F
or Ty, though, the whole episode had shaken his belief in himself. Sure, doctors learn from their mistakes, even from their patients’ deaths, but as far as Ty was concerned that always happened to someone else, not him. Other doctors tried reminding him that the boy’s tumor would have led to his death anyway. That was not an excuse for Ty. He had killed a kid, and he couldn’t get beyond that simple fact. Explaining his role in Quinn McDaniel’s death gave him a new perspective on the proceedings. No doubt, death and complications were the enemies of any doctor, but sometimes death happened. Sometimes, there was no good explanation. Bad things happened to good people. Bad things happened to good doctors. Sometimes. It was a mantra he tried to chant. Bad things happened to good doctors. Still, the vision of Quinn McDaniel was entering his thoughts more and more with each passing day. His smiling, freckled face looking at him, trusting him. Ty wondered what a single mother did when she was no longer a mother. At least his own mother had his two sisters and him when his brother died. She also had her husband, Ty’s dad—on paper anyway.
“Hi, Tina.”
“Ready for Double-Oh-Seven?” Tina asked, as she slipped into the chair next to Ty. The surgeon on the hot seat was Dr. David Martin: his nickname,
007
, a license to kill. He was the same surgeon Ty had diplomatically warned Monique Tran and her grandmother about. Ty didn’t have the heart to join the usual rancor, even though this would be the third time they had seen the infamous Dr. Martin up front at M&M in the past year. From what Ty had heard, today’s case was the most egregious yet.
Martin entered disheveled, even though he’d had a full night of sleep. His brown hair looked as though he hadn’t combed it in two or three days. He wore khaki pants, a rumpled shirt, and a sport coat that looked as if it had been sitting in the back of his trunk. No tie.
“Who’s dressing him? You think he could have found a tie?” Tina said to no one in particular.
Orthopedist Dr. Tom Spinelli, a couple of seats over, leaned over toward Tina. “I heard his wife left him.”
A doctor sitting behind them chimed in, “You can only call the fashion police so often before it’s time to get out.” The doctors chuckled. Ty laughed despite himself.
At the front of the room, Hooten cleared his throat.
“Let’s get on with this. We’re here to talk about the death of Mary Michaelidis. Dr. Martin, I wish I could say it was good to see you again, but it is most definitely not good to see you again under these circumstances.” Hooten stopped and glowered at Martin, who appeared lost. “Dr. Martin, you unfortunately are intimately acquainted with how this works. Go on then. Give us the gory details.”
“Right, well. Mary Michaelidis. Thirty-nine. Schoolteacher. Mother of three. Avid runner. Thirty miles a week.” Martin spoke low and fast, as though if he only went through the facts of the case quickly enough, he might escape from Room 311 unscathed. “She presented on August twelfth with soreness in her left hip. I thought it was from all the running she did. I prescribed a thousand milligrams of Extra Strength Tylenol daily until the pain subsided.”
“An unusual choice, Dr. Martin. Regardless, did the pain subside?” Hooten asked. He sounded both weary and disgusted. He knew the answers, of course, and he, too, seemed to want to get it over with as quickly as possible.
“No. Well, I don’t know. I didn’t hear from her. The next time I saw her was last month. October seventeenth. No, the eighteenth. She was in the ER with a broken hip.”
“The running, no doubt, Dr. Martin,” Hooten said, caustic. Martin winced at Hooten’s remark.
“No, sir. Imaging studies revealed stage four bone cancer.”
Ty almost felt sorry for Martin. Ty had been on the other side now, and he held a new appreciation for what it was like to have your work held up to the harsh light of Room 311 and been found wanting. His sympathy for Martin didn’t last long, though. Martin had been in front of the doctors for Morbidity and Mortality before, and his case histories never ended well. The doctor was a menace, Ty thought.
“And when you saw her that first time, did you do a full physical exam or even ask if she was limping? Did you order an X-ray? Any blood work?” Hooten paused a beat for effect and then continued. “I know you didn’t, Dr. Martin.” Hooten craned his neck to look at the younger doctors behind him. “I want the junior members of our surgical staff to see what can happen when we forget the little things. When we let a runner with a sore hip out the door without a second thought. When we do that, we let metastatic cancer run amok for another two months.” Hooten paused.
“We all want to make headlines. To be pathfinders. Doctors at the top of our profession. We all want to separate the conjoined twins,” Hooten continued, catching Park’s gaze before twisting at the waist to look back toward the sixty or so surgeons behind him. “We all want to do the heart-lung transplant. Rebuild the shattered face. We can’t do any of the big things, none of them, unless we do the little things perfectly.”
It was times like this when Ty was proud to work at Chelsea General, to work under Harding Hooten. For all his brusqueness, here was a doctor in his fortieth year in medicine who didn’t let things slide, who didn’t suffer fools gladly, who didn’t care what anyone thought.
Hooten turned back toward Martin.
“Tell us how our fairy tale ends, Dr. Martin.”
“Mary Michaelidis was admitted to the Intensive Care Unit on October eighteenth. Aggressive cancer treatments began the next day. She never made it out of the hospital, and died yesterday.”
“Three weeks from diagnosis.”
“Yes, sir. Three weeks.”
The case seemed to deflate everyone in the room. This wasn’t a medical mystery from which they could learn. It was a lot closer to murder, although no one could say for sure what would have happened to Mary Michaelidis if her cancer had been diagnosed in August instead of October. Presenting this case at M&M was not intended to educate them in any way but to scare them.
This is what happens when doctors got sloppy
.
When he was doing his internal medicine year, Ty had done a rotation at an oncology unit. He remembered a patient there, a woman who had survived ovarian cancer for four years and had just learned the cancer was back. She said the cancer diagnosis four years earlier was the best thing that had ever happened to her. Before, she told Ty, she waited only for very special occasions to get out the good china. “Now,” she said, “I know to bring out the good china every day.”
Mary Michaelidis did not have a chance to use the good china. She didn’t have a chance to say good-bye to her students, place a memento in her children’s rooms, or share the bed with her husband one more night.
“Dr. Martin,” Hooten said. “I am recommending to the board of this hospital and affiliated institutions that your medical privileges be pulled immediately. At that point, you will lose your admitting and operating privileges, and for all intents and purposes, you will be persona non grata here.”
Hooten stopped. Martin looked around. He looked as though he was unsure if he was supposed to say something. A moment later Villanueva broke the silence. He was on his feet, his voice filling the room like a megaphone.
“That’s it? That’s it? This so-called doctor kills another patient and we tell him he is a
persona non grata.
” Villanueva pronounced the Latin as though he had rotten eggs in his mouth. George pointed to the front of the room. “This guy should be up on charges. In handcuffs. At the very least he should never get near another patient. Never.”
“Dr. Villanueva,” Hooten began calmly. “We have procedures and we must—”
Before he could get any further, Villanueva had pulled a rolled-up newspaper from his back pocket and was reading from the small type of the death notices.
“‘Mary Michaelidis. Thirty-nine. Beloved wife of Stephen Michaelidis, who delighted in her laugh; beloved mother of David, ten, Darren, eight, and Danielle, six, who adored their mother’s everyday kindnesses; beloved daughter of Francis X. and Martha Kelly, who wouldn’t have dared to pray for a daughter as beautiful, kind, and loving as their Mary.’”
With that, George crumpled the paper and hurled it toward the front of the room. It fluttered and died just two or three rows short of Martin.
A
fter M&M, Ty began the day fusing a couple of spines and was cruising into the third case of the day, a Rathke’s cleft cyst, when his self-doubt returned like the dark clouds of a storm front.
The patient was a thirty-year-old woman with the improbable name Sandy Shore. She had been experiencing sleeplessness, dizziness, diminished sex drive, and, most alarming, rapidly deteriorating vision. An MRI had revealed the fluid-filled sac growing near the pituitary gland at the base of the brain that characterized the rare Rathke’s cleft cyst. More tests showed the tumor was growing fast, increasing the pressure on the optic nerve. If the operation wasn’t performed in a matter of days or weeks, she would lose her vision.
To get to the tumor, Ty planned to access her brain through her nose and sinuses. From the patient’s perspective, she would emerge from surgery with no scars and an almost immediate recovery. From Ty’s point of view, the operation would result in less blood loss and a lower risk of infection. Ty had always enjoyed this relatively new route into the brain, called endoscopic transnasal brain surgery. The process seemed so much more clever than getting to the brain by brute force: peeling the skin from the face and cutting open the skull.
ETBS came with its own set of challenges, though. Ty needed to thread a narrow, lighted endoscope and attached miniature surgical tools into the soft tissue of the nasal opening. He wouldn’t be looking directly at the tumor, but at a TV monitor, and using computer mapping to show him exactly where to find the tumor. He would then resect it bit by bit, pulling bits of harmful tumor out the nose, the same way the instruments had gone in.
But ETBS was not risk-free. Cerebrospinal fluid could leak. It also required patience and thoroughness, bringing out the tumor little by little. The procedure demanded a very light touch with tiny instruments. The surgery was certainly ingenious, but it was not foolproof.
Before he operated, Ty liked to take five minutes to find a quiet place in the hospital to visualize step by step what he hoped to accomplish. If it was his first operation of the day, he might sit in his car on the parking deck, close his eyes, and go through the procedure. He’d even move his hands as he went through his visualization. He’d heard that the Navy Blue Angels did this when they weren’t flying, using phantom sticks, as a way to practice the incredible precision formations they managed when they were airborne. If it wasn’t his first operation of the day, Ty would seek out the call room or the surgeons’ changing room, often going into the small bathroom and turning off the light. Visualizing the procedure both calmed and focused Ty. Sometimes, he would repeat a word in his head, trying to access his inner chakras. You couldn’t guess the word Ty used, if you tried. It was
gentle
. A brain surgeon’s hands needed the soft touch of a velvet hammer.
Before Sandy Shore’s operation, Ty didn’t have time to visualize the entire procedure, and he had the feeling of being off balance from the moment he walked into the OR. The day’s schedule started backing up from the get-go, when the anesthesiologist had trouble intubating the first patient, an obese man with a ruptured disk and a slipped vertebra. Getting an airway in the obese was difficult, Ty knew, because fat narrowed the space for the endotracheal tube. The surgery went without a hitch, but Ty was behind. The second operation was delayed when the scrub nurse was late. By the time he finished, Sandy Shore was already on the table and sedated.
Now, as he snaked the lighted scope and instrument through the woman’s nose and sinus and checked the MRI again to see his target, he felt a chill of dread. ETBS was nothing new to Ty. He’d done the procedure two dozen times before. Even so, he couldn’t shake the feeling that the surgery was going to end in disaster. He was almost waiting for a flash of bright red blood from a nick in the carotid artery to show up on the monitor. Ty paused. This sense of impending failure was new, and it frightened him to his core. He checked the MRI yet again. He closed his eyes for a moment and breathed out slowly, hoping to blow the fear out. It didn’t work.
When he opened his eyes, he sensed the furtive glances of the circulatory nurse, the anesthesiologist, and the junior and senior residents. He had the feeling they knew the cold, dark doubt that had suffused his body like some sort of toxic IV.
In training, Ty would joke with his fellow residents about who was suffering from the tightest sphincter. When they were trying a new procedure, first during general surgery internship and then in neurosurgery, everyone but Ty would suffer a case of nerves. His fellow residents in quieter moments or after a few drinks would admit waking up in the middle of the night in a cold sweat thinking about all the things that could go wrong at each step.
Ty’s surgical skills became the stuff of hospital lore when he was a resident. He was called to a psych ward to examine a patient with ptosis. The man had been homeless and delusional, muttering about the CIA putting extra salt on his french fries to dehydrate him and how the Supreme Court had secretly killed Stevie Ray Vaughan. When he arrived, Ty walked past one man sweating and breathing hard as he hit a Ping-Pong ball and ran around the table to hit it back to himself. Others were zoned out and rocking. Ty’s patient turned out to be James Brian Cooper, a man in his midforties looking intently out the window. Cooper did indeed have ptosis, a drooping eyelid.
Ty ordered an MRI. For some reason, no one had thought that Cooper’s psychosis might have roots in his brain physiology until his left eyelid began to droop, but the scan showed a large bi-lobed meningioma on his frontal lobe. Ty attempted to talk to Cooper about the tumor in his brain, the surgery, and its risks, but informed consent in this case was more of a formality than a fact, much as it was in dealing with Alzheimer’s and dementia patients. Cooper merely muttered something about Class 4/5 switching systems and the USS
Pomfret
before signing his name. To Ty’s surprise, Cooper’s signature was beautiful—neat loops and lines that could have come out of a penmanship textbook. The name he signed was a reminder that Cooper lived on the locked psych ward:
James Earl Carter
. Still, the handwriting made Ty wonder where this man had come from before his life on the streets. He did not show the liver function of a man who had spent his life hitting the bottle hard.