Faking the Fiancé (Lakeshore Medical Romance #1)

Chapter 1

The Lie

Arjun

Hour one.

The boy's name is Ethan Hayes. He is six years old.

He likes soccer, dinosaurs, and a cartoon about a dog that solves crimes.

These are details I should not know, because knowing them makes the small, shaved head on the operating table a person instead of a patient, and persons are harder to cut into than patients.

But I know them because his mother told me in the pre-operative consultation, gripping her son's hand while I explained what I was going to do to his brain, and the details lodged themselves in the place where I keep the things I am not supposed to feel.

I do not think about cartoon dinosaurs. I think about the tissue. The margin. The plan.

“Ten blade,” I say.

The scrub nurse places the scalpel into my gloved hand with the precise, silent choreography that my operating room demands.

The weight of it is familiar; the steel is cold through the latex.

I have held this instrument thousands of times, and every time, in the half-second before the first incision, the world narrows to a single point of contact: blade and skin.

I make the incision. A curving line across the back of the boy's shaved scalp, just above the base of the skull, following the planned trajectory I mapped on the MRI scans two days ago.

The skin parts cleanly. Crimson blood wells in the blade's wake, bright and immediate, and the cautery nurse is ready before I ask, sealing the small bleeders with a faint hiss and the smell of burnt flesh that never leaves a neurosurgeon's memory.

We retract the scalp. The muscle layer beneath is divided and reflected. And then, white and curved and impossibly thin for the amount of protection it provides, the skull.

“Craniotome,” I say.

The high-speed drill is heavier than the scalpel, and louder.

It fills the silent operating room with a thin, high-pitched whine that sets the teeth on edge, the sound of surgical steel cutting through bone, and I guide it along the marked perimeter with the same steady, unhurried precision I bring to everything.

A child's skull is thinner than an adult's.

The margin between cutting through bone and cutting into brain measures fractions of a millimetre.

The drill has a clutch mechanism that stops the bit when it senses the change in resistance between bone and the dura mater beneath, but I do not rely on mechanisms. I rely on my hands, which have never failed me inside an operating room.

The bone flap lifts free. Beneath it, the dura mater, the tough, pearlescent membrane that is the brain's last line of defence, glistens under the surgical lights.

I open it with microsurgical scissors, peeling it back like the page of a book, and there, underneath, pink and grey and alive and pulsing gently with each heartbeat, is the brain of a six-year-old boy who likes soccer and dinosaurs. I bring in the microscope.

Hour seven.

The tumour is a pilocytic astrocytoma, Grade I, located in the posterior fossa of the cerebellum.

It is approximately three centimetres in diameter, which does not sound large until you consider it is three centimetres inside a child's skull, nestled against the brainstem like a stone lodged in the roots of a tree, and every millimetre I cut is a millimetre that could end this boy's ability to walk, speak, swallow, or breathe.

I do not think about this. I think about the plane of dissection between what belongs and what does not.

The operating microscope magnifies the surgical field to forty times its actual size.

Through the eyepiece, the world reduces itself to a landscape of grey and white and pink, the glistening terrain of a living brain, and my hands, holding instruments finer than a human hair, navigate this terrain as I have been trained: with absolute, unwavering, millimetre-perfect accuracy.

“Suction,” I say.

The scrub nurse clears the field. Blood and cerebrospinal fluid withdraw, and the tumour margin sharpens into focus, a boundary between healthy tissue and the thing that is trying to kill this child.

The boundary is not clean; it never is. Tumours do not respect borders.

They infiltrate, they extend, they send microscopic fingers into the surrounding tissue, and my job is to follow every finger and remove it without disturbing the surrounding architecture.

The operating room is cold. Eighteen degrees Celsius, which is standard for neurosurgery because cold slows bleeding and a cold surgeon is a precise surgeon.

The anaesthesiologist is monitoring vitals from behind the drape: heart rate, blood pressure, oxygen saturation, end-tidal CO2.

The numbers are stable, which means the child is stable.

The only variable that matters right now is the distance between my scalpel and the brainstem, which is four millimetres, and four millimetres in neurosurgery is the distance between a full recovery and a catastrophe.

“Bipolar at 0.3,” I say. The nurse hands me the cautery. I seal a small vessel that is weeping at the tumour's inferior margin. The bleeding stops, and the field clears.

My back is burning. Seven hours of leaning into a microscope at a fixed angle has turned the muscles between my shoulder blades into a single, continuous knot of fire.

My back stays bent. My shoulders do not move.

I do not acknowledge the discomfort, because acknowledging discomfort requires a portion of the neural bandwidth that is currently devoted to saving a child, and there is none to spare.

“How are we doing on time, Dr. MacLeod?” I ask the anaesthesiologist.

“Seven hours twelve. Vitals are holding. EEG is quiet.”

“Good. I am approaching the superior margin. There is an adhesion to the fourth ventricle wall that I need to dissect. This will be the most delicate portion of the resection. I need complete silence.”

The room goes silent. It was already quiet, because my operating room is always quiet.

I do not permit conversation, music, or the casual, chattering camaraderie that other surgeons allow.

My residents call me the Dread Prince of Paediatrics.

They think I do not know this; they are mistaken.

I have known it since my second year at this hospital, and I have never once corrected it, because the name keeps people silent, and silence keeps children alive.

The adhesion is dense. The tumour has grown into the wall of the fourth ventricle, the fluid-filled chamber at the base of the brain, and separating the two without rupturing the ventricle requires a technique that I developed during my training in Edinburgh: a combination of sharp dissection and gentle hydro-dissection, using saline to create a plane where none exists.

I inject a micro-bolus of saline. With a whisper-thin separation, the tissue planes yield.

I advance the dissector, feeling the slight resistance of the tissue.

The tumour peels away from the ventricle wall like bark from a wet tree, and the satisfaction of it, the clean, precise, millimetre-by-millimetre liberation of healthy tissue from the thing that was invading it, is the closest thing to joy that I experience in my professional life.

Another hour. Hour eight. Then nine. The tumour comes out in pieces, each one placed in a specimen container for pathology, each one a small victory against the biology that was growing inside this boy's head while he played soccer and went to school and slept in his bed and did not know that something was building in the dark.

“Final margin check,” I say. I sweep the cavity with the microscope, examining every surface, every fold, every millimetre of the resection bed.

Clean. The margins are clean. There is no residual tumour visible at forty-times magnification, which means there is no residual tumour visible to the most powerful tool available to me, which is the best I can offer.

This is what I always offer: the maximum of what human rigor can achieve.

“Haemostasis confirmed. Close, please.”

The resident begins closing. I step back from the microscope.

The room exhales. Not literally, not audibly, but the shift in the atmosphere is palpable.

It is the collective release of a surgical team that has been holding its breath, holding its focus, holding the life of a six-year-old boy in a web of coordinated silence for nine and a half hours.

My hands are trembling. They always tremble after a marathon surgery.

Not during. Never during. During the surgery, my hands are the steadiest thing in the room, steadier than the monitors, steadier than the instruments, steadier than the anaesthesiologist's voice reading the vitals.

But after, when the precision is no longer required, when the scalpel is down and the microscope is off and the child is in recovery, my hands shake with the accumulated, deferred cost of nine hours of control.

I clasp them behind my back. I have been doing this since my residency. Nobody sees the tremor. Nobody needs to.

I strip off my surgical gown and gloves in the scrub room, the mechanical process of de-gloving so familiar it requires no conscious thought.

The mirror above the scrub sink shows me what it always shows me after an extensive surgery: a lean man with sharp cheekbones and dark, heavy-lidded green eyes that look like they have been rubbed with gauze.

Dark curls, flattened from the surgical loupes.

Skin that has not seen sunlight in a meaningful way since October.

I look, as my mentor, Dr. Gabriel Moretti, once told me with characteristic theatrical brutality, “Like an exiled prince who has been living in a tower and subsisting exclusively on his own suffering.”