A Brain (6 page)

“What did you feel?” asked Dr. Ranade.

“Help me,” cried Lisa. She tried to move but felt the restraints. She knew the seizure was coming. “Help me.”

“Lisa,” said Dr. Ranade, becoming alarmed, “Lisa, everything is all right. Just relax.”

“Help me,” cried Lisa as she lost control of her mind. The fixation of her head held, as did the leather strap at her waist. All her strength concentrated into her right arm, which she pulled with enormous force and suddenness. The wrist restraint snapped and her free arm arched up through the drapes.

Mannerheim was mesmerized by the abnormal recordings on the EEG when he saw Lisa's hand out of the corner of his eye. If he had only reacted faster he might have been able to avoid the incident. As it was, he was so startled that for a moment he was incapable of reacting. Lisa's hand, flailing wildly to free her body imprisoned by the OR table, hit the protruding electrodes and drove them straight into her brain.

 

Philips was on the phone with a pediatrician named George Rees when Robbins knocked and opened the door. Philips waved the technician into his office while he finished his conversation. Rees was inquiring about a skull X ray on a two-year-old male child who was supposed to have fallen down stairs. Martin had to tell the pediatrician that he suspected child abuse because of the old rib fractures he'd seen on the
patient's chest X ray. It was sticky business, and Philips was glad to hang up.

“What have you got?” Philips asked Robbins, swinging around on his seat. Robbins was the Chief Neuroradiology technician whom Philips had recruited, and there was a special rapport between the two men.

“Just the localization films you asked me to do for Mannerheim.”

Philips nodded as Robbins snapped them up on Philips' viewer. Normally the chief technician didn't leave the department to take X rays, but Philips had asked him to attend personally to Mannerheim just to avoid any trouble.

Lisa Marino's operative X rays lit up on the screen. The lateral film showed a polyhedral lucency where the bone flap had been cut. Within this sharply defined area were the bright white silhouettes of the numerous electrodes. The long needle-like depth electrodes Mannerheim had pushed into Lisa Marino's temporal lobe were the most apparent, and it was the position of these instruments that interested Philips. With his foot, Philips activated the motor on a wall-sized X ray viewer called an alternator. As long as he held his foot on the pedal, the screen in front of him changed. The unit could be loaded with any number of films for him to read. Philips kept the machine running until he found the screen containing Lisa Marino's previous X rays.

By comparing the new films with the old, Philips could determine the exact location of the deep electrodes.

“Gees,” said Philips. “You take beautiful X rays. If I could clone you, half of my problems would be over.”

Robbins shrugged as if he didn't care, but the
compliment pleased him. Philips was a demanding but appreciative boss.

Martin used a finely calibrated ruler to measure distances associated with minute blood vessels on the older X rays. With his knowledge of the anatomy of the brain and the usual location of these blood vessels, he could form in his mind a three-dimensional image of the area he was interested in. Translating this information to the new films gave him the position of the tips of the electrodes.

“Amazing,” said Philips, leaning back. “Those electrodes are positioned perfectly. Mannerheim is fantastic. If only his judgment equaled his technical skill.”

“Do you want me to take these films back to the OR?” asked Robbins.

Philips shook his head. “No, I'll take them myself. I want to talk to Mannerheim. I'm going to take some of these older films as well. The position of this posterior cerebral artery bothers me a little.” Philips picked up the X rays and headed for the door.

 

Although the situation in OR #21 had returned to a semblance of normality, Mannerheim was furious about the accident. Even the presence of the foreign visitors did not temper his anger. Newman and Lowry suffered the greatest abuse. It was as if Mannerheim felt they had deliberately schemed to cause the problem.

He had started the temporal lobectomy as soon as Ranade had inducted Lisa under general endotracheal anesthesia. There had been a panic immediately after Lisa's seizure, although everyone acted superbly. Mannerheim had succeeded in grabbing Lisa's flailing hand before any more damage had been done. Ranade, the real hero, had reacted instantly,
injecting a sleep dose of one hundred and fifty milligrams of thiopental IV, followed by a muscle paralyzer called d-tubocurarine. These drugs had not only put Lisa to sleep, but had also terminated the seizure. Within only a few minutes Ranade had placed the endotracheal tube, started the nitrous oxide, and positioned his monitoring devices.

Meanwhile, Newman had extracted the two inadvertently deeply embedded electrodes while Lowry removed the other surface electrodes. Lowry also had placed moist cottonoid over the exposed brain before covering the site with a sterile towel. The patient had been redraped and the doctors regowned and gloved. Everything had returned to normal except Mannerheim's mood.

“Shit,” said Mannerheim, straightening up to relieve the tension in his back. “Lowry, if you'd rather do something else when you grow up, tell me. Otherwise hold the retractors so I can see.” From Lowry's position the resident could not see what he was doing.

The door to the OR opened, and Philips entered, carrying the X rays.

“Watch out,” whispered Nancy Donovan. “Napoleon is in a foul mood.”

“Thanks for the warning,” said an exasperated Philips. It irritated him that everyone tolerated Mannerheim's adolescent personality, no matter how good a surgeon he was. He put the X rays up on the viewer, aware that Mannerheim had seen him. Five minutes passed before Philips realized that Mannerheim was deliberately ignoring him.

“Dr. Mannerheim,” Martin called over the sound of the cardiac monitor.

All eyes turned as Mannerheim straightened up,
shifting his head so that the beam of his miner-like head lamp fell directly on the radiologist's face.

“Perhaps you don't realize that we are doing brain surgery here and maybe you shouldn't interrupt,” Mannerheim said with controlled fury.

“You ordered localization X rays,” said Philips calmly, “and I feel it is my duty to provide the information.”

“Consider your duty done,” said Mannerheim, looking back into his expanding incision.

Philips' real concern was not the electrodes' positions, because he knew they were perfect. It was the orientation of the posterior or hippocampal electrode in relation to the formidable posterior cerebral artery. “There's something else,” said Martin. “I . . .”

Mannerheim's head shot up. The beam of light from his head strafed the wall, then the ceiling, while his voice lashed out like a whip. “Dr. Philips, would you mind taking yourself and your X rays out of here so that we can finish the operation? When we need your help, we'll ask for it.”

Then in a normal voice, he asked the scrub nurse for some bayonet forceps and went back to work.

Martin calmly took his X rays down and left the OR. Changing back to his street clothes in the locker room, he tried not to think too much; it was easier on his mood. Heading back to Radiology, he allowed himself to ponder about the conflict in his sense of responsibility that the incident evoked. Dealing with Mannerheim called on resources he never imagined he'd need as a radiologist. He hadn't resolved anything when he arrived back at the department.

“They are ready for you in the angiography room,” said Helen Walker when he reached his office. She stood up and followed him inside. Helen was an
extremely gracious thirty-eight-year-old black woman from Queens who had been Philips' secretary for five years. They had a wonderful working relationship. It terrorized Philips to think of her ever leaving, because like any good secretary she was instrumental in running Philips' day-to-day life. Even Philips' current wardrobe was the result of her efforts. He would have still been wearing the same boxy clothes he'd worn in college if Helen hadn't teased him into meeting her in Bloomingdale's one Saturday afternoon. The result had been a new Philips, and the contemporary fitted clothes suited his athletic body.

Philips tossed Mannerheim's X rays onto his desk, where they merged with the other X rays, papers, journals and books. It was one place Philips forbade Helen to touch. No matter what his desk looked like he knew where everything was.

Helen stood behind him reading a steady stream of messages she felt obligated to tell him. Dr. Rees had called asking about the CAT scan on his patient, the X ray unit in the second angiography room had been fixed and was functioning normally, the emergency room called saying that they were expecting a severe head injury that was going to need an emergency CAT scan. It was endless and it was routine. Philips told her to handle everything, which was what she'd planned to do anyway, and she disappeared back to her desk.

Philips removed his white coat and put on the lead apron he wore during certain X-ray procedures to protect himself from the radiation. The bib of the apron was distinguished by a faded Superman monogram, which had resisted all attempts at removal. It had been drawn there in jest two years previously by the neuroradiology fellows. Knowing the gesture had
been made out of respect, Martin had not been annoyed.

As he was about to leave, his eyes swept across the surface of his desk for a reassuring glimpse of the program cassette, just to make certain he hadn't fantasized Michaels' news. Not seeing it, Martin walked over to shuffle through the more recent layers of debris. He found the cassette under Mannerheim's X rays. Philips started to leave, but again stopped. He picked up the cassette and Lisa Marino's latest lateral skull X ray. Yelling through the open door for Helen to tell the angio room he'd be right there, he walked over to his worktable.

He took off his lead apron and draped it over a chair. He stared at the computed prototype, wondering if it would really work. The he held up Lisa Marino's operative X ray to the light that came from the banks of viewing screens. He wasn't interested in the electrode silhouettes and his mind eliminated them. What interested Philips was what the computer would say about the craniotomy. Philips knew they had not included the procedure in the program.

He flipped the switch on the central processor. A red light came on and he slowly inserted the cassette. He got it three-quarters of the way in, when the machine swallowed it like a hungry dog. Immediately the typewriter unit came alive. Philips moved over so he could read the output.

H
I
! I
AM
R
ADREAD
, S
KULL
I. P
LEASE ENTER PATIENT NAME
.

Philips pecked out “Lisa Marino” with his two index fingers and entered it.

T
HANK YOU
. P
LEASE ENTER PRESENTING COMPLAINT
.

Philips typed: “seizure disorder,” and entered that.

T
HANK YOU
. P
LEASE ENTER RELEVANT CLINICAL
information.

Philips typed: “21-year female, one year history of temporal lobe epilepsy.”

T
HANK YOU
. P
LEASE INSERT FILM IN LASER SCANNER
.

Philips went over to the scanner. The rollers within the lips of the insertion slot were moving. Carefully Philips lined up the X ray with its emulsion side down. The machine grabbed it and pulled it inside. The output typewriter activated. Philips walked over. It said: T
HANK YOU
. H
AVE A CUP OF COFFEE
. Philips smiled. Michaels' sense of humor emerged when least expected.

The scanner emitted a slight electrical buzz; the output device stayed silent. Philips grabbed his lead apron and left the office.

 

There was silence in OR #21 as Mannerheim mobilized Lisa's right temporal lobe and slowly lifted it from its base. A few small veins could be seen linking the specimen to the venous sinuses, and Newman skillfully coagulated and divided them. At last it was free, and Mannerheim lifted the piece of the brain out of Lisa's skull and dropped it into a stainless steel dish held by Darlene Cooper, the scrub nurse. Mannerheim looked up at the clock. He was doing fine. As the operation had progressed, Mannerheim's mood had changed again. Now he was euphoric and justly pleased with his performance. He'd done the procedure in half the usual time. He was certain he'd be in his office at noon.

“We're not quite finished,” said Mannerheim, taking the metal sucker in his left hand and forceps in his right. Carefully he worked over the site where the temporal lobe had been, sucking out more brain
tissue. He was removing what he called the deeper nuclei. This was probably the riskiest part of the procedure, but it was the part Mannerheim liked the best. With supreme confidence he guided the sucker, avoiding vital structures.

At one point a large globule of brain tissue momentarily blocked the opening of the sucker. There was a slight whistling noise, before the piece of tissue whooshed up the tube. “There go the music lessons,” said Mannerheim. It was a common neurosurgical quip, but coming from Mannerheim after all the tension he'd caused, it was funnier than usual. Everyone laughed, even the two Japanese doctors.