“Dad, you’re crazy.”
“I grew up with punks like him.”
“I mean it.”
Villanueva rubbed his chest. “He packed more of a punch than I thought.”
“You could have gotten shot or something.”
“And miss a vegetarian dinner with you, Nick?”
“Dad, I’m serious.”
They turned the corner and found the small restaurant.
F
rom surgery, they wheeled Park to the Neuro Intensive Care Unit, where an ethnic melting pot of loyal residents hovered around their mentor. Next to the coffeepot and microwave at the nurses’ station, one of them had left a box of assorted teas. Earl Grey for the Pakistanis and Indians, green tea for the Koreans, rooibos for the African residents. The residents poured tea, fidgeted, and waited to see how their mentor, the hard straight arrow pointed their way in their adopted country, was faring. They clustered there, talking quietly in their variously accented English, going over all the possible complications and post-operative scenarios for Park. “At least it was well away from Brodmann’s area forty-four and forty-six,” one resident said professorially. “Yes, but what about the fine motor movements he requires?” said another with a clipped British accent. Still another resident, with choppy English similar to Park’s, said, “It all depends on how aggressive Dr. Hooten was. Did he go after all the tumor or did he try to preserve some of Dr. Park’s function?” Finally, the nurses shooed them all away.
After nearly twelve hours in the OR, Hooten left the hospital, got in his Volvo, and headed for home. He was completely spent but satisfied he had done everything he could to remove as much of Park’s glioblastoma as possible. In the past, he would have left the operating room and returned to his office to finish up some paperwork, but he was bone-tired. He tried to convince himself the added stress of operating on a friend and co-worker had wrung him out, but he knew that wasn’t true. There was a point during every surgery—when the lights were on, the blue draping framed the tumor, and his eyes were looking into the large microscope suspended over the patient—that Hooten forgot he was looking at a fellow human. In that small rectangle of flesh, he saw a medical problem, a tumor to be resected, an aneurysm to be clipped. The truth about his fatigue was more elemental. He was simply getting older. He couldn’t pull the hours he had when he’d first become chief of surgery at Chelsea General.
Still, he could be proud of his work. Looking through a microscope positioned over a small hole cut in Park’s head, Hooten had carefully reached Park’s tumor after cutting through the dura and splitting the sylvian fissure. He exposed the middle fossa of the skull and lifted the temporal lobe. Once he had exposed the tumor and separated it from the normal surrounding brain using a combination of bipolar cautery, suction, and small cottonoids, he had used an ultrasonic tissue aspirator to remove bit after tiny bit of his colleague’s tumor. To guide him, Hooten used a stereotactic probe that looked like a meat thermometer. The probe had two round reflective balls that a pair of electronic eyes picked up and compared with the three-dimensional MRI image on a screen near the foot of the operating table. By seeing where the probe was relative to the pre-op image of the tumor, Hooten knew where he was. It was like a GPS inside the brain. The tumor also looked different from the tissue around it. It was slightly grayer and more purplish in color. When his eyes and the probe told him he had removed all the tumor possible, Hooten gently handed the instruments back to the nurse. “Head Games” is what the residents called this 3-D navigation system. At first, Hooten had dismissed the new technology as just that—another video game disguised as an intraoperative tool. Over the years, however, he had become quite facile with the device.
For an old dog, I can still learn many new tricks
, he thought to himself. For five minutes, he said nothing, instead just staring through the microscope lens and trickling in very small amounts of irrigation fluid through a small catheter. He was carefully evaluating for any remnant tumor that the imaging technology may have missed, but his experienced eyes could catch. He also searched for any errant drops of red that could be a harbinger of more significant future bleeding in Park’s brain. During this five-minute period, no one in the OR made a sound. After he was convinced, he let the chief resident close.
Hooten knew there was more to the glioblastoma than he could see, though. GBMs did not have a defined edge the way some other brain tumors did, and malignant cells lurked beyond what was visible to Hooten as he looked down into the wrinkles and folds of tissue that held the obstinate, determined person the chief of surgery had come to admire. As he drove home listening to the news on CNN, Hooten knew with the dread he always felt after a GBM resection that even if he’d done his best work, he had not gotten all of Park’s tumor. Sometimes the small remnants could suddenly swell angrily in response to the insult they had just endured. Some of those remnants could simply remain, hidden for a time, only to suddenly start growing and replicating with a fury.
A story came on from Afghanistan with the latest news on the war on terror, and Hooten reflected that the glioblastoma cells he couldn’t see were little different from an al-Qaeda sleeper cell. They lurked unseen in the brain before a violent resurgence. Even with traditional radiation and chemotherapy, the chance of a glioblastoma recurring was 100 percent. The question was not
if
but
when
. Unfortunately for far too many patients, the tumor came back—usually not far from the original spot in the brain—within a matter of months. Patients were lucky if they went a year without a recurrence. The chance of surviving a year with a GBM was a little less than a third. The five-year survival rate was 2 percent, and Hooten suspected those cases had been misdiagnosed.
But doctors had not thrown in the towel against glioblastomas. A new chemo drug seemed to buy patients a little time, and Hooten had immediately enrolled Park in a clinical trial that might buy him still more. It was a vaccine trial. The tissue from Park’s tumor was collected and bagged. Chelsea General would send it off to a lab to make a custom, personalized vaccine. The vaccine would enlist his own immune system to fight his tumor. It was like a red flag to the white blood cells that detected foreign cells. Park would get his first dose in three months.
The vaccine was a weapon also designed to counter another malevolent aspect of GBMs—their ability to turn off the body’s natural defenses against tumors and allow them to grow unchecked.
When he was telling medical students about this aspect of glioblastomas, Hooten, the inveterate birder, always likened this sort of perversion to the cuckoo. Female cuckoos lay their eggs in the nest of another bird and leave them for that bird to hatch. Aiding the ruse, cuckoo eggs look like those of the unwitting host bird. The cuckoo eggs then hatch earlier and the chicks grow faster, receiving their food all the while from the other species. This allows for the final insult: The cuckoo chicks, which resemble the species whose nest they have infiltrated, push out the host’s eggs or smaller chicks, claiming the nest for themselves.
By shutting off the host body’s white blood defenders, GBMs were no less ruthless than the cuckoo. Unlike the cuckoo, though, this wasn’t Darwinism taken to the extreme. This was simply a human body being conned into allowing rapidly dividing cells to run amok in the worst possible place, the brain.
When he operated on glioblastoma patients, Hooten was always tempted to take out a larger area of the brain than the MRI and the probe indicated. He might get a few more cancerous cells this way. But Hooten knew this was a fool’s errand. Excising more of the brain might reduce the number of tumor cells remaining, but it would increase the chances that Park would not be
Park
when he emerged from the anesthetic fog. Somewhere in the tissue lived an impossibly complicated web of neurons that made up the memory, the personality, the abilities that were the essence of Sung Park. Being overly aggressive also would not lessen the chance of the GBM coming back.
Hooten hoped that given the surgery, then radiation, chemo, and the customized vaccine, Park would have a chance. Maybe this vaccine would be a quantum step forward in GBM treatment. Perhaps Park would be on the side of the divide, one of the lucky ones there when medicine advanced a step in its fight against premature death.
Pat Park arrived after lunch and sat in the waiting area, knitting a gray scarf as she waited for her husband to emerge from surgery. She left at four to pick up her daughters at their after-school music program and then returned to continue her vigil.
When Sung Park was wheeled into Post-Op, the residents cycled through his room, checking his vitals and his chart closely and returning to the family waiting area to tell Pat everything was okay. She was touched, and a bit surprised that so many people cared about her husband. She was crying softly to herself when Hooten walked into the room.
Before leaving the hospital, Hooten had decided to stop by and speak to Pat Park. When he saw her crying, he walked over and gave her a hug. He realized he barely knew the woman. The Parks never attended the holiday party, as Sung had usually offered to take call on those days. Even then, he knew Park had been trying to impress him with his work skills, even at the expense of Pat and the kids. Hooten felt a pang of regret. Truth was, he didn’t have much to say, other than the operation had gone as well as could be expected. Hooten was careful not to paint too rosy a picture, although he suspected Park himself had given his wife a clear-eyed view of the operation and his grim prognosis.
Hooten explained that his colleague was lucky—the tumor was in a nondominant area of the brain, meaning Park’s chance of losing his speech or ability to understand was slim. The operation had gone seamlessly, and Hooten thought the chances of Park retaining his ability to move and speak were good.
“If you need anything at all, call me,” Hooten said. He wrote his home and cell phone numbers on the back of his business card and handed it to Pat. He finally walked out, feeling more exhausted than he could ever remember.
P
ark awoke to find his wife and two daughters standing by his bedside. His vision was blurry and his thinking fuzzy, but Park was relieved to find them there. He took in their smiling faces and then took a deep breath. He enjoyed a strange sense of contentment. A rare sense of peace.
“
Gahm-sah-hahm-ni-da
,” Park croaked in Korean. Thank you. His throat was dry and his voice barely audible, but the words came out clearly. Park wasn’t sure why he thanked his wife and daughters; nor was he sure why he was speaking Korean. He spoke English at home, unless he and his wife were alone or he wanted to speak privately to her in front of the kids. It just came out: Thank you. The words weren’t exactly what he intended, but pretty close. He meant to say
thankful
.
Park’s voice was weak and rough. Weak, no doubt from the strain of surgery. Raspy from the intubation, he thought. Still, Park realized he was able to form thoughts, to enunciate, to express himself. Park’s own father had suffered a stroke in his eighties and could not speak the names of places. The frustration brought tears to his eyes. Park’s operation had not seemed to damage his brain or alter his consciousness. That was always a risk in brain surgery. The brain, after all, was complicated.
There is hope
, Park thought.
“Daddy!” five-year-old Emily said. “You’re finally awake.” She jumped up and down. “Hi Daddy!” Natalie said.
Park’s wife took his hand. She had tears in her eyes.
“Sung,” she said as if his name itself were a thing of wonder. “Sung,” she repeated.
“What day is it?” Park added in English, his voice still a dry whisper, like sandpaper.
“Saturday,” she said.
Park offered the hint of a smile, closed his eyes, and fell back asleep.
I
n a small Asian neighborhood home in Ann Arbor, Monique Tran sat next to Sanford Williams. Sanford wore jeans and a freshly pressed white buttondown shirt. Monique wore clogs, jeans, a flowered blouse, and a loose gray hoodie. Her hands were jammed in the hoodie’s pockets. They sat squeezed between her parents, who were dressed as though they were heading to church. Her younger sisters, grandparents, aunts, uncles, cousins—eighteen people in all—filled the small room in an arc, all looking intently at Sanford. The young doctor’s unlined face had the pinched look of someone experiencing severe intestinal distress. Monique gave him a pat on the knee.
“You okay, honey? You look like you’re going to lose your lunch.” Monique turned to the assembled family members. “People, it’s not polite to stare, okay?”
Monique’s family looked down momentarily and then resumed their unwavering gaze.
“Are we all here? Mom, you sure you don’t want to invite even more people, maybe the Nguyens, to come over?” Monique’s mother, sitting next to Sanford, started to get up. “Kidding, Mom.” She returned to the couch. “Okay, people. This is Sanford. We work together at Chelsea General. And…we are engaged.”
Monique pulled her left hand from her hoodie and held it out. On her ring finger she wore a large diamond ring on a simple band. She moved her hand from side to side as though she were a model on a home shopping channel.
“Nice, isn’t it?”
Among the assembled family members, there was a buzz of murmurs commenting on the news, a mix of admiration for the ring and shock at the announcement. Mostly shock. Sanford looked at Monique’s father, whose expression was unchanged, a grim mask, and then around the room expecting a handshake or two, a congratulatory pat on the back, maybe. Only Monique’s grandmother sat smiling nearby in a wheelchair, still recovering from her hip replacement. He strained to hear what the Trans were saying, but they were speaking in Vietnamese.