Susan’s head. “Most of those have to do with the heart itself or the large vessels that pump blood to and from it. But the cardiologists have examined her heart and vessels with every scanner known to modern medicine. The heart’s electrical systems and tissues, its valves and chambers are normal. The large vessels have no abnormalities. There’s no big, honking tumor sitting in or near it.”
“And the other causes?”
Susan’s head did not stop moving. “Simple blood tests. She isn’t anemic. Her endocrine system and kidneys function normally. Her blood pressure is fine.”
“So the reason for her heart failure is?”
Susan still shook her head.
“You know, Dr. Susan Calvin. Don’t you?”
Susan’s head finally stopped moving. She bit her lower lip. “I believe I do.”
“And?”
Everyone else, including the cardiologists and her own attending, had dismissed her idea; but nothing else made sense. She wondered what Nate would think, especially in light of his reading those books. “The initial abnormality in her brain is called an arteriovenous fistula. In Starling’s case, it was congenital, meaning she had it at birth.”
Nate nodded his understanding.
“Normally, blood with oxygen in it flows from arteries to capillaries. The capillaries give the oxygen to all the tissues of our bodies, and the now-deoxygenated blood flows into the veins and goes back to the heart, then to the lungs, for more oxygen. With an A-V fistula, the blood flows right from an artery into a vein, bypassing the capillaries.”
Nate was clearly still following.
“Vein walls aren’t meant for the high-pressure flow of arteries, so the vein wall stretches. Blood pools in the stretched area, making it bigger. If it’s big enough, blood pressure falls. The heart has to pump harder to make up for it, and congestive heart failure can develop.”
“So,” Nate said carefully, “your concern is that the original A-V fistula wasn’t fixed properly.”
Susan cringed. Nate had summarized it perfectly. “And I, Psychiatry R-1 that I am, don’t see how I’m going to convince the greatest neurosurgeon in the world he made an enormous mistake.”
“Surgeons don’t have high opinions of the nonsurgical specialties.” It seemed more statement than question.
Susan could not forget her conversation with Kendall about that exact subject. “In general, that’s true. The more specialized the surgeon, the less he respects the medical specialties. Unfortunately, many of them consider psychiatry the lowest form of medicine. And, of course, R-1s are the lowest form of doctor.”
“Yet you are a doctor.”
“Yes.”
“And obviously a fine diagnostician.”
Susan flushed. She had no idea how Nate would know such a thing. “I’m all right, but mostly unproven.” She returned to her original question. “So here’s my thing. If you were in my shoes, what would you do?”
Nate sucked air through his nose and let it slowly out his mouth. “In your position, I would have no choice but to act in Starling’s best interests.”
“Of course.” It was the job of physicians always to act in the best interest of any patient, regardless of age, situation, symptoms, or desires. “And it’s clearly in Starling’s best interests to find and treat the cause of her heart failure. The question is . . . how?”
Nate drummed his fingers on the end of the chair arm. “It seems to me you’re in a better position to answer that. Are you sure the cause is a botched surgery?”
Susan doubted anything in medicine was a certainty. “Reasonably sure. If it’s something else, it’s an amazing coincidence; but amazing coincidences do occur.”
“Can you prove it?”
Susan bit her lower lip in frustration. “I could, but not without doing tests I have no authority to order, ones that require a neurosurgeon’s approval. It would also take a skilled neurosurgeon to reopen the skull and take another look.”
“So . . . you need a neurosurgeon.”
“Yes.” Susan realized bringing in another neurosurgeon would cause more problems than facing the old one. She doubted any other neurosurgeon at Manhattan Hasbro would dare to second-guess Dr. Mandar’s proficiency and decisions, and they would want to know his opinion first. “Someone has to talk to Dr. Mandar about taking another look inside Starling.”
“Yes.”
“Who?”
“Who indeed?” Though Nate spoke without emotion or accusation, Susan knew the answer. The cardiologists would only throw it back into her lap, and her attending refused to believe the great Sudhish Mandar could have made a mistake.
“Me,” Susan said meekly.
Nate only bobbed his head, more in thought than answer.
Susan glanced up at the clock. It read twelve thirty; she needed to get back to her patients. Sweeping the sandwich container into the bag with the rest of her uneaten lunch, she headed back toward the unit. “Wish me luck.”
“Luck,” Nate said, rising from his chair and heading back to his own work.
The unit phone felt like a lead weight in Susan Calvin’s hands as she punched in the Vox number for Dr. Sudhish Mandar and watched it enter the callback number. She considered using her own Vox but imagined she had a better chance of getting an answer if the neurosurgeon knew for certain the call originated from a number inside the hospital.
To Susan’s surprise, the callback came almost immediately. She picked up the receiver, her palms suddenly slippery. She felt as if someone had dried her mouth with a sponge and then shoved it, in a lump, down her throat. “Hello?”
A male voice in a thick, subcontinental Indian accent came through the receiver. “This is Dr. Mandar.”
Anger tinged the voice. “You paged me during surgery!”
“What?” The word was startled from her.
“How dare you disturb the greatest neurosurgeon in the world in the middle of a procedure. I’ll have you know —”
Susan quailed, and her thoughts muddled. On her M-4 surgery rotations, the attendings and residents had always handed over their Vox to a nurse or unit clerk while they scrubbed. In her experience, surgeons never answered their own calls while performing an operation.
Dr. Mandar’s voice got louder, shriller, and ever more enraged. “The tiniest interruption can mean the difference between life and death. Who do you think you are that you can bother me while I’m completing —”
Susan stopped listening. She could not bear the thought of abandoning Starling, not when she had screwed up her courage to face the self-proclaimed greatest neurosurgeon in the world. She waited only until Mandar took a breath to say in a voice edged with deadly calm, “You can’t shout at me like this. I had no idea you would answer your phone in the middle of an operation. When you’re ready to have a civil conversation, call me back.” Decisively, she hung up the receiver.
Only then, tears stung Susan’s eyes. She found herself trembling in every part, and that only fueled her anger. She doubted anyone had ever spoken to Sudhish Mandar like that, and she wondered how long it would take for the consequences to reach her, how long before she lost her residency at Manhattan Hasbro.
Worried someone might see her in such a state, Susan wiped the tears from her eyes and sought a distraction. She saw the younger children lining up to use the outside playground, including a heavyset biracial girl who could only be Sharicka Anson. The four-year-old wore a pink dress with embroidered flowers, her hair swept
