08/21/16
Crucible

The Crucible

Enter the mind of a brain surgeon!

It’s 1951 & this is a test.

Trevor Mott is a brain surgeon. Jimmy P. is eight years old and plays baseball. Today, the two of them will come together. One will be taken to the very edge of endurance.

The other will go even further.

The Crucible is a far surpassing tale of surgical suspense available on kindle today. Just 99 cents.

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The Crucible
A short story by Edison McDaniels, MD

October 3rd, 1951 

“The Giants win the pennant! The Giants win the pennant! The Giants win the pennant!”  The announcer’s exuberance burst from the radio with the intensity of an artery geysering blood across the room. You couldn’t help but notice it. “The Giants win the pennant! The Giants win the pennant! Bobby Thompson hits into the lower deck of the left…” 

“Turn that damn thing off,” Mott said, putting down the loop cautery and motioning with his arm toward the radio. Jesus Christ, he said to himself, thinking of the damn Brooklyn Dodgers. How could the bums have a virtual lock on first, thirteen and a half games up with just forty-four to play, a month before the season ended, and still manage to rise to that particular level of mediocrity that is second place? It sickened him. 

Second place was an untenable position to Trevor Mott. As a brain surgeon, it represented a compromise he couldn’t afford inside someone’s head, an intolerable concession that could only bring pain or suffering at best, death or invalidism at worst. Of course, it wasn’t he that would suffer in such a case, it was his patients. And suffer they did he thought, for however untenable second place might be in his own mind, it was a plight which visited his – any neurosurgeon’s – operating room with a certain morbid regularity. 

An image of the neurosurgical ward two floors above suddenly flashed into Mott’s head. It was a large open rectangular room with pale cream walls and dingy gray floor tiles, all of it scuffed by too many years of use. Tall windows lined the walls on each side of the room’s long axis and the early morning sun spilled in from one side, lending the room a soothing but unbalanced look; Mott saw tiny specks of dust suspended in the golden light.

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07/20/16

Enza

A Bird Named Enza

A Short Story by Edison McDaniels, MD | surgeonwriter.com
Keywords: fiction, influenza, inspiration

I had a little bird,
Its name was Enza.
I opened the window,
And in flew Enza.

I remember how the words drifted in through the open window, along with the dust motes shimmering in the bright sunlight. The lace curtains hung limp and impotent, the air absolutely still. A waist high table occupied the far corner opposite the bed. Upon it a clean white linen cloth, a metal pitcher of water, and a porcelain basin. I remember how the basin’s edge had a chip out of it the size of a two-bit piece. I remember every detail of that room, for I had in that one terrible week no better occupation than its constant inspection.

The bed itself was a plain enough thing: a sagging mattress set atop cinder blocks, no ornamentation at all. My parents were frugal people, then and forever after. I don’t think it had anything to do with the deaths of my sisters. I never had more than three pairs of pants, or more than twice that many shirts. The walls of my room were barren. My only extravagance was a few peacock feathers I’d plucked from the trash on the way to school. I didn’t know them to be bad luck at the time.

We were clean folks. Cleanliness is next to Godliness my mother used to say. And so laying in that bed all those years ago, what stands out is how my mother kept clean sheets under me all the time I was sick. Given how things turned out, I can’t imagine how she did it. She or Grannie Mae, my father’s mother, changed my sheets once or twice a day.

Yessir, I remember that week like it was yesterday. Nineteen and eighteen it was, ninety-two years ago. I was ten, middle of five kids, the only boy. It was the flu, of course. Influenza. In flew Enza.

No school. They’d all been closed on account of the panic. You couldn’t go anywhere that people didn’t look at you cross-eyed if you so much as hiccoughed. Every one wore a mask. People turned blue and dropped dead in the street. I saw it happen three times. A cart used to come down the road every morning, collecting bodies. I saw that too.

Then I got sick. I lay in my bed and didn’t leave my room for a week. Nothing to do but lay and stare at the ceiling. Couldn’t see but next door brick out the window. Sometimes I practiced sleeping. Mostly I tossed and turned a lot. If the sun was just right, usually about midday this was, I made little shadow animals on the wall with my fingers. A dog, a bird, whatever. Anything to pass the time. Once, I heard a doctor tell my mother to get me on a waiting list for a casket. I never saw that doctor again. I wanted Grannie Mae or mother to keep me company, but they were too busy. I’ll get to that.

Under my window was a little dirt playground. My sisters, the four of them, along with a few neighbor girls, skipped rope there incessantly. The whipping sound of that rope as their thin arms turned it again and again, followed immediately and inevitably by the thump thump of booted feet, was my constant companion that week, as was their chanting and singing. As always, they rose and fell and made up a sing song of different ditties to suit the moment. But that terrible Fall, there was mostly only one ditty:

I had a little bird,
Its name was Enza.
I opened the window,
And in flew Enza.

I remember the sing song rhythm of their collected voices, sung with a choir gusto only little girls of a certain age can muster. Oh how they clapped their hands! And at the end of each line, winded, they barely got the last word out before they gasped in unison and started anew the next. They did this over and over, until it was positively etched in my mind. On my sick bed, with nothing to do for hours at a time save listen to my own tortured breathing, I should have gone mad without my sisters outside my window.

I pictured them in the yard, in their long, white, pinafore dresses, jumping in the dirt alongside the unpainted picket fence. The branches of the twin oaks met and intermingled over their heads. I even pictured the sheets on the clothesline behind them.

What I didn’t picture, or even hear until the last day, was how the voices dropped away. There one day, gone the next. And never to return.After that, the voices I heard were those of my mother and Grannie Mae sobbing in the hall outside my room.

After that week the shine went out of everything. But over the years whenever I have grown the least fed up or restless, my sisters come back to me in their collective chorus, singing about a bird named Enza.

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05/12/16
obdurate

The Brain is Obdurate, Part II

The Brain is Obdurate, Part II of 2

A short but thrilling tale of surgical adventure by Edison McDaniels, MD | surgeonwriter.com | fiction

obdurate

†††

Read Part I here.

† The Fourth Minute †

The patient, his brain exposed to the elements, lay under the sterile drapes, oblivious to the danger ahead, to the final ten minutes of tumor removal.

The surgeon studied the scene through the microscope, learning its intricacies. He had one chance to get this right. Everything the mechanic was—and everything he would ever become—depended on it.

But it was more than that too. The surgeon held to the ancient belief we are, each and every one of us, the sum of all those we touch. These touches are both big and little, some having more impact than others but all contributing to the whole. A mistake at this point, even a small one, and the mechanic would likely never consciously touch another human being again. This, of course, would change the course of history, since we all touch, are touched, by thousands of others in a lifetime.

He knew all of this and dwelled on none of it, of course. Sitting at the microscope and looking inches deep into the mechanic’s head—the mechanic’s brain—he had no time for such introspections. No time even for hesitation. Years of experience informed his every move, had taught him to be decisive.

“Ten,” the surgeon said, holding his hand out to the scrub.

She passed another penfield dissector to him, this one with a small, flat beveled edge to it. He turned to his assist. “Whatever happens, you just keep sucking. Visualization is everything and I can’t see a goddamn thing if this field fills with blood. Don’t move the goddamn sucker around, don’t try to improve my view. Just suck. Got it?”

The assist nodded. He blinked an eye repeatedly, like a man with a tick that had suddenly acted up.

The surgeon turned to the anesthesiologist. “Let me know if anything changes up there.”

“Will do. Rock stable just now.”

The only sound in the room was the rasp of the bellows and the ping-ping-ping of the EKG.

The surgeon took up his own sucker in his off hand, prodding it against the tumor, feeling the pulsations of the nearby artery. He prodded gently at first, and then with greater force. As he did this, the tumor began to come away from the Basilar artery.

Delicate, tedious work. The wall of the Basilar artery was muscular, but still thin enough to see the blood swirling past with every contraction of the mechanic’s heart. The surgeon’s own heart seemed to work overtime with the work, and, like a man digging ditches at the roadside, his own chest heaved with every breath.

His hands were rock steady though.

He stopped periodically to suck away pooling spinal fluid. An occasional wisp of blood clouded the otherwise clear exposure, turning the watery fluid a red so thin he could have read newsprint through it. The tumor, looking ever more dusky, came away in fits and starts as if not wanting to give itself up. But the surgeon was persistent.

He had pulled half of the remaining tumor away from the artery when the ping-ping-ping of the EKG tracing slowed down. An instant later, the pings stopped altogether.

† The Fifth Minute †

“He’s bradying down—asystolic now,” the anesthesiologist hollered over the drapes.

The surgeon relaxed his pull on the tumor. It settled back against the Basilar artery, which in turn settled back against the brain.

Behind his mask, the surgeon pushed a wad of spit around his mouth.

The ping-ping-ping resumed, slowly at first, then with greater gusto. Ten, Twenty, Twenty-five beats per minute.

The anesthesiologist put his clipboard aside and reached for a prepared vial on the countertop. He injected it into the IV tubing. “Atropine going in.”

Thirty-five, Fifty, Sixty, Seventy-five beats per minute. The up-down squiggles on the EKG display sped up. “He’s back.”

The surgeon waited for the atropine to circulate fully, a long minute or more, then replaced both the dissector and the sucker against the tumor. The monitor hiccoughed, then became regular again.

The surgeon and the assist looked through the microscope. The usual small amount of spinal fluid bubbled into view, enough to keep things moist. A good thing.

Still no bleeding, he thought.

The tumor, which had been pink going on red when they started the day, was now decidedly blue. Deprived of blood, the devil had gone dusky. The thing was dying.

“Almost there,” the assist said.

The surgeon didn’t answer. Almost don’t count for shit, he thought.

† The Sixth Minute †

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The surgeon bent to the microscope, his vigor and determination clear. “Let’s get this damn thing out and all go home,” he said.

Again he tugged on the tumor, this time using the sucker to lift the growth while he looked for trappings between it and the artery using the dissector. The heart rate ping-ping-pinged steady at eighty beats per minute.

“Microscissors.”

He cut away at the last piece of tumor and of a sudden the operative field bloomed red. Blood flooded the mechanic’s open head in the instant before the assist reacted with his own sucker. The blood rose like water over a cofferdam.

“Suck here now,” the surgeon said. His voice was the definition of calmness. “Right here, right now.”

He took up a cotton paddy and placed it under his own sucker, then submerged the sucker tip in the bloody lake. The move was more precise than it appeared.

“More paddies. I need cotton paddies.”

He began to insert them one at a time into the depths of the wound, working around all of the delicate nerves and vessels passing through the mechanic’s CP angle. He did this by rote memory, using the mental map he had been constructing so meticulously all day. He moved with purpose, without wasted motion in even the tiniest action. He moved too with precision.

The flood continued unabated.

“Third sucker.”

On the instant, the scrub rolled back one of the covering blue towels and passed the third sucker to the assist, who now held one in each hand. He placed them into the head, the surgeon all the while directing him. The blood diminished and the tumor floated into view.

The surgeon placed one last cotton paddy over what he envisaged to be the source of the bleeding. It trickled and he adjusted his pressure slightly. The bleeding stopped.

He picked up the final nubbin of tumor, the size of his little finger tip, with his other hand. “The devil’s out.” He gave it to the scrub. “How’s it going up there?” he asked the folks at the bellows.

† The Seventh, Eighth, & Ninth Minutes †

“Shit,” the doctor said. “I got 60 over palp for BP.” He had his hand of the plastic IV bag, squeezing saline into the mechanic’s arm as fast as it would go. “Heart’s racing at 130. You about done there?”

“Done.”

“He damn near bottomed out,” the anesthesiologist said.

“But he didn’t,” the surgeon said. He sat on his stool and waited. He had time now. They all had time now.

The mechanic as well. He had all the time in the world.

† The Tenth Minute †

The surgeon waited two minutes by the elementary school clock, watching the sweep of the second hand jump through the seconds.

Experience—no substitute for it—had whispered to him yet again. The worst is over.

He had seen the color of the blood coming out of the mechanic’s head, dark red, and had known that whatever was bleeding it was not the Basilar artery. The Basilar artery would have bled bright red—and stopping it would have proved a fruitless gesture.

It would have stopped eventually of course, but only because all bleeding stops eventually.

A Curious Thing

The curious thing about working inside someone’s head is this: the longer you work, the deeper you get. And the deeper you get, the harder it becomes. This is because while you might be working through a hole the size of a plum on the outside, that hole cones down to a grape or even a pea somewhere deep—sometimes very deep—in the distant hills and valleys of the brain. That, of course, is where the fun really begins, because you have to be at your best when you are most tired.

And remember, the brain is obdurate. It doesn’t shift easily and doesn’t like to be moved about. The cost of this is visualization. Despite the light afforded by the operating microscope (one of the greatest advances in brain surgery in the past fifty years), one is always fighting to see into the crevices and around the many rocks and boulders strewn about.

And one false move in one of those crevices, places never meant to see the light of the surgeon’s microscope—packed with bundles of nerves, arteries, and veins—and the patient might wake up devastated.

Or might never wake at all.

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05/5/16
obdurate

The Brain is Obdurate

The Brain is Obdurate

A short but thrilling tale of surgical adventure by Edison McDaniels, MD | surgeonwriter.com | fiction

obdurate

† Time Slows †

A bead of sweat rolled into the surgeon’s eye and broke his concentration. He blinked at the sudden stinging intrusion, but didn’t wipe it away.

The surgeon pushed back from the microscope and sighed deeply. He tilted his head, feeling the reluctance in his neck, and gazed at the clock on the far wall. The simplest of clocks, the elementary school version with big, block numbers. The sweeping second-hand jumped ahead with each tick. He stared through a teary film as it tick-tocked the seconds away. He looked to the circulator, her attention was on the clock as well. After what seemed a long moment, she turned his way and they locked eyes above their masks. She stepped forward, towel in hand, and wiped the accumulated sweat from his brow.

He craned his neck, working his sore muscles. He remained ever fascinated at how sore these cases made him. Hours under the microscope, hands and fingers moving in small arcs, his arms seemingly not at all, and when it was over the stiffness would be worse than his high school days after football practice. He was still a year shy of fifty, but that was old enough he supposed.

Time slows for no one, and ages everyone.

The scrub stood beside the surgeon, fingering a Penfield dissector in her off hand. She worked her jaw, as if chewing gum. Her gaze went to the clock as well, then to the assistant across the table. The assist ignored her, his gaze moving back and forth between the clock and the exposed brain before him. Sweat darkened the front of his surgical cap, but nobody wiped his brow. Blood stained the front of his gown.

The surgeon looked across the drapes to the anesthesiologist standing beside the churning ventilator. A bellows the size of a small loaf of bread moved up and down at one end of the machine. It rasped as it counted the breaths. The doctor held a clipboard in one hand. He turned a knob on the breathing machine and his attention moved to the EKG monitor, to the blip squiggling its familiar pattern across the screen. With each up-down stroke, the unit uttered a stark tone—ping-ping-ping…ping-ping-ping… He jotted a note on his clipboard and looked up at the clock.

Fourteen minutes past two of a Wednesday afternoon.

† The First Minute †

“That’s a full fifteen minutes then,” the doctor behind the drapes said. “BP’s holding. Pulse looks good.”

The surgeon nodded. “Okay then. We best to get this thing done.” He made eyes at the circulator. Her eyebrows went up subtly and she nodded as if in agreement.

The surgeon turned back to the field, where a square of blue towels surrounded a hole several inches in diameter, large enough to sink a fair sized plum through. The edges of the towels were dyed with black, crusted blood. Within the hole, visible to anyone who cared to look, the pinkish-gray brain pulsated in time with the ping-ping-ping of the pulse tracing.

The surgeon peered through the microscope. The various peaks and valleys of the brain came into focus, appearing on a grand scale as if he had a bird’s eye view on an alien, canyoned world. It seemed only natural how the rivers in such a land ran hard and fast with the reddish ochre of blood. He blinked a few times, adjusting his eyes to the intensity of the light. He put a hand out, pinching his fingers to and fro with apparent impatience. “Bipolar.”

The scrub placed the cauterizing forceps between his outstretched fingers.

“Suction,” the surgeon said.

The assist pushed a thin, metal straw into view under the scope. The diameter of a wet spaghetti noodle, the blunt tip could still do damage if yielded imprecisely. The assist pressed a small cotton paddy into place beneath the sucker tip and the slowly accumulating pool of red disappeared up the sucker. It passed up and out of the head, into an attached clear plastic tube, where it crawled toward a canister against the wall.

The brain on the table belonged to a middle-aged mechanic and a minute passed as the two—the surgeon and the assist—jockeyed back into position inside the mechanic’s head. There followed a curious ballet in which they marched along a natural turn of the skull, then squeezed down a corridor between a bony wall on one side and the cerebellum—the ‘small brain’ at the back of the head—on the other. This brought them to the CP angle, a no man’s land in neurosurgical parlance. They only belonged there because they had to be there. Because it was there.

Because the tumor was there.

† The Second Minute †

The surgeon had worked four hours getting to this point, though only later would he realize how much time had passed. Just now, time seemed to labor, with seconds stretching into minutes. He had made only one mistake so far—only one he was aware of anyway—and not obviously a costly one in neurosurgical terms. Obviously was the operative word. In brain surgery, any mistake could be costly.

And any move could be a mistake.

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He had been dissecting the tumor off a blood vessel, though hadn’t been quite able to see which vessel at the time. That, in itself, was not a mistake but a fact of the mechanic’s particular anatomy. Patient specific anatomy he told himself, knowing every tumor has it’s own peculiar structure. A tumor invades and pushes and insinuates itself in the midst of what is normal. The normal and the abnormal closely apposed. Sometimes one and the same. It is the surgeon’s job to map these peculiarities.

The unseen vessel had torn. The result was a minor bloodletting, perhaps a thousand cc’s—four cups—of blood lost in the thirty or forty seconds it took to bring it under control. That’s when the clock watching had started: “I’ve packed the bleeder off, give me fifteen minutes by the clock.”

All bleeding stops eventually, the voice of experience whispered in his head.

And so the surgeon and the mechanic had arrived at this moment.

The surgeon took another deep breath. Through the microscope, he ran his eyes around the field for the umpteenth time. He knew what he was about to do would mean everything to the mechanic.

The final ten. The last ten minutes of tumor removal. Everything up to that time was just preamble. The last ten minutes were always the hardest minutes, both on the surgeon and the patient—though the patient would never know it if things went well. If they didn’t? Well, the patient likely wouldn’t know that either.

“Lift here,” the surgeon said.

The assist did as directed, lifting ever so slightly on the retractor. The fold of brain behind it moved, perhaps an eighth of an inch but no more. The brain is obdurate. It doesn’t want to be moved, doesn’t like to be moved.

The final remnant of tumor came into view, but just the edge of it.

“Nice,” the surgeon said to nobody in particular. “Damn thing is just there. Penfield six.”

The scrub passed the number six dissector, a narrow, blunt tipped pointer. The surgeon touched it to the tumor, getting the feel of the growth, wanting to know it’s consistency, it’s texture. He’d been working toward this moment for hours, had most of the tumor out. He had learned most of what there was to know about this particular devil’s peculiarities, but it could still bite.

Another truism he knew from experience. Too much experience. It had thinned his hair but quickened his mind and steadied his hand. Behind his mask, the surgeon bit his lip and held back an expletive.

† The Third Minute †

Using the number six, he defined the interface between the tumor and its surroundings. He developed the three dimensional interface, mapping most all of the remaining devil. He couldn’t see or define the underside of the tumor though.

If trouble was coming—the brain is obdurate, the voice of experience whispered again—it was going to come from the under side.

What’s the worst thing I can do right now and how can I avoid it?

Blunder blindly into something, he told himself. I need to know the surroundings better. 

He was three inches inside the mechanic’s head, had ninety percent plus of the tumor out. He looked at the landscape, thought, something isn’t right. Thought, what am I missing?

He took up his own sucker, placing a cotton paddy between it and the brain. He began to work his way over the terrain. At play in the fields of the the Lord, he told himself, thinking there are no atheistic brain surgeons.

He called out the structures as he went. In a half voice mostly, sotto voce. “Seven, eight.” The two cranial nerves crossed the field together, intimate friends, before disappearing into a small opening in the bony wall of the skull base. The tumor had distorted them, but they appeared otherwise none the worse. Same with ‘aica,’ an artery. Just the fact the artery had a name, aica, was enough to suggest it was important, something not to be fucked with. He left it alone out of respect. He found the sixth nerve and followed it’s circuitous path, the longest of any of the cranial nerves, around the periphery of the brain stem.

What he didn’t see, what he hadn’t called out, was the Basilar artery. He hesitated. “Where the hell…”

The large artery came into view just then. A red, pulsating thing, thrumming in exact synchrony with the ping of the EKG. It had an unusual redundant course, turning back on itself as it never should, too curved and twisted for it’s own good. Patient specific anatomy.

He adjusted the focal length of the microscope and the artery moved in and out of focus along its tortured course, worm-like and bloated. “Damn.”

He saw now his worst fear. Or rather his second worst fear. The final remnant of tumor—the very devil himself—had become intimate with the twisted Basilar artery. And the Basilar artery was, of course, intimate to everything the mechanic was.

The brain is obdurate—and the Basilar artery is the most obdurate part of that brain.

The surgeon looked up from the microscope, turned his head. The circulator was at his side on the instant toweling the sweat from his forehead.

The patient, his brain exposed to the elements, lay under the sterile drapes, oblivious to the danger ahead.

Next time on Neurosurgery101—TheBlog: Part II of 2 of The Brain is Obdurate, a short but thrilling tale of surgical adventure well calculated to keep you in suspense, by Edison McDaniels, MD

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