When the Air Hits Your Brain: Tales from Neurosurgery (2 page)

J
uly 1. Neurosurgery residency.

Day one.

Five
A.M.

A sickening wave of déjà vu flooded over me as I looked at the automatic doors to the “porch,” the neurosurgical step-down unit. I had a sudden impulse to flee, to hide under my bed until it all went away. Six more grueling years of training loomed before me. Those years weighed heavily upon my brain that morning, like tons of ocean water submerging me, away from the sunlight of a normal life, normal job, normal things.

Before I could push the wall button to open the porch doors, they abruptly hissed apart on their own. There before me sat two men from my past: Gary, the hyperbolic smokestack of a junior neurosurgery resident who had ascended to become chief resident; and Eric, the once-jittery intern who was now a senior resident. I had worked with both of them years earlier, when I was a lowly medical student. We would be spending the next six months together on the boss’s service, covering his pain patients as well as taking care of the trauma patients and other ER “hits” to neurosurgery. The “boss” was the chairman of neurological surgery, Dr. Abramowitz.

“Well, Eric, look who’s arrived—Mr. Horner’s sign himself,” Gary said, referring to the clinical sign which had landed me in neurosurgery in the first place. Ancient history.

“Hello, Gary, you look—”

“Like hell, as always. Too much chocolate milk and nicotine—but, hey, whatever keeps you going? Listen, there isn’t anything on the schedule this morning—the boss is testifying at a trial. Let’s go back into the conference room. I need to spell out the rules of neurosurgery to you, from day one. After that, we’ll take you down to see the Museum of Pain.”

“The rules of neurosurgery? The ‘Museum of Pain’?”

“Yeah, the rules. Rules you aren’t going to read in any of the six volumes of Youmans’ textbook. You’ll see the Museum later—you have to see it to believe it.” Youmans’ was the bible of neurosurgery, the font of wisdom for trainees.

We went back to the small conference room where I would be making afternoon card rounds for many years to come. Gary went to the chalkboard and began to write.

“Rule number one: You ain’t never the same when the air hits your brain. Yes, the good Lord bricked that sucker in pretty good, and for a reason. We’re not supposed to play with it. The
brain is sorta like a ‘66 Cadillac. You had to drop the engine in that thing just to change all eight spark plugs. It was built for performance, not for easy servicing.”

“The patients seem to do all right,” I protested.

“Yes, they usually do, but every once in a while something funny happens: someone’s personality changes, a patient up and dies without warning—all little reminders that you are treading upon sacred soil. Which leads to rule number two: The only minor operation is one that someone else is doing. If you’re doing it, it’s major. Never forget that.”

He took a sip of coffee and continued. “Rule number three applies equally well to the brain patients and to the spinal discpatients: If the patient isn’t dead, you can always make him worse if you try hard enough. I’ve seen guys who have had two discs taken out of their backs and begged us for a third operation, saying that they had nothing to lose since they can’t
possibly
be any worse than they are. So we do a third discectomy and prove them wrong.”

Another sip. He went on. “Rule four: One look at the patient is better than a thousand phone calls from a nurse when you’re trying to figure out why someone is going to shit. A corollary: When dealing with the staff guy after a patient goes sour, a terrible mistake made at the bedside will be better received than the most expert management rendered from the on-call-room bed or the residents’ TV room. Look at the patient. Rule five: Operating on the wrong patient or doing the wrong side of the body makes for a very bad day—always ask the patient what side their pain is on, which leg hurts, which hand is numb. Always look at the films yourself and check that the name on the film matches the name on the chart. Always look at the consent and look at the patient’s bracelet. To do otherwise is a setup for a
res ipsa.”

“Res ipsa?”
I asked. “They never taught us that one in medical school.”

“And they never will; it’s a legal term. Short for
res ipsa loquitur,
or ‘the thing which speaks for itself.’ It means a malpractice case in which the error is so obvious that even a non-expert can see that a fuckup has occurred. A patient falls off the OR table. You cut off the left leg when it’s the right one that’s gangrenous. You send someone with a broken neck home from the ER with only an aspirin prescription. A patient bursts into flames during defibrillation. You take a disc out of a Mrs. A. Johnson when it was Mrs. J. Johnson who was supposed to have the operation.
Res ipsa
is checkbook time. Just write in a string of zeroes. Have I forgotten anything, Eric?”

Eric thought for a moment. “Well,” he said, turning to me, “just remember the rules of any surgical residency: Never stand when you can be sitting, never sit when you can be lying down, never use the stairs when there are elevators, never be awake if you can be asleep, and always eat and shit at the first available opportunity.” He thought some more. “And always agree with the boss. The boss
is
this residency program. When it comes to ego, neurosurgery is the major leagues, the NFL, the NBA. The big time. Grovel and beg at the appropriate times, and you’ll do fine.”

“This is residency now,” Gary chimed in again, “you aren’t the hotshot medical student or the know-nothing intern who can be forgiven any mistake. This is for keeps. This is your career. No more temporary rotations in pediatric endocrinology or tropical diseases. You’ll do this shit until you die. Are you ready?! I said, are you READY!”

“Yes!”

Let the Games begin.

M
y descent into neurosurgery began in medical school, where I sought refuge from the real world. I took my undergraduate degree in theoretical physics—a great field if your name is Einstein. As a former steelworker, my personality tended toward careers which offered me some realistic chance of making a living. The great Enrico Fermi, father of nuclear fission, once said that there are two types of physicists: the very best, and those who shouldn’t be in the field at all. Any theoretician who isn’t the best is a fraud, a pretender. I had done well in physics, but not well enough to pass Fermi’s test. I decided, virtually by default, to become a doctor.

TV and movies foster many misconceptions about medical students, portraying them as drunken buffoons performing unspeakable acts with mummified body parts in anatomy labs, or as fully competent physicians (Judy can amputate the captain’s leg! She’s a medical student at Harvard!). In reality, medical students are glorified college students, people who think they know something, but don’t.

Although a certain amount of rowdiness exists in any medical school, we were not picked for our social skills. I divided our freshman class into three groups. I was in the biggest: the slackers, consisting of students who had garnered acceptable grades with a minimum of effort since first grade. We studied only as much as absolutely necessary (and only at the last possible moment). We lurked in the rear of the lecture halls, in the “prime bolt seats,” from where an unobtrusive exit could be made if the lecture got too tedious or a good basketball game formed outside. Most importantly, slackers never asked questions in class. Asking questions was a sign of weakness.

The second group, the keeners, were overachievers, who hacked and bludgeoned their way to success through work and more work. They planted themselves in the front of the lecture hall, never exiting a class prematurely even if diarrhea dribbled into their shoes. And they always…ALWAYS…asked questions. A lecture on the tying of shoelaces would still draw some keener into the lecturer’s face after class, waving a grade-school ring binder and saying, “I didn’t quite get it, the loop goes under or over?”

The third group, the wild cards, entered medical school because they knew someone, because one of their parents had graduated from the school decades earlier, or because someone on the admissions committee was intrigued by an unusual entry on their résumés—“Spent one year in Uganda ladling gruel
into starving children.” Unfortunately, these admission criteria did not correlate with IQ. The wild cards became our “cretin buffer,” fattening the grade curve for us slackers. The wild cards never sat in the front
or
the back of the class—they never went to class.

The first two years consisted of didactic lectures on anatomy, physiology, pathology, and the like, with a few brief contacts with patients thrown in as appetizers. The real fun didn’t begin until the third year. At that time, lectures ended and we were thrown into the hospital wards full-time.

Seven clinical tours of duty, or rotations, made up the third year: nine weeks of internal medicine, nine weeks of pediatrics, three weeks of anesthesiology, six weeks of general surgery, six weeks of obstetrics and gynecology, six weeks of psychiatry, and a three-week elective in the surgical subspecialty. My schedule arrived in August, listing my first rotation as the surgical subspecialty rotation. Great, I thought, I’ll do cardiac surgery. Maybe I’ll be a chest surgeon.

When I went to sign up, the secretary in the student affairs office dryly informed me that I could not do cardiac surgery, since the cardiac surgeons wouldn’t let any medical students onto their service unless they had finished the six-week generalsurgery rotation first. She thrust a list of remaining possibilities at me: ear, nose and throat; orthopedics; plastic surgery; urology; neurosurgery.

Students were stacking up behind me. I had to think fast. Nose picking? Carpentry? Face-lifts? The stream team? The head crunchers? Nothing seemed as interesting as cardiac surgery. Oh well, it was just a crummy three weeks, anyway.

“Ahhhh…give me neurosurgery.”

She jotted it down. “Vertosick, neurosurgery. Show up on the neuro floor, five-thirty
A.M.,
September second. Next.”

My fate was decided by a scheduling glitch.

Then it hit me: 5:30
A.M.
, as in before dawn? Was she joking?

On a gray September morning, I slogged to the hospital for my first day as a real doctor on the university neurosurgical service. I was about to step onto the slippery slope.

The neuro floor
was dark and quiet, the nurses’ station empty. I tracked down a nurse making his rounds and introduced myself, then asked him where I might find someone who would know what it was I was supposed to do.

“Look in the porch.”

“The porch?” I had visions of some congenial place, full of wicker rocking chairs.

He pointed to a set of automatic double doors at the end of the long hallway. “You know, the porch, the neuro stepdown unit…right there.”

Thanking him, I wandered to the porch entrance. The doors carried the imposing label “Neurosurgical Continuous Care Unit, Authorized Personnel Only.” I felt a bit of pride. For the first time in my life, I was “authorized personnel.” I pushed a switch on the wall and the doors swiftly separated.

The porch was a small room with a tiny work desk at its center. Six patient beds, five of them occupied, were crammed in a semicircle around the desk. Electronic monitors dangled from the white ceiling and the walls were covered with metal baskets stuffed with gauze sponges, packages of gloves, IV kits, and other disposable medical paraphenalia. The air smelled of antiseptic. Faint monitor beeps were the only background noise. No wicker furniture here.

The patients, looking like giant Q-tips with their heads wrapped in bulky white bandages, were asleep (or comatose, I didn’t know which). At the desk sat a thin, haggard man sporting
a day’s growth of beard and wearing a white jacket over his blue surgical scrubs. He hunched over a stack of charts, scribbling away. I tapped his shoulder and he jumped in his chair, startled by my intrusion.

“Jesus Christ,” he hissed at me, “who are you?”

“Frank Vertosick, third-year student doing a neurosurgery rotation. A nurse told me to come here. Is this the porch?”

“I’m Gary,” he whispered back, calming down a bit, “junior resident…yeah, this is the porch. This is where we keep people who aren’t sick enough for the intensive care unit, but are too sick to go out on the floor and be forgotten. Most of them are post-ops. Except that one.”

He pointed to a young man, perhaps a teenager, with a thin plastic hose leading from his head bandages to a complicated contraption on a metal pole beside his bed.

“That guy’s a head trauma. We’re still watching his ICP, but he’s wrecked. He’ll go out to the graveyard until we can place him.”

ICP, graveyard, place him. Clearly, the language we’d spoken in the first two years of medical school would be of little use here.

“ICP means intracranial pressure; the graveyard is the area of the floor where we keep the unconscious people; and when we say ‘place him,’ that means find some nursing home that will take him off our hands…he isn’t going to be any better than he is now. I see you have a lot to learn.”

“That’s why I’m here,” I beamed.

“No, you are here to be my fucking slave,” he said with a broad grin. “Now, sit there like a good boy and let me finish my notes, then we’ll get some breakfast.”

Gary went back to leafing through the charts, jotting down laboratory values and vital signs onto soiled note cards as he
went. Every so often he would moan or mutter obscenities to himself, displeased with some chart entry. At last, he clapped the last chart shut, stacked the charts in a pile, and placed them in a basket for the porch secretary. He leaped from the chair and beckoned me to tag along. We exited the porch and took the long elevator ride down to the hospital cafeteria.

Gary broke the silence in the humming elevator as he lit a cigarette. “There are three residents and one intern on our service—me, the junior resident; Hank, the senior resident; and Carl, the chief resident. The interns float through on a monthly basis. Our intern right now is Eric Foreman, who’s going to be one of the junior neurosurgery residents next year. We tend to ignore the interns, unless they’re going into the program; then we kick the shit out them. Everybody makes rounds in the morning on a different part of the service. Eric, since he knows nothing, rounds on the people out on the floor. They’re generally pretty stable. I get the porch; Hank covers the intensive care unit; and Carl, as chief, gets to roll in at about six-thirty or seven. He doesn’t see anybody in the morning; we just make ‘card rounds’ with him at breakfast, giving him a verbal report of what, if anything, happened at night.”

“What’ll I do?” I asked, still searching for what my role would be in this well-oiled machine.

“Well, after you get my coffee, I guess you should pitch in and help write progress notes on the patients on the floor. There are plenty of them and it’s tough for Eric to get finished in time to go to the OR by seven thirty. You see, every patient needs a progress note written on their chart every day…You haven’t done any general surgery yet, have you?”

“Well, I haven’t done anything, really.”

Gary rolled his eyes. We exited the elevator and walked the short distance to the cafeteria. Loading up on corned beef
hash and eggs, foods that hospital cafeterias serve in order to guarantee future admissions to the coronary care unit, I followed Gary like a lost dog over to a long table in the corner. Two other residents were already seated there, both dressed in street clothes.

“Carl, this is Frank, MS III.” Gary addressed the more distinguished-looking resident, a slim man with a hint of white about his temples. “Frank’s starting on neurosurgery this morning…No, wait, he’s starting his goddamned medical career this morning!”

I shook the chief’s hand.

“Welcome. This is Hank; he’s a fourth-year resident.” Carl motioned to the other resident seated beside him, a balding, portly fellow who waved at me and smiled as he continued to chew a large mouthful of food.

Gary and I took a seat and began to eat. Several minutes later, a frenetic figure darted to the table, his tray rattling in front of him, the coffee flying out of his cup. He had a boyish face and blond hair. This was clearly Eric, the intern, late for morning card rounds.

Carl cast a perturbed look at the intern, pulled his own stack of index cards from his lab coat pocket, and began the daily litany.

“Beckinger, room nine.”

Eric flipped through his cards, locating Beckinger. I surmised that Beckinger was someone on the floor—Eric’s responsibility.

“She’s fine, afebrile, no headache, no face pain, wound is dry. She’s now four days out from surgery.”

“Has she pooped, yet?” Carl asked dryly, without looking away from his cards.

“Uh, I don’t know.”

“Well, goddamn it, find out. You know the staff man will go nuts if she hasn’t shit four days out. Her fucking cerebellum could be hanging out of the wound and dragging on the floor, and he wouldn’t care as long as her bowels are moving. If she hasn’t done the deed, give her some mag citrate…Rockingham, ten, by the window.”

Eric was still scrawling “BM?=mag cit” on his Beckinger card. He hurriedly shuffled to the next one in his stack.

“Rockingham has some face pain, a little headache, temperature’s 100.8, wound is dry. He’s three days out.”

“How much is a little headache?”

“Just…ummm…a little.”

“Does he need a spinal tap?”

“I don’t think so?”

“Did you wake him up, or is this what his nurse told you?”

Eric grimaced. “I didn’t wake him, he looked so peaceful—”

“Chrissakes, Eric,” Carl exploded, “you have to wake them up! I know it’s early, but this isn’t the Ritz. They can sleep at home, and I’ve got to know how they feel every morning. The staff guys will go around at eight this morning, the patients will start bitching that they were up all night and nobody’s bothered to see them yet. That you stood outside the door and waved at them while they sawed logs isn’t going to appease anybody. After breakfast, go upstairs and ask this guy how bad his headache is and come and tell me.”

And so it went, patient after patient. First Eric, then Gary, then Hank. Each took his turn relating the patients. Eric and Gary took a ferocious beating, while Hank’s presentations went unchallenged. Clearly, Carl looked at Hank as a colleague, while he looked at Gary and Eric as subordinates. He never looked at me at all. We finished at about seven-fifteen. Carl produced a large sheet of paper with the OR schedule for the week.

“Hank, craniotomy for meningioma, room twelve…The only other case is one of the boss’s face pain patients in room five. Gary and I will do that together. Eric, go back to the floor and take care of all the loose ends.” The morning tribunal dispersed.

Gary took me over to the OR dressing room, where gave me quick instructions on how to find scrub clothes and how to put on a hat, mask, and shoe covers. He also let me share his locker.

“Eric’s being punished,” Gary whispered to me as I changed my clothes. “He’s not very up on things yet. Carl could have let him stand around with Hank on that brain tumor case, but he’s been sentenced to the floor to be badgered by the nurses all day.”

“What are you going to do?”

“Carl’s going to teach me to open one of the face pain patients. I haven’t done much more than help on that opening yet.”

His face brightened. He was clearly looking forward to this. So far, I hadn’t seen anything to get excited about—getting up before the trout fisherman, rounding on teenage boys who were headed for a nursing home, eating greasy food, and watching grown men torment one another.

Maybe seeing what went on in the OR would change my mind.

I walked cautiously
into operating room five, the first one I had ever seen “in the flesh.” Much smaller and less grand than I imagined an OR to be, the room’s walls were covered with shiny green tile, the floor a hard, blackish lineoleum. The room had a cold and hollow feel, like a large dormitory bathroom. Against the far wall, a woman in full scrub dress shuffled metal instruments
on a large table. To my left, skull X rays dangled against two light boxes hung at eye level. The patient occupied the center of the room and was already anesthetized, thick bore plastic tubing jutting from his mouth and nose, the eyes taped shut.