Intensive Therapy Part 24

"He's sedated for now, but in another day or two we'll ease off some and try to get a good neurological exam."

"How long before the skull is reattached?" Martin asked.

"The neurosurgeons are estimating three weeks at the earliest, but I've seen them wait as long as three months. It all depends on how quickly the swelling goes down. Gregory's in very good health, which will help. But there was ma.s.sive swelling, which will take longer to resolve. For now, we'll give him medicine to keep him from moving, which means we have to breathe for him-not only to give him oxygen, but to expand his lungs fully. When the lungs don't fully inflate the lower lobes often collapse, and that can cause pneumonia."

"My G.o.d," Victoria said. "So many complications to deal with."

"We try to be proactive," Dr. Meninas continued. "Dr. Breckenridge did a terrific job. She isolated the artery with one hand and cauterized it with the other, entirely by feel. Imagine the skill and sensitivity it takes to do that with blood gus.h.i.+ng and totally obscuring her view. The biggest risk right now is seizure, which we're treating aggressively with anticonvulsants. Even after the swelling goes down Gregory may not awaken fully for weeks, and even then, he'll regain consciousness slowly. I want you to understand, people with Gregory's degree of trauma don't awaken suddenly, like in the movies. They come out of coma a bit at a time.

"But be prepared, though. When Gregory awakens, he'll likely be weak on the contralateral side, and he'll have contracoup symptoms until the brain heals completely."

Victoria sat up erect. "You're saying he will wake up? Dr. Liddle didn't sound that certain."

"I don't want to give you false hope, Mr. and Mrs. Braun, but as long as we get through the next forty-eight hours and nothing unexpected turns up on the MRI, I really think he'll wake up. What's not knowable is what he'll be like. Only time will tell. But because Gregory's young and was healthy to begin with his nerve cells are resilient. A lot of rewiring will need to happen inside his brain, but therapy will help with that. All of Gregory's senses should be stimulated. Some families read to their children, even when they are in a coma. Others play music. Also, try to provide familiar smells. That's important, too.

"For now, we can get away with intravenous fluids, but until he wakes up we'll have to tube-feed Gregory or else his GI tract will go into starvation mode."

Jonas said, "That's right. The intestinal lining is intricately ridged to absorb nutrients. The ridges flatten if there's nothing to digest. I like what I'm hearing. These doctors have everything covered."

"What's does 'countercoup' mean?" Martin said.

"The word is 'contracoup,'" Jonas said. "Since the brain sits in an enclosed s.p.a.ce, the mini-shock-waves from a blow to the head reverberate back and forth like ripples in a pond. The major damage is to Gregory's left hemisphere, which controls the right side of the body, so that's where he'll be the weakest. But because of the shock-wave effect, he'll have symptoms on the left side, too."

Martin reached for Victoria's arm.

"What about Melinda?" Victoria said.

Dr. Meninas said, "Melinda arrived with a core temperature of seventy-eight degrees, borderline severe hypothermia. Hypothermia slows the heart, but for the time being, she's in a normal sinus rhythm. That could deteriorate into a ventricular arrhythmia at any time until her body warms up."

Jonas jumped in, "That could stop the heart from beating."

"We're up to eighty-seven. Her heart rhythm is being monitored very carefully," Dr. Meninas said. "And we can do prolonged resuscitation if necessary."

"ECMO?" Jonas asked.

"That's right," Dr. Meninas said.

"What's that?" Martin asked.

Dr. Meninas replied, "'Extracorporeal membrane oxygenation.' We have machines that can take over for the heart if necessary. Meanwhile, we'll raise her body temperature slowly by infusing warm fluids."

"How warm?" Jonas said.

"One-hundred seven degrees Fahrenheit. It's as fast as we can go. Melinda's fingers and ears are another matter; we're warming them from the outside. I don't expect any problems as long as her heart behaves well. When Melinda's temperature hits around ninety, she may seem as if she has DTs."

"What's that?" Martin said.

"Delirium tremens," both doctors said simultaneously.

Dr. Meninas went on, "Melinda might look like she's in alcoholic withdrawal; if that happened she might shake uncontrollably and become disoriented. I'm worried that she could become agitated, which is why I want a psychiatric nurse with her. I don't want to sedate her, because tranquilizers might destabilize her brain's temperature regulation center. If we need something, we'll pick the safest medication possible."

"Melinda told her mother she'd agree to getting help," Jonas said, "but who knows what she'll be like when she comes to."

Victoria asked, "When can we see them? I need to see my children."

"I'll make sure it's okay to visit. Family only."

Jonas looked at Dr. Meninas intently.

"Right, you have privileges, Dr. Speller. Let's leave the visiting to your discretion."

Dr. Meninas's pager went off and the overhead alarm sounded. He raced out of the room.

"Wait here," Jonas told Martin and Victoria brusquely. He tore off after Dr. Meninas.

44.

Ah.o.a.rde of doctors and nurses converged on the pediatric ICU like firemen rus.h.i.+ng to a five-alarm blaze. Jonas knew some life-threatening catastrophe had occurred. He hoped to G.o.d it wasn't Melinda's heart or Gregory having a seizure. Jonas chased a ponytailed intern through the swinging doors. The doctors and nurses crowded into a corner room while a single clerk manned the telephones at the central nurse's station.

"What's going on?" the intern said to an intensive care fellow.

"It's the girl with bacterial meningitis we admitted this morning," he said. "The bottom just dropped out of her blood pressure. Septic shock. The only thing to do now is push fluids, corticosteroids, and vasopressors. And hope."

Rea.s.sured the crisis didn't involve Gregory or Melinda, Jonas introduced himself to the unit clerk at the nurse's station and then went to Melinda's room. She was hooked to a maze of wires, and a black and green monitor displayed her heart rate, blood pressure, and body temperature, which had climbed to eighty-nine degrees. She had begun to s.h.i.+ver. The psychiatric nurse noted that Melinda was floating in and out of consciousness but hadn't awakened fully.

Looking at Melinda's face was like going back in time. She looked so much like Victoria had when she was angry or frightened. Jonas briefed the nurse about Melinda then moved on to her brother's room.

Gregory's head was bandaged and connected to a drain by a plastic tube. Purple and amber stains on his temples indicated the spots where the scalp had been scrubbed before the operation. Ribbed, plastic tubes connected his endotracheal tube to a breathing machine, while his expression-angelic yet resolute-looked as though he was determined to recover.

Gregory looked exactly like Victoria had described him, right down to the peach fuzz. He had Martin's forehead and chin, but everything in between was his mother's.

While Jonas was studying Gregory's face, a fair-skinned woman in a white lab coat entered. A penlight and a reflex hammer protruded from her pockets. Even before he could read the red embroidery above her vest pocket, Jonas knew she was Dr. Anna Breckenridge come to check on Gregory one last time before going to bed.

Jonas felt an immediate sense of connectedness, as if he knew her from a previous life. After introducing himself, he said, "You're very much like I imagined. You remind me of a woman psychiatrist who trained with us at Mount Sinai. On September 11, 2001, she was visiting her husband, who worked for Cantor Fitzgerald at the World Trade Center. No one above the 85th floor survived. I'd like to think some of her lives on."

"I was a PG-five on September 11th," Dr. Breckenridge said. "They were ready to send us to New York to help with the head trauma cases. But there weren't any survivors, so we stayed here."

Jonas recognized the Maryland accent. "Is that Baltimore I hear?"

"Hopkins undergraduate and medical school; 1991 and 1996."

"Penn undergraduate, 1974. Hopkins med school, 1978," Jonas said. "For all we know we sat in the same seats at grand rounds on Sat.u.r.days."

"Could well be," Dr. Breckenridge said as she checked Gregory's pulse, then lifted his eyelids in succession and s.h.i.+ned her light at them. She smiled. "It's better now. The left pupil was practically fixed when I saw him in the ER. Here," she handed Jonas the penlight. "Take a look."

"He has his mother's eyes," Jonas said as he examined Gregory. "Word has it that you did a great job tonight."

"I hear you were pretty busy, yourself," she said.

"How did you know?"

"Philadelphia's really a small town. Everyone knows everybody's business."

Jonas laughed. "So I've heard."

"Dr. Liddle and I are rounding at 6:30 AM. In case he doesn't see you, he said to tell you Jock's youngest is thinking about medical school. He wants to be a psychiatrist."

"That's wonderful. If I miss him, please tell Dr. Liddle that I'm happy it all turned out well." Jonas looked at Dr. Breckenridge with admiration, then turned back to Gregory. "Amazing organ, isn't it; the brain?" Jonas said. "We both touch it. You with your hands and instruments. Me with words. I thought about going into neurosurgery, but I knew I couldn't survive the training. Put a scalpel in my hands when I'm tired and I'm a danger to society."

"Do you remember the first time you saved someone's life?" Dr. Breckenridge asked.

Jonas nodded. "Of course."

"What happened?"

"I had just gone into practice. A woman with postpartum depression called to say good-bye. I was treating her with medication and psychotherapy and it looked like she was perking up. I usually let calls ring through to my answering service, but I was between sessions so I picked up. She sounded strange, so I asked what was happening. She said she wanted to thank me for trying.

"'Trying?' That sounded strange so I asked what was happening that moment. She said she had just lost her temper and slapped one of her toddlers. She hadn't slept for two nights because her ten-week-old had developed colic. She said her children would be better off without her. She was holding the phone with one hand; in the other she had her pill bottle-before Prozac was widely prescribed we used tricyclics. She had already taken ten and was about to swallow the rest. Fortunately her husband was home. I had him take her to the hospital immediately. By the time they got to the ER she was in a coma. A few minutes later she went into cardiac arrest. They started chest compressions, gave her IV bicarbonate and sympathomimetics; then they shocked her back into sinus rhythm. She survived. After three weeks on the psychiatry ward she went home. We got her a doula and counseled the couple. Today she's fine. Three children under three-can you imagine what her death would have done to that family?"

"Torn them apart, no doubt," Dr. Breckenridge said.

"Do you think Gregory will make it?"

"I think so," she said. "It was good that we got to him early. Your heads-up saved us precious time. The first forty-eight hours will tell. As long as he doesn't develop intractable seizures he should live. What he'll be like is another story.

"I won't forget this night, will I?" she said.

"How did it feel?" Jonas asked.

"I was surprisingly calm. Even though I'd been in ORs for years, when they shut the doors tonight, I felt I had entered another world. I knew exactly what to do."

Jonas smiled. "I played violin. I used to feel that way when I had a big solo. I couldn't wait for my turn."

Dr. Breckenridge said, "I learned to sculpt in elementary school. I made my first model of the brain out of Play-Doh when I was in second grade."

Jonas smiled at her. "It's late, Dr. Breckenridge. I'll let you get some rest. Thank you for giving Gregory a chance."

She hesitated. "Just so you know-it was a b.l.o.o.d.y mess in there. The bone fragment nicked an artery. The clot and the swelling were as bad as anything I've seen. If he had been anywhere else, he wouldn't have had a chance. Still, it could be a very long vigil. And even then, who knows what there'll be on the other end."

"Good luck with your future, Dr. Breckenridge. You know, cracked skulls aren't going away anytime soon in the Big Apple. We could always use a hand."

"Call me Anna. Say, did anyone ever tell you you're easy to talk to?"

Jonas grinned and produced his card. "Pleased to meet you, Anna." He took a step back and smiled at her. "Jonas Speller. Call anytime."

Anna's eyes welled up. "Thanks," she said. "I see some awful stuff. It would be good to have someone to talk about it with."

Jonas looked into the woman's eyes, shook her hand gratefully, and then departed.

45.

Jonas was returning to Martin and Victoria when Dr. Meninas caught up with him. "Do you have a moment?" he asked.

"Sure," Jonas managed feebly, his vision blurring from fatigue.

"Word has it that you saved Melinda's life by helping her mother keep her from jumping off the Strawberry Mansion Bridge."

"Where did you hear that?"

"The neurosurgical attending pieced the story together from the police. How does it feel to be a hero?"

"I don't feel much of anything except the overwhelming need to sleep."

"I won't keep you long, then." Dr. Meninas said. "Lately, I've been thinking about psychiatry, but my peers say child psychiatry is a waste of a medical education; that I'll spend my life writing Ritalin prescriptions and battling school boards to get kids into therapeutic schools. They say I should go into pediatric oncology if I want to save people's lives."

"That's absurd!" Jonas said. "Look at tonight. One child with uncontrolled mania winds up on death's doorstep after nearly killing another. Tell me psychiatry's not about life and death."

"Just so you know, a police inspector named Ruby Pale is here someplace."

"If it wasn't for her, we wouldn't have found Melinda."

"Also, a Dr. Milroy called. He is ...?"

"Melinda's psychiatrist. He's on his way in. We want him to meet Melinda as soon as he can. He's terrific with teenagers. Her transfer to the Pennsylvania Hospital psych unit will be a lot smoother if she feels good about her doctor."

"I can see you've done time in the ICU," Dr. Meninas said.

"My first job in New York City was running the consultation-liaison service at Mount Sinai. That was before Prozac, when patients died all the time from antidepressant overdoses. What a horrible period!"

"I know about those days," Dr. Meninas said. "My Uncle Umberto was a revered pediatrician in Brazil. Whenever he lost a patient, he took to bed for days. His psychoa.n.a.lyst got the family doctor to prescribe an antidepressant. My uncle h.o.a.rded the pills and then took an overdose after his best friend's child died of leukemia. Umberto barely survived."

"How's he doing now?"