by Sanjay Gupta
Ty ordered an MRI. For some reason, no one had thought that Cooper’s psychosis might have roots in his brain physiology until his left eyelid began to droop, but the scan showed a large bi-lobed meningioma on his frontal lobe. Ty attempted to talk to Cooper about the tumor in his brain, the surgery, and its risks, but informed consent in this case was more of a formality than a fact, much as it was in dealing with Alzheimer’s and dementia patients. Cooper merely muttered something about Class 4/5 switching systems and the USS Pomfret before signing his name. To Ty’s surprise, Cooper’s signature was beautiful—neat loops and lines that could have come out of a penmanship textbook. The name he signed was a reminder that Cooper lived on the locked psych ward: James Earl Carter. Still, the handwriting made Ty wonder where this man had come from before his life on the streets. He did not show the liver function of a man who had spent his life hitting the bottle hard.
The operation was a stunning success. The tumor was removed from both hemispheres of his frontal lobe, responsible for judgment. The buzz at the hospital started almost immediately. In Post-Op, Cooper began asking about his wife. The nurses, thinking he was still waking up from anesthesia or delusional, ignored him. He finally grabbed one of them by the arm and started demanding answers. He told them he felt like he had just “awoken” and asked what year it was. When they skeptically told him, he began weeping. He asked for a piece of paper and began writing. He handed over an address and a phone number, again written in beautiful penmanship. Intrigued, a hospital social worker actually drove to the address when the phone number came back as disconnected. Bit by bit, Cooper’s story emerged: The man had been a project manager at Pfizer until the tumor had started affecting his judgment. At first, he started making simple mistakes. He forgot to go to work on a Monday, but was showered and dressed at 6 AM on a Sunday. He had laughed it off at the time. On one occasion, he had spent an hour looking for his car keys when leaving the office, only to get a call from security. It turned out his keys were in the ignition, and the vehicle had been running all day long in the parking structure. From there, it had become much worse. His frontal lobes were slowly being consumed by the tumor. He began drinking, lost his job, his wife, and then his house. As the tumor further invaded the seat of “executive function,” Cooper became homeless and paranoid, seemingly just another delusional man looking for a drink.
The hospital found his tearful ex-wife. She had remarried, but agreed to drive Cooper to his parents’ home in Dahlonega, Georgia, where he began life anew after eleven lost years. It was the stuff of Hollywood, and the story of this medical awakening swept the hospital like kudzu spreading among the pines in Cooper’s hometown. Soon doctors, residents, and house staff Ty didn’t even know were congratulating him on the case. Ty’s legend was born, and his subsequent skills and Zen in the OR only enhanced it. Other surgeons admired—even emulated—his cool, almost spiritual approach to the operating room, but they could not match his skill. And while Ty did not hesitate to perform even the most complicated operations, other surgeons dwelled on the knowledge that even operations that were considered routine, such as a total knee, were in reality complicated procedures. The old knee needed to be removed at just the right point, with the bone sawed at the proper angle. The artificial knee had to be set correctly. There were risks of infection, which could kill a patient; there were risks the knee would not be aligned perfectly, which would limit the knee’s usefulness; there were risks of damaging the surrounding ligaments, which could cause an irregular gait; and then there was the risk of the unknown, especially with anesthesia.
Medicine was designed to bring the best results to the most patients, and surgery was no different. The buzz phrase was evidence-based medicine. Doctors and surgeons based their work on probabilities, but there were always statistical outliers: Patients who responded in unexpected and deadly ways to anesthesia. Or patients whose blood didn’t clot the way it was supposed to, or who reacted to medicine in ways the journal articles never predicted. There were even patients whose body parts were not where they were supposed to be. Ty remembered one patient in general surgery who had been born with a single kidney but didn’t know it until they told her; another who had an extra spur on her humerus bone near her elbow, a congenital defect common enough to have a name, supracondylar process; another who had abnormally long metacarpal bones on both ring fingers. Pulmonary veins were notorious for their anatomical abnormalities.
All this could give residents night sweats. Ty remembered a fidgety, nail-biting resident named Kowalski. The joke among fellow residents was that Kowalski’s sphincter was so tight, if you stuck coal up his ass, you’d make diamonds. They had even stuck some laxatives in his coffee once, to loosen him up. He spent half the day in the bathroom, and came out more neurotic than ever. Kowalski tried amassing knowledge as a way to prepare himself for the strange and unpredictable. What do you do if you discover cirrhosis unexpectedly during surgery? What if you find a surprise lesion during cardiac surgery? If there was a single case in the medical literature of a bowel obstruction presenting as appendicitis, he wanted to know about it. Kowalski tried studying next to orange slices because the sense of smell is so closely linked to memory. He thought this would help burn this information into his brain. Not satisfied with mere eighteen-hour days, Kowalski started taking modafinil to read for longer stretches. If it worked for air force pilots flying halfway around the world and back, why not give it a shot? Kowalski lost weight. His skin took on a grayish pallor, and the dark circles under his eyes made him appear haunted. He became irritable and prone to wild mood swings. One day, Kowalski was operating when he discovered a left-sided gallbladder. Somehow, he’d failed to encounter this possibility in his dogged reading of the journals. The exhausted, stressed, overemotional resident asked the circulating nurse to call the attending and walked out of the OR. The next day, he left the surgical program. He decided living in fear of the next operation was no way to go through life. He became a successful dermatologist.
Ty was different. Even with brand-new procedures or patients with very poor chances of survival, Ty was always loose. Even when the patient died post-op—even when the patient died on the table—Ty knew he had executed the procedure as well as anyone. Had he been deluding himself all this time? Had all this success bloated his ego and clouded his judgment? Had his overconfidence allowed him to kill Quinn McDaniel?
Ty looked down at his patient and the tubes snaking out of her nose, which was the only part of her face visible. The rest of her body was hidden by blue surgical draping. Now it wasn’t overarching confidence but dread that clouded his brain and froze his hands, which were the envy of the neurosurgical world. He had experienced this sweeping fear only two weeks before, clipping an aneurysm. Then, he had merely been undecided about which type of clip to use. This was far worse. This was paralyzing. Ty felt an anger welling inside him.
Ty turned to Mac Ryan, the senior resident.
“Mac, you ready to try ETBS?” Mac’s eyes above his surgical mask showed surprise.
“Sure, Ty.” This was an unexpected gift. Residents were always eager to do more. Usually, though, surgeons told residents ahead of time if they were going to be taking the lead in surgery, especially one as involved as this.
“I’ll walk you through it.”
Ty was sure Mac had read all the literature on the procedure. His senior resident was nothing if not thorough. Mac slid over next to Ty and took the instruments.
“Take a moment to get the feel of the endoscope.”
Step by step, Ty talked Mac through the procedure, admiring—almost envying—the younger doctor’s poise and patience.
When Sandy Shore was in recovery and long after Mac had showered and left, Ty sat in the locker room. He was furious at himself, at his lack of nerve and loss of self-assurance. He’d gone into medicine for two reasons: to be better than the doctors who allowed his brother to die, and to treat his patients’ families better than he had been treated. Rushi
ng Quinn McDaniel into surgery without checking the possibility of a bleeding problem was a rookie mistake. Worse than a rookie mistake. It was an omission that had cost a boy and his mother dearly.
Ty changed out of his scrubs and threw them into the hamper in the corner. He put on his clothes and slammed his locker. He slammed it so hard the metal door didn’t latch shut. Ty grabbed the locker door and slammed it again. Then he walked out the door.
CHAPTER 13
A
t exactly 6:14 AM, Ty found himself back in front of the M&M room. This time, though, he was unable to control his sweats and his shakes. He was drenched and shivering. He looked out into the audience, and everyone there was laughing and pointing at him. Park, Sydney, and even Tina. She mouthed, I’m sorry, and began laughing so hard she doubled over. “The prodigal son…yeah right,” someone muttered. He looked over at Hooten, waiting for him to start. Strangely, every time Hooten opened his mouth to say a word, all that anyone could hear was a buzzing noise. It was as if there were a huge insect inside the man. Hooten tried again, and again made a buzzing noise. Again, the same thing. Bzzz. Bzzzz. Bzzzz. It was terrifying. Something seemed to have taken over the Boss.
Tina rushed forward. Ty was paralyzed. But instead of running toward Hooten, she came running straight for Ty. She was moving quickly, and suddenly her hands were on him. She shook Ty by the shoulders. She looked him right in the face, and then she was making that same weird buzzing noise. Slowly, the buzz turned into words. Ty stared hard at her face to try to understand what she was saying. “Wap,” she said. “Waup. Wake up!” she shouted. Ty rubbed his eyes in his own bed. Tina handed him the buzzing pager. It took him a full minute to acclimate himself. “Bad dream?” Tina asked with a sweet but worried look. She ran her fingers through his wet hair. “Yeah,” Ty muttered as he looked at his pager. Level 1 trauma. Epidural hematoma. ER 20 minutes. Medevac chopper, it read. Ty checked his watch, gave Tina a quick kiss, and jumped out of bed. Just minutes later he was putting on his leather jacket and grabbing his helmet off the back of his Suzuki Hayabusa. Ty knew it was unusual to be riding a motorcycle, given his career choice taking care of head injuries. But the first time someone had explained that this particular bike might just be the fastest in the world, it was all but preordained that he would have one. Ty blasted down Washtenaw Avenue, a beautiful two-lane stretch of road with no traffic lights. He picked up speed, and looked up to see the trauma chopper flying just over him. His patient was on that helicopter. Ty pulled back on the throttle—the Hayabusa responded quickly. And for a few minutes down the nearly abandoned road, it was a man and his motorcycle keeping up with the chopper in the sky. Ty felt exhilarated as he flew by the Washtenaw County Medical Center, forgetting for at least a little while the angst that had crept into his core.
Inside the county medical center, Park sat with his hands folded in the radiologist’s waiting room. He heard the loud motorcycle engine roar outside the window and silently cursed. I will probably be operating on that guy later on, if he isn’t brain-dead and donating his organs, Park thought. He looked around the sterile waiting room. There was the usual collection of untouched preventive health pamphlets on quitting smoking and reducing your chances for a stroke, along with well-worn gossip and women’s magazines with articles on celebrity scandals, becoming thinner, enjoying sex more, and simplifying your life. So much mental energy wasted in the United States, Park thought.
Park had undergone an MRI an hour and a half earlier and had been waiting ever since. He had told his loyal cadre of residents back at Chelsea General he was at his daughter’s cello recital. Since he never took time off for anything, they were enthusiastic. The excuse was starting to wear thin, though. His daughter was surprisingly very good for her age, but she would have to play an entire concerto to take up as much time as he’d spent out of the hospital.
The doctor had poked his head out a few minutes earlier.
“Mr. Song.” Park didn’t look up. “Mr. Song,” the doctor said again, this time louder. Park remembered that he had signed up using his wife’s maiden name. He looked up. “I’ve looked at your MRI. I’ll be ready to talk to you in just a minute.”
Park didn’t want word getting back to Chelsea General about the MRI. He never wanted to show weakness. After all, it was most likely nothing but stress causing the intermittent headaches that had started six weeks earlier and seemed to be increasing in frequency. At first, he tried ignoring them. He was a firm believer in mind over matter. Hadn’t he endured residency’s years of thirty-six-hour days not once, but twice? When he could not will away his headaches, Park began taking Tylenol. By the time he made his appointment at Washtenaw County, he was popping Tylenol like candy.
After the doctor, Milner or Miller, whatever it was, had said he’d be right out, he’d disappeared again. Park checked his watch. Fifteen minutes, and counting. The front desk, too, was abandoned, leaving Park and an elderly man and his wife there to languish in the waiting room. The overhead fluorescent lights were starting to bother him. Were they flickering? He bowed his head and picked up one of the pamphlets: Your Guide to Smoking Cessation. Park knew what cessation meant, thanks to the English-language and vocabulary-building cassette lessons he kept in his car. He’d played them in his ancient Honda until each cassette’s title was worn to nothing. He knew the tapes by heart, but he still played them every time he got in the car. They calmed him. “Cessation: a ceasing. An end; Chimera: a fire-breathing female monster with a lion’s head, a goat’s body, and a serpent’s tail; or, a thing that is hoped or wished for but in fact is illusory; Cognizant: having knowledge or being aware of.”
Park put down the pamphlet and began pacing around the room. He was fidgety, and he couldn’t sit still. For Park, doing nothing violated some basic rule. He was hardwired that way. He was a doer. If you weren’t doing something, you weren’t going to accomplish anything. Doing nothing was wasted opportunity. Doing nothing was something that obese diabetic Americans did between doctor’s appointments.
After so many years, he still found much about American culture difficult to understand. Here was a hospital spending money on a pamphlet suggesting people give up smoking one of the most addictive substances on the planet—when stern warning labels, common sense, family member pleadings, the sight of emphysemics with portable oxygen delivered through their nasal canula, and the near certainty of a miserable death had all failed. A pamphlet? That was going to work?
Much seemed backward about his adoptive homeland. American parents deferred to children, shaping their lives to meet the extracurricular whims and social engagements of their offspring. They kept a calendar for their children as though the youngsters were royals and the elders social secretaries, organizing their work schedules so all the carpools to the various sports and lessons would be covered. The parents even placed stickers on the back windows of their minivans showing silhouettes of gymnasts or football helmets or soccer balls. The icons were labeled BRITNEY or KELSEY or BRANDON. The message was clear: The parents were there to promote and boast of their athletic accomplishments. What trivial pursuits!
Pet owners were perhaps the most baffling to Park. They obediently walked their dogs, even in the most inclement weather, carefully scooping up their turds and carrying them home in plastic bags as though they were some sort of prize. They even gave the dogs the same surname as the owner. It seemed so disrespectful and uncivilized.
Bored with pacing in the waiting room, Park walked up to the front desk and peered over the counter, looking for the doctor, a nurse, the receptionist, anyone he could pester. The office looked deserted. Probably a drug rep serving everyone lunch. It was a beautiful woman, no doubt, showing too much cleavage and persuading the doctors to prescribe her product. He remembered one of them had even tried to give him a book once. It was the story of a Viagra salesman, and the title was Hard Sell. Unacceptable, Park thought.
Park opened the door that read NO UNACCOMPANIED PATIENTS BEYOND THIS POINT an
d headed down the corridor. Framed children’s art decorated the hallway between examination rooms. When he neared the end, he saw an MRI on a light box. It was an axial cut of the brain, Park instinctively thought. The image had contrast, and there was some motion artifact around the border. Probably a lazy technician, Park mused, but he had to admit it was a pretty clear image. He moved closer. The picture showed a bright mass in the right hemisphere. It wasn’t a solid mass, but rather somewhat blurry and uneven with rough borders and scalloped edges. No doubt, Park said silently, a classic glioblastoma multiforme. Probably the most malignant tumor known not just in the brain, but in the entire human body. No cure, and no proven effective treatments. Whoever this poor bastard was would need an operating room immediately. Park shook his head. Even he would have trouble handling that one. He guessed the patient had six months to a year to live. He wanted to tell Milner or Miller, that slow doctor, that he should refer the patient who had this scan over to his clinic. Park looked at the scan again and the patient’s name in the lower corner of the image caught his eye: SONG. Park did a double take. His wife’s maiden name. Strange. Then he remembered. Song. His alias. He nearly threw up.
It had been just ten minutes since Ty arrived at the hospital, parking his motorcycle outside the ER entrance seconds before the helicopter landed. He ran up to the helipad. “Gimme the bullet,” he shouted over the whir of the helicopter blades as he helped wheel the patient toward the open glass doors to the hospital.
“Three-passenger MVA,” the medic shouted. “Father was driving, and was killed at the scene. This is the ten-year-old son, with likely epidural hematoma, and mother is about five minutes out with an intracerebral blood clot in the right frontal lobe…she doesn’t look good, and is going to need an operation quickly as well.”
