Read When the Air Hits Your Brain: Tales from Neurosurgery Online
Authors: Jr. Frank Vertosick
“He’s got a C7 sensory-level,” Gary whispered to me, “and a nearly complete motor-level as well. He looks good, all right, except he’s paraplegic. Walter’s idea of ‘good’ needs some revision.” C7 referred to the seventh cervical vertebra, at the junction of the neck and chest. Billy’s spinal cord wasn’t working below that level, giving him numbness and paralysis from about his armpits down. Gary thought out loud: “But why is he progressing so quickly? He was moving his legs when he came in.”
“Maybe he wasn’t properly immobilized,” I offered. If his neck was broken, improper movements could injure the spinal cord further.
“Naw,” said Gary, “he looks pretty immobilized to me and, besides, he’s wide awake. If someone breaks his neck and is wide awake, they’re in so much pain you could lift them up by their nostrils and they wouldn’t move their necks. Something fishy is going on here.”
“Maybe he’s having a conversion reaction,” chimed an emergency medicine resident.
“Possible,” mused Gary, “maybe he struck out in the bottom of the ninth and his male pride made him a paraplegic to save face…but don’t call the psychiatrists in just yet.”
The phrase “conversion reaction” is a euphemism for hysteria. The patient “converts” an emotional trauma, such as a failed marriage or, in Billy’s case, the shock of being nearly killed in an accident, into a physical complaint such as blindness or the paralysis of an arm or a leg. Although the symptom has no organic cause, the patient isn’t faking in the conventional sense, either. Malingerers don’t
believe
that they are ill. That’s why hidden cameras catch them throwing away their wheelchairs when they think no one is watching. The hysteric, on the other hand, is truly convinced that the illness is real, and will continue to manifest symptoms even when alone. A patient with hysterical numbness will let a needle be pushed through a fingertip without flinching.
The word “hysteria” derives from
hyster,
Greek for uterus and root word of “hysterectomy.” Ancient physicians believed hysteria to be an exclusively female disease. While it remains more common in women, I had seen plenty of conversion reactions in men, too. In fact, anybody can turn hysteric, even people with no obvious mental-health problems.
The X rays were done. I reviewed them with Gary in a back room. The cervical and thoracic spine films showed no evidence of fractures or dislocation of vertebrae.
“See,” the ER resident chided, “I told you, he’s hysteric.
Let’s just watch him for a while. I’ll bet you he walks out the door.”
Gary squinted at the film for another few minutes and then wheeled about. “No…no, no, no. He has a sensory-level, ascending paralysis and neck pain. Frank, get on the horn to Fred, let him know what’s going on…Walter, call the radiology resident, tell him we need a CI puncture for a myelogram and CT. And I mean now, as in now and not two hours from now. I’ll call the OR and tell them we’re coming up as soon as the myelogram is done.”
A myelogram involves instilling some iodine dye directly into the fluid space around the spinal cord, followed by X ray’s and a CT scan to trace the flow of the dye down the spinal column. Gary wanted the dye injected at CI, just behind the ear.
“What do you expect to find?” I asked. “His films are normal.”
“I don’t know,” Gary answered, “a disc rupture, a clot, maybe. But we have to look.” In tense situations, Gary’s flippant facade was jettisoned, exposing a tenacious and humorless professional beneath. He reminded me of the bomber pilot from the movie
Dr. Strangelove,
a buffoonish bumpkin until he receives his orders to deliver a hydrogen bomb on Moscow, at which time he is transformed into a fanatic and competent cold warrior.
We returned to the trauma room and Gary explained the myelogram test to Billy. As we were leaving to head upstairs to radiology, Billy called out: “Doc…”
Gary returned to the bedside. “Call me Gary.”
“Gary,” the man said quietly, “I can’t move my fingers anymore.”
The adult spinal cord
is about two feet long and barely larger than the little finger in girth, passing down the middle of our
backs encased in the bony armor of the vertebral column. Through this thin ribbon of fatty nervous tissue courses life. The spinal cord is notoriously intolerant of injury. Like IRS agents and Mafia dons, the cord will tolerate a certain level of insult, but wise men don’t push to that level.
While portrayed as the “main nerve” connecting the brain to the rest of the body, the spinal cord is more than just a nerve. In fact, it is a complex organ possessing an intelligence of its own. Stereotyped movements, like standing and walking, are preprogrammed within the spinal cord’s gray matter. This frees up our cerebrums to do those things which it does best, such as writing sonatas and inventing lite beer ad campaigns.
In lower animals, the cerebrum is so primitive that complicated motor behaviors originate in the spinal cord out of necessity. There just aren’t enough neurons in puny nonprimate brains to accommodate the “software” necessary to power all of the fins, wings, and feet. A headless chicken can run about
sans
brains. Our neurophysiology department once made a few brainless cats for a vision experiment, later giving them away as pets to unsuspecting cat-lovers who couldn’t tell them from intact animals. (“My Muffin is so smart…she know’s her name, she is just too independent and finicky to come when I call her…”)
As any athlete can verify, thinking too much during competition can hurt performance of repetitive tasks. The higher brain is always trying to embellish movements like a tennis forehand or golf drive, when such actions are best left to the spinal cord alone.
In humans, the “brainlike” behavior of the spinal cord can have macabre consequences. Patients with brains killed by gunshot wounds, hemorrhages, or other injuries can dupe family members, friends, even nurses, into believing that they are awake. An arm reaches up to grab a coat lapel, a hand grasps
the hand of a loved one, a leg withdraws in apparent pain after a hospital tray is dropped on it—all preprogrammed spinal reflexes. Called “Lazarus movements” for obvious reasons, these reflexes make it difficult to convince a bereaved family that their loved one is, in fact, legally dead and should be removed from life support.
A spinal cord injury is either “complete” or “incomplete.” A complete injury deprives the patient of all sensation and movement below the level of the injury. If the spinal cord is injured in the upper back, between the shoulder blades, the patient will have no movement in the legs, no bowel or bladder control, and no sensation below the nipples. A complete neck injury will produce paralysis involving the arms as well as the legs. When the injury occurs very high in the neck, near the base of the skull, the muscles of respiration will be paralyzed and the patient usually asphyxiates before help arrives. A successful hanging produces this injury.
If the patient displays any movement or sensation below the level of the injury, even the faint wiggle of a toe or a twoinch patch of feeling on the inner thigh, the injury is said to be incomplete. This is a crucial distinction. Complete spinalcord injuries virtually never improve, while incomplete injuries, even severe ones, can reverse with time and proper treatment.
Gary and I
walked up two flight of stairs to the X-ray department in silence. His head was down and his brow furrowed in thought. He was agonizing over what to do for Billy. Suddenly, he stopped and turned to me. “Forget the myelogram. Frank, go downstairs and get that guy to sign a consent for an exploratory laminectomy. I’m going up to the OR and make sure they’re set up and an anesthesia resident is available.”
“Why are we skipping the myelogram?”
“He’s going downhill before our eyes; if we wait much longer he’s going to stop breathing, and the horse will be out of the barn. He can’t have just ruptured a disc in his neck, because that shouldn’t cause the weakness in his legs to ascend into his arms. He may be crazy, but I wouldn’t bank on that, either. I’ve seen a lot of conversion reactions and none of them get worse with time. He must have an epidural clot that’s expanding. At least that’s what I think.” Gary turned and began running up the stairs, calling back to me in a feigned British accent: “Hurry, Watson, the game is afoot! Bring your revolver!”
The epidural space lies between the cardboardlike covering of the brain and spinal cord, called dura, and the skull and vertebrae. It is a space densely packed with veins which can be torn during trauma. While epidural blood clots are common in the head, where they compress the brain and cause coma, they are distinctly uncommon in the spine. Gary was guessing. I bet he had never even
seen
a traumatic epidural in the spine before. If he was wrong, we could be subjecting a man suffering from transient hysteria to a risky and painful operation. If he was right, and we waited to get the myelogram to prove it, the spinal cord might be hopelessly damaged. Gary had decided that a hysteric with an incision was better than a quadriplegic with pretty myelogram films.
I returned to the ER. Billy’s wife was sitting by the stretcher, holding his now limp hand and crying. I stopped short of entering the room.
“Where are the kids?” I overheard him ask.
“With my mom,” she replied, “they’re going to spend the night there.”
“Good, good…I don’t know how long I’ll be here. My bank card isn’t in my wallet, it’s on the ‘fridge…”
Life goes on. Honey, call the plumber and, by the way, I’m
paralyzed. I broke in and introduced myself. I examined Billy again. He could no longer grasp with either hand and his biceps were weaker. He still had a few areas of sensation in his legs, although they remained paralyzed. Excellent, I thought, he’s still incomplete.
I explained that the myelogram would take an hour or two to set up and complete and so we had decided to go ahead and take Billy to the OR and explore his spine. If we didn’t do something soon, he might die from the advancing paralysis. After I was through talking, there was a pause. Billy took a deep breath and then spoke. “Let’s do it. But give me a minute with my wife, alone.”
I left the room and closed the door. I found Walter stretched across a tattered vinyl sofa in the ER lounge. “Give them five minutes,” I instructed the intern, “and get him upstairs to the OR. Call Fred back and tell him where we are.” There would be the expected spousal grief when it came time to take Billy upstairs, and I didn’t want to be there. These pathetic scenes, like exposure to X rays, are occupational hazards that take a cumulative toll on a physician’s health. I avoided them whenever I could. I wasn’t a complete psychopath just yet.
I changed back
into surgical scrubs and met Gary in operating room eight. Chun, a senior anesthesia resident, was setting up his machines and Lisa, our scrub tech, was opening a package of sterile instruments.
“We’re on our own, buddy,” Gary said through his mask. “Two other rooms are still running and there isn’t any circulating nurse. Do-it-yourself neurosurgery. Help me with this.” Gary yanked a large metal-and-Styrofoam contraption from the bottom of the OR cupboard. It was the laminectomy frame, used to hold patients prone on the operating table.
The circulating nurse assists with setting up the room. During an operation, the “circulator” serves as an all-purpose gofer, answering phones, opening suture material, checking pagers, and so on. When the OR was understaffed, as it usually was in the evenings and on weekends, circulating nurses were pressed into duty as scrub nurses.
Walter arrived minutes later, pushing Billy on his stretcher. Just then the OR phone rang. Chun answered it, then handed the receiver to Gary. “It’s for you.” Gary thrust the frame at me and took the phone.
“Yeah…Oh, hello, Fred…yeah, he must have a clot…No, I didn’t get any studies, but he’s ascending…What? Uh-huh…of course I gave him steroids…I’m going to start at about T3 and work up…OK, we’ll be here. See you later.”
Gary hung up, his eyes narrowing above his mask. “A dickwith-ears, that’s what he is. He’s pissed because we have no myelogram, but he’s going to have to stay pissed. He only wants a myelogram because he’s at the symphony and it would have delayed the case until after he’s heard his fucking Beethoven. He’ll show up two hours late, anyway. Let’s get started.” He then called out to Walter, who was standing in his street clothes outside the OR, baby-sitting Billy. “Get dressed, amigo, we need you to circulate in here.”
Gary and I wheeled the stretcher into the small OR, parking it parallel to the OR table. The patient would be anesthetized on the stretcher and then flipped onto his stomach on the OR table after he was asleep. Gary examined him again. Billy’s large biceps muscles were now both totally flaccid. “Relax, ace, Dr. Chun here is going to put you to sleep. See you soon.” We then sat on stools in the corner and let Chun do his work.
The room was quiet. Contrary to popular belief, operating rooms are not always crowded, dramatic, and noisy. Nor are there choirs of seraphim basking in the glow of a larger-than-life
surgeon. The OR can be an insufferably intimate place, an arena where an intensely personal transaction occurs: the bartering of one person’s skill for another’s quality of life. There we gathered, two men from a pizza shop, one man from a softball diamond, and an anesthesiologist, spending a tragic Friday evening together.
Chun glided an endotracheal tube into Billy’s throat and began taping it to the sleeping man’s face. I swiftly placed a bladder catheter into Billy and then the three of us, Gary, Chun, and I, grunted and heaved Billy over onto the Wilson frame and positioned him to our satisfaction. “Shit,” said Gary as he stared down at Billy’s broad, tanned back, now faceup on the OR table, “this guy’s built like a rock. What a waste if we don’t get his cord back.”
After we had scrubbed and draped the operative area, Gary and I took our positions on opposite sides of the table. “Knife,” Gary said softly. Lisa suspended the Bard-Parker blade between us, but Gary didn’t move to take it. He just stood and looked at me. “Well, are you going to take it or not? I didn’t tear you away from the Skipper and his little buddy just to watch me do a case, did I?”