Lucy Raines bent over them, comforting them. Larry flapped his hands around, helplessly, and said to Weather, "They're about to give them something."
Weather nodded: "We're not the only ones who feel the stress. They're babies, but they know something is happening."
Ellen pushed against the sides of the hospital bed, and that torqued Sara, who stopped crying and thrashed with her hands. The babies could hear each other talking, but had never seen each other.
Larry said, "We just talked to Gabriel, he said everything was going smoothly."
"Yesterday was like a freak accident," Weather said. "Everything now is just like it was yesterday-maybe better. Maybe some of the nervousness got burned off."
"I felt terrible about that guy," Lucy said.
"So do I." Weather bent forward and kissed Sara on the forehead. "It's hard, baby," she said. AN HOUR LATER, the twins were rolled into the OR, sedated, but not yet fully anesthetized. As the two anesthesiologists worked to position them, to rig them with the drip lines and to take a final look at the blood chemistry, to check their monitors, Maret wandered over to Weather and said, "It's time. No problems with the pharmacy this morning."
Weather nodded and followed him into the scrub room. A few seconds later, Hanson, the bone-cutter, followed them in, with his resident; the surgical assistant stood waiting behind Weather. They scrubbed silently, until Maret said, "That first day of practice, we started with Vivaldi. If no one objects…"
"Perfect," Weather said. She'd always had music in her ORs. "Start with 'Primavera.' "
"Your choice," Maret said, smiling at her. "You're okay?"
"Anxious to get going," she said. Her part, her first part, would be routine, nothing more than she did every day: cutting down to bone, cauterizing the bleeders, rolling back the scalp. Then, she'd get out of the way until the bone-cutter was done.
An anesthesiologist stuck his head in: "We're set. You want to say go?"
Maret looked at the team members in the scrub room, pursed his lips, smiled, nodded and said, "Go." THE OBSERVATION THEATER was packed: team members had the first choice of seats, but after that, it was first-come first-seated, as long as you had the right ID. Barakat looked around: the watchers weren't just residents, but included a lot of senior docs on their own time. He was at the back, in the highest row of seats.
Down below, three nurses and two anesthesiologists clustered around the two small bodies joined at the skull; so close to perfection, and yet so far. Each was an attractive child-if there'd been another inch of separation, they'd have been just fine. Now they lay on the special table, brilliantly lit, cradled in plastic, asleep, their eyes covered and taped, the bottoms of their faces isolated in breathing masks.
The scrub room doors opened in, and a small woman led a first group into the OR. A man sitting in the first row of the observation theater said into a microphone, "Doctors Gabriel Maret, Weather Karkinnen, Richard Hanson. Dr. Karkinnen will begin…"
She was masked, hatted, robed, gloved and slippered, wearing an operating shield over her eyes; but she was the woman from the elevator and the Audi, Barakat thought. Right size, right shape. Now that he knew her name, he could Google her, just to be sure.
The narrator said, "For those who just got here, the first procedure will be to open the scalp at the point of conjoin, to remove the first expander, and to prepare the bed for the initial craniotomy."
The surgical lights were miked. Barakat could hear Karkinnen talking with her surgical tech as they prepared the tools on a tray at her left hand. Karkinnen bent over the babies, with a surgical pen, her head blocking Barakat's view of what she was doing. Then Karkinnen straightened and asked an anesthesiologist, "Where are we?" and the anesthesiologist took a few seconds and then said, "We're good. Sara's heart looks good."
Karkinnen: "Dr. Maret?"
Maret looked around and said, "Everybody… may God bless us all, especially the little children. Weather, go ahead."
With Vivaldi playing quietly in the background, Weather took the scalpel from the surgical tech, leaned over the skulls of the two babies. She'd used a surgical pen to indicate the path of the incision, and now drew the scalpel along it, the black line turning scarlet behind the blade. ALL SKIN has its own toughness and flexibility, and from post-puberty to old age, there was so much variation that you never knew quite what you'd get when you made the first cut. Sometimes it was saddle leather, sometimes tissue paper. Older people often had papery skin, and so did the young, though it was different.
Cutting into the twins was like cutting into a piece of Brie; Weather had noted that in earlier operations and no longer really paid attention to it. There was almost no separation between scalp and bone. She cut the first jigsaw pattern, got one little arterial bleeder, burned it, then slowly peeled the skin away from the incision. The room was suffused with the scent of burning blood, not unlike the smell of burning hair.
Her first part had taken twenty minutes.
She hadn't done much, but at the same time, she thought, everything: they were under way. They could still turn back, but the bone-cutter was right there, with his custom surgical jigs. Once they were in, turning back would be more complicated.
"I'm out," she said.
"Looks good," Maret said. "Perfect." SEPARATING THE TWINS was not a matter of simply cutting bone and then snapping them apart. The venous drainage inside the skull had to be carefully managed, or blood pressure would build in the babies' skulls and damage their brains, and likely kill them.
The brains themselves were covered by a sheath of thin, tough tissue called the dura mater, which acted like a seal between the brain and the skull, and channeled the blood away from the brain. The dura mater, in most places, was thick enough that it could actually be split apart-like pulling a self-stick stamp off its backing-leaving each brain covered with a sheet of dura mater.
However, the imaging had shown that there were a number of veins that penetrated the dura mater, and rather than returning to the original twin, instead drained to the other twin. Those veins had to be tied off, and, in the case of several of the larger ones, redirected and spliced into other veins that drained to the appropriate twin.
To get inside, Hanson would fit a custom-made jig, or template, around the join between the twins' skulls. During the course of the operation, he would cut out a ring of bone, with what amounted to a tiny electric jigsaw. When the twins were taken apart, the holes in their skulls should be precisely the shape and thickness of pre-made skull pieces made of a plastic composite material.
Before that could happen, Hanson had to take out the bone, and then Maret, a neurosurgeon, and a couple of associates, would probe the physiology right at the brain, to make sure there was no entanglement of the brains themselves. Imaging said that there was not; if there had been, the shorter operation would have been impossible. When they'd confirmed the imaging, and that the dura mater stretched across the defect, they would begin separating the tissue, and splicing veins.
Weather's surgical tech started giggling at the scrub sink and said, "I was so scared. I did three little things and I was completely freaked out."
"I was a little nervous myself," Weather said. "Are you okay?"
"Oh, sure. It's just that everybody's up there watching. Everybody important. What if I dropped a scalpel on your foot?"
"I'd have to have you killed," Weather said.
The nurse started giggling again, and it was infectious, and Weather started, though it was unsurgeon-like. They'd just stopped when Weather said, "Couldn't you see it? Sticking out from between a couple toes? What would I say? Ouch?"