“Look at that guy!” Eric chimed in. “My kid’s pictures don’t get as much attention as his X rays! He’s becoming his pain. It’s part of his identity. He’ll be in pain until it’s time for him to make the horizontal call from a brass-handled phone booth—which won’t be long if he keeps slurping up oral morphine.”
We proceeded down the hallway to room eleven.
“Room eleven,” said Eric. “Mrs. Rubinstein, atypical face pain. Had a microvascular decompression of the fifth cranial nerve three days ago. Still has face pain, same as pre-op. Wound looks good, no headache—thank God for small favors…Husband Ben by her side, as usual.” A microvascular decompression is the act of padding arteries away from the cranial nerves at the base of the brain using small Teflon sponges; it was the first operation I had seen—or at least started to see until Gary plunged the drill into the patient’s cerebellum and made me flee the OR.
The body has twelve pairs of cranial nerves, so named because they exit from the brain itself, not from the spinal cord. The cranial nerves mediate the sensory and motor functions of the head and neck. The first cranial nerves are the olfactory nerves, which convey the sense of smell; the second cranial nerves the optic nerves, which convey the sense of sight; and so on. The fifth cranial nerve conveys sensations from the face. It is also called the trigeminal nerve, from the Greek phrase meaning “three origins,” because the main nerve branches into three divisions: V1 (called vee-one, even though the “V” is meant to be the Roman numeral five, not the letter), which supplies sensation to the forehead and eyes; V2, which supplies the cheeks, upper teeth, and upper lip; and V3, which supplies the jaw, lower teeth, and lower lip. The trigeminal nerve is somewhat rudimentary in humans compared to the nerves of lower animals, such as mice or cats, which have whiskers and depend upon keen facial sensation for their survival.
“Atypical facial pain?” I asked. “Is that like trigeminal neuralgia?”
“No.” Gary answered sharply. “It isn’t anything like trigeminal neuralgia, or tic. People with tic have stabbing pains in one, or perhaps two, divisions of the nerve. The pains are elicited by sensations in the affected area: brushing the teeth, cold air or water hitting the face, chewing. Atypical patients have pain all the time, describing it as burning or aching and not shocklike.”
“Does surgery help this?”
“Judge for yourself.”
Mrs. Rubinstein, an attractive woman of about forty, wore a sexy nightgown and large, dangling gold earrings. The right earring smacked repeatedly against the shaven, sutured wound behind her ear as she turned her head to greet us. A bald man sat in a chair beside her bed.
“Mr. and Mrs. Rubinstein, this is Dr. Vertosick. As of today, he’s a brain surgeon. How’s your face?”
“Awful just ahhhwful.” She had a heavy New York accent—I wasn’t versed enough to tell exactly what part of the city it was from. “What can I say, it’s worse than it was before, I’m telling you. Like grease from a doughnut frier being poured onto my face all of the time. My God, I thought that this was really going to do it for me. Right, Benjamin?” (A vigorous nod from the bald man.) “The people at the Mayo Clinic and Hopkins told me that this was the place to go, but I don’t know. Doughnut grease, I’m telling you, doughnut grease. One Percocet just isn’t holding me. I told you people that I need two every four hours or I’m not fit to live with. When we were at Cornell, they tried to switch me to Motrin, but what a scene I made!”
“Is it still hurting you…all the way to here?” Eric reached over and gently touched the woman’s hairline at the top of her forehead. She winced.
“Yeah, yeah.”
“But not here.” Eric drubbed his index finger in her scalp, just behind the hairline.
“No, not the scalp…just the face hurts. Doughnut grease, scalding doughnut grease. My God, I swear one day I’ll wake up and big strips of scalded skin will peel off on my pillow!”
“Is your pain excruciating?” I asked.
“Definitely.”
Gary’s face became stern. “Well, we’ll see what the boss has to say. Good thing the mister’s here to take care of you, huh?”
“Yeah, he’s such a dear.”
“So long.”
“Doctor?”
“Yes, Mrs. Rubinstein?”
“My Percocet?”
“I’ll have to check with your attending surgeon first; I’m sorry.”
Back into the hallway, Gary started grilling me again.
“Anything funny about her pain?”
“She uses that graphic imagery you were talking about with Mr. van Buren.”
“Uh-huh. But what about the distribution of her pain?”
“It stops at the hairline and doesn’t go into her scalp?”
“Bingo! And where does the distribution of the trigeminal nerve stop?”
“At the vertex of the head, almost back to the occipital area.”
“Bingo again! Society defines the face as being from the hairline down, while the brain considers almost the whole head as the face. Patients with V1 tic have pain extending well into their scalps. I’ve seen patients who haven’t washed or combed their hair on the affected side of their heads for days or weeks because they can’t touch their scalps. Her pain distribution follows a culturally defined area, not an anatomically defined one. Her pain has to be psychiatric in origin.”
“But we did a craniotomy on her,” I observed.
“There is no way to be sure she doesn’t have some component of tic pain,” said Eric. “On the pain service, we have to assume all pain to be real, organic, and that the pain makes people eccentric, not vice versa. In any pain patient, no matter how bizarre the history, may be a kernel of real pain, like a splinter at the bottom of a festering sore.”
“So the pain service doesn’t refuse anybody?”
“No,” answered Gary, “and room twenty-two is a case in point.”
In room twenty-two was a wispy little man in his mid-twenties. He was thin to the point of pathological anorexia, his face covered with blemishes and his hair thinning in random spots. An odd collection of items lined the man’s windowsill, each with a note card taped upon it. Across the top of the window was a large banner that read “Harry Gottlieb’s Museum of Pain.”
After I was introduced, Harry, who had suffered from chronic headaches for year’s, showed me his museum.
“This is the Dodgers cap which used to-take away my pain whenever I wore it. It quit working for some reason. And this…this is the TENS unit they gave me at the pain clinic in Erie. It really didn’t help much at all. I even shaved my head so that the electrode patches would stick better, but that didn’t make any difference. And the patches cost a lot of money, so I quit using it…These are a collection of the pain medications I’ve tried over the past eight years…”
I rummaged through the bottles: Dilaudid, Percocet, Elavil, all the bottles large—and empty.
“Mr. Gottlieb, what’s your headache like?” I asked.
“Like a big railroad spike that some large man is hammering right into the top of my head. And it’s one of those square spikes, not sharp at all. Dull. Pounding right down into the center of my head, right here.”
One of the staff surgeons had recently placed a midbrain stimulator into Mr. Gottlieb. This device is a higher-powered version of the epidural stimulator inserted at the very top of the pain pathways.
“Did your operation help you?” I pointed to the incision on his balding scalp.
“Yes, oh, my yes. The spike feels sharp now, not dull and square, anymore.”
I thanked him for the tour of his “museum” and we went back to our rounds. We left him scurrying about his windowsill, tidying up his Museum of Pain for the next visitors.
I stopped and confronted Gary and Eric before continuing with rounds. “You guys are pulling my leg, right? These can’t be typical patients—the only patient with real pain was that Italian man with the sarcoma.”
Gary stop
ped me. “Let’s be serious. These people have real problems and we shouldn’t make light of them. And we can’t be sure whether they are having pain or not. If someone ever invents an accurate pain-o-m’eter, then that person should get a Nobel Prize. But for now, the only way we judge pain is by what the patient says. These people are feeling some kind of pain, if only psychic pain. They need help; I’m just not sure if they need our help. But there is no way to know for sure, so we give them the benefit of the doubt. If we fail, we send them to the pain clinic, where the anesthesiologists, psychiatrists, and social workers take over.”
We finished rounds. My mind was troubled. When I first started working in our local steel mill, I thought I’d be making steel, but I’d spent all of my time shoveling grease. I’d entered neurosurgery to help people, but these people seemed beyond help. My mother had once suggested that I not go to medical school, that I stay in the factory, since that was as good a job as any. Was she right?
The pain patients made up only half of the service. The other half consisted of ER consults, trauma victims, and the elective patients of the other university neurosurgeons. We were also responsible for the in-house neurosurgical consults, which were sometimes interesting, sometimes tedious.
The university’s medical center had a diverse patient population, bringing problems ranging from spinal pain in a melanoma patient to brain mass in a liver transplant recipient. The most common consults were for mundane complaints—say, benign backaches, or requests for the neurosurgery resident on call to perform a lumbar puncture, or LP. Because neurosurgeons violate the brain’s natural barriers to infection, any postoperative fever in one of our patients may herald a bacterial meningitis. Fever in a post-op head case mandated a lumbar puncture, known to laymen as a “spinal tap,” so that some of the cerebrospinal fluid, or CSF, could be sent for a white cell count, glucose measurement, and bacteriological cultures. When we were busy, I would do ten to twelve LPs a day. Medical residents, in comparison, might do ten or twelve a year, while other specialties may do less than that in a career. By virtue of our experience and availability, we were the LP mavens of the health center.
The procedure consists of turning a patient on his or her side, numbing a small patch of skin in the middle of the lower back, and plunging a six-inch-long needle into the spinal canal. (It’s best not to show the needle to the patient, I have discovered.) The fluid is left to drip into sterile plastic containers, like maple sap from a tree.
In younger patients, a spinal tap can be trivially easy. Not so in the aged. As we grow older, the small openings in our spines—tiny windows between the vertebral laminae which permit the entrance of the LP needle—are slowly occluded by the advancing bone spurs of degenerative arthritis. This makes LP’s very difficult affairs in elderly patients, sometimes requiring many minutes of blind probing with the needle before a portal into the spine can be located. One patient suggested that a divining rod might be useful, to point the way to watery paydirt.
More often than not, the failed LP was a result of inexperience, of a medical student or an intern’s sticking the needle far off the mark. Patients will tolerate only so much amateur prospecting in their bones and nerves before they order the procedure abandoned. But if meningitis is suspected, there is no waiting for tomorrow: the test must be done immediately. When the medical interns cannot obtain a successful LP, neurosurgery is called to save the day. This was not a pleasant assignment. We frequently had to try again in a hornet-mad patient whose back looked like a sprinkler head. Ah, but the sweet pleasure of passing the needle effortlessly into a ravaged spine in seconds, when other doctors had tried for an hour or more! All I needed was a ten-gallon hat and I was off into the sunset. Shucks, ma’am, ‘twern’t nothin’!
This dire need to obtain spinal fluid in a case of suspected meningitis illustrates how the physician’s job, particularly a surgeon’s, differs from most others. In medicine, results count, not effort. Get spinal fluid. That’s all, just get it. And soon. Nobody cares how tired you are, or how much the patient bitched, or how the hospital didn’t have a long enough spinal needle, or that the patient was a thousand years old or weighed a thousand pounds. Nobody cares that your technique was correct. Just get spinal fluid. Use fluoroscopy. Sit the patient up.’ Stand him on his head. Give him Valium. Do what it takes; just do it. His life may well depend upon success.
My last physics course as an undergraduate was Mathematical Methods in Physics. On the first day of class, the professor informed us that there would be only one test, the final exam, and that it would consist of only one problem. He wanted only the answer to that problem, accurate to four decimal places, written on a scrap of paper above our name. If we were correct to all four decimal places, we’d get an A. If not, we’d fail. Simple. There were immediate howls of protest from myself and others. One test? One answer? Didn’t he even want to know how we set up the problem? If we even knew what we were doing?
“No,” he replied. “Welcome to the real world, where people only want answers—correct, accurate answers. If a bridge collapses and kills forty people, who do you think cares whether the engineers set up the problem correctly? In life, there is no partial credit for being half right. If you want to accomplish anything important, you have to be totally right—and be willing to take the consequences if you are not.”
As the professor argued, all real-world occupations require a certain level of performance. The physician’s performance must be perfect, however, and it must be perfect right now. In a lifetime, a surgeon performs thousands of operations and makes hundreds of thousands of decisions regarding medications, antibiotics, when to operate, when not to operate. Complicating matters is the fact that these decisions often must be made quickly and with incomplete information. Call a lawyer at three in the morning and ask to have a coherent defense strategy laid out right now! Wake an airline pilot from a dead sleep and expect him to pull the plane out of a nose dive right now! Take a car to a mechanic and say fix it right now—not a day from now, or an hour from now.
One night I was summoned for an emergency LP on a young man from the medical service, admitted that day in a stuporous condition and now nearly comatose. His brain CT showed nothing unusual. He had a slight fever and a stiff neck, and the diagnosis of bacterial meningitis had to be ruled out. Both the intern and the resident on the house medical service had tried to get spinal fluid and had no luck. They called for the radiologist to do the procedure under fluoroscopy, but she refused to come in from home until I had given it my best shot. She paged me to ask if I could spare her a night trip to the hospital, as her daughter wasn’t feeling well.
There was the usual bedside scene: a naked man on his side in a fetal pose, his back purple from failed LP attempts, brown prep solution staining the sheets and floor. A dozen blood-soaked gauze sponges littered the bed, the wreckage of a prepackaged LP tray strewn across the patient’s nightstand.
The man was very tan, even in places that shouldn’t be tan, and he had short, bleached-blond hair. Gold chains adorned his neck and right ankle. He had an excellent physique.
“Is he awake?” I asked. “Any sign of trauma?”
“He moans; that’s about it,” replied the medical intern, still wearing her bloodstained latex gloves. “And no, no sign of trauma.”
“He sure looks healthy for a sick guy…What’s the name?”
“Roger Doe.”
“Roger Doe? Any relation to John?”
“Everybody who comes to the ER without ID is called Doe. They rotate first names to keep the record room from being clogged with John Does. We’re up to the R’s already.”
“No kidding! Like naming hurricanes. What’s wrong with him?” I asked as I pulled on gloves and began to probe the mauled back in search of a virgin interspace. I immediately detected the error of the intern’s failed attempts: she was far too low and had been skewering the hard sacrum, or tailbone. Nothing but blood there.
“He came in like this, found unres
ponsive on the street and brought in by the police from downtown,” the intern continued. “He was probably robbed after he collapsed, since he had no wallet or other ID, even though he was dressed pretty well. He’s not a street person, that’s for sure. No sign of a beating or any struggle. The cops took a few quick fingerprints and we might have some idea of who he is by tomorrow. He has a low white count, and some big cervical lymph nodes. A few in the axilla and groin as well. It’s like mono, or cat scratch fever, maybe.”
“Cat scratch fever? When does cat scratch fever make you comatose?”
“We don’t have the toxicology back yet. His alcohol level is zero, but he may have barbiturates or heroin on board.”
“Did you give him Narcan?” Narcan is the antidote for narcotic overdoses.
“Yeah, but that didn’t do anything.”
“Sort of rules out heroin…Here, here we go!” I pushed the needle forward and clear, watery fluid began to drip out. As I was switching collection tubes, the fluid splashed onto my face and eyes. I brushed it away with my coat sleeve. “This fluid looks pretty clear to me. No meningitis here.”
“Thanks much, er”—she glanced quickly at my name tag—“Frank.”
“No problem…(Try learning where the lumbar spine is next time)…Anytime at all. I’d get a stat gram stain on this stuff, anyway. He ain’t like this for no reason. Maybe he has the Black Plague…maybe those groin nodes are really buboes.” The intern blanched a bit. I was only half joking, since bubonic plague still exists in some parts of the country and, for the moment, we had no idea who Roger Doe was or where he called home.
I went back to my evening scut chores and forgot about the LP. Two hours later, the medical intern paged me with a curious bit of news.
“The Gram’s stain,” she said, referring to the microscopic examination of the fluid, “found many organisms resembling Listeria monocytogenes.”
“What the hell is that? I’m a surgeon, remember?”
When the Air Hits Your Brain: Tales from Neurosurgery Page 7