When the Air Hits Your Brain: Tales from Neurosurgery (23 page)

I dressed hurriedly. This lady couldn’t stay conscious for long, I thought. Surely the bullet must have clipped a large venous sinus. Even if it didn’t, her brain had to swell soon. When I arrived, the victim was still in the ER, awaiting her CT scan—not in a patient exam room, but sitting in the waiting room watching the late movie, her head wrapped with a bloodied Kerlix gauze. A city policewoman sat beside her.

“Are you the woman who was shot?” I asked.

“Uh-huh,” she replied trancelike, her attention still focused upon the TV.

“Could you come with me please?” I crooked my finger at her and motioned to the ER’s metal doors. She cast me an irritated glance, but obeyed. Back in an examination room, she explained what happened.

“My boyfriend was a little drunk and got real mad, you know, like really, really pissed off, so he shot me. I think I passed out right after it happened. I know he didn’t mean it…Do you think, you know, I could go back to him tonight? They say I can’t.” She motioned to the sphinxlike officer who had followed us into the room. “I know that he truly loves me. He didn’t mean it, I know he didn’t.”

The wounds were as Bob had described them. I examined the back of her head, parting the thick brown hair until I saw a jagged exit wound. As I was rummaging around, a nearly pristine bullet fell onto the gurney and was quickly retrieved by the policewoman and turned over to a homicide detective waiting outside. Neither wound was bleeding, and there was no sign of brain tissue or spinal fluid. Her neurological exam was normal. Why was this woman still alive?

The CT scan provided the answer. The bullet had fractured the frontal bone, but had not injured the brain. Between the scalp and skull at the top of her head was a mixture of blood and air which traced from the entrance wound to the exit wound. The bullet had hit the frontal bone and deflected upward, circling over the skull and under the scalp like a roulette ball before blasting out the back of the head. The woman’s skull was unusually thick, a congenital abnormality which had saved her life. She had sustained the handgun equivalent of comedian Steve Martin’s “arrow through the head” sight gag.

As amazing as her injury was, her attitude surpassed it. She held no animosity whatsoever toward a man who had jammed his revolver between her eyes and pulled the trigger. After all, he “missed,” didn’t he? She refused to believe that he had done anything wrong, save for drinking too much and losing his temper.

The skull does a marvelous job
of shielding the brain. A middleaged Protestant minister with intractable depression decided that he couldn’t wait until his appointed date with destiny to meet his Maker. He borrowed a friend’s .22 caliber revolver and, placing it against his right temple, blasted himself senseless. The paramedics, believing him mortally wounded, transferred him to the hospital without intubating his trachea. He arrived in our ER still unconscious, a serene look upon his craggy face.

Because his vital signs were normal and his pupils reactive to light, I ordered a plain skull film immediately. The X ray confirmed my suspicions: the small bullet had lodged in his “pterion,” a hard ridge of bone about two inches in front of the external ear canal. The projectile had failed to enter the brain. The impact of the bullet had struck the minister like a heavyweight uppercut, temporarily rendering him unconscious, but unhurt.

I looked into his face closely as he regained consciousness, curious to see the reaction of a man who believed he was opening his eyes in Paradise. The eyelids fluttered, the eyes squinted into the fluorescent light.

“Is…is this heaven or hell?”

I overcame my irresistible urge to play some form of practical joke, like lighting a match in his face. “To tell you the truth, Reverend, it’s the emergency room. Although it can be hellish at times, I’ll admit.”

He sobbed uncontrollably, covering his face with his hands.
“Oh God, I’m so ashamed…so ashamed. I can’t even kill myself…” Such a profound and desperate act thwarted by an inch of bone. The irony. Betrayed by the Maker’s own blueprint. I said nothing else, leaving him to his inner torment.

He was given a tetanus shot and transferred to psychiatry. I never saw’ him again.

Monday morning.
Residents’ clinic. Failed-back patients and neck injuries littered the schedule. One patient caught my eye, however: Florence Janeway. Diagnosis: meningioma.

Three coverings wrap the brain: the dura mater, arachnoid, and pia mater. These wrappings are known collectively as the meninges. When meninges become infected with bacteria, meningitis results. A tumor of the meninges goes by the name of meningioma.

Meningiomas, nearly always benign, arise from the outer surface of the skull, not the brain, and are removed fairly easily. They may take years, even decades, to reach a symptomatic size, given their slow growth rate.

Neurosurgeons enjoy meningiomas. So much so that Mrs. Janeway’s appearance in residents’ clinic was enigmatic. Why hadn’t a staff surgeon snapped this up? It couldn’t be because of her insurance status. The staff would
pay
patients for the pleasure of rolling out their big, juicy tumors. Dave had already seen the woman.

“Dave, what’s a meningioma doing in our clinic?”

“Oh, you mean Janeway? She’s a pretzel lady. Had a history of depression, couple suicide attempts. Now she has Alzheimer’s disease and lives in Allison Manor Nursing Home.”

“How did they figure out she had a meningioma?”

“One of the aides at the home noticed a lump on the back of her head while combing her hair. They sent her for a scan. I have it in the office.”

“How old is she?”

“Sixty-seven.”

We returned to the office. Dave flipped the scans onto the view box. Mrs. Janeway didn’t have just any meningioma, she had the mother of all meningiomas. A huge white ball occupied a third of her head. Meningiomas induce thickening of the skull, hence the “bump” noticed by the nursing-home aid.

When I saw her, I realized why Dave had called her a “pretzel lady.” Muscle contractures distorted her limbs. Her blank face stared into space. She said a few words and followed simple commands, but she certainly looked like someone suffering with Alzheimer’s disease.

“What are we supposed to do with her?” Dave asked.

“How do they know she has Alzheimer’s?”

“Well…look at her!”

“How do we know this isn’t from her tumor?”

“I guess we don’t.”

“Someone gave her the diagnosis of incurable dementia without doing a head scan?”

Dave rummaged through her thick outpatient chart. “That’s what it looks like.”

I thought for a moment. “The horse is out of the barn, I’m afraid, tumor or no tumor.”

“The horse isn’t just out of the barn,” commented Dave as he looked down at the twisted little frame on the exam table, “it’s at the lake getting a drink of water.”

“Send her back. Tell the nursing home ‘No, thanks.’”

I finished seeing patients and returned to the wards.

But Mrs. Janeway
didn’t leave my mind that night. Or the next day. Was her dementia irreversible? Sixty-seven isn’t old, and her health was good. I called her oldest daughter.

“Mom’s been bad for two years. The depression came on
about three years ago, but the memory loss and incontinence began two years ago. The last six months, she hasn’t recognized me or my sisters at all.”

“Three years ago, what was she like?”

“Mom ran an insurance office for thirty years. Sharp as a tack. Then she started having trouble with arithmetic and had to quit work. That was…hmmm…about 1976.”

I explained the situation, described the tumor, and detailed the risks of surgery—considerable, given the large size of the mass and the fact that it pressed on her left brain. She listened politely, but declined surgery.

But the issue gnawed at her as much as me, and I received a phone call the next morning. The three children had talked (Mrs. Janeway was a widow). They wanted surgery. As I suspected, neither they nor I could live with the slightest possibility that a working brain had been abandoned to the mercy of a benign tumor. I scheduled the craniotomy for the following week.

I requested the boss’s help
—I needed his thirty years of experience.

It was a bloody affair. We reflected the thickened bone from the bulging mass beneath and released a torrent of bleeding. I incised the dura, located the plane separating brain from meningioma, and began pulling the mass out of her head. My slow technique, however, could not keep up with the bleeding.

“This will take forever,” I moaned.

“We need to get it out fast,” observed the boss calmly. “We’re losing about two hundred cc’s of blood every fifteen minutes.” He looked over the anesthesia screen and spoke to the anesthesiologist. “Can you folks keep up?”

“Possibly, but we don’t want to get into big fluid shifts in her.”

The boss looked back at me with a gleam in his eyes. “Frank,
get some cotton balls and have your bipolar ready. We’re going to yank this thing the old-fashioned way. Quick. Are you ready?” I nodded. “Then put a great big nylon stitch through the dura over the tumor…here…that’s it…Now I’ll put my finger here…OK, PULL!”

I pulled the suture as the boss swept his large index finger beneath the tumor. The red baseball levitated from the wound as the chairman advanced his finger deeper. The bleeding increased. I jammed cotton balls between the tumor and the brain with my right hand, my left hand providing traction on the tumor stitch. As he delivered the tumor from the depths, the boss inserted another finger, then another, until Mrs. Janeway’s head swallowed his hand.

The anesthesiologist grew nervous. “We’re getting hypotension here.”

“Fix it,” the boss yelled without looking up, “that’s what they pay you for. Come on, Frank, buzz that artery…there. Keep working, we’re almost home.”

Finally, the great mass slithered out of the skull and dangled on a shred of uncut dura mater. A snip of the scissors and the tumor dropped into a steel pan. Stopping the bleeding took an hour longer. When everything was dry and the patient stable, we could at last see the horrible brain deformation left behind. The meningioma had flattened the left hemisphere into a pancake, and our surgery had chewed up the cortex terribly; I doubted that the brain would recover.

Nevertheless, the boss looked pleased.

“Nice work. That was a monster.” He shook my hand before pulling off his gloves. “You’re really one of us now.”

I still see Mrs. Janeway
once a year. She comes to the office in her smart business suit and tells me about the latest Buick she
drives. Her legs remain stiff, although the orthopedic procedures to release her contractures worked wonders. Her daughters claim she is every ounce the woman she was fifteen years ago.

In my career, Mrs. Janeway was truly a landmark case. If I never accomplish another thing in my life, I will go to my grave satisfied. I will not walk on the moon, or win the Nobel Prize, or live in the White House. But the rare privilege of snatching someone from a nursing home and giving back her mind, her life, her family…I wouldn’t trade that for the world.

Despite the occasional Mrs. Janeways,
chief residency ground me down. Constant exposure to gunshot wounds, brain-dead donors, harried interns, pompous surgeons, patients in pain, and hospital-grade corned beef took its toll. My enthusiasm for the job waned. Some days I no longer cared who lived and who died. I just wanted to be done, to have my life back, to see my wife and baby. Like Humphrey Bogart in
The African Queen,
all I could do was climb back into the leech-ridden waters and keep pulling my boat toward the open sea.

My residency ended at last,
and with little fanfare, I entered practice. “One of them.” Big deal. Overdosed on surgery my final year, I felt little joy for my new profession those first months as an official neurosurgeon. My training finished, I reflected upon my career choice.

We are all slaves to chaos—chaos in the scientific sense. Chaos theory predicts that the outcome of a chaotic process depends upon minuscule variations in the “initial conditions.” Example: a billiard ball rolling off the hood of a car. When placed in one spot, it rolls one way; placed one millimeter to the right or left of that spot, it rolls in a different direction
altogether. Where the ball ends up depends entirely upon where we place it initially.

The impact of the initial conditions has been named the “butterfly effect,” since, in the chaotic theory of weather, the beating of a butterfly’s wings in Asia can cause a hurricane in the southern Atlantic months later. Our lives evolve from our own butterfly effects. The tiniest perturbations in our youths, our “initial conditions,” generate profound alterations in our later lives. In my case, I had wanted to be a computer scientist, but no openings in my freshman computer-science courses existed. If I had jumped one or two places ahead in the registration line, I would have made it into freshman comp sci and never become a physician. What delayed my arrival at the registration office? I don’t remember—stopping for a hamburger, maybe, or speaking to a friend—but whatever this long-forgotten event was, it changed my life. If I could have taken cardiac surgery, as I had wanted, I would probably be one of the “best in the chest” now, and not a brain surgeon.

The butterfly effect: a conversation here, a missed flight there…happenings which redirect the rivers of our lives. After buffeting about in the chaotic currents, I feared that I had been cast onto a distant shore, a place where I didn’t belong.

Three months into my new practice, a seventy-year-old widow named Grace Catalano came to my office, pushed along in a wheelchair by her burly son. She had suffered from back and leg pains for years. The pain worsened with prolonged standing and walking. In fact, she could now barely walk at all, save for the few steps from bed to wheelchair.

“Oh, Doctor, you are my last hope. I have arthritis so bad in my back and legs, so bad, I can’t go from here to the door. Now the pain bothers me even at night, even when I’m off my feet. They have me on narcotic pills. My family doctor says that
it’s just arthritis and I have to live with it, but a neighbor says that maybe it’s a ruptured disc or something.. I’m afraid of surgery, Doctor, but I’ll do anything to get rid of this. Anything. I have two granddaughters—twins—they are four years old now and they want to know why their grandmama never walks with them or takes them to movies…” She began to wipe her tears away.