When the Air Hits Your Brain: Tales from Neurosurgery

by Vertosick, Frank, Jr.

  Gary and Carl backed into the OR, holding their dripping arms high in front of them. They dried their hands and gowned in dramatic fashion, aided by an OR assistant. After soaking the small patch of shaved scalp with a brown solution, Gary layered the prepped scalp areas with blue linen sheets until only the brown postage stamp of bald skin remained visible.

  I stood, my back to the wall, while the surgeons huddled over that brown patch, slicing and dicing and filling the wound with dangling metal clamps, called “dandies,” after Walter Dandy, another historical hero of brain surgery. The blue linen lining the brown patch stained purple with flowing blood. Buzzing noises and smoke filled the air as clamps cluttered the incision. Gathering my courage, I took a few steps closer to the table and peered at the wound. Beneath the pouting ruby lips of the mouthlike gash gleamed a broad white surface.

  “Is that the skull?” I asked

  “Yup,” answered Gary, “time for a drill.”

  A drill? Yikes.

  At that moment a tall, craggy, white-haired man, about seventy years old, flung open the OR door and bellowed into the room, “How much longer, goddamn it? Jesus, Carl, how long have you been here? TEN MINUTES. I’ll be back in TEN MINUTES.”

  “Yessir.” Carl didn’t look away from his work. “I was just showing Gary how to get through the occipital artery—.”

  “Great,” the craggy man answered. “TEN MINUTES and I’m back. I want the cerebellum exposed by then.” The door swung shut and the room fell quiet again.

  I leaned over to Gary. “The boss?”

  He glanced back over his shoulder. “None other.”

  “You heard the gentleman, we have TEN MINUTES to get into this guy’s head,” Carl barked. “Get the craniotome, Gary, and make a hole here, right behind the mastoid eminence.”

  Gary reached into a plastic pan and pulled out an instrument the size and shape of a flashlight. It was connected to a thick black hose which trailed down to the floor and over to a metal gas cylinder at the foot of the operating table. At the tip of the flashlight was a short steel cone topped with a spiral cutting edge.

  “This is the craniotome; we use it to punch through the skull,” explained Carl.

  “How does it know when to stop before it plunges into the brain?” I asked.

  “It has a pressure-activated clutch mechanism,” Gary said as he pushed his finger against the tip of the conical drill bit. “When it penetrates the skull, the clutch disengages and the drill stops. Simple.”

  He squeezed the trigger on the craniotome and the drill whined to life. As Gary pressed the whirling bit against the ivory bone, Carl flooded the wound with water from a plastic syringe which could have been used for basting turkeys. Mounds of white bone chips flew from the deepening hole. Carl washed the bone dust onto the sheets. The whining continued for about a minute or so; then Gary’s arm suddenly jerked forward, thrusting the still-running drill bit to the hilt into the skull. Quickly, the chalklike bone dust around the hole turned beet red. Gary reflexively pulled his finger away from the trigger and the drill stopped. The drill that was supposed to stop before it touched the brain had gone deeper than the residents had planned. A lot deeper.

  “Oh SHIT!” cried Carl. “The fucking drill never stopped. Here we are talking about the clutch mechanism, and the thing doesn’t shut off!” He grabbed the drill away from Gary and yanked it out of the patient’s head. A torrent of blood and some stuff that looked like runny strawberry milkshake poured from the small hole in the bone.

  “What’ll we do?!” moaned Gary.

  “WE don’t do anything. YOU just stand there. Give me a Raney punch!” The scrub nurse handed Carl a large biting thing that looked like toe clippers from hell. He frantically tore at the skull bone, widening the small hole.

  “I need to assess the damage, like real fast. Hopefully, we just trashed the cerebellar hemisphere…If we went down to the stem, we’re all screwed.” Carl’s previous scholarly demeanor deteriorated to a nervous pratter. “I mean, God, I never saw a drill plunge so deep back here…Couldn’t you tell you were going through the inner table of the skull?…Lordy, lordy, just so the stem is OK, tell me the stem is OK…”

  The door swung open. The boss again. “Is everything OK?…I SAID IS EVERYTHING OK?”

  “Yeah…ah…fine, sir,” Carl stuttered, “we just put a nick in the cerebellum, I think…We’re fine—.”

  “FIVE MINUTES. A quick cup of coffee and I’ll be in. In FIVE MINUTES.”

  Carl’s gloved fingers twisted and turned instruments in the wound until at last he pronounced the drill’s damage acceptable.

  “It’s just the lateral hemisphere. This guy’s arm will be a little unsteady for a while, but he’ll be OK. Give me a big cottonoid. The boss will never see it.” He took a large white cloth square and covered the injury to the brain like a small boy covering a large scratch in the new coffee table with a newspaper.

  I couldn’t bear to watch any longer. I left, fearing the verbal explosion that might occur if the boss lifted up Carl’s “newspaper.” Given that “shit rolls downhill,” I also realized that the lowest part of the terrain was me. Seeing Gary in the lounge after the case was done, I asked him how things had gone. He sat on a bench, still sweating and tremulous.

  “Fine, I guess. The patient’s fine, but, boy, I nearly killed that guy. I must have been leaning too hard on the drill or something, I don’t know.” He shrugged his shoulders and stuck out his left index finger. “You see this?”

  “Yeah.”

  “That’s about how big your coronary arteries need to be if you want to do brain surgery for a living.”

  Although I brought Gary coffee each morning, I was really Eric’s slave for the remainder of my neurosurgery clerkship. Eric had more work to do, work that even a third-year student could do. The frazzled intern quickly taught me to remove skin sutures and change dressings. He dispatched me to ask patients questions he had neglected: What were their allergies, did they bring their X rays, had they had their morning bowel movements? I became the “scut doggie,” rounding up laboratory reports, photocopying journal articles, fetching lab coats left behind in patients’ rooms.

  My real contribution was my slew of “H & P’s,” short for histories and physicals. The history consists of the patient’s story told in his or her own words, and includes the chief complaint (“My face hurts when I eat”); the present history (“My face pain started three years ago, and has gotten worse since December…”); past history (“I am diabetic and have had my gallbladder removed”); current medications; allergies; occupation; smoking and drinking behavior; and so on. The physical is the physical examination. Even in an age of increasing technology, a patient’s illness can be diagnosed over three-quarters of the time by the H & P alone.

  Every patient admitted to the hospital must have an H & P written on the chart. On a busy day, the neurosurgical service admitted twelve or more people. Even an uncomplicated H & P took thirty minutes to perform, and the task of getting them all done before nightfall was daunting. Only Gary and Eric did H & P’s; the senior and chief residents considered them menial chores. Gary lived in the OR, leaving Eric saddled with six to twelve hours of H & P’s a day. Taught the fundamentals of history taking and physical examination in our second year, any third-year student could do a passable H & P. I became an H & P machine, cranking out four to six every day.

  Of course, nobody read them. Clinical decisions did not turn upon my findings. The attending surgeon, having performed a very directed history and physical in the office, made the required decisions after some careful thought long before the patient ended up in a hospital. My H & P’s were essentially bureaucratic exercises. With one fateful exception.

  Harvey Rathman, a man in his late fifties, was admitted for the removal of a herniated cervical disc in his neck. His “chief complaint” was right-arm pain, increasing in severity over several weeks. Physical therapy had proved ineffective, and he now ate narcotics just to slee
p at night. At an outside hospital, Mr. Rathman had undergone a myelogram: thick dye was injected into his neck to visualize the shadowy outlines of his spinal nerves on X-ray films. The test had disclosed that one of his neck’s discs, the fibrous pillows between the vertebrae, had ruptured, “pinching” a nerve between a disc fragment and the bony spine.

  While totally incapable of interpreting the X-ray pictures myself, I managed to find the printed radiology report which accompanied the patient’s file. At the bottom of the report, it read: “Impression: small central to left-sided disc herniation, C56.” Left-sided? But the patient’s arm pain was on the right. How does a pinched nerve to the left arm cause pain in the right arm? I showed this paradox to Eric, who shrugged it off. He said that misprints occurred frequently, and that the staff surgeon must know that the disc had really ruptured to the right side or he wouldn’t have brought him in for surgery. “The radiologist probably just goofed up when dictating the report.”

  I accepted this explanation and strolled down the hall to see Mr. Rathman. It was nine in the evening when I entered the dark room. Mr. Rathman sat in his bed, his gaunt, lined face betraying his discomfort. He managed a contorted smile and said in the hoarse voice of a career cigarette user, “May I help you?”

  “I’m Frank Vertosick, Mr. Rathman.” I extended my hand, but he declined to raise his ailing arm and simply waved with his left hand. “I need to ask you some questions and do a brief examination, for the record. Now…” My voice trailed off.

  “Is something wrong?” the man asked.

  Something was wrong. As I glanced closely at his face, it struck me that his pupils were grossly aymmetrical. The right pupil was tiny, but the left pupil was huge, saucerlike. What was going on here? In an instant, a flash of insight burst into my head from nowhere. Deep in the recesses of my memory, brain demons below the level of my consciousness pieced together the man’s diagnosis from the disjointed bits of knowledge garnered during my first two years of medical school. The arm pain…the smoker’s rasp…the thin face…the unequal pupils…it all crystallized for me in a rush. This man did not have a ruptured disc! I stood over him, frozen by the thought that only I knew what was causing his arm pain. But I couldn’t say anything to him. That was not my place.

  “No, nothing’s wrong. Now, tell me about your pain…when did it start?” So it went. I finished the H & P, thanked him, and left. I immediately grabbed Gary, who had just come out of the OR from a head trauma case.

  “Gary,” I said, breathless, “that guy, Rathman, in room fifteen, he’s here for a cervical discectomy, but his disc is on the wrong side! And he has a Horner’s sign! Go look for yourself!”

  “What guy? What the hell are you talking about? You’re babbling. It’s ten o’clock. Go home.” He bolted down a carton of chocolate milk and walked away. I chased after him.

  “No, wait, I’m telling you that this guy is on the OR schedule for seven-thirty tomorrow morning and it’s all wrong. He has a Horner’s sign; you don’t get that from a disc. Just go and look at him.”

  The iris functions like a camera diaphragm, limiting the amount of light entering the eye. Powered by small muscles, the iris becomes paralyzed if its nerve supply fails. If the iris is paralyzed, the pupil remains small. In bright light, when the normal pupil constricts to the same size as a paralyzed iris, the abnormality can be masked. In dim light, however, the normal iris dilates while the paralyzed pupil remains small—an asymmetry known as the Horner’s sign. The difference between the paralyzed and normal iris is so pronounced that even a novice like myself could see it in dim light. When the staff surgeon had examined Mr. Rathman in a bright examination room, the Horner’s sign was not there.

  The nerves to the iris don’t come from the cervical, or neck, nerves, but from the upper chest. This sounds bizarre—eye nerves coming from the chest—but the human body’s blueprints can be hard to decipher at times. Mr. Rathman’s C56 disc wasn’t causing his pupillary asymmetry. Something was going on deep in his chest, gnawing at the nerves to his right arm and amputating the iris nerves. In a middle-aged smoker, the most likely explanation was also the most grim: lung cancer.

  Gary paused. “Didn’t he have a pre-op chest X ray?”

  “Yes, it was read as bilateral apical pleural thickening.”

  “Hmmm, I guess a Pancoast tumor could be hiding at the apex under that pleural thickening and be missed on routine X ray,” he muttered, almost to himself. “Well, let’s have a look.” He walked down the corridor to the patient’s room.

  Mr. Rathman, medicated with morphine, dozed as we entered. Gary gently shook him awake. The junior resident grasped the drowsy man’s chin and turned his head left and right, squinting to see his pupils in the low light.

  “I’m sorry, Mr. Rathman, go back to sleep.”

  Gary walked sullenly to the nurses’ station without saying another word. He sat in a chair by a ward phone, reached into his pocket, and produced a portable phone directory. After finding a number, he punched the buttons and waited for an answer.

  “Hello? Is Dr. Atkins in?…Dr. Atkins, Gary from the hospital…Listen, sorry to bother you, but this Rathman guy you have on for tomorrow, did you know he has a Horner’s sign on the right…No, it’s pretty obvious…uh-huh…Yeah, a Pancoast tumor is a real possibility. Sure…no, don’t thank me, it was the medical stud who found it…OK, so long.”

  He hung up the phone and grabbed the patient’s chart, opening to a physician’s order sheet. He wrote:

  “Cancel OR. Polytomography of the right apex of lung in A.M.”

  Gary looked up at me with a stern face. “That’s the easy part. The hard part is explaining to him why we are canceling his surgery.” He got up and began the walk down the corridor again, this time more slowly. “I’ll take care of it, Frank, that’s why they pay me. Go home.”

  He didn’t need to tell me twice.

  Mr. Rathman’s lung studies showed the expected crablike growth at the tip of his right lung, a Pancoast lesion. A needle biopsy confirmed a squamous-cell lung carcinoma. No thought was given to removing it; his arm pain and Horner’s sign were proof that the tumor had escaped his lung and was encasing his brachial plexus, the network of nerves in the shoulder. There was no hope of cutting it out now. He was transferred to the oncology service for radiation therapy. I never saw him again.

  Mr. Rathman’s case came back to me several months later, after I had left the neurosurgery service and was on my internal medicine rotation at the Veterans Hospital. I received a message that Dr. Abramowitz wanted to see me in his office.

  At the appointed time, I was escorted by a secretary into the boss’s lavish office. The walls were filled with diplomas, citations, awards, and autographed pictures of previous teachers and residents. He glared at me over reading glasses slung low over his long nose, his feet propped up on the broad desk.

  “Please sit down.”

  I complied, almost vanishing into a plush chair. The boss bolted up and continued.

  “I understand that you picked up a lung tumor in one of my staff men’s patients, a man who was headed for a discectomy the next morning?”

  “I just saw his Horner’s sign, that’s all. It was obvious because it was so dark…it could easily have been missed during the day, a fluke really.” I was nervous. Was this some sort of investigation of his attending surgeon?

  “Still, you saved him an operation. Listen, we need good men for this program. How would you like a job when you graduate?”

  “Doing what?”

  He laughed. “Doing this. Neurosurgery. Becoming one of us. It’s tough, but this is one of the best programs in the country, which means in the world.”

  I was stunned. “I’ll have to think about it, sir.”

  “Well, don’t think too long. Over one hundred people apply for the two spots we offer each year, and we like to pick them several years in advance.”

  Thanking him, I beat a hasty retreat. This was an honor, being offered a po
sition in a premier program by an internationally renowned surgeon. 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.

  And why several years in advance? I thought back to my grade school friend David, who committed to the seminary when he was only fourteen years old. Maybe surgical residency was like the priesthood: get ‘em early, before they know what’s happening.

  At least David wised up. He now has three children and sells insurance.

  3

  Thanks for Everything

  I was in the middle of my third-year rotation in medicine when the boss offered to make me “one of them.” The medicine rotation, or clerkship, was offered at the local Veterans Administration Hospital, more commonly known as the V.A. (Vee-Ay), the Vah, or, more sarcastically, the Vah-spa—although it was hardly spa-like. Nestled behind the university football stadium, the V.A. looked like any 1950s-era federal building: bland and boxy, with smooth, yellow-brick walls tinged with industrial soot.

  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.

  The V.A. holds fond memories for me. For medical students and residents, that musty building was, for all of its problems, a fun house filled with discussions of medical esoterica over cold pizza at three in the morning. A place for poring through hospital charts that stood taller than the patients. A place where a baby-faced third-year student like myself could be introduced as “doctor” without being laughed at. The hours were long, the supervision scant, and the aggravations many; but the daily struggle to provide quality health care to men and women who had served their country was rewarding. With the monolithic government as our common enemy, the V.A. forged personal bonds among the resident corps (also called “house staff”), often lasting a lifetime. Jim, my assigned intern-mentor during the third-year medicine rotation, remains one of my closest friends almost two decades later.