Another Day in the Frontal Lobe (22 page)

I examined a Mr. Doe once in the trauma room within minutes of his arrival and knew he probably would not make it. He was a so-called multiple trauma victim: his brain wasn’t the only thing injured. He had been unrestrained in the car—without a seat belt—and that meant that his body was catapulted forward at whatever speed the car was traveling at the moment of impact. (An air bag just isn’t enough.) As I crouched down at the head of his bed to examine a bad scalp laceration, a drop of his blood landed on the right sleeve of my white coat. He died within twenty-four hours of arrival and I filled out his death certificate.

There was nothing unique about his case, nothing particularly memorable. I hadn’t gotten to know his family aside from being the bearer of bad news. He hadn’t been in the ICU long enough for them to bring in photos of him and hang them all around, or to display the traditional (and tragically insufficient, in cases like this) “get well soon” cards with personal messages that get me choked up. Those are the things that make me feel like I kind of know the person lying in the bed, unconscious, whom I have never truly met, and may never get to meet.

(One parent even hung a sign over her teenage son’s bed reminding everyone of what radio station he liked to listen to—“I’m Nate. I like B98”—so that the radio in his room would be appropriately tuned to his individual preferences and not to the default soft rock he would have ridiculed before the accident, in his conscious state.)

I was so busy that week that I didn’t even change my white coat. I just didn’t have the minuscule amount of extra mental and physical energy required to: (a) realize that it would be most appropriate for me to change my dirty white coat, and (b) make my way to the closet in our office where all of our coats are hung after being laundered and rifle through them to find one with my name on it. It was that kind of week, and that particular task was the lowest on my list of priorities.

So I kept seeing this small, neat, round bloodstain in my peripheral vision as I went about my daily activities, and I kept thinking about this patient whom I otherwise would have quickly forgotten. Who was he? What was he like? Who were all the people who would be mourning him? What if he had simply worn his seat belt? What if his injuries had been less severe, and survivable? Could he have been one of the “great saves” that comes to visit the ICU months later, after rehab, and wows all the nurses?

If every patient left a stain, a resident’s life could very well become an unbearable mess. A stain every once in a while, though, can probably help keep us human. That realization must have been one reason I kept a journal during my training. I knew I would otherwise forget along the way, partly because there was too much to remember and partly because I might want to forget.

NINETEEN

Confronting Age

My day-to-day is different now, out of neurosurgical training and into my first real job, so to speak. I work in a genteel Connecticut town outside of New York City. The hospital is well located. I could walk to the local Tiffany’s after finishing a case if I ever decided that I wanted to go to a Tiffany’s (lucky for my husband, I’m not that kind of girl). I could drive into New York for dinner, for the best Japanese cuisine outside of Japan (that’s more like it). The cars in the patient parking garage are more upscale than in the doctors’ parking garage. Many younger doctors—myself included—don’t live in the same town as the hospital; it’s too expensive. It’s more suited for successful hedge fund managers and Fortune 500 CEOs, at least if you’re looking for a home with a place to park and more than one bedroom.

The hospital always scores in the top 1 percent of the country in patient satisfaction. Patients have many reasons to be satisfied. The lobby looks more like a hotel lobby than a hospital lobby, lobster is available on the patient menu on certain days, new moms are offered champagne after delivery, and I’m told that a patient can request to have the art in his room changed if it doesn’t please him. And, by the way, the medical care is excellent, too.

One small downside, I guess, is that the area is such a desirable place to live that many doctors desire to live there, or around there, along with everyone else, which means that it is well overserved. In other words, it is a competitive practice environment. I stopped once at the scene of a bad car accident in town, on a beautiful winding leafy road lined with estates. An SUV had slammed into an old stone wall on the property of a private country club, just seconds before. Two other cars had stopped, and so there were a couple other people on the scene already. Both were doctors. The victim had as many physicians at his disposal—right there on the side of the road—as he would if he had crashed directly into the local emergency room.

So the town is not like certain more remote parts of the country that are dying for a neurosurgeon and willing to offer huge salaries to lure one in. I get ads in the mail at least once a week with cryptic declarations that sound a bit desperate, like: “Practice only 100 miles from a moderate-sized metropolitan city!” My parents even get these letters for me at
their
home, although I haven’t lived there for years. I have no idea how the recruiters even got the address. Once my mom called me and said: “You won’t believe how much
this
one is willing to pay!” (But Mom, what kinds of restaurants would I spend all that money on out there?)

There may very well be more neurosurgeons available to the local population here than there are available to the entire population of sub-Saharan Africa. This is, I have to admit, a small source of guilt on occasion. Maybe I should go to a town that really needs me more. That said, I also have to admit that I thoroughly enjoy living here. One theme of my postresidency life has been of allowing (or catching up on) a touch of hedonism here and there, and for that I don’t have any guilt. Still, I’d love to reach a point, some day, where I would do neurosurgery as volunteer work, for a more desperate population.

A few other things are different now, with my training in the past. As a resident, my youthful appearance wasn’t much of an issue. Patients knew I was a resident—a young doctor training to become a neurosurgeon—and not their “main surgeon.” Now that I am a fully fledged neurosurgeon, comments on my youthful appearance are common. Walking down the hallway in the hospital I might hear, “Hello, Dr. Firlik!” from a nurse who passes by. Then I may hear—usually from an older man who witnessed the exchange—something like: “You’re not old enough to be a doctor!” I laugh, but I usually don’t bother to say that I’ve been a doctor for going on ten years already.

I can understand when patients who are considering surgery ask my age, point blank. I’ve come to see it as natural, even for an otherwise polite and sophisticated clientele. It doesn’t mean they won’t trust me, it just means that I might have to work just a little bit harder to gain their trust than if I were, say, a man with gray hair or a bald pate (even of the same age). Regardless of what we’re taught in elementary school, looks
do
matter. I saw a new patient recently who was referred to me by an already established patient of mine. Upon entering my office and seeing me for the first time she said: “My friend told me about you and recommended you highly, but she warned me to expect someone who looks like a teenager, so I was prepared. Nice to meet you.”

It doesn’t matter what kind of suit I wear and I haven’t bothered to try short hair for a change, because I don’t think it would make a difference. Sometimes I tell colleagues that I’d like to find a plastic surgeon who would be willing to create a few wrinkles for me. I don’t foresee being able to tell that joke for too much longer, though, so I’ll try to appreciate the inevitable age questions in the best possible light.

I have come to see my office as a forum for confronting age. I’m not talking just about my own age, but particularly that of my patients. An average day now revolves around confronting, or facing, up to the effects that aging and the wear and tear of normal life have had on their bodies, and then devising an appropriate treatment plan. This doesn’t sound very glamorous. It may not be what you think of when you think about neurosurgery. Most neurosurgeons, however (except the selected ones in academia who specialize, for example, only in brain tumors), spend most of their time in an endless quest to treat a growing epidemic: the aging spine. The official term for this very common entity is “degenerative spine disease.”

After I take a patient through the details of his or her scan, pointing out the areas of concern, I may get a comment like: “So what you’re telling me is that I’m getting old,” or “It’s not fun getting old.” I always keep a box of tissues at hand, just in case such a comment, or the fresh realization behind it, triggers tears. The fact that I get a sneak preview of “getting old” every day in my office is another reason I don’t feel guilty about enjoying the here and now, while my joints remain pain-free. I don’t expect it to last.

Arthritis refers to a degeneration of the joints. The spine—made up of the cervical, thoracic, and lumbar segments, as well as the sacrum—can be viewed as a long series of joints. Specifically, the discs (a type of joint) are located in the front of the spine, and the facet joints are in back. Because there is no cure for arthritis—only management—an important part of treating arthritis of the spine is managing expectations. Spine surgery can relieve pressure on a given nerve or nerves, caused by a buildup of arthritis, and so surgery can improve the debilitating pain shooting down a leg, but it cannot give a patient a brand-new spine. There is no such thing as a spine transplant, although I have had plenty of patients who have asked for one. Undergoing spine surgery or neck surgery does not mean that you will never have back pain or neck pain again. Aging is a progressive condition. Luckily, though, the management strategies that we have to choose from, both surgical and nonsurgical, do tend to work adequately for most people.

Younger people, oddly enough, can sometimes develop degenerative conditions of the neck and back, too, which always prompts the questions, vexing to both patient and physician: Why me and why so young? I have yet to come up with a satisfying answer, mainly because there really is no definitive answer, but sometimes I liken it to developing gray hair: some people get it earlier than others, but most people will get at least some of it sooner or later, especially if they live long enough.

One of my mentors likes to answer the “why me” question with “There are three possibilities: bad genes, bad habits, or bad luck.” Degenerative spine disease may be a combination of all three, but I tend to downplay the habit part (unless someone is obese, which means the spine has been unduly stressed) because there’s no use blaming the patient, especially when we can’t pinpoint the habits that clearly contribute to the problem. A thin, healthy person with a desk job may develop just as degenerated a spine as an overweight construction worker. It’s not worth spending too much time in the office trying to answer the why question, but there are some interesting theories floating around.

Some surgeons would mention that spinal degeneration is simply a by-product of living an upright life as a member of the Homo sapiens species, as opposed to our primate ancestors, but that doesn’t answer the specific “why me” and “why now,” because the vast majority of us lead upright lives most of the time. Plus, the unfortunate sequelae of evolution are hardly of interest to the average person whose back is killing him.

In an elderly person, I could also add that the human spine wasn’t “designed” (although that’s not the right word) to last eighty-plus years. And, because people aren’t dying of all the infectious diseases they used to die of, they’re living much longer and asking their spines to keep up the support, well past the point where their youthful, formerly well-hydrated discs have dried out. But that explanation does nothing to soften the blow either, or to answer a younger patient.

I recently saw a young man—late twenties—in my office who complained of annoying neck and shoulder pain for a few months, and had tried all the usual home remedies already. His MRI showed a degenerated disc in his neck. He had seen another surgeon who recommended a standard trial of physical therapy and anti-inflammatory medication, and warned that he may eventually need surgery, but that surgery might not be required for one, five, or ten years down the line. That surgeon also tossed in the concern that he could potentially be at “higher risk of paralysis” than the average person off the street if he were to injure his neck. The patient told me that he didn’t like what the orthopedic surgeon told him and—even worse—how he said it. The out-of-network payment, he added, was the final straw. So he went looking for a second opinion.

I largely agreed with the other surgeon, in broad terms, but I explained the situation in a gentler manner. I also mentioned that paralysis, although technically possible, would be extremely unlikely, so he shouldn’t go about his life harboring a new neurosis. As it is, a surprisingly high number of our patients check the “anxiety/depression” box on our intake survey of medical history. I would hate to contribute to that.

“Look,” he said, “I just want you to tell me it’s okay to play football. Okay? I’m a really active guy.” He almost sounded a bit threatening.

Here’s where my lawsuit detector goes wild, even though the patient was not thinking along those lines. The patient wanted to play football, wanted to lead a normal life, and he wanted an assurance of no risk at the same time. I hated to say it, but that’s not how the body works and it’s not how medicine works. How could I predict what would happen to his neck if he were tackled head on, again and again? There is no study out there, for example, that gathered one thousand football players, scanned all their necks in the MRI scanner, let them play football, and then checked to see if the ones who had signs of disc degeneration on their MRIs were the ones who ended up paralyzed somewhere down the line. Not only has such a study not been done, it probably never will be.

So now that I had seen his MRI and now that he had asked, I was pretty much obligated to recommend against football. Because what if, instead, I said it might be okay to play football and then he went out to play, got tackled, and became quadriplegic? Even though a very rare injury like that may have nothing to do with his preexisting disc degeneration—it could be due to a fracture or torn ligament in the neck—try to explain those fine distinctions to a jury. All they would see is a cavalier doctor who said it was fine to play, and a young man whose life was ruined. (At $106,000 per year, my malpractice premium is already high enough.) I have to err on the side of caution, even excessive caution.

I’m not that crazy about football anyway, so I didn’t feel too bad cautioning against it. One of my most depressing moments of residency was having to tell a college football player that he would likely be paralyzed from the neck down, for life. His neck was fractured, and his spinal cord pretty much converted to pulp, during a routine football practice. I’m actually surprised this doesn’t happen more often, in a sport that intentionally involves repeated head-on tackling.

By that point, the patient probably wished he hadn’t gone for the MRI in the first place, leaving his disc degeneration out of sight and out of mind. His next question was obvious: If not football, then what else was out? Was skiing okay? Well, he could fall down at high speed and injure his neck. What about soccer? Did he really want to bounce the ball off his head? And so on. In the end, it was clear to him that the inner workings of the human body could not be predicted with certainty and that common sense would have to rule. He couldn’t change his life completely, but he could modify the higher-risk activities, and I had no crystal ball.

Disc herniations in the low back and neck usually occur unrelated to any real trauma. They can happen to a person who does heavy lifting at work, a secretary who never lifts more than a stack of charts, or a couch potato who lifts nothing but a fork and a channel changer. It’s usually not anyone’s fault, although if it just happens to take place during the nine-to-five hours while filing charts at work rather than while picking up a towel off the bathroom floor at home, then the workplace can be blamed. It’s a “work-related injury.” In such a case, I feel sorry for both the worker and the employer because often, the event that precipitates the actual herniation is really just the straw that broke the camel’s back. The disc probably weakened slowly over time, more because of the individual biology and physiology of that person’s particular disc as opposed to any specific event at work. Even a simple sneeze can be the final straw. (And where were you when that sneeze occurred?) It’s a strange system.