When the Air Hits Your Brain: Tales from Neurosurgery

by Vertosick, Frank, Jr.

  Our transplant service carried a very high profile and consumed the lion’s share of our health center’s OR time and other resources. Their star status imbued the transplant surgeons with the sort of smarmy, menacing charm exuded by bandidos in old westerns. During my residency years, transplant stories became daily fare on the local television news programs, making the senior transplant surgeons into celebrities and hailing every permutation of donor, recipient, organ, and disease as a medical landmark (“Girl becomes first Asian to receive an African-American lung for the treatment of pulmonary hypertension…film at eleven!”). Our center was, and still is, a transplant center of unequaled excellence, but I grew irritated by the news media’s perception that saving a life with an organ transplant is more admirable than saving a life by draining a subdural hematoma or reversing a diabetic coma. When one popular liver-transplant recipient, who had been tracked for years by local journalists, died suddenly, the mayor declared a day of mourning. A tragic death, yes, but aren’t they all? When would the city declare a Sarah Clarke day?

  Heart and liver transplants are indeed heroic affairs, requiring consummate skill to perform and extraordinary fortitude to undergo. But when viewed from a national health-care perspective, such transplants equal zero-sum games: a life saved is a life lost. Our city coaxed people into signing donor cards, although no one really wants to think about ending up young, healthy, and brain dead. Transplant programs survive on a constant diet of good-looking cadavers—people in the prime of their lives with brains extinguished by senseless catastrophe. In adults, our donor supply flowed from auto accidents and gunshot wounds; in children, donors were victims of parental shakings and beatings. By definition, a donor organ flows from some tragic and eminently preventable event.

  Although transplant patients now do quite well, few recipients survive as long as the donor would have had he dodged a bullet or missed a telephone pole and kept his own organs a while longer. I support organ donation wholeheartedly—it makes the most of a bad situation—but we shouldn’t lose sight of a larger objective: preventing people from becoming donors in the first place.

  The neurosurgery service suffered frequent contact with the transplant surgeons. Their potential donors were usually our patients first. Outside hospitals even transferred brain-dead patients to our neuro unit just to be evaluated as donors, a practice which irked us no end. Not only did this practice tie up our beds, but our junior residents had to do histories and physical exams, draw blood work, and manage IV fluids on living corpses—typically in the middle of the night—to spare the transplant fellows such trivialities.

  Before the advent of sophisticated organ-procurement networks and transplant foundations, the task of approaching relatives for permission to harvest the organs fell to the donor’s attending physicians (and then, in turn, to the neurosurgery resident on call). Occasionally, we were surprised to learn that the family hadn’t even been told of the patient’s “legal” death. Outside physicians often sidestepped the issue, telling relatives that their dead loved ones were being transferred to the university for further “evaluation”—a true, if not completely honest, statement.

  On occasion, we solicited permission for organ donation from the person who made the donor brain-dead in the first place. One of our residents had to call the county jail and obtain permission from the donor’s husband—minutes after the man had been arraigned for shooting her in the brain. The suspect later claimed that he wasn’t responsible for his wife’s death—the transplant surgeons were. He was convicted of murder.

  The donor business brought other surprises. A young braintumor victim was flown in from New York for immediate donation to a dying liver recipient. The recipient was already in the OR holding area, prepped and ready to go. The transplant team had been summoned. Preliminary tissue and blood typing revealed an excellent match. One teeny problem: the donor wasn’t brain dead yet. The junior resident, Dave, called me at home and told me that the patient decerebrated to painful stimuli.

  Brain death means the loss of all cerebral and brain stem function as determined by neurological examination. Although ancillary testing, such as EEG (electroencephalograms, a measure of electrical brain activity), can be used, the diagnosis of brain death remains clinical. A brain-dead patient cannot exhibit meaningful movement of the extremities, respiratory motions, response to pain, pupillary response to light, or a gag reflex. Decerebration, the rigid extension of all four limbs to pain, requires a living brain stem and invalidates the diagnosis of brain death.

  I told Dave to scan the patient immediately and rushed from home to see this Lazarus When I arrived, the prospective donor was back in the neuro unit, surrounded by a jittery team of transplant fellows. Dave stood by the X-ray view box looking at the CT scan.

  “This ‘donor’ has a big cerebellar tumor,” said Dave under his breath, “and we might be able to help him, but the vultures are here.” He cast a look over his shoulder. Our nickname for the transplant surgeons derived from their uncanny ability to smell impending brain death. They circled the ICU on a daily basis.

  “Screw the vultures, I’ll deal with them…Just take him downstairs and we’ll take this thing out. What Massachusetts General Hospital did he come from, anyway?”

  “I don’t remember. Some place in outer nowheresville…they told the family he had a cancerous tumor and was as good as dead. Of course, since they heard so many nice things about transplants from the news, they wanted to give his organs. Nice gesture, but a bit premature.”

  I approached the transplant team. “Sorry, gentlemen, but, to paraphrase Mark Twain, the reports of this man’s demise have been greatly exaggerated. We get to keep him. Maybe next time.”

  “Horseshit,” a transplant fellow spat with venom. “Look at him, he’s decerebrate, he’ll be dead soon. We’ll wait an hour or so and stop back.”

  “What neurosurgery residency did you train in, my learned friend? Decerebration from posterior fossa lesions isn’t as ominous as you think. Our New York friend could be eating eggs for breakfast by tomorrow.”

  “Eating osmolyte through an NG tube, you mean. I know a brain-dead guy when I see one, and I have a lady in hepatic failure downstairs.”

  “Is this a Monty Python skit or something? He isn’t dead yet and you can’t have him. So kiss off.”

  The large group flowed from the room. We removed the man’s tumor that night and he walked out of the hospital a week later. The donor pool was reduced by one, but this particular patient didn’t seem to mind. Two years passed before his tumor claimed him for real.

  Clang! What sounds worse than a phone ringing in the middle of the night? When the intern took in-house call, it wasn’t worth going to bed at all. I pulled the phone receiver to my ear. Bob, the orthopedic wannabe, chattered excitedly.

  “It’s a gunshot wound! Right between the eyes! What’ll I do? Should I scan the patient or take her right to the OR?”

  “Slow down, Bob. Where are the entrance and exit wounds?”

  “The entrance is right between the eyes, like I said. About a centimeter hole just above the bridge of the nose. The exit wound is in, the occiput, but a lot of hair and blood’s matted there and I can’t be sure exactly where the exit is…I’m afraid to look too close…”

  “Relax. I wouldn’t want you to puke in the wound or anything. Is the patient intubated?”

  “No. She’s awake, actually.”

  “How’s that again?”

  “She wants a cup of coffee…should we let her drink anything if she’s going to the OR?”

  “Let me try this again. She has a bullet enter between her eyes and exit at the back of her head and she wants a cup of coffee? Is that right?”

  “Yeah. She was unconscious when she came in, but woke right up! Weird, don’t you think?”

  “Call the CT people in. I’m coming in, too. I have to see this. In the meantime, ask her if she wants cream and sugar. Pour one for me, too. Extra sweet. See ya.”

&nbs
p; I dressed hurriedly. This lady couldn’t stay conscious for long, I thought. Surely the bullet must have clipped a large venous sinus. Even if it didn’t, her brain had to swell soon. When I arrived, the victim was still in the ER, awaiting her CT scan—not in a patient exam room, but sitting in the waiting room watching the late movie, her head wrapped with a bloodied Kerlix gauze. A city policewoman sat beside her.

  “Are you the woman who was shot?” I asked.

  “Uh-huh,” she replied trancelike, her attention still focused upon the TV.

  “Could you come with me please?” I crooked my finger at her and motioned to the ER’s metal doors. She cast me an irritated glance, but obeyed. Back in an examination room, she explained what happened.

  “My boyfriend was a little drunk and got real mad, you know, like really, really pissed off, so he shot me. I think I passed out right after it happened. I know he didn’t mean it…Do you think, you know, I could go back to him tonight? They say I can’t.” She motioned to the sphinxlike officer who had followed us into the room. “I know that he truly loves me. He didn’t mean it, I know he didn’t.”

  The wounds were as Bob had described them. I examined the back of her head, parting the thick brown hair until I saw a jagged exit wound. As I was rummaging around, a nearly pristine bullet fell onto the gurney and was quickly retrieved by the policewoman and turned over to a homicide detective waiting outside. Neither wound was bleeding, and there was no sign of brain tissue or spinal fluid. Her neurological exam was normal. Why was this woman still alive?

  The CT scan provided the answer. The bullet had fractured the frontal bone, but had not injured the brain. Between the scalp and skull at the top of her head was a mixture of blood and air which traced from the entrance wound to the exit wound. The bullet had hit the frontal bone and deflected upward, circling over the skull and under the scalp like a roulette ball before blasting out the back of the head. The woman’s skull was unusually thick, a congenital abnormality which had saved her life. She had sustained the handgun equivalent of comedian Steve Martin’s “arrow through the head” sight gag.

  As amazing as her injury was, her attitude surpassed it. She held no animosity whatsoever toward a man who had jammed his revolver between her eyes and pulled the trigger. After all, he “missed,” didn’t he? She refused to believe that he had done anything wrong, save for drinking too much and losing his temper.

  The skull does a marvelous job of shielding the brain. A middleaged Protestant minister with intractable depression decided that he couldn’t wait until his appointed date with destiny to meet his Maker. He borrowed a friend’s .22 caliber revolver and, placing it against his right temple, blasted himself senseless. The paramedics, believing him mortally wounded, transferred him to the hospital without intubating his trachea. He arrived in our ER still unconscious, a serene look upon his craggy face.

  Because his vital signs were normal and his pupils reactive to light, I ordered a plain skull film immediately. The X ray confirmed my suspicions: the small bullet had lodged in his “pterion,” a hard ridge of bone about two inches in front of the external ear canal. The projectile had failed to enter the brain. The impact of the bullet had struck the minister like a heavyweight uppercut, temporarily rendering him unconscious, but unhurt.

  I looked into his face closely as he regained consciousness, curious to see the reaction of a man who believed he was opening his eyes in Paradise. The eyelids fluttered, the eyes squinted into the fluorescent light.

  “Is…is this heaven or hell?”

  I overcame my irresistible urge to play some form of practical joke, like lighting a match in his face. “To tell you the truth, Reverend, it’s the emergency room. Although it can be hellish at times, I’ll admit.”

  He sobbed uncontrollably, covering his face with his hands. “Oh God, I’m so ashamed…so ashamed. I can’t even kill myself…” Such a profound and desperate act thwarted by an inch of bone. The irony. Betrayed by the Maker’s own blueprint. I said nothing else, leaving him to his inner torment.

  He was given a tetanus shot and transferred to psychiatry. I never saw’ him again.

  Monday morning. Residents’ clinic. Failed-back patients and neck injuries littered the schedule. One patient caught my eye, however: Florence Janeway. Diagnosis: meningioma.

  Three coverings wrap the brain: the dura mater, arachnoid, and pia mater. These wrappings are known collectively as the meninges. When meninges become infected with bacteria, meningitis results. A tumor of the meninges goes by the name of meningioma.

  Meningiomas, nearly always benign, arise from the outer surface of the skull, not the brain, and are removed fairly easily. They may take years, even decades, to reach a symptomatic size, given their slow growth rate.

  Neurosurgeons enjoy meningiomas. So much so that Mrs. Janeway’s appearance in residents’ clinic was enigmatic. Why hadn’t a staff surgeon snapped this up? It couldn’t be because of her insurance status. The staff would pay patients for the pleasure of rolling out their big, juicy tumors. Dave had already seen the woman.

  “Dave, what’s a meningioma doing in our clinic?”

  “Oh, you mean Janeway? She’s a pretzel lady. Had a history of depression, couple suicide attempts. Now she has Alzheimer’s disease and lives in Allison Manor Nursing Home.”

  “How did they figure out she had a meningioma?”

  “One of the aides at the home noticed a lump on the back of her head while combing her hair. They sent her for a scan. I have it in the office.”

  “How old is she?”

  “Sixty-seven.”

  We returned to the office. Dave flipped the scans onto the view box. Mrs. Janeway didn’t have just any meningioma, she had the mother of all meningiomas. A huge white ball occupied a third of her head. Meningiomas induce thickening of the skull, hence the “bump” noticed by the nursing-home aid.

  When I saw her, I realized why Dave had called her a “pretzel lady.” Muscle contractures distorted her limbs. Her blank face stared into space. She said a few words and followed simple commands, but she certainly looked like someone suffering with Alzheimer’s disease.

  “What are we supposed to do with her?” Dave asked.

  “How do they know she has Alzheimer’s?”

  “Well…look at her!”

  “How do we know this isn’t from her tumor?”

  “I guess we don’t.”

  “Someone gave her the diagnosis of incurable dementia without doing a head scan?”

  Dave rummaged through her thick outpatient chart. “That’s what it looks like.”

  I thought for a moment. “The horse is out of the barn, I’m afraid, tumor or no tumor.”

  “The horse isn’t just out of the barn,” commented Dave as he looked down at the twisted little frame on the exam table, “it’s at the lake getting a drink of water.”

  “Send her back. Tell the nursing home ‘No, thanks.’”

  I finished seeing patients and returned to the wards.

  But Mrs. Janeway didn’t leave my mind that night. Or the next day. Was her dementia irreversible? Sixty-seven isn’t old, and her health was good. I called her oldest daughter.

  “Mom’s been bad for two years. The depression came on about three years ago, but the memory loss and incontinence began two years ago. The last six months, she hasn’t recognized me or my sisters at all.”

  “Three years ago, what was she like?”

  “Mom ran an insurance office for thirty years. Sharp as a tack. Then she started having trouble with arithmetic and had to quit work. That was…hmmm…about 1976.”

  I explained the situation, described the tumor, and detailed the risks of surgery—considerable, given the large size of the mass and the fact that it pressed on her left brain. She listened politely, but declined surgery.

  But the issue gnawed at her as much as me, and I received a phone call the next morning. The three children had talked (Mrs. Janeway was a widow). They wanted surgery. As I suspecte
d, neither they nor I could live with the slightest possibility that a working brain had been abandoned to the mercy of a benign tumor. I scheduled the craniotomy for the following week.

  I requested the boss’s help—I needed his thirty years of experience.

  It was a bloody affair. We reflected the thickened bone from the bulging mass beneath and released a torrent of bleeding. I incised the dura, located the plane separating brain from meningioma, and began pulling the mass out of her head. My slow technique, however, could not keep up with the bleeding.

  “This will take forever,” I moaned.

  “We need to get it out fast,” observed the boss calmly. “We’re losing about two hundred cc’s of blood every fifteen minutes.” He looked over the anesthesia screen and spoke to the anesthesiologist. “Can you folks keep up?”

  “Possibly, but we don’t want to get into big fluid shifts in her.”

  The boss looked back at me with a gleam in his eyes. “Frank, get some cotton balls and have your bipolar ready. We’re going to yank this thing the old-fashioned way. Quick. Are you ready?” I nodded. “Then put a great big nylon stitch through the dura over the tumor…here…that’s it…Now I’ll put my finger here…OK, PULL!”

  I pulled the suture as the boss swept his large index finger beneath the tumor. The red baseball levitated from the wound as the chairman advanced his finger deeper. The bleeding increased. I jammed cotton balls between the tumor and the brain with my right hand, my left hand providing traction on the tumor stitch. As he delivered the tumor from the depths, the boss inserted another finger, then another, until Mrs. Janeway’s head swallowed his hand.

  The anesthesiologist grew nervous. “We’re getting hypotension here.”

  “Fix it,” the boss yelled without looking up, “that’s what they pay you for. Come on, Frank, buzz that artery…there. Keep working, we’re almost home.”