Monday Mornings: A Novel

by Sanjay Gupta

  There wasn’t much to be said for Room 311. Unlike the Neurosurgery offices, it wasn’t lavishly decorated. On the contrary, the carpet was worn in spots, and some of the seats creaked and groaned from age and wear under the fatigue-heavy weight of the assembled surgeons. Yet it was this small room, largely unknown to the hospital community at large, that drew many of the most gifted surgeons to Chelsea. The draw much like what an orthopedics fellow with gilded credentials might feel toward Rochester, Minnesota, and the Mayo Clinic rather than more forgiving climates and more generous salaries.

  Room 311 was the place the finest surgeons were held to the highest standards. Asking doctors why they wanted to endure the gloves-off version of the Morbidity and Mortality gathering was like asking a soldier why he chose Ranger School. Life was full of creature comforts and compromise. Fuzzy lines and soft edges. Why not find a place where you didn’t get any slack? Where merely good wasn’t good enough. That’s why doctors chose Chelsea. It wasn’t the facility. Chelsea didn’t have all the latest bells and whistles, the latest scanners and lasers—the devices other hospitals advertised on billboards. Nor did Chelsea’s location set it apart. What Chelsea had—for surgeons anyway—was Room 311.

  Ty knew all this. He’d been courted by a number of top hospitals. UCLA even gave him front-row tickets to a Lakers game. Weill Cornell had flown him in to New York City on a Gulfstream. He took a pass and signed on at Chelsea. It was in Room 311 that doctors and scientists had the courage to criticize one another, point out mistakes that might otherwise go unnoticed, and in the process advance science leaps and bounds faster than any other medical center. It was not a secret that more publications and text chapters had resulted from Chelsea’s Monday Mornings than any other conference in the world. They were the best doctors around, and they liked being thought of that way. Of course, it meant many sacrificial lambs were offered up in an intellectual, yet still barbaric ritual.

  The discussion of mistakes, complications, and death is often unsettling, even for seasoned surgeons. For that reason, Room 311 had also become a showcase for the spectrum of surgical personalities, from forthright and blunt to evasive and tentative. Some were quick to blame anesthesia, or any other specialty but their own. Others entertained: surgical showmen wielding black humor. Often, the conference room turned into a battle zone as academic wars were waged, with surgeons picking sides as in a more dignified street fight—sometimes only slightly more dignified. The meeting was fascinating not only in the sensitive topics discussed, but also the human drama that could ensue.

  No one exemplified the hospital’s exacting standards more than Hooten. The Boss. He looked like a dandy with his array of bow ties and the shock of silver-gray hair, but if his staff were like a platoon of Rangers, he was their demanding drill instructor. He’d been known to stop in unannounced in the recovery room, even the OR, to make sure everything was being run to Chelsea’s standards. He’d chew out nurses for leaving charts open, where they could be seen by a passerby, or for allowing themselves to be interrupted while dispensing meds, increasing the chance of errors. He’d dress down a doctor ordering Foley catheters too frequently, raising the chance of infection, and surgeons for allowing surgical techs to triage weekend call. He’d even berated a janitor once for halfheartedly mopping: “You look like you’re trying to paint the floor. You’re supposed to be cleaning. Hospitals need to be clean.” With that, Hooten grabbed the mop and started swabbing until the embarrassed janitor reclaimed it.

  “Everything we do here should be focused on healing. Clean hospitals help people heal.” Hooten had said this loud enough so the doctors and nurses who had stopped to watch the spectacle of the head of surgery wielding a mop could hear. They shuffled away, heads down, all of them holding up their own sometimes faltering standards against Hooten’s and not liking the comparison.

  Ty tried to hold the image of Hooten with the mop in his head, but he couldn’t. His respiration continued to be rapid. His heart was pounding much faster than his usual fifty-two beats per minute. His thoughts were disjointed, panicked. Ty tried to focus on his breathing. He took in a slow, even breath. In through the nose, the maxillary, the ethmoid…Just stop, he said silently. Out through the mouth. He breathed out slowly.

  Ty had skydived on a dare as a high school senior in San Juan Capistrano and scuba dived with sharks in the Bahamas during a break in medical school. Both experiences had given him a few moments of terror, followed by the thrill of avoiding an untimely death. “Nothing makes you feel more alive than—almost dying,” a friend had once said to him. It happened to be his only friend. Tragically, and ironically, that same friend had killed himself a few years ago. Ty winced, and tried to push all these thoughts away. None of those experiences prepared him for this, his first time in the hot seat. Standing in front of his peers to answer for what he’d done caused him not fear but dread. How would his peers judge his actions? Candor was the rule in this secret meeting, egos be damned.

  Ty took another deep breath, trying to regain his wa, and began slowly. “At approximately three-thirty in the afternoon on October twenty-third, I was called to the emergency room to evaluate an eleven-year-old boy.”

  He paused, and in his mind’s eye he saw Quinn McDaniel. The boy appeared perfect in every way. His hair and skin represented the vitality that came only with youth. His smile was a little crooked, and the smattering of freckles suggesting a love for the outdoors. He was carrying a soccer ball in his arms, and his cleats echoed loudly on the hospital’s linoleum floors. Ty thought that if he had a son, he’d want him to look just like this kid. The boy was animated and full of liveliness, making Ty wonder why he had just received an emergency call from the ER to come see the boy.

  “The boy arrived at the ER after a head-to-head collision with another boy during a soccer game. He presented as the picture of health. BP, heart rate, respiration, all normal. He was exceptionally fit,” Ty continued to the assembled surgeons. Ty remembered reading once that if you were able to maintain the vitality you possess at age eleven, you could live twelve hundred years. Not this kid, he thought.

  Ty and the ER doctor who had paged him, Max Goldman, stepped away from the child and his mother. Goldman had ordered a CT scan, not because he expected the images to show anything wrong, but to cover his ass in the event of a lawsuit. He told Ty as much.

  “I know he looks fine,” Goldman said. He spoke in a soft voice meant to reach Ty and no farther. “But there is something you’d better see.” With that, the ER doctor had taken Ty to a small room, dark except for an LED computer screen and a keyboard. Goldman typed on the computer and began showing Ty one image after another.

  “I couldn’t believe what I was seeing,” Ty continued to his peers. “I checked the name twice and the ID number, just to make sure. This boy had a very large malignant-appearing tumor in the left temporal lobe of his brain.” Ty paused and composed himself. “At that moment, I made the decision that if this boy didn’t get an operation immediately, he was at risk of sudden death.”

  “Dr. Wilson, did you bother to order any more tests?” The question came from Hooten. His tone was caustic. In addition to the Boss, Hardy Hooten often lived up to another, less flattering nickname that reflected his icy demeanor at times like this: Hardly Human.

  “No, sir,” Ty answered.

  Someone Ty couldn’t see asked, “Did you consider showing the boy’s films to any of your esteemed colleagues?” The questioner emphasized esteemed in a way that insinuated Ty didn’t think much of his fellow neurosurgeons.

  “No,” Ty answered, looking in the direction of the questioner. From his position in the glare at the front of the room, it was hard for him to see who was talking if they weren’t in front rows. That wasn’t a problem when Hooten was talking. He was right in Ty’s face.

  “Why didn’t you ask for any help, Dr. Wilson?” Hooten asked.

  “Didn’t think I needed it,” Ty answered.

  “Didn’t think you needed
it,” Hooten repeated, letting the words hang in the air. “Potentially life-threatening surgery and you don’t bother talking to anyone else? Consulting any of your colleagues?”

  “That was obviously a mistake,” someone near the back muttered.

  Ty would have guessed that a comment like that came from Sung Park, but Sung was sitting in the front row, legs crossed. Park looked uncomfortable, rubbing his temples. Ty expected the man to be beaming, a competitor who had just witnessed his rival, the favorite, stumble. Even without Park’s involvement, Ty could feel the tide of the room was starting to turn against him.

  “How about a simple history…did you bother doing that before you cut the boy’s head open?” Hooten again. The grand inquisitor, Ty thought. “If you weren’t going to get help from your colleagues, what about from the patient—or the patient’s mother?”

  “In retrospect, it was inadequate.”

  Ty knew Hooten had been aiming at this line of questioning all along, but he wanted others in the room to see the value in consulting one another before driving home the true nature of Ty’s failure.

  “No patient history,” Hooten said and waved off the murmurs in the room. “Dr. Wilson, continue.” If this was going to be a public execution, Hooten wanted to make sure he gave Ty all the rope he needed to hang himself. Maybe I was too cocky, Ty thought. He had been told that he was technically the most gifted surgeon the hospital staff had ever seen. He never doubted them. Now he was starting to second-guess himself. Not his skills in the OR, but his judgment. What if he had waited to operate?

  “I mapped out a left-sided craniotomy with awake speech mapping,” Ty continued. “After placing immobilization pins in the right frontal area and the left occiput, I asked the anesthesiologists to go ahead and wake the boy back up.” During the operation, nurses were going to periodically test his speech by having him identify objects on flash cards. Quinn was lying on his side, his left cheekbone facing up. He opened his eyes, looking a little frightened as he awoke. When he saw Ty, he smiled.

  “Hey, did I tell you…I always wanted to be a brain surgeon when I grow up,” he’d told Ty. The sedative gave the boy’s speech a drowsy quality. Quinn McDaniel paused, then added, “Or maybe a fireman…” The recollection was almost unbearable for Ty. He coughed, so he could choke back a tear.

  “I made an incision from his zygoma in front of his left ear, all the way to the midline. The bone was removed without incident.”

  “How was the patient doing during this part of the operation?” the Boss challenged.

  “No problems, sir. He was awake and talking to the anesthesiologist.”

  “He had absolutely no pain?”

  “No, sir, he said he felt a little pressure as I drilled through his skull, but that was about it.”

  “How about bleeding from his scalp?”

  Ty nodded. “There was bleeding, but I could control it easily with cautery and clips.”

  “Continue,” Hooten said.

  Ty mentally transported himself back to the middle of that operating room. He had looked up at the clock and noted the time: 11:34 PM. Okay, he’d thought. Time to take out a tumor. This was no run-of-the-mill tumor, though.

  “As soon as I saw the tumor, I knew it was malignant,” Ty told the room. “It had tentacles reaching into the normal-appearing brain, and it was an angry reddish color.”

  At the moment, Ty had been overcome with a sinking, black dread. He knew the boy would eventually die of this brain tumor. Medical science had not advanced far enough to be able to save him. All he could do was remove what he could see, buy a little time for the boy and his mother. Ty had already started thinking about the conversation he was going to have with the mother, Allison McDaniel. He would have to tell her that her precious little boy would only have a year, maybe two left, and then he would die an awful death—his mind robbed of its function and his body slowly wasting away.

  “I started to remove the tumor”—Ty looked right at Sung—“and it started to bleed. There was much more bleeding than I expected.” Ty’s voice trailed off. The surgeons in the room were fixed on him. Tina Ridgeway looked like she was about to throw up.

  Hooten broke the silence. His voice was quiet and measured and contained the sort of finality that a well-made door makes when it closes.

  “Hindsight is twenty-twenty, Dr. Wilson. Tell us what you would have found if you had done a detailed history on the boy.” The room was deathly quiet. Ty’s knees felt weak. There was nothing left to say.

  “The boy was healthy. The mother was healthy and had no chronic or heritable conditions.”

  “And the father.”

  “The boy doesn’t live with his father. Never knew his father. I never thought—”

  Hooten suddenly interjected: “You. Never. Thought.” He made it sound like a dark oath. His words hung in the room, an accusation, a lesson to the rest of them.

  “Thinking,” Hooten nearly spat. “I don’t care what any one of you think.” He waved a hand toward the assembled surgeons. “I want you to know. We are healers but we are also clinicians, scientists, we follow time-honored reasoned analysis. We have methods. This is what happens if we follow whatever it is we happen to be thinking.”

  Hooten turned back toward Ty.

  “Let me ask again…Dr. Wilson, what would you have learned if you had taken a detailed history before surgery, including the boy’s biological father?” Ty wanted to hate Hooten at this moment, but he couldn’t. He knew the old doctor was right. Ty knew he was wrong, and the costs of his mistake could not be calculated in any meaningful way. A boy had died sooner than he had to. “Dr. Wilson?”

  “I would have learned the boy had a fifty-fifty chance of inheriting von Willebrand disease and had a risk for uncontrollable bleeding. I would have learned—”

  The back doors to Room 311 flew open. Ty stopped. The assembled surgeons looked back: George Villanueva. He strode forward, gave Tina Ridgeway a little shoulder rub, and then looked up at the Boss.

  “Hey, what did I miss? Did pretty boy explain how he killed the kid yet?”

  Ty flinched noticeably, but then was transported back to the night he’d last seen Quinn. With the persistent bleeding, the anesthesiologist had long since dispensed with his newspaper reading and was peering frantically over the sterile drape that separated surgeons and sleepers. The music had been turned off some time ago. “Uh, Ty,” he whispered so the boy wouldn’t hear him, “…we have three blood transfusions going, and we can’t keep up. His heart is starting to fail.” Ty shot him a glance and then motioned to put the boy to sleep. Syringes were pushed and a tube was placed in the boy’s mouth. Ty was back at work, aggressively trying to stop the bleeding in a boy whose blood would simply not clot. What…is…happening…?

  “Chest tray!” Ty shouted to the now-assembled group of a dozen nurses. He was going to attempt a last-ditch effort to save the boy. He would open up his chest and begin an open-heart massage. He would pump the boy’s heart until they could get enough blood in him.

  Ty’s hands were flailing wildly as he was describing everything to the surgeons in the secret meeting room. He had almost forgotten where he was, until a stern voice jarred him back to the present. Room 311, just after 6 AM.

  “Did you really think that would work?” Hooten asked.

  Ty looked momentarily confused and then met his inquisitor’s eyes head-on. “No, sir, I didn’t.”

  After the boy died, Dr. Tyler Wilson walked numbly into the locker room. It looked every bit like a room you would find in a gym. One of his favorite technicians was in there and cheerily asked how things had gone with the boy. Ty stared at him blankly and said nothing. “Oh …sorry. Well, you can’t win them all,” the technician said softly as Ty sat down and began to take off his clogs. He was soaked to the skin with young Quinn’s blood. His feet were damp from the blood that had seeped through the small ventilation holes in his clogs. He removed all the bloody clothing, including his underwear, whi
ch were red-tinged, and threw everything in the hamper. In the small adjoining shower, he scrubbed his skin till it was raw, trying to cleanse himself of the blood and his despair. He changed into a shirt and tie. Most of all, he did not want Quinn McDaniel’s mother to see any traces of her son’s blood. By the time he walked out of the locker room and into the empty waiting room, it was nearly four in the morning. Only Allison McDaniel was sitting in there.

  She looked into his eyes, and she knew. Her face collapsed.

  The sight of her struck Ty like a blow. He wanted to turn around. He knew other surgeons who sent their residents out to let family members know a loved one had died. That would have been easy. He could have moved on to the next case with barely a glance back. But Ty had vowed years earlier—after what had happened when his own brother and later a sister died—that he would give the bad news himself, no matter what.

  Ty remembered his mother’s face in a hospital three thousand miles away and thirty years earlier when she got the news about his brother, Ted. A brain tumor had been diagnosed just a few months earlier, and he had fought like crazy. He had been young and healthy, and then he was suddenly dead. She didn’t learn of his death from the surgeon but a hospital social worker. For some reason, this seemed to make the news both harder to comprehend and harder to take. In both cases, Quinn McDaniel’s and Ted Wilson’s, the searing grief had an almost physiological effect on the mothers—as though their features collapsed with their faith in the world. The cheeks and muscles around their mouths seemed to drop with the weight of the news. The color left their faces. Their bodies sagged.

  Ty was with his mother at the time. He was eight. His father and two sisters had gone out to pick up some food. Watching his mother in her moment of grief was much more upsetting to Ty than the news of his brother’s death, which he didn’t understand at first.