by Sanjay Gupta
Brenkovski shrugged. Tina realized a tirade would be misplaced. So much seemed to be going in the wrong direction these days. There was the lawsuit facing the resident Michelle Robidaux, and Mark’s outburst at home; even her friend Ty Wilson seemed distant these days.
“It’s just one more thing,” she added. A cloud had crossed her usually implacable facade.
“My dear Tina. Do not fret.” He grabbed her by the shoulders. “Relax. Maybe take a weekend with Mark somewhere. Life is good.”
“Thanks,” Tina said and walked away, unconvinced.
Later that day, Tina stood at The Free Clinic holding the stethoscope to the muscled, stooped back of a patient who told her simply to call him “Rise—like the sun.” He was her final patient of the day. Tina had not taken Brenkovski’s advice and escaped with Mark. She didn’t need a weekend away with him. The Free Clinic was all the escape she needed, and she found herself spending more and more time there.
After learning about the new cardiac wing, she called DeShawn, the clinic manager, to see how it was going. He told her the place was swamped. A young resident was covering for the first time, and things had gotten backed up. It was also Friday rush—folks who didn’t want to spend the weekend sick. Tina had hurried over.
“All right, Rise. Take a deep breath,” Tina said. The man took in a lungful of air through his nose. “Now exhale.” Rise continued to hold his breath. “Exhale, Mr., ah, Rise.” Rise looked up, confused. “Let out your air.” He breathed out.
Tina enjoyed doing her part in offering preventive medicine for many who considered the emergency room their first stop when they got sick. And she liked helping the junior doctor who looked so grateful when she arrived.
However, unlike the stories politicians liked to tell about people showing up in the emergency room with the sniffles, Tina’s experience was that these folks waited way too long to get medical care—from the ER or anywhere else. They held the kinds of jobs that didn’t pay them if they called in sick. Tina recalled one man in his early forties who had walked in with his infant daughter, and a bulging fibrous growth on the side of his head that had swollen one eye shut.
“Why’d you decide to come in today?” the chief resident had asked as casually as possible.
“I can’t see out my eye no more,” the man said matter-of-factly.
There was another man who arrived with his testicles swollen to the size of volleyballs as the result of a long-untreated hernia. The chief resident had asked him the same question.
“Couldn’t find any jeans that fit.”
These were the most blatant cases, but there were others who arrived with stage 4 colon cancer, ignoring the bloody stools they’d experienced for more than a year and only coming in when abdominal cramps started doubling them up with pain. There were others who let teeth become so abscessed, the infection reached their brains.
Cases like these were an open challenge to Tina. She took them to heart. So, while other doctors played golf on Fridays or left early for their homes on Lake Michigan or the Upper Peninsula, she did her part. She realized her efforts were statistically insignificant, but they made her feel better and they did make a difference to the individuals she was able to help. The way Tina saw it, she couldn’t not help these people.
Tina moved the stethoscope on Rise’s back.
“Another deep breath.” Her concentration was broken by her pager. It said simply, 311. 6.
CHAPTER 22
V
illanueva was dressed in a slightly rumpled white dress shirt. His thin, 1980s-throwback tie only came to halfway down his torso, and he was wearing an old tweed jacket, the only one he owned that fit him. His thinning hair was slicked back across his head, and he was sweating, even though he was walking at a slow pace to dinner with his son. His pager was going off, but the sound was muffled by the considerable abdominal bulge covering the device when he was upright. The numbers had been flashing 311. 6. for quite some time. He wasn’t on call, and he hadn’t been paying attention in the movie theater, where he and Nick had seen the five o’clock show of a horror movie about a man with a brain infection that caused him to commit all sorts of bloody murders. Maybe all the screaming had distracted Villanueva. His son had picked out the movie, just as he had picked out the restaurant, a place that served vegetarian pitas.
Parking was always a problem in this neighborhood, which prided itself in its grungy hipness, so they needed to walk a couple of blocks in the brisk fall air past the organic food store that smelled like an incense factory, and the henna stand that specialized in applying the dye to the protuberant abdomens of young, pregnant women. Villanueva had never heard of the restaurant, but Nick had informed him over the phone that he was now a vegetarian.
“Eating meat, it’s bad for the environment. You know how many pounds of grain it takes to make each pound of meat, Dad?” he asked. “And that doesn’t even count greenhouse gases cows burp up and fart. They damage the ozone.”
Villanueva thought there was something odd about picking a movie where people were getting hacked to death every few minutes and then insisting on a vegetarian restaurant, but he bit his tongue. This night was going to be about Nick.
“Whatever you want, Nick,” George said. But he couldn’t resist adding, “You think I put a hole in the ozone after that time we ate at Taco Tony’s?”
Before picking up his son, Villanueva made sure he had a foot-long cheesesteak for lunch so he wouldn’t be in red meat withdrawal for dinner and a movie. Now, as they walked past a white teenager with dreadlocks, the Big Cat finally looked down at his pager and read the numbers.
“Crap,” he said.
“What is it?
“Your dad is going to get his ass handed to him on a silver platter first thing Monday morning.”
“You? How come?” Villanueva looked down at his son. To his surprise, he saw that Nick was interested. More than that, his son seemed concerned about what happened to him. George was surprised, touched by the worried look on his son’s face. He explained the case of Earl Jasper.
“I let my hatred of this guy cloud my judgment,” Villanueva said. “I should have let the neurologist see him and given him the best care possible. And then, I should’ve strangled him.”
Nick looked up, uneasily.
“I’m kidding, Nick,” Villanueva added, giving a pat that nearly sent Nick sprawling on the sidewalk.
“Yeah,” Nick said, forcing a laugh and tenderly rubbing his shoulder.
They turned the corner into a small square where white rastas, Dead Heads, and teenage beggars hung out with aging hippies banging on various percussion instruments. Villanueva thought he could smell the dope mixed in with the patchouli oil. People must be selling drugs by the trunk load down here.
“What a friggin’ circus,” Villanueva said.
“It’s always like this,” Nick said.
“You come down here a lot? Why do you come down here?” Villanueva tried to sound casual but couldn’t keep the prosecutorial tone out of his voice.
“Sometimes,” Nick answered. As soon as the answer was out of his mouth he amended it: “Not much.”
Villanueva was thoughtful for a moment. He realized how much there was about his son he didn’t know. His moment of introspection was interrupted by a woman’s loud voice.
“Let me be. Get your damn hands offa me.”
A small crowd had gathered in their path. An African American woman in her early twenties was trying to pull herself loose from what appeared to be her boyfriend. He was a hard-looking man, also in his early twenties, wearing a green military jacket. Every time she jerked away from him, he’d grabbed her sleeve or her wrist. Each time she tried to free herself from his grasp, he got a little bit rougher.
“Please, K.C. Let me be.”
“You’re not going anywhere.” As he tussled with her, his fist struck her across the cheekbone. She stopped struggling.
Villanueva and his son slowed to take in the sc
ene. For some reason, the man caught Nick staring at him.
“What you looking at?” he asked Nick. His voice was menacing. “I asked you a question.” Nick was speechless.
Villanueva walked through the circle of onlookers until he was standing in front of the man. When Nick realized what his father was doing, he regained his voice and called after him.
“Dad.” Too late.
The woman and man both looked surprised when they saw Villanueva appear at their sides. Her cheek was red and swelling.
“Who the fuck you think you are, fat man?” the man asked Villanueva.
“She wants to go. Let her go.” Villanueva said. He sounded as though he was explaining the most reasonable thing in the world.
“I get it, you think you’re Dr. Phil and shit. I have been itching to kick some ass.”
The woman looked panicked. She turned to Villanueva, “You best bugger out. He whacked.”
“You want to go,” Villanueva said to her. “Go.” With that, he stepped between the stunned couple, looking the man in the eye. His girlfriend, if that’s who she was, stared for a second and then turned and started walking away fast. After she’d passed the onlookers, she broke into a run. She didn’t look back.
The man glared at Villanueva. His jaw muscles bunched.
“You want to get all in my business, motherfucker,” he said. “I should cap your ass right here.”
With that, he swept back his fatigue jacket and put his hand on the barrel of a pistol.
“Dad, come on,” Nick pleaded from the periphery. He was so scared he had tears in his eyes.
There was a whoop, whoop from a police car, and the flashing lights of the cruiser started dancing across the scene. The man removed his hand from his gun and punched Villanueva hard in the chest. Villanueva had braced himself for the blow, which was a lot like a defensive lineman trying to bust through the line. He didn’t budge. The man looked at Villanueva, incredulous, doing his malevolent best to look threatening but clearly unnerved. Villanueva stared back.
“All right, let’s break it up.”
As the patrolman approached, the man broke off his stare and stalked off. Villanueva watched him for a moment and then found Nick in the dispersing crowd.
“Dad, you’re crazy.”
“I grew up with punks like him.”
“I mean it.”
Villanueva rubbed his chest. “He packed more of a punch than I thought.”
“You could have gotten shot or something.”
“And miss a vegetarian dinner with you, Nick?”
“Dad, I’m serious.”
They turned the corner and found the small restaurant.
CHAPTER 23
F
rom surgery, they wheeled Park to the Neuro Intensive Care Unit, where an ethnic melting pot of loyal residents hovered around their mentor. Next to the coffeepot and microwave at the nurses’ station, one of them had left a box of assorted teas. Earl Grey for the Pakistanis and Indians, green tea for the Koreans, rooibos for the African residents. The residents poured tea, fidgeted, and waited to see how their mentor, the hard straight arrow pointed their way in their adopted country, was faring. They clustered there, talking quietly in their variously accented English, going over all the possible complications and post-operative scenarios for Park. “At least it was well away from Brodmann’s area forty-four and forty-six,” one resident said professorially. “Yes, but what about the fine motor movements he requires?” said another with a clipped British accent. Still another resident, with choppy English similar to Park’s, said, “It all depends on how aggressive Dr. Hooten was. Did he go after all the tumor or did he try to preserve some of Dr. Park’s function?” Finally, the nurses shooed them all away.
After nearly twelve hours in the OR, Hooten left the hospital, got in his Volvo, and headed for home. He was completely spent but satisfied he had done everything he could to remove as much of Park’s glioblastoma as possible. In the past, he would have left the operating room and returned to his office to finish up some paperwork, but he was bone-tired. He tried to convince himself the added stress of operating on a friend and co-worker had wrung him out, but he knew that wasn’t true. There was a point during every surgery—when the lights were on, the blue draping framed the tumor, and his eyes were looking into the large microscope suspended over the patient—that Hooten forgot he was looking at a fellow human. In that small rectangle of flesh, he saw a medical problem, a tumor to be resected, an aneurysm to be clipped. The truth about his fatigue was more elemental. He was simply getting older. He couldn’t pull the hours he had when he’d first become chief of surgery at Chelsea General.
Still, he could be proud of his work. Looking through a microscope positioned over a small hole cut in Park’s head, Hooten had carefully reached Park’s tumor after cutting through the dura and splitting the sylvian fissure. He exposed the middle fossa of the skull and lifted the temporal lobe. Once he had exposed the tumor and separated it from the normal surrounding brain using a combination of bipolar cautery, suction, and small cottonoids, he had used an ultrasonic tissue aspirator to remove bit after tiny bit of his colleague’s tumor. To guide him, Hooten used a stereotactic probe that looked like a meat thermometer. The probe had two round reflective balls that a pair of electronic eyes picked up and compared with the three-dimensional MRI image on a screen near the foot of the operating table. By seeing where the probe was relative to the pre-op image of the tumor, Hooten knew where he was. It was like a GPS inside the brain. The tumor also looked different from the tissue around it. It was slightly grayer and more purplish in color. When his eyes and the probe told him he had removed all the tumor possible, Hooten gently handed the instruments back to the nurse. “Head Games” is what the residents called this 3-D navigation system. At first, Hooten had dismissed the new technology as just that—another video game disguised as an intraoperative tool. Over the years, however, he had become quite facile with the device. For an old dog, I can still learn many new tricks, he thought to himself. For five minutes, he said nothing, instead just staring through the microscope lens and trickling in very small amounts of irrigation fluid through a small catheter. He was carefully evaluating for any remnant tumor that the imaging technology may have missed, but his experienced eyes could catch. He also searched for any errant drops of red that could be a harbinger of more significant future bleeding in Park’s brain. During this five-minute period, no one in the OR made a sound. After he was convinced, he let the chief resident close.
Hooten knew there was more to the glioblastoma than he could see, though. GBMs did not have a defined edge the way some other brain tumors did, and malignant cells lurked beyond what was visible to Hooten as he looked down into the wrinkles and folds of tissue that held the obstinate, determined person the chief of surgery had come to admire. As he drove home listening to the news on CNN, Hooten knew with the dread he always felt after a GBM resection that even if he’d done his best work, he had not gotten all of Park’s tumor. Sometimes the small remnants could suddenly swell angrily in response to the insult they had just endured. Some of those remnants could simply remain, hidden for a time, only to suddenly start growing and replicating with a fury.
A story came on from Afghanistan with the latest news on the war on terror, and Hooten reflected that the glioblastoma cells he couldn’t see were little different from an al-Qaeda sleeper cell. They lurked unseen in the brain before a violent resurgence. Even with traditional radiation and chemotherapy, the chance of a glioblastoma recurring was 100 percent. The question was not if but when. Unfortunately for far too many patients, the tumor came back—usually not far from the original spot in the brain—within a matter of months. Patients were lucky if they went a year without a recurrence. The chance of surviving a year with a GBM was a little less than a third. The five-year survival rate was 2 percent, and Hooten suspected those cases had been misdiagnosed.
But doctors had not thrown in the towel against glio
blastomas. A new chemo drug seemed to buy patients a little time, and Hooten had immediately enrolled Park in a clinical trial that might buy him still more. It was a vaccine trial. The tissue from Park’s tumor was collected and bagged. Chelsea General would send it off to a lab to make a custom, personalized vaccine. The vaccine would enlist his own immune system to fight his tumor. It was like a red flag to the white blood cells that detected foreign cells. Park would get his first dose in three months.
The vaccine was a weapon also designed to counter another malevolent aspect of GBMs—their ability to turn off the body’s natural defenses against tumors and allow them to grow unchecked.
When he was telling medical students about this aspect of glioblastomas, Hooten, the inveterate birder, always likened this sort of perversion to the cuckoo. Female cuckoos lay their eggs in the nest of another bird and leave them for that bird to hatch. Aiding the ruse, cuckoo eggs look like those of the unwitting host bird. The cuckoo eggs then hatch earlier and the chicks grow faster, receiving their food all the while from the other species. This allows for the final insult: The cuckoo chicks, which resemble the species whose nest they have infiltrated, push out the host’s eggs or smaller chicks, claiming the nest for themselves.
By shutting off the host body’s white blood defenders, GBMs were no less ruthless than the cuckoo. Unlike the cuckoo, though, this wasn’t Darwinism taken to the extreme. This was simply a human body being conned into allowing rapidly dividing cells to run amok in the worst possible place, the brain.
When he operated on glioblastoma patients, Hooten was always tempted to take out a larger area of the brain than the MRI and the probe indicated. He might get a few more cancerous cells this way. But Hooten knew this was a fool’s errand. Excising more of the brain might reduce the number of tumor cells remaining, but it would increase the chances that Park would not be Park when he emerged from the anesthetic fog. Somewhere in the tissue lived an impossibly complicated web of neurons that made up the memory, the personality, the abilities that were the essence of Sung Park. Being overly aggressive also would not lessen the chance of the GBM coming back.
