When the Air Hits Your Brain: Tales from Neurosurgery

by Vertosick, Frank, Jr.

  Perhaps. But perhaps patients didn’t want compassion from brain surgeons. They might prefer Nietzsche to Alan Alda, a superman who would make them better—even if he didn’t give a shit. Unfortunately, Gary fulfilled neither role for Andy.

  I would have to learn to quit crying at funerals.

  8

  If It Was Easy, Everyone Would Do It

  My junior year of residency was near an end. On a Friday evening in May, Gary, Eric, and I finished rounds about eight o’clock and went to the surgeons’ lounge to change into our street clothes. The intern was “in the house” that night and Gary, who was responsible for backing him up, was in no hurry to head home. An intern can make very few decisions on a specialty service such as neurosurgery, and, as chief resident, Gary never strayed far from the hospital on the nights that the intern took call.

  “Who wants some Roma’s pizza?” he shouted down the long row of lockers. Roma’s pizza parlor was directly across the street from the hospital. So many of the residents ate at Roma’s that a direct hospital line had been installed there.

  “No thanks,” Eric replied. He had been on call the night before and was anxious to see his wife and children. Eric was dedicated to his work but made a quick exit when the work was done. I never liked to hang around the hospital campus and socialize either, but I decided to go because I hated to see the chief eat alone—even if it meant inhaling his cigarette smoke and bullshit another two hours.

  “I’ll go, if you buy,” I agreed.

  “It’s a deal,” said Gary, “but you have to obey Gary’s law of eating pizza.”

  “Another law?! What’s this one?”

  “You’ll just have to wait and see.”

  We hurried through the hospital lobby, casting quick glances around corners and down hallways to be sure that we didn’t accidentally bump into any attending surgeons or patient families who might want to discuss business. A chief resident never finishes a workday, he just sort of amputates it. There was always something more to do if he looked too hard. This night, all was quiet. We made our escape undisturbed.

  Roma’s was filled with the usual crowd of residents. Every specialty was represented, each identifiable by a characteristic uniform and behavior. Two bulked-up orthopedic residents were taking a break from their anabolic steroids and downing a few calzoncs instead. A general surgery resident, still dressed in surgical scrubs and wearing blood-splattered shoe covers, was slamming his hips into a “Star Wars” pinball machine and cursing.

  In the back corner of the pizza parlor a table was crammed with medical residents dithering about some liver syndrome, their stethoscopes draped around their necks and their coat pockets jammed with standard-issue medical resident paraphenalia: the Washington Manual, index cards, photocopies of New England Journal articles, syringes. The pediatric residents were essentially medical residents with small teddy bears wrapped about their pastel-colored stethoscopes and an empathetic gaze permanently welded onto their faces.

  As we passed the table of medical residents, Gary glanced back at me and began scratching violently at the back of his right ear with his cupped hand, imitating a dog scratching a flea. This was his own personal code for internists. In resident lexicon, internal medicine residents are “fleas.” The origin of this epithet is unknown, although several colorful theories have been advanced: fat, loud, egotistical assholes; the last creatures to jump on a dying dog.

  There is a constant tension between internists and surgeons, the internists viewing surgeons as brainless technicians, the surgeons viewing internists as medical Neros fiddling as patients burn. This internecine feud peaks during residency and eases after a few years in practice. New surgeons soon realize that their patients, and mortgage payments, depend upon internists. Internists soon realize a surgeon isn’t such a bad person to have around when a patient is vomiting blood.

  Gary and I ordered a large pizza and found an open booth. The chief lit a cigarette. “Look at those goddamn fleas, jabbering about some disease they’ll see once in their lifetimes. That’s the trouble with fleas, they only like the bizarre stuff. They hate their bread-and-butter cases. That’s the difference between us and the fucking fleas. See, we love big juicy lumbar disc herniations, but they hate hypertension. The pediatric fleas—maybe we should call them gnats?—hate healthy babies. They dream about seeing some poor kid with cystic fibrosis. When we see a guy with pain shooting down his leg, we don’t cross our fingers and hope he’s got a signet cell cancer growing into his parasympathetic plexus like they do. We hope he’s got some garden-variety disc rupture that we can fix and then kiss his ass goodbye.”

  He paused to puff his shortening cigarette and quickly changed the subject. “What staff guy is on call this weekend?”

  “Fred,” I answered, expecting the chief’s reaction.

  “Oh, fuck,” Gary grimaced. “I hope nothing comes in this weekend. I have a month to go and if I can get out of this place without doing another case for that dick-with-ears I’ll be a happy man.”

  “He’s a big fan of yours, too, pal, ever since the bone flap thing.” The bone flap incident had occurred early in Gary’s chief year. Fred and Gary were performing a cranial operation to remove a benign brain tumor. Fred had performed the entire operation himself—a grave insult to a chief resident, known as “stealing the case.” After Fred left the OR, further irritating the chief by dumping upon him the tedium of closing the wound, an angry Gary had engraved the phrase “Fred sucks” with the electrocautery knife on the inside of the bone flap, the plate of skull bone that is temporarily sawed away to gain access to the brain. He had then wired the flap back into place, thinking that the inside of the patient’s skull would never again see the light of day.

  Unfortunately, the bone flap developed a staph infection and had to be removed a week later. Once contaminated with bacteria, the free piece of skull must be removed to cure the infection. The soft spot is filled in with plastic several months later. Gary coerced me into assisting Fred with the surgical removal of the infected flap. I’ll never forget the almost unintelligible stream of invectives that spewed forth when Fred saw Gary’s skull graffitti. Fred was too embarrassed to send the discarded flap to the pathology department as it was, and we spent an hour drilling the message off the bone before allowing it to leave the OR.

  “Screw him.” Gary was characteristically unrepentant. “It was a tiny convexity meningioma and he stole the whole thing. How should I know the flap would get infected?”

  “Well, you should be happy he didn’t tell the administration about it,” I said, trying to maintain some fairness.

  “Are they going to fire me for one skull-o-gram? Where’s that pizza? You were a physics major, weren’t you, Frank? You know about quantum states? Well, I have two quantum states: hungry and nauseated. It’s a curse. I have to eat until I’m nauseated, or I stay hungry.” Gary had the lanky, wiry build of the chain-smoking, eat-anything-and-everything-and-never-gain-a-pound, type A personality. He could consume vast quantities of food.’

  The waitress delivered the pizza several minutes later.

  “And now,” I asked, “what’s Gary’s law of pizza-eating?”

  Gary pulled the pizza toward him and removed half of it, folding it in two and biting into it like a giant sandwich.

  “When I share a pizza with someone,” he replied with a full mouth, “it’s not fifty-fifty—it’s whoever eats the fastest gets the most. That’s Gary’s law. So you better get started.”

  I was no match for him. I managed to eat only two of the. eight slices before Gary had devoured the rest. When we were finished, the chief leaned back in the booth and closed his eyes contentedly.

  “Nauseated?” I asked. He gave a slight smile and nodded. I probed him about his future plans. “Have you decided what job you’re going to take?”

  Gary was silent for a few minutes, as if he was drifting off to sleep. He then opened his eyes and bolted forward, reaching for his nearly empty pack of c
igarettes.

  “I took that job in upstate New York. You know, the old fart who says he wants to retire in two years and turn his onemillion-a-year practice over to me.”

  “Really?” I was amazed. “You interviewed for that job five months ago. When did you decide to go there?”

  “Five months ago. I signed a contract when I was there.”

  “But you’ve interviewed at a dozen places since then! Why didn’t you tell anyone you were already taken?”

  Gary laughed, blowing pulses of smoke. “Naive boy,” he whispered, leaning close, “if you’re a good candidate, people will fly you anywhere to interview. And each interview gets you out of this meat grinder for a day or two. Why the fuck would I tell people I signed a contract five months ago and quit interviewing? Look at where I’ve been since: San Diego, San Francisco, New York—shitty jobs every one of them, but great trips. I didn’t go to Akron, did I? You see, that’s the job of the chief resident, Frank. Everyone thinks we’re here to teach you punks how to sew and tie, but you can learn that shit anywhere. We’re here to teach you really important things, like how to con a dinner at Antoine’s out of a private-practice group in New Orleans that you wouldn’t work for if your life depended on it.”

  I was a Buddhist pupil seated in the presence of the Enlightened Master.

  “The next five years of your life, Frank, will be hard,” Gary continued, “but always remember this: If neurosurgery wasn’t hard, everyone would do it. Look at those fleas over there. Do you think they really want to write prescriptions for Inderal for the next forty years? Do you think they wake up at night screaming ‘Dialysis! I must dialyze one more patient!’ Maybe a few do, but most of them wanted to be surgeons but just couldn’t hack the work it takes to be one. If a genie popped out of their pizza right now and said he could make them into any type of doctor they would want to be, right here and now, which one of them do you think would say ‘Oh, genie please make me a gastroenterologist so that I could look up someone’s ass all day and my office can be filled with spastic-colon patients wanting to show me Polaroids of their latest bowel movement,’ or ‘Genie, I get an erection just thinking about chronic lung patients coughing up goobers at me.’ No way. They’d all want to be heart surgeons or brain surgeons or transplant surgeons.”

  Gary’s beeper went off. It was the emergency room. He dunked his last cigarette into his cup of flat Coke with a hiss and headed for the hospital phone. I watched as he stood hunched over with a finger in his other ear to block out the incessant noise from the video games. He listened for a few minutes, nodded his head, and hung up. He returned to the booth, threw a ten-dollar bill on the table, and grabbed his jacket without sitting down. “Let’s go.”

  “Go where?” I asked, bewildered. “I’m not on call.”

  “Do you want to learn how to be a neurosurgeon or are you going to go home and watch Gilligan’s Island? You can tell some future patient that you had to skip learning about spine trauma because you just had to see the episode where Mr. Howell decides to put Skipper in his will.”

  “All right, all right, I’m coming, but I have to call Kathy first. She’s expecting me.” My future wife was growing used to my last-minute cancellations.

  “Call her from the ER. Walter has some guy who rolled his pickup truck and is getting weak in front of his eyes. You know Walter, he wants to be a plastic surgeon. Stuff like this just panics the shit out of him.” Walter was our intern. He was a good intern, but definitely more of a Bel Air boob-lifter than an urban trauma surgeon.

  As we were on our way out, one of the orthopedic residents called to us. “Hey, Gary, going back again? Don’t you guys ever leave?”

  “Man, this is a tough year for us, Bob,” Gary retorted, “but nothing like those three toughest years in an orthopedic surgeon’s life.”

  “Yeah, what are those?”

  “Second grade.” We exited into the dark street and headed for the ER entrance.

  The ER looked a lot like Roma’s: brightly lit, filled with residents, and humming with electronic beeps and whistles. We tossed our jackets in the nursing station and went to the trauma room. Walter met us there, thin and handsome. An ugly plastic surgeon is about as successful as a fat aerobics instructor. Walter was obviously relieved to see us. Most interns enter our program knowing less neurosurgery then the housekeeping people. When on our service, they wander about clumsily, literally living out the nightmare of being on stage without knowing a single line of the play.

  “Walt, my man.” Gary put his arm around the frazzled intern. “What have you got for us here?”

  Walt pulled out his crib sheet filled with random pencil marks. “Billy Renaldo, age thirty-three, no prior medical history, was coming home from softball practice when his pickup truck was sideswiped as he came off a ramp onto Route 8…his truck flipped over…Uh, let’s see…his vitals at the scene were—”

  “Wait,” said Gary, “do I look like I’m from Haaah-vard? Just the facts. Is he alive, is he awake, does he move anything? Is he really thirty-three and still called ‘Billy’?”

  The intern didn’t miss a beat. “He never lost consciousness. He came in about half an hour ago saying that his neck hurt and that his legs felt heavy, but he could move them OK. But now he says he can’t move them at all and his hands are feeling ‘tingly.’ He has no external marks of trauma and the general surgeons are done with him. He really looks pretty good.”

  Gary didn’t wait to hear more. He darted into the trauma room. The patient, a tanned, muscular man ‘with a shock of black hair and a black mustache, was strapped to a backboard and still wearing his softball uniform.

  “Mr. Renaldo,” Gary began, “I’m Dr. Stancik, chief resident in neurosurgery, and this is Dr. Vertosick and Dr. Schwartz.” He motioned to Walter and me. “Try and wiggle your toes.”

  “Call me Billy. And I can’t. I could about ten minutes ago, and now they just won’t do it.”

  “Move anything from the hips down.”

  Billy weakly rotated his legs at the hips.

  “Try lifting them,” Gary instructed as he loosened the restraining belts holding Billy to the backboard. No luck.

  “Doc,” Billy continued, “now my hands feel funny. Jesus Christ, what’s happening to me?”

  “Don’t panic,” said Gary sternly, “we’ll figure it out.” The chief examined the distraught man completely and then we left the room while some spine X rays were taken.

  “He’s got a C7 sensory-level,” Gary whispered to me, “and a nearly complete motor-level as well. He looks good, all right, except he’s paraplegic. Walter’s idea of ‘good’ needs some revision.” C7 referred to the seventh cervical vertebra, at the junction of the neck and chest. Billy’s spinal cord wasn’t working below that level, giving him numbness and paralysis from about his armpits down. Gary thought out loud: “But why is he progressing so quickly? He was moving his legs when he came in.”

  “Maybe he wasn’t properly immobilized,” I offered. If his neck was broken, improper movements could injure the spinal cord further.

  “Naw,” said Gary, “he looks pretty immobilized to me and, besides, he’s wide awake. If someone breaks his neck and is wide awake, they’re in so much pain you could lift them up by their nostrils and they wouldn’t move their necks. Something fishy is going on here.”

  “Maybe he’s having a conversion reaction,” chimed an emergency medicine resident.

  “Possible,” mused Gary, “maybe he struck out in the bottom of the ninth and his male pride made him a paraplegic to save face…but don’t call the psychiatrists in just yet.”

  The phrase “conversion reaction” is a euphemism for hysteria. The patient “converts” an emotional trauma, such as a failed marriage or, in Billy’s case, the shock of being nearly killed in an accident, into a physical complaint such as blindness or the paralysis of an arm or a leg. Although the symptom has no organic cause, the patient isn’t faking in the conventional sense, either. Malingerers
don’t believe that they are ill. That’s why hidden cameras catch them throwing away their wheelchairs when they think no one is watching. The hysteric, on the other hand, is truly convinced that the illness is real, and will continue to manifest symptoms even when alone. A patient with hysterical numbness will let a needle be pushed through a fingertip without flinching.

  The word “hysteria” derives from hyster, Greek for uterus and root word of “hysterectomy.” Ancient physicians believed hysteria to be an exclusively female disease. While it remains more common in women, I had seen plenty of conversion reactions in men, too. In fact, anybody can turn hysteric, even people with no obvious mental-health problems.

  The X rays were done. I reviewed them with Gary in a back room. The cervical and thoracic spine films showed no evidence of fractures or dislocation of vertebrae.

  “See,” the ER resident chided, “I told you, he’s hysteric. Let’s just watch him for a while. I’ll bet you he walks out the door.”

  Gary squinted at the film for another few minutes and then wheeled about. “No…no, no, no. He has a sensory-level, ascending paralysis and neck pain. Frank, get on the horn to Fred, let him know what’s going on…Walter, call the radiology resident, tell him we need a CI puncture for a myelogram and CT. And I mean now, as in now and not two hours from now. I’ll call the OR and tell them we’re coming up as soon as the myelogram is done.”

  A myelogram involves instilling some iodine dye directly into the fluid space around the spinal cord, followed by X ray’s and a CT scan to trace the flow of the dye down the spinal column. Gary wanted the dye injected at CI, just behind the ear.

  “What do you expect to find?” I asked. “His films are normal.”

  “I don’t know,” Gary answered, “a disc rupture, a clot, maybe. But we have to look.” In tense situations, Gary’s flippant facade was jettisoned, exposing a tenacious and humorless professional beneath. He reminded me of the bomber pilot from the movie Dr. Strangelove, a buffoonish bumpkin until he receives his orders to deliver a hydrogen bomb on Moscow, at which time he is transformed into a fanatic and competent cold warrior.