Hemorrhage
Perhaps it had passed the point of futility, but neurosurgeon Ryan Brenan persisted in packing pristine white cotton balls into the gaping hole. And again, the white turned to red and blood began to stream out of the little girl’s head. With a sigh, Ryan peeled the now spent cotton balls away and tossed them with a dripping wet splat into a nearby stainless-steel basin. He took a shot at several of the bleeding points, the acrid smoke of cauterization mixing with the smell of blood and brain, but quickly abandoned the effort and packed in more cotton.
The evening had started peacefully enough. Ryan had just sat down for dinner at the kitchen table with his wife, Kelly, and their three daughters, Ava, Riley, and Erin, when his phone erupted. He took a last look at his plate of grilled vegetables, then pushed himself away from the table as he answered.
“Hey there, Eric . . .”
“Hey, sir. Sorry to bug you again so soon.” It was ginger-haired Eric Edmundson, third-year neurosurgical resident, known throughout the hospital as “Eric the Red.”
“No sweat, buddy. What’s up?” asked Ryan, as he headed into the dining room.
“We just got called on a two-year-old girl, Olivia Spencer. Head injury from a bad car accident. Reported awake at the scene, now in coma. She just dilated her right pupil. They’re bundling her up for a scan as we speak.”
Ryan’s coal black eyes narrowed.
“Okay, I’m on my way. Meet you in CT.”
Kelly looked up from her dinner, a subtle frown crossing her lips. “Really, Ryan? You just got home.”
“Sorry, honey,” replied Ryan as he kissed each daughter on the top of her head. “They’ve got a kid who’s in big trouble. I doubt I’ll be back any time soon.”
This was code that he was likely headed to the operating room. It was greeted by a chorus of theatrical sighs from the girls.
“But, Dad, we were supposed to carve pumpkins tonight,” protested seven-year-old Riley. “You promised. We’ve been waiting all weeken—”
Ryan was out the house and jogging to his jeep before she could finish. He arrived at the CT scanner just as Eric, two Pediatric Intensive Care Unit nurses, and pediatric critical care specialist Hugh O’Connor pushed Olivia’s hospital crib into the suite. He helped the team load the little girl into the giant, gleaming-white miracle of modern electrical engineering. Within a couple of minutes, pictures of her brain appeared on the monitors. Ryan took one look and pulled out his cell phone, speed-dialing the operating room.
“OR front desk,” came a cheerful response on the second ring.
“Hey, there. Brenan here—”
“You again, Dr. Brenan? I thought we just got rid of you.”
“Yeah, well, we’ve got a little girl in CT who needs to come up right away. Crani—right side—big bleed.” As Ryan spoke, phone held between his ear and shoulder, he helped remove Olivia from the scanner and return her to her crib. Soon, he and Eric were wrestling the bulky apparatus toward the elevators.
Operating room twelve was pulsating with activity when he pushed the crib through its swinging doors. The scrub nurse was laying out an assortment of stainless-steel instruments on tables draped in sterile blue disposable sheets. Other scrub-attired personnel were hooking up drills, suction systems, and electrocautery devices. The anesthesiologist and his assistants were filling various syringes and hanging IV bags, and two circulating nurses were tearing open bundles of sterilized tools and drills. All activity paused for a moment, however, as Ryan lifted Olivia to the operating table, and everyone in the room let out an anguished groan as her bruised and battered body was laid bare.
Ryan shaved a large patch of Olivia’s hair and slathered the exposed scalp with a fluorescent-orange solution. He left the room for only a few seconds to rub antibacterial lotion into his hands and arms, then burst back in, arms held away from his body, impatiently waiting to be gowned. With the scrub nurse’s assistance, he donned his sterile gown and two pairs of gloves, draped out the operative area of Olivia’s head, and picked up a scalpel.
“Okay, guys. Time-out!” he barked. This was an institutionalized nod to patient safety, where the surgeon would normally run through an accounting of his or her surgical plans, needs, and concerns with the rest of the personnel in the room before starting the procedure—like an airline pilot running a pre-flight checklist before a take-off. But with a dying child under his scalpel, he cut short the exchange. “This is miss Olivia Spencer, and we’re about to open the right side of her head for a big-assed bleed. If anyone has any objections, speak now or forever hold your peace.”
He cut into the child’s scalp directly behind the widow’s peak, fashioning a giant question-mark-shaped incision, encompassing the entire right side of her head, while Eric applied blue plastic clips to the cut edges to stop them from bleeding. After a few minutes of operating, Ryan addressed a couple of nursing students who were watching the procedure.
“So, this little girl’s got a large accumulation of blood deep in her brain that’s crushing the surrounding tissue. The longer the brain gets crushed, the more it shuts down and dies. The blood solidifies into a clot or, as we call it, a ‘hematoma.’ Dr. Edmundson and I are trying to get the hematoma out before it’s too late. We’ll see how lucky we are tonight . . .”
The two surgeons continued to operate, peeling the scalp off the skull. Ryan then stepped on a metallic pedal on the floor. An eighty-thousand rpm drill in his right hand leaped into action with a high-pitched scream. With it, he made dime-sized holes in the skull, then switched out the drill bit.
“So, we just made what we call ‘burr holes.’ This new drill bit cuts on its side, so if we insert it into a hole and push it against the bone, we can make nice thin cuts from one hole to another.”
He maneuvered the drill about the child’s head, creating a six-by-five-inch window in the skull. He lifted the freed-up flap of bone and passed it to the scrub tech. Underneath lay a purple-red glob of what looked like currant jelly. Ryan pointed it out to the students.
“So, what do you think this is, guys?”
“Um, is it a subdural hematoma?” replied one of the students who was so tall her scrubs ended halfway down her shins.
“Close!” replied Ryan. “It’s an epidural hematoma. The brain and spinal cord are contained in a bag of fluid called the ‘dura.’ This clot of blood is on the outside of the dura and thus is ‘epi-dural.’ If it were under the dura, it would be ‘sub-dural.’ The problem is, it’s not this little girl’s problem. The clot that we’re really after is in the brain itself. It’s known as an ‘intra-parenchymal’ hematoma.”
Ryan swept the clot off the underlying tissue with his gloved finger. “So, here’s the dura—the leathery bag of fluid that the brain sits in. It feels tight as a drum. That’s not good. It means the pressure in this girl’s head is off the scales.”
Eric incised the dura with a scalpel. A geyser of bloody fluid shot out and hit him in the chest. With further opening, large lumps of clotted blood presented themselves. Eric suctioned them away only to be greeted by bubbling mounds of the child’s brain.
“Normally, guys,” remarked Ryan, “the brain is kind of gray-white in color, with the consistency of overcooked pasta. As you can see, this child’s brain is all yellow, orange, and purple; and is way too mushy—almost to the point of being runny.”
A section of such brain percolated up through the opening in the dura like a volcano rising from the sea, crimson lava coursing down its sides. Ryan incised the apex of the peaking mound, and volumes of clotted and liquefied blood spewed forth. The two surgeons suctioned this away and then worked to remove lumps of clotted blood from well below the surface.
“This is the hematoma we’re after,” said Ryan. “Once we have it all out, we’ll likely have some bleeding to contend with.”
He was proven correct. He and Eric were now facing fierce whirlpools of hemorrhage deep within the cavernous opening in Olivia’s brain.
“When the brain is badly injured, the body’s clotting mechanisms can get all screwed up, and bleeding can be a challenge to control,” continued Ryan, his voice remaining calm despite the constrictive bands tightening around his chest. He had been in the same position just a few nights before with a badly beaten baby. He had been unable to save her. “Dr. Edmundson and I are cramming these sterile cotton balls up against the brain tissue to hold pressure against the bleeding sources,” he continued. “This is known as ‘tamponading.’ We’re hoping our anesthesia colleagues can give our patient enough clotting factors to help us eventually get things under control.”
On the other side of the surgical drapes, the anesthesia team worked at forcing volumes of assorted blood products into Olivia’s veins. Unfortunately, every time the lead anesthesiologist leaped from his supply cart back to the operating table, he bumped into it, jouncing the operative field.
“Of course,” commented Ryan, “we’d be most obliging were they to refrain from kicking the table. . .”
Ryan went silent for a period, but the voice in his head kept chattering away. Come on, you little witch, this is ridiculous. Give us a freakin’ break here, will ya? One dead kid’s enough for the week.
Through the ambient noise of anesthesia machinery, positive-pressure air exchange, and muted chatter, he noticed an increase in the rate of electronic beats coming from the heart monitors. Without taking his eyes off the operative field, he asked, “How’s it going over there, guys? We keeping up on her blood?”
“Christ, I hope so,” came the reply from the other side of the drapes. “You guys’re losing a lot up there.”
“Yeah. I know, I know,” replied Ryan, as he sensed a warm, sticky liquid soaking into his socks.
“Ah, crap,” he mumbled as he shuffled his feet into another position. He looked up at the students for a moment, blinding them with his fiber-optic headlight. “So, guys, we use special drapes for this sort of operation. They have an attached plastic bag and suction system that’s supposed to whisk away all the icky stuff like irrigation, blood, pus, spinal fluid, bits of brain and the like. As always seems to be the case, though, much of said stuff must have skirted the bag and run down the drapes into our shoes. Or at least my shoes. How about yours, Eric?”
“You bet, sir!” replied Eric, as he too shifted his feet.
Ryan went silent again as he and Eric continued their minuet of removing supersaturated cotton balls from the crater in Olivia’s brain and replacing them with fluffy dry ones. God, my eyes are on fire, he thought. I bet I haven’t blinked since we started the case. He deliberately opened and closed them several times, refocused, and went back to work. After what felt like several days, the rapidity of cotton-ball replacement began to slow. The scarlet pool diminished in depth. And soon, upon the removal of spent cotton, instead of a raging torrent, they were greeted by an anemic trickle.
“Much better,” remarked Ryan, as he began to breathe again. “Not good enough yet, but better. The factors seem to be taking hold. We may get out of this little girl’s head after all.”
Within another half hour, Ryan and Eric had the bleeding completely stopped.
“Hey, Joan,” said Ryan, as he lined the cavity with antibleeding materials, “Do me a favor and call out to the family. Tell them, if you would, that we’re closing, and that I’ll be out to talk with them as soon as we’re done.” He glanced up at the clock. Shoot, he thought. The kids are in bed. So much for carving pumpkins. I wonder if they went ahead without me.
“How do you think she’ll do, Dr. Brenan?” asked one of the students, interrupting Ryan’s musing.
“Hard to know. Kids’ brains are unpredictable. Anything and everything’s possible. She might be brain dea—” Ryan choked up for a moment, thinking about the baby from earlier in the week. “Or, she might be left in coma. Or, if we got the pressure off her brain in time, she could come right around. But even if that’s the case, she might be paralyzed on her left side. We really won’t know until we see what she does.”
Soon, Ryan was entering the pediatric intensive care waiting room, scrubs soaked with sweat, mask hanging from his neck. Stuffed into the small airless space were twenty-five to thirty terror-stricken people. Mom, who he had yet to meet, was immediately identifiable. There didn’t appear to be a dad.
“Ms. Spencer?” he asked.
“Yes,” replied the woman looking so fragile she might shatter.
“I’m Ryan Brenan, the neurosurgeon caring for Olivia. I’m sorry we haven’t met yet, but we had to take Olivia straight to surgery.”
“How’s my baby, Doctor?” asked Ms. Spencer, eyes nearly swollen shut from continuous crying.
“We don’t know yet, Ms. Spencer. She was in big trouble when she got here. But the surgery went as well as we could hope for. We’re waiting to see how she responds.”
Tears were streaming down Ms. Spencer’s face. “When will we know?”
“It could be very soon, or it could drag out. I promise you, though, we will keep you informed every step of the way.”
Ms. Spencer collapsed around Ryan. An older couple, probably grandparents, joined in, half hugging Ms. Spencer, half clinging to Ryan as if he were a life preserver thrown into a raging sea. If there was an elixir that fueled Ryan in his efforts, it was this. The humanity of it. The crystalline purity of it. The ripping away of all pretenses and social contrivances. Right down to the bare bones. Right down to the heart. Where a primal connection was forged, a communion of souls. They continued to hug him, raining their unbridled gratitude upon him. Not for any miracle—the outcome was too much in doubt—but for the effort. For doing his best. For being a pillar of strength, of calm, of competent order, in a tempest of mayhem. He never felt more like a doctor than in moments like these.
Ms. Spencer and the grandparents eventually released their grips and began to ask questions—mostly technical in nature. What did he find? What did he have to do? In how bad a shape was her brain? What were the next steps? And so forth. Time stood still, yet time evaporated. In the middle of it all, Eric stepped into the room. He put his hand on Ryan’s shoulder and spoke in a hushed tone.
“Uh, Dr. Brenan, she’s waking up. Moving all extremities . . .”
The room broke open with light, and sighs, and tears of relief. Again, Ryan was engulfed in suffocating hugs. This time, in addition to gratitude, there was love. Immediate, unrestrained, everlasting love. After several minutes, he broke free and took his leave, heading straight for Olivia’s bedside. He found her to be in good shape. He sat down nearby, released a heavy sigh, and dictated an operative note.
When he hung up the phone, he considered heading straight home in the hopes of getting some sleep, but instead, went about checking on some of his sickest patients. They were scattered among five of the medical center’s twelve ICUs. On finishing, he met up with Eric and tagged along for a couple of ER consultations: a young man with a broken neck, and an older woman with a small, deep brain hemorrhage—neither requiring surgery. He then felt compelled to pay one more visit to Olivia. Despite a black eye on the operative side, she looked great. It was a nice punctuation to the night’s work, and he headed out of the hospital, smiling.
By the time he pulled into his driveway, it was very late. All lights in the house were out. It was a dark corner of the universe, and the streetlights on Avenue G were well obscured by large oak trees still jealously clinging to their orange-yellow leaves. Fall had definitely made its appearance, though, and he sat in the jeep for a few moments to savor its crisp, spicy air. Suddenly, his heart jumped. His head reflexively jerked toward the side porch. Something there had moved.
“What the hell was that?” he said to the empty seat beside him.
He had only caught a glimpse out of the corner of his eye. He would have sworn it was a person, a woman, but it—she—had disappeared before he could be sure. He grabbed a flashlight out of the glove compartment, eased out of the jeep, and probed the trilling darkness. Nothing. No one hiding behind a tree or slinking away down Avenue G. He turned his head and listened with all his might. Nothing again. No snapping of twigs or retreating footfalls tucked in among the calls of treefrogs and katydids. He made one further sweep with the flashlight, shrugged his shoulders, and headed for the door. But then stopped. Shoot. What if it was some local delinquent looking to score some cash or opioids. Jesus, with Kelly and the girls asleep upstairs? Perhaps he should take a better look around.
He wandered about the property, shining the flashlight in every potential hiding spot: around the various collections of trees, through the many bushes, in the old icehouse and outhouse, and finally, in the barn. There, he tried the light switches without success. The fuse must have blown again. He stumbled through the bottom floor, then climbed the stairs into the loft and flashed his light on the discarded family goods lying about. Goods that in daylight would offer no threat whatsoever, but in the darkness seemed full of menace. The hairs on the back of his neck stood on end and he shivered. His hands began to shake. Jesus, Ryan. What’s your problem? Chill out, will ya?
He left the barn and strode into the house in as manly a manner as he could affect, but his pounding heart betrayed his growing anxiety. Sheesh, he thought. How easy a shot of Jameson’s would go down right now. But he was still on call. And yet, why not? He was sure some did it. Sneak in a little nip here and there over a weekend like this. And if he did, who would ever know? He wouldn’t skip a beat. But no. He couldn’t do it. What a freaking scandal it would cause if someone found out.
He sighed, opened the refrigerator, and reached for a carton of orange juice. After slugging down several glasses, he entered the front hallway, intent on heading upstairs. But on his way through, he glanced at the front double doors and froze. A dark silhouette was visible through the stained-glass panels. A dark female silhouette. Grabbing an umbrella from a nearby stand, he undid the deadlock and threw himself out onto the porch. Nothing. No one. Lungs heaving, he turned and noted a somewhat anthropomorphic shadow on the doors cast by a moribund birch.
“Ridiculous,” he mumbled. “You’re really spooking the hell out of yourself tonight, aren’t you, Ryan?” Sleep deprivation. That had to be it. He was dog-tired. He hadn’t seen the backs of his eyelids for what now, forty-two hours? Perhaps sleep had momentarily overcome his weary brain and made him see things that weren’t there: things resurrected from the hellscapes of his childhood nightmares; old “friends” who used to visit in the blackest of nights and render him unable to move. He shook his head to clear the memories, closed the doors, and bolted the locks.
Moments later he was upstairs watching his girls sleep. When did he last spend any real time with them? Tuesday? No, he had that meeting in Bellemonte. Monday? Nope, he was still working on that acoustic neuroma. Holy hell, has it been a week? It couldn’t be. But it could. It had been a week, an entire freaking week. God, I hate this.
He made his way down the hallway to his bedroom. After undressing, he crawled up to Kelly, hoping she’d turn and envelop him within a sheltering embrace. But she failed to stir. She always failed to stir. At least they had spent some quality time together on Thursday. Or was it Wednesday?
He rolled onto his back and tried to will himself to sleep. But he was filled with dread. A darkness was gathering around him. And with the darkness, bad things. He shivered as he imagined hearing whispers—the whispers of beings crouching in the closet and under the bed, beings awaiting his surrender of consciousness.
“Ridiculous,” he grumbled, shaking his head.
He sat up, took one last look around the room, then retreated to the safety of his spouse.
