When the Air Hits Your Brain: Tales from Neurosurgery

2. Slackers, Keeners, and Wild Cards

My descent into neurosurgery began in medical school, where I sought refuge from the real world. I took my undergraduate degree in theoretical physics—a great field if your name is Einstein. As a former steelworker, my personality tended toward careers which offered me some realistic chance of making a living. The great Enrico Fermi, father of nuclear fission, once said that there are two types of physicists: the very best, and those who shouldn’t be in the field at all. Any theoretician who isn’t the best is a fraud, a pretender. I had done well in physics, but not well enough to pass Fermi’s test. I decided, virtually by default, to become a doctor.

TV and movies foster many misconceptions about medical students, portraying them as drunken buffoons performing unspeakable acts with mummified body parts in anatomy labs, or as fully competent physicians (Judy can amputate the captain’s leg! She’s a medical student at Harvard!). In reality, medical students are glorified college students, people who think they know something, but don’t.

Although a certain amount of rowdiness exists in any medical school, we were not picked for our social skills. I divided our freshman class into three groups. I was in the biggest: the slackers, consisting of students who had garnered acceptable grades with a minimum of effort since first grade. We studied only as much as absolutely necessary (and only at the last possible moment). We lurked in the rear of the lecture halls, in the “prime bolt seats,” from where an unobtrusive exit could be made if the lecture got too tedious or a good basketball game formed outside. Most importantly, slackers never asked questions in class. Asking questions was a sign of weakness.

The second group, the keeners, were overachievers, who hacked and bludgeoned their way to success through work and more work. They planted themselves in the front of the lecture hall, never exiting a class prematurely even if diarrhea dribbled into their shoes. And they always…ALWAYS…asked questions. A lecture on the tying of shoelaces would still draw some keener into the lecturer’s face after class, waving a grade-school ring binder and saying, “I didn’t quite get it, the loop goes under or over?”

The third group, the wild cards, entered medical school because they knew someone, because one of their parents had graduated from the school decades earlier, or because someone on the admissions committee was intrigued by an unusual entry on their résumés—“Spent one year in Uganda ladling gruel into starving children.” Unfortunately, these admission criteria did not correlate with IQ. The wild cards became our “cretin buffer,” fattening the grade curve for us slackers. The wild cards never sat in the front or the back of the class—they never went to class.

The first two years consisted of didactic lectures on anatomy, physiology, pathology, and the like, with a few brief contacts with patients thrown in as appetizers. The real fun didn’t begin until the third year. At that time, lectures ended and we were thrown into the hospital wards full-time.

Seven clinical tours of duty, or rotations, made up the third year: nine weeks of internal medicine, nine weeks of pediatrics, three weeks of anesthesiology, six weeks of general surgery, six weeks of obstetrics and gynecology, six weeks of psychiatry, and a three-week elective in the surgical subspecialty. My schedule arrived in August, listing my first rotation as the surgical subspecialty rotation. Great, I thought, I’ll do cardiac surgery. Maybe I’ll be a chest surgeon.

When I went to sign up, the secretary in the student affairs office dryly informed me that I could not do cardiac surgery, since the cardiac surgeons wouldn’t let any medical students onto their service unless they had finished the six-week generalsurgery rotation first. She thrust a list of remaining possibilities at me: ear, nose and throat; orthopedics; plastic surgery; urology; neurosurgery.

Students were stacking up behind me. I had to think fast. Nose picking? Carpentry? Face-lifts? The stream team? The head crunchers? Nothing seemed as interesting as cardiac surgery. Oh well, it was just a crummy three weeks, anyway.

“Ahhhh…give me neurosurgery.”

She jotted it down. “Vertosick, neurosurgery. Show up on the neuro floor, five-thirty A.M., September second. Next.”

My fate was decided by a scheduling glitch.

Then it hit me: 5:30 A.M., as in before dawn? Was she joking?

On a gray September morning, I slogged to the hospital for my first day as a real doctor on the university neurosurgical service. I was about to step onto the slippery slope.

The neuro floor was dark and quiet, the nurses’ station empty. I tracked down a nurse making his rounds and introduced myself, then asked him where I might find someone who would know what it was I was supposed to do.

“Look in the porch.”

“The porch?” I had visions of some congenial place, full of wicker rocking chairs.

He pointed to a set of automatic double doors at the end of the long hallway. “You know, the porch, the neuro stepdown unit…right there.”

Thanking him, I wandered to the porch entrance. The doors carried the imposing label “Neurosurgical Continuous Care Unit, Authorized Personnel Only.” I felt a bit of pride. For the first time in my life, I was “authorized personnel.” I pushed a switch on the wall and the doors swiftly separated.

The porch was a small room with a tiny work desk at its center. Six patient beds, five of them occupied, were crammed in a semicircle around the desk. Electronic monitors dangled from the white ceiling and the walls were covered with metal baskets stuffed with gauze sponges, packages of gloves, IV kits, and other disposable medical paraphenalia. The air smelled of antiseptic. Faint monitor beeps were the only background noise. No wicker furniture here.

The patients, looking like giant Q-tips with their heads wrapped in bulky white bandages, were asleep (or comatose, I didn’t know which). At the desk sat a thin, haggard man sporting a day’s growth of beard and wearing a white jacket over his blue surgical scrubs. He hunched over a stack of charts, scribbling away. I tapped his shoulder and he jumped in his chair, startled by my intrusion.

“Jesus Christ,” he hissed at me, “who are you?”

“Frank Vertosick, third-year student doing a neurosurgery rotation. A nurse told me to come here. Is this the porch?”

“I’m Gary,” he whispered back, calming down a bit, “junior resident…yeah, this is the porch. This is where we keep people who aren’t sick enough for the intensive care unit, but are too sick to go out on the floor and be forgotten. Most of them are post-ops. Except that one.”

He pointed to a young man, perhaps a teenager, with a thin plastic hose leading from his head bandages to a complicated contraption on a metal pole beside his bed.

“That guy’s a head trauma. We’re still watching his ICP, but he’s wrecked. He’ll go out to the graveyard until we can place him.”

ICP, graveyard, place him. Clearly, the language we’d spoken in the first two years of medical school would be of little use here.

“ICP means intracranial pressure; the graveyard is the area of the floor where we keep the unconscious people; and when we say ‘place him,’ that means find some nursing home that will take him off our hands…he isn’t going to be any better than he is now. I see you have a lot to learn.”

“That’s why I’m here,” I beamed.

“No, you are here to be my fucking slave,” he said with a broad grin. “Now, sit there like a good boy and let me finish my notes, then we’ll get some breakfast.”

Gary went back to leafing through the charts, jotting down laboratory values and vital signs onto soiled note cards as he went. Every so often he would moan or mutter obscenities to himself, displeased with some chart entry. At last, he clapped the last chart shut, stacked the charts in a pile, and placed them in a basket for the porch secretary. He leaped from the chair and beckoned me to tag along. We exited the porch and took the long elevator ride down to the hospital cafeteria.

Gary broke the silence in the humming elevator as he lit a cigarette. “There are three residents and one intern on our service—me, the junior resident; Hank, the senior resident; and Carl, the chief resident. The interns float through on a monthly basis. Our intern right now is Eric Foreman, who’s going to be one of the junior neurosurgery residents next year. We tend to ignore the interns, unless they’re going into the program; then we kick the shit out them. Everybody makes rounds in the morning on a different part of the service. Eric, since he knows nothing, rounds on the people out on the floor. They’re generally pretty stable. I get the porch; Hank covers the intensive care unit; and Carl, as chief, gets to roll in at about six-thirty or seven. He doesn’t see anybody in the morning; we just make ‘card rounds’ with him at breakfast, giving him a verbal report of what, if anything, happened at night.”

“What’ll I do?” I asked, still searching for what my role would be in this well-oiled machine.

“Well, after you get my coffee, I guess you should pitch in and help write progress notes on the patients on the floor. There are plenty of them and it’s tough for Eric to get finished in time to go to the OR by seven thirty. You see, every patient needs a progress note written on their chart every day…You haven’t done any general surgery yet, have you?”

“Well, I haven’t done anything, really.”

Gary rolled his eyes. We exited the elevator and walked the short distance to the cafeteria. Loading up on corned beef hash and eggs, foods that hospital cafeterias serve in order to guarantee future admissions to the coronary care unit, I followed Gary like a lost dog over to a long table in the corner. Two other residents were already seated there, both dressed in street clothes.

“Carl, this is Frank, MS III.” Gary addressed the more distinguished-looking resident, a slim man with a hint of white about his temples. “Frank’s starting on neurosurgery this morning…No, wait, he’s starting his goddamned medical career this morning!”

I shook the chief’s hand.

“Welcome. This is Hank; he’s a fourth-year resident.” Carl motioned to the other resident seated beside him, a balding, portly fellow who waved at me and smiled as he continued to chew a large mouthful of food.

Gary and I took a seat and began to eat. Several minutes later, a frenetic figure darted to the table, his tray rattling in front of him, the coffee flying out of his cup. He had a boyish face and blond hair. This was clearly Eric, the intern, late for morning card rounds.

Carl cast a perturbed look at the intern, pulled his own stack of index cards from his lab coat pocket, and began the daily litany.

“Beckinger, room nine.”

Eric flipped through his cards, locating Beckinger. I surmised that Beckinger was someone on the floor—Eric’s responsibility.

“She’s fine, afebrile, no headache, no face pain, wound is dry. She’s now four days out from surgery.”

“Has she pooped, yet?” Carl asked dryly, without looking away from his cards.

“Uh, I don’t know.”

“Well, goddamn it, find out. You know the staff man will go nuts if she hasn’t shit four days out. Her fucking cerebellum could be hanging out of the wound and dragging on the floor, and he wouldn’t care as long as her bowels are moving. If she hasn’t done the deed, give her some mag citrate…Rockingham, ten, by the window.”

Eric was still scrawling “BM?=mag cit” on his Beckinger card. He hurriedly shuffled to the next one in his stack.

“Rockingham has some face pain, a little headache, temperature’s 100.8, wound is dry. He’s three days out.”

“How much is a little headache?”

“Just…ummm…a little.”

“Does he need a spinal tap?”

“I don’t think so?”

“Did you wake him up, or is this what his nurse told you?”

Eric grimaced. “I didn’t wake him, he looked so peaceful—”

“Chrissakes, Eric,” Carl exploded, “you have to wake them up! I know it’s early, but this isn’t the Ritz. They can sleep at home, and I’ve got to know how they feel every morning. The staff guys will go around at eight this morning, the patients will start bitching that they were up all night and nobody’s bothered to see them yet. That you stood outside the door and waved at them while they sawed logs isn’t going to appease anybody. After breakfast, go upstairs and ask this guy how bad his headache is and come and tell me.”

And so it went, patient after patient. First Eric, then Gary, then Hank. Each took his turn relating the patients. Eric and Gary took a ferocious beating, while Hank’s presentations went unchallenged. Clearly, Carl looked at Hank as a colleague, while he looked at Gary and Eric as subordinates. He never looked at me at all. We finished at about seven-fifteen. Carl produced a large sheet of paper with the OR schedule for the week.

“Hank, craniotomy for meningioma, room twelve…The only other case is one of the boss’s face pain patients in room five. Gary and I will do that together. Eric, go back to the floor and take care of all the loose ends.” The morning tribunal dispersed.

Gary took me over to the OR dressing room, where gave me quick instructions on how to find scrub clothes and how to put on a hat, mask, and shoe covers. He also let me share his locker.

“Eric’s being punished,” Gary whispered to me as I changed my clothes. “He’s not very up on things yet. Carl could have let him stand around with Hank on that brain tumor case, but he’s been sentenced to the floor to be badgered by the nurses all day.”

“What are you going to do?”

“Carl’s going to teach me to open one of the face pain patients. I haven’t done much more than help on that opening yet.”

His face brightened. He was clearly looking forward to this. So far, I hadn’t seen anything to get excited about—getting up before the trout fisherman, rounding on teenage boys who were headed for a nursing home, eating greasy food, and watching grown men torment one another.

Maybe seeing what went on in the OR would change my mind.

I walked cautiously into operating room five, the first one I had ever seen “in the flesh.” Much smaller and less grand than I imagined an OR to be, the room’s walls were covered with shiny green tile, the floor a hard, blackish lineoleum. The room had a cold and hollow feel, like a large dormitory bathroom. Against the far wall, a woman in full scrub dress shuffled metal instruments on a large table. To my left, skull X rays dangled against two light boxes hung at eye level. The patient occupied the center of the room and was already anesthetized, thick bore plastic tubing jutting from his mouth and nose, the eyes taped shut.

Carl placed the man’s head in a large C-clamp, and then Gary, Carl, and the anesthesiologist flipped him onto his right side and padded him with pillows and pieces of blue foam rubber. They taped his body to the OR table and fixed the Cclamped head to a contraption at the top of the table. Gary quickly shaved a small patch of the recumbent man’s scalp just behind his left ear. The two neurosurgical residents then exiled the OR through a back door. I hurriedly followed them, afraid to be left alone in the OR. I feared I might commit some grievous mistake—touch something, sneeze, fart, anything that would ruin the operation.

The door opened into a smaller room almost entirely filled by a long steel sink. Four faucets arched over the sink like silver swans: the scrub area. The two men taped their surgical masks to their faces, to prevent fogging up the surgical microscope with their breath, and began to scrub their hands and fingernails meticulously. As they scrubbed, Carl swung around and spoke.

“Our chief of neurosurgery, Dr. Abramowitz, specializes in treating pain patients. The man on the altar today”—(he motioned with a lathered finger to the OR door)—”has trigeminal neuralgia, also known as tic douloureux, or tic for short. Tic patients get sharp, stabbing pains in their faces, sort of like a dentist drill hitting a nerve. What the boss—that’s what we call Abramowitz—is doing today is the latest procedure for this condition. We’ll drill a hole in the skull, find the trigeminal nerve to the face as it exits the base of the brain, and pad it from surrounding blood vessels using some bits of plastic sponge. It seems to relieve the pain without causing much numbness. The boss learned it from Jannetta himself, who pioneered this approach.”

Gary and Carl backed into the OR, holding their dripping arms high in front of them. They dried their hands and gowned in dramatic fashion, aided by an OR assistant. After soaking the small patch of shaved scalp with a brown solution, Gary layered the prepped scalp areas with blue linen sheets until only the brown postage stamp of bald skin remained visible.

I stood, my back to the wall, while the surgeons huddled over that brown patch, slicing and dicing and filling the wound with dangling metal clamps, called “dandies,” after Walter Dandy, another historical hero of brain surgery. The blue linen lining the brown patch stained purple with flowing blood. Buzzing noises and smoke filled the air as clamps cluttered the incision. Gathering my courage, I took a few steps closer to the table and peered at the wound. Beneath the pouting ruby lips of the mouthlike gash gleamed a broad white surface.

“Is that the skull?” I asked

“Yup,” answered Gary, “time for a drill.”

A drill? Yikes.

At that moment a tall, craggy, white-haired man, about seventy years old, flung open the OR door and bellowed into the room, “How much longer, goddamn it? Jesus, Carl, how long have you been here? TEN MINUTES. I’ll be back in TEN MINUTES.”

“Yessir.” Carl didn’t look away from his work. “I was just showing Gary how to get through the occipital artery—.”

“Great,” the craggy man answered. “TEN MINUTES and I’m back. I want the cerebellum exposed by then.” The door swung shut and the room fell quiet again.

I leaned over to Gary. “The boss?”

He glanced back over his shoulder. “None other.”

“You heard the gentleman, we have TEN MINUTES to get into this guy’s head,” Carl barked. “Get the craniotome, Gary, and make a hole here, right behind the mastoid eminence.”

Gary reached into a plastic pan and pulled out an instrument the size and shape of a flashlight. It was connected to a thick black hose which trailed down to the floor and over to a metal gas cylinder at the foot of the operating table. At the tip of the flashlight was a short steel cone topped with a spiral cutting edge.

“This is the craniotome; we use it to punch through the skull,” explained Carl.

“How does it know when to stop before it plunges into the brain?” I asked.

“It has a pressure-activated clutch mechanism,” Gary said as he pushed his finger against the tip of the conical drill bit. “When it penetrates the skull, the clutch disengages and the drill stops. Simple.”

He squeezed the trigger on the craniotome and the drill whined to life. As Gary pressed the whirling bit against the ivory bone, Carl flooded the wound with water from a plastic syringe which could have been used for basting turkeys. Mounds of white bone chips flew from the deepening hole. Carl washed the bone dust onto the sheets. The whining continued for about a minute or so; then Gary’s arm suddenly jerked forward, thrusting the still-running drill bit to the hilt into the skull. Quickly, the chalklike bone dust around the hole turned beet red. Gary reflexively pulled his finger away from the trigger and the drill stopped. The drill that was supposed to stop before it touched the brain had gone deeper than the residents had planned. A lot deeper.

“Oh SHIT!” cried Carl. “The fucking drill never stopped. Here we are talking about the clutch mechanism, and the thing doesn’t shut off!” He grabbed the drill away from Gary and yanked it out of the patient’s head. A torrent of blood and some stuff that looked like runny strawberry milkshake poured from the small hole in the bone.

“What’ll we do?!” moaned Gary.

“WE don’t do anything. YOU just stand there. Give me a Raney punch!” The scrub nurse handed Carl a large biting thing that looked like toe clippers from hell. He frantically tore at the skull bone, widening the small hole.

“I need to assess the damage, like real fast. Hopefully, we just trashed the cerebellar hemisphere…If we went down to the stem, we’re all screwed.” Carl’s previous scholarly demeanor deteriorated to a nervous pratter. “I mean, God, I never saw a drill plunge so deep back here…Couldn’t you tell you were going through the inner table of the skull?…Lordy, lordy, just so the stem is OK, tell me the stem is OK…”

The door swung open. The boss again. “Is everything OK?…I SAID IS EVERYTHING OK?”

“Yeah…ah…fine, sir,” Carl stuttered, “we just put a nick in the cerebellum, I think…We’re fine—.”

“FIVE MINUTES. A quick cup of coffee and I’ll be in. In FIVE MINUTES.”

Carl’s gloved fingers twisted and turned instruments in the wound until at last he pronounced the drill’s damage acceptable.

“It’s just the lateral hemisphere. This guy’s arm will be a little unsteady for a while, but he’ll be OK. Give me a big cottonoid. The boss will never see it.” He took a large white cloth square and covered the injury to the brain like a small boy covering a large scratch in the new coffee table with a newspaper.

I couldn’t bear to watch any longer. I left, fearing the verbal explosion that might occur if the boss lifted up Carl’s “newspaper.” Given that “shit rolls downhill,” I also realized that the lowest part of the terrain was me. Seeing Gary in the lounge after the case was done, I asked him how things had gone. He sat on a bench, still sweating and tremulous.

“Fine, I guess. The patient’s fine, but, boy, I nearly killed that guy. I must have been leaning too hard on the drill or something, I don’t know.” He shrugged his shoulders and stuck out his left index finger. “You see this?”


“That’s about how big your coronary arteries need to be if you want to do brain surgery for a living.”

Although I brought Gary coffee each morning, I was really Eric’s slave for the remainder of my neurosurgery clerkship. Eric had more work to do, work that even a third-year student could do. The frazzled intern quickly taught me to remove skin sutures and change dressings. He dispatched me to ask patients questions he had neglected: What were their allergies, did they bring their X rays, had they had their morning bowel movements? I became the “scut doggie,” rounding up laboratory reports, photocopying journal articles, fetching lab coats left behind in patients’ rooms.

My real contribution was my slew of “H & P’s,” short for histories and physicals. The history consists of the patient’s story told in his or her own words, and includes the chief complaint (“My face hurts when I eat”); the present history (“My face pain started three years ago, and has gotten worse since December…”); past history (“I am diabetic and have had my gallbladder removed”); current medications; allergies; occupation; smoking and drinking behavior; and so on. The physical is the physical examination. Even in an age of increasing technology, a patient’s illness can be diagnosed over three-quarters of the time by the H & P alone.

Every patient admitted to the hospital must have an H & P written on the chart. On a busy day, the neurosurgical service admitted twelve or more people. Even an uncomplicated H & P took thirty minutes to perform, and the task of getting them all done before nightfall was daunting. Only Gary and Eric did H & P’s; the senior and chief residents considered them menial chores. Gary lived in the OR, leaving Eric saddled with six to twelve hours of H & P’s a day. Taught the fundamentals of history taking and physical examination in our second year, any third-year student could do a passable H & P. I became an H & P machine, cranking out four to six every day.

Of course, nobody read them. Clinical decisions did not turn upon my findings. The attending surgeon, having performed a very directed history and physical in the office, made the required decisions after some careful thought long before the patient ended up in a hospital. My H & P’s were essentially bureaucratic exercises. With one fateful exception.

Harvey Rathman, a man in his late fifties, was admitted for the removal of a herniated cervical disc in his neck. His “chief complaint” was right-arm pain, increasing in severity over several weeks. Physical therapy had proved ineffective, and he now ate narcotics just to sleep at night. At an outside hospital, Mr. Rathman had undergone a myelogram: thick dye was injected into his neck to visualize the shadowy outlines of his spinal nerves on X-ray films. The test had disclosed that one of his neck’s discs, the fibrous pillows between the vertebrae, had ruptured, “pinching” a nerve between a disc fragment and the bony spine.

While totally incapable of interpreting the X-ray pictures myself, I managed to find the printed radiology report which accompanied the patient’s file. At the bottom of the report, it read: “Impression: small central to left-sided disc herniation, C56.” Left-sided? But the patient’s arm pain was on the right. How does a pinched nerve to the left arm cause pain in the right arm? I showed this paradox to Eric, who shrugged it off. He said that misprints occurred frequently, and that the staff surgeon must know that the disc had really ruptured to the right side or he wouldn’t have brought him in for surgery. “The radiologist probably just goofed up when dictating the report.”

I accepted this explanation and strolled down the hall to see Mr. Rathman. It was nine in the evening when I entered the dark room. Mr. Rathman sat in his bed, his gaunt, lined face betraying his discomfort. He managed a contorted smile and said in the hoarse voice of a career cigarette user, “May I help you?”

“I’m Frank Vertosick, Mr. Rathman.” I extended my hand, but he declined to raise his ailing arm and simply waved with his left hand. “I need to ask you some questions and do a brief examination, for the record. Now…” My voice trailed off.

“Is something wrong?” the man asked.

Something was wrong. As I glanced closely at his face, it struck me that his pupils were grossly aymmetrical. The right pupil was tiny, but the left pupil was huge, saucerlike. What was going on here? In an instant, a flash of insight burst into my head from nowhere. Deep in the recesses of my memory, brain demons below the level of my consciousness pieced together the man’s diagnosis from the disjointed bits of knowledge garnered during my first two years of medical school. The arm pain…the smoker’s rasp…the thin face…the unequal pupils…it all crystallized for me in a rush. This man did not have a ruptured disc! I stood over him, frozen by the thought that only I knew what was causing his arm pain. But I couldn’t say anything to him. That was not my place.

“No, nothing’s wrong. Now, tell me about your pain…when did it start?” So it went. I finished the H & P, thanked him, and left. I immediately grabbed Gary, who had just come out of the OR from a head trauma case.

“Gary,” I said, breathless, “that guy, Rathman, in room fifteen, he’s here for a cervical discectomy, but his disc is on the wrong side! And he has a Horner’s sign! Go look for yourself!”

“What guy? What the hell are you talking about? You’re babbling. It’s ten o’clock. Go home.” He bolted down a carton of chocolate milk and walked away. I chased after him.

“No, wait, I’m telling you that this guy is on the OR schedule for seven-thirty tomorrow morning and it’s all wrong. He has a Horner’s sign; you don’t get that from a disc. Just go and look at him.”

The iris functions like a camera diaphragm, limiting the amount of light entering the eye. Powered by small muscles, the iris becomes paralyzed if its nerve supply fails. If the iris is paralyzed, the pupil remains small. In bright light, when the normal pupil constricts to the same size as a paralyzed iris, the abnormality can be masked. In dim light, however, the normal iris dilates while the paralyzed pupil remains small—an asymmetry known as the Horner’s sign. The difference between the paralyzed and normal iris is so pronounced that even a novice like myself could see it in dim light. When the staff surgeon had examined Mr. Rathman in a bright examination room, the Horner’s sign was not there.

The nerves to the iris don’t come from the cervical, or neck, nerves, but from the upper chest. This sounds bizarre—eye nerves coming from the chest—but the human body’s blueprints can be hard to decipher at times. Mr. Rathman’s C56 disc wasn’t causing his pupillary asymmetry. Something was going on deep in his chest, gnawing at the nerves to his right arm and amputating the iris nerves. In a middle-aged smoker, the most likely explanation was also the most grim: lung cancer.

Gary paused. “Didn’t he have a pre-op chest X ray?”

“Yes, it was read as bilateral apical pleural thickening.”

“Hmmm, I guess a Pancoast tumor could be hiding at the apex under that pleural thickening and be missed on routine X ray,” he muttered, almost to himself. “Well, let’s have a look.” He walked down the corridor to the patient’s room.

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.

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