49

“I’d prefer it if Estella can stay in the room with us,” Meredith Costello said preemptively when Alex entered the exam room.

Alex closed the door and plunked down on the rolling stool. “No problem. Hope you don’t mind me asking, what’s your relationship?”

“She’s my life partner,” Meredith said with a hint of defiance.

Ah. “No problem.” Alex stood up from the stool and motioned for her to sit on the exam table. “Let me take a look at your incision.”

As she stared straight ahead, Alex studied the question-mark-shaped wound on the left side of her head and was pleased. Healing well, no more inflammation than normal. “I’m going to remove the staples now.”

 

Staples removed, Alex returned to the stool, hands clasped together. He dreaded this next part and wished there was some way to telepathically transfer the information rather than having to actually say the words. There wasn’t any, of course, and he certainly didn’t believe in building false hope. After a deep breath, he said, “The pathology report came back and it’s not good, Meredith. You have brain cancer. The formal name of it is a glioblastoma multiforme.” He didn’t add that they’re one hundred percent fatal. “The only thing we need to decide now is what treatment you wish to receive to maximize your quality of life.” He typically paused at this point to allow the awful news to sink in. Usually, the words didn’t fully register until later. Most patients came to this appointment expecting the worst, yet when those fears were realized, they needed time to fully process the implications.

Meredith listened carefully, showing no shock, surprise, or disappointment. She nodded to her partner as if to say, “See, told you so.” Then her eyes misted up as she blinked away tears. “How long do I have?”

Ah, so she did understand. “Can’t say for sure. All I can give you are the broad statistics. With no additional treatment you have perhaps six months to a year. Radiation might extend that by six months. Chemotherapy alone isn’t as effective as radiation, but by combining chemo with radiation, you can perhaps eke out a few extra weeks.”

“A few weeks?” She snorted a sarcastic laugh. “At what price? I mean, what’re the side effects of that combination? I’ve heard some awful things about chemo. Terrible things.” Having anticipated the bad news, she’d prepared the right questions.

Personally, with the present state of the art, Alex wouldn’t choose chemo. The only effective drug—if you could call it that—was BCNU, a drug neurosurgeons darkly referred to as “Be Seeing You.”

“Well, you can always hold off on the chemo and add it later if you change your mind. But I strongly advise you to start the radiation as soon as possible. The wound’s healed enough to be able to tolerate it.” Because the objective of radiation was to kill replicating cells, it was not a good idea to radiate fresh wounds that were still laying down fresh scar tissue.

Now came the part of his canned dialog he hated, because it was intended to instill false hope. “A lot of research is being focused on this problem, and several new drugs are in the pipeline. Who knows, maybe tomorrow we’ll have one with superior effectiveness to what’s now available. What I’m saying is, don’t give up hope.” He hated himself for saying this, because he knew nothing worth a damn was presently in a clinical trial. And if a new drug did come along, Meredith would most likely be dead by the time it could be used on her.

She looked him straight in the eye. “You really don’t believe that, do you Doctor Cutter?”

He hesitated a beat. “Yes, I do believe it.”

She nodded as if to say, “I forgive you for lying.”

“Don’t forget one thing,” he added. “A few patients with this tumor have survived.” But in all likelihood their pathology had been misread. Alex personally reviewed slides of every patient with the pathologist, so he harbored no doubt hers was the real thing. She was terminal and it broke his heart to be the one to tell her.

Betsy Lou poked her head into the room. “Doctor Cutter, see you a moment?”

In the hall, exam room door closed, he asked, “What is it?”

“They want you in surgery STAT. Someone’s in trouble.”

“Who?”

“Don’t know, but it sounds urgent.”

“Okay, tell you what. Explain the situation to Meredith. Then schedule her to see Tom Thatcher.” Tom was the radiation oncologist to whom Alex referred patients. “Set her up to start radiation ASAP. Schedule another wound check in two weeks.” He monitored wounds closely during the radiation treatments.

 

Alex inspected his left palm. Two months ago the skin in the center had broken down to the point of being continually red, painful, and weeping—on the verge of bleeding. The right palm wasn’t as bad but was heading in the same direction. He’d begun to not scrub the area with the disposable plastic sponges, yet during long cases the area would weep, forcing him to double glove.

“What’s up?” Alex asked no one in particular as he shouldered through the OR doors, taping his loupes to the bridge of his nose to hold them in place. The operating room chill immediately sprouted goose bumps on his exposed flesh. The surgeon, Dana Cramer, was one he barely knew. She was second banana in a two-person group that kept to themselves and had never been included in resident coverage. If they got in trouble, they relied on the university surgeons to help.

Cramer’s body language radiated anger and tension. “What took you so long?”

“Hey, I’m here, aren’t I? Had to change into scrubs. What’s the problem?”

“Got a real motherfucker of a bleeder. Can’t control it.” She had stuffed a lap pad into the wound and was holding pressure on it.

Alex stepped in for a closer look, keeping well away from the operative field to prevent contaminating it. “What kind of case is this?” He saw the right side of the patient’s neck exposed in the field.

“Carotid endarterectomy.” She nodded at the X-rays on the view box. The series of shots had been taken as contrast material was passing through the neck vessels. It showed a severely clogged carotid artery, a bad case of carotid stenosis. “Where’s your partner?” he asked out of curiosity.

“You going to help or play twenty questions?”

He did a double take while seriously considering telling her to “fuck off.” Instead, he turned to the scrub tech who, being an employee of Cramer’s group, wasn’t familiar with his routine. “I wear seven and a half browns.”

Outside the room, at the scrub sink, he kneed on the water valve and began to wash his hands with Betadine. Because of the palm sores, he didn’t bother with the more abrasive scrub brush. It was time to make an appointment with Seth Kaufman, the dermatologist three floors above his office. Garrison had recommended him a week ago, but Alex hadn’t gotten around to scheduling a visit because of his busy schedule. Now the sores were becoming a problem he couldn’t ignore, and the risk of them contaminating a wound was forcing the issue.

 

“Let me take a look,” he said as he shouldered Cramer out of the way and took control of the lap pad. He asked the anesthesiologist, “What’s his pressure?”

“140 over 60.”

“How many units we have on tap?” He felt uneasy without Cole on the other side of the drapes to help.

“Four units of red cells. Want his BP lowered?”

“Yeah, take it down to whatever you think you can safely get away with.” Lower blood pressure meant less blood pouring out of the bleeding site. “Let me know when you have it bottomed out.”

“Harry’s out of town,” Cramer said, referring to her partner. “That’s why I called.”

“No problem,” he lied. In fact, he resented this group for cherry-picking insured patients and referring all their uninsured to Baptist’s “charity” practice, which was covered by residents, which in turn became his responsibility. That wasn’t the only issue he had with them.

 

With the blood pressure lowered and Cramer poised with a large-bore sucker, Alex said, “I’m going to take a peek now,” and rolled back the lap pad.

The surgery—to remove cholesterol plaque clogging the artery—requires an incision along a short length of the vessel, directly over the plaque. Once the plaque was scraped off the inner wall, the artery was sewn back together. Although she’d removed the plaque—or at least she claimed to have—she botched the repair. Now the poorly stitched incision was hemorrhaging along the incision line. With a clear idea of the problem, he replaced the lap pad until they had everything set up and ready to go. The problem now was that each puncture wound from each stitch slightly chewed up the two edges of the incision, and replacing the sutures added more punctures. This forced him to plant new stitches slightly further from the edge, narrowing the artery. He withdrew the lap pad again for a closer inspection. It appeared to be repairable, but only if the original sutures were totally replaced.

Satisfied that he now had a plan, he told the scrub tech, “I want two vascular clamps, small pointed scissors, and pick-up. Then load me up a 4-0 Vicryl on a vascular needle.” He planned on using one long suture for a running closure instead of individual sutures.

“Change that to nylon,” Cramer corrected.

Alex’s patience just reached the edge of a cliff. “You want me to do this, or do you want to do it? Be my guest, because I have a full clinic waiting on me.”

“I use nylon,” she said defensively.

“Fine, but I don’t. What’s it going to be? Your call.”

“Oh, for Christ’s sake, go ahead.”

Alex removed the failed sutures as carefully as possible to preserve damaging the edges more. With the old suture gone, he quickly sewed shut the incision and removed the arterial clamps, reestablishing blood flow in the vessel. “Okay, bring the pressure back up to normal and let’s see how it holds.” He glanced at the wall-mounted stopwatch. The amount of time the vessel had been clamped was well within safe limits. Keep the vessel clamped too long and you risk a stroke. The suture held securely.

“Okay, we’re golden. Lay down some thrombin-soaked Gelfoam over that and close it up.” He stripped off his gloves. “I’m out of here.”

“Thanks,” Cramer mumbled begrudgingly.

 

Alex was able to score the one remaining donut from the lounge’s morning supply—a plain cake one, always the last to go—along with a cup of coffee. He munched the donut while changing back into slacks and a sports coat. As he was leaving the lounge, “Doctor Cutter to OR Five, STAT,” came from the overhead speakers.

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.”