When the Air Hits Your Brain: Tales from Neurosurgery (15 page)

“Me?”

“You’ll be a senior resident before you know it. C’mon, bring this guy’s legs back to life for him.”

I took the knife. Gary placed his right index finger on the nape of Billy’s neck and his left index finger in the middle of the his back, just below the rib cage. “Between here and here…let’s go, don’t be shy.” I slid the knife on a line between Gary’s hands and took the incision deep through the skin and fatty tissues. The incision was over a foot and a half in length. “Now get your hot knife,” Gary continued to instruct me. I grabbed the electrocautery pen and began carving the thick
meat of Billy’s back from the spinal bones below. Gary swept away the tissue with large silver scoops as I detached it with the heat. This allows access to the spine, but does no permanent damage since muscle can heal.

About ninety minutes later, we had exposed the laminae of the spine from the neck down to the midback. The laminae are bony shingles which extend along the length of the spine and protect the back of the spinal cord. “OK,” said Gary as he probed under the edge of one of the laminar shingles with a small curette, “get a Kerrison punch under here and get to work.” The Kerrison is a long-handled metal tool with a small biting cup at the tip. It’s used to chip small pieces of bone away, bit by bit. Removing the thick protective bone in this manner is tedious, but it is the only safe way given the delicate organ below. Removing the laminae, a procedure known as laminectomy, is like chiseling through a cinder block to reach an egg encased within—without cracking the shell.

We removed one lamina, at the fourth thoracic level, and found nothing but pristine dura. No clot. I could almost feel Gary’s stomach churning with a mixture of doubt and pepperoni. “Keep going,” he barked, “it’s got to be here. Look, the dura isn’t pulsating.” The lack of pulsations was evidence, albeit weak, that some compression of the cord existed above our laminectomy.

I kept chipping away. Piece by piece, the third thoracic lamina ended up in the silver pan on Lisa’s Mayo stand. Still no clot. “I think the dura is pulsating here,” I observed, trying to be scholarly. Gary was unimpressed. “Keep going, tiger. Higher.”

In and out of the cavernous wound I went, dipping my tiring hand down to the spinal canal, grasping a bite of bone, and then releasing it into a specimen pan. Grasping and releasing,
grasping and releasing, in and out, in and out. A widening expanse of translucent dura, the spinal cord visible just below, grew at the depths of the red wound. I had never worked around the spinal cord before and my arms were tense as I painstakingly guided the metal rongeur repeatedly under the laminae. My fatigue was growing, but I could not show weakness.
If it was easy, anybody could do it.

Suddenly, just below the cut edge of the second thoracic lamina, a small piece of clot, resembling fresh liver, peeked out around the left side of the spinal dura. “There!” Gary shouted with the enthusiasm of a prospector seeing the glint of gold in his pan. He grasped the Kerrison from my hand and began making swift, sure strokes, slicing through the lamina like a rower slicing through a river. The clot grew larger and larger as the spinal opening proceeded higher. “Oh, sorry,” he apologized, handing the instrument back to me, “you’re doing fine.”

Hour after hour, I pulled bone away as Gary suctioned the thick epidural clot. Fred showed up, peered into the wound, and retreated to the lounge to sleep. At 5
A.M.,
over six hours into surgery, we reached the top of the clot at the fourth cervical vertebra. To me, scaling Everest couldn’t have felt better. I gave my aching forearm a rest while Gary probed the side of the spinal canal for further bleeding. “Look, Frank”—he gently tugged the spinal cord to one side, showing a tangle of thick, oozing veins—“I think this is where the clot originated. He must have flexed his neck badly when the truck rolled over and tore one of these veins. The slow ooze gave him the progressive paralysis.” He coagulated the veins with the bipolar cautery and packed the area with a small piece of Billy’s back muscle.

Fred came in again at the end of the case and Gary described the findings. “Very good,” said the attending surgeon, who had retreated to the far end of the room and was
rummaging in an equipment drawer. Fred came over to the scrub nurses’ table and opened a sterile marking pen onto the field. “What’s that for?” Gary gave the staff man a quizzical stare.

“Well,” observed Fred dryly, “you have such a large area of dura exposed, I thought you might want to personalize it by writing ‘Fuck you, Fred,’ or something like that.” Both men laughed. They looked like colleagues now. I felt more like a surgeon and less like a medical student. In the glow of this male bonding, however, a question remained: How would Billy feel?

As for Walter, he wasn’t feeling anything. He had been sleeping on the OR floor for the past three hours.

Billy was no better
the next day, or the day after that. He was transferred to a rotating bed, designed to keep the quadriplegic patient in constant motion and prevent the formation of phlebitis and bedsores. He had regained a little motion in his biceps muscles, but his hands and legs remained paralyzed. He did retain some sensation in his stomach and feet, but not much, and he had lost bladder and bowel control.

He spent his days listening to the radio and talking with his family and friends, all the while turning about like a rack of ribs on a spit. His mood was defiant and upbeat. He talked with his son about the fishing trips they would take. His wife brought in the family finances for his approval and read the newspaper to him daily. He treated his disability as purely temporary and was determined not to let his marriage or his mind wither like his nerveless muscles.

Making rounds on patients like Billy is a difficult task. People complain about the little time their surgeons spend with them, but they should try it from our perspective. What could I say to this man—How are you feeling today? (Paralyzed from
the chin down, thank you, same as yesterday.) Small talk begins to look truly small: How about that win by the Pirates? Do you think it’s going to rain this weekend? Hey, time to get those tomato plants in! Eventually, however, doctor and patient find some neutral ground, some subject they can discuss that does not draw attention to the reality at hand. With Billy it was tennis.

Billy’s wife told me that he was an avid tennis fan. One day in June, after Billy had been hospitalized about three weeks, I found him sitting in a stretch chair watching the French Open on TV. His neck was still wrapped in a rigid plastic collar, and his hands and feet were bound in braces to slow the formation of contractures in his lifeless limbs. He was shouting “Just keep it in, just keep it in!” at the screen.

“What are you watching?” I asked.

“Oh, Jimmy Connors playing some kid at Roland Garros. The kid is trying to play serve-and-volley against Connors on clay. Connors isn’t consistent today, and if the kid would just stay back and play some longer rallies, he might do better. Right now he’s getting his ass kicked. You can’t play serve-and-volley on the brick dust unless you’re McEnroe.”

We sat and talked for an hour about pro tennis and our own philosophies about playing the game. I told him I preferred the baseline game, which surprised him. He thought my height favored a net game. He was being kind. In reality, my body habitus favors sitting in the stands with a Sno-Cone.

He grew quiet. “When do you think I’ll hit a serve again?” I told him I didn’t know. It was the truth: I didn’t. From that day on he called me Pancho, a reference to Pancho Gonzales, the tennis great. I called him Bjorn.

Billy’s huge wound
eventually fell apart and became infected with pseudomonas bacteria. He developed pneumonia and an
infected left kidney. Despite the rotating bed, his legs developed phlebitis. He was young and tough, however, bouncing back from each illness. One day, near the end of his acute hospitalization, something happened. Something small, but very important.

Billy had recovered from his lung problems and was in a regular hospital bed. In another day he would be transferred to the spinal cord rehabilitation unit of West Suburban Rehab Center, about five miles away. The mountains of cards he had received from friends and family had already been bundled together with twine.

“So long, Bjorn.”

“Yeah, see you Pancho.” He was grinning from ear to ear. “There is something I want to show you—I haven’t shown anyone yet, not even my therapists.”

“What’s the secret?”

“Look at my left hand.” I looked. I stared at it for several minutes, and then, quite subtly, almost imperceptibly, the thumb moved. “I think it’s moving,” Billy cried out, “it feels like-it’s moving. Is it moving?”

“Goddamn, Bjorn, it
is
moving! Centre Court, here you come!”

“It’s not much, but maybe I’ll get enough back in one hand to run a computer. If I can run a computer, maybe I can make a living again…” He began to cry, I think for the first time since his truck had flipped over.

I sat down beside him. “No, Billy, if you can move a thumb, it means your spinal cord is waking up. You never had a complete injury. Who knows where this will lead. You have to work hard. When they write your story in
Reader’s Digest
and use the old cliche ‘Doctors said he would never walk again,’ don’t include me in that group, all right?”

“Fucking right.” He composed himself. “Fucking right I’ll work hard. Ask anybody that knows me.”

I looked at his wound, still packed with cotton gauze but slowly healing. Putting a hand on his shoulder, I said goodbye and left.

Billy went to rehab, and I didn’t hear anything about him for a long time. In the ensuing months, Gary went on to New York and private practice, while I left the clinical service for a one-year stint in the basic science program. One of the flaws of surgical residency is that it centers on inpatient care. We often don’t get to see the small miracles that occur beyond our hospital walls.

In early January
I was in neuropathology, imprisoned six days a week in my cubicle surrounded by glass slides, books, and printed handouts from our instructors. Life in pathology was dull, and I could feel blood coagulating in my veins as I sat for hour after mind-numbing hour staring at Carpenters’
Neuroanatomy
text. The pathology viewing room was empty, the attending pathologists were at the V.A. for a staff meeting, and the pathology residents, like mice when the cats are away, had bolted for the local ski slopes. I was half asleep when a tennis ball came bounding into my lap.

I looked up and saw a tall, gaunt man standing in the doorway. He looked into my puzzled face. “What’s the matter, Pancho, don’t you recognize me in the vertical position?”

“Jesus Christ, Billy is that you?” He was right, I didn’t recognize him. The face bloated by months of steroids was now thin; the collar and braces were gone. He turned around, unbuttoned his shirt, and dropped it off his shoulders to show the jagged wound between his shoulder blades I had inflicted eight months earlier. Like doubting Thomas, I felt compelled
to put my hand upon the broad scar. “I guess you did work hard, didn’t you?”

“I started improving pretty rapidly after I got out of this place,” he explained. “By October I was walking on the parallel bars. I went home in December. It was the best Christmas I ever had. I’m here to see Fred, and I wanted to see you guys, too. Where’s Gary?”

“He’s in New York making money.”

“And smoking twice as much, I’m sure. It took me an hour to find you.”

“How do you feel?”

“My feet still feel funny, and I can’t walk as far as I would like, but I’m getting better all the time. I return to work next month.” He thought for a while, then continued. “I can never look at my wife or children in the same way. That doesn’t sound right…Let’s say that when Joey asks to play ball, I’ll play ball as long as he wants. I don’t remember everything that happened, except that it happened so fast…so fast. It’s like that sappy Christmas movie, when an angel shows some guy how the world would be without him, and then lets him go back so that he can appreciate everything more. That’s how I feel. Like somebody let me go back and I can never waste a single day again.” He strode away on his stiff legs.

“Somebody let me go back.” Now, who wouldn’t want to do
that
for a living?

A
ll neurosurgical residencies require their trainees to spend at least three months on medical neurology services. Neurologists treat the nonsurgical diseases of the nervous system: migraines, multiple sclerosis, myasthenia gravis, muscular dystrophy, and so on. At one time, neurologists saw all neurological diseases, operative or otherwise, referring away those cases in need of the surgeon’s knife after an appropriate diagnosis had been made. With the advent of the CT scanner, however, the role of the neurologist in structural diseases of the brain and spine diminished greatly. The internist or general practioner can now order a brain scan on a patient complaining of
headache and, if the scan reveals a tumor, send him or her to the surgeon directly.

The straight pipeline from primary care to the neurosurgeon has created friction between neurologists and neurosurgeons. The neurologists are irritated about being bypassed in favor of surgeons too anxious (in their humble opinions) to cut the patient, while the surgeons increasingly view the neurologists’ contribution to many diseases as nothing short of vestigial. The running joke among the neurosurgical residents was that neurology was a little guessing game to play while the CT films were processed.

The truth is, neurologists still play a valuable role. Not all brain afflictions yield to surgery, and neurosurgeons have little patience for nonoperative problems. As neurosurgeons, we should not mock neurology, since neurology is where our own heritage lies. Neurologists first discovered what different functions lie where in the brain, allowing surgeons some prayer of finding a brain tumor in the decades before CT scanning. A neurologist gave us cerebral angiography. Many early neurosurgeons were neurologists first. Much as I hate to admit it, neurologists understand the brain much more profoundly than most surgeons, just as an automotive engineer understands a V-8 engine better than a mechanic.

The neurosurgeon/neurologist dichotomy in brain disease is similar to the cardiac surgeon/cardiologist dichotomy in thoracic disease, or the general surgeon/internist dichotomy in abdominal disease. My old cardiac chief, Maggie, once observed that internists and other “non-procedure-oriented” specialties stored their knowledge like sugar in great, floppy sacks and we stored ours in tiny sugar cubes. They had much more of it, but ours was more user-friendly.

In our own health center, unfortunately, the tension
between the neurology and neurosurgery services was so great that our department would not permit us to do our required neurology elective with the university neurologists. In fact, they went one arrogant step further and mandated that the only neurology service good enough for
their
residents was at a London hospital. London was the birthplace of both neurology and neurosurgery. The first full-time brain surgeon in history, the great Sir Victor Horsley, practiced there.

I had no burning desire to be in London for three months. Our department of neurosurgery “graciously” paid my airfare, but reimbursed me for nothing else. London is an expensive place to live and I could not just give up my current apartment for only three months, and so I was faced with paying rent on two residences during the rotation. This would consume all of my moonlighting money. I appealed to the department to let me do my neurology at home. They refused, and off to Merrie Olde Englande I went.

I spent my first night
in London lying awake listening to the trains rumble past my bedroom window. I had an uneasy feeling, thousands of miles from home, in a country where I had no friends and no family—no one who would know if I disappeared off the face of the earth. But my discomfort soon passed. Years earlier I would have stayed terrified for weeks, but I was changing. The years of residency had begun to permeate my personality; I now looked at myself as a neurosurgeon. The James Bond feeling that sustained me in moments of clinical crisis was starting to carry over into my out-of-hospital persona as well. Endless days and nights spent summoning the nerve to stick a tube into someone’s nose, a needle into someone’s back, a drill into someone’s skull, or a knife into someone’s brain were now making it easier for me to face challenges outside the hospital
as well. The next morning I confidently walked to Kensington High Street station and boarded the Circle line, headed for my first day in the birthplace of neurosurgery.

After some meandering, I finally located the quaint collection of buildings making up the London medical complex that was my final destination. The main hospital had the musty smell and vaulted ceilings of a structure dating from the previous century, with tall, wooden-framed windows still filled with original glass panes rippled by age. The walls were topped with elaborate plaster moldings. A circular stairway of trodden marble and hardwood bannisters spiraled to the first patient floor. On that floor were two large wards, male and female, each with two dozen metal-frame beds arranged in rows on either side of a long steam radiator covered by an ornate metal grill. These cavernous wards contained the neurology service.

While the foyer and hallways were heated to barely sixty degrees (considered positively balmy by U.K. standards), I found the wards to be quite warm. The increased heating of the patientcare areas was evidence that even the British didn’t believe their own hogwash about lower temperatures’ being “healthier.” In reality, the ambient temperature was directly proportional to the robustness of the government health service’s budget at the time.

This was clearly not American medicine. The wards were bigger and more chaotic than the ones at the V.A. The nurses were universally female and wore long blue and white smocks with watches pinned to the front, outfits in style during World War I. They all answered to “sister.” When I first heard this title, I was confused. Was this a Catholic hospital? In the middle of Anglican London? I later learned that this was the local idiom for “nurse” and was used with respect and admiration.

One of the “sisters” introduced me to William, a tall, pasty
fellow with thick wire-rimmed glasses. William was the senior neurology registrar for the ward. Registrars are the U.K. equivalent of residents, except that the position of registrar may go on indefinitely.

In the United States, residencies have a defined length. As long as a resident meets the minimum requirements for finishing, he or she is virtually guaranteed to enter the realm of attending physician at the expected time. Not so in Great Britain, where the centralized planning of socialized medicine sets the maximum number of attending jobs available. Thus, a neurology registrar can exit training only when openings for an attending neurologist become available. This occurs when an existing neurologist retires, dies, or emigrates for a larger salary—in other words, not very often.

William, at forty-five, had already held registrar positions in internal medicine, pulmonary medicine, and pediatrics. His tactic was to keep changing specialties after four or five years, as opposed to staying as a trainee in one specialty for ten to fifteen years waiting for an opening. At the present rate, he expected to retire before he finished his training. “I’m the smartest, most overtrained, and least-employed doctor in the whole bloody world,” he once bitterly observed.

William’s assistant registrar was David, a man of thirty. David was strikingly handsome, with a granite jaw, coal black hair, and blue eyes. He had a smooth voice and cultured accent which oozed his Oxford background.

Because it was under few financial pressures to behave otherwise, the neurology service operated at a glacial pace. The lone CT scanner was usually backed up for days, even weeks, and more involved studies were even harder to come by. The rate of patient progress was so slow that the attendings rounded only once a week, compared to once or twice a day
in the United States. I would come in every morning expecting the frenetic activity I had come to associate with American inpatient care, only to find the nurses and the patients staring at one another. Watching a case unfold was like watching grass grow.

One Sunday, a middle-aged man was admitted after having a subarachnoid hemorrhage during sexual intercourse with his wife. He was in excellent condition: awake, alert, and with only a trace of headache. Back in the States, we would have performed angiography and surgery to clip the ancurysm within twentyfour hours of his arrival. But this was London. We simply tucked the man into his ward bed and scheduled his cerebral angiogram—the next slot was fourteen days away. He would have to wait. Dr. Newley, the attending neurologist, saw the patient three days after he was admitted.

“Shouldn’t we get the surgeons involved?” I queried him, somewhat brashly.

He looked at me with the serene compassion of a master looking at his impudent dog. “My dear boy,” he replied, “let’s get the angiogram first and see what the chap’s got first. I hate to bother Mr. Davies with this until we’re sure.” British surgeons carry the title “mister,” a throwback to the days when surgeons weren’t physicians but barbers, farmers, blacksmiths, or anybody else a physician could con into wielding a scalpel without benefit of anesthesia or sterile technique.

Wait and see what the “chap” has got?
This calm approach to subarachnoid hemorrhage disturbed me. I was accustomed to a more aggressive management style.

The “chap” waited uneventfully through the first week. The following Sunday, though, while glancing over the sports page and eating lunch, he shouted, grabbed his head, and fell forward into his bowl of vegetable soup. He burbled into the
bowl for untold minutes until one of the sisters found him. She pulled him out and started CPR, but he quickly died.

“He might have had a seizure and drowned in his soup,” said William.

“Bullshit,” I interjected.

“Oh, you Americans are so wonderfully blunt,” William continued, “but I doubt we’ll ever know what really happened.”

No autopsy was performed. The following Wednesday we had weekly rounds with Dr. Newley. Afterward, the attending neurologist grabbed his overcoat and was about to leave when he suddenly turned to William and inquired about “that poor bleed fellow in the next-to-the-last bed on the right.”

“Oh, yes…he died three days ago. Fell plop, right into his soup. Probable rebleed.” William was positively blase. I shuddered to think what the boss would say if one of his hospitalized patients had died and I had waited three days to tell him about it.

The aging neurologist passed a hand through his still-red hair and grinned wickedly. “A bit of hard cheese, those aneurysms!” He walked away and never mentioned the case again.

This was going to be a long winter.

To their credit,
the neurologists, neurosurgeons, and registrars I encountered tried very hard to render good care in the face of bureaucracy, overcrowding, and chronic lack of funds and equipment. Those tasks that required little or no money to do, like taking a patient history or performing a physical examination, they did superbly and with deep attention to detail. The deficiencies in technology had sharpened their personal diagnostic acumen.

On my first day, William took me to a patient’s bedside to observe the complete neurological examination on a woman
with multiple sclerosis. He brought with him a large wooden box. Opening the box, he produced a small tray full of sealed vials and set it upon the patient’s nightstand. As he readied his other equipment, I picked up the vials and glanced at them. They were full of liquids and powders; one was labeled “coffee,” another “cloves,” and yet another “vanilla.”

“What are these for, William? Are we going to do some baking?”

“No,” he laughed, “these are to test the young lady’s sense of smell.”

“Sense of smell?”

“Yes, watch.” He uncapped a vial, occluded the woman’s right nostril, and told her to close her eyes while inhaling with her left nostril. As she obeyed, he thrust the open vial under her nose.

“I think…it’s orange, yes, like orange peel,” said the woman without opening her eyes.

“Excellent!” said William. “See? The sense of smell is diminished in frontal-lobe tumors, particularly meningiomas of the olfactory groove. Testing for smell is often overlooked.”

That was an understatement. Back at home, we
never
tested the sense of smell. But then, at home I could obtain a CT scan for an olfactory-groove tumor in less than two hours. In London, patients often waited months for elective CT scans.

As if he were performing surgery, William methodically conducted the exam over the next hour, pulling tool after tool from his wooden box. There were test tubes filled with hot and cold water to test temperature sensation; a compass to test twopoint discrimination on various skin surfaces; a long strip of black velvet with white stripes painted on it to test for optokinetic nystagmus; a rotating wheel device, which looked like a pizza cutter, to demarcate areas of decreased touch sensation; a goniometer
to measure joint flexibility; little wands with red tips to test peripheral vision; an index card of nursery rhymes and riddles to test mentation. Even his reflex hammer was unique—a huge rubber wheel fixed to the end of a two-foot-long plastic stick. It looked more like a police weapon, or a truck tire fixed to a telephone pole, than a medical instrument. These hammers were standard issue in London. William claimed that the only way to test reflexes was to hit the limbs with “real momentum.”

The history-taking on the neurology service was equally fastidious. One afternoon, after taking a history from a man with headaches, I was grilled by the hospital’s chief neurologist on teaching rounds.

“What does Mr. Hughes do for a living, Doctor?” the kindly professor asked.

“He says he works in a shop.” I replied. At home, that would have been the end of the discussion on that topic.

“What sort of shop?”

“I don’t know, some sort of small store, maybe.”

“Well, what sort of shop might make a difference, don’t you think? If he works in a paint store all day mixing paint with hydrocarbon thinners, might not that be a cause of his headaches?”