by Sanjay Gupta
Park turned to the husband for verification.
“She doesn’t.”
“How about depression medicine? Lithium?” Park asked.
“No, sir,” Ruth said.
Park was intrigued. He turned to Levi.
“Does she have tremors when sleeping?”
“Yes, Doctor. As a matter of fact she does.”
Park now forgot he was showing the couple the door and walked back into his office. He waved for the Hostetlers to follow. He grabbed a pad, excited.
“Come. Sit. This may be true essential tremors,” Park said. “Might be something we can do.” Essential tremor had the somewhat unusual characteristic of getting better when someone drank alcohol, whereas most other tremors became worse.
The couple looked at each other, unclear on what the fast-talking Korean doctor was saying, but with his sudden optimism so strong, it made them smile. Levi leaned forward. He nodded toward the wedding ring on Park’s left hand.
“You’re a married man. If Ruth was your wife, what would you do?”
Park sat up straight, a wry smirk sneaking into the corners of his mouth.
“You didn’t first ask me what I think about my wife.”
Levi looked puzzled for a moment, then Park burst into a gale of laughter, the palm of his right hand coming down on his right quadriceps with a smack. The Hostetlers smiled wanly. Patients routinely asked Park what he would do if he were the patient, or his wife was the patient, or his daughter, and Park always responded with his joke. Park thought the question was utterly ridiculous: What would he do if this patient were his wife? Patients did not want to think for themselves. Why didn’t they ask him what the chances were for a complication?
When his own laughter subsided, Park told the Hostetlers in all seriousness, “I will do what the best science tells me to do. That is all.”
A week or so before the operation, Park had convened his cadre of foreign-born residents to discuss treatment options for Mrs. Hostetler: Wei Yoo, Hyun Kim, Mahendra Kumar, Aisha Ali, Rashmi Patel. These young doctors had, for the most part, defied incredible odds to distinguish themselves in their home countries and receive invitations to US medical schools; then they distinguished themselves once again in medical school to receive one of the coveted surgical residency spots at Chelsea General or an even more coveted neurosurgical fellowship at the hospital.
Rashmi Patel was the only one of the five Park acolytes who grew up in privilege, coming of age on the hills above Mumbai. Now she and the others—a Chinese, a Korean, another Indian, and a Pakistani—stood before their mentor for what Park called his post-graduate education. English—accented and sometimes fractured—was their common language. They also shared a competitive drive, a hunger for success in a world where the odds were stacked against them at each step, and a belief in Park’s promise to make them better prepared than the Anglo colleagues who could rely on looks and connections to ease their way in the world. That promise included Park’s withering office examinations.
“Traditional treatment for severe essential tremor?”
“Anti-seizure medication,” Aisha Ali said.
“What else? That is not all. You need to know this, Aisha,” Park said. The senior doctor gave off an air of omniscience, but he, too, had been studying up on essential tremors.
“Beta-blockers,” Mahendra Kumar added.
“For everybody?”
“I suppose so,” Kumar answered.
“No,” Park said. “Beta-blockers can cause confusion in older patients. Beta-blockers for younger patients. Side effects?”
Kumar paused. He looked crestfallen.
“Fatigue. Shortness of breath.”
“You’re guessing, Mahendra. You’re right, but you are guessing. You guess with patients, they will die.”
“Side effects from beta-blockers include fatigue, shortness of breath, dizziness, and nausea,” Rashmi Patel said in her clipped British accent. “More serious side effects for beta-blockers: hypotension, ataxia, difficulty attending.”
“You forgot the other possible drugs for essential tremor,” Park told Patel. Never mind that he hadn’t asked her. Whenever his charges rose up too far, Park knocked them down a peg. The nail that sticks up gets hammered down. To Park’s way of thinking, this kept them hungry. “Wei?”
“Benzodiazepines.”
“What else, Wei? You need to know this. You been sleeping late?” Wei did not sleep late. She barely slept at all. Between her thirty-hour shifts at the hospital and studying in a language that was sometimes so frustrating it brought tears to her eyes, Wei averaged between three and four hours a night. Her work habits were extreme, even among her equally driven foreign-born colleagues. From them, she earned the nickname the Machine. From them, it was a compliment.
“Anyone?” Park looked around. The younger doctors looked down and fidgeted. “Carbonic anhydrase inhibitors.”
Park was pleased he knew something this group didn’t, but he peered from one to the next, shaking his head with deep disappointment. “You’re not ready for the big league. Maybe you should go back to medical school. Or find a program where you can guess. Maybe some other program that specializes in mediocrity.” Park glared at Mahendra Kumar.
“Now we turn to our patient and essential tremor. What is the difference between intention tremor and essential tremor?”
“Intention tremor is dyskinetic movement during voluntary movement,” Hyun Kim said before someone else could contribute. Silence during these grillings was noted by Park and considered weak by the other acolytes. It was an unwritten rule they should all subject themselves to Park’s abuse more or less equally.
“Etiology?”
“Cerebro-cerebellum.”
“How is essential tremor treated?”
“Medication is the most common—”
Park cut him off. “My daughter could tell me that. Isoniazid. Also, odansetron. Propranolol. Primidone. Not very effective. Let us consider a surgical option for our patient.” Park instinctively avoided her name, Ruth. Despite hundreds of hours of practice, a name with both an r and a th was asking for trouble. He had never mastered either sound, and he now conceded he never would.
“Deep brain stimulation?” Aisha Ali asked, unsure.
“Is this the way you will talk to your patients, as though you are hesitant? Some uneducated foreigner asking where is the bathroom please?” Park asked.
“No, but I thought it was a last resort.” Aisha Ali was the most outspoken of Park’s Posse, as the group of foreign-born groupies was known around the hospital.
“It’s been used for twenty years with good success.”
Truth was, Park had decided he was going to use deep brain stimulation on Ruth Hostetler before he had gathered the small cadre of young doctors together.
So early that Sunday morning, the woman lay flat in an MRI wearing a large curved device on her head. The stereotactic frame looked like an oversize sextant, the navigational tool used by ship captains in the age of exploration to measure the angle of the sun and other celestial objects. Park was using the frame for much the same purpose: to help him navigate his probe to the exact coordinates in the brain to stop his patient’s tremors. Along the curved line of the frame atop the patient’s head like a metallic Mohawk were numbers that would tell Park the exact spot he needed to drill the hole in her head.
Inside the magnetic resonance imaging tube, the device beat out its rhythm, sending powerful magnetic wave pulses through her brain. The magnet in the machine pulled on the cells in her brain, then let them quickly return to their normal position. The little bit of energy that was given off during that process could be measured, and the machine would use that information to create an image of slice after slice of Ruth Hostetler’s brain, until a three-dimensional picture emerged. Deep in her cerebrum, Park saw what he was looking for: a small gray area, called the ventral intermediate nucleus of the thalamus, near the middle of her brain. The stereotactic frame to
ld Park the exact coordinates where he should enter the brain.
Ruth Hostetler was wheeled back to the operating room, her hands doing a silent but wild dance in her lap, where a small crowd of neurosurgical fellows and others waited—all young doctors training under Park for a year after their residency. No one worked their fellows or residents as hard as Park, and these MDs—again, most of them foreign born—took it as a badge of honor to be subordinates to the brusque, abrasive, and brilliant surgeon. In the OR, the patient’s head was immobilized but her hands continued to flop and flutter.
Having a crowd in the OR to observe, energized Park. He had never had a group this large observing his work. Then again, he had never before performed a deep brain stimulation for an essential tremor. The patient was still awake, under only a local anesthetic, as Park allowed Dr. Kin Chang to drill the hole. Most neurosurgeons would allow the patient to select some music to help drown out the noise of the drilling taking place on their head. Park never even considered that; it would be just one more distraction. When Kin Chang was barely finished, Park stepped up. He was wearing his surgical loupes, which resembled a pair of glasses with small jeweler’s lenses attached to each eyepiece.
“Now we start deep brain stimulation,” Park said. He threaded the probe along the angle dictated by the stereotactic brace until he had reached a depth indicated by the MRI. He nodded at the technician standing in the corner of the room. A set amount of current already chosen by Park had been dialed into the savvy piece of machinery, and the technician now pushed a button, which sent the current through the probe.
Within a split second, a look of pure terror filled Ruth Hostetler’s face.
“Dear God, no. Please, Heavenly Father, no. No.” With that, the patient let out a guttural scream that caused the doctors gathered around to recoil. Park didn’t budge. He just paused, and looked fascinated.
Park removed the probe. Ruth Hostetler stopped her anguished cry. She was still breathing fast. She closed her eyes and opened them several times as though to wipe clean the memory of what she had just experienced. Park said nothing to his terrified patient, who only moments earlier had been in a hell of the doctor’s making. Instead, he looked carefully at the probe, the way a tennis player who’d just whiffed a shot might look at his racket. He spoke to the assembled doctors.
“If there is such a thing as a fear center in the brain, I just found it.” Park turned to the nearest acolyte. “Dr. Singh, you and I will write paper.”
There was a smattering of laughter, muffled by the surgical masks.
Park checked his coordinates again and reinserted the electrical lead. A slight nod and the electricity was passed again. This time, the tremors suddenly stopped.
“Now, Miss Hostetler, please snap the fingers of your left hand.” Ruth Hostetler snapped her fingers. She snapped repeatedly, grinning. The doctors in the operating room applauded. Tears of joy ran in straight lines down Ruth Hostetler’s sunken cheeks.
A moment later her mood changed. She became flushed, and a strange look crossed her face. She opened her mouth as if to say something but stopped. Flushed himself from the success of the operation, Park did not notice the change.
“Dr. Singh, close please.”
With that, he left the room and went up to his office, thinking he had just performed a textbook operation. Maybe I really should write up something on the fear center, Park thought.
Two hours later, Park entered Ruth Hostetler’s room like a conquering king, a comet followed by a tail of fellows, residents, and medical students, in that order. The brace had been removed from the woman’s head, and she was sitting upright in bed. She held one of her husband’s hands in both of hers and gazed at him with an intensity Park could not place, though he thought there was something alluring about her. Levi Hostetler, on the other hand, did not look happy. Perhaps, Park thought, he was upset that science had cured what prayers could not. The man strode toward Park.
“Is this your idea of a sick joke?”
The question was so unexpected, for a moment Park didn’t know what to say.
“I don’t understand.”
“My wife.”
“Yes,” Park said, trying to get the conversation back on track. “No more tremors. The procedure work beautifully.”
“No more tremors but there’s something else,” Ruth Hostetler’s husband said. He looked uncomfortably at the small platoon of doctors in the room, then leaned in close to Park. “May I have a word alone?”
“This is teaching hospital. It’s okay.”
The man took a deep breath. “All right then. My wife is having these desires. These urges. Sexual urges.”
“That’s good. You two are married, right?” Park’s comment was met with a collective chuckle from his entourage.
“Dr. Park,” Levi Hostetler said, getting angrier. “The ability to control our base impulses is what sets man apart from beasts. I can’t have a wife who is in heat like some sort of dog. That is not godly at all. James, Chapter One, verses fourteen and fifteen: ‘But each person is tempted when he is lured and enticed by his own desire. Then desire when it has conceived gives birth to sin, and sin when it is fully grown brings forth death.’”
Park was again rendered speechless. But he was not going to let some Bible-quoting husband ruin his successful surgery. It was Park’s turn to get angry, and he was flustered enough that when he spoke his English became more fractured and his accent stronger.
“Mr. Hostetler. Your wife’s hand still. No tremor. She can eat. She can drive. She can work.” He paused. “This other thing.” Park glanced nervously at Ruth Hostetler, who looked as though she was ready to rip off her hospital gown at any moment. “Maybe you’ll see it’s a blessing.”
Without waiting for an answer, Park walked from the room, followed by his phalanx of acolytes.
As they entered the hallway outside the room, one male med student at the tail end of the group turned to another. “He’s complaining? The guy should pay extra. Prisoners with conjugal privileges get more than I do.”
CHAPTER 8
D
rs. George Villanueva and Ty Wilson carried hot dogs and beer to what turned out to be very good seats in the domed stadium, near midfield and up just high enough to gain a good perspective on the field. Light and sound were both muted inside the massive arena as the Lions and Chargers battled. Only Villanueva’s booming voice seemed to pierce the still air, cutting through it like a scalpel through a pustule.
“So, this EMT gets called to a house in Ypsilanti. When they get there, they find the patient in perfect health but one small problem. He has a recently expired canary up his ass.” George paused as he bite off and swallowed half a hot dog.
Ty didn’t know where the story was heading, but smiled anyway. He was enjoying this outing with the Big Cat. The two of them didn’t socialize much. For the most part, they met only at hospital functions, but Ty viewed this as Villanueva’s peace offering after the M&M. Ty saw no reason to hold a grudge.
“The EMT examines the guy and, I’m not shittin’ you here, looks him straight in the eye and says, ‘Dude, you gotta do a better job chewing your food.’”
Villanueva let out a roar of laughter, sending shock waves through his massive gut that nearly launched the two and a half remaining hot dogs off his cardboard tray. Ty laughed. When George caught his breath, he looked over at a Ty, serious now.
“Fired his ass the next day,” he said.
“No shit?”
“Hand to God,” Villanueva said.
The two men turned their attention back to the field, where the players were warming up. The Big Cat could not attend a pro game, especially a Lions game, without a mix of emotions. Nostalgia, for one. Not so much for the game itself. That was hard work, a struggle. As a guard, Villanueva spent much of the game absorbing and deflecting the abuse brought upon him by defensive linemen, blitzing linebackers and the occasional defensive back. They would smack the side of Villanueva�
��s helmet, send a forearm under his face mask. He’d even had players try to gouge his eyes. No, George did not miss the game itself. It was the camaraderie he missed. The guys. They were part of a team, a unit. They won together and they lost together. They shared sacrifice and success. They hit the town together after the game, before the soreness had set like paint.
Villanueva once heard a commentator describe playing professional football as akin to being in a car accident every week, and he thought the comparison was as apt as any. Professional football was carried out on “any given Sunday,” but had its own form of Monday Mornings. Simply getting out of bed was often a struggle. Still, the Big Cat had loved being part of an elite group of athletes. He’d loved playing in the National Football League with all its trappings, not least the young nubile women who seemed to know exactly which hotel the players were staying in and which ones were up for some action off the field.
When he went to a game as a spectator George also experienced something he imagined fathers of high school players did almost every Friday night across the country. He wasn’t sure there was a word for it. The emotion was part panic, part wistful, the notion that time had passed and, in some ways, his own time had passed with it. There were young men on the field doing what he’d done as a young man. By extension, that meant he was no longer a young man. No shit, George thought as most of the stadium stood for the opening kickoff.
Villanueva noticed Ty didn’t stand till a few seconds later. Distracted no doubt about the kid. The Big Cat turned his attention to the field, following not the ball as it arced toward the Lions’ return man but the line of blockers in front of him. As soon as he caught the ball, they moved upfield. As a rookie, George played on special teams. He was one of those guys. Special teams was a place where you could make a name for yourself for fearless play and big hits. In one game against the Packers he had decided to propel himself at the wedge buster, who’d in turn launched himself at the four blockers arrayed in front of the ball carrier. George was knocked out cold. The wedge buster, a kid named Stanton, was out for the season.
