The Year of Magical Thinking

8

They had gotten off the plane.

They had picked up their shared bag.

Gerry was carrying the bag to the car rental shuttle, crossing the arrivals driveway ahead of Quintana. He looked back. Even today I have no idea what made him look back. I never thought to ask. I pictured it as one more case in which you heard someone talking and then you didn’t, so you looked. Life changes in the instant. The ordinary instant. She was lying on her back on the asphalt. An ambulance was called. She was taken to UCLA. According to Gerry she was awake and lucid in the ambulance. It was only in the emergency room that she began convulsing and lost coherence. A surgical team was alerted. A CT scan was done. By the time they took her into surgery one of her pupils was fixed. The other became fixed as they wheeled her in. I would be told this more than once, in each case as evidence of the gravity of the condition and the critical nature of the intervention: “One pupil was fixed and the other went as we wheeled her in.”

The first time I heard this I did not know the significance of what I was being told. By the second time I did. Sherwin B. Nuland, in How We Die, described having seen, as a third-year medical student, a cardiac patient whose “pupils were fixed in the position of wide black dilatation that signifies brain death, and obviously would never respond to light again.” Again in How We Die, Dr. Nuland described the failing attempts of a CPR team to revive a patient who had suffered cardiac arrest in the hospital: “The tenacious young men and women see their patient’s pupils become unresponsive to light and then widen until they are large fixed circles of impenetrable blackness. Reluctantly the team stops its efforts…. The room is strewn with the debris of the lost campaign.” Was this what the New York — Presbyterian ambulance crew saw in John’s eyes on our living room floor on December 30, 2003? Was this what the UCLA neurosurgeons saw in Quintana’s eyes on March 25, 2004? “Impenetrable blackness?” “Brain death?” Was that what they thought? I look at a printout of that day’s CT report from UCLA and still go faint:

The scan shows right hemispheric subdural hematoma, with evidence of acute bleeding. Active bleeding cannot be excluded. The hematoma causes marked mass effect upon the right cerebrum, subfalcial and early uncal herniation, with 19 mm of midline shift from right to left at the level of the third ventricle. The right lateral ventricle is subtotally effaced and the left lateral ventricle shows early entrapment. There is moderate to marked midbrain compression and the perimesencephalic cistern is effaced. A thin posterior falcine and left tentorial subdural hematomas are noted. A small parenchymal bleed, likely contusional, is noted in the right inferolateral frontal lobe. The cerebellar tonsils are at the level of the foramen magnum. There is no skull fracture. There is a large right parietal scalp hematoma.

March 25, 2004. Ten minutes past seven in the evening in New York.

She had come back from the place where doctors said “We still don’t know which way this is going” and now she was there again.

For all I knew it had already gone the wrong way.

They could have told Gerry and Gerry could be trying to absorb it before calling me.

She could already be on her way to the hospital morgue.

Alone. On a gurney. With a transporter.

I had already imagined this scene, with John.

Tony arrived.

He repeated what he had told me on the telephone. He had gotten the call from Gerry at UCLA. Quintana was in surgery. Gerry could be reached by cell phone in the hospital lobby, which happened to double (UCLA was building a new hospital, this one was overcrowded and outdated) as the surgical waiting area.

We called Gerry.

One of the surgeons had just come out to give him an update. The surgical team was now “fairly confident” that Quintana would “leave the table,” although they could not predict in what condition.

I remember realizing that this was meant as an improved assessment: the previous report from the operating room had been that the team was “not at all sure she would leave the table.”

I remember trying and failing to understand the phrase “leave the table.” Did they mean alive? Had they said “alive” and Gerry could not say it? Whatever happens, I remember thinking, she will without question “leave the table.”

It was then maybe four-thirty in Los Angeles, seven-thirty in New York. I was not sure how long at that point the surgery had been in progress. I see now, since according to the CT report the scan had taken place at “15:06,” six minutes past three in Los Angeles, that she had probably been in surgery only about half an hour. I got out an OAG guide to see who would still be flying that night to Los Angeles. Delta had a 9:40 p.m. out of Kennedy. I was about to call Delta when Tony said that he did not think that being in flight during the surgery was a good idea.

I remember a silence.

I remember setting aside the OAG.

I called Tim Rutten in Los Angeles, and asked him to go to the hospital to wait with Gerry. I called our accountant in Los Angeles, Gil Frank, whose own daughter had undergone emergency neurosurgery at UCLA a few months before, and he too said that he would go to the hospital.

That was as close as I could get to being there.

I set the table in the kitchen and Tony and I picked at coq au vin left from the dinner for the family after St. John the Divine. Rosemary arrived. We sat at the kitchen table and tried to develop what we referred to as a “plan.” We used phrases like “the contingencies,” delicately, as if one of the three of us might not know what “the contingencies” were. I remember calling Earl McGrath to see if I could use his house in Los Angeles. I remember using the words “if I need to,” another delicate construction. I remember him cutting directly through this: he was flying to Los Angeles the next day on a friend’s plane, I would go with them. Around midnight Gerry called and said that the surgery was finished. They would now do another CT scan to see if there was additional bleeding they had missed. If there was bleeding they would operate again. If there was not they would do a further procedure, the placement of a screen in the vena cava to prevent clots from entering the heart. About four a.m. New York time he called again, to say that the CT scan had shown no bleeding and they had placed the screen. He told me what the surgeons had told him about the operation itself. I made notes:

“Arterial bleed, artery gushing blood, like a geyser, blood all over the room, no clotting factor.”

“Brain pushed to the left side.”

When I got back to New York from Los Angeles late on the evening of April 30 I found these notes on a grocery list by the kitchen phone. I now know that the technical term for “brain pushed to the left side” is “midline shift,” a significant predictive factor for poor outcome, but even then I knew that it was not good. What I had thought I needed on that March day five weeks before were Evian splits, molasses, chicken broth, and flaxseed meal.

Read, learn, work it up, go to the literature.

Information is control.

On the morning after the surgery, before I went to Teterboro to get on the plane, I looked on the Internet for “fixed and dilated pupils.” I found that they were called “FDPs.” I read the abstract of a study done by researchers in the Department of Neurosurgery at the University Clinic in Bonn. The study followed ninety-nine patients who had either presented with or developed one or two FDPs. The overall mortality rate was 75 percent. Of the 25 percent who were still alive twenty-four months later, 15 percent had what the Glasgow Outcome Scale defined as an “unfavorable outcome” and 10 percent a “favorable outcome.” I translated the percentages: of the ninety-nine patients, seventy-four died. Of the surviving twenty-five, at the end of two years, five were vegetative, ten were severely disabled, eight were independent, and two had made a full recovery. I also learned that fixed and dilated pupils indicated injury or compression of the third cranial nerve and the upper brainstem. “Third nerve” and “brainstem” were words that I would hear more often than I wanted to during the weeks to come.