by Barbara Ebel
“Angelo,” Sara added, “please put it in the center of the table and bring us some small plates.”
“Excellente,” Angelo said, flipping his notepad closed.
Melissa cupped her hand over her mouth, coughing, then drew in air like yanking at a tug of war. She twisted her hands and looked at her father with widening eyes. Wheezing replaced audible breathing, her chest muscles retracted through a teal pullover, and her respiration increased.
Annabel sat next to her. Hastily she shoved away from the table and disappeared towards the floor, rummaging through Melissa’s woven tote. “Do you have it?” she asked while Sara and Danny also rushed to Melissa’s side. Melissa could only nod. Annabel dumped the contents of the bag on the table, spotted the blue plastic inhaler, and shoved it into her sister’s hand.
________
Danny arrived at the Rehab Institute late in the afternoon after finishing his last surgery and post-op orders at three p.m. He never advertised it, but along with a neurologist, he volunteered occasional services to Fort Campbell, Kentucky’s soldiers, to evaluate them after they returned from Iraq and Afghanistan. Danny figured since he had never served in the military, it was the least he could do. The soldiers were surviving brain injuries better than men in previous conflicts because of improved body protection. Blasts from mines, grenades, and other explosives had become survivable, but caused common war disabilities when the women and men arrived back in the United States.
Danny first called Casey, knowing Casey had worked a graveyard shift and would be awake by then, chugging his black java, watching CNN headlines, or catching the bold headlines of the daily paper.
“They called me to see a soldier who returned from Rustamiyah. Eastern Baghdad,” Danny said. “He’s got memory loss and a host of other symptoms. A traumatic brain injury.”
“I bet the poor kid is half our age,” Casey replied.
“He is. I’m not sure if there’s anything surgical I can do for him. A rocket sailed through the building roof where his unit was.” Two occupational therapists passed Danny at the front desk of the therapy room, acknowledging him as they left for the day. “Casey, if you’re free, can you help Sara and Mary pack a car load at Dad’s before work?”
“Sure. I’m meeting Susan in a little while for dinner. I can get over there between dinner and work.”
“You still dating her?”
“A little bit. It’s not serious. Besides, she’s moving to Oregon for a new job.”
“Undoubtedly moving because you broke her heart.”
“Not a chance.”
Across the room, a soldier in a camouflaged combat uniform stood with a therapist near a corkboard plugged with red and blue pegs. “Say hi to the girls,” Danny said, as the young man picked a peg from a hole and placed it in a different row for a coordination test.
________
Casey left his jacket in his Jeep and rapped on Greg’s front door. He never owned a house key of theirs, like he carried for Danny and Sara’s place, so he restrained himself from trying the door. Especially since Mary lived there now.
The heavy front door opened. Mary’s face lit up as she tossed a handful of hair behind her shoulders. Casey’s words tumbled out, as if he couldn’t control them if he wanted. “You look great. Despite the smeared orange and rust paint on the side of your face.”
“Painting myself comes naturally.” She laughed, blushed, and turned around. Casey followed her, infatuated by her easy, but unconventional gait, and tried to pinpoint her aroma. Glorious geraniums.
Sara opened the cardboard box on the counter. “Plenty of pizza left,” she said.
“No thanks. I just ate with Susan. Plus, I’m working tonight, so I’m at your service for a limited time.”
“We’d like to bring over Dad’s rocking chair,” Mary said. “My mom had picked out the striped fabric to reupholster it when she was ill. It’s a family heirloom.”
Casey rolled up his shirtsleeves. “It’ll fit in my car. No problem.”
Melissa and Nancy came bounding down the stairs, each with a storage container of pictures to sort through at Wellington’s.
“My favorite screenagers,” Casey said.
“Thanks for coming to help,” Melissa said.
Greg sat inside on the couch. Annabel took his plate and the pizza crust he’d been flicking on his leg, and brought them to the kitchen. “Don’t take my radio,” he told her.
Casey leaned over, in front of him, to brush crumbs off his pants.
“Who are you?” Greg asked.
“I’m a friend,” Casey said.
________
The girls stayed with Greg while Casey, Sara, and Mary shuttled memorabilia and small furniture to Wellington’s. They walked to the left side of the two-story building; residents on the opposite end lived in assisted living. Casey paused in the front lobby to smirk at the plastic flowers in a ceramic vase.
Mary followed his gaze. “They’ll last longer if they’re artificial,” she said, then grinned.
Greg’s ground floor room at the end of the hallway had a large bathroom with handicap accommodations. Mary and Sara began hanging hooks and pictures. Sara put Greg and Donna’s wedding picture in the center of the empty wall.
“Dad always said ‘If your girlfriend prays with you, she’s worth keeping,’” Mary said.
Sara peeled her gaze off the photo and touched Mary. “He’s still with us, but I miss him already.”
Mary nodded. “Me too.”
Sara commenced rummaging inside a box for the birdfeeders they had bought. She slipped a suet bar into the wooden one, and stepped through the end hallway door to hang it outside Greg’s window.
When she walked back in, she quietly marveled at Casey and Mary. They were preparing Greg’s bed … spreading a soft white bedspread and putting his favorite patchwork quilt at the bottom. They fluffed sham pillows near the headboard. Sara had never seen Casey engaged in a family chore like this one, especially with her sister-in-law.
Chapter 8
Danny’s thirty-eight-year-old patient furrowed his forehead while being examined. “I’ve never had a headache before,” Mr. Donaldson said. “Now I’m walking around with one for two months. I can’t stand it.”
Dr. Singh, the neurologist, had started the man’s workup, but Dr. Singh would be away for two weeks and believed his patient had signs of increased intracranial pressure, so he had referred him to Danny.
Mr. Donaldson put on his blue shirt and began buttoning. He worked as an architect-engineer, sometimes at building sites in Tennessee, sometimes at a project outside Mexico City. He rubbed his stubbly beard and leaned back on the examining table. “Lately I’ve been getting nauseous. But the other day? I didn’t go to an important meeting because I thought I’d get sick.”
“We’ll try to get to the bottom of your symptoms,” Danny said. “Radiology sent me the CT and MRI that Dr. Singh ordered. We can discuss the results as soon as I have more information.” Danny checked boxes on his lab order sheet. “I’d like you to stop in our lab down the hallway to have your blood drawn.”
When Mr. Donaldson left, Danny flipped the man’s brain imaging results on the viewing box and saw a perplexing solitary, space-occupying lesion. He’d confer with Bruce as soon as his returned from a cruise with his wife, and when all results were back.
________
Melissa’s goal to pursue biology hadn’t budged. She seemed ahead of her high school senior classmates filling out college applications because she had narrowed her interest - all she had to do was look at schools with good biology departments and marine-related classes. Danny and Sara told her not to worry about a school’s tuition or financial aid forms. They encouraged her to continue getting high grades and promised to foot the entire four-year bill – whether she attended a college nearby or went away.
During the late winter, Melissa had spent a few weekends barricaded in her bedroom submitting on-line applications and further investigating
school possibilities on web sites. She conscientiously filled out forms, got letters of reference from previous teachers, wrote essays about jobs she’d had, and wrote the reasons why she wanted to attend a particular school. Despite sending out seven applications, she only had two serious choices – University of Alaska and Wake Forest in North Carolina.
Melissa and Sara had toured Wake Forest. North Carolina was as gorgeous as their native Tennessee, and the campus was as spectacular as an overgrown southern plantation with nice student housing. When they got home, Melissa told Danny how much fun she’d have taking a tropical marine ecology class off-site one summer in Jamaica. But Melissa still hadn’t gone to see the campus sites in Alaska.
“No problem,” Melissa said to her parents. “If Mary says the school in Alaska is impressive, then I believe her. Plus, they have a ton of marine ecology, mammalogy, and rainforest studies.” Now she waited tentatively for mail with return addresses from her college choices, worried if their contents contained a rejection.
Melissa doubled her steps up the back deck into the house, dropped her backpack, and slit open The University of Alaska Southeast’s envelope with the bold UAS letters. The day before, Wake Forest had accepted her. Sara put down the grocery list she had started and sat on the stool next to Melissa.
“Yesss,” Melissa exclaimed, and held onto the letter as if it were a treasury note. Sara got up and mother and daughter hugged.
“Mom, this is so exciting. My top choices. I’m in! I can’t wait to tell everybody.” But just as quickly, she aborted the enthusiastic gesturing.
“Oh,” she said.
“What?” Sara asked. Her daughter put the letter on the granite countertop.
“It never sunk in before, Mom. I wouldn’t get home as often if I went to Alaska and I wouldn’t see Pop in the nursing home like I do now.”
Sara patted her shoulder. “Sweetheart, that’s what happens when young people leave for college. It’s time for your most important educational years; it’s the beginning of your new life.”
“But Mom, Pop isn’t going to be around forever. If I go to school in North Carolina, I can see him at Wellington’s every time I have a long weekend or a break.”
“You think about this carefully. Your father and I won’t meddle.”
Sara embraced Melissa again and whispered in her ear. “You need to make your own decision.” She let go of her daughter and smiled. “I’m making a grocery list for your graduation party.”
“Thanks, Mom. Like you said, it’s a good idea to have it before graduation. All my friends will still be here, before they go away or start working summer jobs.”
Sara smiled. “You’re welcome. You’re going to have a super party.”
Melissa started to walk away, but drew in a breath and stopped. “Mom? My mind is made up. I’m going to accept Wake Forest. And we’re bringing Pop here the day of my graduation party.”
Melissa’s words froze Sara to the spot. Her daughter’s thoughtful choice stemmed from startling maturity. Even if she wanted to, Sara realized she couldn’t argue with her. Melissa now held her own reins. With a glow in her eyes, not to her complexion, Melissa turned on her heels and left, her decision solidly rooted in its place.
________
Danny stood in his office on Monday morning listening to Bruce bubbling over with details of his recent vacation. With a few minutes to spare before seeing patients, Danny donned his white coat, told Bruce about Mr. Donaldson’s medical and social history, and waved his colleague towards the imaging room.
“His lab results show a high sed rate and a seventeen-thousand white count,” Danny said, as he put the patient’s imaging results on the screen.
Bruce shot Danny a glance. “CSF has a similar density to this lesion. Did you get a differential on that high white count? Are his eosinophils high?”
Danny nodded his head. “Yes. He has eosinophilia.”
Bruce’s towering frame swung around to Danny. “I think you better get an infectious disease physician in on this case and schedule surgery.”
Danny felt Bruce’s excitement. Although every case was different, most of the time they were dealing with recurrent diagnoses. “Are you implying this is exotic?”
“You ever hear of echinococcosis?”
Danny had heard of it. “Oh my God. Hydatid disease? He has a highly lethal and an aggressive parasite? In his brain?”
Bruce nodded and when Danny shrugged his shoulders to acknowledge he couldn’t remember more facts offhand, Bruce continued. He pointed to the round lesion. “This hydatid cyst is probably caused by the more common species of Echinococcus granulosas. From the dog tapeworm.”
Danny squirmed. He remembered spitting this out on an exam.
“Dogs are the definitive host of the adult worm,” Bruce said. “The intermediate host of the larval stage is a human, sheep, or species that your soon-to-be infectious disease physician will enlighten you about.”
“This thing … in this man’s brain … has probably been growing for years, hasn’t it?”
“Precisely.” Bruce dabbed the cystic image. “And your job? This thing contains hundreds of thousands of parasitic particles. You have to surgically remove this cyst intact. If you rupture it, scoleces will contaminate your patient’s brain or cause a severe allergic reaction.”
Danny shuddered. This was going to be some surgery. He wondered if he would dare to make a bodily movement when he came upon the horror that was living inside Mr. Donaldson’s brain. Maybe he would forget to breathe.
________
By the end of the week, Danny conferred with an infectious disease specialist who further tested Mr. Donaldson and confirmed the diagnosis. “Humans are infected by tapeworm-infected dogs,” said the balding physician. He and Danny poured coffee in the doctor’s lounge. Danny grimaced, but Dr. Ngo continued. “Mr. Donaldson was infected either by direct contact or by eating food with viable parasitic eggs. The eggs hatch in human intestine, their embryos slither through the mucosa, and travel in the blood to other target organs.”
Dr. Ngo then told Danny he would start Mr. Donaldson on the medical drug of choice, albendazole, but concurred that the definitive treatment lay in the hands of a skilled neurosurgeon.
Danny and his office nurse made the necessary arrangements with the operating room for his patient’s craniotomy. He booked it as the first morning case, allowing ample time even though he had to-follow surgeries. He did not want to feel rushed because spillage of the cyst’s contents would be disastrous. Danny wasn’t sure if the case could be done as all macro work. He’d also set it up microscopically, in an electrically operated moving chair, to be safe.
As professional courtesy, Danny alerted the pathologist who would be working that day and stopped by the anesthesia office the day before to inquire, “Who’s doing my morning case tomorrow?”
The CRNA closest to the drug rep food spread pulled the next day’s schedule from her scrub pocket. “Dr. Ebel,” she said.
“Good. I’ll catch her before I leave and tell her what’s pertinent.” He tailed his words with his trademark chuckle. Barbara will love this one, he thought.
________
That evening, conversation centered on Melissa’s college choice; her enthusiasm still bubbled over. Danny had also given her full latitude with her selection. Both parents marveled at her for forsaking her first choice because of her attachment to her grandfather. They couldn’t be more proud of her.
Danny told his family about his craniotomy for the next day. As he explained the lifecycle of Echinococcus granulosas, Annabel twirled the enamel trout earrings dangling from her ear lobes, which had been pierced when she turned fifteen. “Dad,” Annabel said, flippantly, “like that’s more information than we need.”
“Okay, but I may have to tell you how this ends tomorrow night,” Danny said.
Annabel stopped fidgeting and finished her chicken before Melissa and Nancy, who still sat there dismayed that a worm thingamaji
g could end up in someone’s brain.
________
Danny spoke with Mr. Donaldson before Dr. Ebel slid in a radial arterial catheter for continuous blood pressure monitoring. As Danny parted the preop curtain, the Versed she had just injected into Mr. Donaldson’s IV caused his lids to slide down to half-mast. Thirty minutes later, after a bagel and his second cup of French roast, Danny stood in the operating room while his patient was put to sleep and intubated. They turned the table away from the anesthesia machine, the flurry of activity continued, and then Danny scrubbed outside the room. Bruce stopped by, promising to break later from floor rounds to peek in at Danny’s ongoing case.
Danny reentered the room. When the scrub nurse shook the sterile blue gown to unfold it, he slipped into it; and when she opened and parted the sterile latex gloves, he pushed his hands into them. Then he noticed her … her aqua eyes fixed on him. Wide eyed, undistracted except for Danny, as if she were a hypnotist, mesmerizing her subject. For a second, Danny forgot his case, the moment robbed by the salacious stare from above the pale blue mask and below the white OR bonnet.
“Dr. Tilson, good positioning?” asked Debbie, the OR circulator. She pointed to the video system, and he focused again on his work.
Danny nodded okay, so Debbie stepped behind him to tie his gown. He glanced at the IV pole for the bottle of mannitol, the osmotic diuretic, and saw Barbara adjusting the patient’s Foley bag near her side of the table. Danny sat. Everyone was ready to start and he made his incision.
Little chitchat had enveloped the room, but now fewer words were spoken after the hum of the drill. Danny rested his elbows on the armrest, his wrists on the patient’s head. The scrub nurse transferred instruments efficiently by following his procedure. Most of the noise in the room originated from the comforting beeps of the EKG. The pulse oximeter remained quiet.
Moist gray matter under the skull plate looked healthy. Danny gingerly explored to the left of his exposed site. Once he glanced over to the MRI and CT just to assure himself. There. Right there. Like a virus alert on a desktop screen, the top of the round hydatid cyst stared at him. Its fibrous capsule gave him courage. It looked substantial enough to withstand removal without splitting open. Perhaps underneath this capsule, the laminated membrane and germinal membranes also gave it further toughness.
