When the Air Hits Your Brain: Tales from Neurosurgery

11. Nightmares, Past and Future

The 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.

I got Charles to the recovery room shortly after noon. He awakened as expected: thrashing his left arm and leg vigorously, but completely motionless in his right arm and leg. When given commands, he simply widened his eyes in a bewildered, doein-the-headlights stare. His speech, pure gibberish. The left hemisphere was gone. The head gone, the body would not be far behind.

Retiring to the family waiting room, I asked the few other families present to please leave me alone with Mrs. Bognar. I switched off the blaring TV set and closed the door.

“We…we had some bleeding…we were forced to put a clip around the main blood vessel to his left brain…He…he has had a very large stroke, I’m afraid…”

“A stroke? Is he…alive?” Her hands began to shake and her eyes filled with tears.

“Yes. Yes, he is alive. But he can’t speak or move his right arm or leg. I’m afraid that’s…permanent.”

“Permanent! You mean he’s never going to talk again?!”

My eyes looked down. “Yes. Never. He may not even survive.”

She began to hyperventilate, then went to a wastebasket and vomited. Collapsing in a heap on the sofa, she buried her ashen face in her hands and began to weep softly.

“Is there anyone I can call for you? Friends? Family?” I knew that Charles had no children from either of his marriages.

“No, leave me alone. You’ve done enough.”

“It was a risk of the procedure…it was explained to both of you—”

“Go away.”

And go away I did.

The ensuing days were agonizing. Charles spent his waking hours pounding and twisting the sheets with his left hand in purest frustration, yelling “Yaaah…yaaah” in vain attempts to make himself understood. Taking care of patients with aphasia, inability to speak, pushes the envelope of difficulty. Rounding on him was torture. The staff surgeon dragged me to see Charles every morning, grimly displaying my mistake to me like the Ghost of Christmas Future tormenting Scrooge with the outcome of his wasted life.

The second Mrs. Bognar confronted me every day with an unrelenting bitterness. True, he had this aneurysm “thing” in his head, but at least he was all right before the operation. Nothing the aneurysm could have done would have been worse than this, in her mind. And she was right. She didn’t blame me for the poor outcome of the operation, but she believed her husband had been deceived about the necessity of the operation in the first place. Statistical operations are hard to explain to people. Such operations are rolls of the dice, a gamble that operating carries fewer risks than the disease. Anyone who bets the farm and loses winds up feeling duped.

I sank into a deep depression. Ordinary diversions, such as watching television or eating a meal, lost all meaning. All these things seemed trivial when I recalled my patient writhing in his speech-deprived cocoon. Play tennis? Enjoy myself while Charles suffered? No, I could not.

Sleep became difficult. I had a recurring dream. I was back in the steel mill, where my favorite diversion was watching the great plunger cranes as they pulled hot ingots from the flaming bowels of the furnaces. In my dream, the plunger cranes came equipped with great, glittering aneurysm clips in place of their usual iron jaws. The gaping clip dipped into a glowing furnace for an ingot. As the crane emerged, there were no burning coke embers, but bubbling jets of boiling blood. The bloody, hot ooze sputtered and spewed from the pit’s depths, rushing like a river of magma toward me. Clucking workers laughed at me. “Pretender,” they teased.

During my waking hours, the final moments before the aneurysm tore replayed in my head over and over again—my own personal Zapruder film—despite my efforts to shut them out. I almost had the goddamned thing clipped! What could I’ have done differently? If someone else had been doing this case, would things have come out better? Did I play with the dome too long? I simply did not know the answers. Or, worse, perhaps I did.

“Death and doughnuts,” our weekly discussion of complications and operative deaths, dispatched the case with little controversy. The aneurysm ripped, the patient stroked out, tough luck. A big yawn for the more experienced surgeons present. A halfhearted discussion ensued on how to handle the situation—whether a bypass operation could or should have been done to supplement flow to the brain, whether barbiturates would have helped, and so on. The complication was chalked up to PD, patient’s disease—a bit of hard cheese, those aneurysms. In my mind, I feared a PCP complication: poor choice of physician. I thought seriously about resigning and ending my career as an emergency room doc. Enrico Fermi’s admonition came back to me: Be the best or be something else. No room for pretenders here. Had I remembered the great physicist’s maxim one patient too late?

Where did Frank the surgical psychopath go? After Andy died, I thought my personality was annealed to steel. I had what it took to face disappointment—or so I believed. Rebecca’s illness bothered me deeply, but she was an infant, an aberration. Nobody can watch babies die. But Charles more than bothered me—he tormented me. I was Raskolnikov, the protagonist of Crime and Punishment, someone who imagined himself a conscienceless superman until he committed murder and guilt unraveled him. Charles was the first disaster that was my fault and my fault alone. He didn’t have an incurable disease, he wasn’t ancient and doomed to die of something soon, he didn’t succumb to an attending surgeon, he wasn’t born with cancer of the brain—he placed the delicate porcelain of life into my hands and I dropped it.

At the death and doughnuts conference, I gazed about the room at the dozen or more staff surgeons present that morning, one hundred years of neurosurgical experience among them. Surely, these were ordinary men? Their learning curves must have devastated dozens upon dozens of lives. Why were they still sane?

Or were they? During his murder trial, Raskolnikov dreamed of a world full of cruel people endowed with such intense belief in their own moral rightness that they never felt the slightest pang of guilt or remorse, even as their world sank into decay. Is that what it would take for me to go on? A blind belief that there was nothing I could have done better, that no one could have achieved a better result than I did on that day?

That is not the way of the scientist, and I still looked at myself as a scientist. Mathematician Jacob Bronowski believed that the credo of science could be found in an Oliver Cromwell utterance: “I beseech you, in the bowels of Christ, think it possible you may be mistaken.” To live with my failures, would I have to exit Bronowski’s self-critical world and enter Raskolnikov’s dreamworld, the megalomaniac’s Utopia?

Five days after surgery, Charles’s dead left brain swelled and smashed the life out of his brain stem. He was placed on mechanical support. During a tense ten-minute meeting, Charles’s wife and I reached an agreement to withdraw his ventilator. On the seventh post-op day, I went into his room and, armed with the ventilator key, accomplished what four years of living with the Viet Cong could not.

My depression did not relent. In my spare time, I returned to the places of my premedicine days—the tennis courts in the park, the undergraduate library, even the grounds surrounding my high school—in hopes that soaking up the ambience of the past would restore me to the person I once was, to the boy who only worried when his forehand sailed long, for whom an overdue book report was the most pressing problem in the world. But I wasn’t that boy anymore. I was no longer the bright student capable of anything, the slacker who harvested A’s with ease and had the world by the ass. I was now thirty years old, engaged to be married, and possessed of only one way, short of flipping burgers, to make a living. If I bailed out now—changed residencies, went to law school, got an M.B.A.—I risked ending up like William the Registrar, flitting from job to job until I retired, without ever accomplishing anything. Worse, I had no guarantee of being happier or more competent in those fields.

No more second chances. I decided that my random walk through life must end in neurosurgery.

I refused to operate again for weeks after the aneurysm fiasco, a feat possible on the slow V.A. service. Talking with the attendings about my career doubts would have done little good—a marine boot can’t discuss his doubts about the Corps with his drill sergeant. I decided to call Gary in New York.

“Yeah, it’s a bitch, isn’t it?” I could hear him strike a match in the background. Still smoking.

“That’s it?” I grumbled. “‘It’s a bitch’—those are your words of wisdom?”

“Who are you feeling sorry for, you or the poor bastard who died?”

“Both of us, I guess.”

“I don’t think so. Did you go to his funeral, or send flowers or something?”


“So what’s bothering you?”

“It wasn’t that tough an aneurysm. If Charlie Drake or Thor Sundt or some other full-time aneurysm surgeon had been doing it, Charles would be home screwing his brains out again and working on his next bleed. But it wasn’t Drake or Sundt, it was me…”

“Let me tell you a story,” Gary interrupted. “When I was a third-year resident on neuropathology, I moonlighted at Southland Hospital. One night, some guy drags his buddy in off the street after he has a fight with another guy. We put the buddy on a stretcher and find out that he has a steak knife jammed to the hilt in his right chest. He proceeds to turn to complete shit in front of my eyes and the head ER nurse—one of those iron maidens who has worked in the same place for a zillion years—wheels out this big tray of instruments. ‘What’s this?’ I ask. ‘The thoracotomy tray,’ she says. The guy needed to have his chest opened all right, but I sure as shit wasn’t going to do it. ‘Forget it,’ I said, ‘he came to the wrong man.’ He promptly croaked. I felt guilty for a while, real guilty, until I realized two things: one, I didn’t plant the fucking shiv into his chest in the first place; and two, if they want a chest surgeon to be sitting in every two-bit ER in the whole world, they had better be prepared to pay him more than forty dollars an hour, which was all they were paying me.”

“The take-home lesson of this parable?”

“You didn’t make his aneurysm bleed…his wife did. And his hypertension, years and years of hypertension—he was no doubt too goddamned busy to see a doctor about it, too. You didn’t kill him; you were just asked to step in and prevent him from dying on his own…and you couldn’t. Yeah, Thor Sundt wasn’t there, but Thor Sundt can’t do every aneurysm in the country. And I’m sure Thor Sundt has torn a few aneurysms in his lifetime, great as he is—you think he came into this world with a clip applier in his right hand? There will always be people better than you and worse than you. If you worry about not being as good as someone else, why don’t you just give up every case right now? Just set up a phone hot line and sit in an office and match people with the very best surgeons in the whole universe. No point in cursing humanity with your own sorry skills, is there? C’mon! Quit feeling sorry for yourself and do the best you can with those who ask for your help. I’m gone just over a year and you start moping over one postoperative death. Yeah, it’s a nightmare, but that’s neurosurgery. Land of nightmares. There are plenty more nightmares in your future, pal. Remember my index finger: are your coronaries that big?”

“I guess so. How do you do it, Gary? It never looks like you give a shit.”

“You have to care about the patients, but not too much. It’s unethical to operate on our wives. Why? Because we’d be too likely to choke, to get nervous and fuck up if it’s our own family on the chopping block. The very fact that medical ethics forbids treating your immediate family is proof that we shouldn’t get so involved with a patient that we are made nervous by the possibility of failure. Patients want us to care about them, but they want us to perform with the nerveless demeanor of someone slicing bologna in a deli at the same time. It’s one of those unexplained paradoxes we just accept—you know, like the Flintstones’ Christmas Special. How do people from a million B.C. celebrate Christmas? Enough bullshit. Clip the aneurysms and take what happens. Don’t make me come down there and kick your ass.”

Eventually I managed to put Charles behind me. I tossed out my neatly typed resignation letters and halted my searches through the medical want ads. Whether the healing of my psyche came from some maturation process or from the realization that I simply had no other place to go is unclear to me now. Like Raskolnikov in his gulag, I finally acknowledged that psychopathy is not the way to face difficult responsibilities. Some caring is necessary if we are to be the very best surgeons we can be, even if we can’t be the best in the universe.

Caring makes the hands shake, but it also makes us dread disaster and work with every fiber of our being to avoid it. Pain, emotional or physical, is the taskmaster of the animal kingdom. The pain of Charles’s death taught me a deep respect for the campfire of surgery. I would mind the heat more carefully from now on.

Three months after Charles died, a letter appeared in my university mailbox, a thank-you note from the second Mrs. Bognar. It read simply: “I know now that you only did your best. Thanks for everything.”

I was not embarrassed by this thanks, as I had been by the old peach farmer’s misguided gratitude so long ago. This was not a generic homage to the magic white cloak. I had indeed done my best; my best just wasn’t good enough. I accepted the nightmare of the past and awaited the nightmares of the future.

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