Seizure

twenty-six

2:15 P.M., Sunday, March 24, 2002

Dr. Jeffrey Marcus was a local radiologist on the staff at Doctors Hospital on Shirley Street in downtown Nassau. Spencer had made a deal with him that he would cover the Wingate Clinic’s radiological needs on an ad hoc basis until a full-time radiologist could be justified. As soon as it was decided a CAT scan was needed for Ashley, Spencer had a nurse call Jeffrey. Since it was a Saturday afternoon, he was able to come immediately. Dr. Nawaz had been pleased because he was acquainted with Jeffrey from Oxford and knew him to have significant neuroradiological experience.

“These are transverse sections of the brain, starting at the dorsal edge of the pons,” Jeffrey said, pointing at the computer monitor with the eraser end of an old-fashioned, yellow number-two Dixon pencil. Jeffrey Marcus was an English expatriate who had fled to the Bahamas to escape England’s weather, just like Dr. Carl Newhouse. “We’ll be traveling cephalad in one-centimeter increments and should be at the level of the substantia nigra in one or two frames, at most.”

Jeffrey was sitting in front of the computer. Standing to his right and bending over for a better view was Dr. Nawaz. Daniel stood immediately to Jeffrey’s left. By the window facing into the CAT-scan room stood Paul, Spencer, and Carl. Carl was holding a syringe loaded with another dose of sedative, but it had not been necessary. Ashley had not awakened since the second dose and had slept through his craniotomy hole being stitched closed over a metal button, the stereotaxic frame being removed, and his being transferred to the CAT-scan table. At the moment, Ashley was lying supine with his head inside the opening of the giant, donut-shaped machine. His hands were crossed on his chest with the wrist restraints in place but not secured. The IV was still running. He appeared to be the picture of peaceful slumber.

Stephanie was in the background, away from the others and leaning against a countertop with her arms crossed. Unbeknownst to anyone, she was fighting back tears. She hoped no one would address her, because if they did, she feared that she would lose control. She thought about walking out of the room but then worried that doing so would draw too much attention, so she stayed where she was and suffered in silence. Without even looking at the upcoming CAT scan, her intuition told her there had been a major complication with the implantation, and it had broken the back of her emotional control, which had been strained by everything that had happened during the last month. She berated herself for not listening to her intuition back at the beginning of this farcical and now potentially tragic affair.

“Okay, here we go!” Jeffrey said, pointing again at the image on the monitor. “This is the midbrain, and this is the area of the substantia nigra, and I’m afraid there is no radiolucency one would expect from a heavy-metal-tagged monoclonal antibody.”

“Maybe the antibody has yet to diffuse from the cerebrospinal fluid into the brain,” Dr. Nawaz suggested. “Or maybe there is no unique surface antigen on the treatment cells. Are you sure the gene you inserted was expressed?”

“I’m certain,” Daniel said. “Dr. D’Agostino checked.”

“Maybe we should repeat this in a few hours,” Dr. Nawaz said.

“With our mice, we saw it within thirty minutes and maximum at forty-five minutes,” Daniel said. He looked at his watch. “The human brain is bigger, but we used more antibody, and it’s been an hour. We should see it. It’s got to be there.”

“Wait!” Jeffrey said. “Here’s some diffuse radiolucency laterally.” He moved the tip of the eraser a centimeter to the right. The spots of lucency were subtle, like tiny flakes of snow on a ground-glass background.

“Oh my God!” Dr. Nawaz blurted. “That’s in the mesial part of the temporal lobe. No wonder he had a seizure.”

“Let’s look at the next slice,” Jeffrey said, as the new image started to wipe out the old from the top, moving down the screen as if unrolling.

“Now it is even more apparent,” Jeffrey said. He tapped the screen with his eraser. “I’d say it is in the area of the hippocampus, but to precisely locate it, we’d have to get some air into the temporal horn of the lateral ventricle. Do you want to do that?”

“No!” Dr. Nawaz snapped. He straightened up, clasping his hands to his head. “How the bloody hell could the needle have been so far off? I don’t believe this. I even went back and looked at the X rays, remeasured, and then checked the settings on the guide. They were all absolutely correct.” He lifted his hands from his head and spread them in the air as if pleading for someone to explain what had happened.

“Maybe the frame moved a bit when we hit the doorframe with the OR table?” Carl Newhouse suggested.

“What are you saying?” Dr. Nawaz demanded. “You told me the table brushed the doorframe. What exactly do you mean by ‘hit’?”

“When did the OR table touch the doorframe?” Daniel asked. It was the first time he had heard anything about it. “And what doorframe are you talking about?”

“Dr. Saunders said it brushed,” Carl said, ignoring Daniel. “Not me.”

Dr. Nawaz looked over at Paul questioningly. Paul reluctantly nodded. “I suppose it was more of a hit than a brush, but it doesn’t matter. Constance said the frame was anchored solidly when she grabbed ahold of it.”

“Grabbed it?” Dr. Nawaz yelled. “What necessitated her having to grab the frame?”

There was an uncomfortable pause as Paul and Carl exchanged glances.

“What is this, a conspiracy?” Dr. Nawaz demanded. “Somebody answer me!”

“There was kind of a whiplash effect,” Carl said. “I was in a hurry to get the patient back on the monitor, so we were pushing the table rather quickly. Unfortunately, it wasn’t aligned with the OR doorway. After the bump occurred, Constance came over to support the frame. She was still gowned and gloved. At that point, we were concerned about contamination, since the patient had awakened and his hands weren’t restrained. But there wasn’t any contamination.”

“Why didn’t you tell me all this when it happened?” Dr. Nawaz snapped.

“We did tell you,” Paul said.

“You told me the table brushed the door frame. That is a far cry from hitting it hard enough to cause whiplash.”

“Well, whiplash might be an exaggeration,” Carl said, correcting himself. “The patient’s head fell forward. It didn’t snap back or anything like that.”

“Good God!” Dr. Nawaz mumbled with discouragement. He sat down heavily in a desk chair. He pulled off his surgical hat with one hand and gripped his scalp with the other while he shook his head in frustration. He couldn’t believe he’d allowed himself to get caught up in such a burlesque affair. It was now clear to him that the stereotaxic frame had to have slightly rotated as well as tipped down, either on impact or when the scrub nurse grasped it.

“We’ve got to do something!” Daniel said. It had taken him a moment to recover from the revelation about the OR table’s collision with the doorframe and its possible tragic consequences.

“And what do you suggest?” Dr. Nawaz questioned derisively. “We’ve mistakenly implanted a host of rogue, dopamine-producing cells in the man’s temporal lobe. It’s not like we can go back in there and suck them out.”

“No, but we can destroy them before they arborize,” Daniel said, with a flicker of hope beginning to crackle like a fire in his imagination. “We have the monoclonal antibody to the cell’s unique surface antigen. Instead of attaching the antibody to a heavy metal like we did for X-ray visualization, we bind it to a cytotoxic agent. Once we inject this combination into the cerebrospinal fluid, bam! The misplaced neurons are annihilated. Then we merely do another implantation on the patient’s left side, and we’re home free.”

Dr. Nawaz smoothed back his shiny black hair and gave Daniel’s idea a moment of thought. On the one hand, the idea of potentially rectifying a disaster for which he shared a significant responsibility was enticing, even if the method was unorthodox, but on the other hand, his intuition told him he shouldn’t allow himself to be dragged in any further by doing yet another highly experimental procedure.

“Do you have this cytotoxic antibody combination on hand?” Dr. Nawaz asked. There was no harm in asking.

“No,” Daniel admitted. “But I’m certain we could get it concocted on a rush basis by the same firm that supplied us with the antibody heavy-metal combination, and then have it overnighted.”

“Well, you let me know if and when you get it,” Dr. Nawaz railed as he stood up. “I said a second ago that we couldn’t go back in and suck out the misplaced treatment cells. The unfortunate irony is that if nothing is done and the patient ends up with the kind of temporal lobe epilepsy he most likely will, he’ll probably have to undergo something along those lines in the future. But it would be serious, ablative neurosurgery, requiring the removal of a lot of brain tissue with high attendant risk.”

“That strengthens the rationale for doing what I have proposed,” Daniel said, progressively warming to the idea.

Stephanie abruptly pushed away from the countertop and headed for the door. Her fragile emotions and fear of calling attention to herself notwithstanding, she couldn’t bear to hear another word of this exchange. It was as if the conversation involved an inanimate object rather than an iatrogenically stricken fellow human being. She was particularly appalled at Daniel, because she could tell that despite the dreadful complication, he was still maneuvering like a modern medical Machiavelli, in blind pursuit of his own entrepreneurial interests despite the moral consequences.

“Stephanie!” Daniel called, seeing her heading for the door. “Stephanie, why don’t you call Peter up in Cambridge and have him…”

The door closed behind Stephanie, cutting Daniel’s voice off. She began to run down the hall. She fled toward the ladies’ room, where she hoped she could cry in peace. She was upset about a lot of things, but mainly because she knew that she was as responsible as anyone for what had happened.