The Patient Page 17

  Alex laughed disdainfully.

  “My bet is he can speak it and half a dozen other languages without an accent. I’ve got people in Europe trying to see if there even is a Count Rolf Hermann, but that could take time.”

  “You don’t have a lot of that, I’m afraid. Hermann’s being operated on tomorrow afternoon—hell, it’s this afternoon now.”

  Bishop looked startled.

  “I thought he was on the schedule for Thursday.”

  “His wife paid off one of my patients to switch. Dr. Gilbride is operating on him as the second case later today.”

  “If I tip my hand and make a move on Hermann before Cardoza gets here to identify him, and I’m wrong, I’ll most likely have ruined everything. Malloche will hear about it. I don’t know how, but he will. He’ll go someplace else, and I’ll lose what is probably my last chance.”

  “But you think it’s Hermann.”

  “Right age, right build, right wife, right timing, European. Yes, I think it’s him. And those so-called children of his. They’re bogus. I’d bet on it. If he’s operated on today, when will he be ready to leave the hospital?”

  “Assuming there are no unusual problems from the surgery, it could be anywhere from five to seven days. But this is a tough tumor. Given its location”—and the flaws in Carl’s surgical technique, she wanted to add, but didn’t—“there is the significant possibility, even with our robot helping with the operation, that there will be damage to some intervening structures. If that happens, he could be in the hospital much longer.”

  Jessie suddenly realized that she had just crossed the line and disclosed information on a patient. If she allowed Alex to hang around her, it wouldn’t be the last time. She was either in, or she was out.

  “In that case,” Alex was saying, “I’m not going to do anything that will interfere with the surgery. If I’m right about Hermann being Malloche, and if there is a God, the man will end up permanently paralyzed from his eyebrows to his toes—totally aware, but immobile forever. The perfect justice.”

  “Your justice, maybe,” Jessie said. “I’d like you to go now.”

  “But—”

  “You’ve apologized to me, you’ve said your piece, you’ve asked me to help you. Now I’d like you to leave me alone. I told you in my office I would think about getting involved. At the moment, I’m disinclined even to speak to you anymore. If that feeling changes, you’ll hear from me.”

  Their eyes met, and Jessie quickly looked away. She couldn’t stop remembering the hour after Jackie Terrell’s death—Alex’s touch, how much his caring and insight into how she was feeling had meant to her. Well, he wasn’t going to get to her again. Intellectually, she was becoming inclined to believe what he was telling her. But she was not ready to forgive the lies.

  Alex stood and seemed for a moment as if he had something else to say. Then he simply shook his head in frustration.

  “Thanks for listening,” he said as he left.

  CHAPTER 20

  THERE WAS AN ELECTRIC TENSION SURROUNDING the MRI operating room as one by one the players began to assemble for the robot-assisted tumor extraction on Count Rolf Hermann. Jessie stood outside the room, watching the silent, slow-motion ballet through the heavy glass observation window, and wondering if the broad-shouldered man being ministered to by the anesthesiologist was, as Alex had claimed, the ruthless, remorseless killer of hundreds.

  To her right, Hans Pfeffer and the console tech were checking and rechecking their instruments. Jessie pictured the action a floor above them where, in the cluttered, space-age computer center, half a dozen geek geniuses were preparing their remarkable machines to process the imaging data sent to them by the massive MRI. Their focus throughout this operation would be not on the patient, but on the tumor and the normal structures surrounding it. In addition to Pfeffer, a Dutchman, there were scientists from Germany and Sweden, Russia and Israel and the U.S. And for the next four or five hours, the life of a man they had never laid eyes on would be in their hands.

  It was well within her rights for her to watch the surgery, but Jessie still felt obligated to get Carl’s permission. Although she had spent significantly more hours than he had working ARTIE through any number of test matrices and animal models, as well as the ill-fated effort on Pete Roslanski, she felt like the understudy, asking the star if she could watch from the wings. For a few seconds, it seemed that Gilbride might actually refuse her request—surprising, given that he relished an audience for his performances.

  “Well, Jessie, I certainly don’t mind you hanging around during the procedure,” he said, finally, “but with Eastman Tolliver on a riser behind me, and Skip Porter in the OR as well to keep an eye on ARTIE, I think it might be a bit crowded in the room. How about you watch the proceedings outside on the screen in the console area.”

  “Actually, that’s what I was planning on doing,” she replied.

  “Fine, then. I’ve gone over ARTIE most thoroughly with Skip, and both of them appear to be in perfect working order.”

  He chuckled at what was, for him, a raucous joke.

  “That’s great.”

  “The tumor is sitting pretty for a transsphenoid approach—up the nose and in.”

  “Up the nose and in,” Jessie parroted, trying to sound more enthusiastic than sarcastic.

  Hermann’s meningioma was, indeed, the ideal tumor in the ideal location for ARTIE. But Jessie remained unconvinced that Gilbride—or even she herself, for that matter—was fluid enough, and comfortable enough with guiding the apparatus, to risk using it on a patient—even one who might be a remorseless killer.

  It was nearly two in the afternoon of a day that had started clear and sunny, but had clouded over by noon. Jessie estimated she had slept at most for an hour and a half, just before dawn. For once, she was glad she was not the one operating.

  Skip Porter entered the console area from the scrub room, waved a dripping hand at Jessie, and backed into the operating room to be toweled off, gowned, and gloved by the scrub nurse. He was tall, gangly, and refreshingly free of ambition, with bleached blond hair and a ragged goatee that reminded Jessie of Shaggy in Scooby Doo. He also had a commitment to perfection in his work, and a practical understanding of electro-mechanics that rivaled any Jessie had encountered at MIT. If Skip was nervous about his second case with ARTIE and Gilbride, he hid it well. His report to Jessie on the Marci Sheprow surgery was that both robot and surgeon had performed admirably, and that the tumor dissection, however straightforward, had been flawless. But he knew, as did Jessie, that Rolf Hermann’s complex meningioma presented an infinitely greater challenge.

  ARTIE-2 was sterilized and covered on a steel tray. Porter would check it out one final time as he attached it to the port next to the guidance panel where Gilbride would be working.

  There were seven in the OR now: the scrub and circulating nurses, anesthesiologist Pramod Sanjay, a med student rotating through Sanjay’s service, a neurosurgical resident from Ghana named Danl Toomei, who would be Gilbride’s assistant, Skip, and of course, the patient. Next to arrive was Eastman Tolliver, looking fit and trim in his sky blue scrubs. His eyes smiled at Jessie from above his mask as he came over to shake her hand before entering the OR.

  “I must say, this is all very exciting,” he said.

  “Yes, it is,” she replied, “although I’m not sure Count Hermann would share our enthusiasm.”

  She nodded at the scene through the window, where the anesthesiologist was sliding Rolf Hermann through the central opening of the MRI and into position between the huge tori, where his head could be bolted to the circular immobilization frame.

  “Quite a remarkable scene,” Tolliver said. “Most impressive.”

  Carl would be pleased to hear you say that, Jessie thought.

  “I’ve been down here dozens and dozens of times as observer and surgeon, and it still amazes me,” she said. “To someone who hasn’t seen it before, it must be like landing on another plane
t.”

  “Perfectly put. I’m very excited. Well, I guess I’d better get in there.”

  “You’ll have the best view looking over Carl’s right shoulder. That way you can watch the patient, the control panel for ARTIE, Dr. Gilbride’s hands, and the MRI screen.”

  “Excellent. That’s where I’ll set up, then.” He looked through the observation window and added, “I’m going to say a prayer for that poor man.”

  And I’ll say one for Carl.

  “In the OR, prayer is always a good idea.”

  Tolliver lingered for a few more seconds and then entered the operating room.

  Eight in. Moments later, with the arrival of a translator, there were nine. One to go. The crowd around the console outside the OR had swelled as well. Danl Toomei’s back was about all anyone could see through the observation window, so most were clustered near the twin screens—one projecting the surgical field from an overhead camera, and the other displaying a duplicate of the images being transmitted to Gilbride and his assistant from the computer center.

  Surgical theater at its best, Jessie thought. Hog heaven for Carl Gilbride.

  Moments before Gilbride made his appearance, Jessie’s attention was drawn through the crowd to the safe area—the area thirty feet or so from the OR door, beyond which scrubs did not have to be worn. Alex Bishop was there in his hospital security uniform, leaning casually against a thick, concrete-covered support pillar. There was nothing casual, though, in his eyes or in the set of the muscles of his face. He was alternating between scanning the observers and peering as best as he could manage through the window into the OR.

  His gaze connected with hers, and he nodded briefly. She returned the gesture and then shrugged her bewilderment at the whole deal.

  Where’s the truth, Alex? she wondered. Where’s the truth?

  For a time the images of bodies arranged in a grotesque tableau, with bullet holes in their foreheads, occupied her thoughts. Her unpleasant reverie ended abruptly when, hands up, palms in, dramatically banging the scrub room door into the wall as he backed through it, Carl Gilbride crossed before the multitude and entered the OR.

  Let the games begin, Jessie thought as Gilbride was quickly gowned and gloved. Having seen his often rushed and awkward technique in the OR, Jessie realized that ARTIE, with its meticulous, microscopic abilities, might well represent an improvement.

  She scanned the two monitor screens. The operative field was prepped and ready. The color-enhanced image of Hermann’s brain tumor, displayed by the crew upstairs, had excellent resolution. At the moment, normal brain tissue was navy blue, and the meningioma canary yellow. Blood vessels, appropriately, were crimson. On the other side of the observation window, all the principals were in position. Although Gilbride was largely screened from her by the resident, Jessie could see Eastman Tolliver on an eight-inch riser, watching intently from over Carl’s right shoulder.

  A four-million-dollar grant … Claude Malloche … Count Rolf Hermann … Alex Bishop … so much was riding on the next few hours.

  “Ready, Dr. Sanjay?” Gilbride asked.

  “No problems,” the anesthesiologist said.

  “Dr. Toomei?”

  “Ready, sir.”

  “Mrs. Duncan?”

  “All set,” the scrub nurse replied.

  “Dr. Pfeffer?”

  “At your command, sir,” the radiologist called out.

  “Well, then, scalpel and periosteal elevator, please.”

  The approach to getting ARTIE into place was straightforward. With the Count fully asleep, a probe would be inserted through a small incision up one nostril, and a half-inch hole would be drilled through the skull where the bone was thinnest. A fine guide wire would be fed in through the opening, and ARTIE would then be sent in along the wire, and directed to the anterior edge of the meningioma. If all went well, most of the two hours or more that would have been spent simply reaching the tumor by traditional methods would have been saved, to say nothing of the elimination of much of the damage to intervening structures.

  Go, ARTIE! Jessie cheered. Go!

  The insertion went perfectly, and was accompanied by murmurs of amazement from those in the crowd, when Gilbride announced he was in position and ready to begin the dissection. Jessie had to admit grudgingly that the neurosurgical chief was handling the controls of their invention quite expertly.

  The ultrasound liquefaction and removal of Hermann’s tumor began uneventfully. Gilbride, working with appropriate care, seemed firmly in control. In spite of herself, every few minutes, Jessie’s attention drifted away from the screens and over to where Alex was watching. From time to time, he was gone, no doubt going through the motions of his security job. But mostly he was there, up against his pillar, watching.

  “Okay, Dr. Sanjay,” Gilbride said. “I think it is appropriate now to awaken our patient for some functional MRI mapping.”

  Jessie studied the tumor image on the screen. About a third of the meningioma had been removed—the most accessible part. There was still a good deal that could have been melted away before Hermann’s cooperation was needed. It was almost as if Gilbride was stalling—doing whatever he could to delay an attack on the portion of the tumor that was most intimately adjacent to normal brain.

  It took a while for the anesthesia to lessen. During that time, Gilbride continued to pick away at what remained of the bulkiest portion of the tumor. Jessie was watching the monitor nonstop now. She was certain no one else appreciated it yet, but several times, Gilbride had started ARTIE off in the wrong direction, then quickly reversed. He seemed to be having trouble with the spatial relationships between the views of the tumor and the movement of the robot. To Jessie, ARTIE was essentially a videogame race car, able to move in any direction, but with controls that were in a fixed position. So when ARTIE was moving in one direction, a right-hand move on the control panel meant a right turn. But in the opposite direction, a right turn meant going left on the controls, and in between, there were literally an infinite number of permutations. To a video-game junkie like Jessie, the moves were second nature. But she could see that as the field of surgery grew smaller and smaller, Gilbride was having more and more trouble maneuvering.

  Twice he turned off the audio and called Skip Porter over for a whispered exchange. Both times, apparently assured by Skip that the robot was functioning properly, Gilbride returned to the surgery.

  “Count Hermann,” he said now, “lift your right hand a bit if you can hear me.”

  The translator, a nurse who had translated on occasion for some of Jessie’s patients, spoke from behind Gilbride, just to Eastman Tolliver’s left. Despite his adequate comprehension of spoken English, it had been the Count’s decision to have commands relayed to him in German. If Alex was right about the man’s facility with languages, Jessie was thinking, the request was part of the charade. Through the overhead camera, Hermann’s chest, where his hands rested beneath the drapes, was visible. Immediately after Carl’s order was translated, the Count responded with the requested movement.

  The operation proceeded for another twenty minutes. Jessie wished the overhead camera was focused on ARTIE’s control panel rather than the essentially static operative field. That view, along with the MRI, would have told her a great deal. Again and again now, as the dissection became more difficult, she saw Gilbride miss once, even twice, before directing the robot along the proper course. The errors were minuscule hitches—like the feints of a prizefighter before striking in the other direction. But they were errors nonetheless. She was certain of it.

  As ARTIE ate more and more into the tumor, closer to normal brain, Gilbride was clearly having more and more difficulty controlling its movement. At one point, where fibers of normal brain had to have been damaged by an errant thrust, Hans Pfeffer looked over, caught Jessie’s eye, and shook his head grimly.

  Alex, perhaps reading her expression and intensified concentration, managed to connect with her long enough to mouth the w
ords, What’s happening? Her response was a shrug.

  Gilbride placed the LED goggles on his patient and requested a functional magnetic resonance sequence, the brain mapping alternating with more dissection. Twice, Hermann seemed unable to follow commands. Both times, ARTIE was slightly off course. This was no mechanical failure. The technique, at this level, was simply beyond Gilbride’s ability. At one point Jessie thought he might back the robot out—admit he could go no further and simply opt for a full, open craniotomy. But Gilbride persisted. She wondered if it was getting to the point where he was pitting Rolf Hermann’s brain against a four-million-dollar grant.

  Another muted conversation with Skip. Another helpless gesture by the research technician.

  ARTIE is functioning fine, Jessie could almost hear him whispering.

  Hans Pfeffer made his way over to her and pulled her aside.

  “Do something!” he whispered.

  It was the most animated she had ever seen the laconic Dutchman.

  “You have a suggestion?”

  “There’s the microphone. Tell him to stop. The robot’s just not ready for this.”

  Oh, ARTIE’s ready, all right, she wanted to reply. Ready and able.

  “Hans,” she whispered back, “Carl is chief of this department, and one of the most powerful men in this hospital. He controls my job, and I would bet a good portion of your research funds as well. Nobody would survive busting in on him in the middle of a case with an audience like this. Nobody.”

  There were concerned murmurs in the crowd now as first the other radiologist then the two neurosurgeons observing the case picked up on what was happening.

  “Get in there!” Hans whispered. “Jessie, get in there before—”

  Pfeffer stopped in midsentence. He and Jessie stared at the screen where a faint gray puff had just appeared, right at the snout and just to the left of ARTIE, clearly outside the boundary of the tumor. The smudge was tiny but unmistakable, and it was definitely expanding. A deep arterial hemorrhage—the neurosurgical equivalent of a nuclear explosion. Guided off course by Carl, one of ARTIE’s pincers had torn an artery. Seconds later, Gilbride’s strained voice came over the intercom.