When the Air Hits Your Brain: Tales from Neurosurgery (10 page)

The nurse-anesthetist and anesthesiologist came bustling into the room carrying a large tackle box full of laryngoscopes,
endotracheal tubes, and anesthetic drugs. The nurse-anesthetist displaced me at the head of the bed and began squeezing the Ambu bag. “I can’t ventilate her,” she said to the anesthesiologist. He quickly handed her a laryngoscope, which she snapped open like a switch blade. It had a long silver spatula with a light at the tip, which she inserted into Shirley’s mouth. At the same time, the anesthesiologist injected a combination of curare-like drugs and narcotics into one of Shirley’s many intravenous lines. These drugs would paralyze and sedate her so that she would not fight the efforts to breathe for her.

The nurse-anesthetist cocked Shirley’s head back and pushed the steel blade deep into her throat, lifting her tongue away so that the entrance to her windpipe could be seen. Shirley coughed and retched violently on the scope’s blade, straining against the cloth restraints that tied her right arm and leg to the stretcher. The curare finally took effect and Shirley’s struggling ceased. “I see the cords. Give me a tube.” The anesthetist was staring at Shirley’s vocal cords. She was handed a clear plastic tube coated with petroleum jelly, which she slipped between the vocal cords into Shirley’s windpipe.

I stepped out of the room and watched from the hallway. Over a dozen people filled the small room now, and I was the most dispensable of the lot. Since Shirley was under general anesthesia, I could no longer follow her brain function. Her skin color deteriorated further, to the pasty yellow-blue hue of a cadaver. “Pressure fifty over palp.” The EKG monitor showed runs of ventricular tachycardia, the heart’s equivalent of “throwing a rod” from being pushed too hard. Her tank was running dry.

Bill and the cardiothoracic fellow, who had just darted in, took off their lab coats and put on sterile gloves as the intern poured a bottle of Betadine onto Shirley’s exposed chest. The
respiratory therapist, a large man with muscular forearms, attached the Ambu bag to the endotracheal tube and squeezed hard. Even with the tube in place, his strong hands could barely force air into Shirley’s collapsing lungs.

I knew this flurry of activity was nothing but a dance of death for poor Shirley. Her aorta had burst, spilling blood into her chest. Like a jetliner with its hydraulics destroyed, her body was still flying but had no hope of landing safely. In a few minutes her life was going to come thundering to the ground in ER room eight.

Bill plunged a number 10 scapel blade to the hilt in her chest wall and cleaved a twelve-inch window under the left breast. As he entered the pleura, the thick leathery covering of the lung, a huge glob of clotted blood slithered out and splattered to the floor. The cardiothoracic fellow jammed a rib spreader into the wound and cranked it open, splaying open the chest cavity as rib bones cracked and popped. I continued to observe for a while as the two men muttered to each other, passing their arms, bloodstained to the elbow, in and out of the chest wound. They held back the foamy pink lung as they probed with long metal clamps and needle holders. The thin, purple blood continued to flow unchecked out of the wound and onto their clothes and shoes.

Shirley’s blood pressure collapsed. Her tracing on the monitor writhed chaotically as the heart’s rhythm degenerated into fruitless quivering and fibrillations. An alarm sounded from the monitor—it was the sound of my OR schedule becoming whole again. The cardiothoracic fellow reached deep into the chest and grabbed the heart, manually massaging the flaccid ventricles. “Empty,” was his simple pronouncement. She was gone. He withdrew his arm, removed his gloves, and went to the sink to wash.

“Will you talk with the family?” I called in to Bill, who nodded grimly as he continued to stare into Shirley’s chest. Thank God. I could just imagine those poor people sitting out there watching the parade of people rushing into the ER. I’d told her mother I would be back. I’d lied. This was a trauma surgery death, not mine. The general surgeons could play the grim reaper on this one.

In the OR, the chest instruments were being repacked and the room readied once more for Dr. Abramowitz’s first patient. An irate CT technician, his night disturbed for no good purpose, was shutting down his computer. Unused blood was packed up and trundled back to the central blood bank to await the next disaster. The angio people were going home. The small medical army drafted for this war was quickly demobilized. The cleanup people were summoned. Bill assigned the hapless intern the task of closing the dead woman’s chest. “It doesn’t have to be a Rembrandt.”

On this night I had the singular honors of hearing a woman’s last words, of denying her parents the right to see her alive one last time, and of permitting her to die believing that her boyfriend was still alive. Eight floors up, seven people on the neurosurgical OR schedule were sleeping, unaware that, for a few hours, I had been rearranging their futures in my head. As it turned out, their surgeries would go on as planned and the boss would play his squash.

T
he trauma experiences hardened me to death and the pain patients made me cynical about suffering. I felt my personality I slipping away during this arduous process of becoming “one of them.” Clinical cases no longer evoked the strong emotions they once had. The humiliation of that first unsuccessful nasogastric tube, the panic as B.G.’s fingers died at my command—I looked back upon such mushy feelings with a bemused nostalgia, like a worldly playboy reminiscing about the naive crush on his sixth-grade teacher.

Yet, my emotional numbness was still only partial. I hadn’t progressed to the status of a true surgical psychopath, wherein
one’s humanity is placed under general anesthesia. I first learned about surgical psychopathy from the sad case of a man named Andy.

Life had been unkind
to Andy from the very beginning. His troubles started before his conception, with a chromosome blunder within the developing eggs of his mother’s ovaries. The blueprint for a human body resides in its chromosomes, our molecular heirlooms, which consist of tightly coiled bundles of DNA passed from generation to generation. As the human egg and sperm are formed, chromosomes are shuffled like poker cards as nature tries to deal the best hand to our offspring. In Andy’s case, the shuffled DNA deck dealt him a loser.

We’re supposed to possess forty-six chromosomes: twentytwo pairs of non-sex chromosomes, and two sex chromosomes consisting of either two X’s (in women) or an X and a Y (in men). Each parent donates half of the total pool of a child’s genetic material: one sex chromosome and one each of the twenty-two different non-sex chromosomes.

Because of a foul-up in making the egg that would become Andy, his mother gave him not one but two copies of chromosome 21. Since one chromosome 21 was also contributed by his father, Andy thus inherited three, not the normal two, copies of chromosome 21’s DNA blueprints, a condition called trisomy 21.

This mistake most commonly occurs during the process of meiosis, when the mother’s chromosomes are packaged into eggs for dispersion to her children, although the error can occur in other ways as well. The likelihood of producing a trisomy egg increases as the ovaries age and the egg-making machinery becomes senile, misplacing chromosomes as an octogenarian might misplace eyeglasses.

DNA has been called the currency of life. Unlike money, however, it
is
possible to have too much DNA. Trisomy 21 is associated with varying degrees of mental retardation, a high incidence of congenital heart defects, and an increased chance of childhood leukemia. Decades ago, those afflicted with trisomy 21 were called “mongoloids” because of the thick eyelid folds which give trisomies a vaguely Oriental appearance. This offensive label was replaced with the more medical-sounding “Down syndrome.” Some argued that the late Dr. Down should not be so eponymously rewarded. Down’s critics charge that he was a racist who believed that trisomy 21 victims actually were “inferior” Mongolians who appeared sporadically in the Western population. The technical term “trisomy 21” is now most commonly used.

In addition to trisomy 21, Andy was also afflicted with multiple head and neck abnormalities. His ear canals were small and misshapen, making him deaf from birth. A low hairline sat barely an inch above his wide-set eyes. Malformed vocal cords rendered him mute. Unfortunately, this simultaneous clustering of genetic defects is not rare. The opposite situation, people with nothing but stellar genes, also occurs. Who hasn’t known someone born with a royal flush of genes, the high school beauty queen who is class valedictorian and captain of the swim team as well? But alas, for each genetic success story, there is an Andy.

Andy had a social disadvantage as well: he was born in the 1930s, when special education for disabled children was not widely available. Andy
did
have several things going for him. He was born to loving parents who reared him at home when institutionalizing trisomy victims was the norm. Moreover, he had been spared the ravages of trisomy-related heart defects, and he even had a respectable IQ of 80.

Though he never went to mainstream schools, he still managed to learn sign language, as well as how to read a little. He was emotionally untroubled, passing his time doing odd jobs as they became available.

Andy eventually settled into a job as the janitor of his local Catholic church, where he would spend hours polishing the hardwood pews. He particularly enjoyed preparing the church for holidays. As the decades passed, the task of putting up the decorations for Easter and Christmas became entirely his own, a responsibility he cherished. Andy became the bedrock of St. Mary’s, a fixture at Mass, a benevolent Buddha at summer bazaars and spaghetti dinners. Pastors came and went, but Andy stayed.

As years passed, he became increasingly obese, smoked heavily, and developed diabetes and high blood pressure. One day shortly after his forty-fifth birthday, he went suddenly blind in his right eye from a diabetic retinal hemorrhage, making his left eye his sole link to the world. Timely laser surgery forestalled blindness in that good eye, but Andy knew his vision was failing and he subsequently battled bouts of depression. Despite his health problems, he was at the church shortly after dawn seven days a week.

One humid morning in the summer of Andy’s forty-seventh year, his mother was awakened by the sound of retching in the downstairs bathroom. She found her only child seated by the toilet holding his large head in his hands and rocking slowly back and forth. His broad face was chalklike and glistening with cold sweat. He signed, “I’m sick,” and “Help me, mom” repeatedly before slumping onto his side, unconscious.

I was shooting pool
in the residents’ recreational area on the hospital’s tenth floor when my pager went off, disturbing a
surprisingly quiet Saturday afternoon. The beeper display read “1667.” A call from the outside. Bad news.

I dialed the extension and was connected to an ER nurse at Suburban Hospital.

“Please hold for Dr. Najarian.”

During the long wait my mind conjured up all sorts of grim possibilities lurking for me in the Suburban ER. Was it one of the pain patients? A head trauma? A bleed?

“Hello, who am I speaking to?” the voice finally came.

“Vertosick,” I replied dryly, “neurosurgery resident.”

“I have a mongoloid in his late forties, history of hypertension, comes in this morning lethargic, found down in his bathroom by his mother after vomiting times one. BP is 230 over 120, pulse fifty-five. He’s deaf and mute, but can communicate with sign language with his mother as interpreter. He’s com plaining of a headache, has no focal deficits. Our CT scanner is down and we’d like to transport him. I think he has a hypertensive bleed.”

“Is he on any meds?” I pulled out a crumpled note card and began jotting down information.

“Inderal, Dyazide. He’s allergic to penicillin. He’s also diabetic, but not being treated as far as I can tell. He’s got partial blindness, I don’t know what from—perhaps from retinopathy.”

“Do I have this right—he has Down syndrome, he’s deaf, he’s partially blind, he can’t speak, and he has a bleed?” Wow. This was going to be a long weekend.

“Yeah, and he lives at home with his parents, who look about a thousand years old. Still, they seem in better shape than he is.”

“What’s his name?”

There was a pause as Dr. Najarian searched his notes. It’s
amazing how physicians can remember blood pressures, medications, and allergies, but never something as trivial as a name.

“Andy…Andy Wood.”

“Go ahead and send him now. By helicopter.” End of conversation.

I racked up the balls again. It would take several hours for the helicopter to arrive.

At 5
P.M.
the med flight crew rolled into the emergency room with Andy. Forewarned, I was in the ER when the helicopter team wheeled him into the exam room. Even though he was wrapped in a scarlet blanket, Andy’s obesity was obvious. His eyes were covered with a white washcloth, and an oxygen mask clung loosely to his lower face. His mouth was hanging open, his oversized tongue protruding in typical trisomy fashion.

“Is he awake?” I asked one of the flight nurses.

“Yeah,” he replied, “but I guess you know he’s deaf and mute. His mother says that you can write him notes and he’ll write back, but he won’t keep his eyes open long enough to read anything.”

“How’s his pressure?”

“Still high, about 160 to 190. He got some Aldomet prior to leaving, and some Lasix and Decadron.”

He would need an arterial line and a nitroprusside drip to keep his blood pressure from blowing his brain into the next room.

“Anybody know where his parents are?” I yelled into the room.

“They’re driving down, I think,” another one of the flight nurses volunteered, “but I don’t know when they’ll get here.”

I removed the washcloth from Andy’s face. He winced at the glaring ER light and promptly snatched the cloth from my
hand and returned it to his face. Photophobia; the light bothered him. I reached behind his clammy neck and began flexing his head up and down. His arm shot out rapidly to stop me and he made a guttural, almost inhuman, noise. His neck was stiff and sore. Maybe this wasn’t a simple hypertensive bleed. I began to think Andy had suffered a subarachnoid hemorrhage, or SAH.

SAH results from the rupturing of cerebral aneurysms, saccular outpouchings that can occur on the large arteries at the base of the brain. After decades of weathering the incessant pounding of blood, arteries can develop small weaknesses. The weaknesses slowly sprout into thin-walled blebs, similar to the balloonlike outgrowths that form on old inner tubes.

Like the ER doctor, I initially believed that Andy had suffered a hypertensive bleed, an event quite different from SAH. Hypertensive bleeds are not caused by aneurysms on large arteries. They arise instead from tiny arteries that simply “pop” when the blood pressure becomes too great. Hypertensive bleeds occur deep within the brain and, although they can render a patient paralyzed, are rarely fatal. SAH, on the other hand, is quite frequently lethal.

Even though the bleeding during an SAH can be slight and doesn’t damage the brain substance directly, it is a devastating event. A person may silently harbor an aneurysm for years until some stress, such as sexual intercourse, lifting a heavy box, or simply having a violent sneeze, sends a pulse wave of blood pressure that splits the fragile aneurysm sac, spilling a torrent of arterial blood into the space between the brain and the skull. This region is called the “subarachnoid space” because it is below the arachnoid, a cottony substance which covers the brain and which derives its name from its close resemblance to a spider’s web.

The victim of an SAH is felled immediately by a “thunderclap” headache, as if shot by a gun. Vomiting may occur. The body reacts quickly to stem the hemorrhage by sending the blood vessels feeding the aneurysm into spasm, temporarily closing them off. Arterial spasm is the body’s natural defense against hemorrhage—it’s what allows a Kansas farmboy the time to pick up his arm after it has been amputated by a threshing machine and run for help without bleeding to death.

An arm can go hours without blood and survive. The brain’s survival time without oxygen is three minutes. Several minutes after a brain aneurysm ruptures, the feeding arteries are compelled to reopen by chemical signals from the starving brain tissue. If a sufficient protective clot has not formed over the rent in the aneurysm’s wall, the bleeding will resume, with lethal results. If the arteries don’t reopen at all, bleeding will cease but large areas of the brain will die, or “stroke,” with resulting paralysis or coma.

During the first minutes after SAH, the patient’s life teeters on a precipice. The brain’s life-sustaining arteries seek to maintain a level of blood flow which prevents stroke but which will not blow open the aneurysmal tear. Within a two- or threecubic-centimeter area beneath the ailing brain, biochemical processes a billion years in the making converge in a matter of milliseconds—processes such as blood coagulation, already ancient when the dinosaurs roamed. For almost half the victims of SAH, the body’s efforts to save itself are in vain—death follows in days, even hours.

I notified the surgical intensive-care unit that Andy had arrived. We then transferred him quickly to a transport cart. There was little we could do for him in the emergency room, and the faster we got him into the more relaxed environment of a hospital bed, the better. Our trip to the ICU would be
detoured through the CT scan room. Andy was given a few milligrams of morphine intravenously and he became calmer, his blood pressure lower. Prior to leaving the ER, I asked the clerk to check with social service about finding a sign-language interpreter.

The scan confirmed my suspicion: the brain was covered with a white frosting around the cerebellum and occipital loves—subarachnoid blood. The location of the bleeding pointed to an aneurysm on one of the arteries at the rear of the brain, the so-called posterior circulation. Such aneurysms are particularly dangerous to treat.

After the scan, Andy was taken to the ICU and the usual monitoring devices were inserted. He was given medications for sedation, blood pressure control, and seizure prevention, as well as some steroids to reduce brain swelling and inflammation. His parents still hadn’t arrived and the hospital had not yet located an interpreter. These situations made me feel like a veterinarian rendering large-animal care. We probed, scanned, and medicated Andy with no way to communicate with him.

Ethically and legally, we had the right—the obligation—to do so, but it still made me feel very uncomfortable. Andy was awake but refused to read the messages we wrote for him. I could only imagine the fear and confusion of this poor deaf man whom we had stripped of all control of his body.

I notified Gary and the on-call attending neurosurgeon, Dr. Filipiano, of Andy’s arrival and condition. Both agreed that Andy should be tucked in for the night and an emergency angiogram be scheduled for the following morning. Once we knew where the aneurysm was, we could better plan our operative attack upon it.