When the Air Hits Your Brain: Tales from Neurosurgery (9 page)

I crammed my patient sheets back into my coat pocket, finished my coffee, and returned to the trauma room, where Bill was already reviewing the chest film.

“Her mediastinum is a tad wide,” he murmured to me. “She’ll need an aortogram.”

The aorta, a gargantuan artery which carries blood from the heart, descends between the two lungs on its way to the abdomen in a chest space called the mediastinum. In the mediastinum, the aorta is tethered by a short ligament called the
ductus, the remnant of the embryonic artery which shunts blood away from our fluid-filled fetal lungs. In the rapid deceleration of a car crash, the ductus acts as the aorta’s seat belt, restraining the jumbo artery’s midsection while the rest of it continues to move forward at great speed. In a violent crash, even a young and resilient aorta can tear and leak blood into the mediastinum, widening the space around the heart as seen on chest X rays. A leaking aorta, like a leaking dam, can burst at any time. For Shirley, an aortic tear meant that her great blood vessel would have to be replaced with a Teflon tube before a terminal hemorrhage occurred.

Shirley was now the typical “multiple” trauma. With at least two of her vital organs in need of surgical repair, we had to decide which organ took priority. Was it better to have a new Teflon aorta transmitting blood to a worthless brain, or a good brain in a body dead from aortic rupture? We hadn’t even tapped her belly—what surprises lurked there?

Although it was possible to operate on the brain and chest simultaneously, the thoracic surgeons would have to “thin” Shirley’s blood with the anticoagulant drug heparin during the time her damaged aorta was clamped. Otherwise, the stagnant, nonflowing blood would clot off in her aorta. Anticoagulation made brain surgery out of the question. The brain is the bloodiest organ in the body, and any attempt to manipulate it without the body’s clotting mechanisms in full working order would be a lethal exercise. I decided that if she needed both brain and chest operations, they would have to be done separately. I just hoped her belly tap was clean.

A belly tap is made just below the navel: a thin tube is inserted into the abdominal cavity through a tiny incision. Sterile saline is injected, swished around, and aspirated. If the fluid returns tinged with blood, then a spleen rupture or liver laceration
is likely. Yellow, turbid fluid indicates a bowel injury. A junior surgical resident began painting Shirley’s abdomen with orange Betadine solution, while a nurse unwrapped a belly tap kit and placed in on the Mayo stand beside him.

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

“Yes.”

“She was sleepier, more distant. Her left hand grasp was weaker. Worrisome. Her head was going bad faster than I had planned. The scanner people would be here soon. Bill was on the phone to the angio people, arranging a dye test to look for the suspected leak in Shirley’s aorta. With the possibility of a growing intracranial clot, however, she might not last the one or two hours necessary for an aortic angiogram. I would be forced to take her to the OR without it. Of course, Bill would object and we would have one of our frequent fights over which organ system needed attention first.

I reached Dr. Sakren, the attending neurosurgeon on call, and notified him of the situation. His political weight might bully the thoracic surgeons into letting us work first. Sakren was less than enthusiastic—“Call me back if you really need me”: code language for “Deal with it yourself, I’m sleeping.” Thanks a bunch.

That’s why people go to university centers: in search of first-year neurosurgical residents to make their life-and-death decisions for them. I was hoping for more moral support from the attending, but calling him again could be construed as unmanly. In a neurosurgical residency, one of the last maledominated bastions of medicine, looking unmanly is almost as bad as looking lazy. I let him sleep.

Shirley’s belly-tap fluid came back crystal clear—the abdominal organs had escaped major damage. Had Shirley been wearing her seat belt, her injuries would have been reversed. Instead of shattering the windshield with her head when ejecting
from the car, she would have crushed her lower abdomen against the belt, perhaps lacerating her small intestine. In any violent collision, something in the body must take the impact force, something must give. Intestines can be repaired. Fixing the brain is much harder.

The rest of Shirley’s X rays had been developed and delivered to the trauma room. The neck and lower-back films disclosed no fractures or dislocations. I released the straps on her bulky vinyl cervical collar and allowed her to be moved from the backboard. The board was quickly wiped clean and returned to the paramedic crew, who had finished their paperwork and were anxious to get back on the road.

I told the operating room that an emergency craniotomy was brewing, they should set up a brain instrument tray. The night charge nurse gave me the usual grief about the liver transplant that was still going on, the heart patient who was oozing from his chest tubes and might have to “come back,” the open fracture from three hours ago that ortho was still trying to get on the schedule. It was the same story every night I tried to do a case.

“Don’t the transplant people ever work during the day? What are they, vampires? Look, I don’t really care what’s happening up there; just set up a room now.” That James Bond feeling again.

“All right, we’ll set up in one of your morning rooms. You’ll have to bump one of Abramowitz’s seven-thirty retromastoids.” There was a “nyah-nyah” tone in her voice. She knew that bumping his cases carried a risk of castration.

“Can’t you put me in one of the general surgery rooms? We’ll be out by nine or nine-thirty, I promise.” Really, Mother Teresa, you’ll have a wonderful time…I know a place, great Indian food…

“No way. Don’t get greedy. With the backup of cases from
last night, you’re lucky we don’t take away another one of your rooms, too, so be thankful you still have four start times. What time will you be up?”

“The scanner people should be here soon. I guess thirty minutes.” It was actually going to take an hour or more to get to the OR, but they didn’t need to know that.

Bill had overheard my conversation. “What about my aortogram?”

“Sure, Bill, if there’s time.” (No way, my friend. Brains first, big bloody hoses second.)

“We have to make time.”

“If the angio people are here, we’ll take her right from CT to the angio suite, and then to the OR. But she needs a craniotomy before she gets her chest cracked.” No matter what the scan showed, the skull fracture would have to be cleaned out and any bone fragments or hair driven into the brain removed.

“Fine.” Bill seemed satisfied with the compromise. “But I want to see that aortogram. If she’s dissecting we have to do that as soon as you’re through.”

True enough, but an aortic dissection would really blow my OR schedule to hell. To get a new aorta, Shirley would be in the neuro room until two or three in the afternoon, meaning that two or more of our elective patients would have to be canceled outright, not just delayed. Holy shit! I didn’t even want to think about that. I pulled out my patient sheet again. Who would it be? The Italian businessman who’d flown halfway around the world for his operation? Nope, he stays on the schedule. The wife of the director of a major metropolitan opera company? Abramowitz had some big hitters in the day’s lineup. No one would go quietly. Please, Shirley, have a good aorta.

I suddenly felt very tired. The next day’s work loomed
ahead. I could envision each burr hole I would have to drill, each scalp stitch I would have to place, each small brain bleeder I would have to coagulate. Hundreds of tiny motions and I didn’t feel like doing any goddamned one of them.

The trauma room’s intercom buzzed. “The patient’s parents are in the waiting room,” the desk clerk informed us. As bad as I thought my night was, this family’s night was going to be worse. To me, she was as much a bureaucratic nuisance as she was a patient. To them, she was a first step, a first word, a first bicycle, a first date. Decades of their lives, a fond tapestry woven of birthday parties, summer vacations, proms, and graduations, was shredding apart in our ER. The baby they’d tossed into the air now dripped her brains into four-by-four gauze sponges. Bill and I went out to talk with them. Medicine at its ugliest.

The middle-aged couple remained sniffly but stalwart throughout our presentation. Bill discussed the need for a dye test to check the main artery in her body and the possibility that the artery might have to be repaired surgically. I discussed the nature of her head injury and obtained their consent for the brain surgery. They asked the usual questions about her chances for meaningful survival, what she would be like, had her face been badly damaged, and could they see her before she went to surgery. I dodged the recovery issue, stressing that she had suffered no obvious cosmetic damage and was not in severe pain. Doctors are like politicians: we stress the good things. Since we were doing all we could as rapidly as we could, I doubted that there would be time for her parents to talk with Shirley before she went to the scanner.

For her family, this was a nightmare of biblical proportions. Pulled from a sound sleep into a dim ER waiting room and forced to listen to the planned dissection of their daughter,
these poor people could not have been encouraged by our appearance. With our five o’clock shadows, uncombed hair, and iodine-stained lab jackets, we must have looked like high school students to them, right down to our soiled tennis shoes.

I put my hand on the mother’s shoulder, saying that I would be back when I knew more. We returned to the trauma room. The heavy metal door clanked shut, sealing off the waiting room from our brightly lit inner sanctum. A nurse was disconnecting Shirley’s heart electrodes from the wall monitor and hooking them to a portable monitor/defibrillator perched on the end of her bed. A respiratory technician attached Shirley’s oxygen mask to a small green tank. The scanner was ready and they were preparing her to be transported from the ER.

The scanners were in the adjoining children’s hospital, one flight up and about two hundred yards away from the trauma room. The operating rooms were yet another flight up, and another two hundred yards away from the scanners. When transporting an unstable patient, even a brief elevator ride and short roll down a hallway can be an unsettling experience. Surgeons feel comfortable only in the operating room. The operating room sits in a virtual sea of specialized instruments, resuscitation equipment, and anesthesia expertise. Field trips to radiology were like moon walks, the patient tethered to a precarious lifeline of battery-powered monitors and small scuba tanks of oxygen, far from an anesthesiologist and a good instrument set.

“What’s her pressure doing?” Bill asked.

“Ninety over fifty,” replied a nurse.

“I’m not happy about transporting her until we hang some blood. Is there blood in the room?”

I examined Shirley again. Brain matter still oozed from the sutured scalp laceration. “Wiggle your toes.” This time she wiggled only the toes of her right foot. “Wiggle the toes of
your left foot.” Again the right foot. She was developing some paralysis on her left side. At this rate, it was only a matter of time before she started talking about bright lights beckoning her to “cross over to the other side,” or some other hallucination common to dying brains.

“We need to scan her,” I told Bill.

“The blood’s here,” he argued back. “It’ll take just five minutes to hang a unit on a pump bag. Her hematocrit’s only twenty-eight, she’s had seven liters of fluid, and her pressure’s falling again.”

“What’s happening to me?” Shirley cried suddenly as she reached up to pull the oxygen mask away with her remaining good arm. Jan, one of the night nurses, grabbed her arm and told her to relax.

“But I can’t breathe!” she cried hoarsely as she began to struggle with the nurse, jerking with her right arm and twisting her head grotesquely from side to side. I looked at the portable heart monitor. Her heart rate, which had been about 120 for the last hour, had jumped to 190.

“Pressure,” Bill ordered.

“Seventy over palp.”

“Get anesthesia, stat. She’s going to need a tube. And get me a chest tray and call the cardiothoracic fellow down here.”

I knew what Bill was thinking. Shirley was no longer losing blood from her scalp and her belly tap showed no evidence of abdominal bleeding. The falling pressure must be due to blood escaping from the rending aorta in her chest. Her inability to breathe was a sign that her chest was filling with blood, crowding her lungs. Her heart was pumping furiously to make up for the decreased blood volume. She was “shocking out.” Opening her chest and clamping her aorta right there might be her only chance of survival. Anesthesia would have to insert a endotracheal
tube and put her to sleep. If they didn’t arrive in time, Bill would do it with her awake.

Nurses and aides darted from other ER rooms, helping to ferry messages to the front desk. In addition to the anesthesiologist and cardiothoracic fellow, the attending trauma surgeon was notified, and the operating room. Two floors up, the OR technicians began putting away the cranial drills and brain retractors and began setting up the heart-lung machine and chest instruments. An ER medical resident came in and helped Bill insert another IV line. One of the other senior surgical residents on call had arrived and was unwrapping the ER chest tray and preparing some chest tubes, long plastic hoses that are inserted into the chest to drain blood and air. The doors to the other ER rooms were closed to shield the few other patients from the unfolding spectacle.

I remained at the head of her bed. Shirley’s eyes were wide open, her pupils unequal. She was panting in brief, labored breaths; her color had turned ashen. Jan handed me an Ambu bag, a device used to assist the patient’s breathing. I removed the oxygen mask and firmly pressed the Ambu over her mouth, squeezing the bag hard to drive in air. “I’m dying, I’m dying,” she gasped between squeezes.

She was right, she most certainly was dying. We have an innate ability to tell when something is lethally awry in our bodies. My father had chest pains for years before his first heart attack, but we could tell from his face on the morning of that first attack that this pain was different. There was panic in his eyes. Physicians don’t get concerned about patients’ asking if they are going to die, but when a patient blurts out “I’m dying!” we know that this is often an accurate prediction.