by Jenni Ogden
The ritualized scrubbing of my arms and hands completed, I backed through the doors into the cool air of the theater, my fingers tingling and my senses savoring the sights, smells and sounds of an operation about to begin.
Gowned and gloved, I settled myself on the high stool at the head of the operating table. All I could see of the patient was a square on the left side of his shaven head. I made my first incision, slicing the blade cleanly along the blue line already drawn on his scalp by David, my neurosurgical registrar.
“Where’s our music?” I kept my eyes on the scalpel.
“What do you fancy? The patient gave me a CD of Joe Cocker’s to play.” The anesthetist chuckled. “Probably too raw for your taste. Do you want some jazz?”
I hesitated for a second. “It would be bad karma not to play Alfie’s choice. He’s the important one here, and if he likes Joe Cocker, Joe Cocker is who we’ll have. Put him on.”
The anesthetist flicked the play button on the CD player remote and the singer’s gritty voice echoed around the theater. I blinked as an image of Alfie's face imprinted itself on the drapes surrounding the bloodstained operating site. As his face vanished I puffed out a quiet sigh. I didn’t need reminding that this healthy young man was putting a lot on the line. I almost wished I hadn’t met his anxious wife and two seriously cute kids yesterday.
I wriggled my backside. A sharp splinter was trying to separate the ball in my hip from its socket. I eased my buttock off the stool and gingerly put it back down again. Ignore it. Glancing up, I grinned behind my mask at the house officer’s steamed-up glasses. Tension and excitement oozed out of him. Observing an aneurysm clipping for the first time was a big deal.
“Carl, come closer. You’ll never see anything from there. This should be a smooth operation—our patient’s young, he’s got a nice clean, healthy brain, and clipping off those two unruptured aneurysms will prevent them from bursting in the future.”
Carl peered over my shoulder. “How long will he take to recover from the operation?”
“He might have a few days of headache and he won’t be able drive a car for six months because of the craniotomy, but other than that he should be right as rain in a few weeks with no more worry about those two little time bombs lurking in his head.”
I held my hand out for the drill, then the saw, and within thirty minutes I’d fashioned a window in Alfie's skull and cut through the membranes enclosing the soft brain, peeling them back to reveal the fat, pink coils. I gently inserted retractors into a deep fissure, pulling apart the temporal and frontal lobes.
Time disappeared, the sounds of the respirator and the clicks of the anesthesia equipment enclosing me in a familiar bubble. Maneuvering the operating microscope into place, I commenced the delicate work of exposing the middle cerebral artery, cautiously dissecting my way along it to the point where the rogue aneurysm, still intact, ballooned off its surface. David stood at my side, cauterizing bleeding points as small vessels were cut.
Joe Cocker was singing ‘Have A Little Faith In Me’ by the time the aneurysm was visible. Even magnified by the operating microscope it looked innocuous; a small protrusion pulsating quietly off the healthy-looking artery. The nurse placed the instrument holding the tiny spring-loaded titanium clip into my outstretched hand. The most delicate part of the procedure was positioning the clip across the aneurysm neck, taking care not to puncture the large artery in the process.
The neck was wide and in an awkward position and my first two attempts failed. Before trying again I withdrew the clip, sat back from the microscope, and flexed my hands and back. It wasn’t particularly unusual to have to make more than one attempt to place a clip securely, and I was prepared to take as long as needed to ensure that it was completely across the aneurysm neck before closing it. I returned my eyes to the microscope and had just begun to insert the clip once more into the deep hole when a jet of blood exploded from the brain, splashing my gown and rapidly turning my field of view red.
“Shit, it’s ruptured. Suction, hurry.” I dropped the instruments onto the trolley and, using my fingers, tried to feel my way to the source of the bleed. The brain was flooding with blood pumping out faster than David could suction it up and the theater nurse was pushing a second suction pump past my fingers into the blood-filled hole.
“I can’t see anything. Quick, another clip.” My pulse thundered in my head. Gluing my eyes to the microscope I held my hand out to the theater nurse, muttering for Carl’s sake that I’d have to put a temporary clip on the artery to stop the bleeding.
It was another ninety seconds before I succeeded and the pulsing blood finally ceased. The theater had become a bombsite. The anesthetist was fighting to keep Alfie stable and his blood was now spattered over David, the theater nurse, and me, across the concrete floor and onto my white gumboots. I desperately tried again to position a clip across the neck of the now flaccid aneurysm so that the temporary clip blocking off the artery could be safely removed. If it was blocked for more than a few minutes Alfie was in danger of a stroke to the left side of his brain—on top of the brain hemorrhage he shouldn’t have had.
“Five minutes,” said the anesthetist, his tone screaming that it was too long.
“I think it’s clipped off,” I mumbled, rapidly releasing the temporary clip. I watched the blood fill the large artery and flow past the secured neck of the aneurysm without leaking, and breathed again. And then Joe Cocker’s plaintive voice splintered my focus. Georgia, Georgia…
“Turn that off. I can’t stand that song.” My voice was too loud. I lowered it. “Let’s have some quiet so I can concentrate.”
Georgia on my mi… Then grim silence as we all worked to put Alfie back together again. Two hours later he was in Critical Care, intubated and ventilated and in a deep coma.
I changed out of my scrubs and took the lift to the ward to break the news to Alfie's wife. No one had yet told her there’d been any complications— that was my job. And it was never easy. Without a word being spoken, somehow families knew.
As I entered Alfie's small room, the tiny woman sitting on his neatly made bed took one look at me and dropped her head in her hands. “Oh no, please no,” she whispered. “Something’s gone wrong, hasn’t it?”
My hip screeching like a rat caught in a trap, I lowered myself onto the chair beside the bed. “Celia, I’m sorry. I’m afraid there were some problems. We’re going to have to take good care of Alfie for a while.” Celia’s face—so white that the freckles scattered across her upturned nose looked like spots of blood—filled my vision.
“But I thought it was a straightforward operation?” Celia whispered. “You said there was hardly any risk.”
“I know. But there’s always some risk and unfortunately we can never exclude all possibility of complications. The aneurysm was in an awkward position and before I was able to clip it off, it ruptured. I wasn’t even touching it at the time.” I looked past the fear in Celia’s eyes to the dark clouds that filled the window behind her. I swallowed and faced her again. “We’ll know more when we do a brain scan later today. But I’m afraid Alfie had a significant hemorrhage and he’s in a coma, probably because of that.”
“Isn’t a rupture what you were trying to prevent? He was so healthy and happy before you operated” —Celia’s voice broke— “and now he’s in a coma?” Her face crumpled, her eyes lost in tears.
I breathed in, breathed out, but Alfie's blood-smeared face stayed put in my brain. Leaning over I covered Celia’s hand—icy cold—with my own warm one. “I know it’s hard to take in. Alfie’s in Critical Care and everything possible is being done for him. We have to hold onto the hope that he’ll be OK; I just can’t tell you yet. Celia, I’m so very sorry.”
“Can I see him?” She sounded desperate, almost as if she thought she’d be kept from him.
“I’ll take you down now. So that he can be properly treated all his functions have been taken over, so he’s on a ventilator.”
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sp; Celia took in a shaky breath and tried to wipe away the tears that were streaming down her cheeks. I leaned over and pulled a handful of tissues from the box on the bedside table, closing Celia’s hand around them.
“Will he be in pain?” she hiccupped. Her silent plea that Alfie be spared that at least throbbed in the air between us and I swiveled my gaze to a picture of a vase of flowers on the wall, willing the prickle behind my eyes to disappear. Blinking hard, I forced my eyes back to Celia’s anguished face.
“No, he’s not conscious yet so he won’t feel any pain or discomfort. But I’m sure he’ll know you’re there.”
I took Celia to Critical Care and introduced her to Maddie, who, thank goodness, was the charge nurse on duty. She’d had more experience taking care of bewildered and distraught families than anyone else in the hospital. How she stayed so calm and warm and comforting day after tragic day was a bloody miracle.
By seven next morning I was back in the Critical Care Unit. I stood behind the glass in the dimly lit Nurses’ Station, my eyes on the patient tethered to the bed closest to the window—the bed reserved for the sickest of the sick. Caught in the glaring overhead light, Alfie's hair blazed red against the deathly white of his face, tubes invading and distorting his mouth and nose, gurgling and panting like live things as they snaked their way to the whirring machines. Celia was there beside him, tears coursing unheeded down her face, her love in every stroke of the brush as she pulled it repeatedly through the remains of Alfie’s wild hair.
Closing my eyes I saw again the pale scalp where the rest of his hair used to be; the raw, nearly circular wound, contained but not diminished by the neat row of stitches and now blessedly hidden from his wife’s eyes by a thick bandage. I shook my head to dispel the image and looked at Alfie's medical file open on the bench in front of me, seeing my own indecipherable scrawl relating the facts about the surgery, the bald facts about the ‘complications.’ The writing blurred and morphed before my tired eyes and my words seemed to read, ‘The worst that could happen, did.’
“It’s so sad. What will happen to him?” The nurse was whispering, the break in her voice revealing her youth, her inexperience.
I turned to answer and realized she wasn’t speaking to me, but to a junior doctor. Screwing up my eyes against a stabbing pain in my left temple, I tried to blot out the young doctor’s reply.
“It’s tough seeing families go through this. You never really get used to it. He might make it, but as what? The grim truth is he’ll be lucky if he dies.”
My stomach turned and like a coward I fled and made for the staff cafeteria. I needed my morning caffeine before talking to Celia. The cafe was almost empty and I sat alone at a corner table and gulped a mouthful of black coffee, wincing as it burnt my throat. The young doctor’s words echoed in my head. Lucky to die. Celia, your beautiful young husband will be lucky to die.
I rubbed my eyes but the image of Celia’s haunted expression stayed put. The poor woman would be clinging to a desperate belief that a miracle would happen and Alfie would wake up and smile at her. How could she begin to comprehend that her exuberant husband had been destroyed in a few disastrous minutes. That if he did survive he’d probably be paralyzed, unable to speak coherently, unable to understand, depressed, frustrated, with no idea who his children were or who she was, his spark extinguished forever.
“Georgia, are you OK?”
I started and looked up at David, standing on the other side of the table. The cafeteria was buzzing with activity, the sun was streaming through the long windows, and my coffee was cold. “I’ve felt better.” I glanced at my watch. “Holy cow, it’s almost eight. I must have dozed off.”
“It can happen to the best of us. It’s been a rough couple of days. I bet you’re not getting your eight hours sleep.” David was giving me a strange look.
“I can’t remember when I last had more than six hours in one stretch. Probably before I went to Med School.” I flexed my neck and shoulders. “I’ll finish this coffee and then we’d better get up to the ward for the morning round.”
“Yep, that’s why I came to find you. Do you want to check on Alfie Juvnik first?”
“No, we’ll do that later when we’ve seen our other patients. Right now, the very thought of Critical Care turns my stomach.”
“Perhaps a fresh coffee would help,” David said. “I’ll get you another. That cold one looks past its best.”
I focused on my other patients—the ones I could still do something for—while I waited for David to return. But his first words as he parked himself in the chair opposite plunged me back into gloom.
“Are you still beating yourself up over the aneurysm disaster?” David’s tone was sympathetic.
I felt the saliva thickening in my mouth and tried to swallow. “I feel terrible about it. I should have referred him to one of the other consultants.”
“Whatever for? They would have made the same decision and probably had the same outcome.”
“It’s not that. Do you know how his aneurysms were discovered?”
“I thought he was in some psychology experiment at the university—looking at language or something using functional MRI. The researchers found his two aneurysms when they did the imaging.”
“Adam was one of the researchers for that study.”
“Adam? Your Adam, you mean?”
“Of course that’s who I mean.” I glanced at David. “Sorry, I’m a bit uptight.”
“No worries. Poor Adam. I bet he’s a bit shattered. It’s going to happen though, with all these experimental imaging studies being done these days.”
“He is upset, but luckily he wasn’t the researcher running the study on the day Alfie was being tested, so it was his colleague who had to explain to Alfie that the radiologist needed to talk to him about his scan.”
David frowned. “I can see that the connection with Adam’s research would have been a bit of a shock, but it’s hardly a reason for you to have referred Alfie on.”
A spear of pain shot behind my eyes and I screwed them shut and kneaded my forehead. The pain abated and I cracked open my eyes and took a few mouthfuls of the coffee David shoved towards me. His long face was looking even more worried than usual.
Perhaps if I talk about it, it will stop haunting me. I picked up my coffee and put it down again. “The connection with Adam wasn’t the only thing. Alfie reminded me of an old boyfriend of mine. Same eyes, hair, build. Even his voice and the cool way he reacted when I explained the risks of the surgery reminded me of Danny.”
“I know that feeling. When I was on my last rotation, a woman who was a dead ringer for my mum was admitted with a meningioma. Luckily I was not the surgeon and was only assisting, because I had a hard enough time prepping her and shaving her head. When she was back on the ward, every time we did a ward round I half expected her to tell me off about my dirty shoes.”
I forced a smile.
“But I thought by the time I reached your age I’d have gotten over all that,” David went on.
“Thanks. I hadn’t realized 44 was that old.”
“You know what I mean. You’ve had years of experience. You must see patients who remind you of people you know quite often. Obviously you can’t refuse to operate every time that happens.”
“It was more the outcome I suppose. If the operation had been successful, I probably wouldn’t have given Alfie’s likeness to Danny another thought.”
“The poor fellow was simply horribly unlucky. He was the perfect candidate for an aneurysm clipping. If you ask me, he made the right decision. If I’d been Alfie, I’d have opted for the surgery too. He probably didn’t want to spend the rest of his life wondering if one of his aneurysms was going to explode at any minute and kill him.”
My mobile beeped and I pulled it from my pocket.
“Dr. Grayson. Not good news I’m afraid. Alfie Juvnik had another massive hemorrhage, presumably from that second unclipped aneurysm. We had no hope of saving him.�
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I closed my eyes, Alfie’s face filling my head. I sighed. “I didn’t think he’d make it. What a dreadful outcome. Makes me think again about clipping unruptured aneurysms in healthy young people. Does his wife know?”
“Yes. She’s in the family room. She was with him when he died, poor woman.”
“I’ll come now.”
Celia stumbled to her feet when she saw me. We stood silent, our eyes locked. I couldn’t begin to imagine what she was feeling. Then I collected myself and managed to produce some inadequate words. “I’m so sorry, Celia. I’d give anything to be able to go back and advise Alfie not to have that operation.”
“I can’t believe I’ll never see him again. I can’t.”
The raw grief etched on Celia’s face was too much, and I looked away.
“I’m sorry. I can’t think straight.” Celia’s voice faltered and she pressed her lips together and stared blindly past my shoulder. She swayed and I reached out and steadied her, helping her into a chair. After a long few minutes she spoke again, her voice a river of tears. “I wanted to see you to thank you for doing what you thought would be best for Alfie.”
“Celia, thank you. That’s very generous.” I sat on the chair beside her, my arms aching to hold her but knowing I couldn’t.
“I don’t blame you for what happened. Alfie made his own decision to have the operation. We knew the risks and we decided to go ahead. It’s no one’s fault that we lost him.” Then her face seemed to dissolve and she covered it with shaking hands. “What are we going to do without him? How can I tell the children?”
