by Barbara Ebel
“Well, I’d be territorial, too. He’s responsible for the success of his practice, so he better know who he’s handing the plate to.”
Danny nodded, leaned over, and stirred the fire with a wrought iron poker.
“It’s not a well-kept secret that he makes over a million a year. He said he’d start me at one-fifty the first year, but raise me to two-fifty the second year if things work out.”
The two men let this thought settle. “Which brings me to what I wanted to discuss with you,” Greg said. “You know I received a few million selling the two restaurants. I’m having my estate plans changed. You and Sara are going to be fine, financially, with you going into practice.”
“I agree, Dad, no worries there.”
“I want you two to enjoy yourselves, not worry about the girl’s later on or their college education. You two live on, and plan your future, based on your neurosurgery income. I’m having a trust drawn up with everything going to the girls, payable to them equally, in installments, when they turn eighteen.”
Danny pondered this. “Dad, that would be fine. Wonderful, I mean. It’s generous of you. Sara and I won’t need the inheritance. You already gave us this house.”
“Another thing. Instead of bothering you or your sister with the trust paperwork, I’m appointing the bank as the executor. Is that okay with you?”
“That’s fine,” Danny said. “Can I ask you about Mary, though?”
“I’ll leave your sister my house. She can come back from Sitka to live here in Nashville if she wants. Or sell it. Someday maybe she’ll get tired of selling winter artwork and giving fishing boat tours in the summer.”
“I don’t know about that, Dad.” Danny laughed. “She’s the environmentalist.”
Greg took a sip of wine. “But this is all premature anyway, because I’m going to see my grandchildren become young ladies. They’re going to fish with me when I’m ninety.”
“You’ll teach those girls to come home with full stringers,” Sara said, walking in. She gave Danny a kiss, picked up her pillow present and hugged it to her chest. After dessert, Greg, Casey and Carolyn said good-night and Melissa poked through her new treasures under the tree.
In the confusion of gifts, Danny picked up a bag and walked upstairs to the master bedroom. He pulled out the unwrapped leather burgundy case he had bought for himself, monogrammed with his initials DT. Sara had also liked it. On the edge of their bed, he felt the soft leather. Precisely the right size. He leaned forward, opened his bottom drawer, and rummaged in the back. He pulled out a plastic bag. So much for a safe deposit box. It was more fun having his Einstein book at the house.
Danny thought back to the day his mother told him about the historical hoopla. He’d been sixteen when Donna had shown him the Time magazine in l979 with Einstein’s picture splashed on the cover, the hundred-year anniversary of his birth. Although Einstein had been dead twenty-four years, his image and accomplishments kept getting larger, an icon growing like the importance of his formulas.
Danny fished into the plastic baggie, pulled out the book, and stared at the great genius’ signature. He inserted the publication into the new leather case, slid the cover under the leather strap, and stuck it back under his clothes. The old treasure holder, the plastic bag, spun as Danny dropped it into the garbage can in the bathroom.
Chapter 5
Dr. Bruce Garner concurred with Danny. They stood in front of angiography studies … MRI and CT results. Bruce pointed to the angiography, tracing the external carotid artery feeders to the meningioma. Nice to get a second opinion, Danny thought. He turned to Karen, one of their office nurses, and asked her to send Susan Kempler to his office, where he would inform his patient of her diagnosis, treatment, and probable outcome.
Danny had assimilated well with The Neurosurgery Group of Middle Tennessee. With only one other junior colleague, Dr. Harold Jackowitz, Bruce maintained control of a successful, reputable practice and worked as hard as his younger employees. Danny thought of him as a presidential figure. He had Danny’s build, but he dominated their specialty with his authoritative manner, intelligence, and refined manual skills. His thick, graying hair and twinkling, narrow slotted eyes made him stand out in a crowd.
“I’m going over to the hospital to flip-flop lumbar discectomy cases with Harold for the afternoon,” Bruce said. “Just see my two remaining office patients after you talk to Mrs. Kempler about her needed surgery.” Bruce took off his long white coat and folded it over his arm. He tilted his head to adjust for his lower bifocal. “Try and get a spot on the schedule for her for next Tuesday. Then you and I can share backs after your craniotomy and Harold can mind the office.”
“All right,” Danny said. “I’ll ask if Tuesday works for her.”
Danny walked into his office, acknowledging the waiting couple. Mrs. Kempler’s husband placed his hand on his wife’s forearm. At forty-six years old, Susan Kempler had been healthy, a workout fanatic, so she couldn’t understand why she had developed seizures. While waiting for the referral to see Danny, the neurologist had prescribed antiepileptic drugs, but the medications had been unsatisfactory in controlling the frequency or severity of her episodes.
Danny hated telling people grim diagnoses, but this one, compared to many, gave Mrs. Kempler a promising recourse. However, Danny sometimes noticed that patients did not grasp what the diagnosis of their particular tumor, aneurysm or metastasis meant. They focused too much on the fact that they needed surgery inside their head, and sometimes, that could be the easy part. If they had a severely malignant tumor or a mass growing in a precarious region of the brain, it could affect their eyesight, their balance, or their cognition. Their intracranial pressure could go too high. Those were the things to really worry about.
“Mrs. Kempler,” Danny began, “all your studies are back and I can safely assure you we’ve found the culprit responsible for your recent symptoms.”
Danny paused as the couple became more attentive. Mr. Kempler focused on his wife as she clasped her hands on her lap.
“You have a meningioma. Most times, they are slow growing and benign.” Danny spoke softly as Mrs. Kempler’s facial muscles slightly relaxed.
“What exactly is that?” she asked.
“First, I’ll tell you what it isn’t. It’s not a metastasis. Something that could have spread from somewhere else in your body.” Mr. and Mrs. Kempler nodded their heads. “It is the most common primary intracranial tumor. In your case, it’s between the brain and the skull.”
Mr. Kempler leaned forward. “So it’s not in Susan’s brain tissue?”
“Of the three membranes of the brain, there is an intimate layer on the surface, dipping in and out of its grooves, or fissures. Its two components are the pia and arachnoid. Sometimes there’s a large space between them which contains CSF, a protective cushion. Susan’s tumor originates from arachnoid cells.”
“What are my treatment options?” Susan asked.
“Dr. Garner and I agree that surgical removal is the treatment of choice. Radiation therapy is considered ineffective and we would not suggest letting this go.”
“If it’s benign, like you think, then why not?” Mr. Kempler asked.
“If it keeps growing, Susan’s seizures won’t be the only symptoms. More will follow. But of more importance, at present, is that we detect some cerebral edema on the CT. Susan should have the surgery.”
“Cerebral edema?”
“In simple terms, Mr. Kempler, consider the brain inside a closed, inelastic skull. There are three things in there. Blood, CSF and brain. Each takes up a certain volume. If there is an increase in volume of one of these, in this case, a growing brain tumor, it must be offset by a decrease in another. If not, the pressure inside the skull will rise. We treat high intracranial pressure; even have methods to monitor it. High and uncontrolled intracranial pressure can be fatal.”
“If I have surgery,” Susan asked, “what is my prognosis?” She stopped fidgetin
g and held her husband’s hand.
“Outcome is good. Five-year survival for meningiomas is ninety percent. Preventing a recurrence mostly depends on how successful we are in removing the entire tumor.”
“What would you do?” she asked.
Sunlight filtered through the blinds in Danny’s office. A glare reflected off the glass-framed print above the couch.
“Have the surgery,” Danny said without hesitation.
Mrs. Kempler glanced at her husband, whose empathy showed in his moist eyes. He remained silent. It was his wife’s decision.
“Okay, as soon as you can fit me in.”
Danny nodded. When the couple left, he stopped to contemplate his Norman Rockwell Grandpa and Boy Fishing print above the couch.
________
Dr. Simon, the anesthesiologist, busily adjusted Susan Kempler’s IV access and the radial arterial line he had inserted for continuous blood pressure monitoring. Now he could easily take blood samples out of the radial line, to send for evaluation of the patient’s blood gases, to adequately hyperventilate the patient to a pCO2 between 30-35 mm Hg. Blowing off CO2 would cause vasoconstriction, decreasing cerebral blood flow, which would decrease intracranial pressure or ICP. Danny glanced his way, knowing anesthesiologists dealt specifically with neuroanesthesia. Dr. Simon also hung mannitol and piggybacked it into the patient’s IV. A diuretic, it would draw fluid out of the brain, also a measure to decrease ICP.
Danny fixed Mrs. Kempler’s head position. He penetrated the scalp and outer table of the skull with pins and grimaced under his mask with the effort. He planned on macro work for the meningioma, which meant he’d be standing for the case, and hoped its removal would be complete and wouldn’t take all morning. He had not gotten a full night’s sleep because Melissa had a cold. Sara and Danny had woken up with her intermittent coughing throughout the night.
Eileen, the scrub nurse, wheeled the instrument table closer. She had everything aligned precisely the way she wanted it. “How are your girls, Dr. Tilson?” she asked.
“Melissa has a cough, but she’ll be fine.” He pinched the drape around the suction tip, then clipped it together with a hemostat. “The second one is a tomboy. Annabel sulks every time she looks in the mirror at her crooked tooth.”
“She may not be a frilly little girl,” Eileen said, “but she must already understand that a girl’s smile is one of her assets.”
“Must be,” Danny said. “And my wife says that our three year old, Nancy, is growing like suburban Nashville, but she doesn’t like her ears. She thinks they’re too big.”
Dr. Simon looked over from writing on the anesthesia record. “Braces for the crooked tooth and a hairstyle to cover the ears will fix that.”
“Then it’ll be something else,” Eileen said. “Boys are easier.”
“I wouldn’t trade them, though,” Danny said while Eileen passed him the drill. Eileen was a full RN. Danny had found out that one of the scrub nurses wasn’t a nurse but an unlicensed technician, or surgical scrub tech. Due to an increasing nursing shortage and high health care costs, hospitals could have an RN supervise several ORs, but have unlicensed techs fill the scrub and circulator roles. Danny preferred, and had requested, only registered nurses to assist him.
OR banter diminished as Danny’s work became more involved. The morning disappeared as Danny removed the brain tumor and excised some dural attachment and abnormal bone. Luckily, there was no involvement of a sinus and Danny believed his removal of the meningioma was complete. He started his closure when another nurse gave Eileen a short break, then Eileen came back to resume her duties.
In sterile fashion, the relief nurse helped Eileen gown and glove on her return. “Dr. Tilson,” Eileen said, “Casey, the paramedic from the ER, is waiting for you in the doctor’s lounge. He told me to tell you that your wife brought your daughter in to the ER because of her cough, but she’s better now.”
Danny’s heart thumped. Sara wouldn’t have just brought Melissa to the ER if it weren’t serious. “The ER? What else did Casey say?”
“That’s all. He said he would wait for you.”
The circulator refrained from turning on a CD at the end of the case. Danny remained quiet, focusing on closing, but thinking about Melissa, who was so thoughtful of others, like a miniature of his wife. And yet, perhaps he’d missed something. Melissa always seemed paler and more out of breath than Annabel and Nancy when they ran in the yard.
Danny removed the drapes and left the OR. He walked into the doctor’s lounge where Bruce Garner and Casey hovered around the hospital’s complimentary lunch spread.
“Melissa’s been seen,” Casey said, as Danny approached him. “They’re just waiting on paperwork and a prescription in the ER.”
“What happened?” Danny asked, tugging his dangling OR mask off.
“Sara said Melissa’s cough kept getting worse. Then she had difficulty breathing.”
“I’ll get the backs started,” Bruce said. “Link up with me when you get back from the ER. Is Mrs. Kempler off the table yet?”
“No,” Danny said.
“You can tell me about your resection later. I’ll check with anesthesia before I start the back. Go see about your daughter.”
“Thanks, Bruce.” Danny removed his shoe covers and grabbed his white coat from the locker room. He and Casey ran down the staircase to the ER.
The ER had the usual semi-emergent day crowd without any hectic trauma cases or acute heart patients. As soon as Danny and Casey stopped at the desk, the ER doctor came around and escorted them into Melissa’s room. “Danny, your daughter came in with bronchial asthma. A respiratory tract infection probably triggered it.” Danny hung on the physician’s every word. “She responded to a bronchodilator.”
“No shot of epi?” Danny asked.
“No,” he said. “And she was thrilled about that.”
Sara sat stroking Nancy’s hair as her daughter leaned across her lap. Melissa smiled at them as they walked in, opening her arms from her perch on the exam table. A deer stared out from Melissa’s favorite T-shirt. Danny felt his daughter’s opal bracelet at the back of his neck while he squeezed her.
“Are you okay, sweetheart?” Danny asked, and kissed the top of Melissa’s head. “I bet you scared your mom. We’ll get you better.”
“I’m okay. Did you fix somebody this morning?”
“Yes, I did, sweetheart. But right now I’m worried about you.”
Melissa lightly shoved her father to look at him. “It’s okay, Daddy. It was just a little cough.”
“She can go home,” the ER doctor said. “We’ll give her an inhaler. But, Sara, make an appointment with the pediatrician. Your daughter will need to take maintenance medications.”
“I will,” she said, “and thank you.”
“Daddy,” Annabel asked. “Mommy said she’ll buy us an ice cream going home. Can you come with us?”
Danny crouched to her eye level. “No. But why don’t we all go fishing this weekend?”
At that, Annabel wrapped her fingers around Nancy’s hands and shook them up and down. “Yes-s,” she exclaimed, then felt her crooked tooth with her tongue. Danny glanced at the Life is Good baseball cap she wore and couldn’t help grinning at her as he straightened up.
________
Sara pondered over the 2003 calendar on the kitchen counter. Although it was the beginning of October, she already had scribbled things to do in the little squares for November and December. School functions, a 5K charity run, piano lessons for Melissa, soccer practice for Annabel and Nancy, doctor’s appointments. The pediatrician had just prescribed a preventative daily pill for Melissa’s asthma, and he had also announced the disappearance of Annabel’s lingering summer bout with poison ivy.
“Come on girls, everyone will be waiting on us.” Sara yelled up the stairs, swaying her arm although no one could see her. It took her by surprise when all three girls sprang down the steps, in reverse chronologic age. Perhaps t
here wouldn’t be any eight, ten and twelve year old sibling rivalry today. She picked up a corduroy jacket that matched her skirt and draped it on her arm. She tightened her sandals; until her toes got cold, she refused to put real shoes on. Until then, the only shoes that deserved tying were her running sneakers.
“Is daddy going to be there yet?” Annabel asked. She plucked a light hooded jacket from the closet, but skipped a cap, knowing Danny and her grandfather frowned on wearing hats inside restaurants.
“He’s on the last back of the morning,” Sara said. Every other weekend Bruce, Harold and Danny ran a Saturday morning elective surgery schedule for cases that couldn’t be fit in during the week and had piled up. “We’ll see him there. Casey is meeting us, too.”
Sara relished the occasional Saturday or Sunday lunch gatherings at Downtown Italy, especially since she wouldn’t cook the rest of the day. As the three girls and Sara opened the restaurant door, Angelo put the finishing touch to their table, a vase of carnations and a pitcher of cold water. “Ciao bella,” he said to Nancy, pulling out the chair for her. “Buongiorno,” he said to Melissa and Annabel. “Your Grandpapa is not here yet.”
A few customers came in, and Casey followed. He hastened his step, a full smile crossing his face. “I’m having lunch with the prettiest women I’ve eaten with all week. Is this the right table?”
“Here,” Nancy responded, and pointed to the chair next to her. She giggled, wishing she was older than eight, and felt her hair to make sure it draped over her ears.
“Danny’s on his way. Let’s order,” Sara said. She let the girl’s select their lunch and asked Angelo for a small salad and lasagna.
“Any dates this weekend?” Sara asked Casey.
“Last night, an attorney from Bowling Green. And I have the whole weekend off.” Casey extended his arms and rolled up his shirtsleeves. “I’m playing poker tonight with the guys.”
“Daddy’s here,” Melissa said.
