Edison McDaniels is a neurosurgeon and novelist living in the American South. His writing tends to involve ordinary people in extraordinary circumstances, often informed by his knowledge of medicine and surgery. His most recent novels include Not One Among Them Whole and The Matriarch of Ruins, Books I & II of The Gettysburg Trilogy—an intense, engaging, and heartbreaking story of the insanity of battlefield surgery at Gettysburg in 1863. Not for the faint of heart.
The Kowalski Scenario
by Edison McDaniels
One Friday night early in my training as a brain surgeon, a teenager came to the emergency room with a burning fever. He had a toxic look about him, with skin the speckled russet color of spoiled potatoes, and just that smell too. He took in long, almost lackadaisical breaths and the best that could be said of him was how listless he seemed, as if living was an afterthought soon to be a distant memory.
“That ain’t tiddlywinks,” as my mom used to say, and they called me because the kid wasn’t talking and wouldn’t—or couldn’t—move his right side. I looked over his labs, saw his white count was off the charts, and discussed him with the peds resident on call. She had already seen him, had looked in his ears, and hadn’t liked what she’d seen.
“Cherry red,” she said, referring to his left ear drum. “A stiff neck and he’s hot too. Temp’s 106—the boy’s a damn fire hazard.”
His brain is boiling. I thought how a fever of 106 is a black hole. Nothing escapes. If we didn’t do something—and fast—he’d never wake up. If he survived at all.
“I’m guessing he has meningitis,” the peds resident said in some far off land I was barely a part of. My mind had wandered.
“Like hell,” I said, thinking out loud. “Meningitis might cause a high fever, even seizures. But it doesn’t cause paralysis. Sounds more like a stroke.”
“Strokes don’t cause a fever, certainly not 106, and why would a thirteen-year-old have a stroke anyway?” she asked in her junior peds resident naiveté.
I could think of half a dozen reasons right off, like maybe he had hydrocephalus and he’d had a dozen operations and now he’d bled in his head. Or maybe he had moya moya, a ruptured aneurysm, a congenital heart defect, a brain tumor, or a hundred other obscure but scary as the day is long diagnoses.
But, of course, I was hearing hoofbeats and seeing zebras when what was right in front of me was a regular old mutt.
My mind was off wandering again when I heard a woman scream. His mother. I nearly ran into her as I rushed into the room, the peds resident only a step behind. I looked past mom to the boy, felt the fire pouring off him like heat waves from a coal furnace. He looked possessed of a devil thing: deathly pale, shaking all hibbidy gibbidy, his arms and legs going up and down and every which way. His back spasmed taut and his head kept lifting off the bed and smacking back down again. His eyes were about the widest I had ever seen—and they were pupilless. They had rolled so far upward only the whites were visible. He wasn’t quite doing the Linda Blair thing with his head spinning 360, but hell was in session in that room all the same. Any moment he’d start spewing that green pea soup shit from his mouth.
“Ativan, 1 mg IV stat,” the peds resident said. “Seizure, we need a lumbar puncture tray.”
“Let me see his CT scan first.” She was thinking to do a spinal tap on the kid. I was thinking we needed to do something, but not a spinal tap. A spinal tap wouldn’t extinguish whatever fire was raging inside his head.
While the ER doc treated the seizure, the peds resident and I checked out the head CT. Sure enough, a barely perceptible rim of fluid lay over the left side of his brain. The tell-tale smoke to the fire that was killing him.
“Empyema,” I said.
“Subdural empyema. Pus over the surface of his brain. Needs his skull cracked right now. That crap’s poisoning him and inflaming the underlying brain, hence the stroke-like symptoms. He may have had meningitis yesterday, but it’s way beyond that now. What we got here’s a neurosurgical emergency.”
In the next few minutes I spoke with his mom (she looked terror stricken when I told her he needed emergency brain surgery, a look I had come to know well after nearly a year in the trenches—nobody is ever happy to see a brain surgeon, go figure) and made arrangements for him to go to surgery with Charlie, my chief resident, who concurred with my diagnosis.
“The kid’s got a fucking boil in his head. Let’s pop it,” Charlie said with his usual screaming candor when I showed him the films.
I invited the peds resident to the OR with us, but she turned a little pale at the idea and said she’d take a rain check and join us another time. I doubted that, but she did help me wheel him upstairs to the pre-induction area. His seizure had stopped by then, but his breathing had shallowed, and I feared it might shallow further if we waited too long.
We didn’t. Charlie and I had the boy in surgery within thirty minutes and had his skull cracked in another twenty. It was pus city in there all right, and, this was Charlie talking again, “smelled like an unwashed toilet.” We irrigated the bad humors off the surface of his brain for another half hour—extinguishing the flames, so to speak—before piecing his skull back together with a few metal plates and screws.
It was after ten when I came out, just in time to hear the chop, chop, chop of the helicopter landing. It carried a twenty-eight year old man who’d shattered the windshield of his car with his head thirty miles down the freeway. He was drunk—God watches over such fools, or so they say—and he didn’t have a scratch on him otherwise. He wasn’t waking up though, so after an hour I pretty much had no choice but to drill a hole in his head and place a pressure monitor. It showed normal and I tucked him into the ICU confident the major issue was alcohol. That whole process took about two hours, by which time there were two more waiting for me in the ER.
They were also men, both under thirty, and had fought each other outside a downtown bar. One of them had a hyperacute epidural hematoma, a huge clot of blood needing urgent surgical attention pressing inward on his brain. The other was lethargic but still conscious. His scan showed a contusion, a bruise really, in his left temporal lobe. I thought he could wait.
I called Charlie again and for the second time that night we did an emergent craniotomy. It was a quick case, maybe ninety minutes, and undoubtedly saved the man’s life. Two-thirds of the way through that operation, a nurse called from the ER to say she was having trouble with the contusion guy. He had grown increasingly agitated and now she couldn’t get his blood pressure down.
When I’d first seen him, he’d been lethargic but arousable, and his blood pressure hadn’t been an issue. That it had become so was not only disconcerting, it might be lethal. I scrubbed out and ran downstairs to check on him. He wasn’t just unconscious, he was unarousable. When I pulled his eyelids back, his pupils were big as frying pans and didn’t react to light. I ordered mannitol and got a follow-up scan, but it was too late.
What had been a tolerable bruise—tolerable meaning he could get by without surgery if it didn’t enlarge—was now a massive clot distorting his brain beyond any tolerability whatsoever. I was almost certainly looking at a dead brain on that scan. Even so, his heart was still beating and I couldn’t bring myself to write him off completely. He was my age after all, and he had been awake on arrival—lethargic, but awake. I couldn’t help but think his demise was my fault. I decided I couldn’t let him die.
As if I had that kind of power.
I called Charlie. He had just gotten in bed and I hated to wake the guy, but that’s how it goes. I explained the situation.
“The Kowalski scenario,” he said, his voice betraying how deeply the sandman dogged him.
“Operating on a dead man. After Tommy Kowalski. He had a thing for operating on the dead. Don’t recall him ever bringing one back though. You wanna operate on the dead, Dozier?”
“You don’t think we should do it?”
“Didn’t say that.”
“Fuckin A, Dozier. Did you call to tell me you were seeing a dead man in the ER? Or because you think you can save him?”
“Because I want to save him.”
“Want’s got no goddamn place in it. You ain’t God.”
“I think we can save him.”
“All right then. Rack ‘em, stack ‘em, and crack ‘em. Get started. I’ll be there before the blade parts the flesh.” I heard not a wit of sleep in his voice now.
I brought the guy upstairs for our third crani of the night. His heart was still beating, maybe just out of habit. His brain, a substantial part of it anyway, oozed out of his head like toothpaste under pressure as soon as we opened a window on the innards of his skull. Awful to watch.
I thought how a head full of pus was preferable to toothpaste brain.
The Kowalski scenario, no doubt about it. I was operating on a dead man. His heart was still beating, but only because it hadn’t got the memo yet. His bruise had blossomed massively—filling his skull with blood and squeezing his brain as if it was a sponge you could wring out—while I had been in the OR with the other guy, who, incidentally, was his assailant. By saving the assailant, I had put the victim beyond all hope. I suddenly hated my job.
Why hadn’t I taken him first?
Charlie and I got him through surgery and the dead guy’s heart kept beating. His heart was still beating when I made rounds later that morning, as well as when I came back after lunch. He was a mushhead, a dead head on a ventilator with a beating heart.
He was never going to recover and I knew it. He would die, no doubt about that, but not before his family went through their own private little hell. That first morning, I met his wife Dana at his bedside. As we spoke, she held his hand and would steal small glances at him, which made the walls seem they were closing in on me. It wasn’t about me, of course, but the walls closed in just the same.
“Me and Tony, we got three kids. What am I gonna tell them?”
I wished she hadn’t used his name. Using his name made him real. Made him a person. Then I thought persons—people—die. This person should have died. I should have let him die.
I had no answer for her.
They had three kids and he coached the oldest one’s T-ball team. Tony was a crane operator, the sort used to build high rise buildings. He was in good shape too, probably from climbing those tower cranes every day. For the next week and more, when Dana wasn’t around, one of his crane buds was.
It was obvious to all, except perhaps Dana, that he couldn’t survive long like this. A bowl of spaghetti had a higher IQ, and a bowl of Jello more spontaneous movement. I couldn’t believe I’d done this to him. I wished he’d die.
I could hardly stand it. I lost my appetite and couldn’t sleep. In my sleep deprivation, I had a dream of walking into the ICU and every bed was filled by mushheads. Every goddamn one of them was named Tony. Tony Kowalski. Then I looked again. Not Tony but Tommy. Tommy Kowalski.
Fucking Tommy Kowalski, who never met a dead man he didn’t want to operate on.
Not even Grace, my girlfriend, was able to comfort me. Every time she tried I pushed her away, told her she just didn’t understand.
“It’s the goddamn Kowalski scenario.”
Grace had no idea what the hell I was talking about. She tried to understand though, I have to give her that. But in the end she always looked at me the way you’d look at a street person who hadn’t bathed in days. I think she pitied me. To her credit, I think her feelings were aroused out of what she perceived as me suffering. Grace wanted to relieve my distress. But of course she couldn’t do that. It was my own private little hell. Separate and distinct even from Dana and her kids.
I thought about quitting.
The final night of this torture, for the record the eighth day since Tony’s brain had turned to cornmeal under my watch, Charlie and I were sitting in a Chinese diner across from the hospital. I sipped soup and ate won-tons in a state one ratchet short of catatonia. My head throbbed and the odor of poo poo chicken, or whatever the hell Charlie was eating, wasn’t helping.
“That chicken really stinks,” I said after picking at my food for what seemed an eternity but was probably no more than a few minutes.
“Thanks Dozier. I get one lousy meal in twenty-four hours and you gotta piss on it.”
“I ain’t cut out for this.”
“Really,” Charlie said. I couldn’t tell if it was a question or a confirmation. “You think that guy would be walking and talking if you’d taken out that contusion?”
“Why didn’t you take him first then?”
“Cause the other guy was dying.”
“No. Not right.”
I dropped my spoon and it plopped soup on the table. I leaned back in my chair. “What the fuck? You were there that night. The other dude was dying in front of us.”
“Yeah, he was. But he wasn’t just dying. He was dying faster.” Charlie looked up from his stinking chicken.
I felt like I was going to vomit. I doubt it was on account of his chicken. “I don’t get it. That guy’s dead because of me.”
“Did you hit him over the head?”
“Of course not.”
“Exactly. We’re surgeons Zach, not gods. You didn’t put him here. We don’t get to decide who lives and who dies. We treat the stuff we can and are humbled whatever the outcome. You didn’t take this guy first because the other guy was dying faster. You triaged. You—we—did what we could. If we’d have taken the contusion first, the epidural would have died.”
I sat upright in my chair. He had a point.
“Early in my training, I might even have been an intern, I saw old man Gifford take a large tumor out of a retarded woman’s head. I think her name was Sandy or some such.” He thought a moment. “Well, her name doesn’t matter. It turned out to be benign, a meningioma. The poor woman hadn’t been able to participate in the decision to operate though, on account of her being retarded like I said. The tumor itself wasn’t really a problem, though it likely would have been down the road. A year? Five years? Ten years? Who the fuck can say. Anyway, her sister made the choice and we cracked her open. The surgery went well. She woke up no problem a few hours after we came out, in the ICU of course. But by the second day she was sucking wind. Brain swelling. No matter what we did we couldn’t control it and she just kept slipping away. On the fifth day she bought the farm. That really fucked her sister up. There was no consoling her and she wouldn’t stop crying. Old man Gifford wasn’t exactly the comforting type though I guess you couldn’t know that since he died before you came on. Anyway, he walked up to her and grabbed her by the shoulders, right there in the fucking ICU waiting room in front of God and country. She said again how it was her fault and he said no, it damn well wasn’t. He asked if she’d put that tumor in her sister’s head. She, of course, said no. ‘Exactly,’ Gifford said. He told her she was no more responsible for her sister’s death than she was for her getting the tumor in the first place.”
Charlie went on. “That kinda shut her up, or at least she stopped bawling, and we walked out leaving her in a heap on one of the chairs. But I was curious and so had to ask, ‘Dr. Gifford, do you feel responsible for that woman’s death?’ Of course Gifford was old as dirt even back then, and he wasn’t ever one for saying much to us residents. If the man ever uttered a sentence longer than five words to one of us residents, I never heard it.
“Except put me in my own grave right now if he wasn’t feeling talkative that day. He kept right on shuffling down the hall like he used to do, didn’t lose a beat so far as I could tell. ‘Son,’ he said when I was beginning to wonder if I’d made a grave mistake—literally. ‘I didn’t put that tumor in her head either.’ Then he did stop, and he turned real slow like and looked me in the eyes.
“I thought he was gonna fire me for asking that question, truth be told. It was the Queen’s rule—you didn’t ever disturb Gifford, and you sure as hell didn’t ask the old man a question. I stood there looking back at him, and I swear I could feel the blood solidifying in my veins. I thought I was a goner.
“But he didn’t fire me. What he did was the opposite really. He said, ‘The thing about neurosurgery, son, is sometimes you do everything right and things still go belly up. Like a fish in a stagnate pond. There’s plenty of water, but no oxygen dissolved in it. To the fish, it seems like they have control, like they’ve done everything just right. But that’s a goddamn illusion, isn’t it? They can suck all the water they want, but in the end they’re still going belly up. Us doctors—neurosurgeons in particular—we’re like the fish. Us having control is only a goddamn illusion. You’d be well advised to remember that. You do your best and if that isn’t enough, well, don’t beat yourself up over the result.’”
My pager went off. I almost chucked it, but that would only have made my head hurt more.
“And you know what?” Charlie asked.
“That arrogant dead sonofabitch was right.”
I nodded, then thumbed the button on my pager when it shrieked at me again. I squinted through my headache to read the message on the screen.
Tony died 5 min ago.
I read it again and took a deep breath. The pain in my head receded, and for the first time in over a week I relaxed.
“You knew that guy wasn’t going to survive before we took him to surgery, didn’t you?” I asked.
“Then why the hell did we operate?”
“Because you gotta see this shit for yourself, Dozier. That’s what the goddamn Kowalski scenario is all about. You don’t do seven years of residency to learn how to operate. Hell, give me twelve months and I could teach a bright chimp to operate. You, being somewhat smarter, could learn operating in six solid months. You do seven years of residency to learn when to operate.”
So there it was, I thought. The Kowalski scenario wasn’t so much about operating on dead people, it was about when it was appropriate to operate at all. More to the point, it was about knowing when enough was enough.
I wish to God the lesson I learned that night had stuck. Knowing when enough is enough would have made things a hell of a lot easier down the road.
But that’s a story for another time.
Copyright 2015 by Edison McDaniels