Trauma (4 page)

Back at the sink, Carrie followed the proper protocol for the anatomical scrub, and had Margaret help her get gowned and gloved again. Precious minutes lost.

The scrub nurse, Sam Talbot, had done a fine job making sure the operating room was clean and ready for surgery. He had prepared the instruments and equipment and was double-checking his work when Carrie reentered the OR. Carrie was glad Talbot was on the ball so she could concentrate her efforts on Leon.

Leon was on the operating room table, already anesthetized and intubated. Dr. Lucas Fellows monitored vital signs and adjusted the combination of agents used to keep Leon in a state of blissful unconsciousness.

With Margaret's help, Carrie positioned Leon on his back, elevated the head, and turned him toward his left side. Carrie prepped Leon's shaved skull using antiseptic Betadine that turned his dark skin orange. As Carrie finished with her final swab, the OR door swung open and Dr. Metcalf bounded in, fully scrubbed. Margaret, caught by surprise, shrank a little in his presence. A bear of a man with a full beard, broad shoulders, and a barrel chest, Dr. Metcalf struck an imposing figure in the operating room—or anyplace, for that matter. He held up his arms for Margaret to get him gowned and gloved.

“Sorry for the late arrival,” Dr. Metcalf said in his deep, rich baritone. “There was a rollover on I-95 and traffic was backed up for miles. I thought we might have to reschedule, but a friendly cop gave me an escort down the breakdown lane. I can't count the number of angry looks I got.”

Dr. Metcalf chuckled and Carrie felt at ease. He seemed to have already observed all of the hard work that had gone into surgical preparation and deemed it fit. He approached Leon and looked over his mask at Carrie, who was standing on the other side of the operating room table.

Dr. Metcalf's brown eyes narrowed. “Goodness, you look terrible, Carrie,” he said. “Are you feeling all right?”

Carrie nodded. “Tough operation last night, that's all,” she said. “I'm fine.”

The persistent throbbing behind Carrie's temple suggested otherwise, but she knew her limits. She could handle one more case.

A few more hours … you can do it.

Dr. Metcalf scanned the OR and chuckled again. “Forgot I'm not at White Memorial for a second there. I was looking for the NeuroStation.”

Carrie smiled behind her mask. A NeuroStation was a state-of-the-art workstation for localizing brain tumors using a frameless stereotactic system that gave surgeons an unprecedented view into the operative field while relaying the location of instruments to the preoperative imaging data. It cost hundreds of thousands of dollars—well over a million when factoring in all the ancillary equipment. The fancy folks over at White Memorial could afford such luxuries, but BCH didn't have enough funding for such an extravagant expense.

“No worries,” Dr. Metcalf said. “I remember when we used to do these operations without a Midas Rex drill. Hell, the drill and bit set we used during
my
residency looked like something you'd pick up at Sears.”

Everyone laughed politely.

“All right, Dr. Bryant,” he said. “We'll be finished here in no time.”

 

CHAPTER 4

Dr. Metcalf had made the semicircular incision in the temporal-parietal craniotomy site. He was so skilled, had so many years of training, he probably could have done the procedure blindfolded. Nothing was remarkable about his deft handling, except that Carrie could not recall him doing it. It had happened, of course. The skin flap was there, and Dr. Metcalf was busy setting the Raney clips in place, but somehow Carrie had no memory of him actually making the cut. It was like highway hypnosis, only in the OR.

Carrie's body burned with exhaustion that did not justify her lack of concentration. She had pulled plenty of long shifts without her performance suffering. Then again, she'd never been primary surgeon on an operation with serious complications.

Beneath her mask, Carrie gritted her teeth against an onslaught of memories—the blood that kept seeping, the blackened subdermal patches of clotted blood. Beth's operation was hours in the past. She needed to stop it from affecting her performance here and now. Adding to her burden, Carrie's back throbbed from fatigue. Her calf muscles were bowstring tight, and every two seconds she had to fight the urge to rub at her bleary eyes.

Carrie wondered if she'd ever be able to emulate Dr. Metcalf's level of discipline and focus. How did he never seem to tire, no matter how difficult the operation? One thing Carrie knew for certain: She would need his Zen-like mastery of that particular skill to achieve all her professional goals.

“How about some Gelfoam here,” Dr. Metcalf said.

The command snapped Carrie out of her daze. She went to work on the incision area, using Avitene on a pledget and Gelfoam to stanch the bleeding.

“Drill.”

Sam Talbot placed the stainless steel handle of the Midas Rex pneumatic drill in Dr. Metcalf's outstretched hand. The specialized air drill was designed to stop drilling as soon as the skull was penetrated, preventing injury to the brain. With enviable control and precision, Dr. Metcalf whistled a low and indistinct tune as he created the burr holes, each perfectly placed, one behind the standard key point, others located posteriorly in the temporal bone.

“Vitals?” Dr. Metcalf asked.

The anesthesiologist checked his monitors. “All fine,” Dr. Fellows said.

Dr. Metcalf switched to the footplate attachment and started at the temporal burr hole, cutting in a curvilinear fashion, until this region of bone could be removed. Carrie helped by stanching the annoying small bleeders that cropped up on occasion. Everything appeared to be going exactly as planned. Because Leon's tumor was situated deep within the brain, and not a part of the meninges, the dura would have to be excised, which Dr. Metcalf did with great care.

Soon it was time to locate the actual source of Leon's troubles. In the absence of the NeuroStation, Dr. Metcalf relied on the MRI film Carrie had put up on the viewbox to show him where to insert the needle probes. The needles were not really necessary, and Carrie knew Dr. Metcalf was using them for teaching purposes.

Carrie had done this procedure many times herself, but always under careful supervision. Because Dr. Metcalf could not see the tumor, he used the probes to feel for subtle texture changes indicative of touching a growth. For guidance, he occasionally glanced at the MRI while advancing the needle. Carrie knew from her read of the film that the tumor site was approximately 3.5 centimeters deep within the temporal lobe, and Dr. Metcalf was probing in that exact spot.

Carrie watched him work, admiring his steady hand, calm concentration, when Beth again entered her thoughts. Seeing someone so close to her in age suffer like that was a stark reminder of her own good fortune. It was shameful that it took an incident in the OR to make her appreciate her many blessings: her career in medicine, the mentors like Dr. Metcalf who had helped bring her to this point, her family—and even Ian, for ending the relationship and giving her a chance to learn more about herself.

Dr. Metcalf advanced the probe a bit further, then paused. Lifting his head, he gave Carrie a curious stare—not a disapproving look, but something in his eyes looked nonplussed. He maneuvered the probe some more, but this time without a second glance at Carrie. The bleeders were typical for the surgery. No alarms for the patient's vitals, either.

It must have been nothing, because Metcalf removed the probes and was getting the bipolar coagulator and aspirator ready to go. It was time to get Leon's tumor out, or as much of it as they could.

Dr. Metcalf adjusted the frequency on the bipolar coagulator, an instrument with two electrical poles used to cauterize and remove tissue. The tissue here was soft and would require a lower frequency than something more fibrous. The disposable forceps with two small electrodes decreased risk of thrombosis formation, caused minimal tissue damage without suturing, and were effective at hemorrhage prevention.

Dr. Metcalf carefully advanced the bipolar coagulator through the inferior temporal gyros, using a surgical aspirator, more crudely known as a “sucker,” to remove blood and fluids while taking away as little good brain tissue as possible.

Should be at the tumor site any second now,
Carrie thought.

The sounds of machinery thrummed in Carrie's ears as her anticipation grew. As Dr. Metcalf shifted his attention from Leon to the MRI image, a shadow crossed his face, and his furrowed brow put Carrie on edge. Focused again on the work site, Dr. Metcalf advanced the coagulator perhaps a centimeter more, then stopped. Carrie tried to read his expression. He was obviously anxious. Could it be another complication? Goodness, she had no stamina to endure another surgical mishap.

Dr. Metcalf adjusted a power setting on the frequency generator. A second later, the persistent hum of the bipolar coagulator came to an abrupt stop. The absence of sound filled the room.

Dr. Metcalf looked up and his eyes narrowed in a way that made Carrie shrink inside. “Carrie, I can't find any abnormal tissue here, and I'm at the tumor site.”

A chill raced up Carrie's spine.

No … no … everything is fine … it's not panic time
 …
not yet …

“Let's take a closer look at the MRI,” Dr. Metcalf suggested.

Carrie followed Dr. Metcalf over to the viewbox and saw up close what she had observed from a distance. The mass was easy to spot in the medial temporal lobe. It was obvious Dr. Metcalf was seeing the same thing.

“What's going on here?” he asked, mostly to himself. “Jesus, could this be the wrong patient?”

Carrie and Dr. Metcalf simultaneously looked down at the name on the film. As soon as Carrie saw the lettering, a jolt of horror ripped through her body and her breathing stopped. The name was correct, but the letters were reversed!

Oh, God,
Carrie thought.
Oh my God, no. Please no!

Grim-faced now, Dr. Metcalf let his arms fall limply to his side as he fixated on the text, disbelieving.

“Carrie, do you see this? The film was put up backward.”

Carrie staggered on her feet as the room began to spin. She had reversed the film. Following a backwards image, Carrie had set the patient up for an operation on the wrong side of his brain.

She flashed on her brief meeting with Leon, and it hit her. Not only did he have a droopy face, his reflexes were heightened in the right arm and leg, indicative of a left-side problem. But more telling was his speech. He had trouble saying simple words and had not been able to follow one of her commands; those were left-sided problems. If she had remembered, Carrie would have seen her mistake and clipped the image up properly.

This can't be happening … this cannot be happening.…

The shattered look in Dr. Metcalf's eyes cleaved Carrie's heart.

Leon, who already had damage to the left temporal lobe because of the mass, would now have additional damage to the right side of the brain where Dr. Metcalf had probed and removed completely viable brain tissue. It was all her fault.

Dr. Metcalf glowered at the new circulating nurse, Margaret, with venom in his eyes.

“What happened here? What the hell happened here? Don't you know how to read?” Dr. Metcalf's wrathful voice sent Margaret scurrying to a corner.

Dr. Fellows and Sam Talbot stared at each other in disbelief. Carrie took in a shaky breath, but could barely get a sip of air into her lungs. Her face felt flushed, burning hot, and soon the rest of her skin prickled with sweat as a sick feeling washed over her from head to toe. She opened her mouth to speak but at first no sound came out. Courage finally came to her.

“I put the MRI on the viewbox, not Margaret,” Carrie said. “It was my error.”

With that, she lowered her head and began a solemn march to the exit door.

 

CHAPTER 5

By the time Steve Abington made his decision, the April sun had hit its midpoint for the day. Steve had hated Philadelphia since arriving there almost a year ago. It wasn't really any worse than Bridgeport, or Manhattan, or East Brunswick, or any of the other cities through which he'd passed. Maybe it was the homeless shelters in Philly that had gotten to him, or maybe it was just life itself.

Still, the Philadelphia shelters were an abomination. Steve hated being jammed inside an airless room with a hundred other misbegotten men. The stale stench of cigarette smoke escaping from the ratty fabric of soiled clothes. Rows of metallic bunk beds like those on a submarine topped with thin mattresses squirming with vermin, sometimes even live mice. Corroded showerheads on tiled walls caked with mold revolted him.

It was chaos, a constant chatter that grated on Steve's eardrums so he couldn't ever relax. Not for a second. Of course a shelter does not pretend to be a Holiday Inn, but with the reception area located behind reinforced glass, it felt like a country jail segregating the inmates from the cons. The drunks were the worst. Screaming, belligerent, and always getting hurt—either tripping over nothing or cracking their skulls on the concrete floor after tumbling out of bed. There was food, at least, breakfast and dinner. But tuna fish sandwiches most every day could make a man want to give up eating.

Steve preferred the streets.

Or he did until he was robbed.

They came at him in the middle of the night, four teenagers, while he slept on a heat vent, wrapped inside a threadbare blue blanket he'd fished out of a trash can. They came with pipes, steel rods, and a bat. They smashed the side of his face pretty good and throttled his leg, but the blows were meant to intimidate, not kill. They made off with his life savings—a few hundred dollars he had scraped together from change tossed in his jar and the occasional crinkled bill. The next morning the bruise on his cheek still stung, his leg felt a bit lame, and the vision in his eye where one of them managed to land a solid right hook was blurry. Could have been worse; he had shocked them when he fought back. Some skills get drilled into you so hard they become reflex.