When the Air Hits Your Brain: Tales from Neurosurgery

by Frank T. Vertosick Jr.

The James Bond feeling that sustained me in moments of clinical crisis was starting to carry over into my out-of-hospital persona as well. Endless days and nights spent summoning the nerve to stick a tube into someone’s nose, a needle into someone’s back, a drill into someone’s skull, or a knife into someone’s brain were now making it easier for me to face challenges outside the hospital as well.

While the foyer and hallways were heated to barely sixty degrees (considered positively balmy by U.K. standards), I found the wards to be quite warm. The increased heating of the patientcare areas was evidence that even the British didn’t believe their own hogwash about lower temperatures’ being “healthier.” In reality, the ambient temperature was directly proportional to the robustness of the government health service’s budget at the time.

In the United States, residencies have a defined length. As long as a resident meets the minimum requirements for finishing, he or she is virtually guaranteed to enter the realm of attending physician at the expected time. Not so in Great Britain, where the centralized planning of socialized medicine sets the maximum number of attending jobs available. Thus, a neurology registrar can exit training only when openings for an attending neurologist become available. This occurs when an existing neurologist retires, dies, or emigrates for a larger salary—in other words, not very often.

Because it was under few financial pressures to behave otherwise, the neurology service operated at a glacial pace. The lone CT scanner was usually backed up for days, even weeks, and more involved studies were even harder to come by. The rate of patient progress was so slow that the attendings rounded only once a week, compared to once or twice a day in the United States. I would come in every morning expecting the frenetic activity I had come to associate with American inpatient care, only to find the nurses and the patients staring at one another. Watching a case unfold was like watching grass grow.

One Sunday, a middle-aged man was admitted after having a subarachnoid hemorrhage during sexual intercourse with his wife. He was in excellent condition: awake, alert, and with only a trace of headache. Back in the States, we would have performed angiography and surgery to clip the aneurysm within twenty-four hours of his arrival. But this was London. We simply tucked the man into his ward bed and scheduled his cerebral angiogram—the next slot was fourteen days away. He would have to wait.

The “chap” waited uneventfully through the first week. The following Sunday, though, while glancing over the sports page and eating lunch, he shouted, grabbed his head, and fell forward into his bowl of vegetable soup. He burbled into the bowl for untold minutes until one of the sisters found him. She pulled him out and started CPR, but he quickly died. “He might have had a seizure and drowned in his soup,” said William. “Bullshit,” I interjected. “Oh, you Americans are so wonderfully blunt,” William continued, “but I doubt we’ll ever know what really happened.” No autopsy was performed.

Little more than fifty minutes had passed since she had arrived in the casualty department. British medicine at its finest. Although mired in red tape, the U.K. system avoids the legal wrangling that hamstrings American medicine. In the United States, taking a woman to the OR without objective studies, such as MRI or CT scans, invites malpractice action should anything go wrong.

The infamous “swinging chairs,” in which infants rocked for hours on end, lined the halls. Nurses had the audacity to call me when one of the pendular infants puked.

"pendular infants" haha

Hydrocephalus, Greek for “water brain,” results from a blockage of normal cerebrospinal-fluid flow within the brain. CSF moistens and cushions the gelatinous nervous tissue. One pint of CSF is made in the brain daily, percolating through small chambers and tunnels within the head and spine before flowing back to the brain’s surface, where it is absorbed by large veins.

I knew that infants almost never have benign brain tumors.

:(

Myelin first appears during the third or fourth month of life, and continues forming until the nervous system reaches full maturity at age twenty-five. A neuroanatomy professor once lamented to me that twenty-one was too young an age to vote, given that the brain wasn’t even “done” yet.

The exquisite difficulties of infant surgery have a Darwinian explanation: nature doesn’t want sick babies to have surgery, but to be buried. Civilization no longer cares about survival of the fittest, however. We want all our babies to live.

Skin ulceration during prolonged operations is just one example of how anesthesia differs from sleep. During sleep, we change positions every hour, protecting each body area from prolonged pressure.

Now I'm thinking about this all the time

Dr. Wilson put a cotton ball into the tumor bed and squinted at the CT scan hanging on a view box across the room, trying to compose himself. He was motionless for a long time. I have since come to know the agony of those minutes which follow hurting someone badly in the operating room. In those moments, the fear of confronting the family, the panicked thoughts of changing careers, visions of lawyers—all dance through the mind in a flash.

I'll continue appreciating every moment I'm not a brain surgeon.

Ethicists and cost cutters argue that placing a pillow over her tracheostomy would be the best thing we could do for Rebecca—and for society. Rebecca’s hospital costs now topped half a million dollars, a steep price to pay for a baby with a terminal disease. Her death would be brutal, most likely from pneumonia. The ethicists and cost cutters might change their minds, however, if they saw Rebecca. Although imprisoned in a hospital bed, she did not look like she longed for death as she grinned at her rabbit.

:( :( :(

My out-of-control Beetle completed one complete revolution as it exited the bridge, then regained its footing on the warmer asphalt of the roadway before taking off, straight as an arrow. I continued down the expressway at full speed as if nothing had happened. But something had happened. Although I was unhurt and my car undamaged, my outlook on driving could never be the same again. This experience taught me what a dozen Red Highway movies in Driver’s Ed did not: how very easy it was to lose control of a car and die. Decades later, I still feel the steering wheel dissolving in my hands as the car slides. One instant in complete command; the next, a terrified passenger thrown upon the mercy of fate for survival. I had been lucky, learning my lesson and paying no price. If only all lessons were so painless. A Native American proverb states that a child allowed to wander into the campfire learns better than a child told a thousand times to stay away. But this trick fails if that first trip into the fire burns the child to death. On that snowy expressway, I had wandered into the campfire and, by sheer luck, escaped unburned.

To a brain surgeon, there are two cerebral hemispheres: the left one, and the one that isn’t the left one. In over 90 percent of right-handed patients, and in the majority of left-handed patients as well, the left hemisphere contains the apparatus for making and comprehending speech, both written and spoken. The right hemisphere does some useful things, too, like helping us get dressed in the morning and giving us an appreciation of Bach (or the ability to compose music, if we’re among the few so endowed), but its function is merely desirable. The left hemisphere’s function is indispensable. While a total occlusion of the right MCA will leave a patient paralyzed in the left face, arm, and leg, it will spare the intellect and personality. A similar occlusion of the left MCA amputates the patient from humanity and thrusts him forever into a foreign land, where no one will ever speak his language.

Enrico Fermi’s admonition came back to me: Be the best or be something else.

Talking with the attendings about my career doubts would have done little good—a marine boot can’t discuss his doubts about the Corps with his drill sergeant.

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.

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.

“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.

Oof, that ending.

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.

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 recent progress in brain stimulation, as it turns out, is particularly relevant for me. In 2001, I developed a mild tremor of my left hand. This didn’t hinder me in the operating room, at least not at first, but my unsteadiness soon became obvious to my patients and colleagues alike. A brain surgeon with unsteady hands is, well, pick whatever analogy you like, it’s not good. I began limiting myself to operations like simple disc procedures and carpal tunnel releases, but the situation steadily declined. By late 2002, I had to quit surgery and do office consultations only. By 2004, it became clear that I had early Parkinson’s disease. So far, my condition has not progressed much beyond hand tremors and I can still play tennis and golf, and even scuba dive. In fact, I can do most anything—everything except surgery. I found it difficult at first; in fact, even years later, I have occasionally dreamed that I am doing a meningioma removal (my favorite operation). But now, I rarely think of my past life as a surgeon.