The Patient

Book by Palmer Michael

They were nearly three hours into the operation and not one cell of the cancer had yet been removed. But by neurosurgical standards, three hours was still well within the feeling-out period — especially for a procedure involving experimental equipment. And despite huge progress recently, ARTIE most certainly remained experimental.

“Let’s try another set of images with enhancement of the tumor, please.”

To a physician, all growths, benign and malignant, were tumors, although the term “cancer” was generally reserved for malignancies — those tumors capable of spreading to distant organs. This particular cancer, a glioblastoma, was among the most virulent of all brain tumors.

Staring straight ahead at the eight-inch monitor screen that was suspended from the ceiling to her eye level, Jessie Copeland set her gloved hands down on the patient’s draped scalp, which was fixed by heavy screws to an immobile titanium frame. The physical contact wasn’t technically necessary. From here on, ARTIE would be doing the actual surgery. But there was still something reassuring about it.

“You playing gypsy fortune-teller?” Emily DelGreco asked from across the table.

“I just want to make certain the guy hasn’t slipped out from under the sheets, gotten up, and run away while I’m trying to decide whether or not our little robot pal is in position to begin removing this tumor. For some reason ARTIE’s movements forward and left feel sluggish to me — not as responsive to the controls as I think he should be.”

“Easy does it, Jess,” Emily said. “We always expect more from our kids than they can ever deliver — just ask mine. The sensors I’m watching, plus my monitor screen, say you and ARTIE are doing fine. If you start feeling rushed, just say ‘Berenberg.’”

Emily, a nurse practitioner, had been on the neurosurgical service at the Eastern Massachusetts Medical Center for several years before Jessie started her residency. The two of them, close in age if not in temperament, had hit it off immediately, and over the intervening eight years had become fast friends. Now that Jessie was on the junior faculty, Emily had moved into the tiny office next to hers and worked almost exclusively with her and her patients. Neither of them would ever forget Stanley Berenberg, one of the first brain tumor cases the two of them had done together. His operation had taken twenty-two hours. They did the delicate resection together without relief. But every minute they spent on the case proved worth it. Berenberg was now enjoying an active retirement, playing golf and carving birds, one of which — a beautifully rendered red-tailed hawk — held sway on the mantel in Jessie’s apartment.

“Berenberg ... Berenberg ... Berenberg,” Jessie repeated mantralike. “Thanks for the pep talk, Em. I think ARTIE’s just about ready to start melting this tumor.”

Jessie had decided to apply to medical school five years after her graduation from MIT with a combined degree in biology and mechanical engineering. She had spent those five years working in research and development for Globotech, one of the hottest R and D companies around.

“I didn’t mind making those toys,” she had told neurosurgical chief Carl Gilbride at her residency interview, “but I really wanted to play with them afterwards.”

Under Gilbride’s leadership, the Eastern Mass Medical Center’s neurosurgical program, once the subject of scorn in academic circles, was a residency on the rise, drawing high-ranking applicants from the best medical schools in the country. Jessie, who was comfortably in the middle of the pack at Boston University’s med school, had applied to EMMC strictly as a long shot. She was astonished when, following the interview, Gilbride had accepted her on the spot. There was, however, one proviso. She had to agree to spend a significant amount of time in his lab, resurrecting work on an intraoperative robot that a now-departed researcher there had abandoned.

Working in Gilbride’s lab throughout her residency while carrying a full clinical load, Jessie had learned that her boss’s true forte was for self-promotion, but she had been elated to spearhead the development of ARTIE — Assisted Robotic Tissue Incision and Extraction. The apparatus was an exciting fusion of biomechanics and radiology.

Now, after some preliminary animal work, she and ARTIE were finally in the OR.

Over the past few years, Jessie had viewed countless video images produced by the intraoperative MRI system. What she was studying now was the continuous, three-dimensional reconstruction of the brain beneath the intact skull of the patient — images that could be rotated in any direction using a track-ball system bolted to the floor beside her foot. The on-screen presentations of the MRI data were undergoing constant improvement by the extraordinary genius geeks in Hans Pfeffer’s computer lab. And Jessie could not help but marvel at the pictures they were producing. The malignant tumor and other significant structures in the brain could be demarcated electronically and colorized to any extent the surgeon wished.

Jessie had always been a game player — a fierce competitor in sports, as well as in Nintendo, poker, billiards, and especially bridge. She was something of a legend around the hospital for the Game Boy that she carried in her lab coat pocket. She used it whenever the hours and tension of her job threatened to overwhelm her — usually to play the dynamic geometric puzzle Tetris. It was easy to understand why the MRI-OR setup excited her so. Operating in this milieu, especially at the controls of ARTIE, was like playing the ultimate video game.

MRI — magnetic resonance imaging — had progressed significantly since its introduction in the early 1980s. But the technique had taken a quantum leap when White Memorial Hospital, the most prestigious of the Boston teaching hospitals, had designed and built an operating room around the massive MRI magnet. The key to developing the unique OR was the division of the seven-foot-high superconducting magnet into two opposing heads — “tori,” the manufacturer had chosen to call them, a torus being the geometric term for any structure shaped like a doughnut. The tori were joined electronically by under-floor cables, and separated by a gap of just over two feet. It was in this narrow space that the surgeon and one assistant worked. The patient was guided into position on a padded sled that ran along a track through a circular opening in one of the magnets. Jessie understood nearly every aspect of the apparatus, but that knowledge never kept her from marveling at it.

“Let’s do it,” she said, crouching a bit to peer under the video screen and make brief eye contact with her friend. “Everyone ready?”