Beyond the Ice Limit

49

PATRICK BRAMBELL HAD done six months of a general surgery residency, which was how he discovered that he was not cut out to be a surgeon. He was not a team player, which made for bad OR etiquette, and he did not enjoy working with his hands like a mechanic.

And now here he was, performing emergency brain surgery.

The patient, the exobiology lab assistant named Reece, lay anesthetized on the operating table, under bright lights. His head had been shaved and the surgery area cleaned and scrubbed with betadine. Reece’s cranium had been placed in a three-pin Mayfield skull clamp, which held it rigidly in place. A testament to EES thoroughness that such a device happened to be in the surgical cabinets on board.

He had already gone through a stressful procedure—guided in real time by a neurosurgeon in Australia, via Skype—in which he had fixed a lumbar drain in the patient’s lower back to remove some cerebrospinal fluid; this, the Australian neurosurgeon explained, was to “loosen” the brain and make it easier to operate on.

Standing at his side and assisting was Dr. Sax. This was little comfort; Sax was, indeed, an MD, but she had gone on to get a PhD and had never practiced medicine, let alone surgery. She was, if anything, more nervous than he was. As for his own assistant, Rogelio, after Glinn’s crew-wide announcement about the parasitic worms, the man had locked himself in his stateroom, refusing to come out under any circumstances.

On a large monitor in front of him was Dr. Susanna Rios of Sydney, standing over a detailed plastic model of the head and shoulders of a human patient, lying facedown. Next to it was a real human cranium. These were the props she was going to use to guide him through the surgery.

This felt not unlike the nightmare that Brambell sometimes had: of finding himself in the cockpit of a plane, flying it after the pilot had suffered a heart attack, listening to the instructions of an air traffic controller on how to bring the plane in for a safe landing. The dream never ended well.

“The craniotomy will proceed like this,” Rios was saying. “We’re going to remove most of the suboccipital bone in what we call a skull-base surgical procedure. We’re taking out an unusually large bone flap because, while we know the parasite is in the vicinity, we don’t know exactly where it is. You’re sure it’s in between the dura mater and the brain itself?”

“Yes.”

“And the parasite itself is of a rare variety, about which little is known?”

“Quite rare.”

“Very well. I’m going to draw a line on this model, where you’ll make the initial incision.” She drew a line with a Magic Marker, just behind the hairline. “Now you copy it on the patient.”

“Yes, Doctor.” He drew the same line on his patient with a sterile pen.

“Dr. Brambell, your hand appears unsteady.”

Brambell held it up. It was indeed trembling.

“Please close your eyes, take a deep breath, focus, and get that tremor under control.” Rios spoke sternly yet calmly.

Brambell did as she instructed. The trembling steadied.

“Good. Make the incision, like this.” She demonstrated with the scalpel on the plastic model.

He followed suit, the scalpel running lightly along the bone. Guided by the Australian surgeon, Sax followed the incision with an electrical cauterizing tweezers, zapping any bleeders. In between she used a sponge to keep the area wiped clear of blood.

“Now the skin and muscles are to be lifted off the bone and folded back, like this. Clip the edges of the incision with clamps and let the weight of the clamps hang down to keep the incision open.”

She demonstrated with the plastic pieces of the model. Brambell followed suit.

“Very good. Now you’re going to make four small burr holes in the skull with the perforator drill. Like this.”

She drew four black dots on the real skull model and demonstrated. Brambell watched as, ever so gently and deftly, she cut a small hole in the cranium with the drill.

“Go slow. The perforator must be held perpendicular to the bone. Do not stop or pull back until the drill stops itself—which it will automatically just before it penetrates all the way through the bone. Ready?”

Brambell nodded. Sweat was running into his eyes, threatening to blind him. “Dr. Sax, please mop my brow,” he murmured.

He drew four black dots on the cranium, as indicated. He started the air-powered drill, which came up to speed with a soft whine. Then, taking another deep breath, he hovered over the bone with it.

“Do not use downward pressure,” Rios said.

He lowered the drill until it bit into the skull with a high-pitched rasp. He immediately smelled the bone and blood atomized by the device even through his surgical mask.

“Slow…easy…that’s it.”

The drill stopped.

“Pull out and do the next hole. Your assistant needs to be ready with a little bit of saline in there to cool it.”

Brambell eased off and raised the drill, following her directions. In a few minutes he was done with the four holes.

“The perforator,” Rios said, “leaves a very thin layer of bone at the bottom of each burr hole. It has to be taken out, like this.” She demonstrated with a funny-looking tool. Brambell did not have the tool.

“Use a small forceps instead,” Rios said.

He used the small forceps to remove the wafer-thin pieces of bone. He could now see the whitish-bluish-gray membrane, the dura, peeping through the holes.

“Good. Now you’re going to cut from hole to hole using the craniotome. You will cut along the lines, while your assistant uses the suction tube to draw up the saline solution and also gently push down the dura, keeping it away from the saw tip. She should be dribbling the saline into the cutting edge to keep it lubricated and cool.”

Once again she demonstrated. “Ready? Both of you?”

Brambell nodded.

“Turn on the craniotome. Go slow. And steady: there’s no hurrying anything in brain surgery.”

He turned on the saw and it whispered up at a high pitch, like a mosquito. He began to cut along the line. Again that smell came.

As he eased it along the line, Dr. Rios talked him through the procedure, gently correcting him as he went. It took a long time, but was finally done. He expelled air. Sax mopped his brow again.

“Take a moment to rest.”

Brambell closed his eyes, tried to think of something calming—and came up with Hamlet. He began quoting his favorite lines from Hamlet to himself. That worked well. He opened his eyes.

“Now you need to remove the bone piece with a pair of spurtles.” Rios cleared her throat. “May I see your hands?”

Brambell held up his hands. They were steady.

“All right. Use the spurtles to remove the bone flap, but do it slowly and with the utmost care.”

He took the spurtle set and, with infinite care, removed the oval piece of bone.

“Put it aside in the prepared sterile container, and—” Suddenly Rios stopped. “Oh, my God.”

Brambell could see, under the translucent dura membrane, a section of the worm. It was about a quarter inch thick and was coiled, like a snake. It was moving slowly, with a continuous motion.

“What in the world is that?” Rios asked.

“It’s the parasite.”

“That’s like no parasite I’ve ever seen—and I’ve been doing neurosurgery for twenty years.”

“As I told you, it’s rare.”

“Right. Okay.” Now Rios was the one trying to collect herself.

Brambell took a deep breath. He wanted to get this over with. “Dr. Rios, shall we continue?”

“Yes. Yes, of course. Ah, let’s see. Next, wash the dura gently with saline and remove any bone tips.” She demonstrated on her model with the suction tube and saline.

Sax did it.

“Now we’re going to put in two traction sutures with 4-0 silk.”

“What’s a traction suture?”

“It’s a suture that forms an open loop of silk you can stick your finger through and use to lift something up. In this case, you will elevate the dura off the brain, so you can cut it without nicking the organ itself. And…raise the membrane off that parasite.”

Brambell nodded. As Sax gently washed down the dura and suctioned off bits of bone, the worm stopped its slow coiling, freezing in place. It seemed to have sensed something was going on. God, he hoped he hadn’t disturbed the thing. If it slithered off into another part of the brain, they’d have to start all over again.

“This is new to me,” said Rios. “How do you propose to get that thing out?”

“I was thinking I could grab it with forceps through the dura. Get a good grip before it…escapes. Then pull it out.”

“The dura is a tough membrane. You can’t pull it through—that would kill the patient. You’ve got to make an incision first.”

“I understand. But I have to grab the thing by surprise.” He paused. “I’ve got one shot at this.”

“I’m beginning to see the problem. Might I suggest injecting it with an anesthetic first?”

“An anesthetic won’t work.” Brambell didn’t bother explaining that the parasite came from beyond the solar system and had an alien biology; that, he knew, would not go down well with the good Dr. Rios. He cast his eye over the tray of tools, looking for one that would work. There were numerous sets of forceps, including several large ones with teeth.

“So tell me what you think I can do to get that thing out fast,” he said.

“This is outside my area of competence,” Rios said. “Shouldn’t you consult with someone who’s got experience removing these types of parasites?”

“There is no one. Just tell me how to do it, please.”

“Well, the simplest way would be to start with those two traction sutures I mentioned, and use them to pull or lift the dura away from the parasite. Then you make an incision, grasp the parasite with forceps, and remove it.”

Brambell looked at the worm. It had stopped moving, but it didn’t seem alarmed; it looked almost as if it was waiting. “All right. Show me what to do on your model.”

“Keep in mind that any movement that impinges on the brain, even a tiny bit, can cause damage.”

“Noted. Let’s go.”

“First the traction sutures,” Rios said. “These will be two loops of silk that your assistant can put her fingers through to lift or elevate the dura away from the, ah, parasite.” She demonstrated on a second plastic model, using needles to form two loops of silk. She stuck her fingers through the loops and pulled upward, raising the membrane from the brain. “Got it?”

“Got it.”

“The suturing needle should only go two-thirds of the way through the dura. Not all the way. Don’t pierce it.”

Brambell inserted the bent needle into the dura, worked it partway through and then out. He was concerned about disturbing the worm. And in fact, as he worked the bent needle through the membrane—which was very tough—the worm did seem to grow disturbed, and at one point gave a jerk, coiling up tightly. But it stayed put.

“Your assistant will now elevate the dura. Start the incision, and as she elevates it further, it will help you extend the incision to the desired opening. Keep in mind that working with forceps so close to the brain, even the smallest miscalculation—”

“I understand the risks,” Brambell said with ill-disguised impatience. “Dr. Sax? Stick your fingers through those sutures and elevate the dura.” Brambell took up the large, toothed forceps with his left hand and the scalpel in his right, ready to go.

Sax slipped her two forefingers through. The worm moved again, jerked a little. But it remained in place.

“Lift a little more.”

She pulled up ever so lightly. Again the worm jerked, then coiled up tightly, as if to protect itself as the membrane was lifted from it. Brambell poked the tip of the scalpel through the dura, and with a quick, smooth movement cut an opening an inch long, exposing the worm. It remained quiescent.

“A little more.”

The act of lifting helped him open the incision another inch. Now the worm finally seemed alarmed. It coiled itself still tighter. Then, suddenly, its head appeared, raising just like a snake into striking position, pointing at Brambell’s hovering forceps. Its black tooth suddenly unsheathed, like a viper’s fang.

“Good Lord,” breathed Rios.

Brambell moved in with the forceps, slowly, like a cat.

The thing seemed to be watching his hand approach, its head weaving slightly.

Holding his breath, Brambell darted in and seized the creature across its body, the forceps’s hooks sinking in. It slashed about, striking at him like a snake as he pulled it out, at the same time whipping around with its tooth, stabbing its head into the patient’s brain, wriggling around and then pulling its head out with a sucking sound. Blood gushed out.

“Jesus!” cried Rios.

Now it went after Brambell, the head whipping back around again, the black tooth sinking into Brambell’s hand. He gave a yell but didn’t let go, the thing thrashing and stabbing, striking him again and again.

“Son of a bitch!” he cried, throwing it into a container previously prepared for it. Sax slammed the lid. A frantic skittering and high-pitched squealing filled the room. Ignoring his own slashed hand, Brambell turned back to the patient. Blood was welling out of the hole the worm had made, flowing down the sides of the head. The life-support alarms began to beep on the monitoring equipment; the EKG was going crazy—and then, even as he stared, it flatlined and the respiration fell to zero.

Reece died before his eyes, his blood running over the operating table and streaming to the floor.

“Doctor, you’re bleeding,” said Sax, grasping his forearm and pressing sterile pads on the cuts.

He turned on her. “Throw that devil in the blender!”

She obeyed. Brambell pressed the pads against his cut hand, hoping to the living God that the thing wasn’t poisonous.

He turned back to the monitor. Dr. Susanna Rios was still there, staring at the scene with an expression of pure, speechless horror on her face. Her mouth was moving, but no sound came.

“So sorry, Doctor,” Brambell said. “Please stand by—we have another patient.” He heard the blender go on, the squealing of the worm cut short as it was reduced to a gray paste.

He experienced a wave of dizziness, felt Sax gripping his arm and leading him to a chair, sitting him down, giving him a glass of water, and then unwrapping his wounded hand. “Let’s take a look at your injuries,” she said. “Just sit back.”

“We don’t have time,” said Brambell, rising. “We need to bring in Stahlweather.”