Matthew Trujillo came from a lineage of physicians and never seriously considered entering another profession.  His father was a general surgeon in San Antonio and Trujillo’s grandfather had been a family practitioner in El Paso.  Trujillo was in the sixth and final year of the neurosurgical residency.  He had married Teresa five years ago but they had no children yet.  Teresa was expecting any day now after two earlier pregnancies ended in miscarriages.

Trujillo silently got up two hours before morning rounds.  He retained the nimble movements of the college gymnast he had been a decade ago.  Teresa could rest since she had taken leave from her downtown law firm.  Her thick black hair curled around her narrow shoulders.  She had a full night of sleep but Trujillo still saw the weariness that settled on her face after the second miscarriage.  Two years earlier, they held hands as they walked across the gray tiled hospital floor. Trujillo had told her that they would endure whatever happened.  The tense lipped obstetrician reviewed the rare condition: oligohydramnios.  The fetus had undeveloped kidneys so there was too little amniotic fluid.  His tiny heart beat was decelerating and the pregnancy had to be terminated.  

 Afterwards, a nurse brought the fetus, cleansed and wrapped in white towel.  His skin was wrinkled with a thin purple translucency:  a tiny boy curled over with fists clenched tight who never took a breath like a fragile bird who fell from the nest.  On the drive home, they passed families strolling through the park.  Trujillo remembered how they lay silently for hours and awakened to an arid morning where their dream had entered the soil to nourish the grass.  But somehow, an inner map propelled them forward to where they could see a path that circled back to before there was too little fluid.

Trujillo thought that the death of their tiny child had been a lesson that made him a better physician.  He learned how it felt when death claimed a family member but he would have gladly left medicine to have seen that child live.  Teresa’s third pregnancy had gone smoothly except for the expected early nausea.    There were no abnormalities on the ultrasounds but there was still a nagging doubt that would not be resolved until they heard a healthy baby crying with its first breaths.

Trujillo scrambled four eggs with milk and parmesan cheese and left half on a plate for Teresa.  He walked to the driveway of their townhouse to retrieve the newspaper.  An orange haze lingered over the green hills.  Matthew read on the first page that a serial arsonist was suspected in the northern forest fires.  Many people wore face masks and traffic clogged the bridges.

As he ate breakfast, Trujillo looked at the framed photographs on the shelf.  There was a gilt framed wedding photograph taken in the apse of the college chapel and a ceramic framed honeymoon photograph from Cabo San Lucas with Teresa wearing a yellow sundress.  He said a silent prayer for Teresa and the baby.  Trujillo attended Catholic schools through the twelfth grade but was not overtly religious.  He went to church only at Christmas or Easter when his parents visited but in times of need he still prayed.

Trujillo returned to the bedroom where Teresa was still sleeping and kissed her forehead.  She took his right hand and placed it on her drum tight abdomen.  The baby gave a swift kick that brought a smile to both their faces.

“Today could be the day,” Teresa said.  Her obsidian eyes sparkled again.

“Have me paged,” he said.  “I’ll get another senior resident to take over if I’m in surgery.”  In his wife’s eyes, he saw a glimpse of the happiness that filled the early years of their romance and marriage, before the stresses of his neurosurgical residency, her legal associate’s hours, and the miscarriages.

“I can call Maria if you are in surgery.”  Teresa’s sister was a high school teacher who lived six blocks away and had the summer off.

Dense haze shrouded the estuary and the harbor.  As he drove along the familiar switchbacks, Trujillo thought about the first surgical case.  Emily Mason was twenty six years old and in previously perfect health.  Three days ago, she collapsed after a thunderclap ten out of ten on the pain scale headache.    After Trujillo placed a ventricular catheter to relieve the increased intracranial pressure, Emily woke up gradually and was now ready for the aneurysm surgery.

Aneurysms were among the most complex neurosurgical cases and were viewed as a culminating test for the neurosurgical residents.   Trujillo reflected on the years of training that were now coming to a close.  During the first year, residents learned how to stop bleeding and to perform the openings and closures of surgical cases.  By the second and third years, they could perform most of the craniotomies for hemorrhage and trauma.  In the fourth and fifth years, they became proficient in spinal surgery and brain tumor surgery.  By the sixth year, they could take on the aneurysms and complex skull base cases with a senior attending neurosurgeon standing by.

Since Trujillo was the chief resident, he supervised the interns on Emily’s preoperative preparations.  Dr. Sid Narayan, the attending neurosurgeon was listed as the primary surgeon but Trujillo would perform the surgery including the clipping of the aneurysm.  If the case went smoothly as planned, Narayan would observe and then leave the closure to the residents.

In the second floor pre-operative holding area, Trujillo sat down at a computer station to review the cerebral angiogram.  He followed the arboreal branches of the arteries. The carotid artery was the main trunk that branched in the neck with the internal carotid artery piercing the base of the skull.  The internal carotid artery split into the anterior and middle cerebral arteries that then divided further into a fractal pattern of distal branches.  Emily’s aneurysm occupied the bifurcation of the middle cerebral artery.

The patients were aligned in rows of gurneys separated by white curtains.  The stalls were numbered corresponding to the operating rooms.  Trujillo opened the curtain at bed 8.  Emily looked like one of the young interns.  She pulled the blanket up to her chin. Her mother, an elegant looking woman who wore a dark pant suit, sat on a chair at the bedside.  They looked at Trujillo solemnly after greeting him with faint smiles.

“We’ll take good care of you,” Trujillo began.

“Could the aneurysm burst in surgery?” Emily asked.

“That can happen but we have ways to control the bleeding.” Trujillo hoped he projected confidence but also a respectful vigilance.

“I wish it was me and not my daughter that had to go through this,” Emily’s mother said.  Her eyelids were swollen as if she had cried until the tears ran out.

“I fully expect that we will clip the aneurysm successfully and Emily will go on to have a long and healthy life.”

An orderly came to push the gurney into the operating room.  Trujillo followed down the brightly lit hallway.

“Will you talk to my mother after surgery?” Emily asked.

“Of course.  I will also have a nurse call her with updates during the surgery.”

In the operating room, the anesthesiologist stood at the head of the surgical table while the surgical scrub nurse arranged instruments on adjacent higher tables.  As the anesthesiologist prepared for the intubation, Trujillo took in the scene and reviewed the surgical sequence.

The instrument tables were draped in seascape hue.  Any tool on blue was sterile and ready.  Like in an orchestra each instrument had its place but, more like an assembly line, surgery was not music or poetry.  On the front table, rested scalpels and probes.  There was a large blade for scalp and fascia, a small blade to cut the dura mater, and a pointed tip to puncture a cyst.  Curved probes freed dura mater from skull.  In a bucket on a low table, the drill was poised to penetrate the skull along with a saw to connect the holes.  On the back table, waited curettes and punches to remove more bone for a better view. 

The circulating nurse cleaned the skin to begin the ritual.  The scrub nurse helped Trujillo and the intern don the surgical gowns and gloves. Trujillo asked for a sterile pen to mark the incision:  a question mark over the temporal and frontal lobes.  He asked for the knife and extended his right palm.  Surgery was not music or poetry but had aspects of prosody: structure, pace, and rhythm.  There was no rhyme scheme just blank verse.

For the second time that morning, Trujillo composed a silent prayer.  This was not a prayer for hopeless cases like a prayer to Saint Jude.  His thoughts were a free form nondenominational plea.  May the aneurysm not rupture and may the clip close tightly across its neck.  I will praise God with the saints forever, only deliver us from evil now. 

  Trujillo let Gabriel, the young intern, extend the incision that started in front of the left ear and arced up and then in front up to the hairline.  This question mark shaped incision was the most common approach to cerebral aneurysms.   Every time he made this incision, Trujillo understood that the question mark challenged his competence as a surgeon and his assurance to the patient that they were in safe hands.

Trujillo applied plastic clips to the scalp to stanch the bleeding and then retracted the flap to expose the pterion, the point where four skull bones joined to form a shield.  Reed used the suction tip to keep the surgical field dry.  Trujillo used the power drill and saw to define a four burr hole skull flap that he elevated with a probe to reveal the underlying dura mater.  Then, with a diamond tipped drill he removed the sphenoid ridge, the last bit of bone that hid the aneurysm.  Trujillo asked the circulating nurse to call Dr. Narayan.

 Narayan joined the case after reviewing the cerebral angiogram that was on the large wall mounted monitor. Trujillo opened the dura mater to reveal the cream colored and gently pulsating brain.  Reed stepped back to make room for the attending neurosurgeon and then left to see a patient in the emergency room.

The circulating nurse pushed the microscope into place.  Trujillo advanced the retractors to gently pull apart the frontal and temporal lobes and expose the internal carotid artery and the optic nerves.  He advanced the retractor a little more to expose the distal arterial branches.  The aneurysm then came into view, red and pulsating.  The microscope light made the aneurysm dome gleam.

Trujillo selected a small titanium clip that the scrub nurse placed at the tip of a bayonet holder.  He steadily advanced the clip towards the aneurysm.  Then, the surgical field suddenly filled up with blood.  The aneurysm had burst.

There was a red blooming silence in which Trujillo held his breath.  He had a momentary impulse to back away but he did not flinch.  He knew that Dr. Narayan was wondering how he would react.  In that instant, he thought of the young woman on the operating table.  She was shrouded under the blue drapes with only skull and brain exposed but Trujillo saw her fearful hazel eyes and remembered her words before surgery.  He saw Emily’s mother.  He did not want to face that elegant woman to tell her that her daughter had suffered a devastating stroke.

There was no commotion in the cool silence of the operating room.  This was a scenario that they had contemplated and for which they were prepared.  Trujillo pushed a cotton patty into the blood and Narayan followed with the suction.  Trujillo called for a temporary clip and asked Narayan if he agreed that they should temporarily clip the middle cerebral artery proximal to the aneurysm in order to gain some time and stop the bleeding.  Narayan assented and asked the anesthesiologist to get blood ready for transfusion.  The temporary clip stopped the bleeding and then they could see the hole in the artery. 

“We’ll have to use a circumferential clip,” Trujillo asserted calmly.  The circumferential clip might not be as strong as the standard clip but could go around the artery and cover the hole.

“I agree,” said Narayan.

The circulating nurse loaded the cylindrical clip.  With the suction tip, Narayan kept gentle pressure on the cotton patty to plug the hole in the artery.

“Do you want me to take over?” Narayan asked.

“No. I can do it.  If I don’t stop the bleeding with one pass, then I’ll turn the case over to you.”

“Go ahead,” said Narayan.

Behind the sterile drapes, the anesthesiologist declared that the blood pressure and pulse were still stable.

Trujillo focused all his attention on the clip.  He had to succeed for the sake of this young woman.  The consequences of failure were unthinkable. 

Trujillo and Narayan moved in steady unison as if with a single mind melded with the artery and the clip. Trujillo gently squeezed the clip holder to open the cylinder over the artery.  He asked Narayan to pull the string attached to the cotton patty.  Trujillo then released the holder grip.  He could see that the circumferential clip contained the hole in the artery. He removed the temporary clip with another bayonet holder.  Blood flowed freely to the distal artery but none leaked through the circumferential clip.  The clip maneuver took less than five minutes so there was unlikely to be any brain ischemia.

“Good job Matthew,“  Narayan said.  “I could not have done any better.”

“Thank you,” Trujillo said.  He felt a warm flush of success as if he had passed a final examination.

“I will leave you to close with Gabriel,” said Narayan.

            Reed was waiting and already scrubbed.  Trujillo told Reed what to look for after surgery.  He did not want any hypotension and wanted a normal hematocrit even if a blood transfusion was necessary.

            “Emily’s bleed caused a classic neurological syndrome,” Trujillo said to Reed.  “Do you know which one?” he asked in the age honored tradition of pimping or peppering the interns with obscure questions. 

“Gerstmann’s syndrome.”  This was one of the few syndromes Reed remembered from his neurology rotation during the third year of medical school.

“Do you know what Gerstmann’s syndrome involves?”

“Difficulty with writing and calculations along with confusion of right and left sides.” 

“Three out of four.  Also, finger agnosia.”

“Inability to distinguish the fingers, like the thumb from the index finger.”

 “Correct.  Do you know who Gerstmann was?”

“A neurologist?” offered Reed.

“Good guess.  Do you know where he was from?”  Trujillo knew Reed was probably too tired to remember trivial details from his textbooks.

“San Francisco?”  Reed tied the stitches that Trujillo placed through the galeal layer of the scalp.

“Bad guess.  What country?”

“Canada?”

“Wrong again.  He was a distinguished neurologist in Austria before the Second World War.  He escaped the Nazi annexation and fled to New York.” Trujillo started placing the staples on the scalp.

“Good to know,” Reed said.  He thought such information was useless in the daily tasks of taking care of patients but it was interesting that there was an historical drama behind the syndrome.  There was likely a story behind each syndrome, each diagnosis, and each patient. 

Trujillo left Reed to wrap the white turban bandage around Emily’s head.  He strode downstairs and through the lobby to look for Emily’s mother in the waiting room.  She was waiting in a quiet vestibule.  Trujillo sat down in the opposite chair as she looked at him anxiously.

“Good news,” Trujillo said.  “We successfully clipped the aneurysm.”

“You perform miracles each day.”  She said and clasped his hands.

“The surgery was difficult.  The aneurysm did burst but we were able to quickly stop the bleeding and get a clip on.”

“Could she suffer a stroke?”

“That is very unlikely, but I will check on her soon.  I will have the nurses update you again.”

“Thank you and thanks to Dr. Narayan as well.”

“You should be able to visit Emily in about half an hour, after the nurses get her settled in the recovery unit.”

Trujillo returned to the second floor where Emily smiled when she saw him.

“Is the aneurysm clipped?” she asked.

Trujillo beamed as he recognized that there was no worsening in her speech.  “Completely,” he said.

Emily’s shoulders relaxed as Trujillo tested the strength in her arms and legs which were all normal. 

            “There was bleeding from the aneurysm before we placed the clip but you are obviously fine,” Trujillo added.

“When I woke up, I thought I had died and somehow come back.”

“There was bleeding but you were never in such danger.”

“I remember looking at my body from above.  I was level with the two operating room lights that flooded the room bright white.  I had an eerie sensation like I was exiled to a strange planet with two suns.”

“Maybe that was when the aneurysm bled.”  Trujillo had heard about such out of body experiences when death was narrowly escaped.

“I was not afraid and there was no pain.  I could see you and Dr. Narayan huddled over a microscope pointed at my open skull.  I wanted to see the aneurysm but I could not.”

“That must have been frightening for you.”

“I was not afraid and there was no pain but I wanted to come back here.”

“Here you are.”

“Here I am. You have given me a new life.”  She squeezed Trujillo’s hand.

Trujillo went to the doctor’s lounge to get a snack before the next case.  He chose a lemon yogurt and a small apple juice bottle from the refrigerator.  He thought about what Emily had said about almost dying.  When the aneurysm burst, there was no drop in her blood pressure but just beyond the hole in the cerebral artery, brain tissue could have suffered diminished perfusion.  Part of her left frontal lobe had been in the realm between life and death while the rest of her brain and body was fully alive.  The rest of Emily’s brain could have been trying to figure out what was happening in the left frontal lobe.  Possibly, she had a dream that reviewed her fears and hopes as she emerged from anesthesia in a sedated sleep state.  Trujillo recognized that what Emily described might not be in the domain of science with its requirement for verifiable facts but her words seemed true nonetheless. 

Trujillo then thought of Teresa and wondered how her day had gone.  He wanted recount for her the mortal struggle in the operating room.  Blood had poured out and might fill the surgical field if he could not stop the flow with a temporary clip.  They teetered at the verge of a nightmare where blood streamed beyond the skull, down the blue drapes, and dropped down in rivulets across the floor.  Their young patient could soon bleed out and they would have to pull off the drapes to perform cardiopulmonary resuscitation.  Just in the knick if time, Matthew swooped in with the clip, stopped the bleeding, and thereby saved the day.  Teresa might be impressed or she might arch her delicate eyebrows, smile skeptically, and tell him to stop the melodrama.

Trujillo checked his cell phone.  He had missed a text from Teresa’s sister from one hour ago.  Teresa had broken her water and Maria was driving her to the labor and delivery ward.  He texted back that he would meet them within ten minutes.

Trujillo took the elevator up to the fifth floor. On the white board on the wall behind the nursing station, he saw that Teresa had already been assigned a room.  Trujillo rarely visited the neonatal ward to see babies with hydrocephalus or intracranial hemorrhage, but he was wearing a long white coat and there were no questions from the busy nurses as he marched through the sliding doors and down the corridor.

When he stepped into the assigned room, Trujillo saw Teresa in the bed.  Maria was sitting in a chair next to the window.  In the distance, the city towers and boats in the marina shimmered brightly in the afternoon light.  Teresa’s face was flushed and her hair was loosely tied back in a ponytail.  In her arms, she cradled the newborn baby swaddled in a white blanket.

“A baby girl,” Teresa announced.  She looked exhausted but radiant at the same time.  “Perfectly healthy,” she added.

“What was the Apgar score?” Trujillo asked.

“Nine out of ten at five minutes.”  On a zero to two scale, a neonatologist had rated five features of the physical examination: breathing, pulse, muscle tone, reflexes, and skin color.

“We could not have hoped for better.”

“Her fingers and toes were bluish at five minutes but now they are perfectly pink.”

“I missed everything,” Trujillo said.  “I’m so sorry.”  He slumped down on an empty chair beside Maria.

“That’s alright,“  Teresa said.  “We knew you would come as soon as you could.”

“We knew you were in surgery,” Maria added.  “That’s why I didn’t overhead page you.”  Maria was four years younger than Teresa and had her dark eyes but was two inches shorter.

Teresa turned the baby to face him.  The baby had dark gray eyes like pebbles at the bottom of an alpine stream.  She seemed to focus on him as if she wondered who he was.  Trujillo felt as if his heart might detonate with happiness but he did not want to hold her yet.  She seemed so fragile.  He placed his index finger in her palm and she grasped tight.  Then, she stuck out her little curled tongue.  Teresa laughed as Trujillo stared in wonder at both of them. 

“Did your aneurysm case go well?” Teresa asked.

“Yes.  But, I can tell you about that some other time.”

Teresa handed him the baby and as he pressed her against his chest, Trujillo felt both their hearts pounding. The baby’s dark hair was still wet and clumped around her little head. 

 Trujillo knew that this was a day that cleaved past from future.  He could not imagine how he could have persevered with neurosurgery if he had a disastrous case just when he was about to finish his training, if the answer to the question mark had been failure.  He did not know how Teresa could have endured if their daughter had not been healthy. The flow of time had endless possibilities like the branching network of arteries in the brain, like the countless interconnections of the axons and dendrites.  Time was like that bright red life giving blood and could have flowed through any number of pathways and at each branch, there was a question mark.

Somehow, time had paused for a moment, in this hospital room.  All the past was preparation and he could not fathom how their lives had come to this joyful junction.  For an instant, Trujillo thought of their tiny bird like boy from two years ago but then the sight and warmth of their perfect newborn baby girl crowded against that bitter memory.  Life was here and now and in this moment, there was lasting joy that could not be measured on any scale.

By Thomas Mampalam

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