Lie Still (14 page)

The tech said, “Look, Doc, if this is going to take too long, I got a list of patients waiting. . . .”

The girl was on the edge of a coma. I gave him a look intended to say “Shut up and stay put,” but I said, “I’m almost through. And I think Darla probably needs your services about as badly as anybody right now.” I was suppressing several good curses. I got an otoscope from the wall and shone the light into her eyes. Both pupils reacted and they were still the same size, but she barely flinched from the light. “Better get her to CT kind of
stat,
” I said to the tech.

He knew the usual translation of “stat” and got her stretcher going out the door.

When they were on their way I introduced myself quickly to Mom, a rotund woman in bold-patterned clothes, and told her about Dr. Lyle, the attending professor. When I got to the part about we were doing everything possible, she cut me short.

“I know all about this shit. Her older brother like to be the LIE STILL

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death of me. He had bad concussions twice. He done all right though. I mean, he’s back to his normal self and all, not that that’s
all right
.”

Then I made a mistake: an invitation to full disclosure.

I said, “Well, this seems to be worse. We certainly hope that a concussion is all this is, nothing really serious.” I should have nodded and smiled and gotten back to Darla and the CT.

“What you say?” she said. “You mean she’s maybe worse? She had some kind of stroke or blood clot or something?” She was beginning to steam. “She gonna be okay?”

Sometimes, when asked to predict the future, I am tempted toward overwhelming frankness; something like, “I have no idea: We haven’t done the CT yet, brain injuries are less predictable than sunspots, and I’m only a general surgery resident whose concept of the brain is that it’s Jell-O

that bleeds.” Urges like that tell me I’m way too tired.

The party line is, thankfully, available to suppress trouble: “I’m sure she’s going to be back to her normal self soon. She’s going to get every possible thing done for her to make her her normal self again.” I was backing away down the hall. “I’ll come talk to you just as soon as the X-rays are done.”

As I got to the CT control booth the first cut was just being constructed on the screen. That many years ago, it took the computer half a minute to construct each cut.

The pictures start at the bottom of the brain and work up.

The first slices show the brain stem, and then only poorly because of all the surrounding bone at the base of the skull.

Everything looked normal as far as the tech, the ER nurse, and I could tell. Each successive image was equally boring, or reassuring, and I was beginning to think about dinner when the tech muttered, “Uh-oh.”

“What?” I said. “Uh-oh what-oh?” He drew his pencil tip around the inner edge of the skull and I saw the Uh-oh, a lens-shaped rim of matter pushing on the brain—blood.

“Subdural?” I asked.

He paused. The techs are not supposed to read the scans, 100

DAVID FARRIS

but this was probably fairly basic. “Probably epidural,” he allowed. “Got a little shift, too.” The next cut had just popped up, and the midline structures of the brain were clearly being pushed to the side. The tech reached for his phone. I knew he was calling the radiologist even before the scan was completed. I ran out to the ER to find another phone and called Mimi.

That’s when things got unusual.

Mimi told me to “consent” the kid for a crani; she would head right over to the OR and we would be pushing the gurney ourselves if we needed to to get this case started within thirteen minutes. I started to ask if there was some data that supported thirteen minutes versus fifteen or twenty but she had hung up.

“Consenting,” the verb, means getting the standard written consent form signed. I found a form, stamped the top with Darla’s plastic ID card, and found Mom. “Mrs. Winthrop, Darla’s going to need emergency surgery to release—”

Her face screwed up in all three dimensions and she wailed, “Nooo.”

“I’m sorry to have to tell you so bluntly, ma’am, but there’s an expanding blood clot on the outside of the brain and it’s pushing her brain pretty hard right now. That’s why she’s not herself. What we—Dr. Lyle, primarily—

will do is take off a piece of the skull”—I was making a circle with my finger around the top right side of my own skull—“remove the clot, ligate any bleeding sources, and then put it all back together.” I was well aware that some of that deserved more explanation, but I could not take the time. An autocratic approach was completely appropriate in the circumstances.

She wailed again.

“I’m really sorry, ma’am, I’m sure she’s going to be just fine, but the sooner we get this started, the better her chances are.” One of the transparent lies of medicine: She’s going to be fine, but I’m worried about her “chances.” “I need you to sign this consent for surgery, ma’am. It says that Dr. Miriam Lyle and her associates are authorized by you to perform a LIE STILL

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craniotomy, the operation I described, on your daughter, Darla.”

“Ain’t signing.”

I almost fell over. “What?”

“Ain’t signing it. Least not till I met this Dr. Lyle of yours and hear it from her.”

“But Mrs. Winthrop, this is really an emergency. One of the rare cases where minutes count.”

“I know you ain’t the real doctor. I wanna see the surgeon.

You go run and find her and get her butt down here.”

I went back to the central desk and started the phone calls.

Mimi was at the OR control desk, booking the case. “Mom won’t sign till she meets you. She’s up here in ER Eight.”

“Fine. Wheel the kid down. Now.”

“You coming up?”

“I will when I finish lighting a fire under some butts down here, but you should have that kid on the table, asleep, and shaving her head within six minutes. You better get her moving.”

“But the mom is right over her. And surgery without consent is assault and battery.”

“We have two licensed doctors agreeing it is an emergency. We’ll write the chart entry after the clot is out.

Hell, we could get half the medical staff to sign for an epidural.” That was true enough. “And if Mom wants to sue my ass, I’d rather have her daughter standing behind her whining for a new toy than lying beside her drooling.”

Braced for battle, I went back to the bedside. Darla’s mom was stone-faced. She was not happy to see me again.

“Ma’am, I need to ask you again to please sign the consent. I’ve spoken with Dr. Lyle. She’s right now at the control desk of the OR getting everything arranged to do emergency surgery on Darla. It is imperative that this operation begin as soon as possible, and I mean in a matter of minutes.” She just twitched her mouth up around her nose but didn’t look at me. “Ma’am . . .”

“Five minutes gonna make a big damn difference?”

I hesitated. “Yes.”

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“Let me see the goddamn paper.”

I handed it to the woman and immediately kicked up the foot release on the girl’s gurney, freeing it to roll. As Mom was reading the consent I began to maneuver it toward the door. She got the message. “Gimme a pen.”

As I pushed the stretcher through the double doors to the OR suite, I could hear Mimi Lyle’s distinctly elevated voice at the control desk: “. . .
now!
We’ll do it without anesthesia! She’s in a fucking coma, for God’s sake!” She saw me with the patient. To me: “Wheel her on into Six.” I paused. I wasn’t in scrubs, had no hair cover, no mask.

“Get her into the room, then go change.” I moved out.

Mimi to the nurse: “Just send in one of the float nurses and a basic neuro set. But it has to be now. This is a Level One center, is it not? We do deal with life and death emergencies!” She stormed toward the women’s locker room. I was glad to be able to do as I was told and not have to fabricate out of the ether an employable body or a sterile instrument set that didn’t exist.

Nakedness would feel more normal in an OR than street clothes. I reasoned backwards from Mimi’s instructions, though, that sometimes minutes are more important than sterile technique. I backed into OR 6 with the unconscious girl, wheeled her stretcher around 180 degrees, and immediately had the most palpable sensation I had ever had of being alone. Only half the room lights were on. In the middle of the room was the narrow operating table with an intensely white sheet freshly tucked in at the corners. Someone had left one of the surgical spotlights on full power. It was pointed at the head of the table. No one else was anywhere in sight. It was churchlike. I shuddered.

All I could do was push the stretcher sideways up against the table in anticipation of moving the unconscious child over to it if ever help arrived.

My moment of silence was thankfully short-lived. The door from the OR core banged open loudly, and two men issued forth with oaths and a tray of instruments the size of a LIE STILL

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suitcase, wrapped like a cynical Christmas gift in dimpled aquamarine sheets of some paperlike material not found in nature and held together with tape the color of baby poop. I realized why I had brought the patient into the room wearing my street clothes, even though there was nothing to do on arrival: OR staff will do just about anything for a patient-in-need in one of their own rooms.

These angels in my time of need were normally the heathens of bone surgery: One nurse and one scrub tech, both ex-military, who spent most days helping in the major or-thopedic cases because these employed the biggest and coolest power tools. I was quietly thrilled to see them.

“Fucking gotta-go-now,” muttered Ansel, the tech.

Robert, the nurse, looked up at me standing there like a guppy, my mouth opening and closing, apparently in search of oxygen. “We don’t have anesthesia,” he said. “Anesthesia” in this case referred to the person, not the state of in-sensitivity. “They’re all tied up. Ellerby is first to finish but Ganiats is taking fucking forever to finish that knee. It’ll be a half hour easy.”

Ansel said, “Hey, maybe she’ll have you do the anesthesia.”

“Me?” I said.

“Well, I meant Robert, but you’d be okay too. Hell, you’ve probably at least intubated before.”

I had, at the time, intubated precisely three tracheas.

Though the procedure didn’t scare me to death, airway management was always of paramount importance and a child in a coma was not the person on whom I wanted to be expanding my role. I shuddered again. “Let’s get her moved over,”

I said.

I knew at least how to get the basic monitors attached. Her EKG looked normal but slow, and her blood pressure was high.

I looked at the OR crew. They looked at me. I shook my head. The door burst open again: Mimi in scrubs, hands and arms dripping water. Right behind her was Dr. Ellerby, one of the anesthesiologists, huffing and puffing. “Go get changed,” she ordered me with a nod.

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I heard Robert say, “Hey, good to see you, Doc.” I knew he was talking to the anesthesiologist.

By the time I got back from changing clothes and a ten-minute hand scrub compressed to two, the child was intubated and on a ventilator. Dr. Ellerby was putting in an arterial line, and Mimi was drilling in the skull, having just peeled back the skin and clipped off the bleeders. By the time I gowned and gloved, Mimi had sawed out the bone flap. She handed it to me: a concave saucer of skull with irregular edges. I gingerly passed it to Ansel. After it was safely in a tray on the back table, I asked him, “What happens if one of us drops it on the floor?”

“You mean after Dr. Lyle gets through kicking your dead and lifeless body off of a very tall building?” he said.

“Assuming it was my fault,” I said.

“Oh, it would be your fault,” he said, laughing.

The resident is always wrong. “Okay, after my dead and lifeless body hits the concrete.”

“Funny you should ask,” Robert said. “What did we do, Dr. Lyle, when that bone flap hit the floor a few years ago?”

I felt a bit sick.

She hesitated. “We called the Tissue Bank.”

Another pause. Mimi was washing clot off the dura, the lining of the brain, and buzzing little bleeding points with the cautery.

“And . . . ,” Ansel said. He was clearly enjoying this.

“They advised resterilizing the bone in the steam autoclave.”

“Wouldn’t that kill it?” I blurted out.

“Already dead,” Robert answered. He had heard all this before. “Loses its blood supply when it’s cut out of the head.”

Mimi said, “You’re right, Robert.” She didn’t look up.

“So, Dr. Ishmail, why do we return dead bone to the skull at the end of these procedures?”

If the answer to one of these questions is obvious, it’s either wrong or prologue to the next, harder question. You’re obligated to answer anyway. “To protect the brain,” I said in the pious tone I had learned in fourth-grade Catechism.

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“Ultimately, yes, but what becomes of the flap? I mean, why go to the trouble of resterilizing a bone flap that’s been on the floor when we could protect the brain with a helmet?”

I was thinking. She answered for me. “Growth matrix.

The dead bone provides the matrix for the osteocytes to move in and reestablish themselves and re-create living bone.”

“Same as it does in ortho when we use chips from Bone Bank,” Robert said.

By now Mimi was standing with her arms folded and staring at the wound to see if any of the tiny vessels was still daring enough, under her gaze, to bleed. Satisfied that all was dry, she guided me through putting it all back together.

As I was sewing skin, Mimi broke scrub to dictate the Op Report. Darla’s pulse picked up as Dr. Ellerby lightened the anesthetic.

Within two minutes of getting her to the Recovery Room she was crying for her mom, moving everything appropriately and nodding to questions.

I found Mrs. Winthrop in the waiting area. I smiled.

“She’s doing very, very well,” I said. She was biting her index finger. I knew she didn’t know what to believe. “She’s still waking up from the anesthesia,” I said, “but already she’s moving her arms and legs, she answers simple questions, and she’s been asking for you.”