Suddenly, a burst of frantic activity aroused me. Filipiano barked for a larger suction and the nurse-anesthetist pushed her alarm button to summon her staff anesthesiologist to the room. I looked at the monitor. The wound had turned red; the vertebral was gone and the cerebellum was now bathed with pulsatile waves of blood. Gary had slipped and plunged the sharp point of an arachnoid knife into the aneurysm dome.
Gary placed his suction deep into the wound. “Shit, oh shit…,” he moaned. The feeble microsuction did nothing to clear the field as bright blood gurgled audibly from the cranial wound and ran in angulated streams over the drapes.
“Do you want us to take his blood pressure down?” asked the nurse-anesthetist. Lowering the blood pressure with medication sometimes slowed the bleeding.
“No!” Filipiano responded sternly. “We need to temporary-clip and he’ll need his blood pressure up. Just hang some blood, hang it now.”
Working awkwardly from the assistant’s chair, Filipiano jammed a giant glass-tipped suction into the wound and instantly the clear tubing filled with Andy’s blood. On the monitor, I could see the large suction diverting the spewing column of blood sufficiently to see the vertebral artery once again. Gary remained frozen in the surgeon’s chair, still clutching the useless microsuction.
“Give me a fifteen-millimeter straight temporary clip right away, now.” Filipiano reached out with his right hand without looking away from the scope’s eyepieces. The scrub nurse placed a long forceps bearing the open clip into his hand and gently guided it into the microscope’s field of view. He swiftly placed the clip blades around the vessel and squeezed the clip shut. As dramatically as it had begun, the bleeding stopped. The staff surgeon quickly motioned for Gary to vacate the operator’s chair.
“Call me the time, in minutes,” Filipiano said to the anesthesiologist, who had just entered the room, “and load with barbiturates.” The blood flow to Andy’s brain was now ceased. The clock was running on his life. Filipiano had but a few minutes to repair the hole Gary had torn in the aneurysm’s dome, or Andy would die. The barbiturates would protect Andy’s brain somewhat, perhaps give them an extra few minutes.
The surgeon swiftly suctioned away the thick, fresh clot from around the now-collapsed aneurysm sac.
“One minute of clip time.”
Working with reckless desperation, Filipiano tugged and pulled at the sac, peeling it away from the remaining adhesions. He was doing in seconds what would take thirty minutes or longer under more controlled conditions. Such vigorous tugging on the aneurysm ran the risk of ripping it completely away from the vertebral artery, leaving a gaping hole that could not be repaired. Finally, he was able to see the aneurysm’s neck, where he could place a clip without obliterating the vertebral artery itself.
“Two minutes.”
“Fifteen-millimeter bayonetted Yasargil clip.”
The nurse handed him the long forceps again. He glanced at the clip and threw it back to her. “That’s a temporary clip!” he cried shrilly, “don’t kill this man, give me a permanent clip!” Temporary clips, because they are made to be placed on arteries and not on aneurysms, exert less force and cannot be expected to hold an aneurysm permanently closed. The nurse, in her haste, had loaded the wrong clip, wasting precious time.
“Three minutes.”
The nurse rummaged frantically in the large gray tray of aneurysm clips, her hands quaking as she tried to load the requested clip onto the application forceps.
“Clip, clip, clip!” he screamed.
Filipiano finally seized the forceps and clip from her hands and loaded the clip himself. He thrust the clip’s silver blades around the dome as it fluttered in the wake of air and frothy blood rushing up the adjacent suction tip. Slowly, he closed the blades down, killing the aneurysm.
“Four minutes. He’s getting bradycardic.” Andy’s heart rate was falling; his brain was on the brink of oxygen starvation.
“Give me an empty clip applier.” Filipiano removed the temporary clip from around the vertebral and the large vessel billowed once again with incoming blood. The clip on the aneurysm held. The bleeding did not return.
Filipiano decided to abandon the search for the remaining two aneurysms. He did not think Andy could tolerate another temporary occlusion of his vertebral artery, and he was convinced that the one he had just clipped was the aneurysm responsible for Andy’s hemorrhage. He packed some soft gelatin foam around the clip and stepped out of the surgeon’s chair, pulling off his gloves. “Close it up.”
Gary sat motionless for a few minutes, his face pale. After Filipiano had left the room, I moved from my hiding place in the corner and walked up behind the sullen chief resident.
“Hey, Gary,” I said over his shoulder.
“What?”
“Honnnnk.”
He stared at me icily. “Fuck you.”
We closed Andy’s wound and wheeled him to the recovery room. Even after his anesthetic wore off, he remained unconscious and immobile from the large amount of barbiturates he had been given intraoperatively.
Gary sat at the nurses’ station and began writing post-op orders. “If this guy wakes up from this fiasco,” he whispered to me as he wiped his nose with his surgeon’s cap, “I will go and take a dump on Center Avenue in broad daylight. How could his brain have survived five minutes of complete ischemia? Did you see how much back-bleeding there was from that vertebral? Zero.”
I tended to agree with Gary. Five minutes of ischemia, or no blood flow, is usually a devastating insult to the nervous system. However, the effects of ischemia are difficult to predict. Andy was likely to have had some damage, some form of stroke, but where? And how bad would it be? Gary was betting that the damage was so profound as to render Andy forever comatose.
Filipiano told Andy’s family that their son was likely to recover. He believed the episode of bleeding and ischemia was not long enough to cause irreversible injury. Filipiano was the eternal optimist.
We could only wait until the barbiturates wore off, two or three days.
On Thursday morning I met Gary at the door to the neurosurgical intensive-care unit for our usual 5:30 A.M. rounds. I escorted him down the hall to Andy’s room.
“I’ve got something to show you.” We went into the room, where Andy lay motionless, his belly bulging and his eyes closed. He still had a tracheal breathing tube and had not stirred a muscle since his Monday surgery.
“So?” Gary was impassive as he flipped through his index cards of patient data.
I vigorously rubbed Andy’s chest with my knuckles, which prompted Andy to open his eyes and grab at my arm. The chief resident was startled. “Jesus Christ, the poor bastard’s awake.”
“That’s right,” I said, flashing a grin. I pulled a large wad of toilet paper from my white lab jacket and handed it to Gary. “Center Avenue’s ten floors down, but you have to wait an hour or two, since it isn’t broad daylight yet.”
Except for some drooping of his left facial muscles, Andy appeared to have no paralysis. Later that afternoon, when his parents arrived, he even tried to communicate with them in sign language. On evening rounds, Filipiano pronounced the operation a success, hugged the parents, and gave the resident staff a heady discourse on how no blood flow is sometimes better than a little blood flow. Allowing some oxygen to the brain during a period of low blood flow permits the formation of destructive “free radicals,” which does not occur if the blood flow is totally halted.
Over the ensuing days, however, Filipiano’s beautiful freeradical theory was to be spoiled by an ugly fact: we couldn’t wean Andy from the mechanical ventilator. Something was definitely wrong. The operation wasn’t a complete success just yet. Each day Andy became brighter and more alert, passing us notes asking us to remove his breathing tube and allow him to eat. Every time we reduced the ventilator rate, however, he would start to hypoventilate and become lethargic, forcing us to restart the machine. When stimulated by being pinched he would breathe o
n his own for a brief time, only to stop breathing again when the stimulus ceased.
By the following week we had to insert a tracheostomy into his neck to avoid the complications of a. long-standing endotracheal tube. We tried a variety of medications to make him breathe independently of his machine, including amphetamines, but nothing worked. As long as Andy was stimulated to breathe he would do so, but once his attention wandered, or if he started to fall asleep, he simply quit breathing. Tethered to a ventilator, Andy could not leave the intensive care unit.
Filipiano consulted Dr. Leo, one of the university neurologists. Dr. Leo’s diagnosis: Ondine’s curse.
We caught up with Dr. Leo in the cafeteria and asked him for further information regarding this rare condition.
“Ondine’s curse,” explained Dr. Leo as he peered over his half-glasses, “is a result of a stroke in the medulla, in the lower stem. That’s where the respiratory drive center is located. As you know, we can either breathe voluntarily”—he demonstrated by taking a deep breath—”or involuntarily, without having to think about it. If our respiratory center is damaged, we can’t breathe automatically; we have to think about each breath. Stop thinking about breathing, and we stop breathing. It’s that simple.”
“Who was Ondine? Some Queen Square neurologist?” asked Eric referring to the birthplace of neurology in London.
“No,” laughed Dr. Leo, “Ondine was a nymph of Greek mythology who offended the gods. As punishment, she was sentenced by Zeus to think about every breath. She knew she could never sleep, for to sleep meant death. That’s a great curse, right?”
“Does it get better?” I asked.
“Not really, at least nowhere in the neurology literature. No, I think your friend had better give his ventilator a name. They will be companions for life.”
Dr. Leo’s observation was prophetic. A month passed after Andy’s surgery, then two months, then three. Andy remained wedded to his ventilator. He could stay off it thirty minutes, just long enough to be wheeled to an outside courtyard for a respite from the intensive care unit. Andy had visitors during the first few weeks after surgery: the parish priest and some longtime members of the church’s congregation. They never had much to say to him, but then they probably never had much to say to him when he was well, either. As Andy languished in the hospital for months, his parents were the only people who continued to come.
An ICU is a terrible place to live, a place of no night and no day, just eternal light. Ventilator alarms sound at all hours, night-shift personnel laugh and swap stories, cleaning people roam at all hours. The private tasks of life, like bathing or having a bowel movement, are afforded little privacy. The disorienting effect of the ICU environment can cause psychosis in otherwise normal individuals. Andy’s deafness was probably a blessing in the ICU world. It gave him some peace.
At the time, our hospital had no protocol for managing ventilator-dependent patients outside of an ICU. The rising costs of hospital care would eventually force hospitals to deal with ventilators on regular wards, nursing homes, and even in private homes, but those developments were still a decade away. His years of smoking and chronic pneumonias would have made it difficult for him to leave the ICU for more than a week or two anyway, even if his ventilator were moved to a regular hospital bed.
The ICU became Andy’s home. He dressed in street clothes and tennis shoes and watched television in an easy chair, his ventilator hoses draped across his belly. A large crucifix was hung on the back wall, beside a get-well message from the diocesan bishop.
Four months passed. We pushed the limit of medical technology to help him. A portable, vacuum-driven clamshell repirator was fitted to his body, a modern version of the old iron lung. Andy’s round body did not take well to the machine and it never worked properly.
Andy grew more and more despondent. He became inseparable from his rosary and prayed constantly. One day in early December, the fifth month of his hospitalization, I was summoned to the ICU because Andy was having an outburst. For no apparent reason, he had became violent, crying hysterically. He had overturned his bedside stand and hurled his rosary at one of the nurses.
I wrote him a note, asking him what was wrong. He just shook his large head, made some hand signals, and waved me out of the room. We gave him an injection of the sedative Haldol and located his parents, who had become ICU fixtures themselves, in the hospital gift shop. After communicating with Andy for several minutes, they emerged from his room appearing shaken.
“What’s wrong with him, Mrs. Wood? Is he having pain?”
Her eyes filled with tears and she pointed to a small Christmas tree which the nurses had just that morning set up in the corner of the ICU.
“He didn’t know it was getting close to Christmas; he had lost track of time. He wants to leave here and decorate the church. We told him that he knows he cannot leave, and he said he wants to die.”
“He’s been very depressed…,” I started, but Andy’s father stopped me.
“We know, son. We know you have done everything you could. But we think he’s right.” He stopped and gained his composure. “We want him to die, too.”
Andy eventually calmed down, but he remained sullen and bitter. Christmas came and went. A psychiatrist was consulted and prescribed some antidepressant medications, which helped little. The residents learned a rudimentary sign language, but Andy ignored anyone except his parents.
The left-sided facial paralysis he had suffered during surgery had never fully resolved, but it was not much of a problem until late January, when his left eye turned red and swollen. Because of the paralysis, Andy could not fully close the left eye. He had suffered repeated abrasions to his cornea over the past months, but they had all healed quickly before. This time, though, the cornea became infected and, despite antibiotics, developed scar tissue. His other eye was already blind; now the corneal scarring clouded his remaining vision. By February, Andy was totally blind.
This pushed him over the edge. He began pulling out his tracheostomy and pushing the ventilator out of the room. Soon he had to be continuously tied to the bed and sedated to prevent him from committing suicide. His parents tried making signs against his chest and hands to get him to understand them, but he either couldn’t or wouldn’t sign back. Whenever the hand restraints were removed for him to write a note, he immediately grabbed for the tracheostomy, trying to break the one restraint that bound him to the living. One day on rounds, Gary and I stood and watched as Andy grimaced and strained against the leather restraints while the ventilator pumped unwanted air into his lungs.
“I think it was Wyatt Earp who said ‘Any day above ground is a good day,’” mused Gary, “but Wyatt never met this guy.”
• • •
In late February, Andy’s parents called a conference with Dr. Filipiano. They requested that Andy’s ventilator be turned off. The case was taken to the hospital’s ethics committee, which was nervous about approving this. Andy no longer spoke for himself; how could the committee be sure he wanted to die? The parents asked the ethics committee to come and see Andy, imprisoned in a bed, blind, deaf, ventilated against his will, his lungs wracked with pneumonia. The committee obliged and made a trip to the ICU. Shortly thereafter, they approved the request.
At 11:00 P.M. on the evening after the request was granted, Gary and I met the Woods in the ICU. Andy’s mother kissed him on the forehead and then began tracing something into his hands with her index finger. Andy nodded vigorously. A respiratory technician disabled the ventilator alarm with her key. Gary and I stood looking at each other, wondering who would pull the tracheostomy and be the executioner du jour. Before either of us could act, however, Andy’s father motioned for everyone to leave the room. He then closed the door and pulled the window curtains shut.
I waited for an hour or so but no one emerged from the room. I went to bed. At about four in the morning the ICU called me to pronounce Andy Wood dead. When I arrived, his mother and father were sitting on ei
ther side of his giant, lifeless body, still holding his hands, alpha and omega—present at the beginning, present at the end.
His mother stared serenely at her only child through her reddened eyes. There is an old curse: “May you outlive all of your children.” Mrs. Wood now lived this nightmare. She looked up at me and spoke. “They said to put him in a home when he was just a child, but we couldn’t do that. Now, we were afraid he’d end up in nursing home. We couldn’t do that, either. He had a good life. He was a good son…”
Her voice trailed off. The jumbled chromosomes of decades past had turned out to be no mistake to her at all. By her face, I could tell that he would always be the most perfect little boy in the world.
The next morning, Gary and I rounded in the intensive care unit without making further reference to Andy. Gary must have known that his small slip with the arachnoid knife had been as deadly for Andy as a shotgun blast, but the chief resident never spoke about the case again.
Gary’s metamorphosis into a surgical psychopath was now complete. I admired Gary, but he showed not the slightest remorse or concern for his lethal error. He had described Filipiano’s surgical callousness with disdain; he now achieved it himself. Like me, he had entered the chrysalis of residency as the son of a steelworker, little more than a boy out of medical school. In four months he would emerge from his seven years of training with neurosurgeon’s wings. Was this just an act? Was psychopathy part of this transformation? And, I wondered, would I follow his path to indifference? Would my compassion start to slip away?
When the Air Hits Your Brain: Tales from Neurosurgery Page 12