Chapter 62: Shepherdess is Back!

June 10

Before the last shift of her first week back, Amelia sat down with Derek for a heart to heart conversation. She was ready to clearly assert herself to the Head of Neurosurgery and demand that she be trusted with surgeries more complex than aneurysm clips. Her goal was to do so professionally rather than as a pissed sister. By sharing in the beginning that she appreciated his concern for both her and his department, Amelia stressed that she was ready to return to his previous expectations of her abilities.

In order to persuade him, she invited him to challenge her, "Provide the details of any neuro case you can imagine or have ever encountered, and, without any prep, I will provide an initial assessment and plan right here and now," Derek, up for the challenge, rattled off four different scenarios. He was sure that she would be stumped at least a little by each one. After all, he knew that each of those cases had stumped him when he had encountered each one.

Yet once again, his little sister shocked him. After flawlessly providing solid and impressive responses, she suggested they undergo a similar process in the skills lab. Derek was reminded that Amy was no longer his baby sister in need of protection, and he stated that she did not have to prove herself in the lab. She had successfully convinced him that she could handle any neurosurgery that arose. In response, she promised to prove to him that she was the same surgeon who had saved Nicole Herman's life.

While a part of her had wanted to scream and yell at her sometimes arrogant and all-knowing brother, Amelia was proud of herself for having kept an even temper throughout their conversation. As their time together came to a close and they prepared to return to their responsibilities, the sibling part of her wanted to leap up and say, "Ha! See! Remember that I know what the hell I'm doing, jerk!" Instead, she settled for imagining the scene in her head as she told him she'd see him later.

Monday, June 20

After two weeks back at work, Amelia's demeanor at the hospital had returned to determined and confident. Now entrusted with more responsibility, she was ready to more fully rediscover the part of herself that she had set aside while on bedrest and maternity leave. Running ORs and leading traumas once again energized her, and she felt that she was once again thriving in her career.

When Amelia arrived for her shift one Monday morning, she received a note from Derek stating that he would be bogged down in meetings and wanted her to answer any pages for consults until he was available. An hour into her shift, Webber paged and requested a consult on a 32-year-old male, Jason Ball. Jason had been experiencing vague symptoms such as dizziness, moodiness, weakness, nausea, and constant headaches.

After Jason's bloodwork ruled out any obvious diagnoses, Richard went a step deeper and ordered a head CT. He became concerned when the scans came back showing three tumors. Two were relatively small – less than the size of a pencil eraser – while one had the diameter somewhere between a quarter and a fifty-cent piece.

Amelia arrived and found Richard staring blankly at a monitor. "Have a seat," he suggested as he tilted his head to the right. As she joined him, Richard pointed the top of his pen at the image of the larger tumor, "See right there? What's that look like to you?"

"I'm pretty sure you've found an astrocytoma. See the uneven edges? Looks like a Grade II or Grade III to me. Do you have any previous CTs or MRIs as a baseline?" Amelia inquired.

"No. Poor kid is only 32. Jason Ball. Just got married. I've treated his family for years," Richard shared sadly.

Amelia's eyes widened with wonder and anticipation as she studied the tumors. Flipping between various angles and image sizes, Amelia couldn't wait to come face to face with the larger tumor. She pointed at it and observed, "I don't see any reason why we can't get in there and remove most if not all of this monster. It's actually looks like a fun one with the little legs sprouting off the jagged edges," she described as she motioned her fingers in the air. "Worst case scenario, the patient's looking at cancer and some follow up chemo or radiation. We won't know for sure until we get in there."

"So, you think you can help him?" Richard questioned as he sought confirmation.

Looking at Richard with an uneven smile and indignant eyes, Amelia nodded, "Absolutely."

"Great," Richard sighed with relief.

Amelia inquired, "How long has he been symptomatic?"

"Not long. Not long at all," Richard explained.

"Hmmm…" Amelia pondered aloud. "The astrocytoma could be rapid growing then. If that's the case, it might be infiltrating or getting ready to infiltrate into surrounding tissue. When can I meet this guy and massacre the uninvited three amigos squatting in his brain?"

Richard grinned. He appreciated Amelia's unique style and her tendency to personalize brain tumors. He offered, "No time like the present. How soon can you operate?"

"How quickly can he sign a consent form?" she asked as she stood up to head to the patient's room.

After she and Richard spent an hour with Jason and his wife, Amelia was fairly certain the couple was going to opt for surgery. She had explained to them that she saw three options: (1) she could go in and remove only the large tumor or the parts of it she could access without causing damage. In this scenario, she would leave the smaller tumors alone and watch them over time; (2) she could attempt to remove all three tumors as completely as possible; or, (3) they could wait and see if any of the tumors were growing and, if so, how rapidly they were growing.

With the first two options, the standard risks of surgery were a reality. Additionally, the surgeries would be complex and 6-10 hours long depending on factors that wouldn't be clear until the tumors were exposed. Being under anesthesia for an extended period of time always brought risks with it; however, removing all three tumors surgically was the ideal option if the goal was to eradicate them completely. Option 1 would address the most immediate concern and would involve a shorter surgery. Even so, the risk of waiting before addressing the smaller tumors could prove beneficial or detrimental – the odds were 50-50 either way. Option 2 would provide the most risk but also the most likely chance at a full recovery.

Amelia had explained to the couple that even though Option 3 seemed safer, it definitely presented its own risks. The possibility and potential speed of tumor growth were the chief considerations. If the larger tumor was fast growing, it could infiltrate healthy brain tissue in just a day or two. Regardless of the rate of growth, waiting could result in any tumor becoming less operable if it expanded. Having more time to study and analyze the tumors was potentially a benefit of this option. There was a very small possibility that the tumors would not grow. If any of them did grow, Jason's symptoms could become more pronounced; if there was no growth, his symptoms could remain the same and be treated with various medications.

If the couple chose Option 3, then they would need to consider if they wanted to have a biopsy performed and if they were willing to take the risk of bleeding that a biopsy would create. If the biopsy showed a malignancy, radiation or chemotherapy could be considered before proceeding with surgical options.

Although she did not tell the couple her preferences, Amelia personally hoped the couple would choose Option 2. She knew that even if they chose Option 1, she would at least have an opportunity to extricate the larger and trickier tumor that had sprouted legs. Secretly, the non-surgical option was Amelia's last choice.

When Amelia left at the end of her shift on the 20th, the couple had not yet decided which option to pursue. Before promising to check in with the couple the next morning, she provided them with her cell number and encouraged them to call her that night if they had any questions. While the angst-ridden couple considered their options, Amelia hid her enthusiasm deep inside. She couldn't wait to cut into Jason Ball's skull and save his life.

Tuesday, June 21

The next morning, Amelia was awoken by a call on her cell phone. Richard had arrived at the hospital particularly early and learned that Jason and his wife had decided upon Option 2.

"I scheduled the surgery in OR 1 for 9:00am. Will that work for you?" Richard asked.

Amelia beamed as she began walking through the surgery in her head, "Absolutely. I'll be in soon. Can you get Edwards to prep him?"

After hanging up the phone, Amelia looked over at her sleeping husband. Compared to his expressions on the day she diagnosed his ear infections, he looked so peaceful. She brushed some of his hair into place with her fingers before heading downstairs to grab the eardrops that were in the fridge.

As Amelia walked, she made a mental note to call Lynne. According to their complex master schedule, Amelia and Owen were slated to be with all 5 kids from 3:30pm forward. If Lynne would be willing to extend her hours and help Owen with the kids that afternoon, Amelia would not feel quite so guilty about scheduling a surgery that would keep her away into the evening. A tinge of anxiety coursed through Amelia because this was the first instance since her return to work that she'd needed to extend her scheduled hospital hours. Deep down, she knew Owen would understand. A part of her, however, worried that such changes would complicate the delicate balance she, Owen, and Lynne shared.