By A. Scott Pearson
Oceanview Publishing Copyright © 2009 A. Scott Pearson
All rights reserved.
Gates Memorial Hospital
Monday, July 10
Dr. Eli Branch stood at the scrub sink and looked through the window into Operating Room One. He slung soap across his arms and hands while counting blood-drenched sponges that lay on the floor in piles. From the looks of the room he was about to enter, sterility was not a prime concern. Inside, a nurse hustled with bags of warm saline while another scrambled in with more sponges. The anesthesiologist hung two units of blood at the head of the table and forced the transfusion with a white-knuckled grasp. A figure gowned in blue bent over the patient, working frantically, deep in the abdomen, to quell the flow of blood.
Just twenty minutes earlier, Eli's beeper had pierced his sleep.
Dr. Korinsky needs you in room one.
A difficult case.
Cold water splashed off his arms and soaked his scrubs. His pulse quickened. As the newest member of the surgical staff at Gates Memorial, Eli knew to come running when paged, no matter what time of night. Even when he wasn't on call.
From the operating table, a pair of anxious eyes met his — a summons from Dr. James Korinsky, chief of vascular surgery, ten years his senior. On the other side of the table, a surgery intern stared into the wound. An orderly rushed through the room with a cooler of blood, little packets stacked together like summertime drinks waiting to be spiked.
Eli held to one more quiet moment, as if watching a silent movie unfold before him. He closed his eyes briefly, a preoperative routine that had developed not out of principle or theology but from a sense of necessity. Then, with water dripping from his elbows, he bumped the door open with his butt and walked on stage.
"I've got trouble here, Branch," Korinsky said before the door fully closed. "Dumb shit over here doesn't know an aorta from his asshole."
Above his mask, intern Landers rolled his eyes and discreetly shook his head.
Although Eli was a board-certified surgeon, he felt closer in rank to Landers. An awkward, sympathetic twinge grabbed him as the verbal barrage continued.
"I've seen monkeys with better hands."
Eli approached the table and peered over Korinsky's shoulder. Then he looked at Landers and winked. The intern took his first full breath since the start of the case.
"Damndest thing I ever saw," Korinsky said, lifting a matted wad of intestines out of the wound as if handling a tangled ball of Christmas lights.
The scrub nurse draped a towel across Eli's open palm. He quickly dried his hands while studying an X-ray of the patient's abdomen that hung from a lighted view box on the wall. The culprit was immediately apparent, a metallic device embedded in the center of the patient's abdomen, thin metal spikes projecting from the top of a cylindrical cage tilted at a deadly angle.
"Get over here!" Korinsky yelled. "If I needed a radiologist, I'd have called one."
Eli lingered at the view box. He had not scrubbed with Korinsky before and wanted another moment before fully committing himself with bloody hands.
Why does the top vascular surgeon in Memphis need my help on an aortic aneurysm? Especially when he has an assistant?
Then Eli considered the time of year.
The first half of the month, no less, when attending surgeons took vacation just to avoid the new interns who knew only enough to be dangerous, and the naive medical students in shock from sixteen-hour days that started with four a.m. rounds. A man has only so many Julys in him, one of his mentors used to say.
"What kind of endograft is this?" Eli asked, referring to the biomedical device.
"Hell if I know," Korinsky said. "Some older model." And then, as a disclaimer, "Not one of mine, I can tell you that."
Eli peered closer at the X-ray. Surrounding a radiolucent inner fabric tube was an expandable steel mesh visible as a latticework of small V's connected and stacked on one another, like a tube of interlocking paper clips. The device was used to replace the aorta at the site of ballooning or aneurysm, a newer innovation that could be deployed within the vessel itself, avoiding the morbidity of an open abdominal incision. The device was designed to prevent aortic rupture, to save a life. But, as with any medical innovation, this one carried its own set of complications.
And this one is killing the patient.
"Some bastard from St. Screw-up put it in," Korinsky said.
Though the design was outdated, there was something familiar about the device, a recognition that Eli could not fully identify. The metallic image lingered with him as Roberta, the scrub nurse, snapped his gloves into place.
The overhead monitor buzzed with a rapid heart rate and showed a hypotensive pressure of seventy-four. Eli's waist met the patient's arm tucked deep beneath the drapes and he submerged his hands among warm loops of intestine floating in blood.
"Can't see a damn thing," Korinsky said as he wrestled with the matted wad of bowel. Blood welled up from the retroperitoneum and he jammed the wand-shaped sucker deep in the rising pool. The tubing turned bright red from the column of blood snaking its way toward multiliter canisters hanging on the wall.
The temperature of the room had been warmed to combat the patient's progressive hypothermia, his abdomen an open medium for the escape of heat. The air above the operating table was thick and stale, compressed by another boggy southern night. Korinsky's paper cap was plastered against his forehead, moisture forming a pool in the center. A drop of sweat dangled from the cap's rim and threatened the open wound. Eli glanced at Roberta, who shook her head as if the situation was a lost cause. When Eli looked back at Korinksy, the drop was gone.
"Every time I retract to get a look, blood wells up and I can't see shit." Korinsky demonstrated the maneuver by tugging the small intestine to one side.
Eli watched as a crimson lake swelled and obscured any detail of the anatomy. "Is it ruptured at the device or has a second aneurysm blown?"
To Eli's surprise, Landers answered the question. "There are holes at both the proximal and distal end."
Korinsky looked at him with an ice-cold stare. "He's not asking you!"
Roberta handed a second sucker to Eli and both he and Korinsky evacuated the wound, blood gurgling so loud it rendered the rapid beep-beep of the patient's heart barely audible.
"Look what I found," the anesthesiologist said, shuffling through the patient's chart. "A spec sheet for this device you're after."
Korinsky looked up and snarled. "Damn it, Kanter, run the blood in, will you? No one asked you for information."
Kanter ignored him. "It's from our very own RBI," he said, referring to Regency Biotech International, the biopharmaceutical giant that had relocated to Memphis and was world renowned for its innovative medical devices.
"Who cares?" Korinsky shouted. "Just pass gas and hush."
"That's weird," Kanter said, continuing to examine the sheet. "The bottom half of the page is missing, like it was ripped off."
"RBI will be sorry to hear about this," Roberta chimed in. "Device failure can take a company down."
"Oh, they'll cover it up," Kanter said. "Trust me. They've got teams of people waiting to bury an adverse event."
Korinsky acted oblivious to this transaction. "How old is this son of a bitch?" he yelled as he allowed loops of intestine to slip through his fingers like strands of spaghetti plopping into a colander.
Kanter found the date of birth, 1937, and did the math. "Seventy-two."
"An exercise in futility is what this is," Korinsky said. He glanced at a clock above the anesthesia machine.
It was near one A.M.
"I've got three more operations in the morning."
Eli stared at Korinsky. Are you finished?
"And I meet with Dr. Fisher at nine," Eli said, then wished he hadn't.
"The big boss, hmm?" Korinsky raised his eyebrows at Eli's meeting with the chairman of surgery. "You'd better suck up while you can. After your first month here, the honeymoon's over."
"Excuse me, doctors, this isn't bridge club," Kanter said. "His pressure's sixty — and dropping. He's going to arrest."
Nurse Virginia Brewer stood near the head of the table and called out identification from the next unit of blood, a maneuver required to prevent a transfusion mismatch.
"39-11-972 — Gaston, Mortimer."
The medical record number was background noise, but when Eli heard the name, it resonated.
"Who?" Eli peered over the drapes to see the patient's face, but it was wrapped in a towel. He saw only the endotracheal tube sticking out. In an urgent whisper to the anesthesiologist he said, "Show me his face, please."
Kanter peeled the towel back, releasing a tress of matted gray hair. Although the patient's eyes were closed, Eli saw familiar sockets, deeply embedded with years of pain.
"Gaston," Kanter said, reading from his clipboard now.
Eli felt paralyzed and he looked again for confirmation. The man's pale, withered skin and unkempt beard were unmistakable. A collage of images rushed from his childhood, each dingy and out of focus. A boy following the disheveled, gray-haired man among rows of cadavers in Anatomy Hall. The unstoppable image of Gaston alone one night on top of the body, pulling himself, and writhing, over and over.
"His name is Gaston," Kanter repeated.
"Yes." Eli, stunned, fought the insistent memory. "I know him."
Blood-filled suction tubing hung from the side of the table like red tentacles, twitching under the pull of vacuum. Eli took a breath and said, calmly, "We need proximal control to see the tear."
Korinsky held his hand out toward the scrub nurse. "Richardson retractor."
From an array of instruments, Roberta selected an instrument shaped like a large spatula and bent at a right angle on the end. Even though she moved quickly and precisely, Korinsky yelled "retractor" twice more before she slapped the handle against his gloved hand. He slid the instrument along the central diaphragm beneath the left lobe of the liver and pressed hard, collapsing the aorta against the spine like a garden hose caught under a tire.
Korinsky looked at Eli. "See what we got, hot shot."
You want me to take this case? This is your turf.
Korinsky seemed content to hold the retractor, a task usually demanded of an intern. Eli moved the sheath of mesentery to the side of the abdomen and placed Lander's hands over the tissue to hold it in place. He grabbed a pen-shaped instrument, the Bovie electrocautery, and yanked the cord connected to the mobile floor unit to obtain more slack. When Eli incised connective tissue overlying the aorta, plumes of smoke floated out of the wound, the aroma of seared flesh. He cut through the final layer and partially clotted blood burst forward like cherry Jell-O under pressure.
"Lap pads and keep them coming," Eli ordered.
One by one, Roberta tossed absorbent white sponges into Eli's hand and he scooped out blood into a plastic basin.
With his free hand, Korinsky reached for the sucker. But the retractor slipped off the spine and jabbed the base of the patient's liver, ripping its left triangular ligament from the man's diaphragm. Blood spewed from the wound like a fountain, and Eli batted it down with a hand to keep the deluge from covering his face.
"Damnation to hell," Korinsky yelled, scrambling to reset the retractor. Eli plunged the suckers in and with both hands scooped blood onto the floor, bailing a sinking boat.
"I don't have a pressure up here," Kanter yelled. "No pulse."
Korinsky shifted his weight down on the retractor. "He's not going to make it, I'm telling you."
Eli reached toward the anesthesiologist and released the clamp that held a blue drape suspended between the open abdomen and Kanter. As the sheet fell, Eli leaned over, breaking the sterile field, and lingered a moment close to Gaston as if whispering into the ear of an old friend. Then, in one swift move, Eli grabbed a pair of Mayo scissors from the tray of instruments, jammed the tips through the left diaphragm, and opened the muscle in a circular motion as if it were a piece of construction paper. Gaston's heart lay still, with only an occasional quiver of cardiac fibers. Eli inserted his hand into the left chest and began CPR with direct cardiac massage.
"He's exsanguinating," Korinsky yelled at the circulating nurse. "Get the whole damn blood bank in here."
"Three-0 Prolene on a vascular needle — with pledgets," Eli ordered, continuing to rhythmically squeeze the heart, pressing his thumb into the left ventricle, and wedging his hand against Gaston's spine. In a blind move of desperation, he submerged a vascular clamp above the liver.
Kanter was peering over the drapes. He wasn't looking at the patient but at Eli. As if his eyes weren't disparaging enough, he slowly shook his head.
Eli turned to Korinsky. "Throw some sutures in the hole," he said. "That's all we can do."
St. Martin Island
The Caribbean Sea
Applause filled the opulent banquet hall of La Belle de Marigot Resort from eager supporters who had dished out a thousand dollars per plate. Bernard J. Lankford gave a double thumbs-up and winked to his wife in the front row as attendants escorted the distinguished scientist off the stage. Lankford planted his steps with hesitation, testing his weight on the ramp of stairs as the men held firmly to his arms. What he lacked in agility, he more than compensated for in his command of an audience. The clapping had congealed into a rhythm, and a chant of "Ber-nie, Ber-nie" erupted. His wife joined him backstage and they were whisked toward a waiting limousine.
With his closing address, the International Conference on Embryonic Stem Cell Therapy (ICESCT) officially ended after two days of speeches, rallies, and sun-soaked cocktails on the tropical island of St. Martin. The agenda had been crafted to wine, dine, and lull supporters into breaking out their wallets as they popped a complimentary bottle of Dom Pérignon to celebrate the opening of the first embryonic stem cell infusion clinic. Prohibited on American soil, the International Clinic for Embryonic Cellular Therapy was a revolutionary facility. A young woman with a rare neurologic disorder had been selected as the first patient to receive the potentially life-saving embryonic cells. During the conference's opening plenary session, a riveted audience watched a live interview with the patient on a thirty-by-thirty-foot screen. She was scheduled for the treatment in less than a month. Behind the scenes, but in command of it all, hovered Regency Biotech International. RBI stood ready to watch its stock soar.
"You've still got it," Fran Lankford told her husband, sliding across the shiny leather seat until her hip pressed into his. For over thirty years, he had devoted his career to the cellular-based therapy of disease ranging from diabetes to Parkinson's to cancer. And he had reached the pinnacle as the chief medical officer (CMO) in charge of RBI's innovative, world-renowned Division of Stem Cell Therapy.
"Did I ...?"
"No," she said, gently squeezing his knee to reassure him. "No stammering, no stuttering, not any of that. This time."
Lankford smiled, leaned forward, and removed two glasses from a miniature bar carved in the lush interior. "The hard stuff?"
"Yeah, why not."
He plopped a single cube of ice into each glass and poured a round of the island's best sparkling water.
"Now, home to that grandbaby," Fran said.
"I'm sorry, the timing of this conference was awful."
"We've been traveling as a team for what, twenty years or more?" Fran said, as if she needed to convince him of her loyalty. "They'll be fine." But as she said this, her new grandmother voice cracked. "Probably just out of recovery now."
They clinked their glasses in an awkward toast as the limo accelerated toward the airport.
They had landed on the French side of the island barely ten hours before. Upon boarding the company jet in Memphis, they received an urgent call from their son-in-law.
"They're taking the baby. Stat C-section."
Now, Bernie and Fran Lankford stared out the window of their chauffeured car into a black Caribbean night. Each had the same thought. Taking the baby. Our little Celia. We've waited for years to be grandparents. And now we're off on an island in the Caribbean Sea. (Continues...)
Excerpted from Rupture by A. Scott Pearson. Copyright © 2009 A. Scott Pearson. Excerpted by permission of Oceanview Publishing.
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