Across The Red Line: Stories From The Surgical Life

5. Four Patients in Santa Fe

5 Four Patients in Santa Fe Rob reaches down into a hospital crib and scoops up a four-year-old sleeping child. It is 8:30 in the morning, but the boy is still asleep. Next to the bed his mother rocks gently in the plain wooden hospital rocking chair; she blinks at the winter sunlight just now cresting the Sangre de Cristo mountains and sliding down the snow-covered mountainside into their hospital room. “Come on, Josh, wake up.” Rob is firm but pleasant. He doesn’t placate or small-talk. You can tell he means it: Get up. Josh has had hydrocephalus (water on the brain) and he has spastic legs. Two years ago a shunt was put in the ventricles of his brain and connected by a plastic tube under his skin to his abdominal cavity so the excess fluid in his head (a closed space) could drain into his belly (a distensible space where the fluid will be reabsorbed). But the shunt has stopped working and the question is: Will fluid re-accumulate in his brain, cause increased pressure and lead to new neurological symptoms and, if untreated, cause death? Or will the fluid not build up and nothing bad happen ? How is it that the possibilities can be so disparate? Death versus no change. And the doctor cannot predict the difference. 51 Rob is dressed like his colleagues at the hospital: jeans, open shirt, Nike running shoes. No one here in the great southwest considers him underdressed, although such a getup at the hospital in Florida where I work would cause a stir. The boy rubs his eyes as Rob lowers him to the floor with the command to walk toward his mother. On his tiptoes , he does. “Is he okay, has he changed in any way?” Rob asks the mother. “No, he seems all right,” she says. “Okay,” says Rob. “His CT scan of the head shows a lot less fluid than before the shunt was placed, but I cannot tell if it’ll build back up now. We’ll need to keep him here and watch him and get another scan in the morning. He may not ever need another operation to fix the shunt or he may need one today.” The mother, a big-boned woman, handsome in part because she is watching over her son, seems to accept this astonishing ambiguity. “So, we’ll see,” she says. Rob and I were interns together 31 years ago. Rob was doing a year of general surgery en route to a neurosurgical residency and I was doing the same, planning to continue in general surgery. We hit it off, spent lots of off hours together and, although we’ve never again lived in the same state, we see each other two or three times a year and each time I like him and his wife, Ellyn, better. Rob is a serious and thoughtful man. He likes what he does—neurosurgical private practice. Contrary to common assumption, Rob’s not getting rich and he works hard and those are just two of the reasons he’s happy. 52 Chapter Five With deft and practiced ease, Rob has just wakened a sleeping four-year-old in an alien environment, examined his eyes, listened to his speech, felt the rigidity of his limbs, assessed his gait, and taken a careful historical account from the person who knows this boy better than anyone, his mother. He then explains the lack of certainty inherent in the boy’s condition with such directness that the mother understands and accepts. There are no tears shed by mother or son. I am gradually given to understand that in less than ten minutes I have witnessed a thorough neurological examination , a patient interview and a family conference. Over the next day I came to realize I was watching a pro. A pro at medicine, a long-ball hitter unheralded in Santa Fe: diagnosing, examining, operating, talking to patients and families, doing it right. The next patient is a newborn infant with the same problem. His shunt was placed just yesterday as an emergency . Because the bones of the skull are still not fused together in the infant, the soft spot on top of the head (the fontanelle) is Rob’s clue to diagnosis. No CT scan is needed here, because he can feel the soft spot and see if it is...