When the Air Hits Your Brain: Tales from Neurosurgery (4 page)

Mr. Rathman, medicated with morphine, dozed as we entered. Gary gently shook him awake. The junior resident grasped the drowsy man’s chin and turned his head left and right, squinting to see his pupils in the low light.

“I’m sorry, Mr. Rathman, go back to sleep.”

Gary walked sullenly to the nurses’ station without saying another word. He sat in a chair by a ward phone, reached into his pocket, and produced a portable phone directory. After finding a number, he punched the buttons and waited for an answer.

“Hello? Is Dr. Atkins in?…Dr. Atkins, Gary from the hospital…Listen, sorry to bother you, but this Rathman guy you have on for tomorrow, did you know he has a Horner’s sign on the right…No, it’s pretty obvious…uh-huh…Yeah, a Pancoast tumor is a real possibility. Sure…no, don’t thank me, it was the medical stud who found it…OK, so long.”

He hung up the phone and grabbed the patient’s chart, opening to a physician’s order sheet. He wrote:

“Cancel OR. Polytomography of the right apex of lung in A.M.”

Gary looked up at me with a stern face. “That’s the easy part. The hard part is explaining to him why we are canceling
his surgery.” He got up and began the walk down the corridor again, this time more slowly. “I’ll take care of it, Frank, that’s why they pay me. Go home.”

He didn’t need to tell me twice.

Mr. Rathman’s lung studies
showed the expected crablike growth at the tip of his right lung, a Pancoast lesion. A needle biopsy confirmed a squamous-cell lung carcinoma. No thought was given to removing it; his arm pain and Horner’s sign were proof that the tumor had escaped his lung and was encasing his brachial plexus, the network of nerves in the shoulder. There was no hope of cutting it out now. He was transferred to the oncology service for radiation therapy. I never saw him again.

Mr. Rathman’s case came back to me several months later, after I had left the neurosurgery service and was on my internal medicine rotation at the Veterans Hospital. I received a message that Dr. Abramowitz wanted to see me in his office.

At the appointed time, I was escorted by a secretary into the boss’s lavish office. The walls were filled with diplomas, citations, awards, and autographed pictures of previous teachers and residents. He glared at me over reading glasses slung low over his long nose, his feet propped up on the broad desk.

“Please sit down.”

I complied, almost vanishing into a plush chair. The boss bolted up and continued.

“I understand that you picked up a lung tumor in one of my staff men’s patients, a man who was headed for a discectomy the next morning?”

“I just saw his Horner’s sign, that’s all. It was obvious because it was so dark…it could easily have been missed during the day, a fluke really.” I was nervous. Was this some sort of investigation of his attending surgeon?

“Still, you saved him an operation. Listen, we need good men for this program. How would you like a job when you graduate?”

“Doing what?”

He laughed. “Doing this. Neurosurgery. Becoming one of us. It’s tough, but this is one of the best programs in the country, which means in the world.”

I was stunned. “I’ll have to think about it, sir.”

“Well, don’t think too long. Over one hundred people apply for the two spots we offer each year, and we like to pick them several years in advance.”

Thanking him, I beat a hasty retreat. This was an honor, being offered a position in a premier program by an internationally renowned surgeon. But something bothered me: If this was such an honor, then why offer it to someone who got lucky on one patient? I remembered Groucho Marx’s comment about not wanting to belong to any country club foolish enough to take him as a member.

And why several years in advance? I thought back to my grade school friend David, who committed to the seminary when he was only fourteen years old. Maybe surgical residency was like the priesthood: get ‘em early, before they know what’s happening.

At least David wised up. He now has three children and sells insurance.

I
was in the middle of my third-year rotation in medicine when the boss offered to make me “one of them.” The medicine rotation, or clerkship, was offered at the local Veterans Administration Hospital, more commonly known as the V.A. (Vee-Ay), the Vah, or, more sarcastically, the Vah-spa—although it was hardly spa-like. Nestled behind the university football stadium, the V.A. looked like any 1950s-era federal building: bland and boxy, with smooth, yellow-brick walls tinged with industrial soot.

Our V.A. was one of the better veterans’ facilities in the country. Most of its employees tried hard to do a good job,
but the unmistakable footprint of government bureaucracy was everywhere: nowhere to park (unless you were one of the administrators), oppressive paperwork, outdated equipment. Management teemed with career drones who knew they couldn’t be fired and acted accordingly. Surprisingly, the hospital’s many inefficiencies didn’t stem from a lack of money, since the V.A. was well funded. Regulations strangled the place, not poverty.

The V.A. holds fond memories for me. For medical students and residents, that musty building was, for all of its problems, a fun house filled with discussions of medical esoterica over cold pizza at three in the morning. A place for poring through hospital charts that stood taller than the patients. A place where a baby-faced third-year student like myself could be introduced as “doctor” without being laughed at. The hours were long, the supervision scant, and the aggravations many; but the daily struggle to provide quality health care to men and women who had served their country was rewarding. With the monolithic government as our common enemy, the V.A. forged personal bonds among the resident corps (also called “house staff”), often lasting a lifetime. Jim, my assigned intern-mentor during the third-year medicine rotation, remains one of my closest friends almost two decades later.

The public uses the word “medicine” in the generic sense to encompass all aspects of health care, from dermatology to orthopedic surgery to pediatrics. To the layperson, anyone with an M.D. is “in medicine.” To a physician, a person “in medicine” is an internist—as opposed to a surgeon, radiologist, or psychiatrist. Internal medicine residencies train physicians to handle the nonsurgical health problems of adults, such as diabetes, hypertension, and pneumonia.

During those crucial nine weeks at the V.A., I learned many of the minor technical aspects of being a physician: drawing
blood, looking at X rays, interpreting electrocardiograms, writing orders. I hungered for this experience. The neurosurgery elective hadn’t afforded any opportunity to do much beyond yanking stitches and percussing chests. The medicine rotation introduced me to the awesome authority invested in physicians: the power to violate another human being—legally. License to stick our gloved fingers into the rectums of humanity, to jam needles into spines, to thread garden hoses into colons.

I first tasted this intoxicating authority in my second week at the V.A. Jim, my intern, handed me a nasogastric tube, together with a foil packet of K-Y jelly, and told me to insert the plastic snake into one of his cirrhosis patients in the big ward. The patient, nauseated from a bowel impaction, needed the tube to decompress his stomach and make him more comfortable (if having a half-inch tube in your nose is more comfortable than minor queasiness).

“You’ve seen me do it a dozen times,” Jim reassured me as he dashed off to morning report. “Just stick it up his nose until you see it in the back of his mouth, then tell him to swallow…When he does, just feed it in quickly. After about” two feet are in, blow some air into the tube with a fifty-cc syringe and listen for the bubbles in his stomach with a stethoscope. That way you know you’re in his stomach and not his right bronchus.”

I nodded and went to the ward, my heart pounding and palms sweating. The V.A. still gets away with putting ten to twenty patients into a single large ward with beds separated by flimsy curtains. Private hospitals, on the other hand, typically allow only two patients in a room, and many newer hospitals have only single rooms. At the V.A., however, the older veterans preferred the companionship of the ward and demanded to be put there, so there were few complaints.

I found my target propped up in his bed, his abdomen distended and a blue emesis basin in his hand. An elderly, rotund man with a bulbous nose and rosy cheeks sprinkled with thin, spidery veins, he smiled cordially. We talked for a bit; he had a soft trace of a southern accent, betraying his boyhood in Georgia. He rambled on about his experiences in World War II, when he was a bomber pilot flying missions over Berlin. Lifting his gnarled hand, he offered up a steel ring adorned with tiny wings as proof of his exploits, as if he knew that his bloated appearance was too removed from the trim, leatherjacketed aviator for anyone to believe him. Alas, almost forty years had passed since Berlin, and the war hero was now a retired peach farmer with a bum liver.

The tube insertion went badly. I couldn’t get the damned thing up his right nostril. I tried the left nostril. That didn’t work either, so I went back to the right side again. By this time the left nostril was bleeding profusely, rivulets of blood running down the patient’s face into his mouth and onto his green pajamas.

The tube finally slithered up the nose and down the farmer’s throat. Before I could say “Swallow,” he gagged violently and vomited on both of us. The far end of the tube flew out of his mouth, even as the other end remained jutting from his nose. Horrified, I harshly yanked out the tube, as if I were trying to pull-start an outboard motor in his sinuses. He yelped—and then his right nostril started to bleed as well. I fetched paper towels from a nearby sink, wetted them, and spent ten minutes stanching the bleeding and cleaning him up as best I could.

“I’m terribly sorry; we’ll try this again later,” I apologized weakly, fearing his well-deserved anger at my incompetence.

But he just sniffled and smiled. “OK, Doc…thanks for everything.”

After almost running from the ward, I stood in the hallway to compose myself. What had just happened to this man? A total stranger had walked up to him and rammed a weapon up his nose until he was bleeding like Old Faithful, halting the torture only after he had blown lunch all over himself in full view of six other patients on the ward. On the street, this would not be called a medical procedure, but assault and battery—with witnesses, no less! And, amazingly enough, he was thankful. Thankful! For “everything.”

I glanced down at my white coat. This could not be ordinary clothing, I thought, it must be some sorcerer’s cloak, this white linen, my only credential. It had not only shielded me from the ire of this combat veteran, but inspired his gratitude as well.

In the years that followed, I would do worse things to a human body than make it puke or give it a bloody nose—a lot worse. Nevertheless, another milestone had passed. As I threw away the nasogastric tube caked with bloody jelly, I felt the first inkling of what being a doctor involved. The intoxicant of power.

I wasn’t sure I liked it.

All television medical dramas
contain at least one “cardiac arrest.” A dying patient being shocked, pounded, and probed by grimfaced professionals has been replayed so frequently in entertainment venues that the average layperson could probably manage a cardiac arrest just by having watched TV.

During my residency, I moonlighted in urban emergency rooms. As I resuscitated a heart attack victim in the ER hallway one night, another patient came up to me, pointed to my expiring patient, and asked if I had tried intracardiac epinephrine yet. I curtly told him to mind his own business and sent him to his own ER cubicle, then promptly loaded up the intracardiac
syringe and followed his advice. The patient lived. Thank God for television.

Every hospital has its own method of announcing a cardiac arrest in progress. “Code blue” is a popular prime-time choice, but our hospitals used “Condition A,” “Blue alert,” or “Calling Dr. White.” The operator’s disembodied voice cried from every speaker: “Calling Dr. White, room 4835,” and the code team dashed madly to room 4835, life support equipment in tow.

These encrypted messages supposedly avoided panicking the patient’s relatives (even when they
should
panic). “Dr. White” is being asked to go to room 4835—no big deal.

In reality, euphemisms such as “Calling Dr. White” did little to alleviate public distress. Imagine the bustling lunchtime cafeteria of a busy urban hospital. The operator, who has been calmly reciting phone pages for the past hour (“Dr. Nelson, call extension 5545…Dr. Rosenbloom, call the emergency room, please…”) suddenly screams, “CALLING DR. WHITE, OUTPATIENT SURGERY” three times in quick succession, causing a dozen doctors to drop their forks mid-mouthful, bolt their lunch trays, and run away clutching metal boxes full of equipment.

The “Dr. White” phrase had one comical side effect. In the university hospital one morning, we had five “Dr. Whites” called in less than three hours. We thought the worst had passed when a sixth “Dr. White” directed us to a private room on the ninth floor. Rushing to the room, we found a very aged but otherwise quite robust-looking gentleman reading the
Wall Street Journal
and sipping coffee.

“Who called a cardiac arrest here?” angrily demanded the senior medical resident on the resuscitation team.

“I didn’t call any cardiac arrest, young man; I simply asked the operator to send Dr. White to my room. My own internist
isn’t worth a damn and people have been calling for this Dr. White character all morning. I felt he must be pretty damned good if he’s in so much demand.”

Thankfully, the V.A. had no public-address system. The operator merely summoned the designated arrest team through their beepers. As a third-year student on the medicine rotation, I was assigned to the arrest team for the evening every other night. The team consisted of the senior medical resident, Kate; my intern, Jim; a fourth-year student, Pam; and me. At least once a night we answered the call of our whining arrest beepers. We would run a dozen flights of stairs to the designated location and arrive to find some unfortunate soul who had, in euphemistic hospital lingo, CTB’d, or “ceased to breathe.” The poor souls always had a damned good reason for “ceasing to breathe,” like being riddled with cancer or being older than the Appalachians, but we were called anyway.

Before proceeding with resuscitation, Kate would glance through her sign-out sheet to see which patients were marked with the letters DNR—do not resuscitate. At that time, living wills and frank discussions with patients about life support were much less common than they have become in recent years, and so we had to initiate some effort to revive a hopeless case. The floor nurses wheeled in the big red “crash cart” containing the defibrillator and drugs, I would hook up the EKG monitor, Pam would draw blood, and Kate would place an endotracheal tube. The three junior people took turns “bagging” oxygen into the patient’s lungs with a big green balloon, the Ambu bag, while Kate barked out commands. We conned one of the orderlies or respiratory therapists into doing the exhausting manual chest compressions, which are supposed to squeeze blood from the motionless heart.

Despite witnessing dozens of such arrests, I have not seen
a single Lazarus arise from the tomb of ventricular standstill, or “flatline”—no hearts restarted, no brains salvaged. They simply up and died.

I don’t wish to put down CPR training. In rare instances—a near-drowning, a heart attack victim, a recent electrocution, a severe smoke inhalation—CPR and other resuscitation maneuvers save lives. But the ninety-year-old diabetic with endstage heart failure? When that person’s heart gives out, it’s for keeps. That’s one fact that TV dramas don’t advertise: over 95 percent of resuscitations are unsuccessful. Of the few patients who are successfully revived, the majority die in a week.

What about all those near-death experiences? The shining light and all that? The heroism medals given for the quickthinking Boy Scout with the CPR badge who saves the collapsed woman in the street? Unfortunately, many of these “resuscitations” are people who never had a cardiac arrest in the first place. When someone faints in hot weather, for example, the pulse temporarily slows so that even experienced paramedics can be fooled into thinking the heart has stopped cold. I once started chest compressions on a very obese woman who—or so I was told—had stopped breathing. She was so overweight that no one could feel a pulse anywhere in her body. I straddled her large abdomen with my legs and started heaving into her sternum with both hands. She awakened with a start and asked me exactly what I thought I was doing. Red-faced, I replied, “Would you believe saving your life?”

In the little spare time
during the third year of medical school, I did a small research project in the immunology laboratory, studying how white cells migrated from tiny droplets of agarose. Agarose is a clear gelatin extracted from seaweed. A suspension of blood cells was mixed with warm agarose and deposited in
little droplets onto a petri dish. The droplets, so small that their deposition required a low-power microscope, required great practice to get right.

Martha, a lab technician from England, taught me the delicate method of depositing the droplets. During the first few tries it became obvious that my hands trembled slightly under the microscope. Although I had no tremor to the unaided eye, the magnified image under the microscope revealed subtle finger gyrations which made it difficult to deposit a nicely rounded droplet. Martha’s hands were rock steady, and she quickly grew impatient with me.

“Why are you so nervous, my dear?” she asked bluntly.

“I’m not nervous! Why should I be nervous about making silly little drops on a petri dish?” After all, I thought secretly, I have tormented people with nasogastric tubes!

“They are not silly,” Martha snorted indignantly. “We’re studying what causes multiple sclerosis and there isn’t anything silly about that at all. No sir, not at all.” Her British accent grew thicker when she was angry and I sometimes enjoyed tormenting her just to hear her lapse into BBC speech.