When the Air Hits Your Brain: Tales from Neurosurgery (22 page)

Because of their similarities, cancerous and fetal tissues are both susceptible to anticancer treatments directed against dividing cells. As such, a cancer patient’s decision to abort her child lies beyond the scope of ethical debates about pregnancy termination. No one would have blamed Sarah for aborting her child—no one, perhaps, but herself. Whether she based her decision on her religious views regarding abortion or on her desire to see her child before she died, I didn’t know.

As her clinic visits progressed, a terrible thing became apparent: the tumor was winning the battle.

• • •

I continued to follow Sarah;
even residents in the lab have to go to residents’ clinic. Two months after her biospy, a follow-up scan revealed a larger, angrier mass in Sarah’s left brain. She grew clumsy with her right hand and made frequent mistakes with her speech and handwriting. Her arithmetic deteriorated to the point where James took over the family finances. Although he had an M.B.A., she had managed the home budget during their five years of marriage and the forced abdication of this job depressed her immensely.

“James won’t let me…write…the gardens,” she said haltingly.

“The gardens, Mrs. Clarke?” I asked.

“Yes.” She produced a checkbook from her purse. “The gardens…these, he won’t let me…write on them, the gardens, again.” The checks were imprinted with a floral pattern.

“He won’t let you write checks?”

She nodded vigorously. James stood in the background and never intervened to correct his wife’s speech. This may have been denial, or the refusal to embarrass her by publicly acknowledging her obvious decline. Perhaps by living with her he was able to understand her perfectly, and so perceived no need for making translations.

“Do you have headaches?”

“A little time, small…knocks,” she answered, “my head…uh…knocks…a little time at the morning once…only.”

“Uh-huh. How’s the baby?”

She smiled, the right corner of her full mouth lagging slightly. “Yes!” The single word spoke volumes.

“Then everything’s all right as far as the baby’s concerned?”

James spoke.’ ‘We were at the obstetrician’s last week. Everything’s on schedule.” I thought of the progressing scan; some things were ahead of schedule.

“The scan shows some worsening edema, Mrs. Clarke. I think we’re going to have to put you on some steroids again.”

Her smile evaporated.

“How gone worse my head?”

“I think steroids will help. They will help your speech, too.”

I prescribed a low dose of Decadron. During the next week, her speech came back to normal, her right arm became fully functional, and her headaches eased. Sarah and James hailed me as a miracle worker. But in my mind, I knew I was dealing with Mephistopheles again. Just as I had bargained with epinephrine to keep B.G with a Teflon heart alive years earlier, I now sold my soul to Decadron. Like epinephrine, steroids are miracle drugs with a price. They give you the result you want now, exacting their pound of flesh later. With epinephrine, the pound of flesh is taken in kidneys and limbs rendered dead from lack of blood. With steroids, the long-term toll is obesity, diabetes, poor wound healing, muscle wasting, and osteoporosis.

Like B.G. McKenna, Sarah left me with no choice. Decadron was the only agent that could be used safely. Whether it could carry her all the way to her due date in four months remained to be seen.

Months passed.
Each week Sarah’s speech and headaches worsened, prompting me to go up on her Decadron. The combined effects of her pregnancy and escalating Decadron turned her once lithe body into an obese pear. She became an insulindependent diabetic. Her face became bloated and round, her
chiseled features obscured. An acne-like rash covered her cheeks and back; her hair became sparse and brittle. The skin on her hands and forearms became thin and bruised, peeling away to form chronic ulcers. She came to her office visits in a wheelchair, her steroid-sapped legs unable to support her expanding girth. I found it difficult to think of her as the person she once was. The complications of her steroid use were profound, more profound than I would have expected from the doses I’d prescribed.

Despite their terrible side effects, the steroids grew less and less effective. Her stuttering speech gave way to “word salads,” and, finally, to incomprehensible gibberish. The weakness in her right arm became paralysis. Her pregnant belly grew large as her steroid-atrophied limbs withered. Her body was now being devoured from both ends by two parasites—a cancer and a fetus—each with a mandate to pick her bones clean for their own survival. Obstetricians instruct expectant mothers to take vitamins, but for themselves, not for their unborn children. The fetus will take what it needs and the mother’s metabolism will gladly yield it all. Cancer is equally voracious. Sarah was fighting a war on two fronts, and the battle would soon be lost.

I had hoped that the tumor would grow as a spherical mass and that we would be able to give Sarah radiotherapy once she was into her third trimester. Or that we would be able to extend her survival by surgical resecting the tumor once her speech had become so impaired that surgery could not worsen it further. Unfortunately, the cancer refused to cooperate. True to its name, the crab crawled sideways into her cerebral ventricles and spilled into her CSF. Once in her spinal fluid, malignant cells floated to her brain stem and spinal cord.

She presented one evening to Women’s Hospital with intractable vomiting. The obstetricians contacted me immediately,
since, at almost eight months of gestation, she was too far along in her pregnancy for her impending motherhood to be the likely cause. The OB/GYN resident in the ER gave me an ominous bit of history over the phone: “Her husband says she just throws up without warning, without any nausea at all.” I recognized this as “brain stem” vomiting due to the tumor’s invading an area of the brain stem known as the area postrema—the vomit center. Brain stem vomiting, unaccompanied as it is by nausea, causes considerable embarrassment for the patient. She may be feeling fine one minute and abruptly spewing vomit onto an unsuspecting victim the next. Brain stem vomiting is horrific in two other respects: It is often impossible to relieve, and the patient rarely survives for more than a few weeks after its onset.

The ER resident at Women’s asked if we wanted her transferred to our service. I said no. The time was approaching when Sarah’s baby would have to be removed, ready or not. Sarah was already where she needed to be, where she would have asked to be if she could still speak. Not the best place for her, perhaps, but the best place for her child.

I went to see Sarah on
the obstetrics ward. She was awake, but mute. Her right-side paralysis was now complete; it involved the face and leg as well as the arm. A feeding nasogastric tube jutted from her nose. She looked down, slowing rubbing her large abdomen with her left arm as I walked into the room. I approached the bed and she looked up at me with a blank face, then looked down again. Her husband stood up from his chair and motioned me to exit the room with him.

“They are feeding her by tube, but she still vomits a lot,” James began. “They tried antinausea drugs, but nothing works. The doctors say that if she keeps vomiting, they will take the
baby by C-section this week. She’s now about thirty-six weeks and they think it’s safer to deliver now than to let the pregnancy go with the persistent vomiting. She’s also having a lot of problems with her blood pressure and blood sugars, too. And she may have a phlebitis in her right leg, and they can’t treat that. She could have a clot go to her lung at any time and we could lose them both…” He bit his lip and tears filled his eyes.

Inanely, I tried to steer the conversation away from death. “She certainly developed a lot of steroid problems.”

James’s sullen expression turned sheepish. “Well…I have a confession to make. For a few months we doubled the dose of Decadron without telling anyone.”

“How could you do that? The prescriptions were for a set number of pills.”

“We got more from our family doctor and from the obstetricians. We told them that we lost your prescriptions and couldn’t reach you or Dr. Sakren.”

“Why?”

“Sarah wanted to make a series of videotapes for the baby. She taped twenty-one messages—one for each birthday until age eighteen, and special ones for when he graduates from high school and college and for when he gets married.”

“He?”

“An ultrasound showed that it was a boy…Anyway, to do this, to make all of the tapes, she wanted her speech to be as clear as possible for a month or two until she finished. She wouldn’t let me see any of the tapes, so I couldn’t help her in any way. She would take fistfuls of pills at a time just so that she could get a few sentences out. Sometimes she would vomit them up. Once we drove to Ohio and went to an ER pretending we were on a trip and needed a refill of steroids, just to get more. Who was going to question us? The tapes are done and
in our lawyer’s possession. He has instructions to release them at the appropriate times.”

“She’s a strong lady.”

“Too damned strong. I lie awake at night and wonder if we have done the right thing. Lord Jesus, what am I going to do with a baby and without her? What am I going to do? After the baby is delivered, isn’t there anything you can do for her? Can’t we go ahead with the radiation therapy then?”

“We’ve discussed this already, Mr. Clarke. The tumor is lining the ventricles and wrapping around the lower brain stem. It may even be in her spine…in fact, I would be surprised if it wasn’t. Radiotherapy would be cruel at this point.”

He nodded, wiping away the few tears that escaped his brimming eyes.

The following day, Sarah had a seizure which lasted for an hour before it could be controlled. That evening, she was taken to the OR.

I saw Sarah one last time,
four days after her Cesarean section. She subsisted now on intravenous fluids, and her consciousness waned. As I stood beside her bed, a nurse brought in the five-pound, seven-ounce James Junior, who was the picture of newborn health. The squirming bundle rested in her good arm. Sarah gazed down upon the infant with wide eyes, her mute stare betraying no emotion. After a minute or so, she turned her head away and closed her eyes. I could almost see her will to live exit her body, and I half expected to hear her voice return for one last, Christ-like phrase: “It is finished.”

There, in a small room, in a small hospital, in a small city, I witnessed the great wheel of life grind through another revolution of renewal. Parent and offspring had fulfilled their destinies; the tumor would soon fulfill its own.

Did Sarah have enough of her cognition left to appreciate her child during the few days that she had remaining? I didn’t know. I hoped that the ultimate irony was not true, that deep within she rejoiced over her victory in the race of a lifetime.

One week after the birth of her son, social services performed a transfer that they hoped never to make again. They moved Sarah from the maternity ward to a cancer hospice. The steroids—the drugs which she had sought like a heroin addict looking for a fix, the drugs which had bought her enough time to make a video legacy for the son who would not remember her otherwise—were withdrawn.

Years have passed since Sarah’s death.
I
visited her grave to read the epitaph one last time:

SARAH CIARKE

LOVING WIFE

DEVOTED MOTHER

I
stared at my coagulated corned beef hash and contemplated my first day as the new chief resident of neurological surgery. My white coat freshly starched, my index cards virginal white, and my mind well rested, I knew this state to be temporary, the lull before the storm.

Seven o’clock on a humid July morning. I awaited the arrival of my resident team for our inaugural card rounds. My assigned senior resident was Mark, who had just finished a pathology elective. The new junior resident, Dave, a University of Chicago graduate, came fresh from his internship at Penn. As I drummed my fingers nervously on the table, I felt very
alone. Gone were my original mentors, Gary and Eric. I missed their guidance terribly. Although he was in the fourth year of the program, I knew Mark only from death and doughnuts conferences. I had met Dave before, when I escorted him on his residency interview, but that was over two years earlier. The intern (like all interns) was a complete unknown. A baby-faced lad named Bob, who wanted to be an orthopedic surgeon when he grew up, filled the position this month. Ugh! A team of virtual strangers assembled to help me face the lightning.

The success of a chief rests with the resident team. When in full swing, the university service carries twenty or thirty patients on the floors, another six on the porch, ten in the intensive care units, and a dozen or more followed as consults. Our surgical schedule could total nine or ten craniotomies and a dozen spine cases in a day, not counting traumas and other emergencies. The workload had increased by over 50 percent since my junior residency year, while the number of residents assigned to the university service remained the same. By way of comparison, a chief resident in the early 1960s faced an average inpatient census of
eight.
The great Cushing did just over two thousand brain operations in his career. Our program did that number in a year. Like other surgical subspecialties, neurosurgery grew exponentially in the 1970s.

I could not know everything that happened on the service, but this didn’t stop the faculty from expecting their chief to be omniscient. I had to rely upon the lower-level house staff for information.

The chief resident straddles two worlds. To the younger residents, the chief is just one more taskmaster who decides when they will take call, how many spinal taps they will perform, and what operative cases they are “ready” to do. To the attending staff, the chief stays a scut dog, a lackey who dances
to their every whim. The chief resident is a sergeant in the surgical military, friend to neither enlisted man nor officer, endowed with great responsibilities but given little true authority. Despite the abuse heaped upon the chief by the attending surgeons, I had to stay cheerful and cooperative at all times (“Eat shit as if it’s your favorite dish,” in Gary-speak). Being less than a year from a staff job myself, I could ill afford to mistreat the staff surgeons—indispensable sources of job leads and reference letters.

At 7:15, Mark, Dave, and Bob made their way to the table with trays full of food. The charge nurse for the neuro unit joined us.

“Sooo glad to see everybody is right on time!” I moaned, glancing at my watch. “Since the boss just told me the new rule—the residents must be in their respective OR’s by twenty after seven—that leaves us with five whole minutes to cover twenty-two patients. Eat fast, gentlemen.”

The intern went first. In quick fashion, I found myself bitching at him about bowel movements, post-op headaches, and sleeping patients in the same imperious tone Carl had used in my third year of medical school. It was a weird feeling. Years later, I had a similar feeling on a driving trip. I turned to my bickering daughters and threatened to stop the car in the middle of the turnpike if they didn’t keep quiet. In that instant, I became my father. Likewise, I now became Carl, Maggie, Gary, and every other chief resident I had ever known. The wheel turns. Each generation yields to the next, leaving behind some legacy. In six years, Dave would be sitting in this same spot, sounding just like me.

We sprinted through the patient problems and headed for the operating rooms—fifteen minutes late. Needless to say, the boss was furious. So started the worst year of my life.

• • •

“Goddamn it, Vertosick,
is this the same case?” The boss growled at me from outside the OR as he held the swinging door open with his right foot. In the vernacular of surgeons, asking the operator if he or she is doing the “same case” is an insult, an implication that a better surgeon would have progressed to a new patient given the same amount of time.

“Yes sir, it most certainly is the very same case. I had some bleeding from the sigmoid sinus, but it’s stopped now…I’ll be ready to open the dura in another ten minutes.”

“I sure hope so. We have a cervical disc to do in this room next and I have a medical executive committee meeting at three, so look sharp.”

So it went—day in, day out, week in, week out. Staff surgeons beating me constantly. “Same case?” “I have to be somewhere at three…” “Just what the fuck do you think you are doing?” “STAY AWAY FROM THE OPTIC NERVE PLEASE.”

I ate irregularly and my weight dropped twenty pounds. I feared exiting the hospital, terrified that I would not be there when a patient crumped or a trauma rolled in. Because the chief resident is not supposed to take “in-house” call, the surgical administration assigned me no bed in the hospital—even though I spent more nights there than the junior residents. I wandered the hospital in the darkness, like a homeless person in search of someplace warm and soft to sleep. A transplant fellow habitually occupied the sofa in the surgeons’ lounge, so I had to be resourceful. If the ward wasn’t full, I used a patient room. Otherwise, I sacked out on the residents’ pool table. Slate can be quite comfortable when you haven’t slept for thirty-six hours.

I never had the nerve to sleep in one of the OR’s, although previous chiefs often resorted to this. Given the aggressiveness
of our transplantation team, I worried that I would wake up minus my liver.

Our transplant service
carried a very high profile and consumed the lion’s share of our health center’s OR time and other resources. Their star status imbued the transplant surgeons with the sort of smarmy, menacing charm exuded by
bandidos
in old westerns. During my residency years, transplant stories became daily fare on the local television news programs, making the senior transplant surgeons into celebrities and hailing every permutation of donor, recipient, organ, and disease as a medical landmark (“Girl becomes first Asian to receive an African-American lung for the treatment of pulmonary hypertension…film at eleven!”). Our center was, and still is, a transplant center of unequaled excellence, but I grew irritated by the news media’s perception that saving a life with an organ transplant is more admirable than saving a life by draining a subdural hematoma or reversing a diabetic coma. When one popular liver-transplant recipient, who had been tracked for years by local journalists, died suddenly, the mayor declared a day of mourning. A tragic death, yes, but aren’t they all? When would the city declare a Sarah Clarke day?

Heart and liver transplants are indeed heroic affairs, requiring consummate skill to perform and extraordinary fortitude to undergo. But when viewed from a national health-care perspective, such transplants equal zero-sum games: a life saved is a life lost. Our city coaxed people into signing donor cards, although no one really wants to think about ending up young, healthy, and brain dead. Transplant programs survive on a constant diet of good-looking cadavers—people in the prime of their lives with brains extinguished by senseless catastrophe. In adults, our donor supply flowed from auto accidents and gunshot
wounds; in children, donors were victims of parental shakings and beatings. By definition, a donor organ flows from some tragic and eminently preventable event.

Although transplant patients now do quite well, few recipients survive as long as the donor would have had he dodged a bullet or missed a telephone pole and kept his own organs a while longer. I support organ donation wholeheartedly—it makes the most of a bad situation—but we shouldn’t lose sight of a larger objective: preventing people from
becoming
donors in the first place.

The neurosurgery service suffered frequent contact with the transplant surgeons. Their potential donors were usually our patients first. Outside hospitals even transferred brain-dead patients to our neuro unit just to be evaluated as donors, a practice which irked us no end. Not only did this practice tie up our beds, but our junior residents had to do histories and physical exams, draw blood work, and manage IV fluids on living corpses—typically in the middle of the night—to spare the transplant fellows such trivialities.

Before the advent of sophisticated organ-procurement networks and transplant foundations, the task of approaching relatives for permission to harvest the organs fell to the donor’s attending physicians (and then, in turn, to the neurosurgery resident on call). Occasionally, we were surprised to learn that the family hadn’t even been told of the patient’s “legal” death. Outside physicians often sidestepped the issue, telling relatives that their dead loved ones were being transferred to the university for further “evaluation”—a true, if not completely honest, statement.

On occasion, we solicited permission for organ donation from the person who made the donor brain-dead in the first place. One of our residents had to call the county jail and obtain
permission from the donor’s husband—minutes after the man had been arraigned for shooting her in the brain. The suspect later claimed that he wasn’t responsible for his wife’s death—the transplant surgeons were. He was convicted of murder.

The donor business brought other surprises. A young braintumor victim was flown in from New York for immediate donation to a dying liver recipient. The recipient was already in the OR holding area, prepped and ready to go. The transplant team had been summoned. Preliminary tissue and blood typing revealed an excellent match. One teeny problem: the donor wasn’t brain dead yet. The junior resident, Dave, called me at home and told me that the patient decerebrated to painful stimuli.

Brain death means the loss of all cerebral and brain stem function as determined by neurological examination. Although ancillary testing, such as EEG (electroencephalograms, a measure of electrical brain activity), can be used, the diagnosis of brain death remains clinical. A brain-dead patient cannot exhibit meaningful movement of the extremities, respiratory motions, response to pain, pupillary response to light, or a gag reflex. Decerebration, the rigid extension of all four limbs to pain, requires a living brain stem and invalidates the diagnosis of brain death.

I told Dave to scan the patient immediately and rushed from home to see this Lazarus When I arrived, the prospective donor was back in the neuro unit, surrounded by a jittery team of transplant fellows. Dave stood by the X-ray view box looking at the CT scan.

“This ‘donor’ has a big cerebellar tumor,” said Dave under his breath, “and we might be able to help him, but the vultures are here.” He cast a look over his shoulder. Our nickname for the transplant surgeons derived from their uncanny ability to smell impending brain death. They circled the ICU on a daily basis.

“Screw the vultures, I’ll deal with them…Just take him downstairs and we’ll take this thing out. What Massachusetts General Hospital did he come from, anyway?”

“I don’t remember. Some place in outer nowheresville…they told the family he had a cancerous tumor and was as good as dead. Of course, since they heard so many nice things about transplants from the news, they wanted to give his organs. Nice gesture, but a bit premature.”

I approached the transplant team. “Sorry, gentlemen, but, to paraphrase Mark Twain, the reports of this man’s demise have been greatly exaggerated. We get to keep him. Maybe next time.”

“Horseshit,” a transplant fellow spat with venom. “Look at him, he’s decerebrate, he’ll be dead soon. We’ll wait an hour or so and stop back.”

“What neurosurgery residency did you train in, my learned friend? Decerebration from posterior fossa lesions isn’t as ominous as you think. Our New York friend could be eating eggs for breakfast by tomorrow.”

“Eating osmolyte through an NG tube, you mean. I know a brain-dead guy when I see one, and I have a lady in hepatic failure downstairs.”

“Is this a Monty Python skit or something? He isn’t dead yet and you can’t have him. So kiss off.”

The large group flowed from the room. We removed the man’s tumor that night and he walked out of the hospital a week later. The donor pool was reduced by one, but this particular patient didn’t seem to mind. Two years passed before his tumor claimed him for real.

Clang
!
What sounds worse than a phone ringing in the middle of the night? When the intern took in-house call, it wasn’t worth
going to bed at all. I pulled the phone receiver to my ear. Bob, the orthopedic wannabe, chattered excitedly.

“It’s a gunshot wound! Right between the eyes! What’ll I do? Should I scan the patient or take her right to the OR?”

“Slow down, Bob. Where are the entrance and exit wounds?”

“The entrance is right between the eyes, like I said. About a centimeter hole just above the bridge of the nose. The exit wound is in, the occiput, but a lot of hair and blood’s matted there and I can’t be sure exactly where the exit is…I’m afraid to look too close…”

“Relax. I wouldn’t want you to puke in the wound or anything. Is the patient intubated?”

“No. She’s awake, actually.”

“How’s that again?”

“She wants a cup of coffee…should we let her drink anything if she’s going to the OR?”

“Let me try this again. She has a bullet enter between her eyes and exit at the back of her head and she wants a cup of coffee? Is that right?”

“Yeah. She was unconscious when she came in, but woke right up! Weird, don’t you think?”

“Call the CT people in. I’m coming in, too. I have to see this. In the meantime, ask her if she wants cream and sugar. Pour one for me, too. Extra sweet. See ya.”