When the Air Hits Your Brain: Tales from Neurosurgery (19 page)

“Don’t come back?”

“This baby has no future. Why watch her suffer and die? Go home.”

• • •

Rebecca eventually did awaken,
but was virtually quadriplegic, with only weak movements of her arms and no movement in her legs. Her swallowing was impaired. She gagged and choked during feeding. Over the ensuing weeks, we inserted a tracheostomy in her neck, a permanent feeding tube into her stomach, and a shunt into her brain.

While Rebecca’s mother visited her occasionally, she could never hold her, never feed her. She couldn’t bear to watch as the nurses snaked thin tubes into her baby’s tracheostomy to suction away the infant formula overflowing into her lungs. Because the tracheostomy entered below the vocal cords, Rebecca could make no sounds. Her gaping mouth cried in ghostly silence.

Finally, the family heeded Dr. Wilson’s advice. One day Rebecca’s mother stopped coming. Rebecca became the ward of the fifth-floor neuro team. Nurses rotated frequently, to avoid feeling too motherly to the child with no future. Even Dr. Wilson quit making regular rounds on her. She was fed, bathed, and turned. She was given a radio and a ubiquitous Sesame Street mobile to be hung over her crib. Her life became a routine of detached custodial care. She was now adrift in the world, cut free of permanent human bonds, kept at arm’s length by those afraid to see children linger. Yet, for some strange reason, I still visited her every day.

Rebecca Hobson responded to the world that had greeted her with an immediate death sentence. She refused to die. At least for a good deal longer than anyone believed possible.

Months passed.
Rebecca developed a round face, dimples, and a full head of curly hair. She smiled and made feeble swats at her mobile. Though she still could not swallow well enough to be free of the feeding tube, nor breathe well enough to be rid
of the ventilator, she became a person. The scrawny infant that had frightened me in the ER grew to be a beautiful baby.

Rounds became playtime. I shook a rattle or her stuffed rabbit, the sole gift from her mother, as I listened to the litany of blood work and vital signs registered for the day. I harbored a nagging worry that Rebecca wasn’t going to die fast enough, that she was going to grow to be several years old and fully aware of the world before she had to leave it.

Ethicists and cost cutters argue that placing a pillow over her tracheostomy would be the best thing we could do for Rebecca—and for society. Rebecca’s hospital costs now topped half a million dollars, a steep price to pay for a baby with a terminal disease. Her death would be brutal, most likely from pneumonia. The ethicists and cost cutters might change their minds, however, if they saw Rebecca. Although imprisoned in a hospital bed, she did not look like she longed for death as she grinned at her rabbit.

Even after I left Children’s Hospital to return to the adult service, I would sneak back on my rare quiet nights on call to check on Rebecca. She lasted nine months, a year. She began mouthing words and spending time in a little swinging chair, rocking back and forth with blue plastic oxygen hoses swaying at her side. Her mobile grew faded and worn, her stuffed rabbit stained with pureed food. Her family, although informed of her progress, did not waver in their decision to treat her as already dead.

After my pediatrics rotation was over,
I
was assigned to the V.A. hospital for six months and lost track of Rebecca, who was now nearing eighteen months of age. One evening, as I was having dinner in the hospital cafeteria, I spied Eric, the current chief resident at Children’s. I asked him if Rebecca was still the same.

“No, she’s finally started to crump. We think her tumor is recurring.”

“Have you scanned her?”

“Why the hell would we do that? Are we going to operate on her again?”

He was right. This terminal slide was what we had all been waiting for since her first operation. Still, the news disappointed me.

I was going to head home, but I instead wandered down to the fifth floor to see Rebecca again. I hadn’t seen her for the past six months and was curious to see how she looked, what she could do.

It was evening when I arrived. The floor was quiet. I waved at some familiar faces at the nurses’ station and walked quietly down to Rebecca’s room at the far end of the hall. I stopped and looked in the window before entering the room.

The mobile was gone and the radio had been replaced by a television set with the volume turned down. The set flickered silent images of a
MASH
episode. The ventilator clicked and hissed a slow rhythm.

Rebecca blankly stared at the screen, her face paler and thinner than I remembered, her lids heavy. Dark circles underlined her sunken eyes, which were beginning to deviate downward again. The left corner of her mouth drooped from increasing facial paralysis, the dimples victim to her resurrected malignancy.

I stepped in front of the bed and peered down at the tiny face, which looked back at me. She paused, then broke into a crooked grin. Her eyes widened and she gleefully twisted her head and struggled to lift her paralyzed arms to embrace me, happy to see one of her few friends.

That moment remains clear and frozen in my mind to this
day, more than any other moment in my clinical experience. Although in the years that followed I would take care of thousands of patients, marry, and have two daughters of my own, I may never be as important to anyone as I was to Rebecca that night. As I had gone about my own life, I remained special to this pathetic child imprisoned in her hospital crib.

I spent a long time with Rebecca and her rabbit that night. Ten days later she died. The rabbit was buried with her.

The nurses called me
to the neuro floor a month after Rebecca’s death. Her family had sent a gift to the floor and they wanted me to see it: a porcelain statue of a laughing girl. At the base of the figurine sat a small brass plaque, inscribed with the words “In memory of Rebecca.”

I am not particularly religious. In fact, the birth of children bearing cancers I find difficult to reconcile with a merciful God. Nevertheless, there must be someplace where Rebecca now laughs in the bright sunshine, finally free of her ventilator and gastrostomy.

My facade of surgical psychopathy cracking to pieces, I left the floor and walked away from Children’s Hospital.

Never to return.

T
he first years after receiving my driver’s license, I cruised the streets with little regard for the dangers of the road. Protected only by the rusting bodies of cheap used cars, I drove with the confidence of Achilles, afflicted with the youthful delusion of immortality. Until one event penetrated that delusion like the spear which pierced Achilles’ human heel.

My revelation came on a snowy Friday evening. I was piloting a 1967 Volkswagen along the expressway leading from the university to my parents’ home. Blowing powder barely dusted the roadway, and I believed the traction was normal. That is, until I reached the first overpass and discovered for myself
that bridges really
do
freeze before the road surface. I hit the shimmering ice on the overpass going fifty miles an hour. I felt the friction between my worn tires and the glazed road evaporate; the steering wheel became limp in my hands. The car’s tail began a slow, clockwise spin; I saw the bridge rails flash by through my windshield as my vehicle turned perpendicular to the road.

The Volkswagen continued to spin and slide. Transiently blinded by the headlights of a truck behind me, I feared being smashed against the concrete abutment. My out-of-control Beetle completed one complete revolution as it exited the bridge, then regained its footing on the warmer asphalt of the roadway before taking off, straight as an arrow. I continued down the expressway at full speed as if nothing had happened.

But something
had
happened. Although I was unhurt and my car undamaged, my outlook on driving could never be the same again. This experience taught me what a dozen Red Highway movies in Driver’s Ed did not: how very easy it was to lose control of a car and die. Decades later, I still feel the steering wheel dissolving in my hands as the car slides. One instant in complete command; the next, a terrified passenger thrown upon the mercy of fate for survival.

I had been lucky, learning my lesson and paying no price. If only all lessons were so painless. A Native American proverb states that a child allowed to wander into the campfire learns better than a child told a thousand times to stay away. But this trick fails if that first trip into the fire burns the child to death. On that snowy expressway, I had wandered into the campfire and, by sheer luck, escaped unburned.

Before reaching my surgical adulthood, I would again stray into the inferno of overconfidence. And come perilously close to emotional incineration.

• • •

Clipping an intracranial aneurysm
tests the full mettle of a neurosurgeon. While this procedure was not the complete measure of our worth—a neurosurgeon who does excellent spine work but can’t clip an aneurysm has greater value than one whose proficiencies are the reverse—the residents gauged their machismo using the aneurysm scale. At what point a trainee “did” his first aneurysm, and how many aneurysm notches were carved on his belt when he finished training, were statistics known well throughout the department.

Given the stakes involved, what constituted “doing” an aneurysm spurred hot debate. “Mark said he
did
that anterior communicating artery aneurysm with Gupta, but he didn’t dissect it out, he only put the clip on it…and that’s
easy.
” Aneurysms are the bull elephants of our Big Game Club. To put one on your wall, you had to stalk it, stare it in the eyes, and pull the trigger yourself. Letting someone else dissect it out and then ask you to place the clip was like having your hunting guide bludgeon an elephant and then ask you to shoot out the beast’s unconscious brain. No fair.

Average on the aneurysm/testosterone scale, I slayed my first (fairly easy) posterior communicating artery aneurysm six months into my senior residency year. In the second six months I clipped several more. The number of my successful cases mounted, each smoother than the last. Although a few patients succumbed to the inevitable complications of brain hemorrhages, I harmed no one with my surgery. My confidence became dangerously inflated. “These aren’t so tough,” I remarked foolishly to one of the attending surgeons.

“You aren’t a neurosurgeon when you clip your first aneurysm,” he replied grimly. “You become a neurosurgeon when an aneurysm first blows up in your face…have you had that
happen yet, son? Has one of those little bastards exploded on you?” I shook my head and he just smiled, the knowing smile of a weathered gunslinger talking with a pompous greenhorn who has yet to feel a bullet pierce him to the bone. The surgeon continued: “Well, when that first one blows…let’s just say the next one you do won’t look quite so easy anymore.”

My senior residency year
drew to a close. I was five years into the program and slated to start my research time, but due to a sudden change in the schedule, the V.A. beckoned me for three more months of clinical duty. When I took the helm from the previous chief resident, only one patient resided on the V.A. service: Charles Bognar. Charles, in his mid-forties, had seen some action in Vietnam. He had been at the V.A. for less than a day. His diagnosis: subarachnoid hemorrhage.

Charles had experienced the worst headache of his life about forty-eight hours earlier. He said that it had to be bad to achieve the “worst” award; a member of the Woodstock generation, he had known some headaches in his day. The pain overwhelmed him like a “mortar burst” as he made love to his second wife. His admission CT scan showed fresh blood spilling into the left Sylvian fissure, the large cleft between the frontal and temporal lobes—where the mighty middle cerebral artery lives.

The middle cerebral artery, or MCA, is the largest branch of the carotid artery within the head, supplying blood to almost two-thirds of the cerebral hemispheres. In the Sylvian fissure, the thick MCA divides into smaller trunks which exit the fissure and fan out over the brain’s,surface like nurturing fingers. The junction where the MCA subdivides forms a churning vortex of high-pressure blood—fertile ground for aneurysm formation.

MCA aneurysms can be quite difficult to clip. They hide
behind the numerous MCA twigs like plump red birds perched in an arterial cage. These vital branches must be sharply dissected away from the fragile dome before a metal clip can be placed; otherwise they might be inadvertently clipped as well, resulting in a stroke.

Charles the aneurysm was a challenge; Charles the man was unusual. Gregarious to the point of being obnoxious, and given to inappropriate comments, he introduced his wife as the “second Mrs. Bognar…and there’s sure to be a few more.” He loudly gave his definition of a second wife: “someone with real jewels and fake orgasms,” much to her evident embarrassment. He also made some very public observations to his fellow ward patients about his wife’s sexual gymnastics and how they’d caused a blood vessel to burst in his brain. He was clearly proud that he had married a woman capable of such a feat. His crude statements were accompanied by a sinister, wheezing laughter.

With his long ponytail and sinewy arms covered with obscene tattoos, I could easily fear Charles if I met him in a dark alley. But the ward wasn’t a dark alley, and Charles was just one more patient in need of an operation. His angiogram confirmed the presence of a left MCA aneurysm. Surgery would take place on my fourth day at the V.A..

Charles’s aneurysm resided in the left side of his brain. To a brain surgeon, there are two cerebral hemispheres: the left one, and the one that isn’t the left one. In over 90 percent of right-handed patients, and in the majority of left-handed patients as well, the left hemisphere contains the apparatus for making and comprehending speech, both written and spoken. The right hemisphere does some useful things, too, like helping us get dressed in the morning and giving us an appreciation of Bach (or the ability to compose music, if we’re among the
few so endowed), but its function is merely desirable. The left hemisphere’s function is indispensable. While a total occlusion of the right MCA will leave a patient paralyzed in the left face, arm, and leg, it will spare the intellect and personality. A similar occlusion of the left MCA amputates the patient from humanity and thrusts him forever into a foreign land, where no one will ever speak his language.

A human MCA, the caliber and fortitude of a plastic drinking straw, carries the nectar of life—another example of how our futures hinge upon the puniest of physical structures. Billy Renaldo had discovered how useful the rubbery pencil known as the spinal cord can be. Our coronary arteries, smaller than strands of linguini; our pituitary gland, little more than a raisin of gooey tissue—delicate, but essential to life. To compensate for their fragility, nature coats these organs in heavy armor of bone and muscle. In Mr. Bognar’s case, unfortunately, nature could not protect his left MCA from
me.

Charles went to the operating room as scheduled. The opening was uneventful. I dissected through the scar tissue in the Sylvian fissure with ease, exposing the aneurysm and the MCA branches as they spiraled around the pulsating dome. No need to worry now; I had obtained a good view of the main MCA trunk and was prepared to put a temporary clip should an intraoperative rupture occur. The attending surgeon rested in the lounge, available if I “got into trouble.”

Using a microdissector, I worked under the microscope to free the aneurysm from the cage of MCA branches so that I could find the neck and get a clip across it. One MCA branch came away easily, then another. I was almost home!

But as I twisted the aneurysm to get one last look at its backside, disaster struck. In my compulsiveness to free the MCA branches, I screwed around with the fragile sac one too many
times. In a heartbeat, my previously dry operative field turned into a crimson flood. I became paralyzed for a moment, allowing the blood to fill the left side of Charles’s head like a basin and spill into my lap. My mind went blank. This can’t be happening, it was going so well…
what to do, what to do…put a fucking suction in there, idiot!
I put the largest suction into the wound and dove down into the gurgling depths in search of the source of the hemorrhage. The aneurysm had blown. But where was the tear? And could it be fixed?

“I have some bleeding up here.” My voice quavered as I informed the nurse-anesthetist of the intraoperative rupture. He bolted from the chair.

“How much?”

“A lot.”

He pulled the emergency light, summoning help. I screamed for the temporary clip as I relocated the main trunk of the MCA in the bloody maelstrom that swirled within the Sylvian fissure. I placed the clip. The bleeding slowed. The attending surgeon and the anesthesiologist entered the room hurriedly.

“Why didn’t you call me?” my staff man thundered over my shoulder, as if I needed more stress.

“It just happened,” I whined. “I was just looking around the backside and it blew…I have a temporary clip on.”

He squinted into the observer side of the microscope.

“Where…where is your temporary clip?”

“Here.” I used a gold-tipped forceps to point out the clip on the MCA.

“Way down there?! Jesus H. Christ, that’s pretty proximal, probably proximal to the striate perforators…how long has it been on?”

“A minute, maybe two?”

“Shit! I’ll be right in. Meanwhile, try and expose the aneurysm again…and the MCA a little further along. Maybe you can slide the temporary clip further downstream.”

I placed several long cottonoids into the wound to protect the left brain, which was pulped and swollen. Aspirating the clot, I traced the residual bleeding down to the aneurysm’s dome, where, to my horror, I discovered that the dome had been partially torn away from the parent artery.
Bad, very, very bad.
If the tear had been on the dome itself, as had happened with Andy Wood’s vertebral aneurysm, I could have easily clipped the aneurysm. Case finished. But a tear at the neck of the dome left a gaping hole in the MCA itself, a hole which was unfixable. A large MCA branch, perhaps the entire MCA, would have to be occluded just to stop the bleeding. I was crushed in a no-win vise: let Charles die on the table, or take out his left MCA and let him die a speechless relic in a nursing home. ‘What would it be?

After a brief scrub, the staff surgeon displaced me from the operator’s chair and poked around the anatomy with a suction tip. I cowered in the assistant’s chair, awaiting his verdict on the location of the aneurysmal tear, like a small boy awaiting his father’s discovery of a picture window shattered by an errant baseball. In an instant, reduced from brain surgeon to child. In the same instant, the life on the OR table had been laid to waste. Charles’s vast collection of war stories and dirty jokes dissolved from the dying pink circuitry like a Cheshire cat, leaving only the lifeless Sylvian fissure smiling back at me. The temporary clip, on for over five minutes now, left little hope that the left hemisphere—the precious left hemisphere—would survive.

“There is a big hole in the main trunk of the MCA…,” the staff man grumbled with resignation, “and it’ll take too long to patch in a superficial temporal artery bypass. I doubt
the STA could support the entire MCA territory, anyway. I’ll put an encircling clip around the MCA and hope that the vessel stays open. I have my doubts.”

He loaded up an encircling clip, designed to wrap around the entire artery in just such a catastrophe, and crushed it around the MCA. The temporary clip was removed. The MCA stopped bleeding, but the branches of the clipped MCA trunk no longer pulsated. In the ensuing minutes, life-giving arteries thrombosed into rods of purple licorice. The staff surgeon shrugged, pulled off his gloves, and yanked down his mask. The act of removing one’s mask and breaking sterility before the wound is closed is symbolic, tantamount to pronouncing the patient dead before he has left the operating table.

“Talk to the family, will you, Frank?”

“Yessir. I will do that.”

Closing the wound took an eternity, a ridiculous, demeaning exercise, a marathon runner slogging to the finish long after everyone else has gone home. I thought about the second Mrs. Bognar in the waiting room.