Patient (5 page)

Chapter 5

JESSIE’S DAY OF RECKONING WITH SARA DEVEREAU began at five in the morning with fifteen minutes of stretching and two dozen push-ups, followed by a cup of decaf and half a melon, a quick shower, and finally two games of Pin Bot—the full-sized pinball machine that occupied a significant portion of her living room. It was clear from the pile of covers on the floor by her bed that her sleep had been fitful, although as usual, she had no clear recollection of any dream. If a nightmare was responsible for the bedding pileup, she was reasonably certain that a bug-eyed bullfrog had played a leading role.

As always on a day when she was scheduled to operate, Jessie felt keyed up—excited and on edge. She was the starting pitcher in a World Series game, but with no hope of being taken out for a reliever no matter how hard she was being hit. Facing a day as the principal in the neurosurgical operating room was a rush few would ever experience. And Jessie loved the feeling.

One of the fringe benefits of being a surgeon was not having to build up a wardrobe of business clothes. Scrubs and a lab coat were always as fashionable in the hospital as they were functional. Jessie dressed in sneakers, khakis, a button-down shirt, and a blue cardigan, and spent a minute in front of the bathroom mirror, applying a bit of lip gloss and some mascara. Her shoulder-length hair was still mostly chestnut brown, but each day, it seemed, there were a few more gray strands. Monique, the Newbury Street stylist she saw every couple of months, had started pushing for a cosmetic response.

Maybe someday
, she thought, fixing her hair back with a turquoise clip.
Right now you’ve got a little neurosurgery to do
.

She trotted down three flights and exited her building by the basement door. A year or so ago she had won a lottery among the tenants in all of the apartments that allowed her to pay through the nose for one of the parking spaces behind their building. On days like this one—rainy and raw—the absurd tariff seemed almost worth it. Swede, her five-year-old Saab, had begun to nickel-and-dime her, and was especially cranky in rainy-and-raw. Still, out of loyalty, she was totally devoted to the machine. Today Swede turned over on the first try—a good omen.

Traffic to the hospital was so light that Jessie made the drive to parking lot E in fifteen minutes. Her assignment to E—an eight-minute walk to the hospital—easily counterbalanced her success in the apartment building lottery. Monthly petitions to the parking office to move to one of the garages had yet to be dignified with a response. As she hurried, jacket over head, to the hospital, she reminded herself for the hundredth time to get an umbrella.

By the time Jessie arrived on Surgical Seven, Sara was floating through a drug-induced haze. Her husband, Barry, and their three children were at her bedside.

“Hey, I was beginning to think you weren’t going to show up,” Sara said thickly.

“Wouldn’t miss it for the world,” Jessie replied. “At last the chance to look into that goofy brain of yours and find out what really makes Sara Devereau tick.”

“Tell me something. How come I got all that pre-op medication and I’m still scared to death?”

Jessie grinned and took her friend’s hand.

“Beats me,” she said. “I guess you’re just chicken. Listen, Sara, we’re going to do it this time. If it’s humanly possible to beat this thing, we’re going to be fearless, and we’re going to do it.”

Jessie knew that the pep talk was as much for her own benefit as her patient’s, and she suspected Sara knew it as well.

“Fearless,” Sara said. “I trust you, coach.”

“What can we expect?” Barry asked.

Jessie knew better than to measure her response too much. Sara’s kids were not naive. They had been through this twice before.

“The tumor is right alongside some vital neurologic structures,” she began, “including the nerve packages that control Sara’s right visual field, right arm, and right leg. But we’ve got to be especially careful operating around what’s called Wernicke’s area. That’s the center that controls speech and language.”

“Mom could lose her ability to speak?” the oldest child, Diana, asked.

“Yes. I certainly hope not, but that’s a possibility. And maybe even to
understand
speech.”

Jessie could see nine-year-old Jared’s eyes begin to well up. She moved aside so that the boy could take her place beside his mother.
Enough
, she decided. The rest would be between her and Sara.

“There is one thing you all need to know,” Jessie added. “Even if this operation is the total success I hope it will be, we might not know the results for a while—days, even weeks, afterward. Brain tissue has been pushed aside by the tumor. Once the tumor is gone, normal tissue will fall back to where it used to be. But there is always swelling of the brain cells when there is any manipulation or injury, and there might be a period after the operation when things don’t work right. Please don’t get discouraged if that happens. After the first twenty-four to forty-eight hours, things should improve tremendously. Now, if you don’t have any other questions, I’m going to go and get ready.”

She hugged Barry and shook the children’s hands, whispering to each to be brave. Telling them not to worry would have been foolish.

JESSIE MADE QUICK rounds on her patients, then spent twenty minutes studying Sara’s MRIs and reviewing her operative plan. The tumor was in a temporo-parietal location, just above the ear on the left side, just adjacent to the nerves of Wernicke’s area. Speaking ... understanding spoken and written words ... reading ... writing. The biggest danger of the operation would be failing to get out enough tumor to effect a cure. But the risk of having Sara Devereau living out her life in a hell devoid of expressive and receptive language was not far behind. Loss of a limb or a visual field was one thing. Permanent loss of the ability to communicate or to be communicated with was something else again.

Knowing too much and fearing that she didn’t know enough, Jessie followed her pre-op ritual, walking slowly and deliberately down the eight flights to the subbasement. Then she paused briefly before a pair of glass doors before stepping into the world of MRI-assisted surgery.

By the time Jessie emerged from the dressing room after changing into fresh scrubs and her OR Keds, Emily was in the prep area, shaving Sara bald with a disposable, double-edged safety razor. Thousands of hours and hundreds of thousands of dollars had gone into making anesthesia and surgical equipment insensitive to the MRI’s massive magnets, which, themselves, were never turned off except in the event of some mechanical disaster. Once into the OR, even the most insignificant metal object would be snatched across to the housing—a missile with deadly potential. Ultimately, it had been less expensive to build a small prep area than it would have been to develop and manufacture non-ferromagnetic razors.

On the wall of the prep area was a blown-up photo of a janitor, smiling broadly as he pushed an industrial-sized floor buffer along. A red circle and slash had been painted over the picture, which was actually posed for and taken by the residents after an EMMC maintenance worker had missed the multitude of warning signs and cheerfully buffed his way into the MRI operating room. The huge buffer, ripped from his hands and sucked chest-high across ten feet of air, slammed against one of the tori with destructive force. Shutting down the semiconductors to remove the buffer had cost tens of thousands of dollars and closed the operating room for weeks.

“How’re things going?” Jessie asked.

“Excellent pre-op meds,” Emily said. “She’s just passing the second star to the right. Sara, I think you’ll love this new hairdo.”

“Hey, what works for Michael Jordan works for me,” Sara replied dreamily. “Your scalpel sharp, Doc?”

“We’re all set,” Jessie said. “The plan is to put you to sleep until we finish the noisy parts.”

“I never did like listening to my skull being drilled.”

“When you wake up, you’ll be on your side with your head fixed in a frame.”

“I remember.”

“You’ll have an airway in your throat, but we’ll take it out when we need you to talk. You’ll also have on the pair of special goggles I showed you. The goggles will project words or pictures. I may ask you to describe some things you see with one or two words, or else just to think about them. While you’re doing that, we’re going to be making a map of the parts of your brain that are working at that moment. It’s called a functional MRI.”

“Functional MRI,” Sara echoed.

“Jessie,” Emily cut in, “I hate to spoil this highly informative session, but I think she’s probably too squashy to get much out of it. You have already gone over all this, yes?”

“Yes. I’m just ... I don’t know ... trying to be thorough.”

“That’s fine. Listen, we’re going to do great.”

“Yeah,” Jessie replied, with less enthusiasm than she had intended.

“I mean it.”

“Thanks. I know. Anesthesia here?”

“Yup. Byron Wong.”

“Radiology?”

“Everyone’s here. And I’m ready. You can do this, Jess.”

“Yeah,” Sara muttered, as if from down a long tunnel. “You can do this.”

“I only wish I didn’t have to,” Jessie said. “See you inside.”

As she turned and headed for the sinks to begin a lengthy scrub, Jessie was thinking about the cocktail party catch phrase she had heard so many times ...
I mean, it isn’t exactly brain surgery
.

BULKY IN HER surgical gown, Jessie stepped into the narrow world between the MRI tori just as anesthesiologist Byron Wong and the circulating nurse slid Sara through the opening in the magnet to her left.

“We’ll keep her out with propofol and midazolam,” Wong said, “but not too deep. It’ll take just a minute or two to wake her up when you’re ready. She’ll be uncomfortable being on her side for I don’t know how many hours, but thanks to the midazolam, when we’re all done, she won’t remember how miserable she was.”

“If a tree falls in the forest, and there’s no one around to hear it ...” Jessie said, bolting Sara’s head into the frame that would hold it motionless throughout the surgery.

“Pardon?”

“Nothing, nothing,” Jessie said, setting the crosshairs of three lasers so that they would intersect at the center of where she visualized the tumor to be, targeting things for the MRI. “I was just wondering how much someone is suffering if they have complete amnesia for the time when the suffering happened.”

“You’re very deep,” Emily said.

“I know that. I know I am.”

The mindless banter between the two friends would continue on and off throughout the operation. Emily had developed a sixth sense as to when Jessie needed the connection, and when she simply had to be left alone with her thoughts and the awesome responsibility of her job. Because of the teaching hospital’s demand that the residents assist on as many cases as possible, there was constant pressure on Jessie to use them. And, remembering her own residency, generally she did. But for the most difficult cases, she still always stood her ground and insisted on Emily. If she was the World Series pitcher, Emily DelGreco, wise and experienced, was her favorite catcher and lucky rabbit’s foot rolled into one.

After a thorough antiseptic prep, they spread out sterile drapes especially designed for the narrow work space between the tori. Then she and Emily adjusted their MRI screens. It was time. Jessie closed her eyes for several seconds and cleared her mind with a few deep breaths, until one word dominated her thoughts:
steady
. “Ready, Byron?” she asked, her eyes still closed.

“All set.”

“Holly?”

“Ready to go,” the tech at the outside console said through the speakers.

“Ted?”

“Viva Las Vegas,” the radiologist replied.

Jessie opened her eyes slowly.

“Suction up,” she said. “Scalpel, please.”

WORKING WITH PRACTICED quickness, Jessie made a question-mark incision just over Sara’s left ear, then worked the scalp away and began freeing up the temporalis muscle—the broad muscle that closes the jaw. All the while, she was concentrating on locating the upper branch of the facial nerve and the vessels arising off the temporal artery. Cutting through any of those structures would have permanent consequences.

“Nice job,” Emily whispered as she helped move the temporalis aside. “Real nice.”

Jessie called for the bone drill and made a series of large holes that she then connected with a smaller bit.

“Carpentry’s done,” she said as Emily wrapped the bony segment in wet gauze and passed it back to the scrub nurse. Jessie then ran her fingers over the thick membrane covering Sara’s brain. “The dura’s pretty badly scarred down,” she reported.

“You mean Gilbrided down,” Emily whispered.

“Shhhh,” Jessie said, her eyes smiling above her mask. “Let me be sure my microphone’s off before you say anything about our esteemed leader.”

With each progressive layer, the surgery became more demanding. Damaging the veins in the dura, some of which were bound in scar tissue from the two prior operations, could easily cause a stroke.

“When you’re hot, you’re hot,” Emily said, suturing back the membrane after a perfect dissection. “What do you think Paulette would say if she saw how her little girl spends her days?”

Jessie ran her fingertips over the folds of Sara’s cerebral cortex.

“We’re going to do a rapid imaging sequence with contrast,” she said. “Have the IV gadolinium ready.” She shut off her microphone. “My mother’s more interested in how I spend my
nights
. Or should I say how I
don’t
spend my nights. She thinks I never date.”

“I guess that means she’s not wrong
all
the time.”

“Hey, watch it. I date, and you know it.”

“Example?”

“That lawyer from Toronto. The one I met when I went to Cancun. I even flew up to Canada for a couple of weekends with him. Remember?”

“Jess, I hate to tell you this, but that was almost two years ago.

“I’ve been busy. Gadolinium in, please. Besides, all he talked about was how much opportunity there would be for me in Canada. When I suggested
he
might like Boston, I thought he was going to have a seizure. Look, look, there it is, Em. Great pictures, Ted. Perfect. Just think of all those chemists who called gadolinium a useless rare earth element. Surely someone should have known that a hundred years later we were going to invent magnetic resonance imaging and it would be the perfect contrast material. That just goes to show you—never discount anything. Byron, ten minutes and I’m going to want her to start waking up. Em, you get her goggles on while I expose this beast. Holly, how about something mellow—maybe that Irish harp CD. We’re going to get this sucker. We’re going to get every bit of it.”