Table of Contents
Cover Page
Praise
Other Books by
Title Page
Copyright
Dedication
Epigraph
Introduction
Acknowledge
Half Title
1 The Rules of the Game
2 Slackers, Keeners, and Wild Cards
3 Thanks for Everything
4 A Night in the Street, a Night in the Chair
5 The Museum of Pain
6 Ailments Untreatable
7 Surgical Psychopaths
8 If It Was Easy, Everyone Would Do It
9 A Bit of Hard Cheese
10 Rebecca
11 Nightmares, Past and Future
12 The Wheel of Life
13 Belonging
Postscript
More praise for
WHEN THE AIR HITS YOUR BRAIN
“At a time when doctors have forgotten how to be teachers, and medical training has become disease-oriented and depersonalizing, comes a book that can help alter that view. When the Air Hits Your Brain lets you feel the pain, grief and joy of practicing medicine. I know from experience that some physicians believe their M.D. makes them Medical Dieties but I know for me it meant My Disease. Read and understand the emotions and feelings physicians live with that they are poorly prepared for by their disease-oriented training. Physicians know how to think but not how to feel. Dr. Frank Vertosick is not a ‘normal’ doctor, thank goodness. This book should be read by every medical student, doctor and present or potential patient. In other words, by all of us.”
—Dr. Bernie Siegel, author of Love, Medicine and Miracles
“Dr. Frank Vertosick provides an amusing, insightful and honest inside view of the training of the neurosurgeon. This highly readable account of daily life on the wards shows all the humility, fortitude, and humanity that genuinely underlies this sometimes not well-understood but genuinely wonderful profession.”
—Dr. David W. Roberts, professor of surgery (neurosurgery), Dartmouth-Hitchcock Medical Center
Also by Frank T. Vertosick, Jr., M.D.
The Genius Within
Why We Hurt
When the Air Hits Your Brain
Frank T. Vertosick, Jr., M.D.
Tales of Neurosurgery
Copyright © 2008, 1996 by Frank T. Vertosick, Jr., M.D.
All rights reserved
Printed in the United States of America
First published as a Norton paperback 2008
For information about permission to reproduce selections from this book, write to Permissions, W. W. Norton & Company, Inc., 500 Fifth Avenue, New York, NY 10110
For information about special discounts for bulk purchases, please contact W. W.
Norton Special Sales at [email protected] or 800-233-4830
Manufacturing by Courier Westford
Book design by Beth Tondreau Design
Production manager: Devon Zahn
Library of Congress Cataloging-in-Publication Data
Vertosick, Frank T.
When the air hits your brain : tales of neurosurgery / by Frank T. Vertosick, Jr.
p. cm.
1. Nervous system—Surgery—Miscellanea. 2. Vertosick, Frank T.
3. Neurosurgeons—Miscellanea. I. Title
RD593.V47 1996
617.4’8—dc20
95-9790
ISBN 0-393-03894-7
ISBN 978-0-393-33049-6 pbk.
W. W. Norton & Company, Inc., 500 Fifth Avenue, New York, N.Y. 10110 www.wwnorton.com
W. W. Norton & Company Ltd., Castle House, 75/76 Wells Street, London WIT 3QT
4 5 6 7 8 9 0
TO FRANK AND VERONICA,
who raised me to be whatever I wanted to be
Surgeons must be very careful
When they take their knife!
Underneath their fine incisions
Stirs the Culprit—Life!
—EMILY DICKINSON
Introduction
Neurosurgery is an arrogant occupation. Astronomers study the stars but never touch them. Particle physicists see God in the vapor trails of their great atom-smashers, but cannot see the particles themselves, cannot reach into protons and feel the quarks with their fingers. Molecular biologists sing the praises of the double helix, but the gene is forever an abstraction, invisible to the naked eye. These scientists must be content with the shadow nature casts upon their instruments and photographic emulsions. But not the neurosurgeon, for whom the greatest mystery of creation resides in a few pounds of greasy flesh and blood. Only the neurosurgeon dares to improve upon five billion years of evolution in a few hours.
The human brain. A trillion nerve cells storing electrical patterns more numerous than the water molecules of the world’s oceans. The soul’s tapestry lies woven in the brain’s nerve threads. Delicate, inviolate, the brain floats serenely in a bone vault like the crown jewel of biology. What motivated the vast leap in intellectual horsepower between chimp and man? Between tree dweller and moon walker? Is the brain a gift from God, or simply the jackpot of a trillion rolls of DNA dice?
The answers to these questions rest at the uncharted boundary between theology and science. We do know one certain thing about the brain: it is not unbreakable. When an unfortunate homo erectus plummeted from a cliff, suffering the first hominid head injury, mankind learned of the exquisite vulnerability of the pink goo between their ears. Surgeons of antiquity believed the brain sacrosanct, beyond their healing skills. As late as the nineteenth century’, when bold surgeons attempted anything—even the repair of a beating heart—the nervous system was still considered off-limits. Although ancient shamans trephined holes in the skull to allow evil demons to escape, they knew that breaching the dura, the brain’s leathery covering, meant the patient’s sure demise from infection, bleeding, coma.
Some mornings I awaken and wonder how I ended up a neurosurgeon. One day I was a poor college student rummaging under my sofa cushions for a few quarters to buy french fries; the next thing I knew I was wrist-deep in someone’s skull. What happened in between remains a blur.
There is a misconception that surgeons flock to their profession at an early age, drawn as if by a religious calling. Well, I didn’t grow up planning to be a brain surgeon. I admit, as a child, I tried to build The Visible Head model—but I threw away the macabre plastic replica,of a human noggin when the eyeballs fell out and rolled off the kitchen table. I should have taken this as an evil omen, but alas, I didn’t. So here I am.
What draws people into “glamorous” medical careers? For some, it’s vindication for being a loser early in life: the grade school wimp beaten in the playground, the high school geek who never had a date. For others, it’s the secure (and large) income. As for me, I wandered too close to a dangerously seductive profession and wound up stuck for good, a fly in the spider’s web. Had I never seen a brain operation, I doubt that the thought of doing brain surgery would have occurred to me. But once I viewed the living brain and was exposed to the seductiveness of the profession’s arrogance in the flesh…I was hooked.
Brain surgeons have a well-cultivated public mystique, an aura of supreme intellectual and technical competence created by the imperious and brilliant Harvey Cushing, father of American neurosurgery and one of the first surgeons to specialize in brain operations. Cushing descended from a long line of medical men. Aristocratic and dashing, he drank his afternoon tea from fine china and stored his cigarettes in a sterling-silver case. He also had a keen eye for the media, fashioning himself into the medical super
star of the pre-television era—he even made the cover of Time magazine. Cushing knew that the brain was better PR than blocked colons and gangrenous legs. He endlessly exploited the public’s fascination with his infant specialty.
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. I see a blood clot crushing the life from a brain and deduce that the clot should be removed, but Gomer Pyle would reach the same conclusion.
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.
Our training period, simultaneously the worst and best part of our careers, remains one of the most arduous apprenticeships on earth. There are no neurosurgical prodigies. Little Elmo will never be the first in his advanced-track grade school to lop out a frontal lobe. Whether genius or dolt, everybody runs the same seventeen-year gauntlet from high school to board-certified brain surgeon. Why? Because neurosurgery, like all surgical fields, is a cult, a religion with mandatory rites of passage. All trainees must submit to the ordeal, must endure the withering years of death and disease, must feel abject humiliation at the hands of their professor-priests. In addition to professional brainwashing, the training process also achieves the unstated goal of turning out people who not only can do neurosurgery but also look like neurosurgeons in the Cushing mold: gray, chain-smoking males. The longer the program, the older and more persuasive the surgeon. A twenty-five-year-old man can pilot a spacecraft to the moon, but please keep him out of Mama’s head.
This book details my odyssey into neurosurgery. However, the story focuses not upon my own talents, which are far from exceptional, nor upon any bizarre case histories or lurid physician behavior. No sex in linen closets here, no inside scoops on prominent medical personalities. The focus is upon the ordinary: ordinary patients and doctors facing difficult diseases and, at times, displaying extraordinary courage.
The book is a loose collection of clinical tales. I recall my residency as an anthology of patient experiences, not as a didactic education or a plotted story line. I remember nothing of the chapters on rheumatoid arthritis I read in medical school, but I do remember the distraught grandmother with gnarled fingers who could no longer roll cookie dough for her grandchildren. The book, like my training, is a collage of human beings.
The patient vignettes tend toward the gloomy side, and I may be accused of making the field of neurosurgery look like Hamlet, in that nearly everyone dies in the end. These stories do not mirror the field of neurosurgery at large, in which good outcomes vastly outnumber complications and deaths. I chose cases that became landmarks in my own progression from steelworker to surgeon of the central nervous system. Failure instructs better than success. A single death shapes the surgeon’s psyche in a way that fifty “saves” cannot.
Neurosurgeons face terrible diseases—brain cancers, spinal cord injuries, head trauma, lethal hemorrhages. We confront patients deprived of speech, movement, vision. In manycases, disaster strikes them like lightning, in the form of sudden headaches, seizures, car accidents, or simple stairway tumbles. We see what no one would ever ask to see. Nevertheless, the nobility of the human spirit will always shine through the ugliness. The worst tragedies can be the most inspiring. During my training, I felt like Robert E. Lee, who, after witnessing great heroism in the midst of terrific carnage, mused: “It is well that war is so terrible, or we should grow too fond of it.”
While based in reality, all of the names in this book have been changed and the true clinical stories altered substantially, even partially fictionalized, to protect the confidentiality of patients and the privacy of those who were and still are my friends and colleagues. The patients, physicians, and events depicted here are composites of many occurrences, people, and conversations that took place over ten years.
I did not intend to write with journalistic accuracy, or to chronicle my life, which after all is similar to the lives of a thousand other neurosurgeons. If my readers crawl into the mind of a generic neurosurgeon-in-training and witness what he witnessed, feel what he felt, fear what he feared—and marvel at the drama played out in any hospital, in any city, on any given day—then I have achieved my purpose.
I want to thank my wife and children for their support and understanding during the many long, dark nights spent writing. I also wish to acknowledge the many friends, patients, and colleagues who provided the inspiration for my stories. Finally, I wish to thank my agent, Victoria Pryor, and my editor, Ed Barber, for their willingness to listen to the ramblings of an obscure neurosurgeon.
WHEN THE AIR HITS YOUR BRAIN
1
The Rules of the Game
July 1. Neurosurgery residency.
Day one.
Five A.M.
A sickening wave of déjà vu flooded over me as I looked at the automatic doors to the “porch,” the neurosurgical step-down unit. I had a sudden impulse to flee, to hide under my bed until it all went away. Six more grueling years of training loomed before me. Those years weighed heavily upon my brain that morning, like tons of ocean water submerging me, away from the sunlight of a normal life, normal job, normal things.
Before I could push the wall button to open the porch doors, they abruptly hissed apart on their own. There before me sat two men from my past: Gary, the hyperbolic smokestack of a junior neurosurgery resident who had ascended to become chief resident; and Eric, the once-jittery intern who was now a senior resident. I had worked with both of them years earlier, when I was a lowly medical student. We would be spending the next six months together on the boss’s service, covering his pain patients as well as taking care of the trauma patients and other ER “hits” to neurosurgery. The “boss” was the chairman of neurological surgery, Dr. Abramowitz.
“Well, Eric, look who’s arrived—Mr. Horner’s sign himself,” Gary said, referring to the clinical sign which had landed me in neurosurgery in the first place. Ancient history.
“Hello, Gary, you look—”
“Like hell, as always. Too much chocolate milk and nicotine—but, hey, whatever keeps you going? Listen, there isn’t anything on the schedule this morning—the boss is testifying at a trial. Let’s go back into the conference room. I need to spell out the rules of neurosurgery to you, from day one. After that, we’ll take you down to see the Museum of Pain.”
“The rules of neurosurgery? The ‘Museum of Pain’?”
“Yeah, the rules. Rules you aren’t going to read in any of the six volumes of Youmans’ textbook. You’ll see the Museum later—you have to see it to believe it.” Youmans’ was the bible of neurosurgery, the font of wisdom for trainees.
We went back to the small conference room where I would be making afternoon card rounds for many years to come. Gary went to the chalkboard and began to write.
“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.”
“The patients seem to do all right,” I protested.
“Yes, they usually do, but every once in a while something funny happens: someone’s personality changes, a patient up and dies without warning—all little reminders that you are treading upon sacred soil. Which leads to 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.”
He took a sip of coffee and continued. “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.”
Another sip. He went on. “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 expert management rendered from the on-call-room bed or the residents’ TV room. Look at the patient. 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 the chart. Always look at the consent and look at the patient’s bracelet. To do otherwise is a setup for a res ipsa.”
When the Air Hits Your Brain: Tales from Neurosurgery Page 1