At 6 a.m. Janet Ross was on the third surgical floor, dressed in greens, having coffee and a doughnut. The surgeons' lounge was busy at this hour. Although operations were scheduled to begin at six, most didn't get going for fifteen or twenty minutes after that. The surgeons sat around, reading the newspaper, discussing the stock market and their golf games. From time to time one of them would leave, go to the overhead viewing galleries, and look down on their ORs to see how preparations were coming.
She was the only woman in the room, and her presence changed the masculine atmosphere subtly. It annoyed her that she should be the only woman, and it annoyed her that the men should become quieter, more polite, less jovial and raucous. She didn't give a damn if they were raucous, and she resented being made to feel like an intruder. It seemed to her that she had been an intruder all her life, even when she was very young. Her father had been a surgeon who never bothered to conceal his disappointment and irritation that he had a daughter instead of a son. A son would have fitted into his scheme of life; he could have brought him to the hospital on Saturday mornings, taken him into the operating rooms - those were all things you could do with a son. But a daughter was something else, a perplexing entity not suited for a surgical life. And therefore an intrusion…
She looked around at all the surgeons in the lounge, and then, to cover her unease, she went to the phone and dialed the seventh floor.
"This is Dr. Ross. Is Mr. Benson on call?"
"He was just sent."
"When did he leave the floor?"
"About five minutes ago."
She hung up and went back to her coffee. Ellis appeared and waved to her across the room. "There'll be a five-minute delay hooking into the computer," he said. "They're tying in the lines now. Is the patient on call?"
"Sent five minutes ago."
"You seen Morris?"
"He better get his ass down here," Ellis said.
Somehow that made her feel good.
Morris was in the elevator with a nurse and Benson, who lay on a stretcher, and one of the cops. As they rode down, Morris said to the cop, "You can't get off on the floor."
"We're going onto the sterile floor directly."
"What should I do?" The cop was intimidated. He'd been docile and hesitant all morning. The routine of surgery left him feeling a helpless outsider.
"You can watch from the viewing gallery on the third floor. Tell the desk nurse I said it was all right."
The cop nodded. The elevator stopped at the second floor. The doors opened to reveal a hallway with people, all in surgical greens, walking back and forth. A large sign read STERILE AREA. NO ADMITTANCE WITHOUT AUTHORIZATION. The lettering was red.
Morris and the nurse wheeled Benson out of the elevator.
The cop remained behind, looking nervous. He pushed the button for the third floor, and the doors closed.
Morris went with Benson down the corridor. After a moment, Benson said, "I'm still awake."
"Of course you are."
"But I don't want to be awake."
Morris nodded patiently. Benson had gotten pre-op medications half an hour earlier. They would be taking effect soon, making him drowsy. "How's your mouth?"
That was the atropine beginning to work. "You'll be okay." Morris himself had never had an operation. He'd performed hundreds, but never experienced one himself. In recent years, he had begun to wonder how it felt to be on the other side of things. He suspected, though he would never admit it, that it must be awful.
"You'll be okay," he said to Benson again, and touched his shoulder.
Benson just stared at him as he was wheeled down the corridor to OR 9.
OR 9 was the largest operating room in the hospital. It was nearly thirty feet square and packed with electronic equipment. When the full surgical team was there - all twelve of them - things got pretty crowded. But now just two scrub nurses were working in the cavernous gray-tiled space. They were setting out sterile tables and drapes around the chair.
OR 9 had no operating table. Instead, there was a softly cushioned upright chair, like a dentist's chair. Janet Ross watched the girls through the windows in the door that separated the scrub room from the operating room. Alongside her, Ellis finished his scrub and muttered something about fucking Morris being fucking late. Ellis got profane before operations. He also got very nervous, though he seemed to think nobody noticed that. Ross had scrubbed with him on several animal procedures and had seen the ritual - tension and profanity before the operation, and utter bland calmness once things were under way.
Ellis turned off the faucets with his elbows and entered the OR, backing in so that his arms did not touch the door. A nurse handed him a towel. While he dried his hands, he looked back through the door at Ross, and then up at the glass-walled viewing gallery overhead. Ross knew there would be a crowd in the gallery watching the operation.
Morris came down and began scrubbing. She said, "Ellis wondered where you were."
"Tour guide for the patient," he said.
One of the circulating nurses entered the scrub room and said, "Dr. Ross, there's somebody here from the radiation lab with a unit for Dr. Ellis. Does he want it now?"
"If it's loaded," she said.
"I'll ask," the nurse said. She disappeared, and stuck her head in a moment later. "He says it's loaded and ready to go, but unless your equipment is shielded it could give you trouble."
Ross knew that all the OR equipment had been shielded the week before. The plutonium exchanger didn't put out much radiation - not enough to fog an X-ray plate - but it could confuse more delicate scientific equipment. There was, of course, no danger to people.
"We're shielded," Ross said. "Have him take it into the OR."
Ross turned to Morris, scrubbing alongside her. "How's
"He should be," she said. Morris glanced at her, his eyes questioning above the gauze surgical mask. She shook her hands free of excess water and backed into the OR. The first thing she saw was the rad-lab man wheeling in the tray with the charging unit on it. It was contained in a small lead box. On the sides were stenciled DANGER RADIATION and the triple-blade orange symbol for radiation. It was all faintly ridiculous; the charging unit was quite safe.
Ellis stood across the room, being helped into his gown. He plunged his hands into his rubber gloves and flexed his fingers. To the rad-lab man he said, "Has it been sterilized?"
"Has the unit been sterilized?"
"I don't know, sir."
"Then give it to one of the girls and have her autoclave it. It's got to be sterile."
Dr. Ross dried her hands and shivered in the cold of the operating room. Like most surgeons, Ellis preferred a cold room - too cold, really, for the patient. But as Ellis often said, "If I'm happy, the patient's happy."
Ellis was now across the room standing by the viewing box, while the circulating nurse, who was not scrubbed, put up the patient's X-rays. Ellis peered closely at them, though he had seen them a dozen times before. They were perfectly normal skull films. Air had been injected into the ventricles, so that the horns stood out darkly.
One by one the rest of the team filtered into the room.
All together, there were two scrub nurses, two circulating nurses, one orderly, Ellis, two assistant surgeons including Morris, two electronics technicians, and a computer programmer. The anaesthetist was outside with Benson.
Without looking up from his console, one of the electronics men said, "Any time you want to begin, Doctor."
"We'll wait for the patient," Ellis said dryly, and there were some chuckles from the Nine Group team.
Ross looked around the room at the seven TV screens. They were of different sizes and stationed in different places, depending on how important they were to the surgeon. The smallest screen monitored the closed-circuit taping of the operation. At the moment, it showed an overhead view of the empty chair.
Another screen, nearer the surgeon, monitored the electroencephalogram, or EEG. It was turned off now, the sixteen pens tracing straight white lines across the screen. There was also a large TV screen for basic operative parameters: electrocardiogram, peripheral arterial pressure, respirations, cardiac output, central venous pressure, rectal temperature. Like the EEG screen, it was also tracing a series of straight lines.
Another pair of screens were completely blank. They would display black-and-white image-intensified X-ray views during the operation.
Finally, two color screens displayed the LIMBIC Program output. That program was cycling now, without punched-in coordinates. On the screens, a picture of the brain rotated in three dimensions while random coordinates, generated by computer, flashed below. As always, Ross felt that the computer was another, almost human presence in the room - an impression that was always heightened as the operation proceeded.
Ellis finished looking at the X-rays and glanced up at the clock. It was 6:19; Benson was still outside being checked by the anaesthetist. Ellis walked around the room, talking briefly to everyone. He was being unusually friendly, and
Ross wondered why. She looked up at the viewing gallery and saw the director of the hospital, the chief of surgery, the chief of medicine, and the chief of research all looking down through the glass. Then she understood.
It was 6:21 when Benson was wheeled in. He was now heavily pre-medicated, relaxed, his body limp, his eyelids heavy. His head was wrapped in a green towel.
Ellis supervised Benson's transfer from the stretcher to the chair. As the leather straps were placed across his arms and legs, Benson seemed to wake up, his eyes opening wide.
"That's just so you don't fall off," Ellis said easily.
"We don't want you to hurt yourself."
"Uh-huh," Benson said softly, and closed his eyes again. Ellis nodded to the nurses, who removed the sterile towel from Benson's head. The naked head seemed very small - that was Ross's usual reaction - and white. The skin was smooth, except for a razor nick on the left frontal. Ellis's blue-ink
"X" marks were clearly visible on the right side.
Benson leaned back in the chair. He did not open his eyes again. One of the technicians began to fix the monitor leads to his body, strapping them on with little dabs of electrolyte paste. They were attached quickly; soon his body was connected to a tangle of multicolored wires running off to the equipment.
Ellis looked at the TV monitor screens. The EEG was now tracing sixteen jagged lines; heartbeat was recorded; respirations were gently rising and falling; temperature was steady. The technicians began to punch pre-op parameters into the computer. Normal lab values had already been fed in. During the operation, the computer would monitor all vital signs at five-second intervals, and would signal if anything went wrong.
"Let's have music, please," Ellis said, and one of the nurses slipped a tape cartridge into the portable cassette recorder in a corner of the room. A Bach concerto began to play softly. Ellis always operated to Bach; he said he hoped that the precision, if not the genius, might be contagious.
They were approaching the start of the operation. The digital wall clock said 6:29:14 a.m. Next to it, an elapsed-time digital clock still read 0:00:00.
With the help of a scrub nurse, Ross put on her sterile gown and gloves. The gloves were always difficult for her. She didn't scrub in frequently, and when she plunged her fingers into the gloves she caught her hand, missing one of the finger slots and putting two fingers in another. It was impossible to read the scrub nurse's reaction; only her eyes were visible above the mask. But Ross was glad that Ellis and the other surgeons were turned away attending to the patient.
She stepped to the back of the room, being careful not to trip over the thick black power cables that snaked across the floor in all directions. Ross did not participate in the initial stages of the operation. She waited until the stereotaxic mechanism was in place and the coordinates were determined. She had time to stand to one side and pluck at her glove until all the fingers were in the right slots. There was no real purpose for her to attend the operation at all, but McPherson was insistent that one member of the non-surgical staff scrub in each day that they operated. He felt it kept the Unit more cohesive. At least that was what he said.
She watched Ellis and his assistants across the room draping Benson; then she looked over to the draping as seen on the closed-circuit monitor. The entire operation would be recorded on video tape for later review.
"I think we can start now," Ellis said easily. "Go ahead with the needle."
The anaesthetist, working behind the chair, placed the needle between the second and third lumbar spaces of Benson's spine. Benson moved once and made a slight sound, and then the anaesthetist said, "I'm through the dura. How much do you want?"
The computer console flashed "OPERATION BEGUN." The computer automatically started the elapsed-time clock, which ticked off the seconds.
"Give me thirty cc's to begin," Ellis said. "Let's have X-ray, please."
The X-ray machines were swung into position at the front and side of the patient's head. Film plates were set on, locking in with a click. Ellis stepped on the floor button, and the TV screens glowed suddenly, showing black-and-white images of the skull. He watched in two views as air slowly filled the ventricles, outlining the horns in black.
The programmer sat at the computer console, his hands fluttering over the buttons. On his TV display screen, the words "PNEUMOGRAPH INITIATED" appeared.
"All right, let's fix his hat," Ellis said. The boxlike tubular stereotactic frame was placed over the patient's head. Burr-hole locations were fixed and checked. When Ellis was satisfied, he injected local anaesthetic into the scalp points. Then he cut the skin and reflected it back, exposing the white surface of the skull.
With the 2-mm drill, he made the first of the two holes on the right side of the skull. He placed the stereotactic frame - the "hat" - over the head, and screwed it down securely. Ross looked over at the computer display. Values for heart rate and blood pressure flashed on the screen and faded; everything was normal. Soon the computer, like the surgeons, would begin to deal with more complex matters.
"Let's have a position check," Ellis said, stepping away from the patient, frowning critically at Benson's shaved head and the metal frame screwed on top of it. The X-ray technician came forward and snapped the pictures.
In the old days, Ross remembered, they actually took X-ray plates and determined position by visual inspection of the plates. It was a slow process. Using a compass, protractor, and ruler, they drew lines across the X-ray, measured them, rechecked them. Now the data were fed directly to the computer, which did the analysis more rapidly and more accurately.
All the team turned to look at the computer print-out screen. The X-ray views appeared briefly, and were replaced by schematic drawings. The maxfield location of the stereotactic apparatus was calculated; the actual location was then merged with it. A set of coordinates flashed up, followed by the notation "PLACEMENT CORRECT."
Ellis nodded. "Thank you for your consultation," he said humorlessly, and went over to the tray which held the electrodes.
The team was now using Briggs stainless-steel
Teflon-coated electrode arrays. In the past, they had tried almost everything else: gold, platinum alloy, and even flexible steel strands in the days when the electrodes were placed by inspection. The old inspection operations were bloody, messy affairs. It was necessary to remove a large portion of the skull and expose the surface of the brain. The surgeon found his landmark points on the surface itself, and then placed his electrodes in the substance of the brain. If he had to place them in deep structures, he would occasionally cut through the brain to the ventricles with a knife, and then place them. There were serious complications; the operations were lengthy; the patients never did very well.
Now the computer had changed all that. The computer allowed you to fix a point precisely in three-dimensional space. Initially, along with other researchers in the field, the NPS group had tried to relate deep brain points to skull architecture. They measured their landmark points from the orbit of the eye, from the meatus of the ear, from the sagittal suture. That, of course, didn't work - people's brains did not fit inside their skulls with any consistency. The only way to determine deep brain points was in relation to other brain points - and the logical landmarks were the ventricles, the fluid-filled spaces within the brain. According to the new system, everything was determined in relation to the ventricles.
With the help of the computer, it was no longer necessary to expose the brain surface. Instead, a few small holes were drilled in the skull and the electrodes inserted, while the computer watched by X-ray to make sure they were being placed correctly.
Ellis picked up the first electrode array. From where Ross stood, it looked like a single slender wire. Actually, it was a bundle of twenty wires, with staggered contact points. Each wire was coated with Teflon except for the last millimeter, which was exposed. Each wire was a different length, so that under a magnifying glass, the staggered electrode tips looked like a miniature staircase.
Ellis checked the array under a large glass. He called for more light and turned the array, peering at all contact points. Then he had a scrub nurse plug it into a testing unit and test every contact. This had been done dozens of times before, but Ellis always checked again before insertion. And he always had four arrays sterilized, though he would need only two. Ellis was careful.
At length he was satisfied. "Are we ready to wire?" he asked the team. They nodded. He stepped up to the patient and said, "Let's go through the dura."
Up to this point in the operation, they had drilled through the skull, but had left intact the membrane of dura mater which covered the brain and enclosed the spinal fluid. Ellis's assistant used a probe to puncture the dura.
"I have fluid," he said, and a thin trickle of clear liquid slid down the side of the shaved skull from the hole. A nurse sponged it away.
Ross always found it a source of wonder the way the brain was protected. Other vital body organs were well-protected, of course: the lungs and heart inside the bony cage of the ribs, the liver and spleen under the edge of the ribs, the kidneys packed in fat and secure against thick muscles of the lower back. Good protection, but nothing compared to the central nervous system, which was encased entirely in thick bone. Yet even this was not enough; inside the bone there were sac-like membranes which held cerebrospinal fluid. The fluid was under pressure, so that the brain sat in the middle of a pressurized liquid system that afforded its superb protection.
McPherson had compared it to a fetus in a water-filled womb. "The baby comes out of the womb," McPherson said, "but the brain never comes out of its own special womb."
"We will place now," Ellis said.
Ross moved forward, joining the surgical team gathered around the head. She watched as Ellis slid the tip of the electrode array into the burr hole and then pressed slightly, entering the substance of the brain. The technician punched buttons on the computer console. The display screen read: