by Allen Wyler
The young man appeared startled at being asked a question. “Not sure.”
“Means tough, strong, durable. Way I figure, the membrane got its name when Hippocrates was doing his first head dissection. As he was cutting it, he said, ‘Man, this is one tough mother!’ So the scribe, being the diligent worker he was, wrote down ‘tough mother.’ So that’s what it’s been called ever since: the dura mater.” The membrane open now, he turned to the chief resident. “Where’s the tumor?”
The left side of the patient’s skull was exposed in the center of the surgical drapes, a horseshoe-shaped incision of scalp pealed back, a four-inch square of removed skull safely protected in saline-soaked cotton towels on the overhead table with the rest of the surgical instruments. The “skull flap” would be reattached to the skull with wire during the closure, eventually growing together like a bone fracture. A square flap of dura had been opened on three sides, hinged, and held in place with small sutures. Inside this opening, the brain surface glistened from the saline gently squirted over it to prevent drying under the intense surgical lights. But the brain was beginning to bulge out of the opening, pushed by edema and extra mass caused by the tumor. One small area on the surface looked discolored and inflamed.
“There,” said the resident, pointing to the discolored portion. “This one’s relative easy to spot because it comes all the way to the surface.”
“Right.” Alex felt rather foolish playing the professor role, but hey, you had to start sooner or later. “This being the left side of the brain of a right-handed person makes it …?”
“His speech-dominant hemisphere,” the chief answered with an obvious hint of boredom.
Alex noticed the first-year resident hanging on every word. For him this was all new material to be learned as quickly as possible because there was just so much to absorb. “Okay, given that, how do we remove this tumor without damaging the speech cortex?”
“We know from our pre-op exam the patient is presently intact neurologically,” the chief explained, getting into teaching mode for the sake of his junior resident. “On the CT, the tumor looks like a glioma.” Which is a tumor of the brain’s supportive tissue instead of the nerve cells. “As long as we stay within the tumor and don’t get into normal brain, we should be able to gut this without damaging the functional brain.”
“Exactly right.” Alex looked to the junior resident. “Okay, so how do we do that?”
“Very carefully.”
Alex laughed at the stock answer and nodded for the chief to answer.
“After we take biopsies, we use very gentle suction. In these tumors the tissue is softer and more vascular than normal brain, so it can be sucked out bit by bit until we see more normal-appearing tissue. And being able recognize this is where experience comes in.”
Alex laid saline-soaked rectangular strips of cotton—called cottonoids—over the non-involved brain to keep it moist and protected from their instruments. “A fifteen Bard Park, please,” Alex told the scrub nurse, satisfied the tumor was now ready to be removed. A carbon steel scalpel made by the Bard Parker company, the number fifteen indicated the blade size and shape.
Using the very tip of the scalpel, Alex gently cut a half-inch incision in the glistening pia, the brain’s thin outer membrane. As soon as the cut was made, soft, swollen tumor tissue began oozing out of the small incision like toothpaste from a tube. He began carefully sucking away the mushy tumor with a small-bore suction, allowing the pressure in the brain to keep squeezing the tumor out without having to handle or manipulate the surrounding brain. His right hand controlled the sucker while his left hand held a small Malis forceps that could cauterize blood vessels caught between the tips when he stepped on a foot pedal. After several minutes, the pressure inside the brain lessened, allowing Alex to open the pia more.
“Call pathology for a frozen section,” Alex called to the circulating nurse filling out paperwork. Using forceps with a cupped tip, he plucked out ten small globs of tumor, making certain to sample as many areas of it as possible.
Satisfied, Alex then removed bits of tissue to send to his lab where he’d try to grow the tumor cells in a tissue culture. He believed the only way to solve the mysterious cause of these tumors was to be able to control their growth under laboratory conditions.
“What do you think?” he asked the chief, still trying to console him for having stolen the case.
The resident shook his head sadly. “I think he’s totally hosed. I’m betting glioblastoma.”
“Looks like a GBM,” said the pathologist, confirming the chief resident’s hypothesis. The scrub-clad woman poked her head inside the OR doors, holding a mask in place with her hand.
Shit. Alex gave an acknowledging nod. “Thanks. I’ll be by later to take a look.” To the scrub nurse, he said, “Okay, I need to take more samples for my lab.” Turning to the new resident, he asked, “Know what I do in the lab?”
“No sir.”
“I’m trying to learn what makes these damn things grow and become malignant tumors. Unlike some tissue—bone marrow, for example—that’s always reproducing, glia remain fairly static and neurons don’t reproduce at all. So the question is, what kick-starts these cells into growing? And once that happens, what makes them turn malignant? Any guesses?”
“Seriously?”
Alex used the cup forceps to pluck out his last sample, and handed it and the instrument off to the scrub nurse. “Yes, seriously.”
“I have no idea.”
Alex chuckled. “Nor do I. But I do have one theory I’m working on. Know what a stem cell is?”
The junior resident shot his chief a hey-don’t-leave-me-dangling look. The senior resident simply ignored him. Getting “pimped” was part of the game. “Not really,” he finally answered.
“Well, look it up. They were only discovered recently and are still being understood. But they do occur in the brain. I suspect they’re the cause of these tumors. Why? Because they have the ability to turn into many different tissues. That why they’re called stem cells. They’re the stem from which you can produce just about any cell in the body. I need to find what sets them off to go nuts.”
Alex worked swiftly and carefully, saying nothing. He focused intensely on every move, the responsibility of shepherding the patient through surgery unscathed weighing heavily on him.
“Ask you a question?” the chief said, breaking Alex’s concentration.
“What?”
“What made you get interested in GBMs? I mean, they’ve got to be the most depressing tumor I can think of.”
Alex paused, deciding whether or not to tell him. “My mother died from one.”
3
“I’ll check the duck,” Alex said, rubbing the soles of his shoes back and forth on the doormat, “if you pop the cork on the wine. Bottle’s on the counter.” He was still sucking wind from the mile-and-a-half hike back from the stadium, the last quarter mile up a steep, winding street to their neighborhood. It was a glorious autumn Saturday of muted reds, browns, and oranges, the air crisp and slightly biting, tingling his earlobes and the tip of his nose. A perfect football day. Even better because their team won.
“Deal.” Lisa followed suit with her shoes.
Alex passed through the small dining room and on into the kitchen, then out to the back porch and the barbecue. He loved the red lacquered cooker. Bought it at a hardware store as a graduation present. The bottom compartment held charcoal briquettes, the middle section held a pan of water, the top had the grill over which the red dome sat. Cooking was controlled either by frequent monitoring or by simply starting with a limited amount of fuel. He preferred the latter option. After lighting the briquettes he would insert the water pan and then the grill with whatever meat needed cooking. No matter how long the football game lasted, by the time they returned home the food would be cooked to perfection with a lovely smoky flavor. He removed the lid to inspect the duck. Perfect—a crisp golden-brown skin. Even better, it was
still warm.
After setting the duck on the kitchen counter, Alex returned to the front closet to hang his jacket, his face still stinging pleasantly in the cozy warmth after several hours exposed to chilly fall air. Lisa returned to the kitchen. “Sorry, I didn’t open the wine yet—had to make a pit stop.”
“That’s fine, I’ll do it.” He picked up the bottle to start peeling away the foil, and Lisa took one of two chairs at the small bistro table to watch. “Great game.”
Lisa issued a derisive snort. “You say that about every game we win, regardless of how many penalties or mistakes they make. But I have to agree. Certainly was exciting. That ending … wow.”
Foil off, he began screwing the worm into the cork. “Oh man, tied at the start of the fourth quarter. Wasn’t sure they’d be able to pull it off.”
“That punt return was what saved us. Special teams have done it all year long. Not the offense or defense, but special teams.” A rabid NFL fan, she wasn’t as keen on college ball as he was. Still, she could hold up her end of a postgame conversation.
“Well, the punt return and the defensive play in the final ten minutes. Jesus, thought I was going to stroke out those final seconds.” He sniffed the cork, nodded approval, and poured two glasses of cabernet, which he brought to the table. Lisa waited for him to sit before she raised her glass in a toast. “Health and happiness.”
“Health and happiness.” They clinked and sipped, making no effort to dive straight into conversation, just enjoying the beginning of a wonderful fall Saturday evening. He loved these well-worn-jeans-and-sweatshirt moments with Lisa.
Alex sat cross-chaired, back against the wall, admiring the small kitchen of a home someone had classified as Dutch Colonial. He couldn’t define the style. It had three bedrooms, two and a half baths, and an unfinished basement. A good “starter home.” His first. Shortly after moving in, he’d replaced the linoleum kitchen floor with pre-stained parquet squares. Not a perfect job by any standard, but it was work he felt proud of. A butcher block occupied the center of the room and held a wood salad bowl, salt and pepper set, and knife block.
“You know, right now life seems too good to be true. Does it seem that way to you?”
Lisa nodded. “Yeah, it does.”
He swept a hand left to right. “This home, our lives … I just feel so content. Just look at today: we walked to the football game and back while dinner cooked on the smoker. Tonight we’ll stay in and watch a movie. I’m an assistant professor at a good university. We’re both making some money and have our health. What’s not to like?”
Lisa hesitated for a moment, then spoke up. “Well, there’s one thing that could be better.”
“Oh? What?”
She cocked her head as she collected her thoughts. “I just wish we had more time for evenings like this, just the two of us. I don’t really understand why you need to spend so many nights in the lab.”
He reached across the table, took her hand. “I love you. You know that don’t you?”
She nodded.
He’d explained it all before: the junior man gets stuck with the crap the senior partners are sick of—rounds at the VA Hospital Tuesdays and Thursdays that included the outpatient clinic. Not only did the commute burn an hour and a half, but dealing with the bottomless pit of red tape from VA career bureaucrats was hair-tearingly frustrating.
“Things will get better. Once I get my grant I’ll be able to hire another lab tech, and that’ll relieve some of the pressure. Soon as that happens, my productivity will improve to where I can advertise for a postdoc. Things will get better. I guarantee it.”
Lisa sighed. “Heard anything from NIH yet?”
The contented glow vaporized. He snapped back to reality. For the past several hours he’d been blissfully distracted from the issue.
“No.”
“Have you talked to Dr. Waters about it?” Lisa was still finding it difficult to refer to him as “Art.” Only recently had Alex broken the habit of calling him “Dr. Waters.”
“Yesterday, as a matter of fact. He was pretty frank about things, said if I hadn’t heard by now, chances were it didn’t pass study section.” Study section was the group of scientists who reviewed and prioritized grant applications.
“What does that mean for your lab?”
The anxiety eating away at his gut these past few weeks returned, a deep, uncomfortable distress bordering on pain. “Until I’m funded, I’ll have to scale back my work. Art says I have to take over a hundred percent of the trauma center coverage.”
“But you’ve been so productive in the lab.” She was frowning now. “How can they do that to you?”
He downed his wine and poured fresh glasses. “No problem understanding that, Sweetie. My salary is based on lab effort, not clinical work like the other surgeons. If I can’t support myself on grants, I have to earn it clinically. All the other guys have established practices, so I can’t compete at the U hospital. Well, I could over time, but for right now I can’t. The only solution is to cover the trauma center.” A funk settled over him at the thought of having to spend his time in the OR instead of the lab. More than once, he considered going back to school for a PhD to allow him to devote all of his time to research instead of continuing this schizophrenic division of responsibilities.
“Actually,” he continued, “I start taking call Monday.” He’d not mentioned this before for fear of spoiling the weekend. Recently, he’d begun to view himself as a failure. Winners had grant support. Losers had nothing. Twice now, he had served as an ad hoc NIH reviewer, so he had insight into this classic catch-22 conundrum: grants were awarded to seasoned researchers with proven track records, leaving unfunded scientists like himself in the cold. How the hell were you expected to develop a track record if you couldn’t support a lab?
4
“Hummus again?” Alex asked Karen Fitch, his lab tech.
Karen responded with a self-conscious laugh, her habitual reaction to most questions. She pushed strands of scraggly, shoulder-length black hair behind her ear. “Why do you ask?”
Alex, Karen, and Steve Stein, a local student slated to begin Vanderbilt Medical School in ten days, were sitting in the lab having a lunch break.
His turn to laugh. “Seems like hummus and pita bread are all you’ve eaten for lunch these past two weeks. This a new diet?”
Karen, a tall, big-boned free spirit, constantly dove into various special diets reputed to contain undocumented naturopathic benefits. After perhaps a month or so, her focus would shift in a sort of dietary Brownian movement. Last month she ate only sardine sandwiches on whole grain bread, one of which she shared with Alex and Steve. He had to admit it tasted wonderful, but a month of nothing but sardines seemed a bit, well, over the top.
She returned to grinding garbanzo beans with the lab’s mortar and pestle, adding in a splash of extra virgin olive oil and some spices. Her kitchen was the lab’s sheet metal countertop. She routinely bought the beans and other ingredients at a co-op known for predominately organic fare. “Hummus is healthy. You should eat it instead of that greasy fried chicken every day.”
“Already have. You gave me a taste last week. I have to admit, you do a great job with the hummus and bread. Where’d you get the recipe?” He knew she baked breads from a hundred percent organic ingredients.
She perched on a lab stool, her six-foot frame hunched over the counter, knees angled to the right to keep from banging against the shelves. She stopped grinding and plunked her elbows on the countertop, her eyes glazing into a thousand-yard stare. “I was on my ultimate world trip.” Recently everything had become “ultimate”: the ultimate New Year, ultimate birthday, ultimate sardine sandwich. “We’d worked our way through India and were in the Middle East when we stopped at this kibbutz in Israel. Did I tell you about my year at the kibbutz?”
He brought his brown-bag lunch to the counter and took the neighboring stool, with Steve to his right munching a PB&J on white bread—a c
hoice Karen rode him about constantly, yet good-naturedly. “You mentioned it briefly one time but never told me the full story.”
“Well you’re not getting the full story now, or ever. There’s not enough time for the ultimate version.” Another laugh. “Perhaps one of these afternoons when it’s slow. Anyway, this one really amazing Israeli cook taught me the recipe from scratch. I watched her work, and when she finished, she offered me a serving. It was the most delicious food I’d eaten in months. So,” she shrugged, “I tried to remember the exact recipe, but of course, couldn’t. This is close enough. You like it?”
From his brown paper bag, Alex withdrew his daily lunch: two pieces of fried chicken and an orange. “I do. It’s very good.” It wasn’t simply a gratuitous compliment. She was an amazingly good cook.
Steve chimed in. “Sure is healthier than your greasy chicken. How can you eat that? It’s so … unhealthy.” Steve glanced at Karen for support.
Alex couldn’t tell if Steve was joking or not, but laughed anyway. True. Every Sunday he stopped at Safeway for a ten-piece bag of frozen fried chicken and five oranges. Sunday afternoon he baked the chicken, sorted the pieces into five equal portions—each of which he wrapped in aluminum foil—then assembled and stored five sack lunches in the refrigerator. On his way out the door each morning he grabbed a sack, giving Lisa more time to get ready for work.
“I can’t argue with you on that,” he said. “Just seems like so much trouble to go through every day.”
Karen stopped mashing beans to face him, beaming. “Trouble? Not at all. Dishes I make with my own hands,”—she held them up as if mystical instruments—“that I create from raw ingredients taste so much incredibly better than store-bought food. I made the bread too. Did you know that?”
“Yes, that’s why I asked how you do it. You only mentioned the hummus recipe, though. Where did you learn to bake bread like that?”
