When the Air Hits Your Brain: Tales from Neurosurgery (8 page)

My last physics course as an undergraduate was Mathematical Methods in Physics. On the first day of class, the professor informed us that there would be only one test, the final exam, and that it would consist of only one problem. He wanted only the answer to that problem, accurate to four decimal places, written on a scrap of paper above our name. If we were correct to all four decimal places, we’d get an A. If not, we’d fail. Simple. There were immediate howls of protest from myself
and others. One test? One answer? Didn’t he even want to know how we set up the problem? If we even knew what we were doing?

“No,” he replied. “Welcome to the real world, where people only want answers—correct, accurate answers. If a bridge collapses and kills forty people, who do you think cares whether the engineers set up the problem correctly? In life, there is no partial credit for being half right. If you want to accomplish anything important, you have to be totally right—and be willing to take the consequences if you are not.”

As the professor argued, all real-world occupations require a certain level of performance. The physician’s performance must be perfect, however, and it must be perfect right now. In a lifetime, a surgeon performs thousands of operations and makes hundreds of thousands of decisions regarding medications, antibiotics, when to operate, when not to operate. Complicating matters is the fact that these decisions often must be made quickly and with incomplete information. Call a lawyer at three in the morning and ask to have a coherent defense strategy laid out right now! Wake an airline pilot from a dead sleep and expect him to pull the plane out of a nose dive right now! Take a car to a mechanic and say fix it right now—not a day from now, or an hour from now.

One night I was summoned for an emergency LP on a young man from the medical service, admitted that day in a stuporous condition and now nearly comatose. His brain CT showed nothing unusual. He had a slight fever and a stiff neck, and the diagnosis of bacterial meningitis had to be ruled out. Both the intern and the resident on the house medical service had tried to get spinal fluid and had no luck. They called for the radiologist to do the procedure under fluoroscopy, but she refused to come in from home until I had given it my best shot.
She paged me to ask if I could spare her a night trip to the hospital, as her daughter wasn’t feeling well.

There was the usual bedside scene: a naked man on his side in a fetal pose, his back purple from failed LP attempts, brown prep solution staining the sheets and floor. A dozen blood-soaked gauze sponges littered the bed, the wreckage of a prepackaged LP tray strewn across the patient’s nightstand.

The man was very tan, even in places that shouldn’t
be
tan, and he had short, bleached-blond hair. Gold chains adorned his neck and right ankle. He had an excellent physique.

“Is he awake?” I asked. “Any sign of trauma?”

“He moans; that’s about it,” replied the medical intern, still wearing her bloodstained latex gloves. “And no, no sign of trauma.”

“He sure looks healthy for a sick guy…What’s the name?”

“Roger Doe.”

“Roger Doe? Any relation to John?”

“Everybody who comes to the ER without ID is called Doe. They rotate first names to keep the record room from being clogged with John Does. We’re up to the
R’s
already.”

“No kidding! Like naming hurricanes. What’s wrong with him?” I asked as I pulled on gloves and began to probe the mauled back in search of a virgin interspace. I immediately detected the error of the intern’s failed attempts: she was far too low and had been skewering the hard sacrum, or tailbone. Nothing but blood there.

“He came in like this, found unresponsive on the street and brought in by the police from downtown,” the intern continued. “He was probably robbed after he collapsed, since he had no wallet or other ID, even though he was dressed pretty well. He’s not a street person, that’s for sure. No sign of a beating or any struggle. The cops took a few quick fingerprints and we might
have some idea of who he is by tomorrow. He has a low white count, and some big cervical lymph nodes. A few in the axilla and groin as well. It’s like mono, or cat scratch fever, maybe.”

“Cat scratch fever? When does cat scratch fever make you comatose?”

“We don’t have the toxicology back yet. His alcohol level is zero, but he may have barbiturates or heroin on board.”

“Did you give him Narcan?” Narcan is the antidote for narcotic overdoses.

“Yeah, but that didn’t do anything.”

“Sort of rules out heroin…Here, here we go!” I pushed the needle forward and clear, watery fluid began to drip out. As I was switching collection tubes, the fluid splashed onto my face and eyes. I brushed it away with my coat sleeve. “This fluid looks pretty clear to me. No meningitis here.”

“Thanks much, er”—she glanced quickly at my name tag—“Frank.”

“No problem…(Try learning where the lumbar spine is next time)…Anytime at all. I’d get a stat gram stain on this stuff, anyway. He ain’t like this for no reason. Maybe he has the Black Plague…maybe those groin nodes are really buboes.” The intern blanched a bit. I was only half joking, since bubonic plague still exists in some parts of the country and, for the moment, we had no idea who Roger Doe was or where he called home.

I went back to my evening scut chores and forgot about the LP. Two hours later, the medical intern paged me with a curious bit of news.

“The Gram’s stain,” she said, referring to the microscopic examination of the fluid, “found many organisms resembling
Listeria monocytogenes.”

“What the hell is that? I’m a surgeon, remember?”

“A gram-positive rod, a bacteria which causes meningitis, but only in alcoholics and in patients with cancer or leukemia.”

“But he had clear fluid! And no pus!”

“I know. The official white count on the fluid was only three, normal. The glucose was a little low, but the fluid is teeming with bugs.”

I thanked her and hung up. Why does someone have a rare meningitis, with no white cells in his spinal fluid? This was the healthiest sick guy I had ever seen.

Out of curiosity,
I stopped into the medical ICU two days later to check on Roger Doe. He now had a name: William Bishop.

Forty-eight hours of intravenous antibiotics had done nothing to lighten his coma and he was now on a ventilator. The same intern who had botched his LP was standing by his bedside, along with a fellow from the infectious diseases department.

“Have you figured out what’s wrong with Roger…er, I mean, Mr. Bishop, yet? Oh, by the way”—I turned and addressed the infectious diseases fellow, a tall woman with hornrimmed glasses—“I’m Frank, the neurosurgery resident who did his LP. The intern here told me he has
Listeria
meningitis.”

The fellow nodded, her face dour.

“Well, we know several things. He does have
Listeria
meningitis; also has some form of pneumonia, we’re not sure what type…he’s getting an open lung biopsy this afternoon…and he has oral candidiasis.” Candidiasis, called “thrush” in infants, is a yeast infection that almost never occurs in the mouths of adults unless they have had prolonged antibiotic therapy or have had their immune systems suppressed by disease or drug treatments.

“His family showed up from Ohio,” the diminutive medical intern added, “but they haven’t given us much useful information. It seems Mr. Bishop is a freelance artist and graphics
designer who has been in town here for several weeks on a job. They haven’t seen him in months, and he was the picture of health when he left Ohio. He doesn’t do drugs, he doesn’t smoke. In fact, he’s a health nut. Whatever happened to him happened fairly quickly. He must have just passed out in the street one night, was robbed and left there to be picked up by police, who thought he was drunk. His tox screen was totally negative.”

“I wouldn’t say that they didn’t provide us with any useful information,” the fellow interjected. “I got two pieces of information that you didn’t. He’s a homosexual. And he’s been to San Francisco.”

The intern and I screwed up our faces in simultaneous puzzlement. I voiced what we were both thinking: “What difference does that make? I know—too much sourdough bread.”

The fellow removed her glasses and spoke in low tones, as if she was about to convey top-secret information: “There are scattered reports coming out of cities with large populations of homosexual men, San Francisco in particular, concerning a new illness that afflicts only gay men. We’ve known for a while that this group is more prone to hepatitis B and a variety of other unusual things, such as gay bowel disease. Now, however, there seems to be a clustering of weird illnesses—Kaposi’s sarcoma, pneumocystis pneumonia, candidiasis—occurring in homosexual men. Mr. Bishop fits that picture. He’s homosexual, has been to San Francisco several times, has a low white count and several infections that occur only in people without competent immune systems. That seems to be the common denominator: immunodeficiency, or lack of normal immunity. There’s no name for it yet.”

“Is it contagious?” I asked with a shudder, thinking of the CSF I had cavalierly splashed about.

“No,” replied the fellow. “At least we don’t think so. Since
only homosexual men are afflicted, it must be transmitted by something unique to their culture or their environments. One theory holds that it comes from the overuse of amyl nitrate, a drug used by homosexual men to heighten orgasm. Another hypothesis is that this is a virulent form of hepatitis B, but that seems far-fetched. Hepatitis B has been around a long time and has never been seen to cause anything like this. Some feel that geography matters, since the disease seems limited to the West Coast and to sections of Florida and the Caribbean—Haiti in particular.”

I shrugged and left. Clearly not a neurosurgical problem. I found out later that Mr. Bishop had died of complications following his lung biopsy. The biopsy itself showed pneumocystis pneumonia. He became the first person reported to our local county health department with the strange new disease of gay men. Shortly thereafter, the illness got a name: AIDS.

Mr. Bishop’s case
faded from my memory, his name lost in the sea of names, faces, and diseases that a resident in a large medical center must deal with on a daily basis. Looking over my log book of operations and clinic visits, I once estimated that I took care of almost one thousand new patients each clinical year of my training. That number didn’t include the William Bishops, those patients for whom we performed some bedside procedure or informal hallway consultation.

This is not to say that we forgot patients easily. While people in many occupations—bank tellers, food servers, mechanics, to name but a few—must deal with the public by the thousands annually, the interaction of physicians with the flux of humanity is unique. Bank tellers don’t take personal histories. Food servers don’t say you’ll die within a year. For some reason, though, Mr. Bishop drifted out of my memory.

Years later, at the end of my chief residency year, I was speaking to one of the many insurance salespeople who dog us as we are about to finish our training. He was discussing disability policies and mentioned casually that I would have to be tested for cocaine and HIV before a policy could be issued. This was now standard for physicians. I shrugged it off: I don’t use cocaine and I’m not gay…Then, suddenly, I remembered Mr. Bishop! The night of his LP came back to me in a rush, the few drops of spinal fluid that had splashed into my eyes were now oceans of contagion. In five years I hadn’t developed AIDS, but the latency period between HIV infection and the full-blown clinical syndrome can be quite long.

How many other patients with HIV had I dipped my fingers into, whose bone dust had flown into my eyes and nostrils, whose spinal fluid had drenched my clothes? I had been up to my mask in bodily fluids during the blind era of the disease, when the virus was spreading but no test for it was available and few precautions were taken.

I took some comfort in the knowledge that our medical center was in an urban area with a very low prevalence of HIV. Nonetheless, I deferred getting tested for years, until I foundit unavoidable. Mr. Bishop was never far from my mind during that long week which separated the drawing of the blood and the phone call informing me of the negative result.

But nothing would ever be the same again. The next person to roll into the ER could be the one who kills me.

A
t the university hospital, the days belonged to pain, the night to trauma. Our hospital was a “level I” trauma center, able to handle virtually any type of trauma except the most severe burn cases, which were diverted to the burn center across town.

There are two places where a body loses its human facade, where the trappings of personality, intelligence, and spirit fall away to reveal the Frankenstein mechanism of arteries, veins, and nerves beneath. One is the autopsy table. The other is the trauma room.

It was another night on call. I had retired to the spartan
house-staff quarters on the hospital’s uppermost floor to grab some sleep before facing the next day’s overloaded operating schedule. The on-call room was little more than a hard bed and a loud phone. The doors didn’t even lock—the legacy of a previous hospital administrator who feared that locked doors would mean too much sex among the house staff. The little that administrators do know about medicine must be garnered from daytime television. Soap opera M.D.’s may fornicate in the linen closets, but the average surgical house officer would more likely be caught sleeping there.

The emergency room awakened me at two in the morning with word that an ambulance carrying an auto crash victim was pulling in. Before heading down to the ER, I stopped in the bathroom. Any patient too ill to wait for me to pee was likely to die with or without my help.

I entered the trauma room just as a pale and bloodied young woman was being lifted from the ambulance stretcher onto the trauma room gurney. She was strapped to a “backboard,” a wooden platform used to immobilize the entire spine. A paramedic in a blue jumpsuit droned her report to all within earshot: “Caucasian female, age twenty-two…unrestrained passenger in a car traveling at high rate of speed down Bigelow Boulevard. The car crossed the center line and collided with another vehicle. Victim was found awake but incoherent outside of the vehicle. Blood pressure 100 over 60, pulse 125. An open laceration in the right frontal parietal area was packed to stop bleeding. Large blood loss was apparent at the scene. No obvious limb fractures or deformities were noted. The patient moves all four extremities spontaneously, but follows no commands…”

Fearing that more trouble was on the way, I asked the paramedic what had happened to the other victims of the crash.

“Two people in the other car were taken to Mercy Hospital,”
she replied, adding under her breath, “and the driver of her vehicle was dead at the scene. We pronounced him and called a coroner’s ambulance.”

“You pronounced him?” I asked with mock indignation. Officially, only a licensed physician can make the pronouncement of death.

“It doesn’t take an M.D. to know when a headless guy is dead,” she answered with a slight smile. I still had a lot to learn about street trauma. The paramedic crew retired to the front desk to complete their reports and await the return of their backboard.

Nurses quickly cut the clothes from the injured woman’s arms and torso. Until the extent of spinal injury is known, excessive movement of the patient is unwise and the more civil methods of removing clothing are too dangerous. For those with minor injuries, watching a beloved sweater being shorn from their bodies like fleece from a sheep can be more traumatizing than their accidents. The victim’s lower body was encased in a blue MAST suit, a comical set of inflatable pantaloons used to force blood from the expendable legs into the not-soexpendable head.

I donned a pair of latex gloves and removed the gauze pads the paramedics had stuffed into the head wound. Pulling away blood-caked hair, I separated the edges of the lacerated scalp. The wound was eight or ten inches in length and filled with road dirt and fragments of windshield glass. The glistening ivory surface of the skull showed; a jagged fracture ran parallel to the laceration. Pink, macerated brain tissue the consistency of toothpaste leaked from the fracture line.

The Edwin Smith papyrus, an ancient Egyptian medical text dating back to 1700
B.C.
, declared that any patient with brain tissue oozing from a skull fracture had “an ailment
untreatable.” Nearly four thousand years of medical progress had not disproved this grim prognosis.

I ruffled through the papers stuffed under the backboard, searching for her first name…Shirley. Under normal circumstances I would never address a new patient by her first name. Such uninvited familiarity is the province of car salesmen, not physicians, but a severely head injured patient requires a less polite approach.

A first name is the most durable lifeline to the outside world, the first word recognized and the last word forgotten. When a dementing illness erases our awareness of home, spouse, and children, we will still answer to our first name. A first name can pierce the delirious fog of head trauma faster than any other word. Leaning close to her face, I smelled her alcoholladen blood—a nauseating aroma unique to emergency rooms.

“Shirley,” I spoke directly into her ear. She slowly opened her eyes.

“Yes?” she answered, her voice muffled by the green plastic oxygen mask draped over her mouth.

“Shirley, my name is Frank. You’ve been in a car accident and you’re in the hospital. I don’t think you have been badly hurt, but we have to do a bunch of things here. It’s going to be a long night. Can you wiggle your toes and fingers for me?”

After a brief delay she obeyed, feebly, and then closed her eyes again. Although I was encouraged that she was not unconscious, I remained skeptical about her chances for survival. I had seen “talk and die” patients before, those who have a short period of wakefulness followed by a slow descent into coma and brain death. Just as a sprained ankle may not bruise and swell until hours after being twisted, the injured brain may not succumb to edema until several hours after a lethal impact.

The skull is a best friend and worst enemy to the gelatinous
organ within. During normal daily activities, the brain sways to and fro in a watery sea of spinal fluid, tethered to the bone by small veins. During rapid acceleration and deceleration, such as during a car crash or during the vigorous “shaking” of a crying infant (one of the leading causes of infant murders), the brain slams into the skull and rips loose from its venous moorings. Blood oozes from the torn veins, forming compressive clots known as subdural hematomas, while edema fluid collects in the bruised areas of the brain. Trapped within the skull’s bony confines, the swelling brain chokes off its own blood supply and strangulates. In a trauma, the skull turns from a brain’s protector to its murderer, and, finally, to its coffin.

The surgeon can intervene by removing blood clots and giving drugs to reduce brain swelling, but the damage is often irreversible. Surgeons in Japan tried removing the top of the skull in these patients, allowing injured brains unlimited space in which to swell. The skull’s “lid” was stored temporarily in a refrigerator, to be replaced when the swelling subsided. In some cases, unfortunately, the brain swelled to monstrous proportions, making the patient’s head look like something from a bad science-fiction movie. The patients died anyway and the practice has been abandoned.

In desperate cases, large sections of the brain can be hacked away to make room for more swelling—a kamikaze strategy. In a macabre sense, Shirley was performing this type of surgery upon herself by squeezing her swollen brain tissue through the open skull fracture. The continuous decompression of dead, liquefied brain matter from her wound may have been the only thing keeping her alive at the moment.

“Shirley, you have a cut on your head from the windshield and this young doctor is going to put some stitches in your head.” I instructed the general surgery intern to suture the
laceration using a quick layer of running nylon. Since I was likely to reopen the wound in the operating room in a few hours, a cosmetic closure was unnecessary. “It doesn’t have to be a Rembrandt; just stop the bleeding. And try to keep her hair out of the wound.” He grimaced at the sight of a growing mound of brain exuding from the wound. I wiped it away with a gauze sponge. “Memories of third grade,” I whispered, “but don’t let it bother you; she won’t miss it.”

Bill, the senior surgical resident, examined the woman’s chest and abdomen while his junior residents performed other standard chores: drawing blood samples for the lab, inserting large intravenous lines, feeling along her arms and legs for any palpable fractures or lacerations, debriding the skin of dirt and glass.

“Type and cross her for six units of blood,” Bill instructed a trauma nurse, “and see if they can send down some type O in case she crashes. What’s her pressure now?”

“Ninety over sixty.”

“Force in another liter of lactated Ringer’s as fast as you can and get the X-ray people in here.”

I called the CT technician to let him know that we needed an urgent brain scan. A physician must wake up a lot of people in the middle of the night and attempt to engage them in meaningful conversation.

“Hello,” a dreamy voice answered.

“Are you the CT technician on call?”

“Hello?”

“IS THIS THE CT TECH ON CALL?”

There was a pause and the rustling of bedsheets.
Christ, I thought, he’s falling asleep.
The previous month, a tech had dropped the phone on the floor while I was talking to her and gone back to sleep. I had to send the police to get her.

“…Uh, is this the hospital?” The tech was barely conscious.

“No,” I replied, “it’s Ed McMahon calling you from Publisher’s Clearinghouse. You have just won one million dollars. And, by the way, I’ve got a trauma here in the ER and I need a scan now.”

“OK.”

It wasn’t a convincing okay, more like the okay of someone who was slipping back into slumberland, to awake in four hours wondering if the hospital had really called or if he’d just had a nightmare. I called again ten minutes later and was informed by his irate wife that he indeed was on his way.

Perhaps I was a little rude, but I didn’t care. I now knew how James Bond must feel when he thinks he’s saving the world from certain destruction. Politeness and civility are sacrificed without a trace of guilt. As the earth teeters on the brink of nuclear holocaust, Bond runs through a crowded airport knocking people flat, kicking over their luggage and spilling their drinks—all without so much as an “Excuse me.” He’s not rude; he’s a hero on a mission. He can grab people by the throat, hold a gun to their heads—anything to get the job done. I can say: “Get your ass out of bed and scan this lady BEFORE SHE DIES.” In the end, all is allowed, all is forgiven. We do what we have to do. Results, not effort.

Shirley’s blood pressure began to rise and stabilize. The intern had finished closing her scalp and the X-ray technicians were setting up to take chest, neck, and abdominal films.

“Shirley, are you still there?” I asked.

“Yes, but my head hurts. Am I going to die?”

“No. Too much paperwork if you die. We’re going to take some X-ray films.”

“How’s Jack? I want to see him.”

“Uhmmm…he’s not here right now. They took him
someplace else.” A diplomatic response. She was in no condition to learn that her friend had been guillotined. Bill and I retreated to the small coffee lounge, where we feasted on a box of vanilla wafers stamped “For Institutional Use Only.” I had gained twenty pounds in three months on the boss’s service from eating vanilla wafers washed down with chocolate milk and was becoming an “institution” myself, at least in terms of body habitus. The coffee was a day old, but we drank it anyway for its medicinal properties.

“This is just fucking great,” Bill complained. “I have a Whipple to do tomorrow and I’m going to be totally fried. We get a Whipple about twice a year.” An operation for pancreatic cancer, the complicated Whipple procedure was something that the general surgery residents slather over.

“At least you may be able to go back to bed soon,” I countered, “but she’s got the gray matter coming out of her head. She’s going to need a craniotomy if she doesn’t croak first. And the boss has all four of our OR’s booked at seventhirty. If he gets bumped by this case he’ll blow a fuse.”

I glanced at my watch. It was now three-thirty. My mind turned to those bureaucratic dilemmas which consume so much of a resident’s time and energy. There was no way I was going to get Shirley scanned and complete a craniotomy fast enough to avoid delaying the boss in one of his rooms. Tomorrow was his squash day, too. If he wasn’t done by noon it would be me who’d need a craniotomy. And who was going to cover my room if I was in the OR with this case? I could put the intern in my room, but that would piss off the boss. He’d go bananas on the intern, and then the intern would hate me for the rest of his neurosurgery rotation. Tuesday was always our biggest day. Why did these cases always roll in on Monday night? Who went out drinking and driving on a Monday night?

I could ask anesthesia for a fifth neurosurgery room. I
could ask Mother Teresa for a date, too; the answer would be the same. I glanced over the OR schedule tacked to the bulletin board. Four heart rooms, four ortho rooms, four neuro rooms…it was hopeless. They’d never give us five rooms. I had to either bump one of the boss’s cases to a later time or cancel one altogether. I pulled out my patient list, called the neuro nursing station, and spoke to Karen, the night charge nurse.

“Karen, this is Frank. Is there any excuse for canceling one of the seven-thirty cases tomorrow, like a fever, a low potassium—anything?”

“Let me look.” There was a pause as she went off to review the charts. “Well,” Karen returned, flipping pages, “Mr. Jamieson’s potassium is 3.5.”

“Not low enough.”

“How about Mrs. Bates, the hemifacial spasm,” Karen continued, “her temp at midnight was 99.7.”

“Not high enough. Has everyone signed consents? Doesn’t anyone have any doubts? Maybe someone needs an extra day to think about their surgery? It is brain surgery, after all.”

“No chance. These are the boss’s patients, remember?”

“Yeah, right. If you think of anything let me know. I have a trauma down here who is about to fuck with our elective schedule.”