When the Air Hits Your Brain: Tales from Neurosurgery (12 page)

Microneurosurgery is indeed difficult. The surgeon can’t look directly into the wound, but instead looks into the microscope eyepieces. This makes microsurgery similar to operating via remote control. Moreover, the powerful magnification of the scope makes even the slightest hand tremor seem like spastic gyrations. I thought about the agarose droplets.

“Well,” Gary continued, “if I were a program chairman, do you know the first thing I would do when interviewing a prospective resident? I’d get out that Operation game—you, know, the one with all the plastic pieces you have to pick out of small holes in a cardboard patient using electric tweezers? If you touch the patient with the tweezers, his nose lights up and a buzzer goes
honnnk
and scares the shit out of you. That’s right, I’d say ‘Here you go, pal, get out the fucking funny bone. No, not the breadbasket or the wrenched ankle, those are easy. I want the funny bone.’ If he gets a
honnnk
before he pulls out the funny bone, I’d say ‘Great grades, now get out.’ If he can get me the funny bone, I know he has the hands for this.”

“Is that fair?” I argued. “I mean, making the poor creep’s whole future rest on that one task? Don’t you think nerves might play a factor?”

“Of course, and that’s the point,” he countered. “In fact, I want them to be nervous. I want them crapping in their drawers. Anyone can have steady hands if they’re relaxed. It’s the ones who are granite under pressure that make the greatest surgeons.” Maggie, the gung-ho cardiac chief, had also told me that pressure was part of the deal. All chief residents must think alike.

Gary adjusted the retractor and slowly pulled the cerebellum further away from the skull. The thick, pulsating vert came into view, and with it the blue, angry dome of the first aneurysm. At six-power magnification, the vertebral looked more like a redwood than an artery.

“How nervous does that son of a bitch make
you?”
He turned to me and winked.

I saw Dr. Filipiano enter the scrub area and begin putting on his surgical mask. A small man with a gaunt physique and wire glasses, Filipiano, only in his mid-forties, had already established
a reputation as a master of complicated aneurysm cases. Like many neurosurgeons specializing in these “commando” cases, he carried a reputation for indifference to the death and destruction he sometimes left in his wake.

He was, as Gary acidly put it, the “prototypical surgical psychopath”—someone who could render a patient quadriplegic in the morning, play golf in the afternoon, and spend the evening fretting about that terrible slice off the seventh tee. At the time this sounded like a terrible thing, but I soon learned that Filipiano was no different from any other experienced neurosurgeon in this regard. He couldn’t mourn every bad result—not without going insane. He handled hopeless cases on a daily basis. After one especially grisly complication, I asked Filipiano if surgery ever got to him. He quoted an old Russian saying: “People who cry at funerals shouldn’t become undertakers.”

Filipiano swung open the OR door and began drying his freshly scrubbed hands. “How’s it going, chief?”

“I have the first aneurysm partly exposed,” Gary said softly without looking away from the scope.

Filipiano was hurriedly gowned and gloved. He then unceremoniously displaced me from the observer’s seat, relegating me to a stool in the corner. I watched the rest of the operation on the monitor.

There was a quiet lull in the OR as Gary and Filipiano tediously dissected the aneurysm away from the surrounding skull and brain, twisting the dome to and fro in search of the neck that joined it to the vertebral. I become hypnotized by the dull whine of the suctions, the soft clicking of the microscope motors, the hum of the bipolar coagulator being turned on and off.

In low murmurs, the two surgeons muttered into their
masks: “…No, cut here…Can that take a temporary clip?…Stop that oozing, please…Use a ball dissector for that, goddamn it…Clean the tips of this thing…” I drifted into a twilight world between wakefulness and sleep. With my back pressed against the cold tile wall, I hallucinated about getting out of the hospital for an hour or two that evening. Maybe I’d go to the Black Angus for a hamburger. Although banished from the real action in this case, I was the dutiful junior resident: gowned, sterile, and technically impotent, unwilling to leave the OR for fear of appearing uninterested in what was happening on the fuzzy video screen.

Suddenly, a burst of frantic activity aroused me. Filipiano barked for a larger suction and the nurse-anesthetist pushed her alarm button to summon her staff anesthesiologist to the room. I looked at the monitor. The wound had turned red; the vertebral was gone and the cerebellum was now bathed with pulsatile waves of blood. Gary had slipped and plunged the sharp point of an arachnoid knife into the aneurysm dome.

Gary placed his suction deep into the wound. “Shit, oh shit…,” he moaned. The feeble microsuction did nothing to clear the field as bright blood gurgled audibly from the cranial wound and ran in angulated streams over the drapes.

“Do you want us to take his blood pressure down?” asked the nurse-anesthetist. Lowering the blood pressure with medication sometimes slowed the bleeding.

“No!” Filipiano responded sternly. “We need to temporary-clip and he’ll need his blood pressure up. Just hang some blood, hang it now.”

Working awkwardly from the assistant’s chair, Filipiano jammed a giant glass-tipped suction into the wound and instantly the clear tubing filled with Andy’s blood. On the monitor, I could see the large suction diverting the spewing column
of blood sufficiently to see the vertebral artery once again. Gary remained frozen in the surgeon’s chair, still clutching the useless microsuction.

“Give me a fifteen-millimeter straight temporary clip right away, now.” Filipiano reached out with his right hand without looking away from the scope’s eyepieces. The scrub nurse placed a long forceps bearing the open clip into his hand and gently guided it into the microscope’s field of view. He swiftly placed the clip blades around the vessel and squeezed the clip shut. As dramatically as it had begun, the bleeding stopped. The staff surgeon quickly motioned for Gary to vacate the operator’s chair.

“Call me the time, in minutes,” Filipiano said to the anesthesiologist, who had just entered the room, “and load with barbiturates.” The blood flow to Andy’s brain was now ceased. The clock was running on his life. Filipiano had but a few minutes to repair the hole Gary had torn in the aneurysm’s dome, or Andy would die. The barbiturates would protect Andy’s brain somewhat, perhaps give them an extra few minutes.

The surgeon swiftly suctioned away the thick, fresh clot from around the now-collapsed aneurysm sac.

“One minute of clip time.”

Working with reckless desperation, Filipiano tugged and pulled at the sac, peeling it away from the remaining adhesions. He was doing in seconds what would take thirty minutes or longer under more controlled conditions. Such vigorous tugging on the aneurysm ran the risk of ripping it completely away from the vertebral artery, leaving a gaping hole that could not be repaired. Finally, he was able to see the aneurysm’s neck, where he could place a clip without obliterating the vertebral artery itself.

“Two minutes.”

“Fifteen-millimeter bayonetted Yasargil clip.”

The nurse handed him the long forceps again. He glanced at the clip and threw it back to her. “That’s a temporary clip!” he cried shrilly, “don’t kill this man, give me a permanent clip!” Temporary clips, because they are made to be placed on arteries and not on aneurysms, exert less force and cannot be expected to hold an aneurysm permanently closed. The nurse, in her haste, had loaded the wrong clip, wasting precious time.

“Three minutes.”

The nurse rummaged frantically in the large gray tray of aneurysm clips, her hands quaking as she tried to load the requested clip onto the application forceps.

“Clip, clip, clip!” he screamed.

Filipiano finally seized the forceps and clip from her hands and loaded the clip himself. He thrust the clip’s silver blades around the dome as it fluttered in the wake of air and frothy blood rushing up the adjacent suction tip. Slowly, he closed the blades down, killing the aneurysm.

“Four minutes. He’s getting bradycardic.” Andy’s heart rate was falling; his brain was on the brink of oxygen starvation.

“Give me an empty clip applier.” Filipiano removed the temporary clip from around the vertebral and the large vessel billowed once again with incoming blood. The clip on the aneurysm held. The bleeding did not return.

Filipiano decided to abandon the search for the remaining two aneurysms. He did not think Andy could tolerate another temporary occlusion of his vertebral artery, and he was convinced that the one he had just clipped was the aneurysm responsible for Andy’s hemorrhage. He packed some soft gelatin foam around the clip and stepped out of the surgeon’s chair, pulling off his gloves. “Close it up.”

Gary sat motionless for a few minutes, his face pale. After
Filipiano had left the room, I moved from my hiding place in the corner and walked up behind the sullen chief resident.

“Hey, Gary,” I said over his shoulder.

“What?”

“Honnnnk.”

He stared at me icily. “Fuck you.”

We closed Andy’s wound
and wheeled him to the recovery room. Even after his anesthetic wore off, he remained unconscious and immobile from the large amount of barbiturates he had been given intraoperatively.

Gary sat at the nurses’ station and began writing post-op orders. “If this guy wakes up from this fiasco,” he whispered to me as he wiped his nose with his surgeon’s cap, “I will go and take a dump on Center Avenue in broad daylight. How could his brain have survived five minutes of complete ischemia? Did you see how much back-bleeding there was from that vertebral? Zero.”

I tended to agree with Gary. Five minutes of ischemia, or no blood flow, is usually a devastating insult to the nervous system. However, the effects of ischemia are difficult to predict. Andy was likely to have had some damage, some form of stroke, but where? And how bad would it be? Gary was betting that the damage was so profound as to render Andy forever comatose.

Filipiano told Andy’s family that their son was likely to recover. He believed the episode of bleeding and ischemia was not long enough to cause irreversible injury. Filipiano was the eternal optimist.

We could only wait until the barbiturates wore off, two or three days.

On Thursday morning I met Gary at the door to the neurosurgical intensive-care unit for our usual 5:30
A.M.
rounds. I escorted him down the hall to Andy’s room.

“I’ve got something to show you.” We went into the room, where Andy lay motionless, his belly bulging and his eyes closed. He still had a tracheal breathing tube and had not stirred a muscle since his Monday surgery.

“So?” Gary was impassive as he flipped through his index cards of patient data.

I vigorously rubbed Andy’s chest with my knuckles, which prompted Andy to open his eyes and grab at my arm. The chief resident was startled. “Jesus Christ, the poor bastard’s awake.”

“That’s right,” I said, flashing a grin. I pulled a large wad of toilet paper from my white lab jacket and handed it to Gary. “Center Avenue’s ten floors down, but you have to wait an hour or two, since it isn’t broad daylight yet.”

Except for some drooping
of his left facial muscles, Andy appeared to have no paralysis. Later that afternoon, when his parents arrived, he even tried to communicate with them in sign language. On evening rounds, Filipiano pronounced the operation a success, hugged the parents, and gave the resident staff a heady discourse on how no blood flow is sometimes better than a little blood flow. Allowing some oxygen to the brain during a period of low blood flow permits the formation of destructive “free radicals,” which does not occur if the blood flow is totally halted.

Over the ensuing days, however, Filipiano’s beautiful freeradical theory was to be spoiled by an ugly fact: we couldn’t wean Andy from the mechanical ventilator. Something was definitely wrong. The operation wasn’t a complete success just yet. Each day Andy became brighter and more alert, passing us notes asking us to remove his breathing tube and allow him to eat. Every time we reduced the ventilator rate, however, he would start to hypoventilate and become lethargic, forcing us to restart the machine. When stimulated by being pinched he would
breathe on his own for a brief time, only to stop breathing again when the stimulus ceased.

By the following week we had to insert a tracheostomy into his neck to avoid the complications of a. long-standing endotracheal tube. We tried a variety of medications to make him breathe independently of his machine, including amphetamines, but nothing worked. As long as Andy was stimulated to breathe he would do so, but once his attention wandered, or if he started to fall asleep, he simply quit breathing. Tethered to a ventilator, Andy could not leave the intensive care unit.

Filipiano consulted Dr. Leo, one of the university neurologists. Dr. Leo’s diagnosis: Ondine’s curse.

We caught up with Dr. Leo in the cafeteria and asked him for further information regarding this rare condition.

“Ondine’s curse,” explained Dr. Leo as he peered over his half-glasses, “is a result of a stroke in the medulla, in the lower stem. That’s where the respiratory drive center is located. As you know, we can either breathe voluntarily”—he demonstrated by taking a deep breath—”or involuntarily, without having to think about it. If our respiratory center is damaged, we can’t breathe automatically; we have to think about each breath. Stop thinking about breathing, and we stop breathing. It’s that simple.”

“Who was Ondine? Some Queen Square neurologist?” asked Eric referring to the birthplace of neurology in London.

“No,” laughed Dr. Leo, “Ondine was a nymph of Greek mythology who offended the gods. As punishment, she was sentenced by Zeus to think about every breath. She knew she could never sleep, for to sleep meant death. That’s a great curse, right?”