When the Air Hits Your Brain: Tales from Neurosurgery

by Vertosick, Frank, Jr.

  “Res ipsa?” I asked. “They never taught us that one in medical school.”

  “And they never will; it’s a legal term. Short for res ipsa loquitur, or ‘the thing which speaks for itself.’ It means a malpractice case in which the error is so obvious that even a non-expert can see that a fuckup has occurred. A patient falls off the OR table. You cut off the left leg when it’s the right one that’s gangrenous. You send someone with a broken neck home from the ER with only an aspirin prescription. A patient bursts into flames during defibrillation. You take a disc out of a Mrs. A. Johnson when it was Mrs. J. Johnson who was supposed to have the operation. Res ipsa is checkbook time. Just write in a string of zeroes. Have I forgotten anything, Eric?”

  Eric thought for a moment. “Well,” he said, turning to me, “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.” He thought some more. “And always agree with the boss. The boss is this residency program. When it comes to ego, neurosurgery is the major leagues, the NFL, the NBA. The big time. Grovel and beg at the appropriate times, and you’ll do fine.”

  “This is residency now,” Gary chimed in again, “you aren’t the hotshot medical student or the know-nothing intern who can be forgiven any mistake. This is for keeps. This is your career. No more temporary rotations in pediatric endocrinology or tropical diseases. You’ll do this shit until you die. Are you ready?! I said, are you READY!”

  “Yes!”

  Let the Games begin.

  2

  Slackers, Keeners, and Wild Cards

  My descent into neurosurgery began in medical school, where I sought refuge from the real world. I took my undergraduate degree in theoretical physics—a great field if your name is Einstein. As a former steelworker, my personality tended toward careers which offered me some realistic chance of making a living. 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. Any theoretician who isn’t the best is a fraud, a pretender. I had done well in physics, but not well enough to pass Fermi’s test. I decided, virtually by default, to become a doctor.

  TV and movies foster many misconceptions about medical students, portraying them as drunken buffoons performing unspeakable acts with mummified body parts in anatomy labs, or as fully competent physicians (Judy can amputate the captain’s leg! She’s a medical student at Harvard!). In reality, medical students are glorified college students, people who think they know something, but don’t.

  Although a certain amount of rowdiness exists in any medical school, we were not picked for our social skills. I divided our freshman class into three groups. I was in the biggest: the slackers, consisting of students who had garnered acceptable grades with a minimum of effort since first grade. We studied only as much as absolutely necessary (and only at the last possible moment). We lurked in the rear of the lecture halls, in the “prime bolt seats,” from where an unobtrusive exit could be made if the lecture got too tedious or a good basketball game formed outside. Most importantly, slackers never asked questions in class. Asking questions was a sign of weakness.

  The second group, the keeners, were overachievers, who hacked and bludgeoned their way to success through work and more work. They planted themselves in the front of the lecture hall, never exiting a class prematurely even if diarrhea dribbled into their shoes. And they always…ALWAYS…asked questions. A lecture on the tying of shoelaces would still draw some keener into the lecturer’s face after class, waving a grade-school ring binder and saying, “I didn’t quite get it, the loop goes under or over?”

  The third group, the wild cards, entered medical school because they knew someone, because one of their parents had graduated from the school decades earlier, or because someone on the admissions committee was intrigued by an unusual entry on their résumés—“Spent one year in Uganda ladling gruel into starving children.” Unfortunately, these admission criteria did not correlate with IQ. The wild cards became our “cretin buffer,” fattening the grade curve for us slackers. The wild cards never sat in the front or the back of the class—they never went to class.

  The first two years consisted of didactic lectures on anatomy, physiology, pathology, and the like, with a few brief contacts with patients thrown in as appetizers. The real fun didn’t begin until the third year. At that time, lectures ended and we were thrown into the hospital wards full-time.

  Seven clinical tours of duty, or rotations, made up the third year: nine weeks of internal medicine, nine weeks of pediatrics, three weeks of anesthesiology, six weeks of general surgery, six weeks of obstetrics and gynecology, six weeks of psychiatry, and a three-week elective in the surgical subspecialty. My schedule arrived in August, listing my first rotation as the surgical subspecialty rotation. Great, I thought, I’ll do cardiac surgery. Maybe I’ll be a chest surgeon.

  When I went to sign up, the secretary in the student affairs office dryly informed me that I could not do cardiac surgery, since the cardiac surgeons wouldn’t let any medical students onto their service unless they had finished the six-week generalsurgery rotation first. 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? Nothing seemed as interesting as cardiac surgery. Oh well, it was just a crummy three weeks, anyway.

  “Ahhhh…give me neurosurgery.”

  She jotted it down. “Vertosick, neurosurgery. Show up on the neuro floor, five-thirty A.M., September second. Next.”

  My fate was decided by a scheduling glitch.

  Then it hit me: 5:30 A.M., as in before dawn? Was she joking?

  On a gray September morning, I slogged to the hospital for my first day as a real doctor on the university neurosurgical service. I was about to step onto the slippery slope.

  The neuro floor was dark and quiet, the nurses’ station empty. I tracked down a nurse making his rounds and introduced myself, then asked him where I might find someone who would know what it was I was supposed to do.

  “Look in the porch.”

  “The porch?” I had visions of some congenial place, full of wicker rocking chairs.

  He pointed to a set of automatic double doors at the end of the long hallway. “You know, the porch, the neuro stepdown unit…right there.”

  Thanking him, I wandered to the porch entrance. The doors carried the imposing label “Neurosurgical Continuous Care Unit, Authorized Personnel Only.” I felt a bit of pride. For the first time in my life, I was “authorized personnel.” I pushed a switch on the wall and the doors swiftly separated.

  The porch was a small room with a tiny work desk at its center. Six patient beds, five of them occupied, were crammed in a semicircle around the desk. Electronic monitors dangled from the white ceiling and the walls were covered with metal baskets stuffed with gauze sponges, packages of gloves, IV kits, and other disposable medical paraphenalia. The air smelled of antiseptic. Faint monitor beeps were the only background noise. No wicker furniture here.

  The patients, looking like giant Q-tips with their heads wrapped in bulky white bandages, were asleep (or comatose, I didn’t know which). At the desk sat a thin, haggard man sporting a day’s growth of beard and wearing a white jacket over his blue surgical scrubs. He hunched over a stack of charts, scribbling away. I tapped his shoulder and he jumped in his chair, startled by my intrusion.

  “Jesus Christ,” he hissed at me, “who are you?”

  “Frank Vertosick, third-year student doing a neurosurgery rotation. A nurse told me to come here. Is this the porch?”

  “I’m Gary,” he whispered back, calming down a bit, “junior resident…yeah, this is the porch. This is
where we keep people who aren’t sick enough for the intensive care unit, but are too sick to go out on the floor and be forgotten. Most of them are post-ops. Except that one.”

  He pointed to a young man, perhaps a teenager, with a thin plastic hose leading from his head bandages to a complicated contraption on a metal pole beside his bed.

  “That guy’s a head trauma. We’re still watching his ICP, but he’s wrecked. He’ll go out to the graveyard until we can place him.”

  ICP, graveyard, place him. Clearly, the language we’d spoken in the first two years of medical school would be of little use here.

  “ICP means intracranial pressure; the graveyard is the area of the floor where we keep the unconscious people; and when we say ‘place him,’ that means find some nursing home that will take him off our hands…he isn’t going to be any better than he is now. I see you have a lot to learn.”

  “That’s why I’m here,” I beamed.

  “No, you are here to be my fucking slave,” he said with a broad grin. “Now, sit there like a good boy and let me finish my notes, then we’ll get some breakfast.”

  Gary went back to leafing through the charts, jotting down laboratory values and vital signs onto soiled note cards as he went. Every so often he would moan or mutter obscenities to himself, displeased with some chart entry. At last, he clapped the last chart shut, stacked the charts in a pile, and placed them in a basket for the porch secretary. He leaped from the chair and beckoned me to tag along. We exited the porch and took the long elevator ride down to the hospital cafeteria.

  Gary broke the silence in the humming elevator as he lit a cigarette. “There are three residents and one intern on our service—me, the junior resident; Hank, the senior resident; and Carl, the chief resident. The interns float through on a monthly basis. Our intern right now is Eric Foreman, who’s going to be one of the junior neurosurgery residents next year. We tend to ignore the interns, unless they’re going into the program; then we kick the shit out them. Everybody makes rounds in the morning on a different part of the service. Eric, since he knows nothing, rounds on the people out on the floor. They’re generally pretty stable. I get the porch; Hank covers the intensive care unit; and Carl, as chief, gets to roll in at about six-thirty or seven. He doesn’t see anybody in the morning; we just make ‘card rounds’ with him at breakfast, giving him a verbal report of what, if anything, happened at night.”

  “What’ll I do?” I asked, still searching for what my role would be in this well-oiled machine.

  “Well, after you get my coffee, I guess you should pitch in and help write progress notes on the patients on the floor. There are plenty of them and it’s tough for Eric to get finished in time to go to the OR by seven thirty. You see, every patient needs a progress note written on their chart every day…You haven’t done any general surgery yet, have you?”

  “Well, I haven’t done anything, really.”

  Gary rolled his eyes. We exited the elevator and walked the short distance to the cafeteria. Loading up on corned beef hash and eggs, foods that hospital cafeterias serve in order to guarantee future admissions to the coronary care unit, I followed Gary like a lost dog over to a long table in the corner. Two other residents were already seated there, both dressed in street clothes.

  “Carl, this is Frank, MS III.” Gary addressed the more distinguished-looking resident, a slim man with a hint of white about his temples. “Frank’s starting on neurosurgery this morning…No, wait, he’s starting his goddamned medical career this morning!”

  I shook the chief’s hand.

  “Welcome. This is Hank; he’s a fourth-year resident.” Carl motioned to the other resident seated beside him, a balding, portly fellow who waved at me and smiled as he continued to chew a large mouthful of food.

  Gary and I took a seat and began to eat. Several minutes later, a frenetic figure darted to the table, his tray rattling in front of him, the coffee flying out of his cup. He had a boyish face and blond hair. This was clearly Eric, the intern, late for morning card rounds.

  Carl cast a perturbed look at the intern, pulled his own stack of index cards from his lab coat pocket, and began the daily litany.

  “Beckinger, room nine.”

  Eric flipped through his cards, locating Beckinger. I surmised that Beckinger was someone on the floor—Eric’s responsibility.

  “She’s fine, afebrile, no headache, no face pain, wound is dry. She’s now four days out from surgery.”

  “Has she pooped, yet?” Carl asked dryly, without looking away from his cards.

  “Uh, I don’t know.”

  “Well, goddamn it, find out. You know the staff man will go nuts if she hasn’t shit four days out. Her fucking cerebellum could be hanging out of the wound and dragging on the floor, and he wouldn’t care as long as her bowels are moving. If she hasn’t done the deed, give her some mag citrate…Rockingham, ten, by the window.”

  Eric was still scrawling “BM?=mag cit” on his Beckinger card. He hurriedly shuffled to the next one in his stack.

  “Rockingham has some face pain, a little headache, temperature’s 100.8, wound is dry. He’s three days out.”

  “How much is a little headache?”

  “Just…ummm…a little.”

  “Does he need a spinal tap?”

  “I don’t think so?”

  “Did you wake him up, or is this what his nurse told you?”

  Eric grimaced. “I didn’t wake him, he looked so peaceful—”

  “Chrissakes, Eric,” Carl exploded, “you have to wake them up! I know it’s early, but this isn’t the Ritz. They can sleep at home, and I’ve got to know how they feel every morning. The staff guys will go around at eight this morning, the patients will start bitching that they were up all night and nobody’s bothered to see them yet. That you stood outside the door and waved at them while they sawed logs isn’t going to appease anybody. After breakfast, go upstairs and ask this guy how bad his headache is and come and tell me.”

  And so it went, patient after patient. First Eric, then Gary, then Hank. Each took his turn relating the patients. Eric and Gary took a ferocious beating, while Hank’s presentations went unchallenged. Clearly, Carl looked at Hank as a colleague, while he looked at Gary and Eric as subordinates. He never looked at me at all. We finished at about seven-fifteen. Carl produced a large sheet of paper with the OR schedule for the week.

  “Hank, craniotomy for meningioma, room twelve…The only other case is one of the boss’s face pain patients in room five. Gary and I will do that together. Eric, go back to the floor and take care of all the loose ends.” The morning tribunal dispersed.

  Gary took me over to the OR dressing room, where gave me quick instructions on how to find scrub clothes and how to put on a hat, mask, and shoe covers. He also let me share his locker.

  “Eric’s being punished,” Gary whispered to me as I changed my clothes. “He’s not very up on things yet. Carl could have let him stand around with Hank on that brain tumor case, but he’s been sentenced to the floor to be badgered by the nurses all day.”

  “What are you going to do?”

  “Carl’s going to teach me to open one of the face pain patients. I haven’t done much more than help on that opening yet.”

  His face brightened. He was clearly looking forward to this. So far, I hadn’t seen anything to get excited about—getting up before the trout fisherman, rounding on teenage boys who were headed for a nursing home, eating greasy food, and watching grown men torment one another.

  Maybe seeing what went on in the OR would change my mind.

  I walked cautiously into operating room five, the first one I had ever seen “in the flesh.” Much smaller and less grand than I imagined an OR to be, the room’s walls were covered with shiny green tile, the floor a hard, blackish lineoleum. The room had a cold and hollow feel, like a large dormitory bathroom. Against the far wall, a woman in full scrub dress shuffled metal instruments on a large table. To my left, skull X rays dangled
against two light boxes hung at eye level. The patient occupied the center of the room and was already anesthetized, thick bore plastic tubing jutting from his mouth and nose, the eyes taped shut.

  Carl placed the man’s head in a large C-clamp, and then Gary, Carl, and the anesthesiologist flipped him onto his right side and padded him with pillows and pieces of blue foam rubber. They taped his body to the OR table and fixed the Cclamped head to a contraption at the top of the table. Gary quickly shaved a small patch of the recumbent man’s scalp just behind his left ear. The two neurosurgical residents then exiled the OR through a back door. I hurriedly followed them, afraid to be left alone in the OR. I feared I might commit some grievous mistake—touch something, sneeze, fart, anything that would ruin the operation.

  The door opened into a smaller room almost entirely filled by a long steel sink. Four faucets arched over the sink like silver swans: the scrub area. The two men taped their surgical masks to their faces, to prevent fogging up the surgical microscope with their breath, and began to scrub their hands and fingernails meticulously. As they scrubbed, Carl swung around and spoke.

  “Our chief of neurosurgery, Dr. Abramowitz, specializes in treating pain patients. The man on the altar today”—(he motioned with a lathered finger to the OR door)—”has trigeminal neuralgia, also known as tic douloureux, or tic for short. Tic patients get sharp, stabbing pains in their faces, sort of like a dentist drill hitting a nerve. What the boss—that’s what we call Abramowitz—is doing today is the latest procedure for this condition. We’ll drill a hole in the skull, find the trigeminal nerve to the face as it exits the base of the brain, and pad it from surrounding blood vessels using some bits of plastic sponge. It seems to relieve the pain without causing much numbness. The boss learned it from Jannetta himself, who pioneered this approach.”