When the Air Hits Your Brain: Tales from Neurosurgery

1.The Rules of the Game

July 1. Neurosurgery residency.

Day one.

Five A.M.

A sickening wave of déjà vu flooded over me as I looked at the automatic doors to the “porch,” the neurosurgical step-down unit. I had a sudden impulse to flee, to hide under my bed until it all went away. Six more grueling years of training loomed before me. Those years weighed heavily upon my brain that morning, like tons of ocean water submerging me, away from the sunlight of a normal life, normal job, normal things.

Before I could push the wall button to open the porch doors, they abruptly hissed apart on their own. There before me sat two men from my past: Gary, the hyperbolic smokestack of a junior neurosurgery resident who had ascended to become chief resident; and Eric, the once-jittery intern who was now a senior resident. I had worked with both of them years earlier, when I was a lowly medical student. We would be spending the next six months together on the boss’s service, covering his pain patients as well as taking care of the trauma patients and other ER “hits” to neurosurgery. The “boss” was the chairman of neurological surgery, Dr. Abramowitz.

“Well, Eric, look who’s arrived—Mr. Horner’s sign himself,” Gary said, referring to the clinical sign which had landed me in neurosurgery in the first place. Ancient history.

“Hello, Gary, you look—”

“Like hell, as always. Too much chocolate milk and nicotine—but, hey, whatever keeps you going? Listen, there isn’t anything on the schedule this morning—the boss is testifying at a trial. Let’s go back into the conference room. I need to spell out the rules of neurosurgery to you, from day one. After that, we’ll take you down to see the Museum of Pain.”

“The rules of neurosurgery? The ‘Museum of Pain’?”

“Yeah, the rules. Rules you aren’t going to read in any of the six volumes of Youmans’ textbook. You’ll see the Museum later—you have to see it to believe it.” Youmans’ was the bible of neurosurgery, the font of wisdom for trainees.

We went back to the small conference room where I would be making afternoon card rounds for many years to come. Gary went to the chalkboard and began to write.

“Rule number one: You ain’t never the same when the air hits your brain. Yes, the good Lord bricked that sucker in pretty good, and for a reason. We’re not supposed to play with it. The brain is sorta like a ‘66 Cadillac. You had to drop the engine in that thing just to change all eight spark plugs. It was built for performance, not for easy servicing.”

“The patients seem to do all right,” I protested.

“Yes, they usually do, but every once in a while something funny happens: someone’s personality changes, a patient up and dies without warning—all little reminders that you are treading upon sacred soil. Which leads to rule number two: The only minor operation is one that someone else is doing. If you’re doing it, it’s major. Never forget that.”

He took a sip of coffee and continued. “Rule number three applies equally well to the brain patients and to the spinal discpatients: If the patient isn’t dead, you can always make him worse if you try hard enough. I’ve seen guys who have had two discs taken out of their backs and begged us for a third operation, saying that they had nothing to lose since they can’t possibly be any worse than they are. So we do a third discectomy and prove them wrong.”

Another sip. He went on. “Rule four: One look at the patient is better than a thousand phone calls from a nurse when you’re trying to figure out why someone is going to shit. A corollary: When dealing with the staff guy after a patient goes sour, a terrible mistake made at the bedside will be better received than the most expert management rendered from the on-call-room bed or the residents’ TV room. Look at the patient. Rule five: Operating on the wrong patient or doing the wrong side of the body makes for a very bad day—always ask the patient what side their pain is on, which leg hurts, which hand is numb. Always look at the films yourself and check that the name on the film matches the name on the chart. Always look at the consent and look at the patient’s bracelet. To do otherwise is a setup for a res ipsa.”

“Res ipsa?” I asked. “They never taught us that one in medical school.”

“And they never will; it’s a legal term. Short for res ipsa loquitur, or ‘the thing which speaks for itself.’ It means a malpractice case in which the error is so obvious that even a non-expert can see that a fuckup has occurred. A patient falls off the OR table. You cut off the left leg when it’s the right one that’s gangrenous. You send someone with a broken neck home from the ER with only an aspirin prescription. A patient bursts into flames during defibrillation. You take a disc out of a Mrs. A. Johnson when it was Mrs. J. Johnson who was supposed to have the operation. Res ipsa is checkbook time. Just write in a string of zeroes. Have I forgotten anything, Eric?”

Eric thought for a moment. “Well,” he said, turning to me, “just remember the rules of any surgical residency: Never stand when you can be sitting, never sit when you can be lying down, never use the stairs when there are elevators, never be awake if you can be asleep, and always eat and shit at the first available opportunity.” He thought some more. “And always agree with the boss. The boss is this residency program. When it comes to ego, neurosurgery is the major leagues, the NFL, the NBA. The big time. Grovel and beg at the appropriate times, and you’ll do fine.”

“This is residency now,” Gary chimed in again, “you aren’t the hotshot medical student or the know-nothing intern who can be forgiven any mistake. This is for keeps. This is your career. No more temporary rotations in pediatric endocrinology or tropical diseases. You’ll do this shit until you die. Are you ready?! I said, are you READY!”


Let the Games begin.



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