Intensive Therapy

by Jeffrey Deitz

  Jonas had to breathe deeply to keep from vomiting. “Goddammit,” he said. “I was afraid something like this would happen. How’s Victoria?”

  “I think she broke her wrist falling on the ice. She moaned on and on about Gregory, and then she started talking mechanically until the ambulance headed off for Children’s Hospital.”

  “She’s overwhelmed.”

  “What are they going to do at the hospital?” Martin said.

  “First they’ll secure Gregory’s airway by inserting a breathing tube—the EMTs may have done that already—but even if they did, the hospital will want to make sure it’s positioned properly. Then they’ll try and stabilize his heart rate and blood pressure, and rate the depth of the coma. They’ll want a CT scan of his head right away to check for bleeding and assess the swelling. Swelling is the real enemy in head injuries.” Jonas felt confident that practice with head trauma in Philadelphia had kept pace with the latest techniques used in New York.

  Martin said, “Excuse me, the police just pulled up. A policewoman is asking about Melinda.”

  “She’ll get frostbite and hypothermia if we don’t find her,” Jonas said.

  Martin said, “Please call Victoria. She begged me to put you in touch with her. Do you have her cell phone number?”

  “Yes, I do.”

  “She may have some life-and-death decisions to make in the next hour. I know it’s a holiday, but please do what you can. She trusts you with her life.”

  Jonas was glad he hadn’t had much wine, knowing he needed a clear head. He called Victoria.

  “Hello, Martin?” her voice resounded after the first ring.

  Jonas shot up from the chair. “No, it’s Jonas. Martin just called. Have you gotten to the hospital yet?”

  “No. The roads are caked with ice. It’s taking forever.”

  “Did they put in a breathing tube yet?”

  “Yes. He may have stopped breathing. I can’t tell. They also put a brace around his head.” Jonas heard Victoria talking to an EMT. She sounded detached, just as Martin had described.

  Jonas said, “The brace is just a precaution in case he hurt his neck—that’s unlikely, given what Martin described. Gregory’s probably hooked up to a heart monitor. It looks like a mini-TV with green blips. Can you see if the blips have a regular rhythm? Do they all look the same?”

  “I can’t tell.”

  “Give the EMT your phone.”

  “What?”

  “Just do it, Victoria.”

  Jonas heard the phone hit something. An angry voice said, “Who’s this? We’re busy trying to save this boy’s life here.”

  “This is Dr. Jonas Speller. I’m the boy’s mother’s doctor. Has he stopped breathing?”

  “We’re not sure. He’s intubated and we’re bagging him.”

  “Is his heartbeat steady?”

  “It’s slowing.”

  “What about his blood pressure?”

  “It’s going up and down. We’re not sure we’re getting an accurate read.”

  “And his pupils?”

  “The left is barely responding.”

  “Okay. Do you have mannitol?”

  “We’re just starting to administer it.”

  “Good. He probably has a bleed that needs to be evacuated. We may have only one chance to save this boy’s life, so listen carefully. Children’s Hospital has a pediatric neurosurgeon on call. Radio ahead and get him and his team ready. Every second counts. Have him call me on my cell phone the instant you get in touch with him.” Jonas gave his number. “When you radio in, do you talk with triage, or do you speak with the ER doctors directly?”

  “We’ve already notified the trauma team.”

  It’s a teaching hospital, Jonas thought. It’s a holiday. What if there are only residents and interns on duty tonight? God help us if we get some arrogant know-it-all who doesn’t respect his elders.

  Jonas asked the EMTs to have the neurosurgeon call. Then he asked him to hand the phone back to Victoria. He told her, “I’m trying to get the neurosurgeon on the line.”

  “Neurosurgeon. What do we need a surgeon for?” she asked, terror returning to her voice.

  “You’re going to have to trust us, Victoria. That’s all I can say for now. I have to speak with the doctor, and I’ll get back to you the minute I do.”

  35

  For the next ten minutes, Jonas paced around Pete Bodenheim’s den, feeling as though his own son was en route to the hospital. The Connecticut weather had turned frigid, but the ice storm had not advanced that far north. He hoped the turnpike remained passable to Philadelphia. In good weather with no traffic, he could be there in two and a half hours. With icy roads, who knew how long it would take? Using Pete’s computer, Jonas checked the National Weather Service. No updates had been posted.

  His phone rang. “This is Dr. Speller,” he said.

  “This is Dr. Anna Breckenridge, pediatric neurosurgery fellow at Children’s Hospital. I was told to call this number.” She sounded neither irritated nor arrogant.

  Jonas said, “Who’s your attending?”

  “Dr. Liddle, Larsen Liddle. Please, who am I speaking with?”

  Larsen Liddle. Just like Stan Amernick had mentioned to Jonas years ago. What a small world Philadelphia was.

  “I’m sorry, Dr. Breckenridge. I should have introduced myself. My name is Dr. Jonas Speller, and I’m Professor of Clinical Psychiatry and Neurology at Mount Sinai Medical School in New York. One of my patient’s children—her ten-year-old son—is coming your way any minute. He’s had a horrible closed-head injury; his left pupil is blown and his vitals are deteriorating.”

  “How do you know that?”

  “I just got off the phone with the EMTs in the ambulance.”

  “Are there any other injuries?”

  “Not that we know of. The boy’s mother is with him. She’s been a patient of mine for years. Gregory, that’s the boy’s name, is intubated. I hope you don’t mind my asking, but what’s your protocol for severe head trauma?”

  “We use the standard trauma life support protocol. The trauma team will be ready the moment he arrives. They’ll examine him for internal injuries and make sure he didn’t break any bones. While they’re stabilizing his vital signs, I’ll examine his cranial nerves and use the Glasgow Coma Scale to assess his neurological status.”

  “Excellent.”

  “Did the EMTs say anything about the boy’s blood pressure?”

  “They were having trouble measuring it. Why?”

  “Low blood pressure in the field is a bad sign.”

  “I’ll make sure they stay on top of it,” Jonas said. “Is there anything else I should tell them?”

  “See if they can administer mannitol.”

  “They already started.”

  “That’s good,” Dr. Breckenridge said. “Once the boy gets here, the trauma team will X-ray his cervical spine. Then we’ll go straight to CT, where we’ll look for a bleed, determine the extent of the swelling, and see if there’s any midline shift or hydrocephalus.”

  Jonas held his breath. His palms felt clammy. “Do you do craniectomies? Hemi craniectomies, I mean?”

  “Yes, if we have to.”

  “Good. What do you do with the skull?”

  “We used to implant it in the patient’s abdomen. Now we put it in a freezer, so there’s no need for another incision.”

  “Good. That’s what we do here, too. Mount Sinai gets all the bicycle, skateboard, and rollerblade accidents from Riverside and Central Parks. Plus the motorcyclists who’re too macho to wear helmets. I hoped you weren’t still relying solely on mannitol, or hyperventilation, or cold perfusion.”

  “We do give mannitol or hypertonic saline acutely, which is why I want the EMTs to start now. But the definitive treatment is to remove the blood, if the swelling is severe enough, we leave the bone flap off. We try and avoid hyperventilation. We gave up on cooling a while ago.”

  “Do you do a
CT scan on every patient, even when their vitals are deteriorating?”

  “It only takes a few minutes. From what you’re saying, most likely there’s blood on the same side as the blown pupil. But since we’re not sure, we should know how much and where. If there’s no bleed, we can put in an ICP to monitor the pressure. But from what you said, it sounds like we’ll have to open the skull.”

  “That makes sense. You’re going to have a tough time getting the mother to consent to the procedure. That’s where I come in. Let me handle Gregory’s mother. You’ve done this operation before, Dr. Breckenridge? I mean you, personally.”

  “I’ve assisted at several in the last year. Children’s Hospital is the regional trauma center, so we get head injuries from all over the Tri-State Area. As soon as I get off the line, I’ll call Dr. Liddle and tell him what’s happening. From what I hear, the roads are bad. I don’t know how soon he’ll be able to get here, but I don’t want to wait. This would be my first unsupervised as the chief surgeon, but I’ve opened the skull innumerable times for brain tumors, aneurisms, and vascular malformations.”

  Jonas had no time to quibble about her qualifications. Gregory would be in her hands. Dr. Liddle would get there as soon as he could, but no one could say when.

  “I know you’ll do just fine, Dr. Breckenridge,” Jonas said. “Gregory’s fortunate to be in such good hands. I know you’ll take good care of him.”

  “I will, I promise. Thanks for the heads up and the vote of confidence.”

  36

  Just as the ambulance was pulling up to the emergency room, Victoria’s phone rang. She put it to her ear but she was too overwhelmed to speak.

  “Victoria?” Jonas said. “It’s me. Are you still in the ambulance?”

  “No, we just arrived at the hospital. They must have known we were coming because everyone dashed out the minute we pulled in. There’s a lady in blue pants and a white coat sprinting toward us. What’s going on?”

  “Listen to me, Victoria. That’s probably Dr. Anna Breckenridge. She’s an experienced neurosurgeon. We don’t have time to wait for the attending. It could take hours for him to get to the hospital in the storm, and that’s too long.”

  A passel of aides and nurses whisked Gregory through three sets of automatic doors into the trauma bay, where the team was ready to take over. A woman in civilian clothes carrying a clipboard intercepted Victoria as the trauma bay doors closed.

  “They closed the doors,” Victoria said, shocked at how fast the doctors had taken control of Gregory.

  Jonas said, “They have to get a CT scan of Gregory’s head. We suspect there’s been a leakage of blood that’s increasing the pressure inside Gregory’s head. Pressure, that’s the enemy. The skull is like a rigid box. It’s not like your skin that can expand when there’s bleeding or a bad bruise. Imagine a water balloon inside Gregory’s skull: If you press on the top the bottom bulges. That’s what’s happening inside his head—the pressure has nowhere to go except downward to the base of the skull, at the brain stem. That’s the area that regulates blood pressure, breathing, and heart rate. Unless we relieve the brain-stem pressure, Gregory’s heart will stop. Or, just as bad, the increased pressure will choke off the arteries and keep blood and oxygen from nourishing his brain, which will cause a massive stroke.”

  “Oh my God! You mean he could wind up …?”

  “That’s what they’re trying to prevent.”

  A bright light from inside the trauma bay drew Victoria’s attention to the door’s window. “Wait a second. They just turned on a giant overhead light. My God. There must be eight or ten people in there. Jesus! They’re poring all over him.”

  “That’s right,” Jonas said. “They have to make sure he’s getting enough oxygen and that his circulation is okay.”

  “The doctor in the blue pants is rubbing his chest and shining her penlight into Gregory’s eyes.”

  “That’s right,” Jonas said. “She’s rating the depth of the coma and she’s checking his brain-stem reflexes, trying to assess how bad the brain is injured. That’s exactly what she should be doing.”

  “She’s coming out of the room. She wants to talk with me.”

  “Fine. Talk with the doctor, Victoria. Make sure she knows I’m listening. Tell her to speak up so I can hear.”

  A minute later, the doctor spoke. “I’m Dr. Anna Breckenridge. I’m covering pediatric neurosurgery this weekend. I’ve been in touch with Dr. Speller. We don’t have a lot of time to discuss options now, Mrs … Mrs …?”

  “Braun. Victoria Schone-Braun. Dr. Speller is listening.” Victoria pointed at her cell phone. “I want him to hear what you say. He’s already explained the pressure issue. What can you do about it?”

  “Based on the history and my examination, I think the fall ruptured a blood vessel on the left side of your son’s brain,” she said, pointing to a spot midway between her temple and the crown of her head. “If it’s what I think it is, he’ll need an operation.”

  “An operation! Did you hear that, Jonas?”

  “Yes, I did, Victoria,” he said.

  “What kind of operation?” Victoria asked Dr. Breckenridge.

  Dr. Breckenridge said, “It’s too early to tell. We’ll know more after the CT scan. That’s the best test to look for bleeding and skull fractures. I’m leaving for the radiology scan suite now; it’s on the third floor.” She pointed to the woman with the clipboard, who had been at Victoria’s side all along. “This is Mrs. Siskind, our social worker. She will take you to the radiology waiting room. I’ll meet you there in about fifteen minutes.” She departed hurriedly, joining several people who were rushing Gregory’s gurney past Victoria into an open elevator. One of the people was squeezing an inflatable bag connected to the breathing tube inserted into Gregory’s throat.

  Chilled by the sight of Gregory attended by so many people, Victoria, still on the phone, said, “I don’t believe this, Jonas. She’s talking about an operation. Are they serious?”

  Jonas said, “I’m sure they won’t do anything unnecessary. You better hang up now and get to radiology. Call me after Dr. Breckenridge gives you the results of the CT scan.”

  Mrs. Siskind led Victoria into a different elevator, which took them to a small waiting room on the third floor. “I know how upsetting this must be, Mrs. Braun,” the woman said in a consoling voice. “But we do this all the time. There’s no better hands your son could be in than the neurosurgery team at Children’s Hospital.”

  Not long after, Dr. Breckenridge entered the waiting room. “Good. You’re here,” she said to Victoria. “Mrs. Braun, the scan confirmed my diagnosis. There is a considerable amount of blood inside Gregory’s skull under what we call the dura mater, the tough membrane between the brain and the skull. The medical term is subdural hematoma. I can’t be one hundred percent certain if the bleeding has stopped completely, but either way we must operate immediately to relieve the pressure.

  “There is a good chance we will have to do what is called a hemicraniectomy. It’s a relatively new procedure, Mrs. Braun. But it works dramatically well. It’s the best chance your son has to escape devastating consequences from traumatic brain injury. Gregory has unmistakable signs and symptoms of brain-stem compression because of increased intracranial pressure.”

  “Procedure? What’s involved here?”

  “First, we shave Gregory’s head. Then we make a large, question-mark-shaped incision and elevate your son’s scalp and muscle off of his skull. Then we remove a large piece of the skull, and we evacuate the blood clot and make sure the bleeding is stopped. We keep the piece of bone sterile and place it in a freezer. With the bone off, the brain can swell against the soft and pliable scalp tissue, which we sew over to protect the brain from infection. When the brain swelling goes down we reattach the skull, but that can take weeks, even months.”

  “You must be out of your mind!” Victoria said. “You want to remove my son’s skull?”

  “I wish I had
more time to explain, but we can’t wait. Increased pressure keeps blood from flowing into your son’s brain, and that means anoxia—not getting enough oxygen—which causes brain-cell death.”

  “I know. Dr. Speller explained it to me. This isn’t some kind of experimental procedure, is it? Gregory’s not going to be a guinea pig, is he?”

  “Oh no, Mrs. Braun, I can assure you this procedure is the state-of the-art treatment for life-threatening closed-head injuries.”

  “Life-threatening?”

  “Here, let me show you. Follow me.” Dr. Breckenridge conducted Victoria through a doorway into a crowded, windowless space that looked like a war room. The walls ahead and to the left contained light-boxes, computer screens, and X-ray equipment. Through the glass wall on the right, Victoria saw several people transferring Gregory from the CT machine back onto his gurney.

  “Quiet, everybody,” Dr. Breckenridge spoke up, stilling the crush of doctors and technicians scurrying about. “This is Gregory’s mother. Make room so I can show her the scan.”

  Dr. Breckenridge led Victoria to the main screen and pointed to a large glob of white inside the outline of a skull. “See this, Mrs. Braun? That’s the blood clot inside Gregory’s brain.” Dr. Breckenridge enlarged the image and pointed to what looked like an inward-jutting jagged rock surrounded by a thin line. Everyone huddled closer so they could see and hear.

  “This is where the skull is indented,” Dr. Breckenridge said. “See how the white from inside traverses the line? That tells me that the blood is under pressure, probably from a ruptured artery on the surface of the brain. We have to get in there now, not only to evacuate the clot but to identify and cauterize the artery. Otherwise, it will start spurting once the pressure is reduced.”

  Dr. Breckenridge ushered Victoria back into the waiting area and said, “Wait here with Mrs. Siskind. I have to go back inside for a moment. Would you like to call your husband now?”