Maggie grabbed my arm. Disoriented, I jumped from the chair and to B.G.’s bed. Empty. The heat lamps dark. Looking again at the clock, I realized that I had been asleep for over two hours! Panic overcame me. What had I slept through? They had been counting on me.
Maggie chuckled at my frenzy. “Relax.”
“Where’s the baby? Did she go back to the OR?”
“No, I shut off her ventilator an hour ago. She’s in the morgue. Actually, her parents wanted her shut off last night before I left, but I forgot.”
“In the morgue? You forgot what? What do you mean, they wanted her shut off last night?” I was confused, furious.
“Hartley met with them after surgery. You see, we couldn’t repair the right ventricle. All we could do was enlarge it with a Teflon patch, but Teflon doesn’t pump blood, you know. We knew she was a goner when she left the table. The family was very reasonable—the mother’s an ER nurse across town—they couldn’t see prolonging things and they gave us the okay to halt support. I just figured we could wait until morning to do the deed.”
“Why didn’t you tell me all this last night? Why did you let me sit in this fucking chair all night thinking I was making some baby’s fingers drop off?”
Maggie’s smirk vanished. “Your night wasn’t such a waste, was it? You learned how to resuscitate a baby, how to face crisis, what drugs to use and what problems they can cause. I bet you won’t forget the doses of those drugs for a while, either. They are burned into your brain. You did a good job. Not many people can keep a Teflon heart beating for ten hours. Now I know I can count on you to handle a baby with a real chance of living.”
“You could have told me that she was a goner—I was crapping in my drawers.”
“No. Then you wouldn’t have been under the gun. Pressure’s part of the deal. Anybody can sing in the shower, but how many can sing in front of an audience, huh? Pressure makes all the difference in the world.”
* * *
* See William T. Carpenter Jr., and Robert W. Buchanan’s excellent review article, “Schizophrenia,” in The New England Journal of Medicine 330 (1994): 681-90.
5
The Museum of Pain
Pleasure is oft a visitant; but pain clings cruelly to us.
—JOHN KEATS
Pain is the price we pay for mobility. Since the dawn of life creatures have segregated into two camps: motionless foodmakers and migrating food foragers. Creatures in the first camp learned to draw energy from their immediate environments. Plants turn chloroplasts to the sun and use photosynthesis to manufacture glucose, while deep-sea creatures harness heat arising from thermal vents on the ocean floor.
Creatures in the second camp sprouted tails, legs, fins, and wings and set off to eat the food makers, or each other. Lacking a clever trick like photosynthesis, the food foragers came up with a new invention: the nervous system. To say that the nervous system evolved so that animals could sense and respond to their surroundings is only partly correct. Anything alive, brainy or not, must be able to sense and respond to its surroundings. Bacteria “know” when the ambient moisture is too low, and form into spores which are more resistant to drying. A tree senses when autumn comes and jettisons its leaves as the sunlight fades.
But these responses are relatively simple and slow, taking hours, days, even weeks to complete. Moreover, no-brain creatures such as trees and bacteria have only tiny repertoires of stereotyped responses. The tree adapts to the seasons but, having no place to run, falls victim to sudden, life-threatening events—forest fire, bark-eating deer, beavers’ incisors. As compensation for this helplessness, nature blessed the mindless tree with ignorant bliss. The oak feels no pain from the lumberjack’s saw. The pine does not cry out in agony as lightning bursts its trunk asunder.
Animals, constantly at odds with a changing environment or with other animals, could not survive with the tree’s small number of adaptive mechanisms. Peripatetic organisms need complex responses which can be customized in milliseconds—they need a nervous system. Although sensation and adaptation can occur in the absence of brain tissue, these skills are elevated to a new level of speed and diversity by an organ system devoted solely to cognition. The primordial ganglion protobrains became the digital computers of biology, leaving the abacuslike reasoning of the plant kingdom in the dust.
As always, there was a terrible price to pay for this new technology. Animals dependent for survival upon the complex software of nerve cells and the delicate clockwork of churning limbs are very vulnerable to injury. Yes, the big stupid tree doesn’t know enough to run away from fire—but it can lose over half its branches and live. A squirrel with one broken leg is as good as dead. In the natural world, where any breach of the skin can mean infection and death, an animal must stay out of harm’s way. Like the earliest computers, the earliest brains were pretty dim. The only way to keep animals equipped with “first generation” brain hardware out of trouble was through aversion: dangerous things became painful things. Pain became the taskmaster of the animal world.
Unfortunately, the blossoming of our magnificent forebrains did not free us from the bondage of animal pain. We are now smart enough to learn abstractly that fire hurts without having to experience it firsthand, yet we still endure the agony of burns. The pain pathways that torment us with toothaches, menstrual cramps, and bee stings have progressed little from the days of the walnut-brained stegosaurus writhing in a predator’s jaws. The continuing need for pain in humans no doubt derives from the stupidity of young children, who, as any parent can attest, feel compelled to seek what does and does not hurt for themselves.
The pain pathways have no “off” switch. Pain lingers long after its biological usefulness has passed. Although a pain alerting us to the presence of curable cancer is a valuable torment, cancer pain doesn’t have the merciful sense to cease after the cancer has spread to a terminal stage. The nervous system does possess two means of limiting pain perception: chemicals known as endorphins and a spinal-cord switching mechanism called “gating.” They are far from perfect in their natural state but can be augmented with the help of medical technology.
Endorphins, natural substances related to morphine, are released in times of stress. Like morphine they are very good for acute, severe pain, but not so effective for mild or chronic pain. Endorphins evolved so that wounded animals could function, at least for a short while. Example: a doe, mortally wounded by a car, ignores the pain and crawls away in search of her fawn. Endorphins permit a running back to keep chugging for the goal line oblivious to the fact that his arm was broken on the line of scrimmage.
Endorphins also perform a true mercy service, anesthetizing an animal trapped by a carnivore. Those people who have survived being caught in the jaws of lions or grizzly bears speak of the warm, insensate calm that flowed through them as they succumbed to being eaten alive.
The gating phenomenon is a second mechanism for blunting painful sensations. The spinal cord is like a collection of railway tracks: sensations ascend within it like freight trains running on those tracks. Each sensory modality (pain, temperature, fine touch, heavy pressure) is like freight carried to the brain on separate trains. Access to the brain is limited, however. Only so many trains enter at once, only so much freight is unloaded into our consciousness. When one sensation is dominant, the others are blocked, “gated.”
The gating mechanism occurs with the other senses as well. If, as we are listening to one conversation at a cocktail party, we are then engaged in another, the voices in the original conversation fade into the background. Likewise, we find it difficult to smell two strong odors at once. Many commercial products operate on the gating principle. Bathroom deodorizers don’t remove foul odors; they gate them from our brains by superimposing a stronger, more pleasant odor. Noise “masking” devices for airplane travelers gate out the annoying whine of an airplane engine with a more soothing white noise.
Pain can be gated from the brain by superimposing another sensati
on. If we scald a hand with hot water, we immediately rub the burned area. We are inately seeking to gate the pain out, to prevent the pain train from pulling into the brain station. Pain gating is the mechanism behind the old coaching aphorism “Walk it off.” Migraine sufferers knead their temples; sufferers of leg cramps knead their calves. Gating underlies the effectiveness of massage, ice packs, heating pads, liniments, and acupuncture. Attempts to gate pain can be taken to perverse extremes. Napoleon, troubled in his later years by kidney stones, routinely burned himself with a candle to divert his attention from abdominal pain.
Neurosurgeons deal in pain on a daily basis. Pain in the head, pain in the face, pain in the arms, pain in the legs, pain in the neck, pain in the back—all, essentially, a pain in the ass for patient and doctor alike. Over two-thirds of all neurosurgical operations are for pain control—or, more properly, the alleviation of suffering.
There is a profound difference between pain and suffering. All animals feel pain. Only humans suffer. Pain is a physical sensation; suffering is an emotional state induced by pain. Suffering is pain coupled with uncertainty, depression, frustration, anger, fear, despair. We can have intense pain but not suffer. A stubbed toe, a shin whacked against a coffee table, a softball to the groin, a paper cut, a mouth ulcer—all may elicit extreme pain with little suffering. We know these pains are temporary. We know that they will go away and that they bode no longterm ill for our bodies.
But what of a woman who thinks she is cured of her breast cancer and then develops a minor backache? Her mind is troubled. Is it the cancer again? Until she finds out, she will suffer greatly. That small backache will become like a nail driven into her spine until she knows what it signifies. When told that all the tests are negative for cancer, she feels better instantly. No pain medications could accomplish this. The pain is the same, but the suffering is eased. In a sense, suffering is pain augmented by a bleak imagination. We construct dismal scenarios for our unexplained miseries: That toothache must mean a root canal; that hand stiffness is rheumatoid arthritis; that heartburn could be coronary artery disease.
Hippocrates once said that the chief function of medicine is to entertain patients until they heal themselves. On the pain service, we didn’t entertain our patients; far from it. We took their pain away as best we could.
Of course, sometimes we had to poke holes in their heads to do it.
The very first morning of my residency, Gary and Eric took me to the neurology floor and introduced me to some of the pain patients on the service. I had little previous experience with the pain service. At the time of my medical student rotation, there were relatively few pain service patients in the hospital. I had avoided even that handful, concentrating instead on the more “interesting” cases like brain abscesses, pituitary tumors, and carotid aneurysms. A medical student can get away with ignoring tedious problems in favor of more challenging ones. But residency was different. Medical school is five parts learning to one part servitude; the ratio is reversed in residency.
We halted at room nine, a private room.
“Room nine,” Eric whispered, “Mr. van Buren. Status postfive laminectomies for ruptured lumbar discs. He’s from Boston, runs an investment company or something. He has chronic right leg pain and has been on oral morphine for the last six months. We put in an epidural spinal cord stimulator yesterday and externalized it. The guy’s now playing with it to see if any of the settings make his pain go away. If not, we yank it. If it does, we internalize it to an antenna and send him to a detox unit.”
Gary explained that the spinal stimulator’s gate mechanism permits pain to be masked by a simultaneous sensation, such as touching or rubbing. Not surprisingly, people with chronic sciatica find it impractical to go around rubbing their legs all day. To exploit the gate mechanism, devices which continuously stimulate the touch nerves have been marketed. The simplest is the transepidermal nerve stimulator, or TENS unit, which consists of surface electrodes taped to the skin and hooked to a portable battery supply. The TENS unit provides a gentle “buzz” to the affected skin, akin to the low-level shock felt when touching the transformer of a toy electric train set. In patients with “failed back syndrome,” or FBS, severe leg pain from a damaged spinal nerve lingers even after one or more “successful” operations to remove a ruptured back disc. Many FBS sufferers can get by with a TENS unit attached to their affected leg all day.
Eventually the TENS unit fails, though, and more masking stimulation is needed. To accomplish this, a thin electrode is threaded under the skin, between the vertebrae and directly over the spinal cord, into an area known as the spinal epidural space (the same area anesthetized during labor and delivery). The electrode is initially brought out through the skin and hooked to a compact control box to allow the patient to experiment with different spinal stimulation settings. If the patient gets relief, he or she is returned to the OR and the electrode is put under the skin and connected to a subcutaneous antenna. The stimulator is then completely internalized and safe from infection. Stimulating signals are broadcast to the spinal cord electrode via a radio transmitter hooked to the belt or worn over the shoulder like a purse.
We entered the room. Mr. van Buren, dressed in expensivelooking pajamas, sat in a chair by his bed. He was a large man with a pleasant, ruddy face and coarse black hair cropped short, almost in a crew cut. On his lap lay a small beige box, the size of a pack of cigarettes, with several buttons and dials on one side. Two thin wires sprouted from the top of the box and disappeared into the front of his pajama top. He looked to be deep in concentration as his thick fingers twiddled the knobs on the box.
“Good morning, Mr. van Buren. Have you had any luck?” asked Gary in his best professional tone.
“I can get it to buzz a little around my butt cheeks when I use the square wave pulse and turn the frequency to…here.”
“Does that help?”
“A little, but it feels like my pants are warm, like I’m pissing myself all the time. I’m not sure that’s any better than the pain.”
“Mr. van Buren, this is Dr. Vertosick,” Eric spoke, “and he’s joining our team for the next six months. You’ll be seeing him every morning now.”
The man looked up from his box and smiled politely.
“Nice to meet you, Doctor.”
“I understand you have had five disc surgeries?”
“Yes…the first was in 1974…but here, let me show you.”
The man reached over to his nightstand, opened the top drawer, and produced a leather-bound folder with the words “Myelograms and records of A. van Buren” stenciled on the front cover in gold leaf. “Have a seat, Dr. Ferblowstick.”
He proceeded to explain the saga of his many operations in great detail, turning the pages with the slow intensity of a newlywed showing off a wedding album. “Look, here was right after the second operation…there was a little scarring around the fifth lumbar root, but no arachnoiditis yet…My surgeon thought that this might be a disc fragment here, and he looked again in 1981…Here the arachnoiditis got bad…”
Among the photos of myelograms and CT scans and operative notes were other memorabilia: labels from bottles of narcotics, letters containing second surgical opinions, insurance forms, articles on holistic healing and the power of positive thinking. He grew more excited as he spoke, spouting his tale of vertebral vivisection at the hands of three surgeons with as much glee as a fisherman recounting his battle with a prize marlin. He didn’t seem to be in any pain at all.
“Mr. van Buren,” Gary interrupted him, “tell Dr. Vertosick what your pain is like now.”
“Oh,” he replied, still grinning, “it’s awful, excruciating. It’s like an army of red-hot earthworms crawling up inside my leg, wriggling and writhing day in and day out. Occasionally, I get a groin pain, over here, that’s like a C-clamp being slowed twisted down on my pubic bone.”
“Thanks, we’ll see you this afternoon…try turning the amplitude down and the frequency up. If t
hat doesn’t work, we may have to take you back to the OR and reposition the electrode.”
We exited the room and walked a little way down the hall. When we were far enough away from room nine, Gary spoke: “Well, class, what did Mr. van Buren teach us?”
“Ah, that the electrode…”
“Forget the friggin’ electrode. Is this guy in pain?”
I was confused.
“Is he in pain?”
“I guess so?”
Gary motioned me over to another room, room eighteen. Lying in the bed was a pale, wasted man. “Hey, Mr. Angelo, it’s Gary. Tell young Dr. Vertosick what your leg pain is like.”
“I dunno.” The man’s voice was thin, weak. “It hurts like hell is all I can say. Right about here. Real sore.”
“Thanks, Mr. Angelo.” We darted back into the hallway again.
“Mr. Angelo has a malignant sarcoma eating into his lower back and right lumbar plexus,” Gary continued, “and he’s in agony. Does he say he has goddamned electric earthworms in his leg or some such shit like that? No. He says ‘I’m real sore.’ He also uses about one-tenth the morphine that room nine uses. Why? Because he has legitimate pain and he isn’t nuts. Another rule of thumb: The more bizarre the description of the pain, the more likely it is to be a psychiatric delusion. Phrases like ‘I have little gnomes with branding irons running all over my face’ or ‘The hooves of a thousand angry horses are thundering in my head’ should immediately make you suspicious that something else is going on. People with real pain don’t say ‘excruciating.’ The word ‘excruciating’ literally means to feel the pain of crucifixation. Since hardly anybody knows what it’s like to be crucified anymore, no one is entitled to use that word, in my humble opinion.”
When the Air Hits Your Brain: Tales from Neurosurgery Page 6