When the Air Hits Your Brain: Tales from Neurosurgery (20 page)

I got Charles to the recovery room shortly after noon. He awakened as expected: thrashing his left arm and leg vigorously, but completely motionless in his right arm and leg. When given commands, he simply widened his eyes in a bewildered, doein-the-headlights stare. His speech, pure gibberish. The left hemisphere was gone. The head gone, the body would not be far behind.

Retiring to the family waiting room, I asked the few other families present to please leave me alone with Mrs. Bognar. I switched off the blaring TV set and closed the door.

“We…we had some bleeding…we were forced to put a clip around the main blood vessel to his left brain…He…he has had a very large stroke, I’m afraid…”

“A stroke? Is he…alive?” Her hands began to shake and her eyes filled with tears.

“Yes. Yes, he is alive. But he can’t speak or move his right arm or leg. I’m afraid that’s…permanent.”

“Permanent! You mean he’s never going to talk again?!”

My eyes looked down. “Yes. Never. He may not even survive.”

She began to hyperventilate, then went to a wastebasket and vomited. Collapsing in a heap on the sofa, she buried her ashen face in her hands and began to weep softly.

“Is there anyone I can call for you? Friends? Family?” I knew that Charles had no children from either of his marriages.

“No, leave me alone. You’ve done enough.”

“It was a risk of the procedure…it was explained to both of you—”

“Go away.”

And go away I did.

The ensuing days
were agonizing. Charles spent his waking hours pounding and twisting the sheets with his left hand in purest frustration, yelling “Yaaah…yaaah” in vain attempts to make himself understood. Taking care of patients with aphasia, inability to speak, pushes the envelope of difficulty. Rounding on him was torture. The staff surgeon dragged me to see Charles every morning, grimly displaying my mistake to me like the Ghost of Christmas Future tormenting Scrooge with the outcome of his wasted life.

The second Mrs. Bognar confronted me every day with an unrelenting bitterness. True, he had this aneurysm “thing” in his head, but at least he was all right before the operation. Nothing the aneurysm could have done would have been worse than this, in her mind. And she was right. She didn’t blame me
for the poor outcome of the operation, but she believed her husband had been deceived about the necessity of the operation in the first place. Statistical operations are hard to explain to people. Such operations are rolls of the dice, a gamble that operating carries fewer risks than the disease. Anyone who bets the farm and loses winds up feeling duped.

I sank into a deep depression. Ordinary diversions, such as watching television or eating a meal, lost all meaning. All these things seemed trivial when I recalled my patient writhing in his speech-deprived cocoon. Play tennis? Enjoy myself while Charles suffered? No, I could not.

Sleep became difficult. I had a recurring dream. I was back in the steel mill, where my favorite diversion was watching the great plunger cranes as they pulled hot ingots from the flaming bowels of the furnaces. In my dream, the plunger cranes came equipped with great, glittering aneurysm clips in place of their usual iron jaws. The gaping clip dipped into a glowing furnace for an ingot. As the crane emerged, there were no burning coke embers, but bubbling jets of boiling blood. The bloody, hot ooze sputtered and spewed from the pit’s depths, rushing like a river of magma toward me. Clucking workers laughed at me. “Pretender,” they teased.

During my waking hours, the final moments before the aneurysm tore replayed in my head over and over again—my own personal Zapruder film—despite my efforts to shut them out. I almost had the goddamned thing clipped! What could I’ have done differently? If someone else had been doing this case, would things have come out better? Did I play with the dome too long? I simply did not know the answers. Or, worse, perhaps I did.

“Death and doughnuts,” our weekly discussion of complications and operative deaths, dispatched the case with little
controversy. The aneurysm ripped, the patient stroked out, tough luck. A big yawn for the more experienced surgeons present. A halfhearted discussion ensued on how to handle the situation—whether a bypass operation could or should have been done to supplement flow to the brain, whether barbiturates would have helped, and so on. The complication was chalked up to PD, patient’s disease—a bit of hard cheese, those aneurysms. In my mind, I feared a PCP complication: poor choice of physician. I thought seriously about resigning and ending my career as an emergency room doc. Enrico Fermi’s admonition came back to me: Be the best or be something else. No room for pretenders here. Had I remembered the great physicist’s maxim one patient too late?

Where did Frank the surgical psychopath go? After Andy died, I thought my personality was annealed to steel. I had what it took to face disappointment—or so I believed. Rebecca’s illness bothered me deeply, but she was an infant, an aberration. Nobody can watch babies die. But Charles more than bothered me—he tormented me. I was Raskolnikov, the protagonist of
Crime and Punishment,
someone who imagined himself a conscienceless superman until he committed murder and guilt unraveled him. Charles was the first disaster that was my fault and my fault alone. He didn’t have an incurable disease, he wasn’t ancient and doomed to die of something soon, he didn’t succumb to an attending surgeon, he wasn’t born with cancer of the brain—he placed the delicate porcelain of life into my hands and I dropped it.

At the death and doughnuts conference, I gazed about the room at the dozen or more staff surgeons present that morning, one hundred years of neurosurgical experience among them. Surely, these were ordinary men? Their learning curves must have devastated dozens upon dozens of lives. Why were they still sane?

Or were they? During his murder trial, Raskolnikov dreamed of a world full of cruel people endowed with such intense belief in their own moral rightness that they never felt the slightest pang of guilt or remorse, even as their world sank into decay. Is that what it would take for me to go on? A blind belief that there was nothing I could have done better, that no one could have achieved a better result than I did on that day?

That is not the way of the scientist, and I still looked at myself as a scientist. Mathematician Jacob Bronowski believed that the credo of science could be found in an Oliver Cromwell utterance: “I beseech you, in the bowels of Christ, think it possible you may be mistaken.” To live with my failures, would I have to exit Bronowski’s self-critical world and enter Raskolnikov’s dreamworld, the megalomaniac’s Utopia?

Five days after surgery, Charles’s dead left brain swelled and smashed the life out of his brain stem. He was placed on mechanical support. During a tense ten-minute meeting, Charles’s wife and I reached an agreement to withdraw his ventilator. On the seventh post-op day, I went into his room and, armed with the ventilator key, accomplished what four years of living with the Viet Cong could not.

My depression did not relent.
In my spare time, I returned to the places of my premedicine days—the tennis courts in the park, the undergraduate library, even the grounds surrounding my high school—in hopes that soaking up the ambience of the past would restore me to the person I once was, to the boy who only worried when his forehand sailed long, for whom an overdue book report was the most pressing problem in the world. But I wasn’t that boy anymore. I was no longer the bright student capable of anything, the slacker who harvested A’s with ease and had the world by the ass. I was now thirty years old, engaged to be married, and possessed of only one way, short
of flipping burgers, to make a living. If I bailed out now—changed residencies, went to law school, got an M.B.A.—I risked ending up like William the Registrar, flitting from job to job until I retired, without ever accomplishing anything. Worse, I had no guarantee of being happier or more competent in those fields.

No more second chances. I decided that my random walk through life must end in neurosurgery.

I refused to operate again for weeks after the aneurysm fiasco, a feat possible on the slow V.A. service. Talking with the attendings about my career doubts would have done little good—a marine boot can’t discuss his doubts about the Corps with his drill sergeant. I decided to call Gary in New York.

“Yeah, it’s a bitch, isn’t it?” I could hear him strike a match in the background. Still smoking.

“That’s it?” I grumbled. “‘It’s a bitch’—those are your words of wisdom?”

“Who are you feeling sorry for, you or the poor bastard who died?”

“Both of us, I guess.”

“I don’t think so. Did you go to his funeral, or send flowers or something?”

“Er…no.”

“So what’s bothering you?”

“It wasn’t that tough an aneurysm. If Charlie Drake or Thor Sundt or some other full-time aneurysm surgeon had been doing it, Charles would be home screwing his brains out again and working on his next bleed. But it wasn’t Drake or Sundt, it was me…”

“Let me tell you a story,” Gary interrupted. “When I was a third-year resident on neuropathology, I moonlighted at Southland Hospital. One night, some guy drags his buddy in
off the street after he has a fight with another guy. We put the buddy on a stretcher and find out that he has a steak knife jammed to the hilt in his right chest. He proceeds to turn to complete shit in front of my eyes and the head ER nurse—one of those iron maidens who has worked in the same place for a zillion years—wheels out this big tray of instruments. ‘What’s this?’ I ask. ‘The thoracotomy tray,’ she says. The guy needed to have his chest opened all right, but I sure as shit wasn’t going to do it. ‘Forget it,’ I said, ‘he came to the wrong man.’ He promptly croaked. I felt guilty for a while, real guilty, until I realized two things: one, I didn’t plant the fucking shiv into his chest in the first place; and two, if they want a chest surgeon to be sitting in every two-bit ER in the whole world, they had better be prepared to pay him more than forty dollars an hour, which was all they were paying me.”

“The take-home lesson of this parable?”

“You didn’t make his aneurysm bleed…his wife did. And his hypertension, years and years of hypertension—he was no doubt too goddamned busy to see a doctor about it, too. You didn’t kill him; you were just asked to step in and prevent him from dying on his own…and you couldn’t. Yeah, Thor Sundt wasn’t there, but Thor Sundt can’t do every aneurysm in the country. And I’m sure Thor Sundt has torn a few aneurysms in his lifetime, great as he is—you think he came into this world with a clip applier in his right hand? There will always be people better than you and worse than you. If you worry about not being as good as someone else, why don’t you just give up every case right now? Just set up a phone hot line and sit in an office and match people with the very best surgeons in the whole universe. No point in cursing humanity with your own sorry skills, is there? C’mon! Quit feeling sorry for yourself and do the best you can with those who ask for your help. I’m gone
just over a year and you start moping over one postoperative death. Yeah, it’s a nightmare, but that’s neurosurgery. Land of nightmares. There are plenty more nightmares in your future, pal. Remember my index finger: are your coronaries that big?”

“I guess so. How do you do it, Gary? It never looks like you give a shit.”

“You have to care about the patients, but not too much. It’s unethical to operate on our wives. Why? Because we’d be too likely to choke, to get nervous and fuck up if it’s our own family on the chopping block. The very fact that medical ethics forbids treating your immediate family is proof that we shouldn’t get so involved with a patient that we are made nervous by the possibility of failure. Patients want us to care about them, but they want us to perform with the nerveless demeanor of someone slicing bologna in a deli at the same time. It’s one of those unexplained paradoxes we just accept—you know, like the
Flintstones’ Christmas Special.
How do people from a million
B.C.
celebrate Christmas? Enough bullshit. Clip the aneurysms and take what happens. Don’t make me come down there and kick your ass.”

Eventually I managed
to put Charles behind me. I tossed out my neatly typed resignation letters and halted my searches through the medical want ads. Whether the healing of my psyche came from some maturation process or from the realization that I simply had no other place to go is unclear to me now. Like Raskolnikov in his gulag, I finally acknowledged that psychopathy is not the way to face difficult responsibilities. Some caring is necessary if we are to be the very best surgeons we can be, even if we can’t be the best in the universe.

Caring makes the hands shake, but it also makes us dread disaster and work with every fiber of our being to avoid it. Pain,
emotional or physical, is the taskmaster of the animal kingdom. The pain of Charles’s death taught me a deep respect for the campfire of surgery. I would mind the heat more carefully from now on.

Three months after Charles died, a letter appeared in my university mailbox, a thank-you note from the second Mrs. Bognar. It read simply: “I know now that you only did your best. Thanks for everything.”

I was not embarrassed by this thanks, as I had been by the old peach farmer’s misguided gratitude so long ago. This was not a generic homage to the magic white cloak. I had indeed done my best; my best just wasn’t good enough. I accepted the nightmare of the past and awaited the nightmares of the future.

G
et up. Shower. Make the coffee. Our lives cycle like planets trapped in their orbits. Each day brings minor variations which cause our individual orbits to wobble a bit—the car breaks down, the school bus is late—but the grand pattern rarely changes. The sun rises and sets. We get up, go to work, retire to bed. The ponderous wheel of life turns inexorably down the road to our uncertain futures.

For some people the stability of life is drudgery. For them, the daily routine carves an intolerable rut, the fixed patterns growing predictable, boring. I, too, once dreaded the ordinary cycles of life. A major motivation for enduring surgical residencies
lies in the avoidance of a nine-to-five existence. But as a physician, I learned to pray that my todays will be like my yesterdays, that my orbit remains stable and my wheel of life stays a true course. I pray that I will go home as I have gone home a hundred times in the past, to find my wife and children safe, my parents alive, my house in one piece, my paycheck forthcoming.

I have seen too many patients whose ordinary lives detonated in an instant because of the unexpected: auto accidents, brain hemorrhages, heart attacks. People who awakened to face just one more boring day, and instead found the wheels of their lives careening into the darkness.

There was such a day for Sarah Clarke, age twenty-eight, homemaker, wife of a successful black businessman, and expectant mother of her first child. While preparing dinner in her elegant suburban home, she was startled by an abrupt twitching in her right hand. Her spatula jerked rhythmically out of control. Before she could even become alarmed or cry out, her vision blurred and the room spun violently. She dropped to her knees, then collapsed to the floor in a generalized seizure. The convulsions soon stopped, leaving her stuporous on the floor amid the spilled cake batter and broken cookware. An hour passed before her husband discovered her and had her rushed to the local obstetrical hospital.

At first, no one was sure what had happened. “She just passed out, I think…maybe from the heat in the kitchen,” came the reassuring words of the obstetrician, who further declared the pregnancy in no jeopardy. Such fainting is not uncommon in the first trimester, he observed. Before Sarah could be discharged, however, the seizures returned, first in her right hand and then spreading like a wave to involve her entire body, twisting her trunk in grotesque, violent paroxysms.
But this time, the convulsions did not stop until Valium and phenobarbital were given intravenously. The obstetrician, now as alarmed and bewildered as her husband, ordered Sarah transported to the university center—to our neurosurgery service.

As next in line
to become chief, I was summoned from my laboratory year to sub for the current chief resident, who had broken his wrist. My first day back on the clinical service, the junior resident paged me to the neuroradiology reading room to help him review a scan on a young black woman. I joined him in the darkened room and we gazed together at the images on the view boxes.

A dark blotch stained her left frontal lobe, an oval hole punched out of the brain tissue. On the enhanced scan, taken after the infusion of intravenous iodine dye, a few areas of white showed up within the ebony hole. Dye cannot enter normal brain tissue, unable to penetrate the chemical shield which protects the delicate brain from all but the most essential nutrients. Portions of the brain where the barrier is destroyed, due to infection, trauma, or tumor, “enhance” by turning white on the CT images.

“Uh-oh,” I said, noting the enhancing areas, “looks like trouble for this lady.”

“Where? Show me,” the junior peered closer.

“There”—I pointed to the small lesion with my reflex hammer—”in the left frontal area. It isn’t big, maybe two centimeters, but with some areas of enhancement. Definitely a glial tumor, either astrocytoma or oligo. Could be low-grade, but that enhancement is worrisome. Malignant degeneration may be occurring…Let me guess, she came in with a focal seizure, her hand twitched for a minute and stopped. Am I right? This lesion is too small to give her headaches or weakness, but it’s smack in the center of her hand region.”

“Close. The seizure did start in the hand, but became generalized. She was found down in her kitchen, woke up, and was taken to Women’s Hospital, where they…”

“Women’s Hospital?”

“Yeah, she’s pregnant. First trimester…Anyway, to continue, they thought she just fainted, since there were no witnesses, until she started flopping again. Needless to say, the OB guys shit their pants and shipped her here.”

“Pregnant. Wonderful. Simply wonderful.”

“What do we do now, O mighty acting chief?”

“Put her on Sakren’s service.”

“He’s not on call.”

“I know that. But he does the stereotactic biopsies, remember? The only safe approach to this thing is with a needle. An open approach would go right through Broca’s area. She’d end up without her speech. No lullabies for junior that way. If there is a junior.” The speech area of the left frontal lobe is named for Pierre Broca, the nineteenth-century French clinician who first associated left frontal-lobe tumors and aphasia.

“Do you think she’ll lose the pregnancy?”

“I don’t know…probably. While there is nothing about these tumors directly that prevents a normal pregnancy, she may not live six or seven more months without treatment. And I doubt that we could give treatment to a woman who’s in her first trimester. She’ll need radiotherapy, at least six thousand rads, and you can’t shield the fetus from that. At least I don’t think so; we’d have to ask the physicists—this problem has never come up before. Chemo might help, but you aren’t going to give that to a pregnant woman, either. They don’t even let them drink coffee anymore, for Christ’s sake. How are we going to blast her with nitrosourea or platinum? She may have to choose between not surviving until her due date and having a therapeutic abortion. There are your choices, ma’am. Have a nice day!
I’ll go and talk to her. Just think, I gave up dealing with laboratory rats for this.”

Sarah was a stunningly beautiful woman,
endowed with soft hazel eyes that rode the crests of her high cheekbones. She sat upright in her hospital bed as I entered. Her dapper, well-manicured husband, James, sat in a chair at her side. Although still groggy from the anti-seizure drugs, she managed a smile. The seizure had passed.

“Well, Doctor,” she began in a soft, almost apologetic tone, “I guess I’m an epileptic now.”

“I prefer to think of it as ‘seizure disorder,’ and, yes, you do officially have a seizure disorder.”

“Why? What’s happening to me?”

“Mrs. Clarke, anyone can have a seizure. Some people just have a lower threshold for seizures, that’s all. The threshold can be lowered by sleep deprivation, drugs, overexertion…or, in your case, a blemish on the brain.”

“Blemish? Is that a diplomatic way of saying that I have a brain tumor?”

The comment surprised me. Many patients won’t utter the word “tumor,” even months after their diagnosis.

“Well, you see…” I began to flounder, my carefully planned buildup derailed by the patient’s abruptness.

“It’s all right.” She forced a smile again, sensing my shock. “I heard the technicians mumbling something about a brain tumor…they thought I was asleep, but I just had my eyes closed.”

I gathered myself. “Yes, you
may
have a brain tumor, but a scan is not diagnostic of anything. It simply suggests what might be there. We will need to obtain a sample of the abnormal tissue and have the pathologists analyze it…It could be an
abscess, or…or something else altogether.” I didn’t sound very convincing.

“What else could it be?” The husband’s deep baritone pierced the room.

He had outmaneuvered me. I had to tell them the truth. I sat down and pulled my chair closer. “In all honesty, it is almost certainly some form of tumor. Yes, I guess benign infection or some weird stroke are still possibilities, but they would be long shots. Despite that, we still need tissue samples. There are several different types of tumor that occur in the brains of adults, ranging from pretty good to really, really bad.”

“So,” James continued, “we’re talking brain surgery.”

“Yes, but a small brain operation. We won’t shave very much hair, and it’s done under local anesthesia using a special metal frame that is placed on your head. It takes about an hour and is very safe, although all brain surgery carries some risk.”

Sarah spoke up. “Why don’t you just cut the whole thing out, get rid of it? Won’t that make the seizures stop?”

“Mrs. Clarke, your tumor is right here.” I pointed to her left temple. “Are you right-handed?” She nodded. “Then your speech center lies just over this ‘blemish,’ and cutting into that area and trying to remove it all would carry too great a risk to your speech.”

They sat in stunned silence for a few minutes, holding each other’s hands in a kneading grip that reflected their internalized anxiety. Sarah broke the interlude with her frail voice.

“You do know that I’m pregnant?”

“Thirteen weeks, according to the ER sheet,” I replied.

“Will the surgery affect my baby? Or the tumor, or the seizures?”

“The surgery should not affect your child, especially since it will be done without general anesthetic drugs. The seizures
likewise should have little effect, as long as you remain controlled on drugs like phenobarbital that are reasonably safe for the fetus. The tumor…well, the tumor is another matter. It all depends upon what it is and what treatments you may need. Some treatments are just not possible in a pregnant woman. I can see no reason why the tumor would harm the fetus, but our therapies most definitely will. You may need a therapeutic abortion.”

Sarah turned her eyes toward me and gave me a look of iron conviction. “Jesus is my Savior,” she intoned slowly, “and I believe He will let me keep my child. We’ve been trying for three years to get pregnant. So do your biopsy, but spare me the details of your ‘treatments.’ I will keep this baby. Please, I don’t want to be mean, but leave us alone for a while.”

The husband produced a Bible and read silently as I stole away from the room.

Dr. Sakren served as
our “stereotactic” specialist. Stereotaxis is the art of placing biopsy needles and other customized tools precisely into the brain’s depths, using an awkward, expensive device known as a stereotactic frame. Before the widespread use of stereotactic techniques in the 1980s, tumors situated below the brain’s surface were biopsied “freehand,” with the surgeon’s intuition as the only guide to the tumor’s location. The surgeon might cut a large craniotomy flap over the suspected tumor site and take an educated guess as to where the lesion might be, often attempting a dozen or more blind needle aspirates before either achieving a positive diagnosis or abandoning the procedure altogether. “Freehanded” brain-poking carries a high likelihood of missing the tumor completely, and, worse, a significant risk of catastrophic bleeding.

Nowadays, to perform a stereotactic tumor biospy, the surgeon bolts the aluminum stereotactic frame to the patient’s
skull under local anesthesia and then takes the patient to the CT scanner. Brain and frame are imaged together so that brain lesions can be cross-referenced with the frame’s centimeter markings. Because the frame is held in place by graphite pins drilled into the skull’s outer layer of bone, the correlation of the frame’s markings with the internal structures of the head remains exact. The position of a brain tumor relative to the metal frame cannot change, even as the patient jostles from operating room to CT scanner and back again. Such accuracy could never be maintained with more civilized means of attaching the frame to the head (with Velcro chin straps, for example).

After the scan, the surgeon chooses a biopsy point on the scanner’s video screen, using a light pen, cursor, or computer mouse. In Sarah’s case, our target would be one of the enhancing areas within her left frontal lobe. The scanner’s onboard computer provides coordinates of the biopsy point relative to the frame’s markings. Back in the operating room, a metal arm guides the biopsy needle to the target designated by the computer-generated coordinates. Because of the precision of this method, the biopsy requires a scalp incision and skull opening just large enough to admit the biopsy needle (less than half an inch). Since only one or two passes of the needle are needed, the chances of injuring the brain with this method approach nil.

As valuable as stereotaxis has proven, their neurosurgical peers view biopsy surgeons as wimps—surgeons who do tiny operations because they lack the skill or stomach for “real” brain surgery. Stereotactic surgeons are the field-goal kickers of our specialty: skilled, well paid, and thoroughly indispensable on select occasions, but not true players in the eyes of the more violent members of the team.

I presented the case of Sarah Clarke to Sakren the day
after her first seizures. He looked at her scan with a squint. “So she wants to keep her baby. Fine, we’ll see what happens. But I know the type. ‘God wants me to live, He has a special purpose for me.’ If God wanted you to live He would not deposit a malignant glioma into your dominant frontal lobe. Personally, I think she should just get an abortion preoperatively and be done with it. What do you think?”

“I think I wouldn’t waste my breath asking her to consider an abortion. I can tell you the answer to that question right now.”

I had seen the answer in her eyes and heard it in the tone of her voice. Sarah would keep her baby, no matter what. Jesus, and her own iron will, would see to it.

Cancer patients
are told to direct anger at their tumors, to “fight” the disease as they would fight some evil, hateful enemy determined to rob them of all that is precious. A useful technique clinically, perhaps, but the emotional colorations should not be taken literally. Cancer is not evil, not the enemy. Cancer is a biological process which has evolved for a very useful purpose: to kill us.

Although we look at ourselves as organisms, we are really societies comprised of trillions of specialized cells—blood cells, nerve cells, muscle cells, gland cells—cells which behave in accordance with communal laws developed for the good of the society. We are like giant hives and our microscopic cells the bees and wasps within.