Cutting for Stone (62 page)

“An intracranial pressure monitor. Goes into the ventricle. He has cerebral edema. They're giving him mannitol and adjusting the ventilator settings to keep the pressure down.”

Shiva looked skeptical. “It goes through his skull, through brain into the ventricle just to measure? It does not treat?”

Thomas Stone nodded.

“How did this begin?” Hema asked.

As Thomas Stone recounted the sequence of events, Shiva freed the bedside table and found slack between the bed and ventilator. He let down the bed rail on his side. Moving with the slow efficiency of a contortionist, he slid under the tubes and wires. Deepak entered in time to see Shiva lying on his side next to me, his head touching mine. His being there looked both precarious and entirely natural. All Deepak could do was stare, noting, however, that my intracranial pressure tracing, which had done nothing but go up for three days, went down.

No sooner had Deepak introduced himself than Vinu Mehta, the gastroenterologist, filled the doorway, panting from taking the stairs. Vinu had been an internal medicine resident at Our Lady when I was a surgery resident. After specializing in gastroenterology he'd joined a lucrative practice in Westchester but wasn't happy and had returned to the salaried staff of Our Lady.

“Vinu Mehta, Dr. Madam,” he said, putting his palms together in a
ñamaste
before grasping Hema's hand with both of his. “And this must be Shiva,” he said, unfazed at seeing Shiva in my bed. “I know this only because I am certain the other gentleman is Marion.” He turned back to Hema. “What a shock this must be, madam. For everyone here, too. Our whole world is upside down! Marion is one of us.” This sudden switch to the vernacular of feelings made Hema's lips tremble.

One look at Vinu and you knew the stories about him buying groceries for patients he discharged were probably true. Id seen him extend a patient's stay to insulate her from some madness at home. He was the best friend to everyone on the staff and regularly baked cakes and cookies for me. I always sent him a card on Mother's Day, which pleased him no end.

“I was called the minute that Marion was brought here, Dr. Madam,” Vinu went on. “Hepatology, the liver, that is my field. Hepatitis B swims around here. Lots of carriers, intravenous drug addicts and people who acquire it from their mothers at birth—very common in immigrants from the Far East. Madam, we see no end of silent cirrhosis and even liver cancer from this virus. But
acute
fulminant hepatitis B? In my career I have seen only two other patients quite this severe.”

“Vinu, tell me the truth,” Hema said, taking on a no-nonsense, Mother India tone with this young doctor who was all too ready to play the role of nephew. “Is my son a drinker?”

I suppose it was a fair question. I hadn't seen her in more than seven years. She knew it was in my genes. What did she really know of who or what I had become?

“Madam, categorically no!” Vinu responded. “No, no. A gem of a son you have.”

Hema's stern expression softened.

“Although, madam,” Vinu continued, “in the past few weeks, madam—don't take this wrongly—by the report of his neighbor, Marion had been troubled and drinking.”

Deepak had found a new prescription in my house for isoniazid, a drug used to prevent tuberculosis. Isoniazid was also famous for causing severe liver inflammation. It was routine to check liver enzymes two weeks after starting treatment so the drug could be discontinued if there was any sign of liver damage.

“My hypothesis, madam, is that Marion-
bhaiya
started isoniazid on his own. The prescription is a month old. He probably didn't get his blood drawn to check liver functions the way he was supposed to. He is a surgeon after all, poor fellow. What does he know about these fine matters? If he'd only consulted me! I would have been honored to take care of him. After all, Mari
on-bhaiya
took care of my hernia so lovingly.

“In any case, madam, I personally went to Manhattan, to Mount Sinai, and I chauffeured over the world's best liver man, the man who trained me in this specialty. I said, ‘Professor, this is a not a case of hepatitis, but a case of my own brother.’ He is in agreement that the alcohol and the isoniazid might be contributory, but there is no doubt that what we are dealing with here first and foremost is hepatitis B.”

“What is the prognosis?” Hema said. “Will someone tell me that?” It was the most basic thing a mother wanted to know. “Will he get better?”

Vinu looked to Deepak and Thomas Stone, but neither man was willing to speak. The disease was, after all, Vinu's area of expertise.

“Just tell me. Will he live?” Hema spat out.

“It is undoubtedly very grave,” Vinu said, and the fact that he was fighting back tears told her everything.

“Come on!” Hema said, annoyed by this and turning to Thomas Stone, and then to Deepak. “It's
hepatitis.
I understand hepatitis. We see the damage it does in Africa. But … here, America! In this wealthy place, this
rich
hospital”—she swept her hands at all the machinery— “surely here in America you can do more for
hepatitis
than to wring your hands and say
it is very grave.
“

They must have winced when she said “rich.” Compared with the state-of-the-art ICUs in the money hospitals, such as Thomas Stone's institution in Boston, ours was bare-bones.

“We tried everything, madam,” Deepak said now in a more subdued tone. “Plasma exchange. Whatever anyone in the world can do for this disease, we are doing that here.”

Hema looked skeptical.

“And praying, madam,” Vinu added. “The sisters have a prayer chain going around the clock for two days now. Honestly, we need that kind of a miracle.”

Shiva had quietly followed every word from where he lay.

Hema stood looking down at my unconscious form, stroking my hand and shaking her head.

Vinu convinced the two of them to retire to a room readied for them in the house-staff building; he'd even arranged for a light dinner of cha-patti and dal. Hema was too tired to argue.

THE NEXT MORNING,
Hema appeared in an orange sari, looking rested, yet as if she had aged a few years in the course of the night.

Thomas Stone was exactly where she had left him. He looked past her in the doorway, as if expecting Shiva, but Shiva wasn't there.

She stood by my bed again, anxious to see me in daylight. The previous night she'd found it all too unreal, as if it were not me on the bed but some extension of all the noisy machinery which had taken the form of flesh. But now she could see me, see the rise and fall of my chest, the puffiness of my eyes, my lips contorted by the breathing tube. It was real. She couldn't help herself, and began to weep silently, forgetting Thomas Stone was there, or not caring one way or the other. She was only conscious of him when he tentatively offered a handkerchief. She snatched it from him, as if he'd been slow to offer it.

“It feels as if this is happening because of me,” Hema said. She blew her nose. “I know that sounds selfish, but to lose Ghosh, then to see Marion like this … You don't understand, it feels as if I have failed them all, that I let this befall Marion.”

Had she turned, she might have seen Thomas Stone stir, seen him rub his knuckles against his temples, as if trying to erase himself. He spoke, his voice hoarse. “You … you and Ghosh never failed them.
I did.
I failed all of you.”

There it was, Hema must have thought; it was both the sorry and the thank-you that was so long overdue, and the funny thing was that at this moment, she didn't care. It no longer mattered. She didn't even look his way.

SHIVA ENTERED,
and if he saw Thomas Stone, he didn't acknowledge his presence. He had eyes only for me, his brother.

“Where were you?” Hema said. “Did you sleep at all?”

“In the library upstairs. I took a nap there.” Shiva surveyed me, then he studied the settings on the ventilator, and then the labels on the fluid-containing bags hanging over my bed.

“There is one thing I didn't ask Vinu,” Hema said to Stone. “How did Marion get hepatitis B?”

Thomas shook his head as if to say he did not know. But since she wasn't looking his way, he had to speak. “It … was probably during surgery. Nicking himself. It's an occupational hazard for surgeons.”

“It can also be acquired by sexual intercourse,” Shiva said, addressing Thomas Stone. Thomas Stone stammered assent. Hema glared at Shiva, one hand on her hip. She didn't get a chance to speak, because Shiva had more to say: “Genet was at Marion's house, Ma. She showed up there six weeks ago. She was sick. She stayed for two nights and then disappeared.”

“Genet … ?” Hema said.

“There are two people in the waiting room you need to meet. One is an Ethiopian lady, Tsige. She used to live opposite Missing. Ghosh took care of her infant years ago. Marion met her again in Boston. The other is Mr. Holmes—he is Marion's neighbor. They want to speak to you.”

BY MIDMORNING,
Hema knew the whole story. Genet had been ill with TB. But Appleby had his hands on the prison health records and they showed what we had not known before: Genet was also a silent carrier of hepatitis B. She contracted it (or so the prison doctor postulated) from an improperly sterilized needle or a transfusion or a tattoo when she was in the field in Eritrea; she could also have acquired it sexually. Genet had bled readily when we slept together, and I had been generously exposed to her blood and thereby to the virus. The incubation period of hepatitis B fit Shiva's hypothesis: it was six weeks from her visit to my falling ill.

Hema paced the waiting room, cursing Genet and bemoaning my stupidity in letting Genet get close to me again after everything she had put us through. Had Genet appeared just then, I would have feared for her life.

WHEN DEEPAK AND VINU
made rounds together that afternoon they shared the latest lab results: my kidneys were failing; my liver, normally the source of clotting factors, wasn't producing any. If there were any viable liver cells left, they were showing no signs of recovering. There was not a bit of good news they could convey. They withdrew, Shiva following them. Thomas Stone and Hema stayed, silent around my immobile form. Now it was a watching game, a vigil to the end. There was no hope. The two of them as physicians knew it all too well, but if anything, experience made it even less palatable.

AT NOON,
an ICU nurse paged both Deepak and Vinu to a Stone family conference. They came to find Hema and Shiva seated across from Thomas Stone in the small meeting room.

Hema, weary, head in her hands and elbows on the table, gazed up at the two young doctors in white coats, her son's peers. “You wanted to see us?” she said impatiently to Vinu and Deepak.

Deepak looked puzzled. “I didn't call this meeting.” He turned to Vinu, who shook his head.

“I did,” Shiva said. He had a stack of photocopied papers in front of him. A yellow legal pad was covered with notations in his careful script. Hema noticed an authority to his voice, a sense of action and energy and initiative that no one else seemed capable of displaying in the face of my terrible prognosis. “I called the meeting because I want to talk about a liver transplant.”

Deepak, who found it difficult to sit face-to-face with Shiva and not feel he was speaking to me, said, “We considered a transplant early on, Shiva. In fact, Dr. Stone and I talked about transferring Marion to Mecc—I mean to Boston General, Dr. Stone's hospital. Dr. Stone's team does more transplants than anyone on the East Coast. But we decided against it for two reasons. First of all, transplants are notoriously unsuccessful when the liver is being destroyed by fulminant hepatitis B. Even if we found a cadaver liver of the right blood group and size and we did the transplant successfully, we would have to use massive doses of steroids and other drugs that suppress the immune system to prevent rejection of the new liver. That would give the hepatitis B virus a field day and the new liver would be destroyed and we would be back to exactly where we are now.”

“Yes, I know,” Shiva said. “But what if the transplant is a perfect match? Not just the same blood group, but all six HLA antigens and other antigens you don't even measure—what if they
all
matched? Then no immune-suppressing drugs would be needed? Right? None. No steroids, no cyclosporine, nothing. Would you agree?”

“Theoretically, yes, but …,” Deepak said.

“A perfect match is what you would have if you took the liver from me,” Shiva said. “His body would see it as self, not as foreign in any way.”

The air had been sucked out of the room. No one spoke for a few seconds. Seeing Hema's expression, Shiva quickly explained, “I mean take a
part
of my liver, Ma. Leaving enough for me and taking out a lobe to give to Marion.”

“Shiva …” It was on Hema's lips to apologize for Shiva—this clearly was not his field, or hers for that matter. But then she changed her mind. She knew something about his tenacity when it came to medical situations that others thought impossible. “But, Shiva, has that ever been done—transplanting part of a liver?”

Shiva slid one of the articles over to her. “This is from last year. A review by Deepak Jesudass and Thomas Stone on the prospects for
live donor
liver transplant. It hasn't been done in humans, Ma, but before you say anything, read page three where I have underlined. They say, ‘Technically, the success in almost one hundred dogs, the ability to sustain life in the recipient and not jeopardize life in the donor, suggests that we are ready to perform this operation on humans. The risks to a healthy donor present a significant ethical obstacle, but we believe the critical shortage of cadaver organs obliges us to move forward. The time has come. Live donor transplant will overcome both the problem of organ shortage and the problem of cadaver livers that are damaged because it has taken too long to get consent and too long to remove the organ and get it to where it needs to be. Live donor liver transplant is the inevitable and necessary next step.’ “