When the Air Hits Your Brain: Tales from Neurosurgery (7 page)

“Thanks, we’ll see you this afternoon…try turning the amplitude down and the frequency up. If that doesn’t work, we may have to take you back to the OR and reposition the electrode.”

We exited the room and walked a little way down the hall. When we were far enough away from room nine, Gary spoke: “Well, class, what did Mr. van Buren teach us?”

“Ah, that the electrode…”

“Forget the friggin’ electrode. Is this guy in pain?”

I was confused.

“Is he in pain?”

“I guess so?”

Gary motioned me over to another room, room eighteen. Lying in the bed was a pale, wasted man. “Hey, Mr. Angelo, it’s Gary. Tell young Dr. Vertosick what your leg pain is like.”

“I dunno.” The man’s voice was thin, weak. “It hurts like hell is all I can say. Right about here. Real sore.”

“Thanks, Mr. Angelo.” We darted back into the hallway again.

“Mr. Angelo has a malignant sarcoma eating into his lower back and right lumbar plexus,” Gary continued, “and he’s in agony. Does he say he has goddamned electric earthworms in his leg or some such shit like that? No. He says ‘I’m real sore.’ He also uses about one-tenth the morphine that room nine uses. Why? Because he has legitimate pain and he isn’t nuts. Another rule of thumb: The more bizarre the description of the pain, the more likely it is to be a psychiatric delusion. Phrases like ‘I have little gnomes with branding irons running all over my face’ or ‘The hooves of a thousand angry horses are thundering in my head’ should immediately make you suspicious that something else is going on. People with real pain don’t say ‘excruciating.’ The word ‘excruciating’ literally means to feel the pain of crucifixation. Since hardly anybody knows what it’s like to be crucified anymore, no one is entitled to use that word, in my humble opinion.”

“Look at that guy!” Eric chimed in. “My kid’s pictures don’t get as much attention as his X rays! He’s
becoming
his pain. It’s part of his identity. He’ll be in pain until it’s time for him to make the horizontal call from a brass-handled phone booth—which won’t be long if he keeps slurping up oral morphine.”

We proceeded down the hallway to room eleven.

“Room eleven,” said Eric. “Mrs. Rubinstein, atypical face pain. Had a microvascular decompression of the fifth cranial nerve three days ago. Still has face pain, same as pre-op. Wound looks good, no headache—thank God for small favors…Husband Ben by her side, as usual.” A microvascular decompression is the act of padding arteries away from the cranial nerves at the base of the brain using small Teflon sponges; it was the
first operation I had seen—or at least started to see until Gary plunged the drill into the patient’s cerebellum and made me flee the OR.

The body has twelve pairs of cranial nerves, so named because they exit from the brain itself, not from the spinal cord. The cranial nerves mediate the sensory and motor functions of the head and neck. The first cranial nerves are the olfactory nerves, which convey the sense of smell; the second cranial nerves the optic nerves, which convey the sense of sight; and so on. The fifth cranial nerve conveys sensations from the face. It is also called the trigeminal nerve, from the Greek phrase meaning “three origins,” because the main nerve branches into three divisions: V1 (called vee-one, even though the “V” is meant to be the Roman numeral five, not the letter), which supplies sensation to the forehead and eyes; V2, which supplies the cheeks, upper teeth, and upper lip; and V3, which supplies the jaw, lower teeth, and lower lip. The trigeminal nerve is somewhat rudimentary in humans compared to the nerves of lower animals, such as mice or cats, which have whiskers and depend upon keen facial sensation for their survival.

“
Atypical
facial pain?” I asked. “Is that like trigeminal neuralgia?”

“No.” Gary answered sharply. “It isn’t anything like trigeminal neuralgia, or tic. People with tic have stabbing pains in one, or perhaps two, divisions of the nerve. The pains are elicited by sensations in the affected area: brushing the teeth, cold air or water hitting the face, chewing. Atypical patients have pain all the time, describing it as burning or aching and not shocklike.”

“Does surgery help this?”

“Judge for yourself.”

Mrs. Rubinstein, an attractive woman of about forty, wore a sexy nightgown and large, dangling gold earrings. The right
earring smacked repeatedly against the shaven, sutured wound behind her ear as she turned her head to greet us. A bald man sat in a chair beside her bed.

“Mr. and Mrs. Rubinstein, this is Dr. Vertosick. As of today, he’s a brain surgeon. How’s your face?”

“Awful just ahhhwful.” She had a heavy New York accent—I wasn’t versed enough to tell exactly what part of the city it was from. “What can I say, it’s worse than it was before, I’m telling you. Like grease from a doughnut frier being poured onto my face all of the time. My God, I thought that this was really going to do it for me. Right, Benjamin?” (A vigorous nod from the bald man.) “The people at the Mayo Clinic and Hopkins told me that
this
was the place to go, but I don’t know. Doughnut grease, I’m telling you, doughnut grease. One Percocet just isn’t holding me. I told you people that I need two every four hours or I’m not fit to live with. When we were at Cornell, they tried to switch me to Motrin, but what a scene I made!”

“Is it still hurting you…all the way to here?” Eric reached over and gently touched the woman’s hairline at the top of her forehead. She winced.

“Yeah, yeah.”

“But not here.” Eric drubbed his index finger in her scalp, just behind the hairline.

“No, not the scalp…just the face hurts. Doughnut grease, scalding doughnut grease. My God, I swear one day I’ll wake up and big strips of scalded skin will peel off on my pillow!”

“Is your pain excruciating?” I asked.

“Definitely.”

Gary’s face became stern. “Well, we’ll see what the boss has to say. Good thing the mister’s here to take care of you, huh?”

“Yeah, he’s such a dear.”

“So long.”

“Doctor?”

“Yes, Mrs. Rubinstein?”

“My Percocet?”

“I’ll have to check with your attending surgeon first; I’m sorry.”

Back into the hallway, Gary started grilling me again.

“Anything funny about her pain?”

“She uses that graphic imagery you were talking about with Mr. van Buren.”

“Uh-huh. But what about the distribution of her pain?”

“It stops at the hairline and doesn’t go into her scalp?”

“Bingo! And where does the distribution of the trigeminal nerve stop?”

“At the vertex of the head, almost back to the occipital area.”

“Bingo again! Society defines the face as being from the hairline down, while the brain considers almost the whole head as the face. Patients with V1 tic have pain extending well into their scalps. I’ve seen patients who haven’t washed or combed their hair on the affected side of their heads for days or weeks because they can’t touch their scalps. Her pain distribution follows a culturally defined area, not an anatomically defined one. Her pain has to be psychiatric in origin.”

“But we did a craniotomy on her,” I observed.

“There is no way to be sure she doesn’t have some component of tic pain,” said Eric. “On the pain service, we have to assume all pain to be real, organic, and that the pain makes people eccentric, not vice versa. In any pain patient, no matter how bizarre the history, may be a kernel of real pain, like a splinter at the bottom of a festering sore.”

“So the pain service doesn’t refuse anybody?”

“No,” answered Gary, “and room twenty-two is a case in point.”

In room twenty-two was a wispy little man in his mid-twenties. He was thin to the point of pathological anorexia, his face covered with blemishes and his hair thinning in random spots. An odd collection of items lined the man’s windowsill, each with a note card taped upon it. Across the top of the window was a large banner that read “Harry Gottlieb’s Museum of Pain.”

After I was introduced, Harry, who had suffered from chronic headaches for year’s, showed me his museum.

“This is the Dodgers cap which used to-take away my pain whenever I wore it. It quit working for some reason. And this…this is the TENS unit they gave me at the pain clinic in Erie. It really didn’t help much at all. I even shaved my head so that the electrode patches would stick better, but that didn’t make any difference. And the patches cost a lot of money, so I quit using it…These are a collection of the pain medications I’ve tried over the past eight years…”

I rummaged through the bottles: Dilaudid, Percocet, Elavil, all the bottles large—and empty.

“Mr. Gottlieb, what’s your headache like?” I asked.

“Like a big railroad spike that some large man is hammering right into the top of my head. And it’s one of those square spikes, not sharp at all. Dull. Pounding right down into the center of my head, right here.”

One of the staff surgeons had recently placed a midbrain stimulator into Mr. Gottlieb. This device is a higher-powered version of the epidural stimulator inserted at the very top of the pain pathways.

“Did your operation help you?” I pointed to the incision on his balding scalp.

“Yes, oh, my yes. The spike feels sharp now, not dull and square, anymore.”

I thanked him for the tour of his “museum” and we went back to our rounds. We left him scurrying about his windowsill, tidying up his Museum of Pain for the next visitors.

I stopped and confronted Gary and Eric before continuing with rounds. “You guys are pulling my leg, right? These can’t be typical patients—the only patient with real pain was that Italian man with the sarcoma.”

Gary stopped me. “Let’s be serious. These people have real problems and we shouldn’t make light of them. And we can’t be sure whether they are having pain or not. If someone ever invents an accurate pain-o-m’eter, then that person should get a Nobel Prize. But for now, the only way we judge pain is by what the patient says. These people are feeling some kind of pain, if only psychic pain. They need help; I’m just not sure if they need
our
help. But there is no way to know for sure, so we give them the benefit of the doubt. If we fail, we send them to the pain clinic, where the anesthesiologists, psychiatrists, and social workers take over.”

We finished rounds. My mind was troubled. When I first started working in our local steel mill, I thought I’d be making steel, but I’d spent all of my time shoveling grease. I’d entered neurosurgery to help people, but these people seemed beyond help. My mother had once suggested that I not go to medical school, that I stay in the factory, since that was as good a job as any. Was she right?

The pain patients
made up only half of the service. The other half consisted of ER consults, trauma victims, and the elective patients of the other university neurosurgeons. We were also responsible for the in-house neurosurgical consults, which were sometimes interesting, sometimes tedious.

The university’s medical center had a diverse patient population, bringing problems ranging from spinal pain in a melanoma patient to brain mass in a liver transplant recipient. The most common consults were for mundane complaints—say, benign backaches, or requests for the neurosurgery resident on call to perform a lumbar puncture, or LP. Because neurosurgeons violate the brain’s natural barriers to infection, any postoperative fever in one of our patients may herald a bacterial meningitis. Fever in a post-op head case mandated a lumbar puncture, known to laymen as a “spinal tap,” so that some of the cerebrospinal fluid, or CSF, could be sent for a white cell count, glucose measurement, and bacteriological cultures. When we were busy, I would do ten to twelve LPs a day. Medical residents, in comparison, might do ten or twelve a year, while other specialties may do less than that in a career. By virtue of our experience and availability, we were the LP mavens of the health center.

The procedure consists of turning a patient on his or her side, numbing a small patch of skin in the middle of the lower back, and plunging a six-inch-long needle into the spinal canal. (It’s best not to show the needle to the patient, I have discovered.) The fluid is left to drip into sterile plastic containers, like maple sap from a tree.

In younger patients, a spinal tap can be trivially easy. Not so in the aged. As we grow older, the small openings in our spines—tiny windows between the vertebral laminae which permit the entrance of the LP needle—are slowly occluded by the advancing bone spurs of degenerative arthritis. This makes LP’s very difficult affairs in elderly patients, sometimes requiring many minutes of blind probing with the needle before a portal into the spine can be located. One patient suggested that a divining rod might be useful, to point the way to watery paydirt.

More often than not, the failed LP was a result of inexperience,
of a medical student or an intern’s sticking the needle far off the mark. Patients will tolerate only so much amateur prospecting in their bones and nerves before they order the procedure abandoned. But if meningitis is suspected, there is no waiting for tomorrow: the test must be done immediately. When the medical interns cannot obtain a successful LP, neurosurgery is called to save the day. This was not a pleasant assignment. We frequently had to try again in a hornet-mad patient whose back looked like a sprinkler head. Ah, but the sweet pleasure of passing the needle effortlessly into a ravaged spine in seconds, when other doctors had tried for an hour or more! All I needed was a ten-gallon hat and I was off into the sunset. Shucks, ma’am, ‘twern’t nothin’!

This dire need to obtain spinal fluid in a case of suspected meningitis illustrates how the physician’s job, particularly a surgeon’s, differs from most others. In medicine, results count, not effort.
Get spinal fluid.
That’s all, just get it. And soon. Nobody cares how tired you are, or how much the patient bitched, or how the hospital didn’t have a long enough spinal needle, or that the patient was a thousand years old or weighed a thousand pounds. Nobody cares that your technique was correct. Just get spinal fluid. Use fluoroscopy. Sit the patient up.’ Stand him on his head. Give him Valium. Do what it takes; just do it. His life may well depend upon success.