When the Air Hits Your Brain: Tales from Neurosurgery

by Vertosick, Frank, Jr.

  The public uses the word “medicine” in the generic sense to encompass all aspects of health care, from dermatology to orthopedic surgery to pediatrics. To the layperson, anyone with an M.D. is “in medicine.” To a physician, a person “in medicine” is an internist—as opposed to a surgeon, radiologist, or psychiatrist. Internal medicine residencies train physicians to handle the nonsurgical health problems of adults, such as diabetes, hypertension, and pneumonia.

  During those crucial nine weeks at the V.A., I learned many of the minor technical aspects of being a physician: drawing blood, looking at X rays, interpreting electrocardiograms, writing orders. I hungered for this experience. The neurosurgery elective hadn’t afforded any opportunity to do much beyond yanking stitches and percussing chests. The medicine rotation introduced me to the awesome authority invested in physicians: the power to violate another human being—legally. License to stick our gloved fingers into the rectums of humanity, to jam needles into spines, to thread garden hoses into colons.

  I first tasted this intoxicating authority in my second week at the V.A. Jim, my intern, handed me a nasogastric tube, together with a foil packet of K-Y jelly, and told me to insert the plastic snake into one of his cirrhosis patients in the big ward. The patient, nauseated from a bowel impaction, needed the tube to decompress his stomach and make him more comfortable (if having a half-inch tube in your nose is more comfortable than minor queasiness).

  “You’ve seen me do it a dozen times,” Jim reassured me as he dashed off to morning report. “Just stick it up his nose until you see it in the back of his mouth, then tell him to swallow…When he does, just feed it in quickly. After about” two feet are in, blow some air into the tube with a fifty-cc syringe and listen for the bubbles in his stomach with a stethoscope. That way you know you’re in his stomach and not his right bronchus.”

  I nodded and went to the ward, my heart pounding and palms sweating. The V.A. still gets away with putting ten to twenty patients into a single large ward with beds separated by flimsy curtains. Private hospitals, on the other hand, typically allow only two patients in a room, and many newer hospitals have only single rooms. At the V.A., however, the older veterans preferred the companionship of the ward and demanded to be put there, so there were few complaints.

  I found my target propped up in his bed, his abdomen distended and a blue emesis basin in his hand. An elderly, rotund man with a bulbous nose and rosy cheeks sprinkled with thin, spidery veins, he smiled cordially. We talked for a bit; he had a soft trace of a southern accent, betraying his boyhood in Georgia. He rambled on about his experiences in World War II, when he was a bomber pilot flying missions over Berlin. Lifting his gnarled hand, he offered up a steel ring adorned with tiny wings as proof of his exploits, as if he knew that his bloated appearance was too removed from the trim, leatherjacketed aviator for anyone to believe him. Alas, almost forty years had passed since Berlin, and the war hero was now a retired peach farmer with a bum liver.

  The tube insertion went badly. I couldn’t get the damned thing up his right nostril. I tried the left nostril. That didn’t work either, so I went back to the right side again. By this time the left nostril was bleeding profusely, rivulets of blood running down the patient’s face into his mouth and onto his green pajamas.

  The tube finally slithered up the nose and down the farmer’s throat. Before I could say “Swallow,” he gagged violently and vomited on both of us. The far end of the tube flew out of his mouth, even as the other end remained jutting from his nose. Horrified, I harshly yanked out the tube, as if I were trying to pull-start an outboard motor in his sinuses. He yelped—and then his right nostril started to bleed as well. I fetched paper towels from a nearby sink, wetted them, and spent ten minutes stanching the bleeding and cleaning him up as best I could.

  “I’m terribly sorry; we’ll try this again later,” I apologized weakly, fearing his well-deserved anger at my incompetence.

  But he just sniffled and smiled. “OK, Doc…thanks for everything.”

  After almost running from the ward, I stood in the hallway to compose myself. What had just happened to this man? A total stranger had walked up to him and rammed a weapon up his nose until he was bleeding like Old Faithful, halting the torture only after he had blown lunch all over himself in full view of six other patients on the ward. On the street, this would not be called a medical procedure, but assault and battery—with witnesses, no less! And, amazingly enough, he was thankful. Thankful! For “everything.”

  I glanced down at my white coat. This could not be ordinary clothing, I thought, it must be some sorcerer’s cloak, this white linen, my only credential. It had not only shielded me from the ire of this combat veteran, but inspired his gratitude as well.

  In the years that followed, I would do worse things to a human body than make it puke or give it a bloody nose—a lot worse. Nevertheless, another milestone had passed. As I threw away the nasogastric tube caked with bloody jelly, I felt the first inkling of what being a doctor involved. The intoxicant of power.

  I wasn’t sure I liked it.

  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.

  Every hospital has its own method of announcing a cardiac arrest in progress. “Code blue” is a popular prime-time choice, but our hospitals used “Condition A,” “Blue alert,” or “Calling Dr. White.” The operator’s disembodied voice cried from every speaker: “Calling Dr. White, room 4835,” and the code team dashed madly to room 4835, life support equipment in tow.

  These encrypted messages supposedly avoided panicking the patient’s relatives (even when they should panic). “Dr. White” is being asked to go to room 4835—no big deal.

  In reality, euphemisms such as “Calling Dr. White” did little to alleviate public distress. Imagine the bustling lunchtime cafeteria of a busy urban hospital. The operator, who has been calmly reciting phone pages for the past hour (“Dr. Nelson, call extension 5545…Dr. Rosenbloom, call the emergency room, please…”) suddenly screams, “CALLING DR. WHITE, OUTPATIENT SURGERY” three times in quick succession, causing a dozen doctors to drop their forks mid-mouthful, bolt their lunch trays, and run away clutching metal boxes full of equipment.

  The “Dr. White” phrase had one comical side effect. In the university hospital one morning, we had five “Dr. Whites” called in less than three hours. We thought the worst had passed when a sixth “Dr. White” directed us to a private room on the ninth floor. Rushing to the room, we found a very aged but otherwise quite robust-looking gentleman reading the Wall Street Journal and sipping coffee.

  “Who called a cardiac arrest here?” angrily demanded the senior medical resident on the resuscitation team.

  “I didn’t call any cardiac arrest, young man; I simply asked the operator to send Dr. White to my room. My own internist isn’t worth a damn and people have been calling for this Dr. White character all morning. I felt he must be pretty damned good if he’s in so much demand.”

  Thankfully, the V.A. had no public-address system. The operator merely summoned the designated arrest team through their beepers. As a third-year student on the medicine rotation, I was assigned to the arrest team for the evening every other night. The team consisted of the senior medical resident, Kate; my intern, Jim; a fourth-year student, Pam; and me. At least once a night we answered the call of our whining arrest beepers
. We would run a dozen flights of stairs to the designated location and arrive to find some unfortunate soul who had, in euphemistic hospital lingo, CTB’d, or “ceased to breathe.” The poor souls always had a damned good reason for “ceasing to breathe,” like being riddled with cancer or being older than the Appalachians, but we were called anyway.

  Before proceeding with resuscitation, Kate would glance through her sign-out sheet to see which patients were marked with the letters DNR—do not resuscitate. At that time, living wills and frank discussions with patients about life support were much less common than they have become in recent years, and so we had to initiate some effort to revive a hopeless case. The floor nurses wheeled in the big red “crash cart” containing the defibrillator and drugs, I would hook up the EKG monitor, Pam would draw blood, and Kate would place an endotracheal tube. The three junior people took turns “bagging” oxygen into the patient’s lungs with a big green balloon, the Ambu bag, while Kate barked out commands. We conned one of the orderlies or respiratory therapists into doing the exhausting manual chest compressions, which are supposed to squeeze blood from the motionless heart.

  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.

  What about all those near-death experiences? The shining light and all that? The heroism medals given for the quickthinking Boy Scout with the CPR badge who saves the collapsed woman in the street? Unfortunately, many of these “resuscitations” are people who never had a cardiac arrest in the first place. When someone faints in hot weather, for example, the pulse temporarily slows so that even experienced paramedics can be fooled into thinking the heart has stopped cold. I once started chest compressions on a very obese woman who—or so I was told—had stopped breathing. She was so overweight that no one could feel a pulse anywhere in her body. I straddled her large abdomen with my legs and started heaving into her sternum with both hands. She awakened with a start and asked me exactly what I thought I was doing. Red-faced, I replied, “Would you believe saving your life?”

  In the little spare time during the third year of medical school, I did a small research project in the immunology laboratory, studying how white cells migrated from tiny droplets of agarose. Agarose is a clear gelatin extracted from seaweed. A suspension of blood cells was mixed with warm agarose and deposited in little droplets onto a petri dish. The droplets, so small that their deposition required a low-power microscope, required great practice to get right.

  Martha, a lab technician from England, taught me the delicate method of depositing the droplets. During the first few tries it became obvious that my hands trembled slightly under the microscope. Although I had no tremor to the unaided eye, the magnified image under the microscope revealed subtle finger gyrations which made it difficult to deposit a nicely rounded droplet. Martha’s hands were rock steady, and she quickly grew impatient with me.

  “Why are you so nervous, my dear?” she asked bluntly.

  “I’m not nervous! Why should I be nervous about making silly little drops on a petri dish?” After all, I thought secretly, I have tormented people with nasogastric tubes!

  “They are not silly,” Martha snorted indignantly. “We’re studying what causes multiple sclerosis and there isn’t anything silly about that at all. No sir, not at all.” Her British accent grew thicker when she was angry and I sometimes enjoyed tormenting her just to hear her lapse into BBC speech.

  “Well…I must have had too much coffee or something…that’s all it is. We’ll try again later.”

  She looked up from the microscope and peered at me skeptically with her green eyes. “All right, later then. You’re not planning to be a brain surgeon with those hands are you, old man?”

  This comment cut me to the bone, as if she could read my mind. I laughed nervously without making a reply.

  When she had gone to another room, I played with the microsyringe, trying to steady my hands. After an hour of practice, I finally made a few decent droplets. It was the coffee, after all.

  But Martha’s parting words reverberated in my head. She didn’t know what she was talking about! I could be anything in medicine I wanted to be. Even a brain surgeon! But how would I know that? There was only one way. I picked up the phone and called the neurosurgery office.

  Yes, I would become “one of them.”

  4

  A Night in the Street, a Night in the Chair

  The clinical rotations of my final years of medical school passed quickly—except for psychiatry, which I found tedious. The patients were interesting, but the clinical pace was too slow for me. Assigned to the affective disorders unit, or ADU, I spent my six-week tour of duty in the university psychiatric institute. The ADU housed patients with severe disturbances of affect (psychiatry’s term for mood). The ADU population consisted mostly of middle-aged women with major depression and young men with uncontrolled mania.

  The ADU population harbored a fair number of schizophrenic patients as well. Schizophrenia isn’t really a mood disorder—it’s a thought disorder, or psychosis. But the institute had a limited number of beds on locked wards, and the ubiquitous schizophrenics were quartered in any empty beds.

  Closet psychiatrists lurk everywhere, anxious to render armchair analyses of coworkers and friends. The workaholic in marketing, he’s manic. Margaret next door sank into depression when her daughter went away to school. And John down the street—he’s schizophrenic, totally bonkers. Amateurs toss these diagnoses about with no insight into their true manifestations. After encountering my first bona fide depressed, manic, and schizophrenic patients, the magnitude of their mood changes and aberrant behaviors shocked me.

  Is that man in marketing manic simply because he’s the first one into the office and the last out? How about a housing contractor I encountered who read the Bible, rode an exercise bike, dictated a letter to his secretary, and expounded on the dangers of having too many Jews in government—all at the same time?

  Is the homemaker next door clinically depressed because she gets teary-eyed every morning looking at the photo of her daughter boarding a bus for college? How about a grandmother of three I saw, who spent eighteen hours a day sitting on her haunches, banging her head on the floor and repeating “God, kill me now” over and over again?

  And the oddball down the street—is he schizophrenic because he wears black socks with white tennis shoes and talks to his tuberous begonias? How about a nurse’s aide who plunged a bread-knife into her vagina and partially cut away her own uterus because Satan told her that Julius Caeser’s baby was in there?

  Of all the illnesses I witnessed at the institute, the most fascinating was schizophrenia, a cruel and enigmatic disease which robs us of our most human quality: our reason. The word derives from the Greek for “split mind,” and many still confuse schizophrenia with the very rare condition known as split, or multiple, personality disorder. Ironically, a schizophrenic barely posesses one complete personality, let alone two or more. Although many subclasses of the disorder exist, they all share common characteristics: apathy, deranged thought processes, the tendency to leap chaotically from topic to topic during a conversation (flight of ideas), feelings of persecution, and, finally, hallucinations—both auditory and visual (although the former are more common).

  Schizophrenia stems from an imbalance in the brain chemical dopamine, the same chemical involved in the movement disorder Parkinson’s disease. Prior
to the introduction in 1952 of chlorpromazine, which normalizes the dopamine balance in schizophrenic brains, treatments of the disease ranged from the merely inane (dunking the patients in ice water) to the dangerous (lobotomy). Although a family of effective chlorpromazine-like drugs, known as antipsychotics, has been developed over the past forty years, the treatment of schizophrenia remains imperfect. Many patients become resistant to the medication, refuse to take it, or develop a Parkinson-like disability as a permanent side effect.

  Some believe that schizophrenia is a modern illness, since ancient historians don’t mention it. Others contend that earlier societies ignored schizophrenics—or treated them as possessed. How could such a dramatic syndrome be ignored, discounted into nonexistence?

  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 believeable.

  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.