“Thanks, everyone,” Ian said, taking the form, folding it, and placing it in his white coat pocket as he stood up.
The staff began chatting as Janel’s nurse wheeled him out of the room. Others filed out after him.
I sat frozen in my seat, trying to make sense of what had just happened. Why had Janel shaken his head no moments before? Had it been to signal that he didn’t want to sign or just that he couldn’t sign? And the X . . . ?
I saw Ian leaving the room and jumped up from my chair to catch up to him in the hallway.
“Thanks so much for taking this on,” I said, looking up at him.
“Thanks for involving me,” he replied. “It’s a huge case.” He looked above me for a moment, then back at me. “We’ll proceed with an infratentorial supracerebellar approach to get at the fourth ventricular component,” he explained, putting one palm on top of the other and opening them at the wrist with his fingertips touching to demonstrate the space between the roof of tissue over the cerebellum (the tentorium) and the top of the cerebellum itself. He became more animated as he described the details of the operation. “I’m hoping that the upper components of the tumor will then fall into the field so we can debulk those as well.” He moved his loosely cupped right hand downward and toward himself as if gently pulling an apple off a tree. “But he may need a second approach in a separate surgery.”
I wondered what he was seeing in his mind as he described all of this. He had delayed surgery from the date we had initially planned, saying he needed a few days to strategize. How did the two-dimensional black-and-white MRI pictures translate into vivid three-dimensional full-color maps in his mind? And how did he use those maps to imagine his way to and through some of the most delicate areas of the brain in what would likely be a daylong surgery, or now perhaps two daylong surgeries?
“I’ll keep you posted on everything,” he said. “It’s a fascinating case. Thanks again for involving me.”
“Thank you,” I said. We shook hands and then he walked past me down the hall with determined, swift, large strides—a surgeon’s gait.
I went to the elevators and pushed the DOWN button. I replayed the meeting in my mind as I waited.
An X!? I shook my head, took a deep breath, puffed out my cheeks, and blew the air out in a long sigh. It was a decompression habit I had picked up sometime during my residency.
The elevator doors opened. I entered and pressed 1 for the lobby. I was alone. The doors closed, and the elevator began its slow descent.
Of course, from the medical perspective, Janel needed the surgery. Nobody would argue that. The HUM mental health team report was clear with respect to his understanding, his wishes, and his desire to have Wilner speak on his behalf. And Wilner had told us that Janel and his family would want whatever he needed to try to treat his tumor, acknowledging the risks. But Janel had made no outward sign of any of this to anyone since his arrival in Boston. He hadn’t really made any outward signs at all except one smile when a young woman put on a romantic film, and then this X. An X over the signature line to his surgical consent form!
But Hermide had said it was just him signing his name, as simple as that.
As the elevator descended, I noticed I was still shaking my head. “X marks the spot,” I murmured out loud to nobody and tried to force a laugh.
Except here the X meant, “Yes, you may slice open the back of my head and operate on my brain. I may have a stroke. I may have a seizure. I may be more disabled than I am now. I may even die. I understand. Go ahead.”
At least that’s how we interpreted it. The elevator doors opened, and I stepped out into the bright, bustling hospital lobby.
I hoped that was what he had meant.
“Si Bondye vle,” he might have added. If God wants.
8
Before dawn, Janel was wheeled on a gurney through swinging double doors into the operating room.
He was put under by an anesthesiologist, who then passed various lines, catheters, and tubes into his arteries, veins, lungs, and bladder to support and monitor him during the surgery.
His head was shaved and scrubbed with a dark brown iodine solution by the operating room nurses.
His limp, sedated body was lifted by the team into a seated position with his face down and arms out to the sides so Ian could approach Janel’s tumor from the back of his head. Tethered by the lines and tubes coming out of his mouth, arms, and penis, he looked as if he were descending toward the floor by parachute.
His shaven head was fixed into position with a Mayfield three-point head holder—a vice with two points on one side and one on the other—to ensure there would be no movement while Ian performed a procedure requiring millimeter precision. As the vice was tightened through Janel’s scalp into his skull, tiny rivulets of blood emerged around the sharp points and trickled down a few inches to his ears.
The operating room team then unfolded a tablecloth-size light blue sterile drape and laid it gently over Janel’s entire body. The paper-thin drape had a square plastic window, which they positioned over the back of his head.
Ian entered backward through the swinging doors of the operating room, his arms in front of him with his elbows bent. Droplets of water dripped from his hands, which he had spent the last several minutes washing with sterilizing soap. He was dressed in blue scrubs, a blue bouffant cap (a wispy hairnet) covering his head, a blue surgical mask covering his nose and mouth, and blue paper shoe covers over his sneakers. Only his eyes and arms were exposed.
A masked nurse passed Ian a blue sterile towel, and he dried his hands and forearms with it. The nurse then shook open a blue sterile paper gown and held it up. Ian passed his arms into it but kept his hands hidden inside the sleeves, the white cuffs covering his hands like floppy mittens. He grabbed a cardboard tag from the front of the gown with his mittened hand, handed the tag to the nurse, and then quickly pirouetted so she could tie the gown closed in the back. Ian then slid tan sterile surgical gloves over the cuffs of the gown and protruded his hands from the sleeves into the gloves so that the gloves made a tight seal over the cuffs.
The head nurse in the operating room paused for a time-out, a standard, designated pause to make sure the right surgery was being performed on the right patient. Everyone confirmed the patient’s name (Janel) and the operation to be performed (suboccipital craniotomy for tumor resection).
Ian positioned the bright operating room light over the square plastic window of the blue drape. The operating room nurse passed him a scalpel. Along the same line he had traced with his finger days before, Ian made a vertical incision from Janel’s occiput to midway down his neck. Bright red blood oozed around the wake of the scalpel’s path, and Ian’s assisting resident suctioned it away with a straw-size vacuum to clear the operating field. Together they gently retracted the scalp and the skin of the back of the neck to give access to the muscles beneath, which they then teased apart to bring the skull into view.
Using an electric drill, Ian bored four holes into the skull, each creating a sawdust-like mound that his assisting resident dampened with sterile water and wiped away with gauze. The four holes outlined a Post-it-size square. Ian connected the dots with a small saw and gently lifted out the swatch of bone, revealing the blood-streaked tan dura mater beneath. Meaning “tough mother” in Latin, the dura mater is a thick protective outer covering of the brain.