When the Air Hits Your Brain: Tales from Neurosurgery

by Frank T. Vertosick Jr.

Surgeons must be very careful When they take their knife! Underneath their fine incisions Stirs the Culprit—Life! —EMILY DICKINSON

Is the brain a gift from God, or simply the jackpot of a trillion rolls of DNA dice?

But, in truth, the myth of the brain surgeon is largely that—a myth. While one can’t be stupid and be a neurosurgeon, brain surgery isn’t the most intellectually demanding occupation on earth. I can read a CT scan, but the people who designed and built the scanner’s circuits tower over me in cognitive power.

My job is not easy, however. The high stakes make it tough. Unlike other parts of the body, the brain and spinal cord have little capacity for self-repair. If a general surgeon injures a piece of bowel during an abdominal operation, she simply stitches the injury, or, if that’s not possible, removes the injured segment. With eight yards of bowel, there’s plenty to spare. Even a trashed heart or liver is replaceable. But when I cut a nerve, it stays cut.

Neurosurgeons do things that cannot be undone. The grave consequences of our actions render even the most trivial of tasks difficult. Put a footwide wooden plank on the driveway and walk its length: no problem. But suspend that same board ten stories in the air and try walking its length again. The difficulty of a task transcends mere mechanics. Irreversibility of our missteps is one reason why I also awaken each morning wondering how I can get out of neurosurgery. The fly struggles in the web.

Failure instructs better than success. A single death shapes the surgeon’s psyche in a way that fifty “saves” cannot.

“Rule number one: You ain’t never the same when the air hits your brain. Yes, the good Lord bricked that sucker in pretty good, and for a reason. We’re not supposed to play with it. The brain is sorta like a ‘66 Cadillac. You had to drop the engine in that thing just to change all eight spark plugs. It was built for performance, not for easy servicing.”

rule number two: The only minor operation is one that someone else is doing. If you’re doing it, it’s major. Never forget that.”

“Rule number three applies equally well to the brain patients and to the spinal discpatients: If the patient isn’t dead, you can always make him worse if you try hard enough. I’ve seen guys who have had two discs taken out of their backs and begged us for a third operation, saying that they had nothing to lose since they can’t possibly be any worse than they are. So we do a third discectomy and prove them wrong.”

“Rule four: One look at the patient is better than a thousand phone calls from a nurse when you’re trying to figure out why someone is going to shit. A corollary: When dealing with the staff guy after a patient goes sour, a terrible mistake made at the bedside will be better received than the most ...

Rule five: Operating on the wrong patient or doing the wrong side of the body makes for a very bad day—always ask the patient what side their pain is on, which leg hurts, which hand is numb. Always look at the films yourself and check that the name on the film matches the name on...

“just remember the rules of any surgical residency: Never stand when you can be sitting, never sit when you can be lying down, never use the stairs when there are elevators, never be awake if you can be asleep, and always eat and shit at the first available opportunity.”

The great Enrico Fermi, father of nuclear fission, once said that there are two types of physicists: the very best, and those who shouldn’t be in the field at all.

She thrust a list of remaining possibilities at me: ear, nose and throat; orthopedics; plastic surgery; urology; neurosurgery. Students were stacking up behind me. I had to think fast. Nose picking? Carpentry? Face-lifts? The stream team? The head crunchers?

heh

But something bothered me: If this was such an honor, then why offer it to someone who got lucky on one patient? I remembered Groucho Marx’s comment about not wanting to belong to any country club foolish enough to take him as a member.

I keep misattributing this to Woody Allen.

Our V.A. was one of the better veterans’ facilities in the country. Most of its employees tried hard to do a good job, but the unmistakable footprint of government bureaucracy was everywhere: nowhere to park (unless you were one of the administrators), oppressive paperwork, outdated equipment. Management teemed with career drones who knew they couldn’t be fired and acted accordingly. Surprisingly, the hospital’s many inefficiencies didn’t stem from a lack of money, since the V.A. was well funded. Regulations strangled the place, not poverty.

All television medical dramas contain at least one “cardiac arrest.” A dying patient being shocked, pounded, and probed by grimfaced professionals has been replayed so frequently in entertainment venues that the average layperson could probably manage a cardiac arrest just by having watched TV. During my residency, I moonlighted in urban emergency rooms. As I resuscitated a heart attack victim in the ER hallway one night, another patient came up to me, pointed to my expiring patient, and asked if I had tried intracardiac epinephrine yet. I curtly told him to mind his own business and sent him to his own ER cubicle, then promptly loaded up the intracardiac syringe and followed his advice. The patient lived. Thank God for television.

Despite witnessing dozens of such arrests, I have not seen a single Lazarus arise from the tomb of ventricular standstill, or “flatline”—no hearts restarted, no brains salvaged. They simply up and died. I don’t wish to put down CPR training. In rare instances—a near-drowning, a heart attack victim, a recent electrocution, a severe smoke inhalation—CPR and other resuscitation maneuvers save lives. But the ninety-year-old diabetic with endstage heart failure? When that person’s heart gives out, it’s for keeps. That’s one fact that TV dramas don’t advertise: over 95 percent of resuscitations are unsuccessful. Of the few patients who are successfully revived, the majority die in a week.

Tough stats to hear.

Today, almost one in every hundred people in the United States is schizophrenic. One percent of the population suffers from the illness, yet its profile stays low and, on a dollars-per-new-case basis, schizophrenia* receives few government research funds. Given that they are virtually invisible now, the exclusion of schizophrenics from history becomes believable.

These statistics really surprised me -- had no idea schizophrenia affected 1% of people in the US.

Years ago, the great medical essayist Lewis Thomas wrote a poignant treatise on dead birds. He noted that we rarely see dead birds, certainly not in the numbers one would expect. The summer skies fill with live birds, pigeons choke our cities like rats with wings, gulls hover like been around ships and beaches—yet their dead vanish. Aware of their impending demise, dying birds instinctively hide themselves away, perhaps to avoid contaminating the world of the living with their carrion. Schizophrenics do likewise. Like dead birds, their obscurity belies their swelled ranks. They seek heaven on street grates, in halfway houses, in prisons, in attics.

In Joseph Conrad’s novel Lord Jim, Marlow observes that extracting truth from Jim was like trying to find out what was in a sealed metal box by beating upon it with a stick: you got a lot of noise, but no useful information. An excellent description of psychotic speech.

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.

I love this and aspire to be this in my own things.

Pain 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.

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.

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.

Hippocrates once said that the chief function of medicine is to entertain patients until they heal themselves.

This ends up being a recurring theme throughout this memoir, with the anecdotes being... sadly consistent correlations.

The more bizarre the description of the pain, the more likely it is to be a psychiatric delusion.

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.

My last physics course as an undergraduate was Mathematical Methods in Physics. On the first day of class, the professor informed us that there would be only one test, the final exam, and that it would consist of only one problem. He wanted only the answer to that problem, accurate to four decimal places, written on a scrap of paper above our name. If we were correct to all four decimal places, we’d get an A. If not, we’d fail. Simple. There were immediate howls of protest from myself and others. One test? One answer? Didn’t he even want to know how we set up the problem? If we even knew what we were doing? “No,” he replied. “Welcome to the real world, where people only want answers—correct, accurate answers. If a bridge collapses and kills forty people, who do you think cares whether the engineers set up the problem correctly? In life, there is no partial credit for being half right. If you want to accomplish anything important, you have to be totally right—and be willing to take the consequences if you are not.” As the professor argued, all real-world occupations require a certain level of performance. The physician’s performance must be perfect, however, and it must be perfect right now. In a lifetime, a surgeon performs thousands of operations and makes hundreds of thousands of decisions regarding medications, antibiotics, when to operate, when not to operate. Complicating matters is the fact that these decisions often must be made quickly and with incomplete informati...

A first name is the most durable lifeline to the outside world, the first word recognized and the last word forgotten. When a dementing illness erases our awareness of home, spouse, and children, we will still answer to our first name. A first name can pierce the delirious fog of head trauma faster than any other word.

Perhaps I was a little rude, but I didn’t care. I now knew how James Bond must feel when he thinks he’s saving the world from certain destruction. Politeness and civility are sacrificed without a trace of guilt. As the earth teeters on the brink of nuclear holocaust, Bond runs through a crowded airport knocking people flat, kicking over their luggage and spilling their drinks—all without so much as an “Excuse me.” He’s not rude; he’s a hero on a mission. He can grab people by the throat, hold a gun to their heads—anything to get the job done. I can say: “Get your ass out of bed and scan this lady BEFORE SHE DIES.” In the end, all is allowed, all is forgiven. We do what we have to do. Results, not effort.

I could ask anesthesia for a fifth neurosurgery room. I could ask Mother Teresa for a date, too; the answer would be the same.

Decades ago, those afflicted with trisomy 21 were called “mongoloids” because of the thick eyelid folds which give trisomies a vaguely Oriental appearance. This offensive label was replaced with the more medical-sounding “Down syndrome.” Some argued that the late Dr. Down should not be so eponymously rewarded. Down’s critics charge that he was a racist who believed that trisomy 21 victims actually were “inferior” Mongolians who appeared sporadically in the Western population. The technical term “trisomy 21” is now most commonly used.

Even though the bleeding during an SAH can be slight and doesn’t damage the brain substance directly, it is a devastating event. A person may silently harbor an aneurysm for years until some stress, such as sexual intercourse, lifting a heavy box, or simply having a violent sneeze, sends a pulse wave of blood pressure that splits the fragile aneurysm sac, spilling a torrent of arterial blood into the space between the brain and the skull. This region is called the “subarachnoid space” because it is below the arachnoid, a cottony substance which covers the brain and which derives its name from its close resemblance to a spider’s web. The victim of an SAH is felled immediately by a “thunderclap” headache, as if shot by a gun. Vomiting may occur. The body reacts quickly to stem the hemorrhage by sending the blood vessels feeding the aneurysm into spasm, temporarily closing them off. Arterial spasm is the body’s natural defense against hemorrhage—it’s what allows a Kansas farmboy the time to pick up his arm after it has been amputated by a threshing machine and run for help without bleeding to death. An arm can go hours without blood and survive. The brain’s survival time without oxygen is three minutes. Several minutes after a brain aneurysm ruptures, the feeding arteries are compelled to reopen by chemical signals from the starving brain tissue. If a sufficient protective clot has not formed over the rent in the aneurysm’s wall, the bleeding will resume, with lethal results....

Oh good, this helps me sleep at night.

Too risky. I think trapeze artists call it ‘working without a net.’ Remember the rule: You can always make someone worse.”

“Remember, Frank, when we were interviewing to go into neurosurgery? They would look at your medical school grades, your research projects, whether you were an honor student and shit like that? Well—give me a micropatty please—well, none of that was worth a squat. I mean, how can you tell if someone can do this by what grades they made? A guy could have fingers like sausages, but because he got an honors in neuroanatomy they think he can become a microsurgeon. It doesn’t make sense.”

He was, as Gary acidly put it, the “prototypical surgical psychopath”—someone who could render a patient quadriplegic in the morning, play golf in the afternoon, and spend the evening fretting about that terrible slice off the seventh tee. At the time this sounded like a terrible thing, but I soon learned that Filipiano was no different from any other experienced neurosurgeon in this regard. He couldn’t mourn every bad result—not without going insane. He handled hopeless cases on a daily basis. After one especially grisly complication, I asked Filipiano if surgery ever got to him. He quoted an old Russian saying: “People who cry at funerals shouldn’t become undertakers.”

“Ondine’s curse,” explained Dr. Leo as he peered over his half-glasses, “is a result of a stroke in the medulla, in the lower stem. That’s where the respiratory drive center is located. As you know, we can either breathe voluntarily”—he demonstrated by taking a deep breath—”or involuntarily, without having to think about it. If our respiratory center is damaged, we can’t breathe automatically; we have to think about each breath. Stop thinking about breathing, and we stop breathing. It’s that simple.” “Who was Ondine? Some Queen Square neurologist?” asked Eric referring to the birthplace of neurology in London. “No,” laughed Dr. Leo, “Ondine was a nymph of Greek mythology who offended the gods. As punishment, she was sentenced by Zeus to think about every breath. She knew she could never sleep, for to sleep meant death. That’s a great curse, right?”

“I think it was Wyatt Earp who said ‘Any day above ground is a good day,’”

We hurried through the hospital lobby, casting quick glances around corners and down hallways to be sure that we didn’t accidentally bump into any attending surgeons or patient families who might want to discuss business. A chief resident never finishes a workday, he just sort of amputates it. There was always something more to do if he looked too hard.

Roma’s was filled with the usual crowd of residents. Every specialty was represented, each identifiable by a characteristic uniform and behavior. Two bulked-up orthopedic residents were taking a break from their anabolic steroids and downing a few calzoncs instead.

haha and the typo makes it even better

“Are they going to fire me for one skull-o-gram?

“But you’ve interviewed at a dozen places since then! Why didn’t you tell anyone you were already taken?” Gary laughed, blowing pulses of smoke. “Naive boy,” he whispered, leaning close, “if you’re a good candidate, people will fly you anywhere to interview. And each interview gets you out of this meat grinder for a day or two. Why the fuck would I tell people I signed a contract five months ago and quit interviewing? Look at where I’ve been since: San Diego, San Francisco, New York—shitty jobs every one of them, but great trips. I didn’t go to Akron, did I? You see, that’s the job of the chief resident, Frank. Everyone thinks we’re here to teach you punks how to sew and tie, but you can learn that shit anywhere. We’re here to teach you really important things, like how to con a dinner at Antoine’s out of a private-practice group in New Orleans that you wouldn’t work for if your life depended on it.” I was a Buddhist pupil seated in the presence of the Enlightened Master.

As we were on our way out, one of the orthopedic residents called to us. “Hey, Gary, going back again? Don’t you guys ever leave?” “Man, this is a tough year for us, Bob,” Gary retorted, “but nothing like those three toughest years in an orthopedic surgeon’s life.” “Yeah, what are those?” “Second grade.”

Haaa

“Maybe he’s having a conversion reaction,” chimed an emergency medicine resident. “Possible,” mused Gary, “maybe he struck out in the bottom of the ninth and his male pride made him a paraplegic to save face…but don’t call the psychiatrists in just yet.” The phrase “conversion reaction” is a euphemism for hysteria. The patient “converts” an emotional trauma, such as a failed marriage or, in Billy’s case, the shock of being nearly killed in an accident, into a physical complaint such as blindness or the paralysis of an arm or a leg. Although the symptom has no organic cause, the patient isn’t faking in the conventional sense, either. Malingerers don’t believe that they are ill. That’s why hidden cameras catch them throwing away their wheelchairs when they think no one is watching. The hysteric, on the other hand, is truly convinced that the illness is real, and will continue to manifest symptoms even when alone.

The spinal cord is notoriously intolerant of injury. Like IRS agents and Mafia dons, the cord will tolerate a certain level of insult, but wise men don’t push to that level.

While portrayed as the “main nerve” connecting the brain to the rest of the body, the spinal cord is more than just a nerve. In fact, it is a complex organ possessing an intelligence of its own. Stereotyped movements, like standing and walking, are preprogrammed within the spinal cord’s gray matter. This frees up our cerebrums to do those things which it does best, such as writing sonatas and inventing lite beer ad campaigns.

The OR can be an insufferably intimate place, an arena where an intensely personal transaction occurs: the bartering of one person’s skill for another’s quality of life.

“How do you feel?” “My feet still feel funny, and I can’t walk as far as I would like, but I’m getting better all the time. I return to work next month.” He thought for a while, then continued. “I can never look at my wife or children in the same way. That doesn’t sound right…Let’s say that when Joey asks to play ball, I’ll play ball as long as he wants. I don’t remember everything that happened, except that it happened so fast…so fast. It’s like that sappy Christmas movie, when an angel shows some guy how the world would be without him, and then lets him go back so that he can appreciate everything more. That’s how I feel. Like somebody let me go back and I can never waste a single day again.” He strode away on his stiff legs. “Somebody let me go back.” Now, who wouldn’t want to do that for a living?

Words to literally live by.

The straight pipeline from primary care to the neurosurgeon has created friction between neurologists and neurosurgeons. The neurologists are irritated about being bypassed in favor of surgeons too anxious (in their humble opinions) to cut the patient, while the surgeons increasingly view the neurologists’ contribution to many diseases as nothing short of vestigial. The running joke among the neurosurgical residents was that neurology was a little guessing game to play while the CT films were processed.