Peter Jenson slipped off his wedding ring and examined it, feeling its weight in his hand and his heart. He closed his fist around it for a moment, then put it into his trouser pocket. He had been slipping that ring on and off for nearly twenty years. He wondered now how much longer he would have the privilege of slipping it back on.
Next, he took off his watch, a gift from his wife, Ellen, and slid it into the same pocket as the ring. The watch had come with a handwritten note: Time is not money; time is love. Measure it…and spend it wisely. Peter sighed and took off his trousers. As he hung them in his locker and put on a fresh set of extra long green surgical scrubs, he told himself that he had no choice. Megan Kaiser’s brain tumor had to come out, and it had to come out today. Waiting, even overnight, entailed a risk that she could fall into a coma or die. But if he operated now, he would miss the psychiatry appointment at 4:30. Ellen had cut time out of her business as an interior designer and planned the appointment around his schedule. She was worried about their son, Daniel. Peter was worried she was ready to walk away. They, all three, had to be there, no matter what, and he had agreed. He had promised.
And his plan had been good. If Megan’s case had started at 7:30, as it should have, then it would have been finished by noon, a four-plus hour buffer before the 4:30 appointment. But his case had been bumped by an “emergency” operation by the chief of surgery, Joe Bell. Bell’s “emergency” was that he wanted to do his lumbar disk surgery first so as not to disturb his afternoon office hours and five-o’clock quitting time. Bell was the chief of surgery; he did what he wanted.
Initially, Peter didn’t worry about it. He’d still make the appointment. But Bell was too old to be good and too young to know it. The case should have taken two hours. It took four. Add the turnover time for the room, and Peter was running late before he’d even begun. And he’d made the mistake of letting Bell know how slow and incompetent he was.
Although he was still angry, he regretted his words. Bell would be just as slow the next time, and now he had made an enemy. No good would come of the fight; Bell would get even. But it was too late now. Peter drew a deep breath and exhaled, shutting out the vision of Bell’s red face. Then he shut out the vision of Ellen’s disappointed face. Then Daniel’s. Then he breathed again and visualized the MRI images of Megan’s tumor, focusing on the first of the thousand perfect steps that made up a good operation.
The intercom announced that his patient was in the operating room. He entered the hallway leading to the OR suites, sweeping past the control desk where Bell stood, his stocky frame hovering over Amanda Stark, the slinky scheduling secretary. He had one hand around her shoulder, the other pointing down. Amanda looked away from Peter and leaned into Bell. Peter pitied her.
Entering the neurosurgery operating room, he found Megan already under anesthesia. Dr. Archie Davis monitored the anesthesia and vital signs. Archie nodded, an acknowledgement more than a greeting, his expression as stoic and neutral as it had been when he’d witnessed the confrontation between Peter and Bell.
Peter took comfort in seeing his usual OR team: Carl, the scrub tech, and Nancy, the circulating nurse. Everything would go faster and smoother with experienced help. He glanced at the clock. Twelve-thirty. “Aren’t you out of here at three, Carl?”
“That’s right, Doc. Admin’s got no interest in paying us overtime. But we’ll all be going home by then, right?”
“I hope so,” Peter said, but he knew it was not to be.
Carl was a college dropout, a Navy corpsman, and now, for the past five years, a surgery tech. If Peter didn’t finish before three, he would have to deal with an inexperienced replacement.
Nancy shrugged. No case and no surgeon intimidated her—she had years of experience as a circulating nurse in neurosurgery at hospitals across the country. She had seen it all. Peter doubted she was impressed by Bell. He wasn’t sure she was impressed with him, either.
“We tried to get everything ready to save time,” she said. “The neuro-navigation is up and programmed.”
The neuro-navigation system used images from the MRI and CT scans to correlate with three-dimensional information gathered in the operating room, much like the GPS systems used on smart phones and in cars. With the device, he could pinpoint critical locations within the head, like the tumor, to sub-millimeter accuracy in real time. He used it with nearly every tumor case. But not this time.
“Shut it down,” he said.
Nancy narrowed her eyes and stood still. “Really? You’re sure?”
She was right, of course. The better operation would be with the navigation device. But it would add time, fifteen minutes, maybe a half hour, and Peter still had hope. He could finish this four-hour operation in three and get to the appointment before it was over. He could apologize profusely to Ellen and Daniel, and move on. After all, the tumor was only a glioma; the old- fashioned way would be good enough.
“You’re the surgeon,” Nancy said. She shrugged again and shut down the equipment.
Peter approached Megan, anesthetized on the OR table. When she first sought help, she was a single, young waitress with a headache. After her MRI scan, she became a thirty-two-year-old white female with a right temporal lobe brain tumor. Now, asleep, her humanity slipped even further away, allowing him the psychological distance he would need to perform the violence that was surgery. She transformed into a living anatomy project—hair and scalp, skull and brain, and a tumor that needed to come out. Peter gently touched her face and smoothed back her hair, imagining the tumor beneath the surface.
With the image clear in his mind, he shaved a two-inch strip of her blonde curls from the midline of her forehead to the top of her left ear. After the wound healed she could comb the longer hair from the right scalp over the incision line. Perhaps only able to question what she didn’t fear, Megan had asked more questions about her hair than she had about her tumor.
Peter stepped out of the OR to scrub his hands and forearms for the requisite five minutes, all the while keeping a close eye on the sterile prep of Megan’s scalp through the observation window. He reentered the room, and Carl handed him a sterile towel.
“You gonna be okay, Doc?” Carl asked. “You know I’d stay if I could. It’s Everett, though…”
Carl shared custody with his only son, Everett, while his ex-wife worked as an OR tech at another hospital. Three o’clock would be quitting time for Carl, no matter, because he had to get Ev from daycare or get a complaint from his ex’s lawyer that he was neglecting his child.
Peter nodded, thinking about his own son, Daniel, now nine. Once Daniel was three and brought him joy. Now he hid in his room playing computer games and no longer made him laugh.
He started the sterile draping procedure, holding a sheet so that Archie Davis could fasten it to an IV pole, isolating his aesthesia position from the operative field. Archie had always been taciturn, even more so in the last few weeks, so his stoicism earlier during the squabble with Bell did not surprise Peter. What surprised him was that Archie actually asked a question.
“So, Doc,” he said, “what’s the story on this patient? She seems way young for a brain tumor.”
“Yes,” Peter replied, as he outlined the skin incision with a sterile marker. “About six weeks ago she started having headaches. Unusual for her. No insurance, so she waited it out until she couldn’t stand it and went to a free clinic at her church.” He paused, thinking about the doctor she saw there.
He injected the incision line with a dilute epinephrine solution. “She’s lucky, I guess. She saw a Dr. Luke Ryan. Used to be a neurosurgery resident.” Before his wife died. Before his son died.
Peter forced his concentration back to the incision line. “Anyway, he arranged her CT and MRI and got her in here.” Even though she would have to see me.
“He’s got an arrangement with the hospital to care for his indigent patients with the understanding he’ll send his paying patients here, too.” Wasn’t my fault about his family. He should’ve been able to see that.
Archie spoke again. “So what are her chances?”
“We’ll know after we get the pathology report back. From the scans, I think it’s an astrocytoma of some type, more than likely malignant.”
Peter held out his hand for the scalpel.
“Time out,” called Nancy.
The “time out” was a rule that mandated the entire surgical team stop whatever they were doing and confirm the patient identification and surgery plan. Yet another irritating delay.
“Come on. Get it over with,” Peter said.
Nancy narrowed her eyes and stared him down before she called out, “The patient is Megan Kaiser, the consent form is for ‘craniotomy for tumor.’ The schedule states ‘left temporal craniotomy for tumor.’ Vancomycin was given as the pre-op antibiotic at twelve noon. Are we all agreed?”
“Agreed,” Archie said.
“Yeah, yeah,” said Peter. “Let’s go.” He tapped his foot and impatiently shook his outstretched hand, waiting for the scalpel. This time Carl handed it to him.
The incision began over the root of the cheekbone, just in front of the ear, and carried up, back a bit over the ear, before it gently sloped forward to end in the forehead at the hairline. With the underlying muscle and skin flapped forward and down, the exposure of the skull would be enough for gross total resection of the tumor. Peter worked with the skill earned from doing hundreds of similar cases but pushed his speed, his hands frenetic, tossing the used instruments back on the tray and holding out an impatiently bobbing hand for the next. Carl rushed to keep up.
Then he asked for the craniotome, an air-driven high-power drill used for bone removal. “Carl, irrigate for me while I drill, but not too much. Just enough to keep the bone dust off the bit so I can see what I’m doing.”
Peter used his right foot to depress a floor pedal, and the acorn-shaped bit started spinning at twenty thousand rpm. He touched the bit to that part of the skull neurosurgeons call the keyhole. Carl delivered a gentle flush of saline as the surface of the bone turned into a fine, wet powder that disappeared into the suction tube.
Peter reviewed in his mind what could go wrong. Too much pressure on the drill bit could cause a sudden break through the bone and damage the left frontal lobe. That could cause speech problems, expressive aphasia—always a risk with left-sided tumors. He hadn’t reviewed this risk with her because…
She doesn’t have a left-sided tumor. Her tumor is on the right.
Peter’s foot came off the pedal. The drill stopped. He stood up straight and looked across the room at the CT and MRI scans on the monitor.
Carl irrigated a moment longer, then stopped. “Doc. What’s the matter? You okay?”
Peter felt a knot in his gut. “No. No, I am not okay.”
Brain scans were, by convention, marked with the patient’s left brain on the right side of the scan, the patient’s right brain on the left side of the scan. When a surgeon stood at the top of a patient’s head at surgery, right was on the right, and left was on the left. Since scans were reversed, the surgeon needed to do the mental gymnastics of flipping the images in his mind to interpret them correctly. As Peter looked down at the open wound and back at Megan’s MRI, he confirmed that she had a right-sided tumor and a left-sided scalp incision.
An easy mistake to make. Easy, not forgivable.
“No,” he repeated, “I am not okay. We are not okay. Her tumor is on the right side of her brain and we are drilling holes in the left side of her skull.”
Nobody moved, nobody spoke. The only sounds were the beeping heart monitor and the wheezing respirator.
“I’m sorry, Doc,” Carl said. “We didn’t know. The schedule said left side.”
Nancy confirmed. “The schedule said left side.” She tapped the printout hanging on the door. “In the time-out we all agreed to the left side. The procedure line on the consent form…” She swiped on the computer tablet until a copy appeared. “…says ‘temporal lobe tumor.’ We didn’t read the X-ray reports, but it’s not our job. We just brought the images up on the monitor.”
“You set up the room wrong. Look at the MRI. Here’s the tumor, here’s the right-side marker. We’ve made the wrong incision.”
Nancy stood from her stool and put her hands on her hips. “We set the room up like it said on the OR schedule. You booked the case and you filled out a consent without a specific side. We had a time-out, Doctor. If there was a mistake on the OR schedule, you had a chance to fix it.”
Archie looked up from his place on the other side of the drapes. “Nancy’s right, Pete. We didn’t make a wrong incision. You did.”
The room was silent again, except for the monitors. Peter’s gut tightened and heat rushed to his face. His hands started to shake. He checked himself to keep from screaming at Archie and heaping sarcasm on Nancy. He wanted the mistake to be their fault. Anybody’s fault except his own. He even wondered if Bell could have been engineered this. He was there with the scheduling secretary, leaning over her, touching her, pointing at something.
But even as Peter thought about Bell’s possible culpability in altering the OR schedule, he knew it wouldn’t matter. The surgeon was the captain of the ship. If he hadn’t been in a hurry, or if the schedule or permit had been clearer, or if he’d used the navigation equipment, the right side would have been prepped, draped, and targeted. But the left scalp lay open in front of him, and it was his responsibility alone.
Peter broke the silence, steeling himself, erecting again the great wall between his feelings and his actions. “Fine. But we still have the same problem we did when we walked into the room. The patient still has a brain tumor. We have done her a disservice by a wrong-side incision, but we will do her another disservice if we don’t get her tumor out.”
Nancy and Carl both stiffened at his use of the term we, but Carl reorganized his instruments while Nancy notified the control desk of the delay and filled out the reports required when things went wrong.
Peter held out his hand and asked for sutures, needle holders, and forceps. His right hand shook visibly.
“You all right, Doc?” Carl stared down at his hand. “Take a break? Sit down, maybe.”
“I’m going to be less all right if you don’t hand me the suture right now and we start getting this thing fixed.”
Peter began closing the long scalp incision. Action tranquilized his stress. With each stitch, his hand tremor lessened, and his breathing steadied. Recriminations would come later. This was how he approached problems—by working harder, faster, longer. But he still felt this one in his gut.
The room was quiet. He reviewed what excuses he could make for such an egregious error and came up with nothing. Everyone else in the room was no doubt distancing themselves from the mistake, and from him.
With the first incision closed, Peter removed the drapes and repositioned the body and head. He shaved the right side of her head, leaving a ridiculous haircut, now regretting the reassurances he had given her about her post-op appearance.
A new skin prep and drape, another incision, another operation. This one was textbook pretty, with neat incision lines, precision bone cuts and dural openings, and a nice, clean resection of the right temporal lobe that gave the widest safe margin of resection.
The tumor was sent to pathology. Peter could have gotten a preliminary report, but he knew without the report that it was likely malignant. Today’s troubles had been enough. Tomorrow would be soon enough to receive the official path report.
Midway through the second procedure, Nancy slipped out, replaced by a silent nurse with dark skin and Asian eyes.
“Gotta go, Doc,” Carl said. He stepped back from the table and pulled off his gloves. When he reached the door he hesitated, then turned around. “Sorry,” he said and left. Not an apology. A condolence. He was replaced by a quiet African-American woman, whose name Peter couldn’t remember and didn’t care to ask.
The second closure went smoothly, if quietly. Peter removed the bloody drapes and washed her scalp and hair. Now she was no longer an anatomy project with a brain tumor. She was again Megan Kaiser, a woman with a malignant brain tumor and a bad haircut, and someone to whom he was accountable.
He wrapped her head in a turban dressing that covered both incisions so that now she looked as if everything had gone according to plan. Technically speaking, Megan’s surgery was successful. The tumor was resected. Biopsies would lead to a definitive diagnosis and the best treatment plan. But “technically successful” was little comfort to Peter.
Archie extubated Megan and supervised her transfer to the anesthesia recovery room. “These things have a way of working out,” he said on his way out.
Peter nodded, unable to think of a reply. He stripped off his bloodied gloves and surgery gown, deposited them in a biohazard container, then washed his hands of the sweat and glove powder. The operation was over, but the next few hours would be more difficult than the last.
Peter knew good news traveled slowly in hospitals, but bad news spread faster than the limits of physical science. No doubt by now everyone—including the janitors just coming to work on the fifth floor and food service workers isolated deep in the hidden kitchen—knew he had made a mistake in the operating room. The risk manager would be waiting in the anesthesia recovery room. Dr. Bell would be gloating.
Everyone knew except Megan.
And Ellen. Peter now allowed himself to look up at the OR clock. Six p.m. No credit for showing up. The therapy session was over and, possibly, so was his marriage.
After Megan had been taken to the recovery room, he sat alone on one of the stainless steel stools and surveyed the carnage: discarded drapes stuffed into biohazard containers, bloody towels on the floor, and urine collection bottles in the corner. He put his elbows on his knees, his head in his hands, and said softly to no one, “Oh, Jesus.”August 5, 2020.