The second patient, Barack Balinsky, did not require anyone to hold him. Like Neal Fontaina, he was a catatonic schizophrenic, and he had not deliberately moved a muscle in nearly sixteen years. He had spent almost half his life in his mother’s living room, a feeding tube dripping liquid food into his throat while he lay nestled into a mechanical bed that constantly shifted his position so he would not develop bedsores and contractures. Clearly long-suffering, his mother signed the consent form in silence, then left the residents alone to do their work. Susan supposed she appreciated the reprieve. She wondered if the mother hired babysitters to watch him while she went about her business or if she simply left him to his still and silent world.
When Susan injected the needle, the patient did not so much as stiffen in response. Susan waited for the clear drip of cerebrospinal fluid from the needle’s barrel, only to get a disappointing wash of reddish liquid instead. “Damn it!” She gently removed the catheter, then held pressure over the tiny hole she had made.
Remington looked over the patient’s body. “What’s wrong?”
“Traumatic tap.” Susan realized she must have nicked a small blood vessel on the way in. It happened fairly frequently, usually with a writhing pediatric patient and inexpert restraints. “I’m going to have to send this one home and try again tomorrow.”
Remington stepped around Barack and examined Susan’s work. She removed the gauze so he could look. The wound had already stopped bleeding. “I’m sure you know if you just let it drip a bit, it probably would have cleared.”
“I’m aware of that.” Susan hoped anyone performing a lumbar puncture was. “But it’s protocol. Once we see blood, even if it’s just peripheral, we have to redo the tap. We’re not supposed to take a chance of injecting the nanorobots into the circulatory system. They’re not programmed to function in that environment, and it doesn’t help the patient, either.”
“May I look?”
Susan stepped aside. Remington expertly palpated the area while the patient remained on his side. “You went in at L4/L5.”
His words were not a question, and it was standard procedure, so Susan saw no reason to reply.
“We can still use L3/L4.”
Susan did not know that. In her experience, bloody taps occurred for two reasons: Either the patient had a brain hemorrhage or the needle caught a blood vessel on insertion. In the first case, the tap should not be repeated because of serious danger of brain herniation. In the second, the fluid usually cleared in time, as Remington had stated. The technician could simply discard the first output and wait until the fluid became clear or use the bloody fluid for culture and the rest for cell studies.
If a nonurgent tap had blood, they either tried to work around it or repeated it the next day. If an urgent tap showed blood, they took the presence of the blood into account when performing tests. She had never heard of performing a second tap on the same day. “You can do that?”
“Sure, why not? It’s upstream, so anything you might have nicked the first time shouldn’t cause a problem.”
Susan still hesitated. “And it’s safe?”
“The spinal cord ends at L1 in adults.” Remington pressed a finger into the indicated place in Barack’s back. “It comes down a bit farther in kids, but L3/L4 should be safe for anyone.” He indicated a spot one vertebral space up from Susan’s tap. “Do you want me to do it?”
When Susan had offered to allow Remington to perform Fontaina’s tap, she had not realized the irony of the situation. This time, she laughed out loud. “Isn’t that rather like paging a cardiovascular surgeon to put in an IV?”
“Not exactly.” Again, Remington examined the vial of greenish liquid, paying particular attention to the seal. “Unless you’re planning to bring in Dr. Mandar.”
Susan remembered when she had called on the neurosurgeon to reevaluate Starling Woodruff, and an involuntary shiver suffused her. “Not this time. A first-year neurosurgery resident is as expert as I’m willing to bother for a routine lumbar puncture.”
Now, Remington had to laugh. “Could you imagine? After you gained his admiration, treating him like a scut puppy? He wouldn’t know whether to jump at your command, in case you bested him again, or disarticulate your cervical vertebrae and show your body to your head.”
Susan blushed, not wanting to be reminded of her earlier successes. She felt as if her recent blunders washed those away entirely. “If I paged him for this, I’d deserve the beheading.”
Without further encouragement, or even a definitive answer, Remington set to work on the lumbar puncture. Usually, Susan enjoyed procedures. This time, she felt relieved to surrender it to Remington. He worked with a smooth and confident precision she did not have the experience to equal. In seconds, he had the stylet removed and clear fluid dripping from the barrel.
Removing the seal, Susan handed him the nanorobot vial. Using sterile technique, he attached it, manipulated the plunger, and patiently injected the fluid, a bit at a time.
Susan had done things slightly differently and wondered if Remington had a reason or simply another style. “Is there an advantage to allowing that much CSF to drip out before you start? Also, the slower injection?”
Remington continued to inject the vial slowly. “There’s an article in last month’s Oncology that suggests making a bit of space before injecting intrathecally might decrease the risk for increased intracranial pressure.”
That made sense to Susan. Emptying some air from a balloon prior to twisting it into a new shape did reduce the chances of popping it. What surprised her was discovering a neurosurgery resident who read cancer journals.
“Also, slower injections might minimize postinjection headaches.”
“When did you start reading Oncology?”
Remington injected the last bit of nanorobots and fluid. “I don’t usually. That article caught my eye.” He stepped back, tossing the vial into the biohazard can. “There.” He removed the needle and held a small piece of sterile gauze against the tiny hole it left.
“Wish I’d read it.” Susan did read a lot of articles, about twenty percent of which were outside her field. She made a mental note to further broaden her research. “Do you want to do the last one?”
Remington snapped off his gloves and tossed them as well. “Why?” he asked suspiciously. “Is it an ill-tempered kangaroo?”
Susan cocked her head and turned him a searching look. “No, it’s a paranoid schizophrenic. Why would you ask such a thing?”
Remington cleaned up his workstation, while Susan opened the door to admit the orderly who had brought Barack. The young man swept in, wheeling the patient away.
“Because that’s one of the few reasons one of my colleagues would give up a procedure. I know you’re not anticipating a call for an astrocytoma resection, so if you’re giving away a procedure, it must have the fun factor of a digital bowel disimpaction.”
Susan wrinkled her nose. “Actually, psychiatrists don’t generally fight over medical procedures. We’re more of the pensive variety.” She recalled the joke she had contemplated a few days earlier, certain he knew it. “When a duck flies overhead, we’re more interested in what it might be thinking and feeling than in blasting it out of the sky.”