Patient (2 page)

Chapter 1

THEY WERE NEARLY THREE HOURS INTO THE operation and not one cell of the cancer had yet been removed. But by neurosurgical standards, three hours was still well within the feeling-out period—especially for a procedure involving experimental equipment. And despite huge progress recently, ARTIE most certainly remained experimental.

“Let’s try another set of images with enhancement of the tumor, please.”

To a physician, all growths, benign and malignant, were tumors, although the term “cancer” was generally reserved for malignancies—those tumors capable of spreading to distant organs. This particular cancer, a glioblastoma, was among the most virulent of all brain tumors.

Staring straight ahead at the eight-inch monitor screen that was suspended from the ceiling to her eye level, Jessie Copeland set her gloved hands down on the patient’s draped scalp, which was fixed by heavy screws to an immobile titanium frame. The physical contact wasn’t technically necessary. From here on, ARTIE would be doing the actual surgery. But there was still something reassuring about it.

“You playing gypsy fortune-teller?” Emily DelGreco asked from across the table.

“I just want to make certain the guy hasn’t slipped out from under the sheets, gotten up, and run away while I’m trying to decide whether or not our little robot pal is in position to begin removing this tumor. For some reason ARTIE’s movements forward and left feel sluggish to me—not as responsive to the controls as I think he should be.

“Easy does it, Jess,” Emily said. “We always expect more from our kids than they can ever deliver—just ask mine. The sensors I’m watching, plus my monitor screen, say you and ARTIE are doing fine. If you start feeling rushed, just say ‘Berenberg.’ ”

Emily, a nurse practitioner, had been on the neurosurgical service at the Eastern Massachusetts Medical Center for several years before Jessie started her residency. The two of them, close in age if not in temperament, had hit it off immediately, and over the intervening eight years had become fast friends. Now that Jessie was on the junior faculty, Emily had moved into the tiny office next to hers and worked almost exclusively with her and her patients. Neither of them would ever forget Stanley Berenberg, one of the first brain tumor cases the two of them had done together. His operation had taken twenty-two hours. They did the delicate resection together without relief. But every minute they spent on the case proved worth it. Berenberg was now enjoying an active retirement, playing golf and carving birds, one of which—a beautifully rendered red-tailed hawk—held sway on the mantel in Jessie’s apartment.

“Berenberg ... Berenberg ... Berenberg,” Jessie repeated mantra-like. “Thanks for the pep talk, Em. I think ARTIE’s just about ready to start melting this tumor.”

Jessie had decided to apply to medical school five years after her graduation from MIT with a combined degree in biology and mechanical engineering. She had spent those five years working in research and development for Globotech, one of the hottest R and D companies around.

“I didn’t mind making those toys,” she had told neurosurgical chief Carl Gilbride at her residency interview, “but I really wanted to play with them afterwards.”

Under Gilbride’s leadership, the Eastern Mass Medical Center’s neurosurgical program, once the subject of scorn in academic circles, was a residency on the rise, drawing high-ranking applicants from the best medical schools in the country. Jessie, who was comfortably in the middle of the pack at Boston University’s med school, had applied to EMMC strictly as a long shot. She was astonished when, following the interview, Gilbride had accepted her on the spot. There was, however, one proviso. She had to agree to spend a significant amount of time in his lab, resurrecting work on an intraoperative robot that a now-departed researcher there had abandoned.

Working in Gilbride’s lab throughout her residency while carrying a full clinical load, Jessie had learned that her boss’s true forte was self-promotion, but she had been elated to spearhead the development of ARTIE—Assisted Robotic Tissue Incision and Extraction. The apparatus was an exciting fusion of biomechanics and radiology.

Now, after some preliminary animal work, she and ARTIE were finally in the OR.

Over the past few years, Jessie had viewed countless video images produced by the intraoperative MRI system. What she was studying now was the continuous, three-dimensional reconstruction of the brain beneath the intact skull of the patient—images that could be rotated in any direction using a track-ball system bolted to the floor beside her foot. The on-screen presentations of the MRI data were undergoing constant improvement by the extraordinary genius geeks in Hans Pfeffer’s computer lab. And Jessie could not help but marvel at the pictures they were producing. The malignant tumor and other significant structures in the brain could be demarcated electronically and colorized to any extent the surgeon wished.

Jessie had always been a game player—a fierce competitor in sports, as well as in Nintendo, poker, billiards, and especially bridge. She was something of a legend around the hospital for the Game Boy that she carried in her lab coat pocket. She used it whenever the hours and tension of her job threatened to overwhelm her—usually to play the dynamic geometric puzzle Tetris. It was easy to understand why the MRI-OR setup excited her so. Operating in this milieu, especially at the controls of ARTIE, was like playing the ultimate video game.

MRI—magnetic resonance imaging—had progressed significantly since its introduction in the early 1980s. But the technique had taken a quantum leap when White Memorial Hospital, the most prestigious of the Boston teaching hospitals, had designed and built an operating room around the massive MRI magnet. The key to developing the unique OR was the division of the seven-foot-high superconducting magnet into two opposing heads—“tori,” the manufacturer had chosen to call them, a torus being the geometric term for any structure shaped like a doughnut. The tori were joined electronically by under-floor cables, and separated by a gap of just over two feet. It was in this narrow space that the surgeon and one assistant worked. The patient was guided into position on a padded sled that ran along a track through a circular opening in one of the magnets. Jessie understood nearly every aspect of the apparatus, but that knowledge never kept her from marveling at it.

“Let’s do it,” she said, crouching a bit to peer under the video screen and make brief eye contact with her friend. “Everyone ready?”

The scrub and circulating nurses acknowledged that they were, as did the radiology imaging fellow and the team working the console outside the OR. Through the glass viewing window, Jessie could see radiologist Hans Pfeffer—Ichabod Crane with a stethoscope in one pocket, a calculator in the other, and an IQ that had to be off the charts. The imaging system was as much his baby as ARTIE was hers. He had been watching, motionless, for every minute of the three hours. Now, as their eyes met, he simply nodded.

“Come on, ARTIE,” Emily said. “Do that thing that you do.”

The flexible robotic surgeon, three-quarters of an inch long and a third of that in width, was packed with microelectronics and gears. The guidance console by Jessie’s right hand was connected by microcable to six pods—tiny sets of pincers—three to a side. The pods enabled ARTIE to move along—and, where necessary, even through—the brain with minimal damage to the structures it passed. In addition to the guidance cable, ARTIE carried two other fine tubes, one capable of delivering ultrasonic waves powerful enough to liquefy tumor cells, and the other, a hollow suction catheter, designed to remove debris or to implant slivers of radioactive isotopes. Not counting the tubes and cable, the remarkable little robot weighed less than two ounces.

Jessie stretched some of the tension from her neck and began the meticulous process of liquefying and removing the large glioblastoma. She had inserted ARTIE up through the patient’s nose and into the cranial cavity, and then guided it to the diseased tissue. The tumor would have been virtually inoperable by conventional methods because of the normal brain tissue that would have been destroyed in the process of simply reaching the spot. ARTIE had made it with only minimal damage to healthy brain. Test one, passed with honors.

“He’s working perfectly, Jess,” Emily said. “Just don’t let him forget for a moment that’s brain he’s sucking on.”

“To do that I’ll have to change his program. I have him thinking he’s operating on kidney. I thought he’d be less nervous that way.”

The two women communicated with each other directly, while overhead cameras recorded the operation. They spoke over their shoulders to the nurses and technician, and by microphone to the team managing the console. Although neither of them was large, gowned as they were, surgeon and assistant virtually filled the spaces between the huge MRI tori. As long as neither of them keyed the microphone, by keeping their voices low they could conduct a conversation in virtual privacy. But at the moment, there was no need to speak. It was time to begin the actual operation. For a silent, motionless minute, they shared the appreciation that for the next three to ten hours, a narrow, twenty-six-inch space would be their world.

Bit by bit, Jessie began the dissection of the cancer, dissolving the cells with ultrasound and removing the resulting debris. As the procedure progressed, Emily monitored the various parameters within ARTIE and occasionally broke the viselike tension with small talk about the latest examples of Carl Gilbride’s florid egomania, about her two teenage sons, or about Jessie’s life—especially her mother, Paulette, whose shameless determination to do something about her forty-one-year-old daughter’s single status was a cartoon that never failed to amuse them. From here on, Emily was the supporting player, but she handled her role well. The two of them had spent so many hours together in the operating room that they functioned essentially as one. But today a third player had been added—a tiny robot that might, with time, revolutionize neurosurgery.

An hour passed with little conversation. To Jessie, it seemed like a minute. Every microscopic movement of the robot had to be visualized in three dimensions: anterior, posterior, right, left, up, down, and every diagonal in between. She asked the console tech for
Scheherazade
, one of a dozen or so CDs she had on file to be played while she operated. The slow, hypnotic music instantly softened the hollow, tiled silence. The electronically enhanced tumor as displayed on the monitor was crimson—a deadly hydra, its many tentacles probing deep into the dark blue of normal brain. ARTIE, the defender of the realm, was bright yellow. Delicately, deftly, Jessie directed its snout and the ultrasonic sword it wielded. Bit by bit the crimson receded. Bit by bit the blue expanded—swollen but intact brain, filling the void where the tumor had been liquefied, then aspirated. Another hour passed. Dave Brubeck replaced Rimsky-Korsakov on the sound system. Two of the eight tentacles and a portion of the cancer’s body were now gone.

Still, to Jessie, ARTIE’s responsiveness in one particular maneuver seemed slightly sluggish.

“Em, is there anything the matter?” she asked. “I still feel out of sync some of the time. There’s a choppiness when I try to back ARTIE up. Have you checked each of the pods?”

“I will. ... I don’t see anything striking, although numbers five and six are spinning a bit more rapidly than the others. I’m not sure, but I would think that’s just because they’re moving through liquefied tumor and aren’t actually connecting with solid tissue.”

“Maybe. I’m telling you, Em, we’ve still got a lot to learn about this little fella.”

Jessie suddenly stopped humming along to Brubeck’s “Take Five.” Something was definitely wrong with ARTIE.

“Em, check the pods again, please,” she said with unmistakable concern.

When she called for ARTIE to move right, forward and posterior, the robot gave a sharp jab to the left.

“The problem’s in five and six,” Emily replied. “RPMs are staying up. They’re not shutting off.”

“Jessie, you’re drifting posterior and left,” Hans called in over the intercom, his English perfect although his Dutch accent remained pronounced. “A millimeter ... more now. ... You are closing in on brain stem.”

Disaster. Jessie battled the controls, but she could see that ARTIE wasn’t responding the way it had been. From beneath her hair guard, sweat beaded across her forehead. Several drops fell onto her glasses.

“Wipe, please, John,” she said, turning her head briefly so the circulating nurse could dry her with a cloth sponge. “My glasses, too.”

The image on the screen was devastating. A rim of blue had begun to appear between one of the crimson tentacles and the robot. ARTIE was veering away from the cancer and through normal brain tissue toward the densely packed neurons of the brain stem, where even a millimeter of tissue destruction, properly placed, could be lethal.

“Jess, you were right,” Emily said. “Things just went haywire on the panel here. Five and six are continuing to spin. And now four is acting strange. It’s like ARTIE’s had a stroke or something.”

“Damn,” Jessie muttered, tapping rapidly at the key that should have reversed the malfunction.

Communication between the panel and ARTIE had somehow been disrupted. An overheat someplace? A computer glitch? Jessie cursed herself for not delaying the procedure until Skip Porter returned from having his painfully abscessed molar taken care of. A wizard with electronics, Skip was her lab technician and knew ARTIE at least as intimately as she did. But the truth was, with the robot buried deep in the brain, all the knowledge in the world wasn’t going to salvage the operation.

The blue rim expanded.

“You’re well into brain stem now, Jessie,” Hans reported.

Unspoken was the estimate of the neurologic damage that had already been done. Jessie could feel the deflation of her team’s energy and enthusiasm. There had been such high hopes for this day, ARTIE’s first under actual OR conditions. Somebody switched off the stereo.

Now there was only dense silence.