Intensive Therapy Page 19

  Jonas held her close. He said, “It’s all right. You’re all that matters. If we want children, we’ll adopt. Or we can go the surrogate mother route.”

  “Suppose she decided to keep the baby or wanted visitation, and we wound up in some terrible legal mess? I can’t bear the thought of someone raising my child. I’m so sorry, Jonas. I know how much you wanted a son to name after your father,” she wept.

  The prospect of losing Jennie was unbearable. “Don’t think about that now. I’ll call the chairman of surgery in the morning and find out whom he trusts at Sloan-Kettering. We’ll get you scheduled as soon as we can.” Jonas poured himself a scotch. “I can’t believe I made you take that goddamn Clomid. I saw what it did to you.”

  “Nobody made me do anything,” Jennie said. “I wanted it as much as you.”

  “It’s like pouring gasoline on a smoldering fire. That’s what I tell my patients about fertility drugs. Why didn’t I take my own advice?”

  “It’s nobody’s fault.” Jennie clutched him tightly. “I’m scared. I don’t want to die young. There’s so much I want to do, so many places I want us to go.”

  “Without you, nothing matters,” Jonas said, and he meant it. “No more about children for now. That settles that.”

  But did it?

  Still thinking of that day and all that had followed it, Jonas called home. It was 2:47 AM.

  Jennie picked up on the first ring. She sounded wide awake. “Where are you and what happened? I’ve been worried.”

  Jonas choked up. “Yeah, I’m okay,” he managed. “Well, not really. It’s been a very hard day. I hope you understand.”

  “What is it?”

  “I just want you to know how much I love you and our children.”

  “Of course you do. We know that.” Jennie cleared her throat, as she did when she was troubled. “Are you all right?”

  The question gave him pause. The sequence of events that brought Jennie and Jonas together shined on Jonas like Venus on a moonless night. Had Victoria not inspired him, Jonas wouldn’t have left Dr. Fowler, and his relationship with Jennie’s father wouldn’t have blossomed, which meant they would have never been introduced.

  “This is the twenty-third anniversary of the day we met. Remember? You wore your grandmother’s emerald. I couldn’t take my eyes off you.”

  “Jonas, what is going on down there?”

  He interlaced his hands on his lap the way he did when he was in psychoanalysis. “It involves a woman I knew years ago, a clinic patient. We became close. Don’t take that wrong, Jennie. You know I would never do anything to hurt …”

  “You don’t have to say that.”

  Jonas felt his heart breaking, but he had no idea why. “She has two children—a girl, and a boy a few years younger than ours. She showed up in pieces the other day, because her daughter had fallen apart. Tonight, the children got into a fight. Both of them wound up in intensive care at Children’s Hospital. I’m heading there after we talk. It made me realize how fragile this whole thing is, our wonderful life. It could all fall apart in a minute.”

  “That’s why we have to cherish every moment,” Jennie said. “Every single one. That’s why you drove to Philadelphia tonight. It made a difference, didn’t it?”

  “We saved her daughter’s life.”

  “I’m so proud of you. No one could have done that but you, could they? Dad always knew you had a big heart. So did I.”

  “Once the situation is stable, I’m going to crash at your parents’. I have a key and the alarm code. I’m so tired I wish I could go there now, but there’s more to do. Once things are okay tomorrow, I’ll head back to New York. Everything’s canceled tomorrow anyway, so there’s no big rush.”

  “Please drive carefully, Jonas. You know, I can always take an early train to Philadelphia, and we can drive home together.”

  “I don’t know what I’d do without you.” Jonas began to feel better. “Plan something for the weekend that the four of us would enjoy.”

  “I could try to land tickets for The Nutcracker. Everyone likes that. There are usually three performances on holiday weekends, so we might be able to wiggle our way into one of them. How’s that sound?”

  “I don’t care if we go window-shopping on Fifth Avenue, as long as it’s something everyone enjoys. I just want us to be together. I’ll be back in time for dinner. I’ll call from the road. I love you, Jennie.”

  “Come home safe, you hear. I love you, too.”

  43

  When Jonas returned to CHOP, the families of patients in critical condition were waiting in designated rooms outside intensive care. Comfortable chairs and recliners allowed family members to sit quietly or even to snooze. Jonas understood the layout all too well; the curtained Plexiglas walls were soundproofed, so that a doctor could deliver bad news privately. Martin and Victoria were pacing one of the rooms when Jonas entered and met Martin for the first time.

  Before long, a white-coated man with an olive complexion, older than the typical intern or resident, emerged from the intensive care unit. Jonas bolted to intercept him.

  “I’m Dr. Jonas Speller, Mrs. Braun’s doctor.”

  “I’m Dr. Carlos Meninas, senior pediatric ICU fellow. I’d like to speak with Mr. and Mrs. Braun.”

  “Is there anything I should know before you speak with them?”

  “You understand, Dr. Speller, that I’ll need their permission before I talk with you,” Dr. Meninas said.

  “Dr. Goodman, the chairman of psychiatry, granted me temporary privileges.”

  “Oh. Good, then. Glad you’re here. As you probably know, both children are in critical condition.”

  “Melinda, too?”

  “Her body temperature was so low in the ER that we needed an esophageal probe.”

  “How low?”

  “Seventy-eight degrees.”

  “Wow, that low? Is she stable?”

  “For now, yes. We’re watching her very closely.”

  “And Gregory?”

  “He’s stable, too.”

  Jonas breathed a sigh of relief. “At least they’re both alive. Have you been in touch with your attending?”

  “We inform Dr. Renehan of every admission. He goes over every protocol.”

  They went over to the Brauns, and Dr. Meninas introduced himself to Martin and Victoria.

  Martin said, “I’m glad we’re all here. Dr. Speller can clarify anything we don’t understand.”

  Dr. Meninas closed the door. “Gregory remains comatose after surgery, but his vital signs are normalizing, which is what we were hoping for. The ventilator is working well. His oxygen saturation is ninety-eight percent. So far there’s no seizure activity on his electroencephalogram. Neurosurgery is happy with the post-op CT scan; thankfully there’s no more bleeding. Once he’s more stable, we’ll get an MRI, which is much more sensitive in assessing tissue damage. He has a mild leukocytosis that is normal post-operatively.”

  “That means Gregory’s white blood cell count is slightly elevated—that’s normal after an operation—” Jonas said, “and that his brain is getting enough oxygen.”

  “He’s sedated for now, but in another day or two we’ll ease off some and try to get a good neurological exam.”

  “How long before the skull is reattached?” Martin asked.

  “The neurosurgeons are estimating three weeks at the earliest, but I’ve seen them wait as long as three months. It all depends on how quickly the swelling goes down. Gregory’s in very good health, which will help. But there was massive swelling, which will take longer to resolve. For now, we’ll give him medicine to keep him from moving, which means we have to breathe for him—not only to give him oxygen, but to expand his lungs fully. When the lungs don’t fully inflate the lower lobes often collapse, and that can cause pneumonia.”

  “My God,” Victoria said. “So many complications to deal with.”

  “We try to be proactive,” Dr. Meninas continued. “Dr. Brecke
nridge did a terrific job. She isolated the artery with one hand and cauterized it with the other, entirely by feel. Imagine the skill and sensitivity it takes to do that with blood gushing and totally obscuring her view. The biggest risk right now is seizure, which we’re treating aggressively with anticonvulsants. Even after the swelling goes down Gregory may not awaken fully for weeks, and even then, he’ll regain consciousness slowly. I want you to understand, people with Gregory’s degree of trauma don’t awaken suddenly, like in the movies. They come out of coma a bit at a time.

  “But be prepared, though. When Gregory awakens, he’ll likely be weak on the contralateral side, and he’ll have contracoup symptoms until the brain heals completely.”

  Victoria sat up erect. “You’re saying he will wake up? Dr. Liddle didn’t sound that certain.”

  “I don’t want to give you false hope, Mr. and Mrs. Braun, but as long as we get through the next forty-eight hours and nothing unexpected turns up on the MRI, I really think he’ll wake up. What’s not knowable is what he’ll be like. Only time will tell. But because Gregory’s young and was healthy to begin with his nerve cells are resilient. A lot of rewiring will need to happen inside his brain, but therapy will help with that. All of Gregory’s senses should be stimulated. Some families read to their children, even when they are in a coma. Others play music. Also, try to provide familiar smells. That’s important, too.

  “For now, we can get away with intravenous fluids, but until he wakes up we’ll have to tube-feed Gregory or else his GI tract will go into starvation mode.”

  Jonas said, “That’s right. The intestinal lining is intricately ridged to absorb nutrients. The ridges flatten if there’s nothing to digest. I like what I’m hearing. These doctors have everything covered.”

  “What’s does ‘countercoup’ mean?” Martin said.

  “The word is ‘contracoup,’” Jonas said. “Since the brain sits in an enclosed space, the mini-shock-waves from a blow to the head reverberate back and forth like ripples in a pond. The major damage is to Gregory’s left hemisphere, which controls the right side of the body, so that’s where he’ll be the weakest. But because of the shock-wave effect, he’ll have symptoms on the left side, too.”

  Martin reached for Victoria’s arm.

  “What about Melinda?” Victoria said.

  Dr. Meninas said, “Melinda arrived with a core temperature of seventy-eight degrees, borderline severe hypothermia. Hypothermia slows the heart, but for the time being, she’s in a normal sinus rhythm. That could deteriorate into a ventricular arrhythmia at any time until her body warms up.”

  Jonas jumped in, “That could stop the heart from beating.”

  “We’re up to eighty-seven. Her heart rhythm is being monitored very carefully,” Dr. Meninas said. “And we can do prolonged resuscitation if necessary.”

  “ECMO?” Jonas asked.

  “That’s right,” Dr. Meninas said.

  “What’s that?” Martin asked.

  Dr. Meninas replied, “‘Extracorporeal membrane oxygenation.’ We have machines that can take over for the heart if necessary. Meanwhile, we’ll raise her body temperature slowly by infusing warm fluids.”

  “How warm?” Jonas said.

  “One-hundred seven degrees Fahrenheit. It’s as fast as we can go. Melinda’s fingers and ears are another matter; we’re warming them from the outside. I don’t expect any problems as long as her heart behaves well. When Melinda’s temperature hits around ninety, she may seem as if she has DTs.”

  “What’s that?” Martin said.

  “Delirium tremens,” both doctors said simultaneously.

  Dr. Meninas went on, “Melinda might look like she’s in alcoholic withdrawal; if that happened she might shake uncontrollably and become disoriented. I’m worried that she could become agitated, which is why I want a psychiatric nurse with her. I don’t want to sedate her, because tranquilizers might destabilize her brain’s temperature regulation center. If we need something, we’ll pick the safest medication possible.”

  “Melinda told her mother she’d agree to getting help,” Jonas said, “but who knows what she’ll be like when she comes to.”

  Victoria asked, “When can we see them? I need to see my children.”

  “I’ll make sure it’s okay to visit. Family only.”

  Jonas looked at Dr. Meninas intently.

  “Right, you have privileges, Dr. Speller. Let’s leave the visiting to your discretion.”

  Dr. Meninas’s pager went off and the overhead alarm sounded. He raced out of the room.

  “Wait here,” Jonas told Martin and Victoria brusquely. He tore off after Dr. Meninas.

  44

  Ahoarde of doctors and nurses converged on the pediatric ICU like firemen rushing to a five-alarm blaze. Jonas knew some life-threatening catastrophe had occurred. He hoped to God it wasn’t Melinda’s heart or Gregory having a seizure. Jonas chased a ponytailed intern through the swinging doors. The doctors and nurses crowded into a corner room while a single clerk manned the telephones at the central nurse’s station.

  “What’s going on?” the intern said to an intensive care fellow.

  “It’s the girl with bacterial meningitis we admitted this morning,” he said. “The bottom just dropped out of her blood pressure. Septic shock. The only thing to do now is push fluids, corticosteroids, and vasopressors. And hope.”

  Reassured the crisis didn’t involve Gregory or Melinda, Jonas introduced himself to the unit clerk at the nurse’s station and then went to Melinda’s room. She was hooked to a maze of wires, and a black and green monitor displayed her heart rate, blood pressure, and body temperature, which had climbed to eighty-nine degrees. She had begun to shiver. The psychiatric nurse noted that Melinda was floating in and out of consciousness but hadn’t awakened fully.

  Looking at Melinda’s face was like going back in time. She looked so much like Victoria had when she was angry or frightened. Jonas briefed the nurse about Melinda then moved on to her brother’s room.

  Gregory’s head was bandaged and connected to a drain by a plastic tube. Purple and amber stains on his temples indicated the spots where the scalp had been scrubbed before the operation. Ribbed, plastic tubes connected his endotracheal tube to a breathing machine, while his expression—angelic yet resolute—looked as though he was determined to recover.

  Gregory looked exactly like Victoria had described him, right down to the peach fuzz. He had Martin’s forehead and chin, but everything in between was his mother’s.

  While Jonas was studying Gregory’s face, a fair-skinned woman in a white lab coat entered. A penlight and a reflex hammer protruded from her pockets. Even before he could read the red embroidery above her vest pocket, Jonas knew she was Dr. Anna Breckenridge come to check on Gregory one last time before going to bed.

  Jonas felt an immediate sense of connectedness, as if he knew her from a previous life. After introducing himself, he said, “You’re very much like I imagined. You remind me of a woman psychiatrist who trained with us at Mount Sinai. On September 11, 2001, she was visiting her husband, who worked for Cantor Fitzgerald at the World Trade Center. No one above the 85th floor survived. I’d like to think some of her lives on.”

  “I was a PG-five on September 11th,” Dr. Breckenridge said. “They were ready to send us to New York to help with the head trauma cases. But there weren’t any survivors, so we stayed here.”

  Jonas recognized the Maryland accent. “Is that Baltimore I hear?”

  “Hopkins undergraduate and medical school; 1991 and 1996.”

  “Penn undergraduate, 1974. Hopkins med school, 1978,” Jonas said. “For all we know we sat in the same seats at grand rounds on Saturdays.”

  “Could well be,” Dr. Breckenridge said as she checked Gregory’s pulse, then lifted his eyelids in succession and shined her light at them. She smiled. “It’s better now. The left pupil was practically fixed when I saw him in the ER. Here,” she handed Jonas the penlight. “Take a look.�
��

  “He has his mother’s eyes,” Jonas said as he examined Gregory. “Word has it that you did a great job tonight.”

  “I hear you were pretty busy, yourself,” she said.

  “How did you know?”

  “Philadelphia’s really a small town. Everyone knows everybody’s business.”

  Jonas laughed. “So I’ve heard.”

  “Dr. Liddle and I are rounding at 6:30 AM. In case he doesn’t see you, he said to tell you Jock’s youngest is thinking about medical school. He wants to be a psychiatrist.”

  “That’s wonderful. If I miss him, please tell Dr. Liddle that I’m happy it all turned out well.” Jonas looked at Dr. Breckenridge with admiration, then turned back to Gregory. “Amazing organ, isn’t it; the brain?” Jonas said. “We both touch it. You with your hands and instruments. Me with words. I thought about going into neurosurgery, but I knew I couldn’t survive the training. Put a scalpel in my hands when I’m tired and I’m a danger to society.”

  “Do you remember the first time you saved someone’s life?” Dr. Breckenridge asked.

  Jonas nodded. “Of course.”

  “What happened?”

  “I had just gone into practice. A woman with postpartum depression called to say good-bye. I was treating her with medication and psychotherapy and it looked like she was perking up. I usually let calls ring through to my answering service, but I was between sessions so I picked up. She sounded strange, so I asked what was happening. She said she wanted to thank me for trying.

  “‘Trying?’ That sounded strange so I asked what was happening that moment. She said she had just lost her temper and slapped one of her toddlers. She hadn’t slept for two nights because her ten-week-old had developed colic. She said her children would be better off without her. She was holding the phone with one hand; in the other she had her pill bottle—before Prozac was widely prescribed we used tricyclics. She had already taken ten and was about to swallow the rest. Fortunately her husband was home. I had him take her to the hospital immediately. By the time they got to the ER she was in a coma. A few minutes later she went into cardiac arrest. They started chest compressions, gave her IV bicarbonate and sympathomimetics; then they shocked her back into sinus rhythm. She survived. After three weeks on the psychiatry ward she went home. We got her a doula and counseled the couple. Today she’s fine. Three children under three—can you imagine what her death would have done to that family?”