All In Jest
Chapter One
All In Jest is dedicated to all those competent, professional, and caring physicians who contribute to the welfare of the citizens of the world.
Too frequently, patient encounters include the grim specter of a malpractice lawsuit hanging over the physicians’ heads like the proverbial sword of Damocles.
It is also dedicated to the defense attorneys who make it possible for the system to keep functioning despite disputes.
Obviously, it is also dedicated to the plaintiff’s attorneys who provide redress for grievances of trusting patients who suffer from the inadvertencies of their medical care and who would likely suffer from the injustices of a defense system that militates against them.
The book is written in the hope that a better no-fault system will be implemented to obviate the entire malpractice process that is so inimitable to the needs of the people of medicine and their patients.
The plaintiff’s attorney paused mid-tirade to take a sip of water. The brief interval of quiet that followed was grudgingly appreciated and respected by the parties to the suit and the large gallery of spectators. Everyone waited impatiently for the next salvo in the acrimonious conflict between the most successful American trial lawyer and the nation’s best known and respected woman neurosurgeon.
“Isn’t it true, Dr. de Montesquiou?” the attorney asked, and paused again for effect, “isn’t it the simple truth that Dr. Norcroft fabricated a case for surgery from flimsy evidence?”
“I am afraid that is the conclusion that I would have to reach,” Pierre de Montesquiou replied, looking directly at the jury and smiling slightly. “Much as I hate to speak or even think ill of a colleague.”
Dr. Norcroft, sitting beside her attorney at the defendant’s table looked down so that the jury would not see her eyes rolled back in disgust.
“Could you review for us the elements of that medical evidence and why you think it should be faulted, why you think it is inadequate?” Paul Bel Geddes, attorney for the plaintiff, did a dramatic slow three quarter turn towards the jury, briefly flashed his copyrighted knowing grin and paused once again. Then, in a stentorian voice, finished his question, “And why you think it led to this fine young man’s untimely and unnecessary death?”
“It is really quite simple,” the renowned French Canadian expert on pituitary surgery began his answer.
Neurosurgeon defendant Dr. Sybil Norcroft steeled herself to hear the description that could possibly spell the end of her rising career. Even a glance at the imperturbable face of her defense attorney failed to convey any calm to the roiling tempest in the surgeon’s brain.
Sybil Norcroft, M.D., PhD, F.A.C.S. first saw Brendan McNeely as a patient on the third of January, five years previously.
The earnest young man’s face and the events of the operation she performed on him had been indelibly imprinted on the surgeon’s memories by the events themselves and by the conflict laden aftermath.
Brendan was her first and only operative disaster in ten years of neurosurgery practice up to that time, and the catastrophe had haunted her in a variety of anticipated and unexpected ways.
On the third day of testimony in the malpractice trial against her, Sybil once again mulled over Brendan in her mind, unable to shake the memories long enough to concentrate on the testimony of the hired gun–Pierre de Montesquiou–brought in by the plaintiff’s attorney, Paul Bel Geddes.
It was the first of July, the day she first met Brendan, five years before he became her patient. It was odd, even considering the lawsuit and the deluge of accompanying publicity, that she remembered the young man with such precision.
Brendan had just finished nursing school and was full of enthusiasm in refreshing contradistinction to the world weary, becoming-burned-out older nurses in the intensive care unit. Sybil recalled the contrast.
It had been something of a memorable day for Sybil, herself, because it was the grand opening of the separate neurology-neurosurgery section of the emergency, post-op recovery, and intensive care complex of Joseph Noble Memorial Hospital.
The facility was the latest in a series of major successes for Sybil Norcroft. She was five years out of her neurosurgery residency at the University of Texas and had worked feverishly to develop her practice.
Sybil had achieved almost every goal of her life in that brief span of half a decade. She no longer had to listen to the condescension of her fellow physicians for her lonely role as one of the few female neurosurgeons in the United States.
She was no longer hailed by the local feminist factions by the unimportant but often repeated paean that she was the youngest woman–youngest person–to complete a fully accredited neurosurgery residency. Sybil Norcroft had arrived. Even her detractors and enemies, of which there were now a few–neurosurgeons from the old SOB school of neurosurgery–to underscore that she was a mover and a shaker, had to admit that Dr. Norcroft was a force to be reckoned with.
She had become the most significant money earner for the hospital, and there was nothing that the administrators of Joseph Noble Memorial Hospital would not do for their rising star. The Neuro ICU was their greatest concession yet.
The administrator, Michael Strong, cut the ceremonial ribbon and said simply, “This is another dream come true for Joseph Noble making us the biggest and the best.
Our tradition of service to the people of this city has always demanded that we give our best. This ultramodern facility is another milestone in our ongoing demand for the finest care for our patients.”
He stepped aside and gestured magnanimously at the senior ICU nurses with whom he maintained a cordial mutual disdain.
“Speech! Speech!” one of the orderlies shouted.
A forest of thumbs-up signaled to whom the chanter directed his request, and all eyes turned to Sybil Norcroft, known to have been the real force behind the extravagant new treatment complex.
Heather Larkin, RN, head nurse of the unit, gave Sybil a solid elbow to the side and propelled her towards the cut ends of the ceremonial ribbon.
Sybil was striking, a slim, Patrician Nordic with movie-star natural blond hair coifed by Hollywood’s best.
She wore a designer dress unapologetically and spike heels which accentuated her curvaceous and muscular calves.
Sybil trotted athletically to the front and flashed a victory grin at the assembled nurses, administrators, and doctors.
“I can’t take credit for this place, but I’m thrilled it’s finally here.
We can do for our patients in this suburb every bit as much as can be done at the Mayo Brothers or Mass General with this cutting edge equipment.
Our annual budget allows for covering every need of the people in these beds that can be addressed at this point in medical history.”
She looked over the beaming faces. It was her day.
“So let’s get to work!”
“Let’s have doughnuts! Forget about the work.
We can work anytime!” said Jasper Heaton, the orderly who had insisted on having Dr. Norcroft speak.
He was Sybil Norcroft’s greatest fan.
“She’s something, isn’t she?” asked the new nurse on the ward, Brendan McNeely.
“She’s all of that and then some,” said Jasper who had edged his way close to an attractive young woman as he replied to the male nurse.
His contact with the attractive secretary seemed entirely unintentional since his attention was directed to the new male nurse.
Jasper had his reputation as the hospital’s chief swordsman to uphold and never let an opportunity pass.
“We’re lucky to have her here. I heard that the university has offered her the moon to woo her away from JNMH,” Brendan said, echoing the widely circulated scuttle-butt he had picked up from the admiring crowd.
“Yeah, she livens up the place.
You’d be surprised what she’s done to this place since she got here five years ago.
Made it the best hospital in the state, at least neuro wise. She made a ton of money, too.
I don’t begrudge her a penny of it. She is the worst workaholic I ever saw.
Many’s the morning I’ve had to wake her where she went to sleep on a gurney.
And she’s eye-candy big-time.”
“I’d like to take on that job,” murmured Brendan under his breath and with a smile.
“No, no, no. Banish those naughty thoughts, new nursie.
Big Dr. Sybil Norcroft is not only rich, famous, and talented, but she is very married and to society as you might have guessed.
The husband’s family owns half the hospital, and all of Main Street.
They breathe special air.
You can count the pretty doctor. among the untouchables.
We are part of the crowd that doesn’t call her “Sybil”.
Just admire from afar like the rest of us humble mortals.”
Brendan gave a slight theatrical sigh. “So I guess it’s off to work.”
He made a smart about face and walked away.
“Watch it!” called Jasper.
Brendan turned to acknowledge the orderly’s parting comment and walked straight into Sybil Norcroft, knocking the breath out of both of them.
Brendan apologized profusely and excessively.
Dr. Norcroft smiled indulgently at the overheated efforts of the young man until his protestations began to interfere with her progress.
“Just try and be a little more careful. We all have things to do, and we have to look out for one another as we hurry.
Now, if you’ll excuse me.”
She was gone before Brendan could apologize again.
“Nice start,” said Heather Larkin, ICU head nurse, “you seem to have made a nice impression on the Snow Queen your first day.”
Heather was smiling.
“Oh, man,” Brendan groaned.
“My goal since I started nursing school was to work in the Neuro ICU.
I heard Dr. Norcroft talk about head trauma in one of the clinical lecture series.
It’s where I wanted to be, and now on day one, I just screwed my career.”
“Don’t get melodramatic on me.
Sybil Norcroft doesn’t know you exist.
She’s married to God and his family, does nothing but spectacular operations all day, and in her rare off hours, she is the twenty-first century’s version of God’s gift to women.”
“I’m not sure that makes me feel any better.
Anyway, what’d you mean by God’s gift to women?”
“Oh, just that she is in big demand on the circuit.”
Brendan had an uncomprehending look.
“The new softer, gentler feminist lecture tour.
She is a member of a very exclusive organization of ultra-successful, ultra-high profile women who go around to colleges, companies, and the like giving the new PC line, sort of a Jungfraus Uber Alles, and isn’t it nice that we treat you men so well anyway kind of group.”
“Oh,” Brendan said. “I’m too new here even to ask, but maybe I detect a little negativity towards…what did you call her? the ice queen?
I take it you don’t subscribe to all of the famous neurosurgeon’s gender based opinions?”
“You are too new, and it’s the Snow Queen which could just mean that she is prematurely gray.
And I guess I would be considered an old-fashioned sort of girl on the latest trend in feminism.”
Brendan fixed Heather’s face with rapt attention.
“And if you repeat one word of this conversation, I’ll cut your throat, capiche?” she managed to smile toothsomely and malevolently at the same time.
Brendan did not get his throat cut and became an accepted part of the NICU social world in a short but grueling two weeks.
He was as too-tired, as red-eyed, as profane, and as flippant as anyone on any of the three shifts by that time.
If Brendan had thought that he would have a grace period to grow into the job, or to grow-up, which was more like it, he was decidedly wrong.
At least he was wrong about the time-frame. He thought he would ease into the job and be comfortable with it inside a year.
He never became comfortable despite his rapid passage through that educational crucible and his wonder at his own growing experience and expertise.
At the end of the second week Brendan was a very capable neuro intensive care nurse, and he and everyone else had forgotten just how short a time it had been since he had been newbie.
Some of the sets of toes Sybil Norcroft had stepped on in her ascent to the pinnacle level of the hospital elite belonged to every member of the Ear, Nose, and Throat department.
On the third day after she obtained full operating privileges at Joseph Noble Memorial Hospital, Dr. Norcroft had admitted a woman with a prolactin secreting pituitary tumor.
She scheduled a transsphenoidal pituitary tumor excision and did the entire operation with the help of an OR tech, thereby injuring every ENT surgeon in the house.
To a man, every ENT surgeon deemed it his bailiwick to do the approach up the nose to the base of the skull with the neurosurgeon opening the floor of the sphenoid sinus and sella turcica and taking out the pituitary tumor lying above.
Also to a man, every neurosurgeon on the staff who did the exacting lower approach to the pituitary was glad to have the ENT man do the approach, collect the co-surgeon’s fee, and provide valuable backup and help in the primary part of the operation.
Dr. Sybil Norcroft violated them all, particularly since she did the procedure in half the time and for the same fee that the two surgeons usually collected.
When she became aware that she was the object of a negative covert whispering campaign, Sybil ignored the patriarchy of the two surgical services.
When they became overt and challenged her openly for her solo practice of a series of thirty-one flawlessly done pituitary tumors done from below, she forever disingratiated herself by smiling and replying sweetly, “I just don’t think nose-pickers should be involved in pituitary surgery, gentlemen. Have a nice day.”
Sybil cemented relations with the ENT department by insisting on doing all of her own tracheostomies, heretofore an operation considered to be the sole province of the otorhinolaryngologists.
When challenged, Sybil showed her critic what a fine job she had done on her most recent trach procedure and earned eternal enmity by letting slip the incidental fact that the patient was not her private patient, but in fact, she had been consulted by the pulmonologists for the sole purpose of providing a surgical airway.
Brendan McNeely began to develop a conversational relationship with the eminent neurosurgeon by assisting on a series of four tracheostomies in one marathon day of admitting head injuries.
It never could be said that the two became friends–Dr. Norcroft did not become friends with the staff–but she did develop a certain rapport with the earnest young nurse.
“Passed your qualifying licensure test I hear from Heather,” Dr. Norcroft said as her hands flew through the almost rote movements of the tracheostomy.
Brendan had to hurry to keep up.
“Yes, Ma’am,” he said and quickly reached to place the hooked trach retractor into Dr. Norcroft’s waiting hand.
“Today, Mr. McNeely, I need it today.”
“Yes Ma’am.”
There was nothing to be gained by arguing. Dr. Norcroft meant nothing by her little jibes. I
In fact, Brendan was coming to see that the small digs were a sign of attention, bordering on acceptance.
“Not bad for the new kid on the block,” she said when they finished.
That was the highest compliment the reserved neurosurgeon had ever paid him.
It was the first and only one to date.
Brendan felt as if he had arrived.
By the end of the fourth tracheostomy of that long difficult day of head injuries, Dr. Norcroft was conversing with Brendan, at least, she spoke to him regularly.
He interjected “Yes, Ma’ams”, and “No, Ma’ams”, and “Thank you, Ma’ams”, at strategic intervals.
“Nose pickers don’t know when to do a trach.
They make such a big production out of a little trach that I get embarrassed for them. They take every one to the OR, am I right, McNeely?”
“Yes, Ma’am.”
“No excuse for not just doing them here in the ICU, don’t you think, McNeely?”
“Seems like the place to do them to me.
We did a passel of them today…saved the OR fees.
I’d say that was a good day’s work, Dr. Norcroft.”
“Mind cleaning up, McNeely?
I have to dictate these big cases of ours.
Anyway, what’s your first name?
Do they give new nurses first names?”
“Yes, Ma’am. It’s Brendan.”
“Mind if I call you Brendan?”
“Nope. Of course not.”
“Then, Brendan it is.
And, at the risk of sounding like a bull dyke feminist, would you mind stopping calling me Ma’am.
It’s not strictly PC, you know, and for whatever reason, the term just grates on my nerves.”
“Yes…Dr. Norcroft.”
They both smiled at Brendan’s obvious effort.
At the end of the third month of Brendan’s career on the NICU at Joseph Noble Memorial Hospital, he was made charge nurse for the graveyard shift, and in a year he was assistant head nurse.
His rapid rise was due, in no small part, to his having found favor with Dr. Sybil Norcroft, the undisputed queen of the neuro ICU.
The degree of that favor was only partly due to the quality of the young man’s work.
The major part of the approval and support from Dr. Norcroft came after she met Brendan at a Rankin County Tennis Club cultural exchange with the sister city of Yogyakarta, Indonesia.
Brendan had been keeping a secret. His family, on his mother’s side, the Mintons, were old friends and social equals of the Daniels, Dr. Norcroft’s husband’s family.
Sybil’s husband, Charles Daniels, and Brendan’s father had been classmates at Groton.
Furthering Brendan’s career had followed the most natural progression after that.
Consciously, or unconsciously, Sybil viewed Brendan as “one of our kind” and dropped the right word in the right ears at the right time.
Brendan was suctioning the tracheostomy on Juan Dominguez, one of Dr. Norcroft’s weekend murdercycle admits.
She had done an emergency midnight craniotomy to remove a subdural blood clot that was crushing the life out of the young gang-banger’s brainstem.
His prognosis was poor.
“How’s our model citizen this morning, Brendan?” Dr. Norcroft asked breezily.
She always looked fresh and icy calm, even when she should have been exhausted.
It was a matter of self-discipline. Her favorite T-shirt had a red circle with a line through it that canceled out the word “Whiners”.
Brendan could not recall a time when the well-known neurosurgeon had looked done in or disheveled even after an all-nighter in the OR. Even in a joke T-shirt, the woman was a svelte socialite with perfect make-up, not that she needed any.
“Still on the respirator, still decerebrate, still has dilated pupils, still incontinent,” Brendan reported.
“Other than that, he’s doing okay, I take it,” Dr. Norcroft responded cheerfully.
Neurosurgery is not for the faint of heart nor for those easily discouraged by failures beyond their control.
Brendan laughed and stood up from his flexed position. He stretched out the kinks, drawing his scrub shirt tight across his thin chest.
“Brendan,” Dr. Norcroft looked at him seriously.
“What?” he asked.
“What had he done now?” he thought.
“What is that on the front of your shirt?”
Brendan self-consciously folded his arms across his chest and blushed. He avoided her eyes.
“Brendan,” she urged.
“It’s nothing, Dr. Norcroft. Some silly hormonal thing, I guess. I’m embarrassed. It just started happening a few weeks ago.”
He was looking down, uncomfortable with her scrutiny and questions.
“Let me look. Please.”
Brendan slowly dropped his arms. On the front of his shirt, immediately over his nipples were two small, but unmistakable patches of sticky wetness. Sybil Norcroft observed the twin wet spots then reached out and rubbed one of the areas of wet cloth in her fingers.
“Milk,” she said laconically. “May I examine your chest, Brendan?”
Her voice was gentle and persuasive.
“Sure. I guess. It’s kind of public here, though.”
“I start my office patient schedule at nine this morning.
Come on over to the medical office plaza at quarter to, and I’ll see you before I begin seeing the usual crocks.”
“I’ll be your first crock of the day then, Doc,” he said jokingly.
“Brendan, I don’t want to alarm you, but I don’t at all think you are a crock. I really think this is something a bit more serious,” she said kindly but decisively.
He shivered a little.
“What do you think it is?”
“Like you said, ‘This is kind of public’, let’s look into this and talk about it in the privacy of my professional office.”
Dr. Norcroft wore her determined look.
Brendan knew better than to argue further. Her concern worried him.
She did not express uneasiness frequently. Her reputation as the Snow Queen came from her icy calm in the face of trouble and her seeming indifference to other peoples’ distress.
If Dr. Norcroft was concerned, Brendan McNeely was worried.
“I’ll be there. I want the straight skinny, Doc. Okay?”
“That’s all I deal in, Brendan, you know that.”
She gave Brendan a slight dismissive wave and turned to leave the cubicle to complete her rounds.
It was six am.
“Eight forty-five sharp,” she called over her shoulder.
“Yes, Ma’am,” he said, emphasizing the ‘Ma’am’.
She gave him a parting grimace.
At nine o’clock the next morning, the simple physical examination was completed.
“What do you think, Dr. Norcroft?” Brendan asked, patient up until then.
She had taken a thorough history from him while doing a thorough close off whole body examination with special emphasis on Brendan’s leaking nipples, eye, and neurological systems. Most of her attention had focused on his chest and on his visual field examination.
“I can’t be sure, but you have some increase in the size of your breasts; and as you saw, I could express a drop or two of milky stuff from your nipples.”
“Not all that manly, right, Doc?”
“Manly has nothing to do with it. I’d bet a whole bunch that you have a prolactin secreting pituitary tumor as the source of this milk. There are other things, like adrenal problems, or some sort of weird breast disease that I don’t know about, in the differential diagnosis, but when you hear hoof beats, you ought to think of horses first, not zebras.”
“But pituitary tumors that cause milk production in men are pretty much ‘zebras’. I mean, who ever heard of a man having milk from his breasts. Jeez!”
“I have,” she said and looked at him levelly.
He glanced about as if seeking a place to retreat.
He saw her diplomas, a tennis trophy on her book shelf, her state medical license.
On her desk was a bronze name plate on which was engraved, “GOD”.
He looked from it to her and shrugged to show his resignation.
“This is what we have to do,” she said and proceeded to outline a thorough workup plan.
“Is your health insurance any good?” she asked.
“It’s with the Blues through the hospital. I presume they’ll cover all this.
We don’t have to start the HMO and its third world level of coverage until next January.”
“Then let’s get started today. I’ll have Rachel, my secretary, schedule the CT. I would prefer an MRI, but the insurance company wouldn’t hear of it. We would be a month haggling over the question that is not terribly important. Anyway, you might be able to get the CT today since it’s early in the week. You can get the blood and urine tests done at the lab without an appointment.”
Brendan returned to Dr. Norcroft’s suite of offices four days later.
He did not have to wait.
Dr. Norcroft took great pride in the punctuality with which she saw her patients.
He was ushered into her private office half a minute before the time of the appointment.
“Have a seat. I have the results of the tests. We can look at them together,” she said.
Sybil Norcroft, like most of her neurosurgical colleagues, was nothing if not direct. Apparently, small talk, or some said, bedside manner, was not part of the neurosurgical training curriculum.
“First, the hormonal workup. Adrenals and thyroid are okay. You’re a little low on TSH, but that’s probably still in the low normal range.
What is significant is the prolactin level of 75. That’s high, not off the chart, but high. Should be about 5. In my experience lactation usually doesn’t occur with levels under a 100 or even more, but, given the fact that you are a male, or maybe just something about your physiology makes you susceptible.
Anyhow, the abnormality fits the clinical presentation, even if it is not statistically the most common.
So let’s look at the films.”
She led him into the hallway where a bank of x-ray view boxes was stationed. The CT scan was already in place on the lighted boxes.
“The rest of the brain looks all right. No tumors, ventricular indentations, no anomalies. Bones of the skull look fine. I kind of wonder about this little thinning in the floor of the sella turcica…”
“I’m sorry, Dr. Norcroft, I forgot what the sella turcica is,” Brendan said, a bit ashamed, knowing that he should have remembered from his anatomy classes in nursing school or from his work in the NICU.
He guessed that he was a little excited under the circumstances.
“Tsk, tsk,” Dr. Norcroft said with mock sternness. “Means Turkish saddle.
It is the fossa in the floor of the skull that houses the pituitary gland.”
Brendan shook his head, vexed with himself.
“Maybe I just have milk producing Alzheimer’s”, he said in self-deprecation.
“Relax, Brendan.
This isn’t a test.
I know this is stressful.
Let’s follow the evidence through to the end.
I don’t think too much about the thinning in the sellar floor, as I said.
But I do think this little round lucent area in the middle of the fossa, in the middle of the gland may be our culprit.
There’s no evidence of any tumor in the parasellar area or of any large pituitary tumor.
Prolactin secreting tumors are usually very small.
It’s not a great picture, but I think it is highly suggestive of an intrapituitary adenoma.”
“What’s that on top of the sella?”
Brendan had straightened out a paper clip to use as a pointer.
He indicated a rounded structure just in front of and above the bony concavity that held the body’s master gland.
“That’s the optic chiasm,” she replied. “And that small lump above the gland…right there…is an artery, probably the basilar. Nothing to worry about. If you wanted to be completely thorough, we could do a cerebral angiogram and take a look at the vessels.”
“No thanks, not if it’s not absolutely necessary. Angios are punitive, in my book.”
Brendan had taken care of a host of patients after the procedure that required a needle puncture in the artery of the groin and passage of an injection tube up the artery where it was used as a conduit to instill contrast material into the vessels for outlining the vascular system.
Nearly every patient complained that it was a miserable experience.
“We could miss an aneurysm, but that really is a zebra,” said Dr. Norcroft. “I think we are pretty firm in our diagnosis without it, with the CT scan. Look right here,” she indicated.
There were strand-like structures that Brendan presumed were vessels caught passing vertically and circular structures that he presumed were vessels seen end-on.
The optic chiasm was almost as evident as a line drawing in his anatomy textbook. In the middle of the pituitary was a slightly irregular and indistinct ovoid area that was a few measures brighter than the surrounding pituitary tissue.
“Is that a tumor?” he asked.
“I’m pretty sure it is, Brendan,” Dr. Norcroft answered.
“‘Pretty sure’?”
“This is still medicine–biology, if you please.
We can’t be certain without a biopsy.”
The sound of the word made the young man wince.
“As in surgery?” he asked, knowing the answer before he voiced the question.
“Only way, Brendan. And it is the definitive treatment.”
“Transsphenoidal hypophysectomy?” he asked, taking care not to stumble over the mouthful of syllables.
“To be technical about it, not a hypophysectomy.
It would be a transsphenoidal selective excision of a pituitary adenoma. The difference is a lot more than just semantic. We–I mean I–should be able to take out the little mass and leave the pituitary functional.
You would probably not have to take pituitary replacement meds except during the post-op period, maybe a couple of months.”
“Isn’t there another way. Pills or something?”
“Yes, but they don’t cure the tumor or do anything except hold down the growth.
You keep the little time-bomb ticking in your sella.
If you stop the drug, bromocriptine, the tumor is likely to grow rapidly. The drug is not a cure.
You know my bias, Brendan.
I’m a surgeon.
I believe in surgery.
It is the only way to effect a cure. You want a cure.”
“How safe is the surgery? I mean, I see all of your patients coming back to the NICU doing just fine.
I don’t think I have seen any complications. Am I right?”
“Pretty much. There is always the possibility of having a complication.
Even in the best of hands.
You need an experienced surgeon, a surgeon who has done a lot of these.
False modesty is silly.
I’ve done a lot, and I could count my complications on one thumb.
For the record, I’ll list the possibilities.”
“That’s not necessary, Doc, I trust you completely.”
“I’ll do it anyway.
You need to be able to give informed consent, even if you are a nurse.
There is about a one percent total possibility of one of these complications happening.”
Dr. Norcroft spent the next three minutes listing a dizzying array of potential hazards–bleeding, infection, cerebrospinal fluid leaks, pituitary failure, death from the anesthetic, brainstem or blood vessel injuries, drug interactions and allergies.
When she finished and looked at the patient for any questions he may have had, Brendan added, “Or the nurse drops the patient on his head in the ICU.”
“And that’s probably the most likely scenario for trouble of them all.
Nogoodnik nurses!”
They both smiled.
“Any questions?”
He shook his head.
“Want to have a second opinion? By the way, does your insurance require a second opinion?”
“I don’t want anyone else’s opinion. I trust you all the way,
Dr. Norcroft. In my book, you’re the best.
The hospital’s health coverage doesn’t require a second opinion so long as the doctor of choice is on the staff of JNMH.
I’m satisfied.”
“Want to do it tomorrow? I know that might come as a kind of a shock.
It’s a bit abrupt, but I have an empty OR slot tomorrow at about ten.
I might not be able to get you in for another couple of weeks.”
“Whew! That’s a reality check!
I guess I should.
Nothing to be gained by waiting, I suppose.
All right, what do I have to do?”
She gave the young man his instructions and a prescription for oral cortisone to protect his pituitary from the shock of surgery.
“See you in the morning.
Don’t be late,” she said.
The following morning Sybil stood at the scrub sinks cleaning her nails.
She kept them as short as a man’s to prevent the accumulation of any dirt and microbes.
Her fingers were those of a pianist–long and very strong.
Her hands were too muscular to be attractive, too hard and dexterous to be considered pretty.
She was looking through the observation windows at Brendan who was in position for the transsphenoidal pituitary operation.
Sybil ran through her mental pre-op check list as she surveyed the room.
Satisfied, she reached for a packaged disposable scrub brush.
“Hello, sweet thing,” came a voice from around the corner, mildly startling her.
She recognized Darryl Hankin, chief of ENT’s, voice.
“You’re about to perform the miracle of one woman, or should I say, super woman, surgery on the scion of one our most prominent families, I hear.”
“That’s right, except for the part about sweet thing.
Do you feel it necessary to act the part of a chauvinistic throwback all the time, Darryl?”
“Excuu-uuse me for being friendly, my dear.
Do all the ladies at your Dyke Club carry such big chips around on their shoulders all the time?”
“I wouldn’t know.
And Darryl, how is it that you always seem to choose a time when there are no witnesses to spout your anti-women nonsense?”
She made her eyes wide with questioning above the surgical mask.
She scrubbed her hands assiduously as if he were not there.
“Why not try a little sugar, Sugar?” Darryl persisted.
His voice was soft and sincere now.
He moved close to her.
“I don’t mean you any harm. Quite the contrary.”
He moved a little closer.
“That’s nice perfume. Chanel Number 5?”
“Alfred Sung, and please don’t crowd me. I don’t want to be contaminated…in any sense of the term.”
“OOh, feeling feisty today are we?
I like your spirit.
I just wish we could get along.
I’m not such a bad guy.
I could show you my better side.
We could do a lot working together instead of at cross purposes, you know.”
He placed an affectionate hand on the back of her neck.
She stiffened immediately, almost reflexively.
“I consider that an assault, sexual harassment, Dr. Hankin.
Do not even think of doing it again.”
He withdrew his hand as if he had been burned.
He glowered at her.
“You come by your title of Snow Queen rightly.
You ought to hope that you never need a friend, sweetheart, because there will be precious few of them available.
Have a nice cold day.”
He abruptly walked off.
Down the hall she could hear him laughing as he met another of the surgeons about to start his day of operations.
Sybil’s hands fairly flew through the preliminary approach to the floor of the sella turcica.
In part she knew that her movements were more rapid and intense because of her smoldering anger at her sexist colleague.
She took a deep breath and told herself to calm down.
No social dinosaur was worth a minute of her disgruntlement.
He was beneath her disdain, in fact, she was more angry at herself than at him for letting him get under her skin.
The bone of the sphenoid sinus at the base of the skull drilled off easily, and the clean, glistening mucous membrane came out almost in one smooth sheet.
The operation was proceeding better and more quickly than usual.
Maybe it did her good to have a little righteous wrath.
She checked the small bone chisel to be certain it was sharp.
Again, she went through her mental check-list at this critical juncture in the operation.
She stepped back.
“Let’s change gloves. Everybody. And wash off the powder. I don’t want to get any powder granulomas inside the skull.”
Regloved, she painstakingly chiseled out a small square of bone and gingerly lifted it away from the underlying dura of the pituitary fossa. The piece of bone was stuck by strands of connective tissue, and Sybil had to tease it away with a fine probe.
She used the probe to undermine the rest of the bone of the floor of the sella turcica and ronguered out enough bone to give her a good view and an ample area to work in under the microscope.
She noticed that her attention to the details of the surgery had calmed her, and she no longer thought about the boorish Dr. Hankin.
“Mary Ellen, please set up the video now.
I want to record the rest of the procedure for the AANS meetings in Chicago.
I have to give a paper on microadenomas, and this one should be ideal.
It’s a good teaching tool for the staff, too.
Why don’t you take some footage of the operative set up while you’re at it, okay?”
“No problem, Dr. Norcroft.
Watch your eyes while I snap the camcorder into place on the microscope strut.”
The video picture was fuzzy and greenish.
“You can do better than that, Mary Ellen. It looks like we’re working in a fungus,” Sybil commented when she looked at the TV screen image of the operative site.”
“Patience is a virtue, Dr. Norcroft,” chided Mary Ellen, the circulating nurse.
She deftly twiddled the two adjustment knobs, and the image came into focus.
“How’s that?” she asked.
“Much better. A little too red. Tone it down a bit.”
Mary Ellen shook her head, “Nattering Nabob of Negativity.
No offense meant,” she muttered good naturedly and made the final adjustment.
“All right. I want everyone’s attention.
No talking. I’m going to open the dura,” Sybil said.
Mary Ellen rolled her eyes at Tanya Jenkins, the scrub tech.
Tanya did a small surreptitious and silent drum roll with her fingers.
She took pains not to let Dr. Norcroft see the small gesture of disrespect.
The doctor had a reputation for getting nasty over little slights.
Tanya had been the object of her wrath more than once and did not feel like having a problem today.
Tanya had been the one who coined the term Snow Queen in the first place.
That was a fact she kept a strict secret.
“Camera on?” Dr. Norcroft asked.
“Yes, Doctor,” answered Mary Ellen.
“Eleven blade knife on a long handle.”
The scalpel was pressed firmly into Sybil’s hand.
She made a cruciate incision in the tough covering, making several gentle passes until she broke through. Dural venous bleeders oozed into the field briefly obscuring visibility.
“Bipolar coag,” Sybil ordered.
She buzzed the tiny bleeders and sucked out the small amount of accumulated blood.
“The opening’s too small. Curved micro scissors, please.”
“Sharp or blunt tips?”
“Sharp.”
The delicate long shafted scissors passed between the self-retaining retractors keeping the tubular tunnel up the nose open. Sybil began to make little nibbling cuts in the limb of the cross on the patient’s right side.
“Thick dura, tough,” Sybil said, thinking out loud.
There was a little bleeding. Bright red.
“Coag,” Sybil ordered.
She electrocoagulated the bleeder.
“Okay, I buzzed that one.
Scissors again.”
Sybil gently insinuated one of the points beneath the dural opening a distance of about three millimeters and mentally calculated the necessary further opening to give her access to the pituitary.
“That ought to be about right,” she said to no one in particular.
She could feel beads of sweat forming on her forehead.
“Wipe, Mary Ellen.”
“Yes, Ma’am,” Mary Ellen said innocently and immediately regretted her choice of titles.
She knew that Dr. Norcroft did not like being ma’amed.
“Mary Ellen,” Sybil scolded mildly.
“Sorry, it just slipped out.”
Very carefully and slowly Sybil approximated the edges of the blades of the scissors and began the fastidious slicing through of the remaining dural impediment.
“Just about there, Doc,” said Mary Ellen watching on the video monitor.
Sybil ignored the nurse’s small breach of her order for quiet.
Her attention was riveted on that tiny spot between the blades of the scissors.
She advanced the cut the final two millimeters.
There was a nanosecond of time when a small stream of bright red blood started out of the last opening in the dura.
Then the microscopic stream changed into a Vesuvial eruption.
A miniature fire hose force jet of arterial blood blasted out of the opening and obscured everything in sight with an opaque sea of blood.
The actual outpouring was only ten or fifteen ccs of blood a second, but, under the microscope, it looked as if the gates of Boulder Dam had suddenly been opened and released a Lake Mead of blood.
Sybil Norcroft forced her attention to return to the witness in the courtroom.
Dr. de Montesquiou was declaiming, “To make a long story short, the preoperative evaluation was altogether too brief and hasty, especially in one particular, and that led to a flawed diagnosis and to an inappropriate operation, and eventually to this fine young man’s death.”
“Objection. Witness is giving the summation.
His response is not an answer, it is a speech,” spoke up Carter Tarkington, Dr. Norcroft’s attorney, from his seat at the defense table.
“Sustained,” said the judge. “Jury will disregard that reply.
Please keep your answer to the pertinent facts within your knowledge or based on your expertise.
Let’s have the question reread, please.”
Dr. de Montesquiou waited until the question was repeated.
“Dr. Norcroft ordered a very short form of the pituitary workup.
She should have done provocative tests to ascertain the function of the gland, to see if it was truly the source of this young man’s very limited symptoms.
She should have tested the secretions, and we have only her statement that there were in fact secretions, for the presence of fat, to be sure that the fluid was in fact milk.
She should have ordered an arteriogram.
Had she done so she would, no doubt, have discovered the cerebral aneurysm that she perforated and caused the fatal hemorrhage.
Finally, she should have repeated the serum prolactin levels.
I am quite sure that a second value would have been normal or nearly so.”
“Let’s take your answer in parts, Doctor.
Are there tests to determine the presence of milk in secretions from the breast?”
“Certainly.”
“Are they expensive, difficult to obtain, available only in a few isolated laboratories?”
“Not at all. Any hospital could have an answer in a matter of hours, probably in minutes.”
“What is an arteriogram, Doctor?”
“The doctor punctures a groin artery, places a slender tube into the artery through the needle, and passes that tube up to the vessels going to the head.
He squirts contrast, a sort of x-ray dye, into the tube and takes a series of timed x-rays that show up the vessels.”
“Is that an expensive, dangerous, or difficult to obtain test, Doctor?
Are there only a few centers that can do that sort of sophisticated test?”
“Objection, compound question,” Mr. Tarkington said.
There was no real enthusiasm in his objection.
“Denied. Witness may answer.”
“The test has a cost, of course, since it entails a well-trained doctor to do the procedure, technicians to provide the needed help, and sophisticated equipment, but the patient in this case had insurance that would pay for the test.
As to the danger, in good hands, there is less than one in a hundred chance of any kind of complication, and probably more like one in ten thousand or maybe even fifty thousand of a serious or crippling complication.
Any full service hospital has the wherewithal to do angiography and thousands of them are done every day across North America.
I am informed that the Joseph Noble Memorial Hospital has full facilities to do the test.”
“Are you aware of whether such facilities were present five years ago when Mr. McNeely fell into the hands of Dr. Norcroft?”
“Objection! Objection! That is entirely uncalled for. Move to strike!” Tarkington was on his feet.
“Sustained. Mr. Bel Geddes, will I have to remind you to take care to watch your characterizations in the future?”
“No, your honor.”
“I hope not. The jury will disregard that last question by plaintiff’s counsel. Rephrase your question, Mr. Bel Geddes.”
“Are you aware of whether facilities for cerebral angiography were available at Joseph Noble Memorial Hospital at the time Mr. McNeely was being evaluated five years ago?”
“Yes, Sir. I asked at the hospital.”
“Objection, hearsay.”
“Sustained. Strike the response. Rephrase your question, counsel.”
“Only answer of your own knowledge, Dr. de Montesquiou. Were facilities to perform angiography readily available in North America five years ago?”
“Readily.”
“Was it common for hospitals such as Joseph Noble Memorial Hospital to have angiographic suites five years ago?”
“Objection, calls for a conclusion based on hearsay.”
“Overruled. Witness may answer. It is within his field of expertise.”
“Yes, it was common, really the rule for medium and large sized hospitals to have such capability.
I am sure that the hospital in question considered itself a full service hospital and had angiography in order to qualify for that ranking in state and national accreditation.”
Tarkington started to object but thought better of it.
“And what could have been, should have been, learned by an arteriogram?”
“Whether or not there was an aneurysm on an artery in Mr. McNeely’s head.
In my opinion there was, and that is the crux of the problem here.”
“Objection.
Answer exceeds the scope of the question and is not responsive. It is another concluding summary remark.”
“Sustained.
Jury will disregard.
Strike the answer.
Try again, Mr. Bel Geddes.
If Bel Geddes was getting frustrated, he did not show it.
“Of what benefit to the evaluation of Mr. McNeely would an arteriogram have been, Dr. de Montesquiou? In your medical opinion?”
“It could have ruled in or out the presence of a cerebral aneurysm, a crucial bit of evidence,” de Montesquiou replied.
He turned to look thoughtfully at the jury as he did.
“He’s good,” thought Sybil and her lawyer on the same telepathic link.
“And what is the significance of a cerebral aneurysm in this case, Dr.? In fact, perhaps you could enlighten the ladies and gentlemen of the jury about aneurysms.”
“Indeed, I can,” he said.
Sybil raged silently at the sheer arrogance of the pompous little Frenchman on the witness stand.
“Indeed, I can,” she mocked to herself, taking care to keep her face benign and expressionless lest the jury take offense.
“Aneurysms are small blisters, weak spots on vessels.
They are weak enough to break and to cause bleeding.
In the brain such hemorrhage can destroy or compress vital centers.
I have seen them many times. Very nasty.”
“How much manipulation can you perform on aneurysms, Doctor?”
“Almost none. They are extremely fragile, sometimes only one cell layer thick.”
“Could you…say, touch an aneurysm with the point of a knife, say, an eleven or stab blade knife with any degree of safety?”
“Objection, calls for a conclusion regarding facts not in evidence.”
“Sustained. Rephrase your question, counselor.”
“Dr. de Montesquiou, I would like to ask you a hypothetical question. If a person had a cerebral aneurysm, and a surgeon made a three millimeter long and two millimeter deep cut with a sharp knife or the sharp points of a pair of scissors, what would be the likely result?”
“Severe hemorrhage.”
“Possibly life threatening bleeding?”
“Definitely.”
“How could one know if a patient had such an aneurysm?”
“By doing an arteriogram.”
“Was an arteriogram done in the case before this court?”
“No Sir, it was not.”
“Object to this entire line of questions.
Assumes facts not in evidence.”
“I’ll allow some latitude here.
How much further do you intend to pursue this line of interrogation, Mr. Bel Geddes?”
“I have finished.
With the court’s permission I would like to obtain the doctor’s opinion in another area.”
“Proceed.”
“Now, Doctor, let me ask you about the serum prolactin level in this case.
Do you have a copy of the report in front of you?”
“Someplace. I can’t put my finger on it just now.”
“Perhaps I can help. Look at plaintiff’s exhibit A, the office chart of the defendant. I believe we are looking for page eleven.”
“I have it.”
“Now, Doctor, could you describe that report?”
“It is a report from the Energetics Specialties Lab, New York, dated 5/9/01.”
“Excuse me for interrupting, Doctor. In the United States we usually present dates with the month first, then the day, then the year. Could you give us the date of that report in words so there will be no confusion?”
“The fifth day of September, two thousand one.”
“Thank you. Please go on with your discussion of the report.”
“In the mid portion of the report, under Results, the report reads: ‘Serum Prolactin – 75’.”
“What, if anything, is significant about that value, Dr. de Montesquiou?”
“Not much. That’s the point. While normal values are in the range of less than five, in certain circumstances, it may be normal to have a value of fifteen. It is generally held throughout the medical literature that a value of 100 or more is clearly abnormal, and absent any other obvious cause, is indicative of a prolactin secreting pituitary tumor. Values less than that can be but are less reliable for the presence of tumor. There can be other causes of such modest elevations of the prolactin level.”
“Doctor, could you tell us, please, what other causes there might be for a level of 75?”
“Breast fondling and sucking as in sexual activity. I believe the practice would have to be quite frequent. Most people would say excessive, even obsessive.”
“Objection, vague.”
“I’ll allow it. But, counselor, I am only going to allow so much latitude. I hope this is leading somewhere.”
“I believe I can demonstrate a definite purpose to the line of questioning, if the court will indulge me for a few more questions.”
“Proceed.”
“In your long experience as an expert in transsphenoidal surgery and in treating pituitary problems, have you seen such a cause for an elevated level of prolactin?”
“Yes, a few.”
“In what group of people did you find this elevation resulting from nipple manipulation, Dr.?”
Sybil quickly scrawled a note and slid it to Tarkington: “I am suspicious that this is leading somewhere dangerous.”
Tarkington glanced at the note and acknowledged only with a scarcely perceptible tightening of his lip muscles.
“It was exclusively in young women.
I am not aware of such practices in men, but then I do not see the number of, shall we say, the third sex, that are seen in the United States.
Nevertheless, I don’t think it happens with any frequency in men.”
“For that matter, how common are prolactin secreting tumors causing lactation in men, Dr. de Montesquiou?”
“Rare as hen’s teeth.”
Sybil looked expectantly at Carter Tarkington to make an objection, but he only looked as if he were intently listening.
“Hmm, then Doctor, what possible explanation could there be for a prolactin level of 75 in this otherwise healthy young man?
You don’t have any evidence that he was a homosexual, a member of the third sex as you put it, do you?”
“No indication that he was bent that way, Mr. Bel Geddes, but there is another stronger likelihood.”
Tarkington was afraid there might be. He passed a note to Sybil Norcroft:
“?”
Sybil scribbled a reply.
“Drugs”.
de Montesquiou appeared almost apologetic as he turned slowly to the jury.
“I have no such knowledge about Mr. McNeely. I mean about the…the deviation. But a more likely possibility, actually, a probability, is that the pituitary was stimulated by one of a group of drugs called the phenothiazines.”
“What sort of drugs does that class include?”
“Major tranquilizers–drugs like Mellaril, Prolixin, and Thorazine.”
Tarkington turned slightly towards Sybil and raised one eyebrow in a question mark. She shrugged to indicate ignorance by way of reply.
“Was Mr. McNeely on a phenothiazine, Dr. de Montesquiou?”
“That can be the only explanation,” the witness responded with a look of minor triumph on his face.
“Objection, your honor.
My client objects to this entire line of questioning as being irrelevant and entirely lacking in foundation or evidence.”
“Gentlemen, approach the bench, please,” asked the judge.
At the side bar, Judge Kendricks was barely audible in her effort to prevent the jury from hearing.
“Mr. Bel Geddes, is this speculation, or are you going to produce a witness or are you going to surprise us all with a heretofore unknown tidbit of information from the medical chart?”
Bel Geddes’s voice was several decibels louder than Judge Kendricks’s.
Carter Tarkington rolled his eyes at the blatant effort to communicate with the jury sotto voce.
“Nothing in the chart, your honor, for this witness to testify to, but I am laying foundation for future evidence.
I don’t believe I am obligated to share plaintiff strategy with defense.”
“But you are obligated to share your list of witnesses. The rules of evidence do not permit last minute introduction of witnesses who could have been made available to the opposing side for deposition by a reasonable and prudent effort on the part of the attorney making the introduction of the new witness,” Tarkington said acerbically.
“Mr. Bel Geddes?” Judge Kendricks queried quietly.
“I will have such evidence against Dr. Norcroft, your honor. It will be brought out forcefully during the plaintiff’s case.”
He might as well have stood on the judge’s desk and shouted it; his whisper was so stagey and carrying.
Kendricks shook her head, Tarkington started to object, the jury hushed, and their twenty-four eyes were fixed on the side-bar.
Bel Geddes asked sweetly and very quietly this time, “Was there anything else, your honor?”
Kendricks shook her head again.
“I just have a few more questions of you, Dr. de Montesquiou.
I know you are tired. It has been a long day.
Thank you for your patience.”
“Glad to be of service, counselor.”
Sybil gave a groan.
Tarkington put a quick finger to his lips.
“If Mr. McNeely did not have a pituitary tumor, then what did he have that caused his elevated prolactin?”
“I believe he must have been taking Thorazine or Mellaril, some phenothiazine.”
“And what happened in the operating room to cause the terrible bleeding?”
“In my studied opinion, after operating on over 8000 of these cases, the lady doctor, there,” the witness paused to point at the defendant, “put a knife into a cerebral aneurysm that was sticking down into the pituitary fossa.
That aneurysm could have been detected by an angiogram, and this whole sorry catastrophe could have been prevented.
The operation should never have been done.
When it was done, it was performed with negligent and careless haste. This was a case of medical malpractice pure and simple. Maybe not so simple.
I think it was criminal.”
There was an audible chorus of inhalations from the spectators that was loud enough for the judge to rap her desk once with her gavel.
“Thank you, Doctor. I have no further questions.”
Three reporters quietly walked out through the tall doors of the courtroom, pulling cellular phones from the jacket pockets of their blue blazers.
The initial shock of seeing that column of bright red blood erupting from the tiny operative site was enough to make Sybil Norcroft feel as if she would faint.
It was the nearest she had ever come to fainting, and in all her thirty-eight years of life, it was the worst she had ever felt. For the rest of her life, Sybil would never quite be able to exorcise that image.
The worst thing about the feeling at the time was the sense of paralysis.
The shock, dread, indecision, fear, anger, and visualization, of the worst-case scenario passed through the neurosurgeon’s nimble mind like a slow motion tape with time to examine and to suffer from each surging emotion.
In fact, the time that elapsed from observation to action was well under a second.
“Large bore sucker,” Sybil ordered.
She placed the large suction apparatus as near the site of bleeding as she dared.
“Get me the muscle fragment I took out of his leg at the start. Wrap it in gel foam soaked in thrombin. When you have it in a pair of pickups, hand it to me.”
Sybil held out her right hand in a position of readiness. She continued to evacuate blood with the other hand.
“Howard, T and C ten units of blood and ten units of fresh frozen plasma,” she said to Howard Derriel, the anesthesiologist.
“Way ahead of you, Sybil.
I’ll take care of my end.
Mary Ellen, set up a strict blood loss regimen.
Sybil, I know how you feel about this kind of case, but do you think maybe you need some help?
You don’t have enough hands for this.”
“You’re right, Howard. First things first.
Tanya, what’s taking you so long.
I need that muscle plug ASAP, now, even today.
You can take your siesta later.”
“It’s right here, Doctor. You were talking.”
“This is not the time to argue, Tanya. Understand?”
“I understand, Doctor.”
Despite the urgency of the situation, there was a note of hurt in Tanya’s voice.
“It’s not my fault that things are going badly,” she said to herself.
“Get me a neurosurgeon, stat! I need help.
Mary Ellen, just call the desk and find out who’s on call and get him here!
The muscle plug washed out of the operative site like a twig in Niagara Falls.
“Get me a cotton ball soaked in hydrogen peroxide.”
The video ground on showing minute after minute of torrential bleeding.
When the foaming cotton ball was pushed up against the bleeding site, the video showed nothing but a cloud of whiteness.
Without anyone paying the filming any attention, the video tape recorded 72 minutes of redness, attempts at tamponade, desperate conversations.
“I think I have it stopped for a minute. This’ll never hold, though.
How’re you coming on getting me some help?”
“Not great, Dr. Norcroft.
This is Saturday, everybody’s gone somewhere.
Dr. Nielson is on call, and he is up to his knees in alligators in OR 4. They’ve got a GSW to the head, and the patient chose this particular minute to bleed out and to have his brain swell out of his head.
Nielson says he’ll be at least another hour and to find someone else.”
“And?”
“And, so far, nada, zip.
Nobody is in the valley.
It seems to be neurosurgery sluff day. T
They have not been able to rustle up a single head cutter.”
The video image began to change from stark white to pink and then to deep maroon red and then to the earlier bright red swirling arterial column.
The cotton ball splashed out of the speculum retractor in a gesture of futility.
“Okay to use uncrossed blood, Sybil? BP is starting to go down, and I have given all the D5RL and plasma that could possibly do any good.
His blood is starting to look like cherry soda.”
“Go ahead.
Do anything you have to do. Just don’t let this boy die, all right?!”
Sybil’s voice was stressed and pleading.
Howard listened for any note indicative of loss of control and decided that there was none.
“GET ME SOME HELP! GET ENT IF YOU HAVE TO!” Sybil shouted.
Nothing was stopping the bleeding now.
She knew that this could not go on much longer.
“Take it easy, Sybil.
That won’t help,” Howard soothed.
“Don’t patronize me, Doctor.
If I were a man, you would just swear and try to help.
Don’t treat me like some helpless out-of-control girl, thank you very much!”
Howard gritted his teeth and held his tongue.
“Here’s another cotton ball, Doctor,” said Tanya calmly.
Sybil sucked out as much of the blood as she could and inserted the ball onto the bleeding site.
She pressed as hard as she dared, knowing that directly above the site of bleeding lay the optic chiasm and the brainstem.
It was becoming a case of damned if you do and damned if you don’t.
“How can I help, Dr. Norcroft?”
Sybil did not have to look up to know that the voice belonged to Darryl Hankin.
Worst fears realized.
Sybil swallowed all her pride and mastered her tongue with a ferocious effort.
“Thanks for coming Darryl.
I have a bleeder that won’t quit.
I think I’m in the carotid artery, some sort of anomalous branch.
I need you to cut a big piece of muscle out of the leg.
I already have an incision. Just reopen it.”
“No sooner asked than done. Your wish is my command, my dear.”
Dr. Hankin rushed out to do an emergency scrub.
He was back in two minutes and flew into the proffered sterile operative gown.
He produced a four by four centimeter block of still quivering muscle and waved it near Sybil’s peripheral vision.
“That big enough, hon?” Darryl asked with too much cheerfulness for the situation.
“Great.
Cut it in fourths, wrap them in Surgicil or Gelfoam and soak the pieces in thrombin. T
Tanya can hand them to me as I need them.
Next, arrange to open his neck.
I’m afraid that I am going to have to clamp of his carotid, maybe even both of them.”
Howard Derriel’s gloved fingers were already pressing on the neck trying to compress the carotids but without apparent success.
Sybil got a muscle ball up into the operative area, but it was too large and blocked vision and got stuck.
She wasted several precious seconds getting it out.
“Half that size, Darryl.”
She put the next ball of muscle and coagulative materials into place and managed to get the torrent to slow to a gentler stream.
“I’m pushing as hard as I dare, Darryl.
Much as I hate to do it, I guess we have to go after the carotids in the neck.”
“My head and neck training is going to finally pay off.
I’ll have you a carotid exposed in a jif, hon., don’t fret your pretty little head.”
Sybil bit down hard on her tongue to keep from screaming at the silly chauvinist.
But she knew she needed him.
The bleeding started up again.
“Sybil, I’ve given him ten units, four of them were uncrossed.
We’re losing ground.
If you can’t get control of that hemorrhage in ten or fifteen minutes, we’re gonna lose this boy,” Howard said dispassionately.
It was just a matter of fact, and everyone in the room knew it.
“Darryl, put a clamp on both common carotids. It’s our only chance.”
Sybil put more pressure on the bleeding site with a little success.
The bleeding decreased about twenty percent.
“I’ve lassooed one, sweetheart. You sure you want it cinched?” Darryl asked, making it altogether clear who was in charge of this train wreck.
“Do it,” snapped Sybil.
“Done. Any luck?”
“No visible decrease. Do the other side. This is a real Hobson’s Choice–a live gork or a death in the OR. It’s the only thing I know to do.”
Sybil was at her wits end but was fighting not to let that MCP Darryl Hankin see her cry or break down or give up.
“Got it!” Darryl exulted.
It was the world’s most awkward position for operating. Darryl was working in a convoluted stance.
He deserved a couple of ‘attaboys’ he thought to himself.
The blood abruptly slowed to a slow pulsatile stream.
“All right, good work, Darryl, Howard. We are getting into the manageable range. I think I can get it to stop if you make sure he has enough FFP to provide some clotting factors.”
“He’s had ten units of fresh frozen plasma to date. I have ten more coming; they have to come in from the County Hospital. We’re all out here. Do what you have to do now while there’s still some capacity to coagulate left,” Howard urged.
“Let’s pack all these open wounds,” said Dr. Hankin.
It was ENT to the rescue, but even the iron men of ENT know their limits.
“I can’t get at those wounds now.
I’ll hang in here ‘till you’re done, little lady.
Glad I could be of help.”
The man was positively gloating.
Sybil never thought she could hate any person so much.
But she needed him.
She would have to be civil.
“I will not react,” she said over and over to herself.
“I will get through this…and without barfing or screaming.”
She placed the last of the muscle packs that Darryl had made. It fit perfectly.
The bleeding finally stopped.
