When the Air Hits Your Brain: Tales from Neurosurgery (6 page)

My chief cardiac fellow, Maggie, exemplified the drill-sergeant demeanor. The ER called Maggie and me one night to evaluate an elderly woman flown in from another hospital. The woman was barely clinging to life. A ventilator tethered her to earth, else she would have expired hours earlier. A cardiac catheterization, done at the first hospital, had disclosed a blown
mitral valve. The mitral valve, stopcock between left atrium and left ventricle, had stuck in the open position, its mechanism damaged by a fresh heart attack. With each beat, blood drove backward into the atrium, not forward into her body. Unless replaced with a synthetic valve, the broken mitral would kill her before the sun rose.

Maggie, fresh from two straight cabbage procedures, was clearly tired. She scanned the cath report with a heavy-lidded stare, then shook her head slowly. I expected her to pound her fist with rage, angry at the unceasing workload. I had seen residents in other fields crumble under the onslaught of a neverending day. Instead, she looked at me with a wicked grin. “Frank, we’ve got a mitral valve to do! Oh, baby, this is great…YOU GOTTA LOVE THIS!!” She gleefully pranced to a phone to call the OR. She should take up bowling, I thought, just for a change of pace.

In the uterus,
the fetus breathes through the umbilical-cord blood, not the lungs. The unborn possess an elaborate bypass system which shunts blood away from their water-logged lungs and into the mother’s placenta. At the moment of birth, this bypass system shuts down, clotting off the umbilical cord and diverting blood to the virgin lungs.

The
in utero
blood shunt carries two consequences for the cardiac surgeon: The closure of the shunt at birth occasionally fails and must be completed with a knife; and, since the normal circulation of blood is superfluous until after birth, some truly terrible heart malformations pass undetected until the delivery room, requiring the surgeon to rebuild the heart from scratch.

Although many malformations have been described and named—tetralogy of Fallot, total anomalous venous return,
hypoplastic left ventricle—malformations are as individual as fingerprints, hence the less restrictive “fucked-up heart” category.

Some malformations kill the infant minutes after birth; others are mild, and their correction can be deferred for years. Most deformities, however, fall between these two extremes, producing a heart good enough to sustain life for a month or two but not good enough to last years. In these instances, the surgeon must decide whether the defect is correctable. If not, the child is left to die, or referred to the heart-transplantation waiting list.

Baby girl McKenna had entered the world with a small right ventricle. This pumping chamber receives depleted venous blood from the body and flushes it into the lungs, where it is replenished with oxygen. A month premature, she had arrived before her parents could agree upon a name. Her condition had deteriorated rapidly after birth, and she was sent to our pediatric heart service during one of my nights off. When I arrived in the pediatric ICU to make rounds at 5
A.M.,
little B.G. McKenna, a blue blob on maximal life support, awaited the next operating-room slot. Maggie sat in her surgical scrubs and rocked slowly in a large wooden rocking chair—known as
the
chair by cardiac interns.

“I don’t know what we can do for this munchkin,” she said, sipping from a vending machine cup. “Hartley and I are doing her as soon as they finish the trauma patient that’s in the heart room.” Hartley was the chief of pediatric cardiac surgery.

That’s great, I thought. I was on call for the night. B.G. and I were sure to have a fun time together. Babies this small can’t tolerate the heart-lung machine, and are done instead under “profound hypothermia.” Packed in ice until suspended
animation occurs, the infant’s heart is stopped and repaired as quickly as possible.

Certain species of frogs and fish can be frozen solid and rethawed with no apparent injury. But babies are neither frog nor fish. Without the protein antifreezes that circulate in those animals, they emerge from profound hypothermia near death, their blood-clotting mechanisms deranged, their livers reeling, their brains dysfunctional. I looked at
the
chair, now occupied by Maggie—the command seat for the pediatric heart patients in the children’s ICU. We spent many nights in it, wrapped in an afghan and rocking nervously, watching patients too unstable to be unattended.

B.G.’s surgery commenced later that morning and finished around five o’clock. Having scrubbed on cabbages until about eight, I finally wandered down to the pediatric ICU for signout at nine. Maggie awaited me, anxious to sign out B.G. before leaving. The service was quiet…except for B.G. As I expected, the problem for the night.

Surgical soap stained her scrawny little body orange from her neck to feet. Heating lamps dangled above the bed, to restore warmth to her frigid body. She looked like a little cornish hen roasting under the heat lamps of a delicatessen.

Maggie handed me an index card. “Here, I’ve calculated the doses of the resuscitation drugs for her weight. I think everything is there—epi, bicarb, bretylium…The nurses know the defib settings, they’ll help you with that. You’ve taken infant CPR? Good. You’ll need it. She’s going to have a rough night, but if she makes it twelve or twenty-four hours, she has a shot. The parents have just left…We’re all counting on you. I want her alive tomorrow morning. You know how to reach me if you get up to your ass in alligators…So long.”

Maggie left. I dragged the heavy rocking chair beside the
rotisserie bed and plopped myself in for the night. Gazing at the monitor, I watched the little squiggles that B.G.’s damaged heart traced across the fluorescent screen. So far, so good.

I dozed for a short time. A nurse shook me awake. “Her pressure’s falling,” she whispered.

I cleared the cobwebs from my head and ordered an infusion of albumin and an increase in her dopamine, an intravenous drug which stimulates the failing heart muscle. (The drug dopamine is the same as the brain chemical dopamine which is deranged in schizophrenics. The human body uses many chemicals in multiple roles.) B.G. stabilized for an hour before her blood pressure dipped precipitously again. Despite more albumin, the pressure bottomed out completely and her heart fibrillated wildly.

I jumped from the chair and started cardiac compressions on her tiny chest with my index and middle fingers. I order a bolus of epinephrine (also known as adrenaline) and the fibrillation reverted to a normal rhythm. The blood pressure went up to ninety. Breathing a sigh of relief, I went to the nurses’ station and called Maggie at home, informing her of the successful resuscitation.

“What do you want, a medal?” she croaked. “What is it, two
A.M.
? You got hours to go before she’s stable…and go easy on the epi; her perfusion is poor as it is and I don’t want her fingers to die. Push the fluid harder.”

My ego deflated, I went back to the chair. Maggie was right about the epinephrine. B.G.’s fingertips grew more discolored by the hour. Like Mephistopheles, epinephrine will do your bidding—for a price. The increase in blood pressure and heart contractility after an epi infusion comes at the expense of blood flow to the limbs. Too much epi and the hands and feet will become gangrenous.

Another hour passed before the hypotension and fibrillation returned. More CPR, more albumin. Some lidocaine and bretylium. A blast from the miniature defibrillator. Nothing worked. I gave yet another bolus of epi. Again, the pressure shot up, the heart rhythm stabilized. B.G.’s fingers and toes became darker and more mottled.

To prevent another round of hypotension, I increased the intravenous infusions drastically, but her lungs filled with fluid and the oxygen level in her arteries fell dramatically. To counteract this, I gave her Lasix, a strong diuretic. The Lasix, had no effect. The urine output slowed, no doubt due to lack of blood flow to the kidneys: another side effect of the epi.

The fibrillation came again.

They are all counting on me. The words rang in my tired brain. Her mom and dad, Hartley, Maggie…they are counting on me to keep this baby alive. I ordered another bolus of epinephrine. Take this child’s fingers, Satan. Faustus selling his soul for another hour of stability, another hour of fitful sleep in the chair…

The epi kept the devil’s bargain: the blood pressure soared and a sinus rhythm once more hammered its way across the monitor screen. I glanced at the clock: four-thirty. Time for rounds soon. My eyes closed.

Maggie
grabbed my arm.
Disoriented, I jumped from the chair and to B.G.’s bed. Empty. The heat lamps dark. Looking again at the clock, I realized that I had been asleep for over two hours! Panic overcame me. What had I slept through? They had been counting on me.

Maggie chuckled at my frenzy. “Relax.”

“Where’s the baby? Did she go back to the OR?”

“No, I shut off her ventilator an hour ago. She’s in the
morgue. Actually, her parents wanted her shut off last night before I left, but I forgot.”

“In the morgue? You forgot what? What do you mean, they wanted her shut off last night?” I was confused, furious.

“Hartley met with them after surgery. You see, we couldn’t repair the right ventricle. All we could do was enlarge it with a Teflon patch, but Teflon doesn’t pump blood, you know. We knew she was a goner when she left the table. The family was very reasonable—the mother’s an ER nurse across town—they couldn’t see prolonging things and they gave us the okay to halt support. I just figured we could wait until morning to do the deed.”

“Why didn’t you tell me all this last night? Why did you let me sit in this fucking chair all night thinking I was making some baby’s fingers drop off?”

Maggie’s smirk vanished. “Your night wasn’t such a waste, was it? You learned how to resuscitate a baby, how to face crisis, what drugs to use and what problems they can cause. I bet you won’t forget the doses of those drugs for a while, either. They are burned into your brain. You did a good job. Not many people can keep a Teflon heart beating for ten hours. Now I know I can count on you to handle a baby with a real chance of living.”

“You could have told me that she was a goner—I was crapping in my drawers.”

“No. Then you wouldn’t have been under the gun. Pressure’s part of the deal. Anybody can sing in the shower, but how many can sing in front of an audience, huh? Pressure makes all the difference in the world.”

Pleasure is oft a visitant; but pain clings cruelly to us.

                                                         —JOHN KEATS

P
ain is the price we pay for mobility. Since the dawn of life creatures have segregated into two camps: motionless foodmakers and migrating food foragers. Creatures in the first camp learned to draw energy from their immediate environments. Plants turn chloroplasts to the sun and use photosynthesis to manufacture glucose, while deep-sea creatures harness heat arising from thermal vents on the ocean floor.

Creatures in the second camp sprouted tails, legs, fins, and wings and set off to eat the food makers, or each other. Lacking a clever trick like photosynthesis, the food foragers came up with a new invention: the nervous system. To say that the nervous
system evolved so that animals could sense and respond to their surroundings is only partly correct. Anything alive, brainy or not, must be able to sense and respond to its surroundings. Bacteria “know” when the ambient moisture is too low, and form into spores which are more resistant to drying. A tree senses when autumn comes and jettisons its leaves as the sunlight fades.

But these responses are relatively simple and slow, taking hours, days, even weeks to complete. Moreover, no-brain creatures such as trees and bacteria have only tiny repertoires of stereotyped responses. The tree adapts to the seasons but, having no place to run, falls victim to sudden, life-threatening events—forest fire, bark-eating deer, beavers’ incisors. As compensation for this helplessness, nature blessed the mindless tree with ignorant bliss. The oak feels no pain from the lumberjack’s saw. The pine does not cry out in agony as lightning bursts its trunk asunder.

Animals, constantly at odds with a changing environment or with other animals, could not survive with the tree’s small number of adaptive mechanisms. Peripatetic organisms need complex responses which can be customized in milliseconds—they need a nervous system. Although sensation and adaptation can occur in the absence of brain tissue, these skills are elevated to a new level of speed and diversity by an organ system devoted solely to cognition. The primordial ganglion protobrains became the digital computers of biology, leaving the abacuslike reasoning of the plant kingdom in the dust.

As always, there was a terrible price to pay for this new technology. Animals dependent for survival upon the complex software of nerve cells and the delicate clockwork of churning limbs are very vulnerable to injury. Yes, the big stupid tree doesn’t know enough to run away from fire—but it can lose
over half its branches and live. A squirrel with one broken leg is as good as dead. In the natural world, where any breach of the skin can mean infection and death, an animal must stay out of harm’s way. Like the earliest computers, the earliest brains were pretty dim. The only way to keep animals equipped with “first generation” brain hardware out of trouble was through aversion: dangerous things became painful things. Pain became the taskmaster of the animal world.

Unfortunately, the blossoming of our magnificent forebrains did not free us from the bondage of animal pain. We are now smart enough to learn abstractly that fire hurts without having to experience it firsthand, yet we still endure the agony of burns. The pain pathways that torment us with toothaches, menstrual cramps, and bee stings have progressed little from the days of the walnut-brained stegosaurus writhing in a predator’s jaws. The continuing need for pain in humans no doubt derives from the stupidity of young children, who, as any parent can attest, feel compelled to seek what does and does not hurt for themselves.

The pain pathways have no “off” switch. Pain lingers long after its biological usefulness has passed. Although a pain alerting us to the presence of curable cancer is a valuable torment, cancer pain doesn’t have the merciful sense to cease after the cancer has spread to a terminal stage. The nervous system
does
possess two means of limiting pain perception: chemicals known as endorphins and a spinal-cord switching mechanism called “gating.” They are far from perfect in their natural state but can be augmented with the help of medical technology.

Endorphins, natural substances related to morphine, are released in times of stress. Like morphine they are very good for acute, severe pain, but not so effective for mild or chronic pain. Endorphins evolved so that wounded animals could function,
at least for a short while. Example: a doe, mortally wounded by a car, ignores the pain and crawls away in search of her fawn. Endorphins permit a running back to keep chugging for the goal line oblivious to the fact that his arm was broken on the line of scrimmage.

Endorphins also perform a true mercy service, anesthetizing an animal trapped by a carnivore. Those people who have survived being caught in the jaws of lions or grizzly bears speak of the warm, insensate calm that flowed through them as they succumbed to being eaten alive.

The gating phenomenon is a second mechanism for blunting painful sensations. The spinal cord is like a collection of railway tracks: sensations ascend within it like freight trains running on those tracks. Each sensory modality (pain, temperature, fine touch, heavy pressure) is like freight carried to the brain on separate trains. Access to the brain is limited, however. Only so many trains enter at once, only so much freight is unloaded into our consciousness. When one sensation is dominant, the others are blocked, “gated.”

The gating mechanism occurs with the other senses as well. If, as we are listening to one conversation at a cocktail party, we are then engaged in another, the voices in the original conversation fade into the background. Likewise, we find it difficult to smell two strong odors at once. Many commercial products operate on the gating principle. Bathroom deodorizers don’t remove foul odors; they gate them from our brains by superimposing a stronger, more pleasant odor. Noise “masking” devices for airplane travelers gate out the annoying whine of an airplane engine with a more soothing white noise.

Pain can be gated from the brain by superimposing another sensation. If we scald a hand with hot water, we immediately rub the burned area. We are inately seeking to gate the pain
out, to prevent the pain train from pulling into the brain station. Pain gating is the mechanism behind the old coaching aphorism “Walk it off.” Migraine sufferers knead their temples; sufferers of leg cramps knead their calves. Gating underlies the effectiveness of massage, ice packs, heating pads, liniments, and acupuncture. Attempts to gate pain can be taken to perverse extremes. Napoleon, troubled in his later years by kidney stones, routinely burned himself with a candle to divert his attention from abdominal pain.

Neurosurgeons deal in pain on a daily basis. Pain in the head, pain in the face, pain in the arms, pain in the legs, pain in the neck, pain in the back—all, essentially, a pain in the ass for patient and doctor alike. Over two-thirds of all neurosurgical operations are for pain control—or, more properly, the alleviation of suffering.

There is a profound difference between pain and suffering. All animals feel pain. Only humans suffer. Pain is a physical sensation; suffering is an emotional state induced by pain. Suffering is pain coupled with uncertainty, depression, frustration, anger, fear, despair. We can have intense pain but not suffer. A stubbed toe, a shin whacked against a coffee table, a softball to the groin, a paper cut, a mouth ulcer—all may elicit extreme pain with little suffering. We know these pains are temporary. We know that they will go away and that they bode no longterm ill for our bodies.

But what of a woman who thinks she is cured of her breast cancer and then develops a minor backache? Her mind is troubled. Is it the cancer again? Until she finds out, she will suffer greatly. That small backache will become like a nail driven into her spine until she knows what it signifies. When told that all the tests are negative for cancer, she feels better instantly. No pain medications could accomplish this. The pain is the same, but the suffering is eased. In a sense, suffering is pain augmented
by a bleak imagination. We construct dismal scenarios for our unexplained miseries: That toothache must mean a root canal; that hand stiffness is rheumatoid arthritis; that heartburn could be coronary artery disease.

Hippocrates once said that the chief function of medicine is to entertain patients until they heal themselves. On the pain service, we didn’t entertain our patients; far from it. We took their pain away as best we could.

Of course, sometimes we had to poke holes in their heads to do it.

The very first morning
of my residency, Gary and Eric took me to the neurology floor and introduced me to some of the pain patients on the service. I had little previous experience with the pain service. At the time of my medical student rotation, there were relatively few pain service patients in the hospital. I had avoided even that handful, concentrating instead on the more “interesting” cases like brain abscesses, pituitary tumors, and carotid aneurysms. A medical student can get away with ignoring tedious problems in favor of more challenging ones. But residency was different. Medical school is five parts learning to one part servitude; the ratio is reversed in residency.

We halted at room nine, a private room.

“Room nine,” Eric whispered, “Mr. van Buren. Status postfive laminectomies for ruptured lumbar discs. He’s from Boston, runs an investment company or something. He has chronic right leg pain and has been on oral morphine for the last six months. We put in an epidural spinal cord stimulator yesterday and externalized it. The guy’s now playing with it to see if any of the settings make his pain go away. If not, we yank it. If it does, we internalize it to an antenna and send him to a detox unit.”

Gary explained that the spinal stimulator’s gate mechanism
permits pain to be masked by a simultaneous sensation, such as touching or rubbing. Not surprisingly, people with chronic sciatica find it impractical to go around rubbing their legs all day. To exploit the gate mechanism, devices which continuously stimulate the touch nerves have been marketed. The simplest is the transepidermal nerve stimulator, or TENS unit, which consists of surface electrodes taped to the skin and hooked to a portable battery supply. The TENS unit provides a gentle “buzz” to the affected skin, akin to the low-level shock felt when touching the transformer of a toy electric train set. In patients with “failed back syndrome,” or FBS, severe leg pain from a damaged spinal nerve lingers even after one or more “successful” operations to remove a ruptured back disc. Many FBS sufferers can get by with a TENS unit attached to their affected leg all day.

Eventually the TENS unit fails, though, and more masking stimulation is needed. To accomplish this, a thin electrode is threaded under the skin, between the vertebrae and directly over the spinal cord, into an area known as the spinal epidural space (the same area anesthetized during labor and delivery). The electrode is initially brought out through the skin and hooked to a compact control box to allow the patient to experiment with different spinal stimulation settings. If the patient gets relief, he or she is returned to the OR and the electrode is put under the skin and connected to a subcutaneous antenna. The stimulator is then completely internalized and safe from infection. Stimulating signals are broadcast to the spinal cord electrode via a radio transmitter hooked to the belt or worn over the shoulder like a purse.

We entered the room. Mr. van Buren, dressed in expensivelooking pajamas, sat in a chair by his bed. He was a large man with a pleasant, ruddy face and coarse black hair cropped short,
almost in a crew cut. On his lap lay a small beige box, the size of a pack of cigarettes, with several buttons and dials on one side. Two thin wires sprouted from the top of the box and disappeared into the front of his pajama top. He looked to be deep in concentration as his thick fingers twiddled the knobs on the box.

“Good morning, Mr. van Buren. Have you had any luck?” asked Gary in his best professional tone.

“I can get it to buzz a little around my butt cheeks when I use the square wave pulse and turn the frequency to…here.”

“Does that help?”

“A little, but it feels like my pants are warm, like I’m pissing myself all the time. I’m not sure that’s any better than the pain.”

“Mr. van Buren, this is Dr. Vertosick,” Eric spoke, “and he’s joining our team for the next six months. You’ll be seeing him every morning now.”

The man looked up from his box and smiled politely.

“Nice to meet you, Doctor.”

“I understand you have had five disc surgeries?”

“Yes…the first was in 1974…but here, let me show you.”

The man reached over to his nightstand, opened the top drawer, and produced a leather-bound folder with the words “Myelograms and records of A. van Buren” stenciled on the front cover in gold leaf. “Have a seat, Dr. Ferblowstick.”

He proceeded to explain the saga of his many operations in great detail, turning the pages with the slow intensity of a newlywed showing off a wedding album. “Look, here was right after the second operation…there was a little scarring around the fifth lumbar root, but no arachnoiditis yet…My surgeon thought that this might be a disc fragment here, and he looked again in 1981…Here the arachnoiditis got bad…”

Among the photos of myelograms and CT scans and operative notes were other memorabilia: labels from bottles of narcotics, letters containing second surgical opinions, insurance forms, articles on holistic healing and the power of positive thinking. He grew more excited as he spoke, spouting his tale of vertebral vivisection at the hands of three surgeons with as much glee as a fisherman recounting his battle with a prize marlin. He didn’t seem to be in any pain at all.

“Mr. van Buren,” Gary interrupted him, “tell Dr.
Vertosick
what your pain is like now.”

“Oh,” he replied, still grinning, “it’s awful, excruciating. It’s like an army of red-hot earthworms crawling up inside my leg, wriggling and writhing day in and day out. Occasionally, I get a groin pain, over here, that’s like a C-clamp being slowed twisted down on my pubic bone.”