A Brain

by Robin Cook

  He flipped the switch on the central processor. A red light came on and he slowly inserted the cassette. He got it three-quarters of the way in, when the machine swallowed it like a hungry dog. Immediately the typewriter unit came alive. Philips moved over so he could read the output.

  HI! I AM RADREAD, SKULL I. PLEASE ENTER PATIENT NAME.

  Philips pecked out “Lisa Marino” with his two index fingers and entered it.

  THANK YOU. PLEASE ENTER PRESENTING COMPLAINT.

  Philips typed: “seizure disorder,” and entered that.

  THANK YOU. PLEASE ENTER RELEVANT CLINICAL information.

  Philips typed: “21-year female, one year history of temporal lobe epilepsy.”

  THANK YOU. PLEASE INSERT FILM IN LASER SCANNER.

  Philips went over to the scanner. The rollers within the lips of the insertion slot were moving. Carefully Philips lined up the X ray with its emulsion side down. The machine grabbed it and pulled it inside. The output typewriter activated. Philips walked over. It said: THANK YOU. HAVE A CUP OF COFFEE. Philips smiled. Michaels’ sense of humor emerged when least expected.

  The scanner emitted a slight electrical buzz; the output device stayed silent. Philips grabbed his lead apron and left the office.

  There was silence in OR #21 as Mannerheim mobilized Lisa’s right temporal lobe and slowly lifted it from its base. A few small veins could be seen linking the specimen to the venous sinuses, and Newman skillfully coagulated and divided them. At last it was free, and Mannerheim lifted the piece of the brain out of Lisa’s skull and dropped it into a stainless steel dish held by Darlene Cooper, the scrub nurse. Mannerheim looked up at the clock. He was doing fine. As the operation had progressed, Mannerheim’s mood had changed again. Now he was euphoric and justly pleased with his performance. He’d done the procedure in half the usual time. He was certain he’d be in his office at noon.

  “We’re not quite finished,” said Mannerheim, taking the metal sucker in his left hand and forceps in his right. Carefully he worked over the site where the temporal lobe had been, sucking out more brain tissue. He was removing what he called the deeper nuclei. This was probably the riskiest part of the procedure, but it was the part Mannerheim liked the best. With supreme confidence he guided the sucker, avoiding vital structures.

  At one point a large globule of brain tissue momentarily blocked the opening of the sucker. There was a slight whistling noise, before the piece of tissue whooshed up the tube. “There go the music lessons,” said Mannerheim. It was a common neurosurgical quip, but coming from Mannerheim after all the tension he’d caused, it was funnier than usual. Everyone laughed, even the two Japanese doctors.

  As soon as Mannerheim had finished removing brain tissue, Ranade slowed the ventilation of the patient. He wanted to let Lisa’s blood pressure rise a little while Mannerheim inspected the cavity for any bleeding. After a careful check Mannerheim was satisfied the operative site was dry. Taking a needle holder he began to close the dura, the tough covering over the brain. At that point, Ranade began carefully to lighten Lisa’s anesthesia. When the case was over he wanted to be able to remove the tube in Lisa’s trachea without her coughing, or straining. This required a delicate orchestration of all the drugs he’d been using. It was imperative that Lisa’s blood pressure not go up.

  The dural closure went swiftly and with a deft rotation of his wrist, Mannerheim placed the last interrupted stitch. Lisa’s brain was again covered, although the dura dipped down and was darker where Lisa’s temporal lobe had been. Mannerheim cocked his head as he admired his handiwork, then stepping back, he snapped off his rubber gloves. The sound echoed in the room.

  “All right,” said Mannerheim, “close her up. But let’s not make it your life’s work.”

  Motioning for the two Japanese doctors to come with him, Mannerheim left the room.

  Newman took Mannerheim’s position at Lisa’s head.

  “Okay, Lowry,” said Newman, echoing his boss, “let’s see if you can help me rather than hinder me.”

  After dropping the bone flap into place like the top of a Halloween pumpkin and tying the sutures, Newman was ready to close. With a pair of rugged tooth forceps, he grabbed hold of the edge of Lisa Marino’s wound and partially everted it. Then he plunged the needle deep into the skin of the scalp, making sure he picked up pericranium, and brought the needle out in the wound. Detaching the needle holder from its original position on the shank of the needle, he used the instrument to grab the needle tip, bringing the suture out into the wound. With essentially the same technique, he put the silk through the other side of the wound, trailing the suture off into Dr. Lowry’s waiting hand so he could tie the stitch. They repeated this procedure until the wound was closed with black sutures, giving the impression of a large zipper on the side of Lisa’s head.

  During this part of the procedure, Dr. Ranade was still ventilating Lisa by compressing a breath bag. As soon as the last stitch was to be placed, he planned to give Lisa one hundred percent oxygen and reverse the remaining muscle paralyzer her body hadn’t metabolized. On schedule his hand again compressed the breathing bag, but this time his experienced fingers detected a subtle change from the previous compression. Over the last few minutes Lisa had begun to make initial efforts to breathe on her own. Those efforts had provided a certain resistance to ventilating her. That resistance had been gone on the last compression. Watching the breathing bag and listening with his esophageal stethoscope, Ranade determined that Lisa had suddenly stopped trying to breathe. He checked the peripheral nerve stimulator. It told him the muscle paralyzer was wearing off on schedule. But why wasn’t she breathing? Ranade’s pulse increased. For him anesthesia was like standing on a secure but narrow ledge on the side of a precipice.

  Quickly, Ranade determined Lisa’s blood pressure. It had risen to 150 over 90. During the operation it had been stable at 105 over 60. Something was wrong!

  “Hold up,” he said to Dr. Newman, his eyes darting to the cardiac monitor. The beats were regular but slowing with longer pauses between the spikes.

  “What’s wrong?” asked Dr. Newman, sensing the anxiety in Dr. Ranade’s voice.

  “I don’t know.” Dr. Ranade checked Lisa’s venous pressure while preparing to inject a drug called nitroprusside to bring down her blood pressure. Up to this point Dr. Ranade believed the variation in Lisa’s vital signs was a reflection of her brain responding to the insult of surgery. But now he began to fear hemorrhage! Lisa could be bleeding and the pressure in her head could be going up. That would explain the sequence of signs. He took the blood pressure again. It had risen to 170 over 100. Immediately he injected the nitroprusside. As he did so, he felt that unpleasant sinking feeling in his abdomen associated with terror.

  “She might be hemorrhaging,” he said, bending down to lift Lisa’s eyelids. What he saw was what he’d feared. The pupils were dilating. “I’m sure she’s hemorrhaging,” he yelled.

  The two residents stared at each other over the patient. Their thoughts were the same. “Mannerheim’s going to be furious,” said Dr. Newman. “We better call him. Go ahead,” he said to Nancy Donovan. “Tell him it’s an emergency.”

  Nancy Donovan dashed over to the intercom and called out to the front desk.

  “Should we open her back up?” asked Dr. Lowry.

  “I don’t know,” said Newman nervously. “If she’s hemorrhaging inside her brain it would be better to get an emergency CAT scan. If she’s bleeding into the operative site, then we have to open her up.”

  “Blood pressure still rising,” said Dr. Ranade with disbelief as he watched his gauge. He prepared to give her more medication to bring the blood pressure down.

  The two residents remained motionless.

  “Blood pressure still rising,” shouted Dr. Ranade. “Do something, for Christ sake!”

  “Scissors,” barked Dr. Newman. They were slapped into his hand and he cut the sutures he’d just finished placing. The wound spontaneously gaped o
pen as he got to the end of the incision. As he pulled the scalp flap back, the section of skull they’d removed for the craniotomy pushed up at them. It seemed to be pulsating.

  “Let me have the four units of blood that’s on call,” shouted Dr. Ranade.

  Dr. Newman cut the two hitch sutures holding the bone flap in place. The piece of bone fell to the side before Dr. Newman picked it up. The dura was bulging out with an ominous dark shadow.

  The OR door burst open and Dr. Mannerheim came flying in, his scrub shirt was unbuttoned save for the bottom two.

  “What the hell’s going on?” he shouted. Then he caught sight of the pulsating and bulging dura. “Jesus Christ! Gloves! Let me have gloves!”

  Nancy Donovan started to open a new pair of gloves, but Mannerheim snatched them away from her and pulled them on without scrubbing.

  As soon as a few sutures were cut, the dura burst open, and bright red blood squirted out over Mannerheim’s chest. It soaked him as he blindly cut the rest of the sutures. He knew he had to find the source of the bleeding.

  “Sucker,” yelled Mannerheim. With a rude sound, the machine began to draw off the blood. Immediately it became apparent that the brain had shifted or swelled because Mannerheim quickly encountered the brain itself.

  “The blood pressure is falling,” said Ranade.

  Mannerheim yelled for a brain retractor to help him try to see the base of the operative site, but blood welled up the moment he took the sucker away.

  “Blood pressure . . .” said Dr. Ranade, pausing. “Blood pressure unobtainable.”

  The sound of the cardiac monitor, which had been so constant during the operation, slowed to a painful pulse, then stopped.

  “Cardiac arrest!” shouted Dr. Ranade.

  The residents whipped up the heavy surgical drapes, exposing Lisa’s body and covering her head. Newman climbed up on the stool next to the OR table and began cardiac resuscitation by compressing Lisa’s sternum. Dr. Ranade, having obtained the blood, hung it up. He’d opened all his IV lines, running fluid into Lisa as fast as possible.

  “Stop,” yelled Mannerheim, who’d stepped back from the OR table when Dr. Ranade had shouted cardiac arrest. With a feeling of utter frustration, Mannerheim threw the brain retractor to the floor.

  He stood there for a moment, his arms at his sides with blood and bits of brain dripping from his fingers. “No more! It’s no use,” he said finally. “Obviously some major artery gave way. It must have been from the God-damned patient pushing in those electrodes. Probably transected an artery and put it into spasm, which was camouflaged by the seizure. When the spasm relaxed it blew. There’s no way you can resuscitate this patient.”

  Grabbing his scrub pants before they fell, Mannerheim turned to leave. At the door he looked back at the two residents. “I want you to close her up again as if she were still alive. Understand?”

  5

  “My name is Kristin Lindquist,” said the young woman waiting at the university’s GYN clinic. She managed a smile, but the corners of her mouth trembled slightly. “I have an appointment with Dr. John Schonfeld at eleven-fifteen.” It was exactly eleven according to the wall clock.

  Ellen Cohen, the receptionist, looked up from her paperback novel at the pretty face smiling down at her. Immediately she saw that Kristin Lindquist was everything Ellen Cohen was not. Kristin had real blond hair, which was as fine as silk, a small turned-up nose, big deep blue eyes, and long shapely legs. Ellen hated Kristin instantly, labeling her in her mind as one of those California sluts. The fact that Kristin Lindquist was from Madison, Wisconsin, would not have made any difference to Ellen. She took a long drag on her cigarette, blowing the smoke out her nose as she scanned the appointment book. She crossed off Kristin’s name and told her to take a seat, adding that Kristin would be seeing Dr. Harper, not Dr. Schonfeld.

  “Why isn’t Dr. Schonfeld going to see me?” asked Kristin. Dr. Schonfeld had been recommended by one of the girls in the dorm.

  “Because he’s not here. Does that answer your question?”

  Kristin nodded, but Ellen didn’t notice. She’d returned to her novel, although when Kristin walked away, Ellen watched her with jealous irritation.

  It was at that moment that Kristin should have left. She thought about it, realizing that no one would have noticed if she just continued walking the way she’d come. She already disliked the hospital’s dilapidated environment, which reminded her of disease and decay. Dr. Walter Peterson in Wisconsin had an office that was clean and fresh, and although Kristin still did not enjoy her semiannual exam, at least it hadn’t been depressing.

  But she did not leave. It had taken a significant amount of courage for her to make the appointment, and she was compulsive about finishing what she’d started. So she sat down on the stained vinyl waiting-room chair, crossed her legs, and waited.

  The hands of the wall clock advanced painfully slowly and after fifteen minutes Kristin realized the palms of her hands were sweating. She recognized she was becoming more and more anxious, and wondered if there was something psychologically wrong with her. There were six other women in the small waiting room, all of whom seemed calm, a fact which magnified Kristin’s distress. It made her sick to think about her internal structure, and coming to the gynecologist forced the whole issue at her in a brutal and unpleasant way.

  Picking up a tattered magazine, Kristin tried to divert her mind. She was unsuccessful. Almost every advertisement reminded her of her upcoming ordeal. Then she saw a picture of a man and a woman, and a new concern entered her mind: how long after sex can sperm be found in the vagina? Two nights previously Kristin had seen her boyfriend, Thomas Huron, a senior, and they had slept together. Kristin knew that she’d be humiliated if the doctor could tell.

  The relationship with Thomas was the reason Kristin had decided to make an appointment at the clinic. They’d been seeing each other steadily since the fall. As their relationship grew, Kristin realized that trying to decide when it was “safe” was no longer a reasonable method of birth control. Thomas refused to take any responsibility and continually pressured Kristin for more frequent sex. She’d inquired about birth control pills at the student dispensary and had been told she first had to have a gynecological exam at the Med Center. Kristin would have preferred to have gone to her old doctor at home, but her concern for privacy made that impossible.

  Taking a deep breath, Kristin realized her stomach was now a knot and she could feel unsettling rumblings in her abdomen. The very last thing she wanted was to get so upset she got diarrhea. Even the thought mortified her. Looking up at the clock, she hoped she wouldn’t have to wait much longer.

  One hour and twenty minutes later Ellen Cohen called Kristin into one of the exam rooms. The linoleum floor felt cold to her feet as she undressed behind a small screen. There was one hook and she hung up all her clothes. As she had been directed, she put on a hospital gown, which came to mid-thigh and tied at the front. Looking down she noticed her nipples were erect from the cold, poking out through the worn cotton fabric like two hard buttons. She hoped they’d go down before the doctor saw her.

  Emerging from behind the curtain, Kristin saw the nurse, Ms. Blackman, arranging instruments on a towel. Kristin averted her eyes, but not before she’d caught an unwanted glimpse of a host of gleaming stainless steel instruments, including a speculum and some forceps. The mere sight of these devices made Kristin feel weak.

  “Ah, very good,” said Ms. Blackman. “You’re quick, and we appreciate that. Come!” Ms. Blackman patted the exam table. “Climb up here now. The doctor will be in shortly.” With her foot Ms. Blackman moved a small stool to a strategic position.

  Using both hands to clutch at her flimsy gown, Kristin made her way to the examination table. With the metal stirrups jutting off at the end, the table looked like some medieval torture device. She stepped on the stool and sat down facing the nurse.

  Ms. Blackman then took a detailed medical history, which impressed Kr
istin with its thoroughness. No one had ever taken the time to do such a complete job, which included careful inquiries into Kristin’s family history. When Kristin had first seen Ms. Blackman, she’d been uneasy, fearing that the nurse was going to be as cold and harsh as her appearance suggested. But during the course of the history-taking, Ms. Blackman was so pleasant and so interested in Kristin as a person that Kristin began to relax. The only symptoms of note that Ms. Blackman wrote down were a mild discharge Kristin had noted over the last several months and occasional intermenstrual spotting, which she’d had as long as she could remember.

  “All right, let’s get ready for the doctor,” said Ms. Blackman, putting aside the chart. “Lie down now and feet in the stirrups.”

  Kristin complied, vainly trying to hold the edges of her gown together. It was impossible and her composure began to fade once again. The metal stirrups felt like ice, sending a chill through her body.

  Ms. Blackman shook open a freshly laundered sheet and draped it over Kristin. Lifting up the end, Ms. Blackman looked beneath. Kristin could almost feel the nurse’s gaze on her totally exposed crotch.

  “Okay,” said Ms. Blackman, “move yourself down to the end of the table.”

  Using a kind of rotational movement of her hips, Kristin walked her backside toward her feet.

  Ms. Blackman, still looking under the sheet, wasn’t satisfied. “A little more.”

  Kristin moved farther until she felt her buttocks half off the end of the table.

  “That’s fine,” said Ms. Blackman, “now relax before Dr. Harper comes in.”

  Relax! thought Kristin. How could she relax? She felt like a piece of meat in a rack waiting to be pawed over by customers. Behind her was a window and the fact that its drape was not completely closed bothered her immensely.

  Without a knock, the door to the exam room opened and a hospital courier thrust his head in. Where were the blood samples that were going to the lab? Ms. Blackman said she’d show him and disappeared.