Monday Mornings

by Sanjay Gupta MD

Overview

Every time surgeons operate, they're betting their skills are better than the brain tumor, the faulty heart valve, the fractured femur. Sometimes, they're wrong. At Chelsea General, surgeons answer for bad outcomes at the Morbidity and Mortality conference, known as M & M. This extraordinary peek behind the curtain into what is considered the most secretive meeting in all of medicine is the back drop for the entire book.

Monday Mornings, by Dr. Sanjay Gupta, follows the lives of five surgeons at Chelsea General as they push the limits of their abilities and confront their personal and professional failings, often in front of their peers at M & M. It is on Monday mornings that reflection and introspection occurs, usually in private. It is Monday Mornings that provides a unique look at the real method in which surgeons learn - through their mistakes. It is Monday Mornings when, if you're lucky, you have a chance at redemption.

Product Details

ISBN-13:	9780446583855
Publisher:	Grand Central Publishing
Publication date:	03/13/2012
Pages:	304
Product dimensions:	9.10(w) x 6.10(h) x 1.20(d)

About the Author

Sanjay Gupta, MD, is a practicing neurosurgeon at Emory University Hospital and associate chief of service at Grady Memorial Hospital in Atlanta.

Read an Excerpt

Monday Mornings

A Novel

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By Gupta, Sanjay

Grand Central Publishing

Copyright © 2012 Gupta, Sanjay
All right reserved.
ISBN: 9780446583855

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CHAPTER 1

The EMTs crashed through the swinging bay doors of the emergency room. Wearing bright blue polyester jumpsuits with a yellow insignia on the left front pocket and standard-issue black boots, they were moving fast. It was impossible to miss the concern, and also the soot, on their young faces. Wherever they were, there had clearly been smoke, probably a fire. Between them was a woman on a gurney, in a silver reflective thermal cocoon. An IV bag, slowly dripping into plastic tubing connected to her arm, swayed wildly on a pole as they wheeled her toward the center of the crowded emergency room.

It was only when you saw the ER from the top that you understood the ingenuity of the layout. It was not a single room, but an apparent maze designed like a large round tire with a series of spokes. There were rooms around the periphery; patients were placed closer and closer to the middle depending on how critical they were. This woman was coming to the epicenter.

“I got an attempted suicide. Single vehicle into a telephone pole.” The EMT’s voice carried across the ER, above the urgent voices of doctors and nurses, the moans of patients, a crying baby, the beeping monitors, the adjoining waiting room’s blaring television.

Dr. George Villanueva was the man who lived and worked in the center of the ER, and his eyes were on the woman even before the words reached him. Villanueva was a gargantuan man who sat on a swivel stool that was barely able to contain his significant girth. He gave the impression of an elephant in the circus—or perhaps a supernova at the center of a solar system. He had followed the patient as soon as her small prone form came into his ER. From his perch, Villanueva immediately noted that her face, immobilized by a slightly crooked, hard plastic neck brace, was unlined. He guessed her age as twenty-five. She was pale. Her lips were almost bluish in tint. Her nose looked as though it might have been broken by the air bag, and deep bruises were beginning to bloom below the orbits of both eyes. “Raccoon’s eyes,” he muttered to himself. It was an indication that the base of the young woman’s skull had been smashed. He quickly counted the number of drips from the IV bag. “Too slow.” The paramedics repeatedly squeezed a bag connected to a breathing tube, forcing air into her lungs. “Also too slow,” he mumbled.

“Trauma Bay Eight,” Villanueva shouted, sending the patient to the trauma bay near the center of the ER. The doctor’s small brown eyes locked on the woman, his massive, watermelon-size head pivoting on his even more massive torso like some sort of giant Claymation figure. As the EMTs veered past Villanueva, he continued to make mental notes. He noticed that her eyes were open but pointing in slightly different directions, with one pupil a little larger than the other. She was weakly moving both her arms beneath the foil blanket. He glanced down to the catheter bag, draining the young trauma victim’s bladder. It was nearly empty. Her heart monitor beeped too fast. Villanueva calculated 124 beats a minute.

“What’d you say happened?” Villanueva called to the paramedics.

“Tried to flatten her Camry into a telephone pole. No skid marks. Didn’t even try to stop. Suicide by car, without a doubt,” the EMT answered without stopping, sweat dripping from his brow.

“Like hell,” Villanueva said. He launched his 350-pound frame off his stool and caught up to the fast-moving EMTs. He moved with an extraordinary grace for such a big man, and the speed at which he crossed the tile floor was startling. There was still the glimpse of the agility that had made him the Detroit Lions second-round draft pick out of the University of Michigan. Now he strode step for step with the EMTs as they raced toward the trauma bay. Villanueva looked as though he were leading a sweep. He’d lasted four years in professional football before his relatively diminutive 275 pounds became a liability. By the time he left the league, even high schools had three-hundred-pounders on the offensive line. Of course, Villanueva’s weight was now well into the acceptable range for an NFL offensive lineman. But instead of a helmet and pads, he wore size XXXL scrubs that strained to contain his midsection, which had grown to enormous proportions in the twenty-two years since he had left the NFL. Often the scrubs failed, and a small rim of belly was visible beneath his shirt. Villanueva’s scrub pants were so tight that many of the nurses found them obscene. He usually had the decency to wear his white coat, which was the only thing big enough to cover the large man and all his parts. But today, the coat was lying bloodied and crumpled in another trauma bay. It was the casualty of an emergency resuscitation a few hours earlier.

As the paramedics slid the injured woman from the gurney to the examination table, Villanueva and an ER nurse converged on the spot. Villanueva reached down and quickly adjusted the woman’s neck brace so it was perfectly straight, then glanced at the closest EMT.

“Turn up her oxygenation, increase her ventilation, get her some more fluids, and call the neurosurgeons. This wasn’t a friggin’ suicide attempt. She just had a bomb go off in her head! Stop screwing around. Let’s go!”

The nurse hesitated for a split section, considering whether to deny that she was screwing around, thought better of it, and began moving around the injured woman, turning a large valve to increase the flow of pure oxygen through a clear mask.

The paramedics looked at each other and shook their heads in wonder as though they had just seen their favorite magician performing another mind-bending trick. Then they began retracing their steps through the emergency room, their radios squawking, and their black laced-up boots leading the way.

Villanueva’s impulsive diagnoses were the stuff of legend around Chelsea General. His quick thinking and physical agility earned him the nickname El Gato Grande—the Big Cat—or simply Gato. Dr. George Villanueva himself spoke only a smattering of Spanish, and he hadn’t gone by his given name, Jorge, since he was six and started school. Still, the Gato Grande nickname stuck.

Earlier that same shift, Villanueva had been on his stool watching the actions of two emergency room doctors in a close-by trauma bay. They were arguing back and forth when their patient’s blood pressure started to plummet. If you had been watching Villanueva closely, you would’ve seen a flush appear on his cheeks and a nearly imperceptible squint in his eyes. It was vintage Villanueva, and not a look you would ever want directed at you. A second later he’d had enough and burst into the room while the two emergency room doctors were unsuccessfully trying to revive a man in his sixties. One of them had his mouth to the patient’s ear and was shouting, “Sir, can you open your eyes?”

“No…he can’t…” Villanueva angrily mumbled as he strode toward the slumped man, almost gliding on the balls of his feet. He grabbed a bottle of iodine in his left hand and an enormous sixteen-gauge Cook needle in his right.

He told the ER doctor to “please step aside” and when the man didn’t react fast enough, Villanueva swept the MD aside with his forearm, the way he might have handled a defensive back in his previous career. Before the doctor could protest, Villanueva had pulled the patient’s shirt open and was squirting iodine onto his left chest to sterilize the area. A second later Villanueva plunged the needle deep into the man’s chest. A faint smile crossed his face as the needle found its mark. He pulled back on the plunger, and the syringe started to fill with bright red blood.

“Cardiac tamponade,” he said to no one in particular. “Five. Four. Three. Two. One.” Villanueva paused. Nothing happened. He gave another squint to the monitor next to the patient. “One half.” Suddenly the patient’s blood pressure and heart rate normalized as the pressure was relieved around his heart. The patient’s skin started to pink up. “Zero.”

Villanueva turned and walked away.

The other doctors in the room were stunned. They had missed the problem, almost costing the man his life.

“There was nothing to suggest this man had a tamponade,” the ER doctor stammered to the receding Gato Grande. Villanueva didn’t look back, instead tearing off his now-bloodied white coat and throwing it into a passing bin of laundry.

The jacketless Villanueva strutted back across the emergency room toward his stool, his head held high as he passed the nurses admitting, the kid getting his head stapled, the group of obstetricians trying to coax a young fetus to stay in its mother’s womb, the drunk who fell off his roof, and a businessman in a suit who had been complaining of chest pain. A medical student who looked as though he’d be much more at home in the library stacks than the ER caught up to Villanueva. The student carried a clipboard and a quizzical expression. He was now rapidly turning his head back and forth between the young woman Villanueva had diagnosed with “bomb in head,” and Gato himself.

“But how?” was all the med student could muster. He pulled his pen from his pocket and prepared to write. Villanueva abruptly grabbed the pen and the clipboard, and even loosened the student’s tie for good measure before stopping and facing him.

“Don’t write. Listen and learn from the master,” he said. He winked at an attractive nurse standing at the station. “I knew she needed more oxygen because her skin was pale and her lips were blue, that’s an easy one.” He was in full professor mode now, standing tall and upright, using his entire six-foot-two frame to project across the emergency room. As intimidated as all the students were by him, he was the reason the best of them from all over the country chose to come to Chelsea General. In the world of medicine, it is tough to call anyone the “best” at anything, but that wasn’t the case here. Villanueva was the most celebrated trauma chief in the country, hands down.

“Always remember to look at the Foley catheter bag,” he instructed the medical student. “These patients should be making plenty of urine. If they aren’t, it means they need more fluid.” The med student looked for something to write with before remembering Villanueva had his pen and clipboard. “Don’t worry about writing this stuff down,” Villanueva said again, reading the student’s mind. “Just immerse yourself in this situation and you will never forget.” The med student nodded like a true believer.

“By the way, how old is this woman?” Villanueva asked. The med student scurried over to Trauma Bay 8, checked the chart, and returned.

“Twenty-six,” he said. Squint. “No wait, her birthday’s in December. She’s twenty-five.” Villanueva smiled to himself.

“Now, I bet you’re wondering how I knew this little lady had a bomb explode in her brain,” Villanueva called for all to hear, enjoying his moment center stage. Truth was, a lot of people who pretended to be disinterested in the bombastic Villanueva were craning their necks trying to garner a little of his amassed wisdom.

He quickly grabbed a penlight from the student’s jacket. Villanueva himself never carried anything—no stethoscope, no tongue depressors, nothing to write with, certainly no penlight. He just grabbed what he needed from the closest victim. The penlight was simple white with no pharmaceutical advertising on the outside. Everyone knew how Villanueva felt about freebies from Pharma companies. “No such thing as a free lunch,” he had once shouted across the ER at an attractive woman drug representative as she scurried out of the ER. A single bright light emerged when he pushed the button, and he pointed it at the woman’s eyes.

“This young lady has a ruptured cerebral aneurysm. See here, a little disconjugate gaze,” he said.

“Disconju—what?” the med student replied.

“It means her eyes aren’t quite lined up.” Another squint. “Jesus, what are they teaching you these days? You think between the sensitivity training and the financial investment classes, they could teach you some medicine.” The med student blushed. “Oh, and her pupil on the right is larger than the one on the left. It means the aneurysm was pushing on one of the nerves in her brain that controls eye movements.”

“Oh, I get it.” A light went off in the med student’s brain. “The aneurysm ruptured while she was driving. Rendered her unconscious. That’s why she crashed her car…” He trailed off.

“Yes!” Villanueva shouted. “Like I said, she had a bomb go off in her head. Speaking of which, did anyone page Neurosurgery?”

“Yes, Dr. Villanueva,” an unseen female voice answered from across the room.

“Well, where the hell are they?”

“On his way,” the same faceless voice said.

“Which one of those overpaid and underutilized guys is it this time?” Villanueva asked.

“Dr. Wilson.”

Squint.

“Oh boy! I am surprised all you nurses haven’t already run to the powder room to doll up your hair and put on some lipstick,” Villanueva bellowed. “Oh, Dr. Wilson, can I help you, anything at all…really, Dr. Wilson…anything at all.” He had an alarmingly good falsetto.

The nurses giggled and shook their heads.

“Hey,” Villanueva said to the medical student. “Since I taught you all that, why don’t you go and get me a sandwich?” The student looked around, trying to figure out if Villanueva was joking or not. To no one in particular, the doctor called out, “And will someone please page pretty boy Wilson again?”

In a darkened call room, Ty Wilson sat, eyes closed, motionless and very still. There was a window cracked, and the smell of freshly fallen leaves wafted through the air. In the distance, the ripple of the Huron River could be heard. Other than that, the room was absolutely silent. His scrubs were a deep shade of blue, seemingly designed to match Wilson’s eyes. They also fit him perfectly, with no extra folds or wrinkles. He was on his knees, with his back straight as a dead man’s EKG. The neurosurgeon visualized his breath as he inhaled. In through the nose and then around the sinuses. First the maxillary and then the ethmoid sinuses, followed by the frontal sinuses. He visualized the breath going down the trachea, anterior to the esophagus. “About fourteen millimeters anterior to the esophagus,” Wilson had told his therapist.

“I don’t think you necessarily need to go into that level of detail,” the therapist had replied. “Actually…I do,” Wilson said.

Now he visualized the breath making its way into the progressively smaller bronchioles and then slowly getting absorbed into the bloodstream. It was his form of relaxation. Meditation didn’t really fit with his image of being a neurosurgeon, which was why Wilson mainly practiced it in the solitude of the call room. His beeper went off again. Gato needs you. Now.

Wilson opened his eyes, stood and walked out of the room. A minute later, when he pushed through the ER’s swinging doors, he looked every bit like a USC quarterback in to run the two-minute drill and win the game. He was tall and fit, with wavy dark hair and those blue eyes, which had a hypnotic effect on nurses, patients, just about anyone locked in his gaze. Villanueva, as it turned out, was an exception.

“Trauma Bay Eight,” Villanueva called to him. Villanueva glanced down at his beeper, which had just gone off. It said simply, 311. 6.

The medical student had returned with his sandwich and was peering over Villanueva’s shoulder at his beeper.

“What do all those numbers mean?”

Villanueva quickly crammed his pager back on his scrub pant waistband.

“What are you, a spy or something?” Villanueva took the sandwich and started eating, garbling a thank-you through his full mouth.

“No, just trying to learn,” the med student answered. “From the master,” he added, laughing.

Villanueva cackled. “Good, kid, I like that.” He thought about it for a second. “Those numbers represent an invitation to the most secret and best-guarded meetings that ever take place in a hospital,” he whispered. “Every few weeks, a select group of surgeons get together and discuss mistakes.”

The student’s eyes widened. “What kind of mistakes?”

“All kind of mistakes. Morbidity and Mortality, some call it. Others call it Death and Complications. I call it the Someone Effed Up Conference. Capiche?”

“Can I come?” the student asked.

“You one hundred percent, absolutely, without a doubt cannot come,” replied Villanueva. “Did you not hear me when I said this was a secret meeting? Strictly invitation-only. No other doctors, no administrators, and certainly no friggin’ lawyers! This conference is for us, and us only.”

In the trauma bay, Wilson assessed the situation in just a few seconds. As he started to examine the young woman, he agreed with everything Villanueva had said. It was a classic case of chicken-and-egg in the world of neurosurgery. Doctors at many hospitals around the country would have heard the woman’s story and deduced in a matter of moments that the blood in her brain was a result of the car accident. They would also deduce that since she’d been in a single-car crash into a telephone pole, she was trying to kill herself. The truth was far different. The aneurysm, a small blister on the surface of an artery, had suddenly let loose, spraying blood throughout her brain. She had likely felt a sudden thunderclap headache, and within seconds was rendered unconscious. That was why she’d crashed her car. In this case, the aneurysm was the chicken. The car accident was the egg. The science of deduction, and Ty knew there was no one better at it than Villanueva.

Ty’s beeper went off again. Like Villanueva’s, it read 311. 6. He took the message like a punch, sucking in air involuntarily. Tomorrow morning, he was going to be where no doctor at Chelsea General wanted to be. Ty forced himself to breathe out slowly, then caught Villanueva’s eye across the room. He wanted to see if the trauma chief had gotten the page. One glance at Villanueva’s expression of near pity, and Ty knew he had. Damn, Ty thought. The last thing he wanted was the fat man feeling sorry for him.

Villanueva muttered to himself, “Poor bastard.”

CHAPTER 2

In the neurosurgery offices up on the twelfth floor of the hospital, a single light still shone along the long hallway, leaving the beautifully framed pictures of neurosurgeons present and past adorning the walls in subtle darkness. The names were all giants in the world of surgery: Edgar Kahn, Richard Schneider, Lazar Greenfield, Bob Bartlett, and Julian T. Hoff, who was widely credited with building Chelsea General into the powerful institution it now was. His nickname buzz was engraved under his name. The last picture was of Harding L. Hooten, the current chairman of surgery. Underneath the beautifully engraved wording of his name was his simple nickname: the boss. There were also several museum-worthy paintings Hooten had requested through old-boy connections in the art world, also in shadows at the late hour.

Right outside his office was one of his favorites, Mark Rothko’s Untitled 1964, which was on loan from the National Gallery of Art. The abstract painting consisted of a large black rectangle with a dark gray rectangle inside. No one knew why the Boss liked it so much, but no one dared ask. There was a large Cy Twombly abstract and a David Hockney photo collage, also on loan, and a couple of John James Audubon prints Hooten brought from home. One showed a yellow-crowned heron, the other, a South American scarlet ibis. This particular ibis was one of the few birds Hooten had never seen with his own eyes, and he had spent a lot of his life hunting for the bird around the world. Most people who saw the art either had no idea of the works’ gilded provenance or assumed they were reproductions. The air smelled of the expensive cologne that seemed to linger around Hooten’s office.

Amid the grit of Chelsea General, Neurosurgery was far from the norm. Many other departments were so strapped for decorations that doctors would frame their children’s artwork and hang that up, or order the type of forgettable prints of generic landscapes or flowers more at home in discount hotels—anything to distract. Neurosurgery was so atypical that several faculty members were embarrassed by the appearance and often took pains to see their patients in other areas, instead of the museum-like atmosphere of their own department. Few things killed rapport with patients more than the impression that the doctor was getting rich treating them.

Inside one of the more modest offices near the end of the mostly dark hall, Dr. Tina Ridgeway sat next to a tired-looking junior resident holding a bag of microwave popcorn, a whiff of melted butter in the air. There were a few framed pictures on the bookcase in the corner. One was of a couple of young girls in cheerleader uniforms. Another was a wedding picture of a very pretty Tina and her new husband. There was a picture of the whole family crouched around a young girl in a wheelchair. Everyone was smiling, almost laughing in the picture, including the girl in the middle. They sat on a couch across from Tina’s desk, peering at Michelle’s book of neuroanatomy lying on the coffee table. The picture showed the two lobes of the cerebellum, and all the various blood vessels that supplied blood to the back of the brain. There were a lot of nonsense scribbles on the page, in typical doctor’s bad handwriting.

“C’mon Michelle, I’m not leaving till I’m sure you understand this,” Tina said. While Michelle slouched on the couch with a few kernels of popcorn sitting in her lap, Tina sat up straight. She looked crisp and in command. “Tell me again, what are the different types of posterior fossa tumors in children, and how you would manage each one?”

Michelle nervously adjusted her glasses. “Uh…medullo…uh, something like that.” She stammered something incomprehensible. Then she just sat, dejected and embarrassed.

Tina offered the younger woman some more popcorn as though that might fuel a burst of understanding. Michelle Robidaux was a resident pretty much everyone in the department had given up trying to help. She’d failed the boards twice, and all the faculty members were waiting for her to either quit or be fired. They ignored her during teaching rounds and hardly called her name when they needed a resident to scrub in on a case. They even asked senior residents to take extra call so Michelle was never allowed on call by herself. That served to alienate her even further from her colleagues. What they hadn’t counted on was Dr. Ridgeway’s unfaltering support for the young woman. The neurosurgeon had convinced all of her colleagues to give Michelle one more chance and allow Tina herself to mentor her. Some of her colleagues were sure Tina felt sorry for Michelle more than anything else. After all, Tina had grown up with everything, and Michelle, by all accounts, had been brought up on the wrong side of the tracks. This type of extra help was unheard of, considering Tina’s packed schedule as well as her husband and three children at home. Still, here Tina was teaching long after her family ate dinner, again, without her.

The contrast between the two women was striking. Aside from the fifteen-year gap that separated them, Dr. Tina Ridgeway was gorgeous in a way that went beyond her flawless skin, high cheekbones, and the kind of lips lots of women were paying lots of money to replicate. She carried herself in a way that somehow suggested elegance and grace, unheard-of commodities in an urban hospital like Chelsea General. Even though Tina always wore her hair pinned back and was rarely found in anything but scrubs, male residents from all over the hospital could be found furtively walking the hallway in front of her office for no apparent reason. They called her Chelsea-Lina, given her resemblance to the famous movie actress. Anyone spotting Dr. Ridgeway outside the hospital might guess that she was in the fashion business, or maybe a politician or community leader. She was the kind of woman who seemed to attract attention without trying.

Michelle Robidaux, on the other hand, was a face in the crowd. She was slightly overweight, medium height, with bad posture, stringy hair, and skin pocked by teenage acne. She always looked tired and besieged, even after the rare full night of sleep. Still, her story was remarkable. She was from a small town in Louisiana, where most of her family lived under the thumb of relentless poverty. Her parents raised chickens and grew vegetables and sugarcane, eking out a living on the small patch of land south of I-10 between Lafayette and Lake Charles. Michelle’s father had quit school in eighth grade to help his own father with the farm. Her mother made it through high school, but college was out of the question. Michelle’s grandfather was a mechanic who fixed mowers, boat engines, pretty much anything customers wanted to drop off and didn’t care if they didn’t get back for a month or so. Papi Bill was a clever enough mechanic but he was also a whiskey man, Southern Comfort specifically. “Created right here in Louisiana,” he often said when he poured a glass, and drinking it was always the first order of business. He’d start the day with a tumbler of SoCo and Coke, along with a couple of Tums. By midafternoon, he was skipping the mixer and the tumbler and could be found on a folding chair outside his workshop, drinking straight from the bottle, much of his unfinished work scattered in front of him like lawn decorations.

Michelle’s parents were too overworked to care much about the public school she attended, where teachers considered anyone who showed up regularly and stayed out of trouble to be a standout student. Not only did she show up, but Michelle proved herself different right from the start. She turned in her assignments. She asked smart questions, often beyond the ken of her teachers: “That’s an excellent question, Michelle. Why don’t you look it up yourself, come back tomorrow, and share your answer with the class.”

Most of all, Michelle was a voracious reader. In books, she could forget about her growling stomach, indifferent parents, and two older brothers who were drinking and stealing before they were teenagers. Michelle exhausted her elementary school’s library by third grade and moved on to the town library, where she caught the interest of the librarian, a matron named Mrs. Truex whose dowdy clothing and cat glasses on a chain were right out of central casting. Bobbie Truex had a brother, Rex, who had emerged from the town’s middling schools to become a successful car dealer in Baton Rouge. When he heard about the remarkable girl frequenting his sister’s library, Rex became a patron of sorts for Michelle, first encouraging the girl on visits to his hometown, telling her she could do whatever she wanted, and then paying her expenses in college.

To say Michelle was the first member of her family to graduate from college was true but missed the point: She was the first Robidaux to consider college. To them, college was a place for rich kids. Sure, college kids may have book smarts, but the only book that counted for Michelle’s family was the Good Book. As for medical school, becoming an astronaut would have seemed less alien to family and neighbors living across the flat, sun-scorched stretch of land wedged between the Gulf and I-10. There wasn’t a single medical school graduate from her zip code. Michelle’s story was a testament to her resolve. Now, though, the young woman began to wonder if she had traveled beyond the limit of that innate drive and intelligence. Maybe her reach now exceeded her grasp. Maybe striving to become a brain surgeon was too much for her. She thought about her upbringing and a family tree known more for boozing, brawling, and petty crime than any kind of success. For the first time in her life, Michelle started to question herself.

Prior to her arrival at Chelsea General, Michelle never doubted she was as smart as her Ivy League colleagues. But twice now, she had failed her exams, and it seemed everyone had abandoned her. They had been so excited to accept her into the program, and reveled in the telling of her story: See that young doctor, she was raised on a dirt-poor farm. She was an oddity to them, yet they took great pride in her achievements. They patted themselves on the back for taking her in at their prestigious hospital. Now only Tina Ridgeway seemed to care. A John F. Kennedy quote Michelle had first learned in second grade came uninvited and hit her like a slap: “Success has a thousand fathers; failure is an orphan.” She was fast becoming Chelsea’s orphan.

Tears formed in the corners of Michelle’s eyes, and she wiped them away with the backs of her hands before they could begin an unprofessional path from her tear ducts, past the conjunctiva, and down her cheeks.

“All right, look, Michelle, I know you’re tired. Let’s pick this up tomorrow,” Tina said.

“Thanks, Dr. Ridgeway,” Michelle said.

“Tina,” Ridgeway reminded, “call me Tina.”

“Right, Tina.”

A beeper went off, and both doctors reached for their sides.

“It’s mine,” Tina said. She was hoping it would be Ty. It said simply, 311. 6. A cloud crossed her face.

“Are you all right, Dr. Ridgeway?” Michelle asked.

Ridgeway sat staring at her beeper, and answered without looking up.

“Again, Michelle, it’s Tina, just call me Tina. And yes, I am fine,” she answered, perhaps a little too harshly. Tina realized her worry about Ty must have been broadcast across her face, and she quickly composed herself. As hard as they worked to keep it a secret, the hallway whispers had started. What’s going on with Ty and Tina? Are they dating, sleeping together, and what about her husband? It probably didn’t help they ate lunch together and often sat next to each other at conferences. If Tina had a question about a patient, she always took the case to Ty. Still, it would probably surprise other doctors at Chelsea General to know that Tina had spent four nights in the last two weeks at Ty’s apartment.

Tina knew life had a few hinge moments, when your actions or inactions could dictate your remaining path. That first night with Ty was one for her. It was both an admission and an indulgence: an admission that her marriage was all but over, and an indulgence in something improper. Her husband just assumed she was on call and was busy at the hospital. Truth was, he had stopped caring a couple of years before.

Now everyone was saying Ty Wilson might get fired or even worse. Ty hadn’t even told her what had really happened in the operating room that night. He hadn’t told anyone. But he was going to have to divulge all the details in Room 311 at 6 am tomorrow.

CHAPTER 3

Across town in Dr. Sung Park’s house, dinner had just been cleared. His wife, Pat, had loaded the dishwasher, wiped the table down, and packed away the leftovers. There was not a speck of food to be seen, and the house was almost silent. This was especially odd considering there were three children under the age of six. Everything in the home smacked of bargain shopping, right down to the sensible dress Pat wore. It had been on sale for 70 percent off at a wholesale department store. Still, Sung had given her a disapproving look when she showed him the bill.

The children were reading to themselves, the only sound coming from the turning of pages. Even the two-year-old was flipping through a cardboard book of animals without uttering a sound. Pat Park admonished the five-year-old when she giggled at something she had read.

“Your father is working,” she said. Sung sat in his study reviewing a detailed paper on conjoined twin surgery. He was making meticulous notes, and drawing the operation step by step in a notepad he carried with him everywhere. He also used the exact same kind of pen every time. It was a red uni-ball micro pen with a .38mm tip. They cost fifty cents apiece at the office supply store, but Park got them for free. He pocketed them from the various department secretaries’ desks when they were away. Now he was using them to detail a picture of two infant heads pointing in opposite directions with a band of veins still connecting them. He made bullet points of how much blood-thinning medication would be given at this point of the operation, along with the desired blood pressure of each twin. Even though their names were written on the medical records, he called them simply twin A and twin B. Bad luck to use real names, he thought to himself.

The following day, he was going to try to edge his way into the operating room, where his chairman was scheduled to separate the conjoined twins. Every other neurosurgeon including the legendary Ben Carson had turned the family away, saying it was too risky.

Still, “the Boss,” as everyone called the chairman of Neurosurgery, was going to operate. Sung had been trying to take over the case, and when the chairman didn’t budge, Sung had even tried to undermine him. He’d gone to the CEO of the hospital to remind him that he had a lower complication rate than the Boss. Sung had done his research, and learned the CEO, like many heads of hospitals, really didn’t know anything about medicine, let alone brain surgery. So Sung had collected data. He handed the CEO a folder of information, including not only his low complication rates, but also his operative times, which were second only to Ty Wilson. He also had carefully copied his drawings of the operation step by step, and placed that in the folder, which Pat had bound for him this morning. The CEO pored over the papers for a few minutes, took a couple of sips of coffee, and then started grinning. For several seconds he didn’t say a word, he sat just grinning and impassively staring at Park. Park thought the man might be having atypical symptoms of a stroke. Just as Sung was about to say something, the CEO came around the desk and put his hand on Sung’s shoulder, like a schoolteacher might with a fifth grader. “I am telling you, Hooten find himself between eight-ball and hard place,” Sung said. He regretted it as soon as the words had come out of his mouth. He had mixed up his metaphors, something that was very embarrassing to him. The CEO smiled and walked back behind his desk. “No he won’t, Sung. He may find himself behind the eight-ball…or he may even be between a rock and a hard place…but not between an eight-ball and a hard place.” Sung turned bright red, and the CEO waved him out of the office. On his way out, the smug ass had told Sung he should sit in the corner during the operation and take notes. It was all Sung could do to keep from screaming. After all, he had completed not one, but two full neurosurgery training programs. After he became a full-fledged neurosurgeon in his homeland of Korea, he emigrated to the United States, only to be told his training would not be enough to become certified. He was asked to complete another seven years of training, working well over a hundred hours a week. It would’ve dropped most men to their knees. Not Sung. Even though he was a full decade older than his co-residents at the time, he outworked them and beat them every step of the way. At the same time, he had studied and practiced weekends and nights to master the English language, although he still spoke with a choppiness that seemed to worsen when he was angry or nervous. He knew he would never even have a chance at becoming chairman himself unless his English was better. Being a foreigner was one thing. Sounding like a foreigner was another. The teenager at the kiosk in the local mall had smirked when he purchased Rosetta Stone for English from her.

Now nearly fifty years old, Sung was just starting his neurosurgery career and wanted to make up for lost time. Suddenly, in the quiet house, came a shrill one-second beep, followed by another. Sung reached out his hand without looking, and his wife placed his beeper in his hand. Even at home, he ran the place like an operating room.

The page said, 311. 6.

Sung allowed himself a rare smile. Ty Wilson, the bright star of Chelsea General whose skills had put Sung’s own formidable talents in the shadows, was going to be publicly crucified. Sung made a note to wake up especially early, so he could get a seat in the front row. He wanted to see Wilson squirm.

Dr. Sydney Saxena took her pager wherever she went. It was an annoying habit, but without it she felt naked, exposed, in danger of failing. She wore her pager in the bathroom, the movies, even to her grandmother’s funeral. She checked it more often than most people check their watches. She carried it now, in her left hand, jogging past the elegant Barton Hills homes where a number of her colleagues lived. She could often be seen texting while running.

Anytime Sydney went somewhere without her pager, even for a minute, she feared it would buzz and she would not be there when she was needed or, worse still, miss an opportunity. When a professor had asked her, “What’s the worst part of being on call every other night?” Sydney had immediately responded, “You miss half the good cases.”

Sydney always wanted to be the first to respond, to be the most dependable among the neurosurgical staff. While many of her colleagues had distractions like husbands, wives, children, she was unencumbered. Most of the time, Sydney viewed this as strength. When the hospital chiefs were looking for someone utterly committed to the hospital when the Boss retired, she wanted her name to be at the top of the list. Even if they denied the opportunity this time, they would not be able to pass her over twice.

Sydney ran at a clip that would cause a casual jogger to wilt, usually right around seven minutes a mile. On one level, running went against her fierce work ethic. She wanted to outwork everyone at the hospital, and running took time away from that commitment, no matter how fast she was. But she also wanted to be sharp and have fresh ideas. She’d once learned in a college psychology class from an aging hippie named Professor Quattlebaum that some of our best insights come when our minds are not engaged. Mowing lawns. Showering. Jogging. It was one of those bits of counterintuitive knowledge Sydney believed and adopted as her own. Now if only Professor Quattlebaum had had the flash of insight telling him to replace the threadbare corduroys he wore to every class. She smiled at the recollection.

Sydney checked her watch. She had been running for exactly fifty-six minutes and fifteen seconds, her eighth mile of a ten-mile run and feeling good. The air was warm and fresh, thanks to a cleansing rain earlier in the day. She felt as though she could run all night. Three miles back, on Washtenaw Avenue, she had passed the 555 Building and noted that Ty’s fourteenth-floor window was dark. Sydney ran the schedule in her head and realized Ty was on call.

Then she passed Tina Ridgeway’s home, a large, two-story Cape Cod–style house with faded gray shingles and black shutters. The Ridgeway minivan was there, but Tina’s car wasn’t. Sydney figured her colleague was at the hospital. Sydney prided herself on knowing what was going on at the hospital. Her mind wandered, and she wondered if anything was going on between Ty and Tina. They were spending a lot of time together. Sydney had a sixth sense for these things, and she smelled a whiff of added intimacy between the two doctors.

The thought of work of course prompted Sydney to suddenly stop and check her pager. Nothing. It was no surprise that Sydney hadn’t been able to actually get through dinner and a complete romantic date for the last two years. If the pager went off, she stopped whatever she was doing and rushed to check it. Ross, her last real boyfriend, had gone so far as to buy an engagement ring. He had it in his pocket the night they went to Gandy Dancer, the nicest restaurant in town. He picked an evening when she wasn’t on call and should have had no reason to wear her pager. After she answered it for the seventh time, though, disappearing for thirty minutes, Ross decided the ring was better off in his pocket. Afterward, Sydney didn’t know why their relationship had soured, only that the vision she had of “punching the marriage ticket” as her career powered ahead had vanished with the empty cups of decaf at the Gandy Dancer.

Sydney headed downhill, her legs churning, moving away from the million-dollar homes toward the ranches and teardowns in the next neighborhood over, Sung Park’s neighborhood. Even though he was making a good salary now as a neurosurgeon, he still lived in the same house he bought when he was a resident. She had asked him once if he was planning on getting a bigger place now that he had three children and a better-paying job. He looked at her for a long second, and then said, “Why?”

Sydney’s pager went off. Her pulse quickened. She checked it without breaking stride. It said, 311. 6. Poor Ty, she immediately thought. The bigger they are, the harder they fall. Ty was the big man on campus in the hospital, and was naturally gifted, but no one escaped Monday Mornings.

In the operating room, Ty stood over the twenty-five-year-old woman’s exposed brain. He now knew her name was Sheila, she was a teacher, and she’d been driving home after a long bike ride on the Kensington Park trail. Her father had given Ty these details while her mother sat next to him sobbing. When Ty handed over the consent form for surgery, the reality of the situation hit both parents, and they broke down. Ty had gently put his hands on their shoulders and said simply, “Don’t worry, when she’s in there with me, I will treat her like a member of my own family.” Sheila’s mother wiped her eyes, stood up, and gave Ty a hug. Her father signed the form giving permission for Ty to open up his daughter’s brain with a series of drills, saws, and scalpels.

The rest of her head was covered by a light blue drape, framing the gray tissue visible through a round hole in the side of her skull. It had taken Ty just twenty-five minutes to open the skull, delicately cut the outer layer of the brain, and split the natural fissure between the frontal and temporal lobes. This was arguably one of the most difficult operations a brain surgeon could perform, but no one in the operating room seemed anxious. When Ty Wilson walked into the room, everything seemed to fall into a state of order and calm. Now Ty was carefully peering into the microscope, the bright light reflecting the gray-red brain onto his blue eyes. He needed to clip the aneurysm that had almost killed her earlier that night and could kill her in the days or weeks ahead if he did not disarm it.

The operating room was cold, and Eddie Vedder played over the stereo system: “Just Breathe.” The Northwest grunge music was the choice of the anesthesiologist, a petite doctor named Mickie Mason. She stood next to a bank of devices monitoring the woman’s vital signs. Most surgeons held strong opinions about what music played in the OR when they operated. Truth was, Ty didn’t even hear it when he was in the zone, so he let the gas passer—his affectionate moniker for anesthesiologists—pick. In addition to Mason, a nurse stood behind Ty and slightly to his right, next to a tray of instruments. A resident stood on the other side of the operating table, studying every move of a surgeon considered one of the greatest natural “athletes” ever at Chelsea General.

Ty had cut through the thick, fibrous outer layer of the brain, the dura, with his usual quip: “That’s one tough mother.” The name for this outer membrane of the brain came from the Old English dura mater or “tough mother,” a piece of medical arcania passed along by his chief resident during training. The chief resident, now a full professor of neurosurgery at UCSF, where they had both trained, also made this quip at the start of every operation. Ty had performed more than a thousand operations on the brain since training. Still, at the start of each, he’d say, “That’s one tough mother.” It was now part ritual, part homage to his mentor.

Looking through the microscope, Ty could see the optic nerve, a thick white filament stretching toward the back of the skull. Nearby was the carotid artery, one of the major vessels supplying blood to the brain. On the other side of the artery was another nerve, a thread-like strand, almost imperceptible, even with microscopic magnification. “Gotcha,” Tyler whispered to himself. Between the two structures deep in the brain, Ty found what he was looking for, the ballooned side of a blood vessel or aneurysm that had bulged and then burst with such catastrophic results. It looked every bit like a blood blister. Just as Villanueva suspected, the aneurysm was big enough to put pressure on that small strand, the oculomotor nerve, as it exited the brain stem. That was why her pupil had been dilated.

The brain was such an elaborate organ, there were times Ty wondered how it managed to function without complications for as many people as it did. So many things could throw the brain’s delicate mechanisms out of balance, with lifelong, disastrous effects. A vessel could blow and spray blood across the delicate, spongy matter, the command center that controlled everything from breathing to consciousness. A single cell could grow out of control, squeezing out sight or memory or life itself. Lead in the blood, courtesy of a few chips of old paint, could dampen a child’s learning for the rest of his or her life. A shortage of serotonin could result in crippling depression. A blow to the head could cause a bruise to the soft loops and folds of the brain and affect balance, speech, or judgment. The inability to produce enough dopamine resulted in the tremors of Parkinson’s. A severe vitamin B₁₂ deficiency could cause dementia. The list was almost endless. Protected by a helmet of bone, the brain was an organ of mind-boggling complexity and ability.

During his training, Ty’s chief resident had challenged Ty and the three others who had made the cut into one of the smallest and most challenging subsets of modern medicine. He asked them why they thought they were good enough to operate on “the most complicated structure in the known universe.” That phrase, too, stuck with Ty: the most complicated structure in the known universe.

Why, indeed. Ty’s thoughts returned to the page he had received earlier: Room 311. Six o’clock in the morning.

Quinn McDaniel’s mother had not asked him why he felt qualified to operate on her son’s brain. She saw a confident, handsome surgeon, the very picture of what a surgeon should look like. She saw an attending neurosurgeon at a large teaching hospital with an international reputation. She figured everything would be fine. Before walking into surgery, the boy’s mother had called after him, “Doctor. Take good care of him. He’s my…well, everything.” She smiled when she said it, a look of pride on her face.

Ty studied the woman’s aneurysm.

“Straight clip.”

“Straight clip,” the surgical nurse replied, handing Ty the small metal object.

The woman lying on the table in front of him was somebody’s “everything.” A daughter. A wife. A mother. Ty again flashed on Quinn McDaniel’s mother, and in that moment experienced an alien sensation in the operating room: doubt. It was almost like another presence in the room, a shadow looking over his shoulder. He had a slight shudder. Ty had never doubted his surgical skills. He had never had a reason to do so. His extraordinary dexterity, his cool under pressure, and his ability to figure out the three-dimensional puzzle presented by the brain came naturally to him. He could visualize the brain the way some could solve a Rubik’s cube. Ty was grateful he possessed these skills. He had always considered them permanent, immutable. Now he wondered whether he had been fooling himself and others. Maybe he didn’t have these extraordinary talents after all. Just ask Allison McDaniel.

Ty’s pause broke the rhythm of the surgery, and the nurse looked at him, concerned. The break was unusual, out of the ordinary, and anything that deviated from the expected was cause for concern in the operating room. The resident, who had been leaning over, peering intently through the microscope at the operating field, stood up straight. He, too, looked over at Ty, wondering what the maestro was up to.

“Nancy, I think I’ll go with a fenestrated clip instead.” Ty handed the nurse the straight clip. He then took the other one. He turned to the resident.

“What do you think, Jason, fenestrated?” The question caught the resident by surprise. It was as though the all-star quarterback had just asked the third-string signal caller what play to call with two minutes left and the outcome of the game hanging in the balance.

“Um, sure, Ty. Fenestrated.” Ty paused, and then nodded. The nurse placed the instrument in his hand, and he let out a silent breath. He counted to ten in his mind as his right hand directed the clip onto the blistered aneurysm. Barely perceptible were millions of micro motions between his thumb and forefinger coordinated with his wrist, all happening at lightning speed. And the clip was placed perfectly.

The rest of the operation was uneventful. Ty left the OR more tired than he should have been by what was a straightforward procedure for him. Two things were picking at his consciousness: the doubt he had experienced back there, and the page he had received earlier. The doubt was troubling, but he tried to push it from his consciousness as a freak and ultimately irrelevant experience. A rogue wave. He had never experienced doubt before and probably never would again, he reasoned. The page was far more disturbing. He would be answering for Quinn McDaniel in the morning, and he needed to be ready. Most of all, he needed a good night’s sleep, but he knew the fatigue he felt as he traded his scrubs for a lab coat would not help. A good night’s sleep was impossible. Room 311. Six o’clock in the morning.

CHAPTER 4

Room 311 was dim except for a bank of overhead lights focused on the front of the small auditorium. Ty Wilson stood in the band of light. Dressed in blue scrubs and a crisp white lab coat, he clasped his hands behind his back, giving the impression he was relaxed. Just waiting to talk to some of his friends on a Monday morning. Above his left pocket was his full name and department of neurological surgery, written in neat cursive. There was nothing in any of his pockets.

Truth was, Ty was anything but calm. He was nauseated as the epinephrine coursed through his blood and constricted the blood flow to his stomach. He tried breathing deeply and slowly, exhaling through his mouth, but his respiration was faster than he wanted, and even before he spoke Ty had started to sweat, ever so slightly, and beads started to form on his upper brow. He was experiencing a reflex that had been preserved throughout all evolution in every single animal species, including humans. Fight or flight.

Apocrine, Ty thought, marveling for a moment on how this word from medical school had bubbled into his consciousness on this of all mornings. As medical students learned, there are two kinds of perspiration: eccrine, the healthy, cooling sweat of exercise, and apocrine, the hormone-drenched sweat of fear. Ty had little doubt his body was excreting apocrine.

Dogs could smell fear and desperation. Women could, too, as far as Ty was concerned, although he’d reached this conclusion primarily through observation. He’d watched friends, college roommates, med school classmates—intelligent, perfectly reasonable-looking men—who gave off the whiff of desperation, and women could sense it even before his friends opened their mouths. Ty was sure he now gave off the whiff of fear, and his colleagues’ olfactory glands three rows up were getting doused with apocrine. He was usually the cool observer, not the doc on the hot seat.

Ty had the irrational urge to simply bolt up the stairs and not look back. Turn right, sprint past Radiology, down the stairs, take a left, pass the pharmacy and the gift shop, through the marbled lobby, and out through the revolving doors, escaping the orbit of the sprawling twelve-story hospital the way a rocket breaks the earth’s gravitational pull. He’d pass the valet stand, the smoking patients from the lung cancer ward with their IV poles and their oxygen, the waiting relatives, the lingering vagrants. He’d pass Stan the sleeping security guard, the small food carts and trailers circling the hospital like satellites and serving everything from doughnuts to Chinese food, and run into the garage, where his Aston waited. He’d peel out of the garage, turn left on Linden through town, past the lakes, get on the interstate heading south, and not look back. Surely a hospital somewhere in Mexico or Costa Rica or Chile would value his training and skills, if not his choppy Spanish. Ty could almost see himself practicing somewhere else. Almost. But the inchoate picture in his mind’s eye never fully materialized. He didn’t want to be playing in the minors.

Ty could feel his fists tensing and his muscles swelling with more blood flow. He began fidgeting, tapping his feet. No question, Ty wanted to take flight, but that was not an option. Monday Mornings at Chelsea were the main reason he’d picked the hospital. Ty looked around Room 311, filled with sixty doctors or so, all the surgeons in his department. No one was skipping this particular meeting. They were seated in an ascending arc around Ty. Many of them held large cups of coffee, but they didn’t take their eyes off him. It was as though they couldn’t believe what they were seeing: Ty Wilson standing where no surgeon wanted to be, waiting to explain his mistake. You couldn’t get to that spot without something going horribly wrong.

Ty could see Tina, Sydney, and Park, all in the front row. Tina, he noticed, looked grim. She tried giving Ty a reassuring smile, but wound up looking terrified. Of course, Dr. Harding L. Hooten, chief of surgery, the Boss, was there, too, front and center, looking severe and pinched with his small bifocals and bow tie. Hooten called the meeting and did his best to pick a time that would inconvenience the most people, reminding them who was the boss: 6 am. Of course, Hooten himself had been in much earlier going over the final preps for his conjoined twin separation surgery.

There wasn’t much to be said for Room 311. Unlike the Neurosurgery offices, it wasn’t lavishly decorated. On the contrary, the carpet was worn in spots, and some of the seats creaked and groaned from age and wear under the fatigue-heavy weight of the assembled surgeons. Yet it was this small room, largely unknown to the hospital community at large, that drew many of the most gifted surgeons to Chelsea. The draw much like what an orthopedics fellow with gilded credentials might feel toward Rochester, Minnesota, and the Mayo Clinic rather than more forgiving climates and more generous salaries.

Room 311 was the place the finest surgeons were held to the highest standards. Asking doctors why they wanted to endure the gloves-off version of the Morbidity and Mortality gathering was like asking a soldier why he chose Ranger School. Life was full of creature comforts and compromise. Fuzzy lines and soft edges. Why not find a place where you didn’t get any slack? Where merely good wasn’t good enough. That’s why doctors chose Chelsea. It wasn’t the facility. Chelsea didn’t have all the latest bells and whistles, the latest scanners and lasers—the devices other hospitals advertised on billboards. Nor did Chelsea’s location set it apart. What Chelsea had—for surgeons anyway—was Room 311.

Ty knew all this. He’d been courted by a number of top hospitals. UCLA even gave him front-row tickets to a Lakers game. Weill Cornell had flown him in to New York City on a Gulfstream. He took a pass and signed on at Chelsea. It was in Room 311 that doctors and scientists had the courage to criticize one another, point out mistakes that might otherwise go unnoticed, and in the process advance science leaps and bounds faster than any other medical center. It was not a secret that more publications and text chapters had resulted from Chelsea’s Monday Mornings than any other conference in the world. They were the best doctors around, and they liked being thought of that way. Of course, it meant many sacrificial lambs were offered up in an intellectual, yet still barbaric ritual.

The discussion of mistakes, complications, and death is often unsettling, even for seasoned surgeons. For that reason, Room 311 had also become a showcase for the spectrum of surgical personalities, from forthright and blunt to evasive and tentative. Some were quick to blame anesthesia, or any other specialty but their own. Others entertained: surgical showmen wielding black humor. Often, the conference room turned into a battle zone as academic wars were waged, with surgeons picking sides as in a more dignified street fight—sometimes only slightly more dignified. The meeting was fascinating not only in the sensitive topics discussed, but also the human drama that could ensue.

No one exemplified the hospital’s exacting standards more than Hooten. The Boss. He looked like a dandy with his array of bow ties and the shock of silver-gray hair, but if his staff were like a platoon of Rangers, he was their demanding drill instructor. He’d been known to stop in unannounced in the recovery room, even the OR, to make sure everything was being run to Chelsea’s standards. He’d chew out nurses for leaving charts open, where they could be seen by a passerby, or for allowing themselves to be interrupted while dispensing meds, increasing the chance of errors. He’d dress down a doctor ordering Foley catheters too frequently, raising the chance of infection, and surgeons for allowing surgical techs to triage weekend call. He’d even berated a janitor once for halfheartedly mopping: “You look like you’re trying to paint the floor. You’re supposed to be cleaning. Hospitals need to be clean.” With that, Hooten grabbed the mop and started swabbing until the embarrassed janitor reclaimed it.

“Everything we do here should be focused on healing. Clean hospitals help people heal.” Hooten had said this loud enough so the doctors and nurses who had stopped to watch the spectacle of the head of surgery wielding a mop could hear. They shuffled away, heads down, all of them holding up their own sometimes faltering standards against Hooten’s and not liking the comparison.

Ty tried to hold the image of Hooten with the mop in his head, but he couldn’t. His respiration continued to be rapid. His heart was pounding much faster than his usual fifty-two beats per minute. His thoughts were disjointed, panicked. Ty tried to focus on his breathing. He took in a slow, even breath. In through the nose, the maxillary, the ethmoid…Just stop, he said silently. Out through the mouth. He breathed out slowly.

Ty had skydived on a dare as a high school senior in San Juan Capistrano and scuba dived with sharks in the Bahamas during a break in medical school. Both experiences had given him a few moments of terror, followed by the thrill of avoiding an untimely death. “Nothing makes you feel more alive than—almost dying,” a friend had once said to him. It happened to be his only friend. Tragically, and ironically, that same friend had killed himself a few years ago. Ty winced, and tried to push all these thoughts away. None of those experiences prepared him for this, his first time in the hot seat. Standing in front of his peers to answer for what he’d done caused him not fear but dread. How would his peers judge his actions? Candor was the rule in this secret meeting, egos be damned.

Ty took another deep breath, trying to regain his wa, and began slowly. “At approximately three-thirty in the afternoon on October twenty-third, I was called to the emergency room to evaluate an eleven-year-old boy.”

He paused, and in his mind’s eye he saw Quinn McDaniel. The boy appeared perfect in every way. His hair and skin represented the vitality that came only with youth. His smile was a little crooked, and the smattering of freckles suggesting a love for the outdoors. He was carrying a soccer ball in his arms, and his cleats echoed loudly on the hospital’s linoleum floors. Ty thought that if he had a son, he’d want him to look just like this kid. The boy was animated and full of liveliness, making Ty wonder why he had just received an emergency call from the ER to come see the boy.

“The boy arrived at the ER after a head-to-head collision with another boy during a soccer game. He presented as the picture of health. BP, heart rate, respiration, all normal. He was exceptionally fit,” Ty continued to the assembled surgeons. Ty remembered reading once that if you were able to maintain the vitality you possess at age eleven, you could live twelve hundred years. Not this kid, he thought.

Ty and the ER doctor who had paged him, Max Goldman, stepped away from the child and his mother. Goldman had ordered a CT scan, not because he expected the images to show anything wrong, but to cover his ass in the event of a lawsuit. He told Ty as much.

“I know he looks fine,” Goldman said. He spoke in a soft voice meant to reach Ty and no farther. “But there is something you’d better see.” With that, the ER doctor had taken Ty to a small room, dark except for an LED computer screen and a keyboard. Goldman typed on the computer and began showing Ty one image after another.

“I couldn’t believe what I was seeing,” Ty continued to his peers. “I checked the name twice and the ID number, just to make sure. This boy had a very large malignant-appearing tumor in the left temporal lobe of his brain.” Ty paused and composed himself. “At that moment, I made the decision that if this boy didn’t get an operation immediately, he was at risk of sudden death.”

“Dr. Wilson, did you bother to order any more tests?” The question came from Hooten. His tone was caustic. In addition to the Boss, Hardy Hooten often lived up to another, less flattering nickname that reflected his icy demeanor at times like this: Hardly Human.

“No, sir,” Ty answered.

Someone Ty couldn’t see asked, “Did you consider showing the boy’s films to any of your esteemed colleagues?” The questioner emphasized esteemed in a way that insinuated Ty didn’t think much of his fellow neurosurgeons.

“No,” Ty answered, looking in the direction of the questioner. From his position in the glare at the front of the room, it was hard for him to see who was talking if they weren’t in front rows. That wasn’t a problem when Hooten was talking. He was right in Ty’s face.

“Why didn’t you ask for any help, Dr. Wilson?” Hooten asked.

“Didn’t think I needed it,” Ty answered.

“Didn’t think you needed it,” Hooten repeated, letting the words hang in the air. “Potentially life-threatening surgery and you don’t bother talking to anyone else? Consulting any of your colleagues?”

“That was obviously a mistake,” someone near the back muttered.

Ty would have guessed that a comment like that came from Sung Park, but Sung was sitting in the front row, legs crossed. Park looked uncomfortable, rubbing his temples. Ty expected the man to be beaming, a competitor who had just witnessed his rival, the favorite, stumble. Even without Park’s involvement, Ty could feel the tide of the room was starting to turn against him.

“How about a simple history…did you bother doing that before you cut the boy’s head open?” Hooten again. The grand inquisitor, Ty thought. “If you weren’t going to get help from your colleagues, what about from the patient—or the patient’s mother?”

“In retrospect, it was inadequate.”

Ty knew Hooten had been aiming at this line of questioning all along, but he wanted others in the room to see the value in consulting one another before driving home the true nature of Ty’s failure.

“No patient history,” Hooten said and waved off the murmurs in the room. “Dr. Wilson, continue.” If this was going to be a public execution, Hooten wanted to make sure he gave Ty all the rope he needed to hang himself. Maybe I was too cocky, Ty thought. He had been told that he was technically the most gifted surgeon the hospital staff had ever seen. He never doubted them. Now he was starting to second-guess himself. Not his skills in the OR, but his judgment. What if he had waited to operate?

“I mapped out a left-sided craniotomy with awake speech mapping,” Ty continued. “After placing immobilization pins in the right frontal area and the left occiput, I asked the anesthesiologists to go ahead and wake the boy back up.” During the operation, nurses were going to periodically test his speech by having him identify objects on flash cards. Quinn was lying on his side, his left cheekbone facing up. He opened his eyes, looking a little frightened as he awoke. When he saw Ty, he smiled.

“Hey, did I tell you…I always wanted to be a brain surgeon when I grow up,” he’d told Ty. The sedative gave the boy’s speech a drowsy quality. Quinn McDaniel paused, then added, “Or maybe a fireman…” The recollection was almost unbearable for Ty. He coughed, so he could choke back a tear.

“I made an incision from his zygoma in front of his left ear, all the way to the midline. The bone was removed without incident.”

“How was the patient doing during this part of the operation?” the Boss challenged.

“No problems, sir. He was awake and talking to the anesthesiologist.”

“He had absolutely no pain?”

“No, sir, he said he felt a little pressure as I drilled through his skull, but that was about it.”

“How about bleeding from his scalp?”

Ty nodded. “There was bleeding, but I could control it easily with cautery and clips.”

“Continue,” Hooten said.

Ty mentally transported himself back to the middle of that operating room. He had looked up at the clock and noted the time: 11:34 pm. Okay, he’d thought. Time to take out a tumor. This was no run-of-the-mill tumor, though.

“As soon as I saw the tumor, I knew it was malignant,” Ty told the room. “It had tentacles reaching into the normal-appearing brain, and it was an angry reddish color.”

At the moment, Ty had been overcome with a sinking, black dread. He knew the boy would eventually die of this brain tumor. Medical science had not advanced far enough to be able to save him. All he could do was remove what he could see, buy a little time for the boy and his mother. Ty had already started thinking about the conversation he was going to have with the mother, Allison McDaniel. He would have to tell her that her precious little boy would only have a year, maybe two left, and then he would die an awful death—his mind robbed of its function and his body slowly wasting away.

“I started to remove the tumor”—Ty looked right at Sung—“and it started to bleed. There was much more bleeding than I expected.” Ty’s voice trailed off. The surgeons in the room were fixed on him. Tina Ridgeway looked like she was about to throw up.

Hooten broke the silence. His voice was quiet and measured and contained the sort of finality that a well-made door makes when it closes.

“Hindsight is twenty-twenty, Dr. Wilson. Tell us what you would have found if you had done a detailed history on the boy.” The room was deathly quiet. Ty’s knees felt weak. There was nothing left to say.

“The boy was healthy. The mother was healthy and had no chronic or heritable conditions.”

“And the father.”

“The boy doesn’t live with his father. Never knew his father. I never thought—”

Hooten suddenly interjected: “You. Never. Thought.” He made it sound like a dark oath. His words hung in the room, an accusation, a lesson to the rest of them.

“Thinking,” Hooten nearly spat. “I don’t care what any one of you think.” He waved a hand toward the assembled surgeons. “I want you to know. We are healers but we are also clinicians, scientists, we follow time-honored reasoned analysis. We have methods. This is what happens if we follow whatever it is we happen to be thinking.”

Hooten turned back toward Ty.

“Let me ask again…Dr. Wilson, what would you have learned if you had taken a detailed history before surgery, including the boy’s biological father?” Ty wanted to hate Hooten at this moment, but he couldn’t. He knew the old doctor was right. Ty knew he was wrong, and the costs of his mistake could not be calculated in any meaningful way. A boy had died sooner than he had to. “Dr. Wilson?”

“I would have learned the boy had a fifty-fifty chance of inheriting von Willebrand disease and had a risk for uncontrollable bleeding. I would have learned—”

The back doors to Room 311 flew open. Ty stopped. The assembled surgeons looked back: George Villanueva. He strode forward, gave Tina Ridgeway a little shoulder rub, and then looked up at the Boss.

“Hey, what did I miss? Did pretty boy explain how he killed the kid yet?”

Ty flinched noticeably, but then was transported back to the night he’d last seen Quinn. With the persistent bleeding, the anesthesiologist had long since dispensed with his newspaper reading and was peering frantically over the sterile drape that separated surgeons and sleepers. The music had been turned off some time ago. “Uh, Ty,” he whispered so the boy wouldn’t hear him, “…we have three blood transfusions going, and we can’t keep up. His heart is starting to fail.” Ty shot him a glance and then motioned to put the boy to sleep. Syringes were pushed and a tube was placed in the boy’s mouth. Ty was back at work, aggressively trying to stop the bleeding in a boy whose blood would simply not clot. What…is…happening…?

“Chest tray!” Ty shouted to the now-assembled group of a dozen nurses. He was going to attempt a last-ditch effort to save the boy. He would open up his chest and begin an open-heart massage. He would pump the boy’s heart until they could get enough blood in him.

Ty’s hands were flailing wildly as he was describing everything to the surgeons in the secret meeting room. He had almost forgotten where he was, until a stern voice jarred him back to the present. Room 311, just after 6 am.

“Did you really think that would work?” Hooten asked.

Ty looked momentarily confused and then met his inquisitor’s eyes head-on. “No, sir, I didn’t.”

After the boy died, Dr. Tyler Wilson walked numbly into the locker room. It looked every bit like a room you would find in a gym. One of his favorite technicians was in there and cheerily asked how things had gone with the boy. Ty stared at him blankly and said nothing. “Oh …sorry. Well, you can’t win them all,” the technician said softly as Ty sat down and began to take off his clogs. He was soaked to the skin with young Quinn’s blood. His feet were damp from the blood that had seeped through the small ventilation holes in his clogs. He removed all the bloody clothing, including his underwear, which were red-tinged, and threw everything in the hamper. In the small adjoining shower, he scrubbed his skin till it was raw, trying to cleanse himself of the blood and his despair. He changed into a shirt and tie. Most of all, he did not want Quinn McDaniel’s mother to see any traces of her son’s blood. By the time he walked out of the locker room and into the empty waiting room, it was nearly four in the morning. Only Allison McDaniel was sitting in there.

She looked into his eyes, and she knew. Her face collapsed.

The sight of her struck Ty like a blow. He wanted to turn around. He knew other surgeons who sent their residents out to let family members know a loved one had died. That would have been easy. He could have moved on to the next case with barely a glance back. But Ty had vowed years earlier—after what had happened when his own brother and later a sister died—that he would give the bad news himself, no matter what.

Ty remembered his mother’s face in a hospital three thousand miles away and thirty years earlier when she got the news about his brother, Ted. A brain tumor had been diagnosed just a few months earlier, and he had fought like crazy. He had been young and healthy, and then he was suddenly dead. She didn’t learn of his death from the surgeon but a hospital social worker. For some reason, this seemed to make the news both harder to comprehend and harder to take. In both cases, Quinn McDaniel’s and Ted Wilson’s, the searing grief had an almost physiological effect on the mothers—as though their features collapsed with their faith in the world. The cheeks and muscles around their mouths seemed to drop with the weight of the news. The color left their faces. Their bodies sagged.

Ty was with his mother at the time. He was eight. His father and two sisters had gone out to pick up some food. Watching his mother in her moment of grief was much more upsetting to Ty than the news of his brother’s death, which he didn’t understand at first.

“I’m sorry, ma’am, your son didn’t make it through surgery” were the words the social worker had spoken that day three decades earlier. Ty didn’t know what that meant. Was Ted back in the hospital room with the cool bed and the TV bolted to the wall? Ty hoped so. He never told his parents, but he had hoped his brother would get to stay in the hospital forever. Whenever he visited his brother, Ted would ask if he had an E Ticket. Ty would hand him a make-believe Disneyland ticket and climb up on the bed, and Ted would hit the buttons to make the sections of the bed rise and fall. Watching his mother, he knew something much, much worse had happened, though he wasn’t sure what. He could not imagine life without his big brother. The notion of Ted dying was not even in the realm of the possible for young Ty, who idolized his older brother to the point of mimicking his pigeon-toed gait and squinty stare.

The tragedy devoured his parents’ relationship. His father would disappear for long stretches. When he was home, he said little. He wandered around their small home as though he were lost. His mother dove into work. She was a realtor and spent most weekends driving clients around Southern California. She specialized in first-time home buyers even though the commissions were smaller and financing was often a problem. Ty wondered if she somehow liked being around the hope these young couples carried with them. His parents’ marriage didn’t last long after Ted’s death. Maybe a year or two. Their bond eroded and then collapsed under the burden of the grief.

When Ty was a teenager, his mother and father reunited briefly in another ER for another family tragedy. They were in their late forties but looked much older. Even though they were both remarried, they hugged for a long time when they saw each other. They shared a rare and horrible bond: a parent’s grief multiplied now over two children. Ty’s sister Christine was already in the OR undergoing emergency surgery when they arrived. Christine had been standing in line at a convenience store waiting to buy a Coke and some gum. All of her friends were outside waving to her when they had seen a man enter the store in a hurry.

“It seemed like just a moment had passed when we saw a few bright flashes of light and heard a loud noise,” those friends of Christine had told Ty’s parents. The gunman had never been found. He had left two people dead at the scene and Christine with a devastating bullet hole in the back of her brain. The prognosis was not good.

When the young neurosurgeon emerged, he informed Ty and his parents drily that Christine had lived but would be in a vegetative state for the rest of her life. His tone was so clinical, so cold, he could have been a service rep at the local car dealership telling them they needed new tires. In that moment, whatever flicker of life remained in his parents extinguished. They breathed, their hearts beat, but the spark of life was gone.

At the time, though, the news had the opposite effect on Ty. It transformed him, awakened his drive, gave his life purpose. His brother’s death years earlier triggered in Ty an outrage at the callousness of the surgeon and a fury at the unfairness of the world, a rage that made Ty a volatile teenager. He was easy to anger and indifferent about school. His sister’s state sparked in Ty something else entirely: a desire to be a neurosurgeon who could save patients and render them functional when others could not. From that moment on, Ty approached life with a single-minded purpose that made him a top student and eventually one of the best neurosurgeons in the country. Ty never forgot about the way his family had been treated, though. Doctors had ducked out when they should have been talking to Ty’s mother. He never forgot how much a doctor’s lack of compassion had added to his mother’s pain. It was no surprise, then, that while Ty could be remarkably arrogant to his colleagues in medicine, with his patients and their families a remarkable humility and compassion emerged.

Standing in front of Allison McDaniel with the worst news he could give her, Ty’s thoughts returned to those California hospitals: the news of his brother’s death delivered casually by a hospital bureaucrat, his sister lying in a sterile long-term care facility, and his subsequent vow to be the surgeon who could save the impossible cases. Ty had become aware tears were burning a path down his cheeks. “Things didn’t go so well in there, did they?” Allison asked softly. Ty cleared his throat. “No, ma’am,” he replied softly. “I am afraid we lost your son tonight.” Allison started to sob, and Ty took her hands into his own.

“I know you did all you could,” Allison said. Ty was too choked up to answer. Allison McDaniel walked over to him and gave him a hug. Ty found the embrace comforting and somehow unnerving: Chelsea General’s star surgeon needed comforting from the mother of the patient he had just killed. That was how he saw it. Allison slowly collected her belongings and started to walk out of the room. Just before leaving, she turned. She wiped away a tear while looking at Ty and said, “I know what happened in there must’ve been so hard for you.”

Around the corner, nurse Monique Tran had also been in tears. She was calling her boyfriend from a quiet corridor.

“I’ve decided to keep the baby.” With that, she couldn’t say any more. She hung up.

CHAPTER 5

Mitchell S. “Mitch” Tompkins checked the notes on a yellow legal pad and fingered a diamond-crusted gold band on his right hand. He gave a little tug on his Italian suit coat and turned a set of too-shiny white teeth toward Tina Ridgeway. Tina sat upright, legs crossed, her elegant hands folded in her lap in an effort not to show how uncomfortable the deposition was making her. She wore scrubs, sneakers, and her spotless white coat.

Now, Dr. Ridgeway, before the surgery, did you tell Mary Cash exactly how you planned to destroy her sense of smell?”

Tina returned the stare, winced slightly, and took a deep breath.

“Of course not. We didn’t plan anything of the sort.”

“You did it anyway, though. Didn’t you?” Tompkins pressured.

Tina paused, and tried to choose her words carefully. “No operation is without risks.”

Tompkins paced the conference room on the twelfth floor of Chelsea General when he talked. Like the rest of the floor, the room was elegant, with a cherry-and-oak table and high-backed leather chairs all around. A few of Hooten’s paintings hung on the wall, along with gold-plated light sconces. It was perhaps the worst place to hold a malpractice deposition, but Tompkins had insisted and the hospital lawyers had relented. Tina closed her eyes and tried to remain calm. If Mitchell S. “Mitch” Tompkins planned to rile her up, he was succeeding. She had seen the man’s name before. It was on the back of every phone book, above a picture of him surrounded by concerned-looking patients. have you been wronged in an injury? have you had a bad medical outcome? Tompkins didn’t look as good as the picture. In the photograph, he gazed at the camera with a confident air and the hint of a smile. Somehow, the picture made him look tall. In person, he was medium height and build. His handsome features were a little puffy, his face pale, with dark circles under his eyes, but he had swagger, and he was using it right now.

He was perched under an expensive chandelier. “You say no surgery is without risks. So then of course, before the operation you told Mary Cash about the risks?”

“Yes.”

Continues...

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Excerpted from Monday Mornings by Gupta, Sanjay Copyright © 2012 by Gupta, Sanjay. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Editorial Reviews

In his fiction debut, Dr. Gupta—a practicing neurosurgeon and Chief Medical Correspondent at CNN—transports readers into an exclusive cadre of Chelsea General surgeons linked by the dreaded and revered Morbidity and Mortality (M&M) conferences on the titular Monday mornings—the meetings at which doctors are held accountable for mistakes or deaths in the operating room. Each of the lavishly described (though emotionally flat) main characters is a caricature of a surgeon: for the overly-dedicated Sydney Saxena, life is career, pager, exercise. Tina Ridgeway—the gorgeous, married brainiac—and heartthrob Ty Wilson, the first to endure an M&M, satisfy the requisite hospital drama illicit romance; meticulous Sung Park wants to see Ty "publicly crucified;" and XXXL-scrubbed George "Gato Grande" Villanueva is the brilliant, brash, ER chief and former NFL player around which much of the novel revolves. Despite these potentially intriguing character sketches and plot points, Gupta (Cheating Death) attempts to weave too many threads and is thus unable to sufficiently develop his doctors or a compelling story line. Though the book reads quickly, medical jargon will alternately intrigue and frustrate a general audience, and readers will be left wondering whether Gupta should be the subject of his own M&M. (Mar.)

Publishers Weekly

"In MONDAY MORNINGS, Dr. Sanjay Gupta takes us inside the veins of the patients, the hospital, and the brilliant surgeons at Chelsea General in a thrilling, often funny, and sometimes heartbreaking read. You'll laugh. You'll cry. I could not put it down."

David E. Kelley

"MONDAY MORNINGS launches off the page like a thoroughbred out of the gates: the pace is fast and furious and the authenticity of the surgical situations make this a hard-to-put-down novel. Gupta has created a group of unforgettable characters and placed them in situations in the fictional Chelsea General that feel all too real. But hospitals are , after all, Gupta's turf; his insights into the craft of surgery combined with vivid story-telling make MONDAY MORNINGS a gripping and wonderful read right down to the wire. MONDAY MORNINGS is a winner.

Abraham Verghese

"A brilliant and authentic inside look at the high-stakes world of neurosurgery, filled with memorable characters and searing moments, written with a surgeon's deftness and a healer's heart."

Samuel Shem

In his first novel, neurosurgeon and CNN medical reporter Gupta follows the professional and personal lives of five doctors at Chelsea General Hospital in Michigan. Ty Wilson, Tina Ridgeway, and Sung Park are neurosurgeons; Sydney Saxena is a cardiothoracic surgeon; and George Villanueva is chief of the emergency department. The book's title refers to conferences held early on Mondays at which hospital physicians must acknowledge and learn from their mistakes. Wilson, who is having an affair with the married Ridgeway, must appear at one of these conferences after his overconfidence results in the death of a young boy. Park and Saxena both drive themselves relentlessly as they vie eventually to replace "the Boss," chief of medical staff Harding Hooten. Former pro-football player Villanueva is trying to reconnect with his estranged teenage son, who lives with Villanueva's ex-wife. VERDICT Anyone who enjoys medical fiction should like this novel, despite a few less-than-realistic plot developments. Gupta keeps his numerous characters and their intermingled lives and crises in play and convinces readers to care about each one. [See Prepub Alert, 9/25/11.]—A.J. Wright, Univ. of Alabama at Birmingham Lib.

Library Journal

Standard-issue medical procedural from CNN medical correspondent and surgeon Gupta (Cheating Death, 2009). In this debut novel, Gupta commits some of the more common errors of Fiction 101 by telling more than showing, and then showing the mundane with as much attention as the distinctive. Thus the second sentence of the book: "Wearing bright blue polyester jumpsuits with a yellow insignia on the left front pocket and standard-issue black boots, they were moving fast." Moving fast, check. But would it have mattered whether the uniforms were of green cotton, the badges red, the boots brown? The matter-of-factness and attention to every detail would probably serve a surgeon in theater very well, the purposes of a yarn less effectively; yet both qualities overwhelm the dramatic: "The aneurysm, a small blister on the surface of an artery, had suddenly let loose, spraying blood throughout her brain. She had likely felt a sudden thunderclap headache, and within seconds was rendered unconscious." "One of the possible risks was damage to the olfactory nerve that ran near the cancerous growth. If that was nicked or cut, the patient would lose the sense of smell." Just so, Gupta's characters are of the stock variety: the hardbitten, arrogant master cutter, the encouraging mentor, the poor kid out to save the world ("the first Robidaux to consider college," the foreign resident who works twice as hard as everyone else--in short, the kind of people whom, mutatis mutandis, you'd send into combat in a World War II film, or, in this instance, into the emergency ward. In that regard, Gupta's book makes its greatest contribution: It shows that a doctor's life isn't all glamour and golf on one hand or completely clinical on the other, even if most of the coitus is interruptus. All does not end well, not for certain patients and certain docs alike, but the quotidian world ticks on; it's very much as if James Michener had attempted a medical thriller, though without the thrill and without Michener's epic length. Competent but no more--and, of course, one always wants something beyond mere competence from a surgeon.

Kirkus Reviews

Praise for CHEATING DEATH: "You will be on the edge of your seat as you read the superbly crafted stories of people who have beaten the odds, something I like to think I know quite a bit about. My friend Dr. Sanjay Gupta, America's doctor, has written a page-turner. It's an exciting medical thriller with the compassion, hope, excitement and aspiration that define Sanjay." —Lance Armstrong

Praise for CHEATING DEATH: "I owe my recovery and my health to medical advances and the remarkable pioneers behind them. In his new book, the World's Doctor, Sanjay Gupta, delivers a breathtaking preview of a coming revolution in medicine that challenges virtually everything we think we know about living and dying. A truly provocative and fascinating reading experience." —President Bill Clinton

From the Publisher

This novel takes place at a fictional hospital in Michigan, but it’s reasonable to believe that it’s informed by the experiences of the author, who is a neurosurgeon. The story follows five neurosurgeons as they confront their performance on the operating table by reflecting on their successes and failures at each week’s Monday Morning Morbidity and Mortality conference. Narrator Christian Rummel gives this book a fast-paced, dramatic reading that makes it both compelling and entertaining. He effectively uses his deep, authoritative, nasal-tinged voice to portray the doctors as they see themselves. Some are methodical while others believe themselves to be healing gods. Rummel has excellent diction, and he’s a master of pacing and emphasis. He’s also fully committed to his character voices, and they fit the book’s tone perfectly. R.I.G. © AudioFile 2012, Portland, Maine

MARCH 2012 - AudioFile