When the Air Hits Your Brain: Tales from Neurosurgery (5 page)

“Well…I must have had too much coffee or something…that’s all it is. We’ll try again later.”

She looked up from the microscope and peered at me skeptically with her green eyes. “All right, later then. You’re not planning to be a brain surgeon with those hands are you, old man?”

This comment cut me to the bone, as if she could read my mind. I laughed nervously without making a reply.

When she had gone to another room, I played with the microsyringe, trying to steady my hands. After an hour of practice, I finally made a few decent droplets. It was the coffee, after all.

But Martha’s parting words reverberated in my head. She didn’t know what she was talking about! I could be anything in medicine I wanted to be. Even a brain surgeon! But how would I know that? There was only one way. I picked up the phone and called the neurosurgery office.

Yes, I would become “one of them.”

T
he clinical rotations of my final years of medical school passed quickly—except for psychiatry, which I found tedious. The patients were interesting, but the clinical pace was too slow for me. Assigned to the affective disorders unit, or ADU, I spent my six-week tour of duty in the university psychiatric institute. The ADU housed patients with severe disturbances of affect (psychiatry’s term for mood). The ADU population consisted mostly of middle-aged women with major depression and young men with uncontrolled mania.

The ADU population harbored a fair number of schizophrenic patients as well. Schizophrenia isn’t really a mood disorder—it’s
a thought disorder, or psychosis. But the institute had a limited number of beds on locked wards, and the ubiquitous schizophrenics were quartered in any empty beds.

Closet psychiatrists lurk everywhere, anxious to render armchair analyses of coworkers and friends. The workaholic in marketing, he’s manic. Margaret next door sank into depression when her daughter went away to school. And John down the street—he’s schizophrenic, totally bonkers. Amateurs toss these diagnoses about with no insight into their true manifestations. After encountering my first bona fide depressed, manic, and schizophrenic patients, the magnitude of their mood changes and aberrant behaviors shocked me.

Is that man in marketing manic simply because he’s the first one into the office and the last out? How about a housing contractor I encountered who read the Bible, rode an exercise bike, dictated a letter to his secretary, and expounded on the dangers of having too many Jews in government—all at the same time?

Is the homemaker next door clinically depressed because she gets teary-eyed every morning looking at the photo of her daughter boarding a bus for college? How about a grandmother of three I saw, who spent eighteen hours a day sitting on her haunches, banging her head on the floor and repeating “God, kill me now” over and over again?

And the oddball down the street—is he schizophrenic because he wears black socks with white tennis shoes and talks to his tuberous begonias? How about a nurse’s aide who plunged a bread-knife into her vagina and partially cut away her own uterus because Satan told her that Julius Caeser’s baby was in there?

Of all the illnesses I witnessed at the institute, the most fascinating was schizophrenia, a cruel and enigmatic disease which robs us of our most human quality: our reason. The word derives from the Greek for “split mind,” and many still confuse schizophrenia with the very rare condition known as split, or
multiple, personality disorder. Ironically, a schizophrenic barely posesses one complete personality, let alone two or more. Although many subclasses of the disorder exist, they all share common characteristics: apathy, deranged thought processes, the tendency to leap chaotically from topic to topic during a conversation (flight of ideas), feelings of persecution, and, finally, hallucinations—both auditory and visual (although the former are more common).

Schizophrenia stems from an imbalance in the brain chemical dopamine, the same chemical involved in the movement disorder Parkinson’s disease. Prior to the introduction in 1952 of chlorpromazine, which normalizes the dopamine balance in schizophrenic brains, treatments of the disease ranged from the merely inane (dunking the patients in ice water) to the dangerous (lobotomy). Although a family of effective chlorpromazine-like drugs, known as antipsychotics, has been developed over the past forty years, the treatment of schizophrenia remains imperfect. Many patients become resistant to the medication, refuse to take it, or develop a Parkinson-like disability as a permanent side effect.

Some believe that schizophrenia is a modern illness, since ancient historians don’t mention it. Others contend that earlier societies ignored schizophrenics—or treated them as possessed. How could such a dramatic syndrome be ignored, discounted into nonexistence?

Today, almost one in every hundred people in the United States is schizophrenic. One percent of the population suffers from the illness, yet its profile stays low and, on a dollars-per-new-case basis, schizophrenia
^*
receives few government research
funds. Given that they are virtually invisible now, the exclusion of schizophrenics from history becomes believeable.

Years ago, the great medical essayist Lewis Thomas wrote a poignant treatise on dead birds. He noted that we rarely see dead birds, certainly not in the numbers one would expect. The summer skies fill with live birds, pigeons choke our cities like rats with wings, gulls hover like been around ships and beaches—yet their dead vanish. Aware of their impending demise, dying birds instinctively hide themselves away, perhaps to avoid contaminating the world of the living with their carrion. Schizophrenics do likewise. Like dead birds, their obscurity belies their swelled ranks. They seek heaven on street grates, in halfway houses, in prisons, in attics.

The first schizophrenic I met face to face was Jake, a street dweller who wandered into the institute’s evaluation center (a gentler title than “emergency room”). A winter evening had caused Jake to see refuge from the cold…and “the wolves.” The chief psychiatry resident instructed me and two other thirdyear medical students to chat with Jake in one of the interview areas. She handed us a three-inch-thick hospital folder marked “Jacob N. Guy.” Jake was apparently a regular patron of the evaluation center.

The interview room was a cozy alcove with blue walls, soft chairs, and a long table of fake wood. Jake sat leaning his elbow on the table. He appeared to be about forty. Matted, filthy brown hair draped over his hunched shoulders, his tangled beard showed traces of gray. He wore a tattered spring jacket suited for April, not January. His face, white as Elmer’s glue, had unremarkable features save for the eyes. Those wild eyes, unblinking black lasers, looked straight through me.

As we entered the room, my two colleagues pushed Jake’s chart into my hand and then madly scrambled for the two chairs
behind him, leaving me the sole chair facing him. My “friends” then waved their hands as a signal for me to proceed with the interview, as they smiled and held their noses. The room reeked of stale urine, and odor growing stronger as I leaned forward to introduce myself. I extended my hand to him, but Jake ignored me.

Thumbing quickly, through the chart, I read that Jake had been a troubled child who had dropped out of school in the tenth grade. He drifted around Pennsylvania and Ohio, holding odd jobs until his behavior became too erratic even for menial work. A car wash in Steubenville fired him because he dried the same car a dozen times, fearing that the owner might die of germs unless he wiped them all away. A small landscaping company in Altoona could no longer deal with his bolting the lawnmower and cowering behind a tree for hours. A supermarket used him as a bag boy for less than a day.

Finally diagnosed as a schizophrenic at the age of twentyfive, Jake had been committed by the state to Woodville Mental Hospital, then released to a halfway house at the age of thirty-three. He spent less than a year there before taking to the streets, where he had lived ever since. He presented to the evaluation center every six months or so, when the weather outside got too formidable or when his most-feared hallucination, the wolves, haunted him. He would get a shot of Prolixin, an antipsychotic drug with effects lasting a month or more, and then be sent away. Rarely, he was admitted for a week or two.

I began timidly. “Jake, can you tell me why you are here to see us today?”

He said nothing for a few minutes as he sat and stared around the room, his mouth twisting and contorting—a side effect of the the antipsychotic drugs. He then erupted with a single word:

“Wolves!”

“Wolves?”

“Yeah, shit, the wolves are out there, you know. They like us street meat. Christ, they chewed me up last year…If I had my gun, man, I could fight ‘em…naw there’re too many.” He became more animated, his speech flowing in a rapid monotone. “They chased me down Grant Street last night and then they ate my buddy, Tommy. They go for the guts first, you know, flip you right over on your fuckin’ back and start digging, like this”—Jake scraped frantically at the table with his nicotinestained fingernails—”and then just pull your guts out and eat ‘em. Shit and all. Poor Tommy, goddamn it…If I had my gun, he’d…but they don’t let shitheads like me carry a gun anymore. Not since Nam. No sir—”

“You were in Vietnam?”

“I was in Vietnam, Russia, Cuba…the CIA sent me everywhere. Special Forces. Hamburger patties, that’s all we are out there for them wolves. Yeah, Tommy and I were in Nam. That’s when the wolves got wind of me. The Cong sent the wolves, and the bastards have been after me since 1971. Gook wolves, wolf gooks. Shit, let me in here so the gooks don’t get me. Put me in a cage, I don’t give a damn.” The crazed look in his eyes faded into a sincere look of desperation and fear.

Jake’s flight of ideas continued for another ten minutes, his thoughts ricocheting from subject to subject like a pinball. In Joseph Conrad’s novel
Lord Jim,
Marlow observes that extracting truth from Jim was like trying to find out what was in a sealed metal box by beating upon it with a stick: you got a lot of noise, but no useful information. An excellent description of psychotic speech.

I broke off the interview and exited the room to seek out the psychiatry resident. We found her watching TV in the lounge.

“Well,” she said upon seeing us, “what did you think of Jake?”

I related the story of the wolves and Tommy and Vietnam and the other observations I had hurriedly jotted down on his progress notes. “He’s a little scary,” I concluded.

“Schizophrenics are like rattlesnakes,” she observed dryly. “They look scary, but they’re far too frightened of
you
to be really dangerous. Personality disorders are a whole lot scarier, trust me. Tommy is Jake’s brother, a systems analyst for CocaCola. Jake talks about him, although they haven’t spoken in years. Tommy was wounded in Vietnam while Jake was institutionalized. When Jake has an acute episode he usually says wolves are after him. Two years ago, it was a pack of dogs—the hallucination is being upgraded all the time. It’s hard to tell if he really is afraid of his hallucinations or whether he just wants a night away from his cardboard box. I think it’s the hallucinations—they can be frighteningly real to these people, like a waking nightmare. If he just wanted to be admitted for a few days, he could threaten violence or suicide and try to get a 302 that way—but he never has. Not yet, anyway.” A 302 is an involuntary commitment to a psychiatric hospital, which can be imposed on patients only if they are perceived as an immediate physical threat to themselves or others.

The resident gave Jake his shot of Prolixin and returned him to the street. I watched him walk jerkily through the automated front doors, his gait bending under the weight of the brain-altering drugs, which had done little for him except make his movements as distorted as his thoughts. A wispy snow fell about him, dusting the walkways like confectioner’s sugar. Jake pulled his spring jacket around his neck and wandered off into the blackness to face his wolves alone.

• • •

I graduated from medical school
in May and began my surgical internship that July. Like medical school, internships consist of different rotations, providing the broadest possible experience before our careers funnel into single, narrow specialties. My first assignment as a full-fledged M.D. was cardiac surgery. The chest team at last!

Our cardiac service included both adults and children. A curious thing about illness: it strikes the very young and very old—but few in between. On the cardiac service, patients were either seventy years old and undergoing coronary artery bypass grafting (CABG, or “cabbages,” as the residents affectionately called them), or three days old and undergoing a repair of a congenital FUH (fucked-up heart).

Interns did nothing of any consequence on the cardiac service. Not that we didn’t work hard; there was a massive amount of inconsequential nothingness to do. To be stuck in the hospital for two or three days at a time was not unheard of. Every year, the police ticketed at least one cardiac intern for falling asleep at a red light while driving home.

Our purpose was to take night calls and to be human retractors in the operating room. During the day, I held quivering hearts upside down so that a vein graft could be sewn into their backsides. Immersed in iced saline during cardiopulmonary arrest, the hearts froze my fingers, and only hours after surgery did my frostbitten fingers regain their feeling.

The nights on call terrified me. Cardiac patients destabilize in an instant, and my knowlege of cardiac surgery bordered on the nonexistent. Opportunities for sleep were rare—the few moments between beeper pages were spent searching for drug dosages in the pocket-sized Washington Manual. We might be called to administer drugs to a 300-pounder one minute, and to medicate a four-pound infant the next.

I lived in constant fear of a patient “tamponade,” when a blood clot forms around the post-op heart and smothers the life from it. If left untreated, even for a few minutes, tamponade kills swiftly. Faced with tamponade, we must tear out the skin sutures without delay; cut the bone wires to separate the halves of the freshly sawed sternum, or breastbone; and scoop the clot away from the heart. A set of suture-removal scissors and wire cutters sat taped at the bedside of every post-op cabbage for just such a delightful occasion.

Patients survived—provided the intern recognized the tamponade quickly and opened the chest immediately. There was no time for anesthetic during this emergency maneuver, however. Opening an awake patient’s chest and showing them their own beating heart did not make my top-five list of favorite activities. When closing the chest cases on my call days, I prayed, “Please, dry this wound up, stop the bleeding…no tamponades tonight.”

Heart surgery is a tough profession. A cardiac surgeon must complete six years of general surgery, followed by a two- or three-year cardiac fellowship. Operations stretched for hours; intraoperative deaths occurred frequently. Because of the hardships of training, cardiac programs attracted people with a Marine Corps attitude, residents so in love with their profession that the suffering became sweet nectar. They sported T-shirts that beamed:
THE BEST WORK IN THE CHEST,
and hung autographed pictures of Michael DeBakey in their lockers.