Michael, inspired by what Rita had told him, reviewed Karthey's scans again. He considered the location of the shunt. There was nothing to tell him whether it was working or not, but as he clicked through the layers, he discovered that it wasn't buried in tissue at all, only pulled away from the main ventricle in it's own little pocket. Perhaps this is what caused the pressure to build in the ventricles, expanding them past their normal capacity. He knew that a hose, pinched off on one side, would "inflate" under the added pressure of the water-flow, giving the appearance that the kink might be smaller than it really was. What if the real reason for giving the appearance that the duct between the third and fourth ventricles was the fact that these two ventricles were ballooned past their normal size, and the duct wasn't blocked in any way at all?
"In that case," he told himself, "The answer is obviously shunt revision." But how? Dare he risk removing the old tubing? He pulled up the "shuntagram" he had taken on Karthey's first visit, when the headaches proved to be shunt-related. The tubing was indeed torn at the clavicle, and he could clearly see where the material had actually calcified to the ribcage. Such a thing certainly happened a long time ago.
"Well that's certainly not something you see every day," a voice spoke behind him.
Michael knew who it was without turning around. "I'll admit, it's one of the more challenging cases," he told the ghost of his ex-wife, Anna.
She surveyed the screen over his shoulder with concern, "She came to you with headaches?" she referred to his notes about Karthey.
"Yeah; apparently her shunt decided just now to bite the dust. To think she could go her whole life without even realizing that it was there, if this hadn't happened!"
"I remember several incidents of hydrocephalus in Alaska," Anna said faintly. "Most of those children died before we could do anything about it." She smiled, "This girl has someone watching out for her; she's lucky to have only had an encephalocele to alert the doctors about her condition."
"Not to mention that she's never had a problem before now," Michael agreed. "These things are supposed to only last, what, five? Eight years?"
"How old is she?"
"I think she's about eighteen or so."
"Lucky indeed," Anna nodded. "So what are you going to do?"
"I think a simple shunt revision would solve the issue," Michael answered promptly. "I would just need to insert the new tube alongside the old one, and voila!" He spread his hands for emphasis.
Anna frowned, "More tubing in her abdominal area?" she questioned skeptically.
Her tone grated on Michael. "Yes, it's the only way. You see this here?" he gestured to the ribcage, "The tubing has pretty nearly become part of the bone. If I did try and pull it out, it might leave shards of calcification or even tubing behind, which could cause great damage to the tissue. At least we know that such as it is will remain harmless."
Anna sat on the desk in front of him, staring deep into his eyes. She smiled. "What about children?"
Michael shifted in his chair, "Children?"
"Yes; does Karthey want to have a family someday?"
Michael shrugged, "Well, she's said as much, I guess."
"And don't you think having all that extra tubing in her abdomen might get in the way of that?"
Michael rolled his eyes, "It's not my problem to deal with; there's nothing else I can do about it."
"Take the tube out, Michael."
"It's too risky."
Anna actually threw her head back and laughed loudly, "Oh-ho! Be it never said that Michael Holt is a coward! I thought I was the one who objected because of risk, and you were the one to rationalize them away!"
"Well—"
"So, Michael, rationalize this!"
"It's not my life!"
"Mine wasn't, either!" Anna bit her lip when she saw how her words jolted him. She continued quietly. "Are you saying that nothing in your training has prepared you for this?"
Michael dropped his gaze, "Well, no; I know exactly how it should work," he admitted.
"Then Michael," Anna waited till he looked up at her. "Do it; you have the skill. If there is anyone in New York qualified for this procedure, it's you." She raised his hand and clasped it in hers, tracing his fingers with her own. "These hands are very careful and very gentle. They've saved so many lives doing things no one else thought possible—taking risks. I believe you can do it, Michael," she looked at the screen, calling his attention back to it. Even as she said the words, he could see clearly now what had been invisible before, a way that he could actually work around the calcification to extract the most amount of tubing with minimal tearing. He nodded.
"Okay Anna," he said, "I'll do it—" By the time he turned around, she was gone.
Karthey proved admirably punctual. Emerging from a post-op at 11 o'clock sharp, Michael met Rita in the hallway.
"Karthey's waiting in Room 5," she informed him.
Michael did not have to miss a step as he proceeded down the hall to her room.
"Good news," Michael said as he entered the room and sanitized his hands. "Karthey, you need a shunt revision."
She frowned at him, "That's supposed to be good news?"
Michael nodded and took the seat next to the bed. Mrs. Devanne sat by the table at the foot of the bed, anxiety creasing her face.
"It is," he affirmed, "because I am going to be the one to do the surgery."
Karthey sighed and ran a hand through her hair. "Okay; Dr. Medino said I might consider postponing college for a month, so that I would have time to plan the surgery within the next couple weeks, and at least a month of recovery."
It was all Michael could do to keep from smirking. "If all goes well, Karthey, I don't see that you'll be needing more than a week of recovery. And if you're worried about being ready for college in time, I can do the surgery tomorrow."
Karthey nearly started off the bed. "Tomorrow?" she shrieked. Michael clearly saw the fear in her eyes.
"I can shift my schedule so you'll be my first patient," he explained, trying to calm her down, "We can start the pre-op stuff today and by this time tomorrow it will be done. You don't have to worry, Karthey. I'll have you know that the national average failure rate for shunt revisions is right around eight to eleven percent, and often the kids who need them have more health issues than you do."
"What's your average?" Karthey muttered, still stunned.
Now Michael smiled, "Last I checked it was below seven percent."
"See, Karthey?" Martha encouraged, "You said yourself that you'd consider anything less than ten percent a small enough margin!"
Karthey covered her face with her hands. "But…" she spluttered, "Tomorrow! I can't do brain surgery tomorrow!"
Martha rushed to her daughter's side and slipped a comforting arm over her shoulders. She looked up at Michael. "Dr. Holt, having two weeks to prepare for something like this is one thing; having less than twenty-four hours is another. Could you give us a while to think this through?"
"Sure," Michael agreed immediately. He stood, "Take all the time you need. I'll be by again around five to see how you're doing."
"Thank you, Dr. Holt," Martha nodded to him. Karthey wouldn't look up.
Michael moved on, and on his next gap between appointments paid a visit to the comatose wing. He smiled to see the Tanners and the Chungs finally happy to be around one another, enjoying one another's company and bearing with the gradual pace of Lianne's steady "beep-beeep-beep" of her call button. He approached the group just as Minnie read out the message: "Goodbye, my children. I love you." Her hands shook as she reached for her grandmother's hand. Minnie looked up at Dr. Holt with tears streaming down her cheeks.
"Thank you for helping us, Dr. Holt," she choked, "We would never have gotten this chance without you."
Lianne tapped out her own message. Michael listened to the letters, emotion constricting his own throat.
"T-H-A-N-K Y-O-U D-O-C-T-O-R."
There was a pause, then a long, extended beep as every monitor flat-lined. Michael escorted the family out of the room.
That evening, Karthey Devanne waited patiently as the nurses went over the pre-operation procedures, drawing vials of blood for testing, explaining exactly what they intended to do, what to expect when Karthey awoke, and the like.
Michael ensured that Mrs. Devanne had a comfortable place to sleep in Karthey's room.
"See you in the morning," he said.
The following morning, Michael greeted Rita and immediately proceeded to the scrub room. Karthey lay on the table while the anesthesiologist calmed her with his gentle banter on the early uses of nitrous oxide as a recreational drug. He slipped the mask over her face, and Karthey was unconscious after two deep breaths.
"Let's get to work," Michael announced to his team.
The surgery went even better than Michael could have asked for. The old shunt came out cleanly, and the new shunt slipped right into place. Michael saw Karthey off to the recovery room to wait until she regained consciousness, and walked out to the lobby.
Minnie Tanner was waiting for him. She held a small book in her hands.
"Dr. Holt," she said, "I wanted to show you this, to show you how much your help means to all of us." She opened the book and showed him the spidery Chinese characters mixed with English letters and simple words.
"It's Gramma Lianne's journal," Minnie said, "from when she lived in an internment camp in California. We would have thrown it away with the rest of her books if we had not known that she could tell us what it was." Minnie sniffed and wiped her eyes, "Reading this, it's like she is still here with us."
Michael laid a comforting hand on her shoulder, "Lianne probably wanted nothing more than to see her grandchildren getting along. I am sure she died exactly how she wanted to, among her loving family who loved her and loved each other. I don't doubt that she could have died earlier, but she was waiting for you all."
Minnie nodded.
"Michael?" Rita approached and took Minnie's hand. She looked at him, "Karthey's awake."
Michael nodded and left Minnie in Rita's capable hands.
Karthey was indeed awake by the time he arrived in her room. She was still a bit woozy from the morphine, but she looked plenty healthy.
"How do you feel?" he asked her.
Karthey smiled, "It's great to be alive," she admitted.
The three of them chuckled.
"Thank you, Dr. Holt," Karthey told him. "I owe you my life."
Michael shrugged, "I'm just glad everything worked out okay. We got the old shunt out, too."
"You did? That's great!"
"We'll see you later, Karthey."
"All right."
Michael left the room resolving to pay more attention to patients in the future.