Preferential Treatment, page 10
“Hello, Dr. Montgomery. I’m Dr. LaCava, your anesthesiologist.”
“Nice to meet you,” Montgomery beamed. LaCava nodded. To Montgomery, LaCava appeared to be as young as he. She had an attractive, kind face and was slightly on the portly side. She sported a paisley surgical cap and matching scrubs.
“I’ll be in and out today,” the anesthesiologist stated. “I’ve got a couple of other cases going on, but you’ll be in good hands with Jake. He’s been around a long time, and I’ve found him to be a great CRNA in my short time here.” Baldwin blushed.
“You’re a relative newcomer, too?” Montgomery asked.
“Yeah. Finished my residency training three months ago. This’ll be my first aneurysm surgery since I came to St. John’s. I guess they don’t do a whole lot of them here—at least from what I understand,” said LaCava.
“Well, that makes two of us,” Montgomery replied. “Not only my first aneurysm surgery since I finished training, but my first surgery—period.”
Montgomery paused and looked around the surgical suite. “Are we ready to go?”
Nods from around the room.
Joe was appropriately positioned on the operating table, and his head secured in the Mayfield pin headrest so that the left side was turned toward Montgomery. He meticulously shaved a large portion on the left side of his patient’s scalp and scrubbed the shaved area with Betadine solution to sterilize the incision site. The operative site was then draped to keep the operative field sterile.
Montgomery, desiring some magnification for the next part of the surgery, donned his surgical loupes, a strange looking pair of spectacles with magnifying glasses attached. Thereafter, an incision was made in Joe’s scalp, and the skin was gently peeled off of Joe’s skull forming a flap. Montgomery used an air-powered drill to make four burr holes in the skull down to the dura mater, the tough fibrous covering of the brain. The four holes framed the intended operative site. Montgomery paused and admired his work.
Next, the surgeon cut the bone from hole to hole using an air driven craniotome forming a bone flap that was removed exposing the dura that Montgomery inspected carefully. Satisfied that the dura appeared to be relaxed, evidencing that his patient’s brain was no longer swollen, he cut the dura and exposed Gunther’s brain. The surgeon felt a rush of adrenalin.
Montgomery wanted added exposure of the aneurysms that lay at the base of Gunther’s brain. “Leksell rongeur,” the doctor commanded. Jane Thomas, the scrub nurse, complied, slapping the pincer-like instrument into the doctor’s open palm. Using the rongeur, Gunther’s sphenoid wing, a section of bone inside of his skull, was removed giving the surgeon additional exposure to the aneurysms.
“Let me know when you want me to lower the blood pressure,” the anesthesiologist stated.
“Not yet. We’ll take it down when I’m ready to start dissecting the first aneurysm. What’s the mean pressure now?”
“Mean pressure is seventy-four,” stated LaCava.
“Fine. Try to keep it around there. I’ll let you know when.”
Slowly and carefully a brain retractor was placed on Gunther’s brain, and the surgeon gently lifted it from the floor of the cranium. Montgomery then removed the surgical loupes and opted to bring the operating microscope into the surgical field. After the device was properly draped, he positioned it and peered through the lenses.
Montgomery then opened the arachnoid over Gunther’s optic nerve and carotid artery. On the internal carotid artery, he spied two aneurysms, not more than seven millimeters apart. The deeper of the two was partially obscured from his vision; however, as was expected from the previous angiogram, this one appeared to be easily accessible and, in Montgomery’s judgment, the clipping would not be problematic. It was relatively small and had a well-defined and narrow neck.
The second aneurysm was a different can of worms. The body of the aneurysm had two lobes, one of which extended under the clinoid process. The second lobe curved around the clinoid process in the opposite direction. Not only was the clinoid process in the surgeon’s path to clip the neck of the aneurysm, but also the neck was abutting the floor of the cranium where the carotid artery entered to nourish the brain. Montgomery knew that getting a clip on the neck of that aneurysm would be difficult. The risk of inadvertently rupturing the aneurysm during either the removal of the clinoid process or attempting to place the surgical clip on its neck was a real possibility.
Jesus, this is going to be a tough one, he thought. Primum non nocere—First, do no harm.
Montgomery studied the surgical field and bit his lower lip in thought. Due to the close proximity of the two aneurysms, he knew he needed to clip the deeper aneurysm first prior to attacking the nearer and more problematic bi-lobed one lurking around and under the clinoid process. He pulled back from the operating microscope and looked at the clock on the wall—10:15 a.m.
He turned his attention back to the surgical field and relaxed the retractor which was elevating Gunther’s brain from the floor of his cranium. He repositioned the retractor and once again elevated the brain. Suddenly, the surgical field began to fill with blood.
“Damn!” exclaimed Montgomery. “The thing is leaking again! Suction!”
Montgomery was handed a suction tube by the surgical tech, and he applied suction to the bloody field. “Marie, grab another suction tube!” the surgeon ordered. Cabot quickly complied. With his free hand, Montgomery guided his PA’s hand with the suction tube into the bloody abyss.
“Hold it there!” Montgomery yelped at his physician’s assistant. “I need that field cleared so I can see what I’m doing.”
The surgical field slowly cleared, and Montgomery could see bright red ooze coming from the aneurysm that he had thought posed the lesser problem.
“Get me some half inch square Cottonoids!” Montgomery ordered. The surgical tech complied, and Montgomery used the patties to put pressure on the oozing aneurysm. The surgeon grabbed the suction tube from his PA’s hand and held the cotton patty on the breach while he suctioned the remaining blood out of the surgical field. Several minutes passed while the surgeon maintained gentle pressure. Both suction tubes continued to work, clearing the free blood from the field. Slowly, the bleeding subsided, and he pulled the sponge from the previously bleeding aneurysm.
“Got it!” cried Montgomery. “How much blood did we lose?”
The circulating nurse checked the suction bottle. “500 ccs.”
“How’s the mean pressure?” Montgomery asked.
“Steady at 65,” LaCava reported.
Montgomery peered into the operating microscope when suddenly the aneurysm once again began to bleed, though more profusely than it had before.
“More Cottonoids,” panted Montgomery. A bead of perspiration formed on his brow. “And get some cotton balls. This thing is going to need some major soaking up!”
Montgomery worked furiously. He used suction to try to keep the surgical field clear as he attempted to prevent the oozing blood from irritating the delicate structures of the brain. He knew that too much free blood would cause spasm and swelling of the brain tissue, both of which could cause long term disability or even death.
“I need more suction!”
The PA brought the sucker near the field and awaited instruction. Montgomery became more and more irritated and stressed as the minutes ticked by. Frustrated, he reached up and grabbed the PA’s hand and placed the sucker on one of the cotton balls soaking up the blood.
“Just hold it right there,” Montgomery ordered, “and get me another sucker.”
More perspiration on the surgeon’s forehead formed a rivulet down the side of his face. A second suction tube was handed to Montgomery, and he carefully placed it near the other two.
For what seemed like hours, the surgeon held one suction tube in each hand. He felt virtually paralyzed. Once again, the bleeding subsided, and the field was cleared of all remaining blood. Montgomery removed the bloody Cottonoid patties and cotton balls.
As the last tampon was removed, he released an audible puff of air from his lips.
“It stopped,” a relieved Montgomery sighed. “How much blood loss?”
Jake Baldwin, the CRNA, checked the suction bottles. “Twenty-two hundred ccs.”
“How’s the pressure?”
“It dropped below where we wanted it, but we’re catching up with packed red cells, whole blood, and platelets,” LaCava replied.
Montgomery looked up at the clock.
Almost noon and I don’t even have the first one clipped. Jesus, it’s going to be a long day.
Montgomery knew that he and his patient were facing a dilemma. He realized he needed assistance that was apparently not available in the operating room. As professionally distasteful it was, he made the decision to swallow his pride and seek another surgeon to assist him with what was escalating into a potential disaster. He searched his memory banks and recalled that a few days ago he had been introduced to a kindly, elderly doctor who practiced neurosurgery and had privileges at St. John’s.
Hall, Dr. James Hall, Montgomery thought to himself.
“Nurse, could you try to get ahold of Dr. Hall and see if he could come over here and give me a hand?” Montgomery asked his circulating nurse, Susan McGuire.
McGuire nodded and left the operating room in search of reinforcements.
“Everybody take a breather,” Montgomery commanded. He stretched one leg and then the other and tried to relax the tension that was building by the minute.
McGuire located Dr. Hall. After the situation was explained to him, he reluctantly agreed to come to the hospital to see what, if any, assistance he could render.
At 12:35 p.m., Hall arrived at the O.R. All eyes swung toward the doctor. From his appearance, Montgomery surmised that the elderly surgeon was somewhere around seventy-two years of age. He had light grey eyes and sported a small white goatee. His white hair was receding and neatly styled. He appeared extremely trim and fit and was dressed immaculately in a navy blue blazer, a sky-blue buttoned down shirt, a yellow club tie, and khaki pants. His brown wingtips bore a military quality shine.
“Hello, Dr. Montgomery. I understand you could use some help.”
“Hi, Dr. Hall. Thanks for coming in. We’ve got a tough case here, and I could use another set of experienced hands if you’ve got the time,” said an already relieved Montgomery. “We seem to have encountered some uncooperative aneurysms.”
Hall’s brow furrowed. He stroked his goatee and looked at an unconscious Joe Gunther.
“I haven’t done an aneurysm surgery in a while now. Goddamned lawyers and their frivolous law suits, you know,” Hall grunted.
“No problem,” Montgomery said. “I’ll handle the dissection and clipping. I just need someone with experience who can assist if things go haywire again.”
The PA, Cabot, glared at Montgomery, perceiving that his statement was a not so subtle dig directed at her.
“You’re lucky you caught me. On my way to my weekly bridge game at the Club. Another five minutes and you’d have been out of luck. I’ll get scrubbed. Back in a jiffy.”
“Thanks,” Montgomery said. “I’ll be here.”
After his five-minute surgical scrub, Hall reentered the operating room adorned in blue scrubs. He extended his hands in front of him in the “I’m scrubbed” position. He approached the scrub nurse, Jane Thomas, who laid a towel across his outstretched arms. He meticulously dried each hand, wrist, and forearm. The nurse then assisted him with his surgical gown and latex gloves and handed him a sterile mask. Hall secured the mask snuggly to his face.
“I think we’re ready to proceed,” Hall announced to the room. He approached the sterile field and an unconscious Joe Gunther. He then peered sternly at the operating microscope that hovered by the operating table. “Don’t have much use for this,” Hall said, pointing at the scope. “Prefer the loupes.” He reached for a pair of operating loupes on the instrument table in the sterile field. Hall slid the loupes onto his nose and looked toward Montgomery for direction. Montgomery, somewhat taken back by the elder surgeon’s reluctance to use the operating microscope, swung the device away from the table and grabbed his own set of loupes that he had used in the early stages of the surgery.
I can’t argue with the guy. He was nice enough to come in here and give me a hand, thought Montgomery.
“Fill me in on what we’re dealing with,” Hall said.
After Montgomery brought Hall up to speed on the progress of the surgery, he began the delicate process of dissecting adhesions that had developed around the bleeding aneurysm.
Suddenly, the same troublesome aneurysm began to bleed again.
“Dr. Hall, if you could give me some suction here, I’ll try to get another Cottonoid on the breach. Maybe a couple of cotton balls, too.”
Hall nodded in agreement. The two surgeons used the suction tubes to clear the blood that was, once again, filling the field and making it impossible to see the lesion to place a clip on it. LaCava and her nurse anesthetist, Baldwin, worked feverishly to replace the blood.
After more than fifteen minutes, the pesky aneurysm’s bleeding slowed to the point that Montgomery was able to complete the task of dissecting the aneurysmal dome from the previously formed adhesions. One thousand ccs. of additional blood were lost in the process.
With the aneurysm clip loaded into its applicator, Montgomery approached the neck of the aneurysm. Ever so slowly, Montgomery placed the jaws of the clip across the aneurysm’s neck. He inhaled deeply and released the clip.
“Got it!”
“Well done, doctor,” Hall said. “Shall we proceed with the next one?”
“How’s the fluid replacement?” asked Montgomery.
“We’re catching up. Mean pressure is sixty-two.”
Montgomery glanced at the clock. 2:45 p.m. The surgery had now been going on for seven hours and fifteen minutes.
Outside the surgical suite, a nervous Samantha Hunter paced back and forth in front of her mother. “What’s taking them so goddamned long?” Her frustration level was mounting by the minute. She looked at her watch and frowned. “I’m afraid something is going on in there that’s not good.” She needed a cigarette but knew the hospital’s campus was a “No Smoking” area. She would stay put until she saw that young doctor, in whose hands her father’s fate was placed, come into the waiting room and tell them the score.
“Honey, quit pacing. I’m sure things are going well,” said Mary, her voice cracking. “You should be praying instead of taking our Lord’s name in vain.”
“I’ll leave that to you, Mom. I’ll just continue to pace, if you don’t mind.”
Mary bowed her head, folded her hands in her lap, and wept softly.
“The paraclinoid aneurysm is going to be tough,” Montgomery said. “Take a look, and I think you’ll see what I mean.”
Hall gazed at the angiogram on the x-ray view box. He then peered through his loupes, adjusting his headlamp to optimize his view.
“Yeah, I see what you mean. Looks like we’re going to have a tough time getting a clip on this one,” Hall said.
“I thought I’d burr out the anterior clinoid process to get us exposure to the whole thing. It’s in the way, and one of the lobes of the aneurysm is obscured by it.”
Hall shook his head and looked at the young surgeon. “It’s problems like this that made me glad I quit doing these things years ago,” mused Hall. “Couldn’t stand to see ‘em die or, worse yet, become physical and mental cripples.”
Montgomery winced. “We’ll try to not let that happen.”
Montgomery returned to the operative site armed with a high-speed air drill equipped with a diamond burr. As the drill began to whine, Montgomery slowly approached the small boney clinoid process that partially obscured the aneurysm. As the drill began to do its work, Montgomery watched as the clinoid process began to shrink.
After a few minutes of grinding, Montgomery was satisfied that he could attempt to place a clip across the aneurysm’s neck; however, as he pulled the drill from the area of the aneurysm, it suddenly burst.
“Jesus Christ,” screamed Montgomery. “The goddamned thing exploded.”
Massive amounts of blood spurted from the wound. The surgical field became a sea of red. Montgomery and Hall scrambled to clear the field as a huge amount of blood engulfed the frontal and temporal lobes of Gunther’s brain.
“There’s no way we’re going to get that thing stopped. Even if we clear out some of the blood, there’s so much swollen brain tissue in the way now we’ll never be able to clip the neck!” exclaimed Hall.
“We need to amputate!” Montgomery cried. “If we don’t get some of that brain tissue out of the road and get a clip on this thing, anesthesia will never be able to keep up with the blood loss, and we’re going to lose him!”
Around the O.R. eyebrows raised.
This guy’s having a really bad day, thought Cabot.
“Pressure’s at 15 systolic, Doctor,” panted Baldwin as he and LaCava feverishly worked to raise the blood pressure to a safe level by replacing the huge amount of blood that was coursing from Gunther’s cranial artery.
“How much blood have we lost so far?” Montgomery asked, his heart now racing.
“Forty-five hundred ccs.,” barked Jane Thomas.
“I’m going to clear some of this out of the way. Give me a sucker,” Montgomery ordered. He applied suction directly to the lower portion of the frontal lobe of Gunther’s brain. An audible sickening slurp permeated the operating room as brain tissue was sucked up the tube and into the suction bottle. He next placed the suction tube onto the surface of the upper part of the temporal lobe where swollen tissues blocked any possibility of the surgeon’s clipping the exploded aneurysm. Another audible slurp emanated from the suction tube. LaCava gagged at the sound.
