Cookie's Case

MYSTERIOUSPRESS.COM

There are always people who will take advantage of others. Unfortunately, their victims are usually predisposed to becoming … well, victims.

In my line of work, the story invariably opens with an unfortunate event. And often ends with the injured party receiving monetary compensation for pain and suffering. There can, however, be other sorts of outcomes. This is one of those.

The Unfortunate Event

“S
calpel.”

“Scalpel,” repeats the nurse. She delivers the instrument with just the right authority.

The neurosurgeon slits his patient's throat in one fluid motion. The incision is quick, decisive, and skillful. A seeping red river fills the canal.

“Give me some suction here.”

“Suction,” repeats the nurse. She vacuums the blood. Unexpectedly, Dr. McElroy breaks into song. “Stairway to Heaven.”

The nurse looks at him, taken aback. His a cappella is as good as his surgical technique, but she disapproves of the buds in his ears.

“Doctor,” she asks, “do you really think you should be listening to Led Zeppelin while performing surgery between the jugular and the base of this young woman's brain?”

Ignoring her, the surgeon proceeds to carry out the necessary dissection through the various layers of soft tissue that will take him where he needs to be. He uses his arrival at a deep ligament as a natural breaking point where he can respond.

“Nurse, tell me your name again.”

“Molina.”

“Nurse Molina,” he says, as blood collects, “a study almost published in the
New England Journal of Medicine
presented correlations indicating that certain harmonies in this song were shown to elevate serotonin levels. Serotonin plays an important role as a neurotransmitter for the regulation of mood—and it relaxes me. Of course, skeptical peer reviewers claimed the study was based on unreplicable methodology. There's always a divide among the members of the medical community, isn't there?” Then he adds, “You were off on your landmarks, by the way. I'm nowhere near the base of this girl's brain, anatomically speaking, that is. Now give me more suction.”

“Suction,” she repeats, clearly annoyed.

McElroy resumes the song but is finished with the scalpel. With a long reach in front of Molina, he returns the blood-tinged instrument to the surgical tray. It would be possible to perceive this bypassing of Molina, the surgical nurse, as a snub. He breaks off his singing.

“Retractors here … here … here … and here.” He points to four spots along the edges of the incision.

“Retractors,” repeats Nurse Molina, applying them, two on each side. She's unhappy about their exchange—and about the snub—but understands a good working relationship in the OR takes time to develop. Nonetheless, she regards this young doctor as a cowboy, given his decision to perform spine surgery through the front of the neck.

“Give me a little more exposure with those retractors, Nurse.” Pause. “That's better. Now more suction.”

“Suction.”

“Give me a fifteen blade.”

“Fifteen blade,” she repeats. She hands it to him.

McElroy inserts the blade, crooning, “
Oooooh
…” transitioning from the song's mellow front end into its up-tempo crescendo in perfect pitch.

“Pay attention!” bursts out Nurse Molina. She can't help herself. “To what you're doing,” she finishes, in a more collected tone. “I think you nicked her.”

“Thank you, Nurse.”

“No, I mean I think you accidentally cut through the lining of her spinal cord, the dura into the arachnoid.”

“Thank you for defining the medical terms, Nurse.”

Frustrated, she tries again. “Doctor, I mean lower on her neck. Near the fourth cervical vertebrae, away from where you're operating up at C2.” Molina points to the lower aspect of the exposed surgical field. “Over here.”

“Thank you, Nurse,” McElroy responds in a firm tone. He is dismissing her.

Molina takes two determined steps, nudging Reggie, the physician's assistant, who is keeping mum, out of the way. She moves closer to McElroy, invading his space. This is a clear violation of the unwritten rules and regulations of operating room decorum. He stops and withdraws. She looks deep into the neck cavern where glistening white vertebral bones are visible. Molina points and counts, “C2, C3,” as she moves down the stack. “Right here, Doctor, at C4, there's a fluid leak. That shouldn't be.”

She points to a clear liquid slowly leaking out of a thin layer of tissue, one microdrop at a time. Drip … drip … drip.

“See it?” She gestures emphatically. “You somehow punctured those layers, into the subarachnoid space, and now she has a cerebral spinal fluid leak. You better take care of that right now.” Her tone is insistent.

“How about I'll be the doctor and you be the nurse?”

“Dr. McElroy,” she says, angered, “if you don't stop that leak this very instant, she'll lose too much fluid, and then we'll have a real problem on our hands.”

Staying focused, he responds, “Nurse, I may be new to this hospital, but I've had enough of you. Leave the OR this minute. You're distracting me.”

At this she turns, adamant. “I won't leave until I know that hole is sealed, the fluid bathing her brain has stopped leaking, and she's out of harm's way.” The OR team—Reggie, the two circulating nurses, the anesthesiologist, and the anesthesiology resident—all freeze, waiting for his response.

Dr. McElroy raises his head, and now he and his antagonist share their first sustained eye contact since the initial incision. Reciprocal glares result.

“Leave this instant!” he commands. “I said you're distracting me!” Molina, still angrily staring at him, pulls off her rubber gloves, which creates violent snapping sounds.

“I'll leave all right,” she retorts. “I don't want to be a part of this. Your patient can sustain irreversible brain damage or die on the table if she loses too much fluid. I've been the senior neurosurgical scrub nurse here for eleven years, and I know such leaks can be disastrous if not addressed promptly. And there're post-operative complications associated with continued spinal fluid leakage, as well. You're setting her up for a spinal tap if that fluid collects and compresses her nerve structures.”

“Thank you, Nurse. Good-bye. Reggie, step in here.”

He watches as she stomps out, slamming through the OR doors, which fly back, though designed not to. He reorients himself to his patient. “Now where was I? Oh, yes.” He delivers the song's famous last line—a bit out of tune.

Drip … drip … drip.

SELF-LIMITING

Two well-manicured but sausage-fingered hands are holding a piece of paper. It is a surgical report.

REPORT OF OPERATION

PATIENT NAME: CLAUDETTE KRUMKE

MEDICAL RECORD NUMBER: 06041933

DATE OF OPERATION:

SURGEON: DR. JAMES McELROY

ASSISTANT SURGEON: REGGIE HARRIS, PA

PREOPERATIVE DIAGNOSIS: NERVE COMPRESSION IN THE NECK AT C2

SECONDARY TO TRAUMA

POSTOPERATIVE DIAGNOSIS: SAME

ANESTHESIA: GENERAL

OPERATION PERFORMED: ANTERIOR CERVICAL DISCECTOMY AND FUSION

COMPLICATIONS: NONE

INDICATIONS: This is a 25-year-old female with no prior surgical history who has developed progressive, severe, intractable neck pain with radiation and associated symptoms of numbness and weakness to her hands after a job-related injury. After thorough discussion with the patient about her condition—findings; indications; benefits, risks, and alternatives to surgery—she requested to proceed. Complications include, but are not limited to, loss of voice, swallowing difficulties, quadriplegia, and death. No complications occurred during surgery.

The hospital risk manager looks up from his reading of McElroy's operative report and rests it on his desk. He skims through page two, which contains the significant body of the report. Dr. McElroy and Nurse Molina are sitting next to each other across from him. Up to this point, neither has acknowledged the other. The body language of each clearly indicates mutual contempt.

“I've read enough,” says the risk manager. “Nurse Molina, it makes no mention of a complication of a tear or laceration or hole into the subarachnoid space at the C4 level with a resultant cerebral spinal fluid leak.”

“Well, I was there, and I know what I saw. You should make him,” she nods in McElroy's direction, “redictate that report. Or include an addendum. If this patient develops future complications, no one would ever know to consider that leak if not given reason to. That's one of the principle purposes of an operative report.” Her tone is determined. “To state what went on during surgery, allowing a subsequent treating doctor to act accordingly in the event something comes of it. It's part of the written rules and regulations of this institution, and is in the best interests of the patient.”

“I have to agree with you there, Nurse,” replies the risk manager. “Well, what do you have to say about this, Dr. McElroy?”

“There was a small leak at the C4 level,” he responds calmly. “I'm not really sure how it occurred. I could've stitched it closed or sealed it with heat or applied some bonding agent to it. But I felt, given such an insignificant hole, I'd be making things worse by intervening, so I monitored it during the entire operation. As I proceeded, the leaking slowed and, within an hour, it stopped. It was self-limiting, as I expected. No harm, no foul, end of story. Had Nurse Molina been able to conduct herself appropriately, she would've witnessed the reparation marvels of the human body. It's been two days and Miss Krumke, my patient, has not had one post-op complication or complaint. When I discharge her later today, it will be a thing of the past. Why dwell on it?”

Their listener looks at the two of them. “As risk manager here,” he says judiciously, “I find your explanation is reasonable. Although I ask that you amend your operative report, Dr. McElroy, so that it reflects the date of the procedure in the heading. I see it's dated underneath your signature, but it's hospital policy to have the date of surgery in the heading. Is that satisfactory to you, Nurse Molina?”

Her face is red with fury. “That's ridiculous. We haven't heard the last from this patient. At the very least, a post-op MRI should be performed.” She stands up. “
Pendejos
,” she mutters under her breath, then turns before leaving to make a final statement. “That's not managing risk, that's creating it.”

Chapter One

M
ajor watches Cookie prepare. She's getting out her bag, the one in which she packs her special outfits before heading to the club. Tonight, she's planning to appear onstage garbed as a saucy police officer. It's intended as a tribute to the men in blue.

The whip she'll be cracking is her extra touch. It goes in first.

To every costume she wears, Cookie adds an offbeat accessory—for the surprise value. It's her trademark. Machine gun–toting nurse, ax-wielding librarian, banana-eating buccaneer; she likes to keep her fans guessing.

However, she's retired the banana, ever since what became known as “The Fall.” Just about all the guys who frequent Manhattan's gentlemen's clubs know and love Cookie. They're aware of what went down one night as she was exiting the stage. What went down was Cookie.

Now checking that her Sergeant Sexy name tag is securely attached to her dark blue shirt, Cookie smoothes out a wrinkle with her hand, then neatly folds and tucks the authentic NYPD uniform into her bag. She'd received it, tag included, as a gift from a loyal customer, a veteran cop. She'd had it altered to suit her professional needs so she could tear it off mid-dance without missing a step.

“Watch out!” Major yells from the living room. Cookie has been kneeling and now starts to rise.
Bang!
Too late. Her head contraption has struck the side of the closet's doorframe, rendering her a tad unsteady.

“Whoops!” she says, laughing it off as she extends her arms with the grace of a ballerina to recapture her balance. Taking two shaky steps forward, she puts her bag down at the front door. Then, gingerly, she turns and walks back toward the living room, one careful step at a time.

Major takes note of her gait pattern.

Entering, she carefully maneuvers herself down onto the couch. He watches as she takes a few deep breaths to collect herself.

“Whew,” she says and smiles at him. What he's doing is studying her. Suddenly her smile begins to fade. Major can tell it's time. She's displaying her distinctive grimace, the one she tries to suppress as long as possible. It's not just
any
frown but rather a look that sends a critical message.

For his part, he'd never ask. This Major has his own MO. His way is to play things out until the last moment. Nonetheless, thoughts of his reward start infiltrating his mind—and his loins. Although he won't initiate what's about to happen, dropping a subtle hint is completely acceptable when it comes to Major's little game of needing her to need him. He's become expert at finding clever ways to spark the cycle of mutual reciprocation.

Cookie, on the other hand, has issues asking any person to do anything. Girls from Sheepshead Bay are raised to be self-reliant. It's a Brooklyn thing. The fact that she actively resists dependence makes their relationship all the more difficult for outsiders to understand. And that's over and above the age difference of forty-two years and their unmatched levels of attractiveness.

Major is a gray-haired, well-groomed, retired doctor. He's the type who belongs in Boca, practicing putting. You might trust him instinctively, but you'd never look at him twice. Cookie, on the other hand, is a tall, slender, extremely pretty exotic dancer. A hot cookie indeed, she's also as sincere and genuine as they come, entirely confounding the stereotype of her chosen profession. Major could easily be mistaken for her father or grandfather.

“Are you sure you should be dancing tonight?” he worries aloud. “You know what your doctor said.”

“What does she know?” Cookie snaps back in a rare moment of exasperation. “I wouldn't be wearing this thing around my head if these doctors really knew anything. What am I going to do? Hurt myself?” She giggles, then gives him one of her rare, utterly serious looks. He understands she's only venting. He's aware few others could handle such a situation with so much courage, grace, and reserve. It's been three long, hard years of pain and suffering since the surgery that changed her life.

“I've had three neck procedures,” she points out, although it's hardly news to him. “So what's a little dancing going to do to me? Besides, it's been seven weeks since the last one, and I'm just itching to get back in there. I can't sit around here anymore.” It was as close to a complaint as she'd ever express. “You know I don't like to disappoint my regulars. My dancing's like going to therapy for them, and they depend on my advice. I've saved twenty-three marriages,” she proudly states. “And counting. Besides, I don't want Ruby trying to snap up my guys for the wrong reason, making them feel special just to pinch their hard-earned cash.”

“I'm simply questioning whether it's a good idea, Cookie. You know you have a tendency to overdo it. And it's not as if you need the money.” Instantly, he realized his mistake. But it was too late.

“I appreciate all the wonderful things you've surrounded me with for the last three years.” Cookie's tone manages to be both earnest and severe. “But I told you before I moved in with you that I'm always going to want to feel independent and productive. Dancing for my clients satisfies my needs, and theirs.”

Her sincerity is evident, and so is her resolve. Then a cloud passes over her face.

Continuing to watch her closely, he understands that the pressure is building. He knows the signs. Her composure, therefore, is remarkable.

“I'm sorry,” he says. “You know I'm supportive of everything you do. It's only that I don't want to see you compromise your recovery by going back to work too soon. It's unfortunate but true that too much activity can cause headaches in your condition.”

There it is. The hint has been dropped—at just the perfect moment. Major waits. Then Cookie crumbles. She looks at him in a summoning way, a needing way. It's the most she'll allow herself when it comes to requesting anything from anyone else. Major responds now, in accordance with their routine.

“Come on, Cookie, it's time for tap.”

“Yes … I think it is.”

She shimmies her bottom to the edge of the couch and gets up slowly. As she walks into the kitchen, she pretends she's on a balance beam, placing one foot in front of the other, heel to toe, with arms spread wide. Going over to her junk drawer, she takes out a pair of Ray-Bans—the classic gold-tone aviators. She holds them up to the light for inspection. Bright light magnifies the intensity of the pounding in her head. The medical term for this sensitivity is photophobia.

She buffs the lenses, then slides on the sunglasses. Although they hide her dark chocolate eyes, the shades bring her other features into relief. The high cheekbones with dimples underneath, the regal nose and pointed chin, the latter with a cleft so deep you could do a shot of vodka out of it.

But, in fact, she's wearing the Ray-Bans for Major's benefit. Cookie knows he loves the way she looks in them—topless, that is. He'd told her this once on a trip to Santorini, before her condition made travel ill-advised.

Now she's heading toward the dining room, falling off her pretend beam three times as she does so. The medical term is disequilibrium. Once she's reached the heavy wooden table, she readies herself for the procedure. As she begins to unbutton her shirt, she's a little clumsy. The pressure inside her head is compromising her fine motor skills, and she knows it.

Her breasts, once she's removed the shirt, jut out from the openings in the custom-fitted plastic medical vest she has to wear. It serves as an anchor for the contraption affixed to her head. She stops for a moment, then pulls out one of the hand-carved high-backed chairs and turns it around. Sitting down backward on the red velvet cushion, she straddles it with her long, shapely legs. Then she leans forward and hugs the back of the chair.

“All set!” she calls out. At this point, anguish can be heard in her voice. Her statement of readiness more resembles a plea for help. She's in pain, real pain. Once the pressure inside her skull begins, it will soon turn overwhelming. Without immediate medical attention, inevitably it will result in a seizure that will send her into a coma. Within a matter of minutes, she'll die from brain stem compression, brain herniation, or both.

Major has played the role of spectator up to this point, watching from his Eames lounge chair like a pervert at a peep show of the surgically disabled. And who could blame him? She's beautiful, even in all her pain. He stands and, in his movements, reveals himself as old.

Once upright, though, his pace quickens. He's heading for the surgical pouch kept on the kitchen's center island. As he reaches it, Cookie says, “Oh, I forgot.”

Major looks over.

She sits up and takes a red hair scrunchie off of her wrist. She reaches behind her head and, despite the obstacle presented by the bars of the obtrusive metal device, executes a ponytail. Then she reassumes the position, with her lower back angled at forty-five degrees so Major won't have to bend too much.

He walks over carrying the already prepared pouch and places it on the table. Once it's opened, he returns to the kitchen where, at the sink, he carefully performs a hand scrub. After rinsing, he uses the inside of his left elbow to push the hot water control into the off position, all the while keeping his hands face up to ensure their continued sterility. He'd changed the faucet himself, for just this purpose. Major does all the maintenance in his luxury apartment, with its spectacular East River views, himself. He's very private.

Peering inside the pouch, he looks up and says, “More gauze is needed.” Cookie winces. She knows the journey to get it from the other room will take approximately thirty seconds for the round trip.

“Um, just use a paper towel if you need to. The pressure is getting bad. Hurry, please.” Her resistance to making any complaints is breaking down.

“Will do,” he responds. He moves behind her using the upper aspect of her sacrum as his anatomical landmark. Counting the notches between her individual vertebrae he makes his way up. “L5, L4, L3 … perfect. Right here.”

“Hurry. Please,” she says again.

“Soon, my dear, soon.” Major hadn't needed to identify his entry point, knowing it to be the intervertebral space just above a birthmark shaped like the isle of Ios. But he counts each time anyway, as a matter of medical procedure and precaution.

Now wearing disposable latex gloves, he first wipes her back with an antiseptic pad, then puts iodine onto the last piece of gauze, making sure not to spill any on the antique Persian rug.

“Hurry!” she reiterates.

From the pouch, he now removes a small plastic syringe. It's for the local anesthetic. He addresses her lower back at the predetermined mark. “A little sting,” he says, just as he always does.

“Sting, sting … sting, sting,” she responds. His jabs are fast and skillful, but it helps Cookie to comment like this. It is, after all, happening to her.

Next he prepares a different sort of syringe—a bigger, metal one. It has a built-in spinal-fluid pressure gauge and a glass collection tube running through its center. A large spinal needle is attached to one end, with three circular finger rings on the other. Clearly, it's designed for the withdrawal of fluid. He sterilizes the needle, at last ready to get down to business.

“Just a pinch,” he tells her. “That's all.” Nonetheless, Cookie squeezes the back of the chair. She's well aware what's next.

Major inserts the hollowed needle point into her spine, where it meets with resistance. “Slow, slow, slow,” Cookie says as he pushes forward steadily.

“Easy, Cookie. Easy, girl,” he soothes her. He applies a little more force. Suddenly, the resistance lets up.

“We're in.” Cookie sighs with relief. Major looks at the gauge. “Hmm, I've never seen your fluid pressure so high. And you weren't due for a tap today—that's why you chose tonight to go to the club in the first place. You just can't accurately predict this, as we've learned.”

He now inserts his three middle fingers through the rings, curling them, then slowly pulls on the plunger, filling the barrel of the collecting tube with Cookie's cerebral spinal fluid.

“Yeah, that's it, baby,” she says, exhaling. “I can feel the relief already. Keep going.
That's it.
That's how I like it.”

Major smiles. He relishes the foreplay surrounding the tap, even as he's aware of its peculiarity. “We're done. And your fluid's nice and clear. Hold still now.” He withdraws the spinal needle and immediately applies direct pressure over the access site with the iodine-soaked gauze.

After a minute more of compression, he inspects the area. “You're good to go.”

“Hey, I feel great! Ready to dance, dance, dance. Gee, I hope this thing on my head doesn't get in the way too much.” She rolls her eyes drolly at the thought. “I need a tall glass of cranberry and Red Bull. The usual.” He follows her into their kitchen, where he puts away his medical supplies. Peeling off the gloves, he discards them along with the rest of the medical refuse into a special container. Major then puts away his treasured spinal syringe, knowing it'll be needed again.

“Go sit in your chair,” she instructs him. “I'll tend to you in a minute.”

Obeying her command, he stares at Cookie, thinking how sexy she looks. He whispers under his breath, “She's mine, all mine.”

Then he waits.

Cookie finishes her drink and heads over. Major feels his excitement build as she approaches. Stopping in front of him, she places the tip of her finger on her bottom lip, then slowly inserts it into her mouth, giving it a sensual suck.

He sighs in pleasure.

“You like that, you dirty old man?” she teases. Then she asks, “Are you a good doctor or an evil doctor?” Her naughty-girl voice is adorable.

“I'm a good doctor
and
an evil doctor.”