Finally, the great mass slithered out of the skull and dangled on a shred of uncut dura mater. A snip of the scissors and the tumor dropped into a steel pan. Stopping the bleeding took an hour longer. When everything was dry and the patient stable, we could at last see the horrible brain deformation left behind. The meningioma had flattened the left hemisphere into a pancake, and our surgery had chewed up the cortex terribly; I doubted that the brain would recover.
Nevertheless, the boss looked pleased.
“Nice work. That was a monster.” He shook my hand before pulling off his gloves. “You’re really one of us now.”
I still see Mrs. Janeway once a year. She comes to the office in her smart business suit and tells me about the latest Buick she drives. Her legs remain stiff, although the orthopedic procedures to release her contractures worked wonders. Her daughters claim she is every ounce the woman she was fifteen years ago.
In my career, Mrs. Janeway was truly a landmark case. If I never accomplish another thing in my life, I will go to my grave satisfied. I will not walk on the moon, or win the Nobel Prize, or live in the White House. But the rare privilege of snatching someone from a nursing home and giving back her mind, her life, her family…I wouldn’t trade that for the world.
Despite the occasional Mrs. Janeways, chief residency ground me down. Constant exposure to gunshot wounds, brain-dead donors, harried interns, pompous surgeons, patients in pain, and hospital-grade corned beef took its toll. My enthusiasm for the job waned. Some days I no longer cared who lived and who died. I just wanted to be done, to have my life back, to see my wife and baby. Like Humphrey Bogart in The African Queen, all I could do was climb back into the leech-ridden waters and keep pulling my boat toward the open sea.
My residency ended at last, and with little fanfare, I entered practice. “One of them.” Big deal. Overdosed on surgery my final year, I felt little joy for my new profession those first months as an official neurosurgeon. My training finished, I reflected upon my career choice.
We are all slaves to chaos—chaos in the scientific sense. Chaos theory predicts that the outcome of a chaotic process depends upon minuscule variations in the “initial conditions.” Example: a billiard ball rolling off the hood of a car. When placed in one spot, it rolls one way; placed one millimeter to the right or left of that spot, it rolls in a different direction altogether. Where the ball ends up depends entirely upon where we place it initially.
The impact of the initial conditions has been named the “butterfly effect,” since, in the chaotic theory of weather, the beating of a butterfly’s wings in Asia can cause a hurricane in the southern Atlantic months later. Our lives evolve from our own butterfly effects. The tiniest perturbations in our youths, our “initial conditions,” generate profound alterations in our later lives. In my case, I had wanted to be a computer scientist, but no openings in my freshman computer-science courses existed. If I had jumped one or two places ahead in the registration line, I would have made it into freshman comp sci and never become a physician. What delayed my arrival at the registration office? I don’t remember—stopping for a hamburger, maybe, or speaking to a friend—but whatever this long-forgotten event was, it changed my life. If I could have taken cardiac surgery, as I had wanted, I would probably be one of the “best in the chest” now, and not a brain surgeon.
The butterfly effect: a conversation here, a missed flight there…happenings which redirect the rivers of our lives. After buffeting about in the chaotic currents, I feared that I had been cast onto a distant shore, a place where I didn’t belong.
Three months into my new practice, a seventy-year-old widow named Grace Catalano came to my office, pushed along in a wheelchair by her burly son. She had suffered from back and leg pains for years. The pain worsened with prolonged standing and walking. In fact, she could now barely walk at all, save for the few steps from bed to wheelchair.
“Oh, Doctor, you are my last hope. I have arthritis so bad in my back and legs, so bad, I can’t go from here to the door. Now the pain bothers me even at night, even when I’m off my feet. They have me on narcotic pills. My family doctor says that it’s just arthritis and I have to live with it, but a neighbor says that maybe it’s a ruptured disc or something.. I’m afraid of surgery, Doctor, but I’ll do anything to get rid of this. Anything. I have two granddaughters—twins—they are four years old now and they want to know why their grandmama never walks with them or takes them to movies…” She began to wipe her tears away.
I examined her, but detected neither weakness nor numbness to confirm her spinal problem. Her story sounded like lumbar stenosis, arthritic narrowing of the lower spine. Lumbar stenosis results from deposition of bone spurs and thickened ligaments in the lower vertebrae. The spinal canal, which conveys the nerves to the legs, narrows during stenosis. A napkinring constriction of the nerves forms, with chronic leg pain as a result. The disease occurs in the elderly and still goes largely unrecognized, the leg pains and shuffling gait attributed to incurable arthritic deterioration of the spine, or to old age. Fortunately, even in the advanced stages the condition responds well to surgery, the overgrown bone and ligaments safely trimmed away.
I ordered a myelogram, which verified severe narrowing between her fourth and fifth lumbar vertebrae, at the base of the spine. I performed a laminectomy and decompressed her spine uneventfully, but she left the hospital in her wheelchair. Transferred to a rehabilitation center, she didn’t return to see me until months later.
Glancing at my office schedule one day, I noticed that Grace Catalano topped the list. When I entered the exam room, however, I saw her son, not Grace, seated on the exam table.
“Where’s your mother? Is she all right?”
“Mama didn’t want to come in. She wants you to go out in the waiting room.” I agreed.
There, erect as a young sapling, stood Grace Catalano, flanked by two raven-haired little girls.
“Watch,” she said. Her son swung open the waiting-room door and Grace waddled into the long corridor outside, a granddaughter on each hand. She strolled easily for twenty yards, then slowly turned around and returned. We looked at each other with matching grins.
Yes indeed, if it was easy, everyone would do it. I checked her wound, made some small-talk and said goodbye.
She strode back into the corridor, out of my life and back into her own, her precious grandchildren at her side. Mrs. Catalano was where she belonged.
And so was I.
Postscript
Twelve years have passed since I wrote this book, the chronicle of a neurosurgical residency that took place nearly a quarter of a century ago. Not surprisingly, many aspects of neurosurgery have changed over the years, in both how the specialty is taught and how it is practiced. The biggest change in residency programs has been the recent legislativelymandated restrictions on how many hours a resident trainee can work in a week (eighty hours); when I trained, we worked until everything was done, sometimes days in a row, often over one hundred hours a week. Needless to say, we “gray hairs” look upon today’s trainees as—I grope for the right word—wimps!
As for the surgeries, the procedures depicted here are still done in pretty much the same way as I have described them, but the trend over the last two decades has been toward less invasive ways of dealing with neurological disease. Indeed, the goal has been to avoid surgery altogether. As one of my colleagues used to say, “The person who dies with the least scars wins.” He was an internist, of course. A surgical practice with no scars is not victorious. Bankrupt is a more accurate description.
Most cerebral aneurysms are now treated nonsurgically by filling them with tiny platinum coils. The coils are threaded into the defective blood vessel through a long catheter inserted into the patient’s femoral artery, in the groin. The metallic fibers induce clotting and scar formation in the aneurysm without the risk of an open operation. Surgery is now used only in the rare instances when this approach fails. Likewise, pituitary tumors are still
removed through the nose, but many more now receive nonsurgical radiation treatments using sophisticated computer-guided cobalt machines, a procedure known as stereotactic radiosurgery. Radiosurgery has also reduced the need for surgical treatment of brain tumors, both benign and malignant. Unfortunately, patients with malignant brain tumors fare no better now than they did in the 1990s, or the 1980s, or the 1970s. In fact, the last significant improvement in the prognosis of brain cancer came in the 1950s, with the advent of more powerful radiotherapy machines. There has been little or no progress since.
These changes do not spell doom for the working neurosurgeon, however. Spine surgery, always the bulk of any neurosurgical practice, still thrives. As the population ages, and as older patients deservedly seek a higher level of activity despite their deteriorating joints and discs, the number and complexity of spinal operations are rising exponentially. Likewise, the neurosurgical treatment of pain disorders, including the implantation of spinal cord stimulators and morphine pumps, remains a growth industry.
Brain surgery is still done, of course, for traumatic blood clots, life-threatening brain tumors, abscesses, bullet wounds, and the like, but the operations are getting smaller and “more intelligent” all the time. Thanks to technologies like “frameless stereotaxis” (a kind of GPS system for navigating the brain), surgeons now have an unprecedented ability to know where they are going and see what they are doing inside the “threepound universe” of the mind. A few operating rooms in the United States now have MRI scanners installed at the head of the operating table, enabling the surgeon to see inside the brain in real time as the surgery progresses.
Presently, the most rapidly growing sector of our field is socalled “functional” neurosurgery, the treatment of neurological dysfunction by destroying tiny bits of brain or by installing electrical stimulating devices akin to brain pacemakers. These approaches were around for years even prior to my residency in the 1980s, but recent advances in computer hardware, coupled with an ever-increasing knowledge of the brain, have allowed functional neurosurgery to achieve unparalleled successes. Deep-brain stimulation for Parkinson’s disease has become so effective that it may soon become the preferred initial treatment. Currently, initial therapy consists of drugs like L-dopa or other dopamine-like oral medications; surgery traditionally has been reserved for patients in whom the beneficial effect of drugs has begun to wane (typically between five and fifteen years into the course of the disease), or for those patients who develop intolerable side effects. The call for an earlier use of stimulators, instead of drugs, represents an unusual reversal of the modern trend against invasive surgery.
Brain stimulation may have wider application. Recently, the journal Nature reported a case of semi-coma reversed by the use of brain stimulation. Thus, as in many aspects of life, as one door closes for the surgeon (no more aneurysm surgery), another opens (many more functional surgeries). I doubt the surgeon will ever be out of business entirely.
The recent progress in brain stimulation, as it turns out, is particularly relevant for me. In 2001, I developed a mild tremor of my left hand. This didn’t hinder me in the operating room, at least not at first, but my unsteadiness soon became obvious to my patients and colleagues alike. A brain surgeon with unsteady hands is, well, pick whatever analogy you like, it’s not good. I began limiting myself to operations like simple disc procedures and carpal tunnel releases, but the situation steadily declined. By late 2002, I had to quit surgery and do office consultations only.
By 2004, it became clear that I had early Parkinson’s disease. So far, my condition has not progressed much beyond hand tremors and I can still play tennis and golf, and even scuba dive. In fact, I can do most anything—everything except surgery. I found it difficult at first; in fact, even years later, I have occasionally dreamed that I am doing a meningioma removal (my favorite operation). But now, I rarely think of my past life as a surgeon.
Despite the passage of time and the numerous changes in the field, I still believe this book is relevant today. When the Air Hits Your Brain is not about the technology, it isn’t even really about the medicine. It’s about the human aspect of disease, the human dimension of those who suffer from it, and the human dimension of those neophytes, like me, who learn to treat it. And that dimension is timeless.
As for me, I sense the cycle may soon become complete as I gradually transform from healer to patient. One day, medications will fail and I will need a brain stimulator. So, when the air hits my own brain as the electrodes go in, will I be the same? I hope not. I hope to be better.
Isn’t that what it’s all about?
Frank T. Vertosick, Jr., M.D.
August 4, 2007
When the Air Hits Your Brain: Tales from Neurosurgery Page 24