was put at real risk. Aren’t we supposed to try to minimize risk? Where we can?”
“Of course, Malcolm. That’s our job.”
“And one of the next ones won’t be lucky.”
We were quiet a moment. I said, “How did she get this far?”
“Well, I imagine she can take blood clots off the surface of the brain. From what you’re saying that wouldn’t provoke her deficit.”
“No, not as long as you pick the correct side of the head.
I could probably do those by myself by now. You cut off part of the skull and it’s right there in your face.”
“Don’t be flip.”
“Okay, but you know what I mean.”
“Yes, I do.”
I went on, “And she can drill straight down on a spine and LIE STILL
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usually find the chunk of disc rubbing on the nerve. She can probably find most aneurysms. You look under the right—
the correct—lobe and there it is. It’s when it’s a little around a corner she has trouble. She gets lost.”
“So most of her patients do fine.”
“Exactly, Dad. Except aneurysm patients. Most of them do lousy, anyway. Everybody knows that.”
He said, “Look at it this way. All we have as scientists are probabilities. You took statistics in medical school.”
“Sure.”
“So you learned about coin flips as the basis for everything in medicine.”
I laughed a little. “Well, that’s not how they put it.”
“But, have you ever told a patient or his family you knew for sure how something was going to come out?”
“No.”
“Of course not. Because you know all we have in medicine are probabilities—coin flips. Or rolls of the dice. But each individual patient gets only one. You know it’s a single patient lying in front of you. One case at a time. Some patients buck the odds, some succumb. That’s what we doctors do. We don’t have yeses and noes. So we try to make the odds as favorable as we can for our patients.”
“And the odds she gives aren’t good enough. That’s what I’m up against.”
“Right,” he said, “but when a case goes bad she can say it was just the odds. A run of bad luck. If she’s getting lost in there on the tough ones, who would know?”
“Me.”
He nodded. “Do you know of any other cases? Like the aneurysm? I mean is this a pattern?”
“No. I mean I know other cases like that one have happened. She’s kind of a legend around the OR. But I don’t have specific names and dates of birth.”
“Do you think she’s hurting patients?”
I hesitated. “I’m not a brain surgeon.”
“You’re a doctor. You have your patients to think of.”
“Yes. Dad, I think she’s hurting patients. I know, if that’s 156
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true, as I understand the problem, that it is preventable. But I can’t prove it’s true.”
“Do you believe it’s true?”
“Yes. I believe it is. It all fits.”
“It fits the data.”
“Yes, it’s the only explanation for what I have in front of me.”
He said, “Is there a need to act?”
Again, I hesitated. “Most wouldn’t,” I said.
“You’re not most.”
He had spent his entire life winnowing integrity from natural tendencies. That was why I’d come. “Yes, I believe there is.”
“Have you thought about your options?”
“It seems the only thing left is to go to the heads of her department.”
“It seems. But think it through, Malcolm.”
“I will, Dad.”
“And don’t ever forget how proud we are of you.”
“Thanks. I won’t.”
The next morning I called the Maricopa Surgical ICU. The charge nurse told me Ms. McKenzie was waking up, though slowly. She was still on the ventilator but there were no gross neurologic deficits. Her family had been in to see her.
I clicked off and sat with the receiver in my lap until the piercing tone came on to remind me the phone was off the hook. I would have done anything to help Susan McKenzie, but her die had been cast. I said to the ether, “For the next one, then.”
I needed an appointment for a meeting.
I little relished the idea of a second session of incestuous politics with a Professor of Brain Surgery. Having tried Joe Kellogg with little to show for it, I would have to go to Dr.
Marshall Bullock, the über-boss, and from everything I’d heard, a real fingers-in-the-light-socket kind of guy.
His reputation among the U of A medical students was unique. He was said to be an exemplary gentleman teacher LIE STILL
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to medical undergrads—tolerant of relative ignorance, patient with uncertainty, and never failing of manners. Apparently, though, the initials “MD” behind a name made a man or woman fair game for any and all sorts of embarrassment and invective. It was said that newly minted interns were regularly reduced to blubbering under his withering assault of obtuse questions, mid-level residents clambered over one another to avoid him, and chief residents survived by memorizing his personal repertoire of physiologic fine points like kindergartners learning the Pledge of Allegiance.
I called Cynthia Blachly, our residency coordinator, my Mom-away-from-Mom. Besides being the one who could arrange my sit-down with Dr. Bullock, she would have been the first to know about my having gone AWOL from Mimi.
Expecting a shocked response I said, “Hi, Cynthia. Malcolm Ishmail.”
She said, “Hi, Malcolm. What’s up? You sound far away.”
“It’s a cheap phone.”
She said, “What can I do for you?” in a normal tone. Apparently I was still alive as far as the Residency Office knew.
I inhaled deeply and asked if I could meet with Dr. Bullock early the next week.
“Rethinking your story?” she said.
“I just thought of something I need to add.”
“Disclaimers?”
“You’re such a help.”
“Dr. Bullock is in Tucson, honey.”
“I know.”
“He’s not coming to Maricopa any time soon.”
“I was thinking I should go to Tucson.”
“Well, I can try to set it up, but I don’t have direct access to his schedule and your schedule is not exactly wide open.
Besides, Dr. Kellogg was supposed to be handling anything that comes up here. He was a little testy, I understand, about not being in on every interview and every message that came out of his backyard. You sure you don’t want to meet with him?”
“I already did.”
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She sighed. “Wanna pick up a phone? You don’t want to drive to Tucson. It’s an ugly drive.”
“I’ll risk it.”
When I called her back Cynthia had set up an appointment for me the next Monday afternoon. She still gave no sign that Dr. Lyle had ever mentioned my absence. Maybe Mimi was happy to be rid of me.
For two days I lived in Hooker. I went to Dad’s office. The locals—all shapes and sizes—came and went, some jaunty, some on crutches, some hunched over walkers, all smiling.
I hiked along the river. I ran on the high school’s oval track. I did push-ups and sit-ups. I ate home cooking. I caught up on my sleep. I made no excuse to Cynthia nor Mimi nor anyone else for missing most of the last week of my time as a brain surgeon.
That Friday I left on the return trek. I intended to perform my usual head-down sprint, but somewhere on the eastern slope of the Rockies, driving in the dark, I began to cry. It didn’t interfere with my momentum, steering on the interstate being practically foolproof, and no one could have seen, so I just let it flow, examining, as they came up, the no-tions and images that made it throb.
Certainly I feared for my career. Medical academics, like everyone else, do not like having their major mistakes exposed. Even messengers can get killed and in my case I might be mistaken for more of a problem than a messenger.
More aching, though, was the loneliness. It was not as acute and searing as being dumped by a lover, but more pervasive.
Even more formidable. Intellectually, after a breakup, one knows the pain is finite—there will be another lover. This, on the other hand, might never go away. Always—high school, college, med school, internship, and residency until now—I had been able to rely on my compañeros in times of trouble.
There had always been those among whom there were no secrets, no lies.
I stopped for a sit-down meal and a cheap motel. I wanted to call Mary Ellen.
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*
*
*
When I got to Phoenix Sunday afternoon, I went to Maricopa to check on Susan McKenzie. I found her chart and read Dr. Lyle’s notes. Mimi’s tone was completely self-satisfied.
The patient was not in her room, but her nurse said her husband had taken her for a walk. Maybe a good sign. I found them just outside the cafeteria. Her husband, looking aged since I had met him in the presurgery room, was pushing her IV pole. I spoke briefly to both of them. It was obvious she did not remember me. It was unclear whether she knew her husband.
Her acute mental vacancy, while not necessarily permanent, was frightening. Much of the good stuff of brain function—memory, personality, sexuality, impulse control, sense of humor—lives where we’d been pressing. It sometimes takes weeks or months to reappear. Sometimes parts of it are gone forever, the gaps invisible to the doctors who do not know the subtleties of the person.
The calendar having ended our academic relationship, my tour with Madame Lyle was over. There was neither party nor speech. There never is—residents come, residents go, easily forgotten. I had ended our personal relationship with my in-subordinate absence from the last few days of clinics and rounds. I’m sure we both knew that any further words between us must necessarily begin with an apology from me, something I was not planning. If she wanted to lodge a complaint or add a nasty letter to my file, I would deal with it as I could.
Monday at 0700 sharp I stopped being a faux–neurosurgeon, transforming instantaneously into a faux-vascular surgeon. After morning rounds I made my scraping apology for having to leave for most of the day on an administrative matter. My Attending snorted. “Hell of a way to start a new service, Ishmail.”
“I know, sir. But I have to meet with the Chairman of Neurosurgery. It’s pretty serious.”
He gave me a hard look but waved his hand dismissively.
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*
*
*
The interstate out of Phoenix, south to Tucson, cleaves vast expanses of dust speckled with the occasional chancre of industrial farms and a seemingly random smattering of abandoned farmhouses and roadhouses, anachronisms in the age of the sixteen-row tractor and the interstate highway. It invites a heavy accelerator.
The only remarkable thing about Dr. Bullock’s office was his Executive Assistant. A woman best described as
“huge,” sporting a tower of lacquered hair, but with eyes sparkling from beneath the folds of flesh. She was kind and grandmotherly and called me “Dear.” She insisted on getting me coffee, then brought cookies along for good measure. I waited in the relative warmth and safety of her maternal domain. When I was almost asleep in the armchair she gently called my name and nodded me in the correct direction.
I faced the office door. I paused and steeled myself before knocking. The portal to purgatory, I discovered, looks just like something you see every day.
Marshall Bullock was sitting sideways to his desk, bent over an old typewriter. I remembered having seen him at Maricopa once, being led around by a stiff-looking team of doctors and their hangers-on, each gussied up in something more formal than usual, each in a brightly clean white lab coat. He looked to be of above-average height with broad shoulders and a thick, athletic neck. His face was tanned and lined, his reddish hair sun-streaked.
Before I could sit down he asked, “What brings you to Tucson?” He did not look up. I hesitated. “I don’t want to be rude,” he continued, “but our report on Dr. Lyle is all written.
And the Chief Resident has made a mess of this paper we were to have in press next month. If I don’t get it in the mail by four-thirty this afternoon, the editor is going to come out here from Yale just to have a go at me with a switch.”
I smiled. One could sell tickets to such a meeting. “Sorry, sir. It’s not really a straightforward thing.” I sat. “Since I LIE STILL
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talked to Dr. Kellogg two weeks ago, I’ve been thinking about the implications of what he was asking me.”
“About Dr. Lyle.” His voice had an unnerving booming quality.
“Yes. I thought about the nature of the questions and all.”
Silence but for the typewriter. It occurred to me that if I quietly left he might not be certain I’d ever been there. I ventured on: “It seemed the issue was probably bigger than just the Coles case.”
He typed on, but finally said, “It may have been. In some people’s minds.”
“Actually, Dr. Bullock, something came up. She said something to me that got me worried about another patient. . . .”
He glanced up briefly. “A particular patient.”
“Yes, sir. I mean, as an example of the problem . . .”
“Someone . . . in the hospital? The ICU?” He turned toward me.
“No, sir, not exactly. She’s in the hospital, was in the ICU.
A woman I saw in clinic and scheduled for surgery. We did the case last Tuesday.”
“A completed case?”
“Yes, sir. But something she said . . .”
“What kind of case?”
“A pituitary adenoma. Trans-sphenoidal approach.
Thirty-two-year-old mother of three.”
He rocked back in his armchair but stared at me intently.
I got the impression I might have touched a sore spot.
I said, “Something Dr. Lyle said, too. I mean we both felt bad for the Coleses, and she was kind of getting down on herself. . . .”
“That’s a natural reaction for a good surgeon,” he said.
“Oh. Of course,” I said. “I’ve been wondering ever since his operation if I could have done anything differently, you know . . .”
He waved his hand. “Of course.”
“But she said a couple of things that got me wondering.
And it’s been like a rock in my shoe ever since.” He waited.
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It was time to shoulder the load, but I stumbled. I said, “In clinic she said, ‘Here we go again.’ ”
He frowned. I scrambled: “Since I met with Dr. Kellogg and he pointed out how long Keith Coles’s operation had taken—I mean, fourteen hours—how she had ultimately needed help, and all that, I got to wondering if this might turn out the same way. If that was what she meant.” His frown tightened. “I checked around with some OR people and they told me about one of these adenomas she did a few years ago that turned into a disaster and left the man half blind.”
“You were concerned about this woman being made blind.”
“Well, yes, sir.”
“Dr. . . . Ishmail, is it?”
“Yes, sir.”
“We all know Dr. Lyle does some operations slowly. All of us like to be meticulous.”
“Yes, sir.”
“And the OR people do not like slowness,” he boomed,
“unless it’s their own.”
“Yes, sir.”
“And blindness is a known complication of that operation.
It’s in the texts. It’s part of the explanations we give these patients ahead of time. It’s not like that man was the first.”
“No, sir.” A pause. Sink or swim. I blurted Mimi’s secret:
“But what else she said was, ‘I get so lost inside the brain.’ ”
He looked up slowly. Our eyes met. I went on, in a slow careful tone: “She said to me, ‘I memorize the CTs, cut by cut, but I can never stack them up again to re-create the whole. I can’t roll things around in my mind in three dimensions and see what’s on the other side. I never could. I just don’t think in three dimensions. Ever.’ ” He stared at me.
“She said it’s a ‘daytime nightmare.’ Apparently recurring.”
There was a long silence. I sat still. Dr. Bullock was leaning heavily on his elbows on the desk, but said nothing. He had both hands cupped over his chin.
“I tried not to think much about it at the time. But then LIE STILL
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Ms. McKenzie came into clinic. I was the one who worked her up for Dr. Lyle. It really began to bother me. I realized that, well, if there’s one place you really need three-dimensional thinking, it’s got to be brain surgery. Maybe surgery inside the heart, too, fixing a valve, but . . .”
“Yes. Quite.” He cut off my nervous prattling. There was silence as he stared. “She told you she cannot reconstruct anatomy in three dimensions. Mentally.”
