by Allen Wyler
Not wanting to change back into scrubs again, he slipped on a “bunny suit” and shoe covers, walked quickly down the hall, and poked his head back in the room. “What is it?”
“Motherfucker’s bleeding again.”
“Let me see.” He stepped closer for a look at the surgical field.
Cramer lifted the corner of the lap pad.
He was stunned. “What the hell did you do? That isn’t my closure.”
Silence.
“She replaced it with nylon,” the scrub nurse muttered.
“You …” Enraged, speechless, he stared at the mess for a few seconds before turning to leave. “Call a vascular surgeon in here. Someone’s going to have to lay in a patch or something, but it’s out of my area of expertise now.” Still fuming, he pushed open the door.
“We’re getting into some clotting problems,” the anesthesiologist called after him.
“That’s your problem.” Then on second thought, he said, “Call Gene Roux.”
50
Alex snapped wide awake.
The telephone rang again. He rolled onto his left side, his back to Lisa, and picked up the phone. “Cutter here.” The clock digits glowed 2:32 a.m.
“Sorry to bother you, Doctor Cutter. Sam Riddell. I’m covering the trauma center. We just got a GSW to the head in and Kotell”—a clinic partner—“refuses to come in.”
“Refuses?” Alex was on the edge of the bed now, knuckling eyes with his free hand.
“Yes, sir.”
With Reynolds in Bethesda, backstopping the trauma center defaulted to him, although he doubted Reynolds would have come in. “Be right in.”
He drove deserted Central Avenue doing a slow burn. Refused to come in? What kind of bullshit was this? Alex picked up the car phone—a new addition he was rapidly learning to love—and found Kotell’s number in the programmed directory, punched “Dial.”
Kotell’s sleepy voice answered. “Hello?”
“Kotell, Cutter. Did you just get called by the trauma center?”
“Why?” He sounded incredulous.
“Why?” Another spike of anger. “Because I’m the one having to cover your sorry ass. That’s why. Why did you refuse to cover? You’re on call.”
“Damnit, Alex. Can’t we discuss this another time? I have a case in the morning and I’m trying to sleep.”
“Yeah? Well I was sleeping too, but because you’re too lazy to take your call, I have to do it for you. What do you think you’re doing?”
“Listen, you sanctimonious ass. Think about it. I bet you a thousand dollars the clinic won’t get paid a goddamn cent for that case. Some nigger gets shot at two in the morning, you know chances are overwhelming it’s crime related. I’m sick and tired of taking care of ’em. Let ’em all shoot each other and be done with it. That’d be fine with me. Besides, the resident is more than capable of handling a head wound without either of us standing in the OR with our thumbs up our ass.” Kotell hung up.
Alex slammed down the phone, almost hard enough to break the handset. A full surgical load—two craniotomies—scheduled for later today, and now he wouldn’t sleep until evening. Why did he put up with assholes like Kotell? Easy answer: the pay was too good.
He locked up his Audi in the empty Baptist parking garage instead of using the reserved “Physician On Call” spot at the trauma center ambulance bay. He decided to walk the two blocks between hospitals, because by time he finished the case, it’d be senseless to drive home and shower, only to turn around and come back downtown. His only consolation prize was a full choice of the prime parking stalls just outside the doors to the sky bridge. Still fuming, he trudged down the stairwell to the alley, the muggy night air residually thick with car exhaust from the previous day’s rush hour.
4:45 a.m. Alex sauntered out through the automatic glass doors of Trauma Center ER into the brightly lit parking lot. He took the ramp at a leisurely pace down to the deserted street. No sense hurrying now. A layer of clouds hid the stars. Dawn would begin soon. To him, this hour of the morning seemed the stillest of all twenty-four, a transition time between a sleeping city and a city ready to work. Feeling heavy and sluggish from fatigue, he continued the leisurely walk, enjoying the quiet solitude. The cafeteria wouldn’t open for another hour and fifteen minutes. His first case didn’t start until seven thirty. He wanted nothing more than to curl up and sleep, but that was impossible now.
In the middle of the block, he took a shortcut into the shadowy alley between two large medical center buildings. Glass crunched underfoot and the smell of rotting garbage filled his sinuses. Puddles in the rutted asphalt reflected light from the mercury vapor streetlight at the far end of the alley. For the first time in a week, he thought about his research, about his frustrated attempts to rekindle it and how they repeatedly failed for one reason or another. Yes, he was passing off chunks of tissue to his collaborator in Cell Biology, but their work was pedantic and unimaginative, just barely funded. The longer the gap without solid funding, the murkier his name would become in the minds of NIH. He needed to stay firmly on their radar if his research was going to succeed. He’d debated reaching out to his academic contacts to see what openings might be available, but the thought of packing up and moving and starting over again seemed too daunting. Worse yet, he hated to admit how much he’d become addicted to the quarterly bonuses. Yet he couldn’t shake the belief that the key to understanding the horrible disease of glioblastoma resided within the stem cells he saw in the tumors. No one had addressed this particular issue yet, and he still possessed all his lab books and journals from his previous job. Sooner or later, though, someone would come along the same path of research and, Alex believed, make a huge breakthrough. He despised himself for aimlessly floating along.
The surgeon’s lounge was empty when he arrived, yet one coffee pot contained what looked and smelled like freshly brewed coffee. He chose the most comfortable of the three couches and stretched out, the heels of his Nikes propped up on the arm. Eyes closed, he rested, knowing sleep would be impossible, but at least he could relax until the lounge began to fill up for the day’s schedule.
Sometime later, he heard hushed movement and cracked his eyes. Phil Chapman, an anesthesiologist, was pouring a cup of coffee. Phil glanced at him. “Sorry. I was trying to not disturb you.”
Alex sat up, working out a kink in his neck. “Wasn’t asleep anyway. You in the bucket or just getting started?”
Phil glanced at his watch. “In the bucket. Just finished a caudal up on OB. What’re you doing here so early?”
Alex decided on having a cup to help perk him up, so he poured one while telling Phil about the trauma center case.
First cup of coffee drained, Phil poured a second one. “Want another?” he asked, holding the pot at the ready.
“Naw. Limit myself to one on days I operate.”
“Why’s that?” Phil came over to sit at the end of the couch at a right angle to him.
“Causes a caffeine tremor in my hands. Never realized I had one until I took Rhoton’s microsurgery course in Gainesville. The first lab day we were doing a carotid anastomosis with 10-0 silk”—a suture thin enough to place through a human hair—“and my fingers were shaking too badly to do a good job. I couldn’t stop it, so I called over the instructor over, had him look through the observation side of the scope. Didn’t take him five seconds to tell me it was a caffeine tremor. Next day I skipped my morning coffee and, voila, the tremor wasn’t there. Now I limit myself to one cup when I have to operate.” He laughed. “Helps with the bladder issue, too.”
Chapman laughed, too. “We’re lucky. Our group is big enough to always have a rover who can spell us periodically. You guys aren’t so lucky.”
Alex stretched out again. “Go ahead, talk. I’m going to relax until the room starts filling up.” He decided to take a shower once people started to wander in, just to invigorate him. He kept shaving gear in his locker for just such occasions.
5
1
“Doctor Cutter? Please follow me.” The nurse led Alex past the reception desk and down a short hall to an exam room where he took a chair.
Minutes later the dermatologist entered, shook hands. “Pleasure to meet you, Doctor. What am I seeing you about?”
Alex held out both hands, palms up. “This. It’s getting worse and becoming painful. Dermatology was probably my worse subject in med school. Every skin lesion looked the same to me.”
He moved Alex’s hand into better light, rotating the palm slightly this way and that. “Hmmm … Left looks worse than the right. What about your family? Have any history of similar problems?”
Alex shook his head. “Dad died of a quirk pulmonary embolism when I was five. Mom died of a brain tumor my senior year of high school. My sister believed in naturopathic medicine and died of untreated lymphoma. Other than that, nothing.”
“That’s quite a lot, actually. Any other skin problems?”
Alex was about to say no when he remembered something. “Yeah, come to think of it, my ear canals itch. Only thing that seems to help is steroid cream.”
“Let’s have a look.”
“It’s a mild case of psoriasis, probably exacerbated by the number of hours you wear gloves. The time you spend scrubbing doesn’t help either. I’ll give you a prescription for a steroid cream. Know what an occlusive wrap is?”
“Actually, I do.” Alex laughed. “That was the one part of dermatology that stuck with me.”
“Good. Before going to bed apply the steroid over your palms, then put on an occlusive wrap. Use Saran Wrap or a similar product. Try to minimize the brush during scrubs. Considering the amount of surgery you do, a brush probably isn’t needed at all.”
Alex thought about that. Scrubbing without a brush would seem, well, somewhat ineffectual. But having open sores on his palms would be far worse. And double gloving impeded his sense of fine touch. He’d keep an eye on his infection rate, just to be sure.
He checked the name on the next patient’s chart, saw “Meredith Costello,” the gliobastoma patient. He pushed open the door to the exam room. “Hey, Meredith. How you doing?”
“We need to talk,” she said. “I want a favor from you.”
Her serious expression struck him as unusual, not that he expected levity considering her diagnosis. “Sure. What’s on your mind?” He sat on the rolling stool, put the chart on the fold-down desk.
“Been thinking a lot. Obviously. You know I’m lesbian, don’t you?”
“I did suspect. I met your partner when you were in for staple removal. Why?”
“I want you to understand my situation.” She glanced at her hands and swallowed.
“Go on.”
“It’s hard on us … being, ah, different in spite of there being other gays and lesbians in town. We have friends, but it doesn’t mean most folks accept us or our lifestyle. My parents totally reject us as a couple and me as their daughter. Basically I’m facing this awful situation alone.” She was fidgeting with the zipper of her coat.
Alex waited a few beats. “Go on.”
“What’ll happen to me? I mean … how’s this … this thing going to end?”
Ah, the big question. He suspected it was the one every patient wonders about but is afraid to ask. Yet he wasn’t sure this was her question, so he didn’t want to volunteer something until he was certain. It was a touchy subject. “I’m not sure exactly what you’re asking.”
“Let me try this: I have a brain tumor. True?”
“Yes, you do.”
“It’s going to kill me.”
He nodded. “Eventually.”
“How will it kill me? What will happen? I want the details.”
He hated this question because there was no one answer—every tumor spread differently. His job at this point was to provide comfort, but this was an impossibility under the circumstances. Alex the surgeon had functioned perfectly, removing as much tumor as possible without damaging function. But Alex the healer was failing miserably. This was the hardest part of his job.
“Please, Doctor Cutter, I need to know.”
He searched for a humane answer. “Most likely you’ll eventually slip into a coma. Once that happens, I’ll make certain you receive enough medication to make you as comfortable as possible, even if you can’t communicate with me.” And if a little extra medication helps you exit this life, then so be it.
She squirmed anxiously in her chair, obviously frustrated with not hearing whatever information she sought. “But what about before that happens? What will I be like before I slip into a coma?”
Every brain tumor patient he’d ever dealt with harbored similar questions. Some were just more vocal than others.
“That depends on which parts of the brain the tumor grows into. I can’t predict where it will grow and what effects it will cause, exactly.”
“A friend’s father had the same tumor on the same side as mine. Three months before he died, he lost his ability to talk or move his right side. It was like he’d had a stroke. Will that happen to me?”
Cancer patients became gravitational fields for well-intentioned friends, or friends of friends, who were eager to share advice or relate anecdotal information of questionable relevance, the content of which inevitably provoked more angst than relief. “It’s a possibility. But only one of many possibilities. Like I said, it depends on several factors totally out of our control.”
She nodded as if this confirmed something. “Then my question is this: Do you believe a patient with a terminal disease has the right to take their own life? To have final control over the disease that will kill them?”
And there it was. “I can’t answer that.”
“Why not?”
“Because when you say ‘the right,’ do you mean legally or theologically?”
“I’m asking you as my doctor.”
Ah, man … At this point medical ethics and law collided head-on with Alex’s personal beliefs. Like every graduating student in his med school class, he’d sworn to uphold the Hippocratic oath. There were times in his years of practice that he’d read and reflected on the modern translation of the original Greek words. Most of what the oath prescribed was straightforward. However, there were two lines in potential conflict: “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. I will give no deadly medicine to anyone if asked, nor suggest any such counsel.” He’d seen too many patients die lingering, demeaning, disabling deaths from this very tumor, their brain being destroyed by tumor while their minds remained intact and fully aware of their awful predicament. How humane was that?
Would he choose to commit suicide if faced with the same disease? Hard question.
“Oh boy, Meredith … I really don’t know.”
She looked deeply into his eyes. “Our discussions—doctor-patient relationship I guess you call them—do these stay private?”
“If I don’t record any of it into your medical record, it does. There are circumstances in which lawyers can demand to review your records.”
“Then this is private, just between us.” She swallowed. “Think about this: I’m totally and absolutely screwed. I don’t want to die paralyzed and shitting myself as a prisoner in a paralyzed body. I don’t know anyone who would want to go through their final days in that condition. I want my final days to have some dignity, but I don’t have the nerve to off myself with a painful method, like jumping off a roof or slashing my wrist.” She paused, as if fighting for the next words. “But if I had some sleeping pills like Nembutal and could down a bottle of them when I reach the point of becoming incapacitated, then that’s what I would want to do. Understand what I’m saying?”
He inhaled slowly. “Just so we’re absolutely clear, you’re asking me to give you the means to commit suicide.”
She seemed relieved to have the words clearly laid out. “Exactly.”
“What makes you think I could live wi
th the guilt of aiding a suicide?”
“Because I know you care about your patients. And I know you want to give me the option of having at least some control over my disease.”
Her words resonated more strongly than she might’ve imagined. No patient had ever requested this from him, and he wasn’t sure what to say.
“Well?” she asked.
“I can’t answer you today. That doesn’t mean I’ll say no, and it doesn’t mean I’ll say yes. This is a very serious request you’re asking of me. I think we both need to take a deep breath and think very hard about this. Are you religious?”
“Yes.”
“Okay, then I want you to discuss this with your pastor, rabbi, or whomever that person is. Will you do that for me?”
She nodded, her eyes showing the first sign of hope since hearing the diagnosis. “If that’s what I need to do for you to do this for me.”
52
“Got a question for you,” Alex said to Martin as they jogged. “I have a glioblastoma patient who wants me to give him”—purposely changing Meredith’s gender—“a prescription for Nembutal so he can OD when the tumor starts to incapacitate him.” He paused before adding, “This ever happen to you?”
Martin answered immediately. “Nope.”
“How would you handle it if you were me?” Strange, who you end up becoming friends with. When he started at the clinic, he never suspected Martin would become the partner with whom he was closest.
Martin slowed for half a block before stopping. He bent over, grabbed his ankles, and held that position several seconds before straightening. He mopped his brow with his wristband. “Why do you ask?”
Stupid question. “Because I want to know your answer.”
