When the Air Hits Your Brain: Tales from Neurosurgery

4. A Night in the Street, a Night in the Chair

The clinical rotations of my final years of medical school passed quickly—except for psychiatry, which I found tedious. The patients were interesting, but the clinical pace was too slow for me. Assigned to the affective disorders unit, or ADU, I spent my six-week tour of duty in the university psychiatric institute. The ADU housed patients with severe disturbances of affect (psychiatry’s term for mood). The ADU population consisted mostly of middle-aged women with major depression and young men with uncontrolled mania.

The ADU population harbored a fair number of schizophrenic patients as well. Schizophrenia isn’t really a mood disorder—it’s a thought disorder, or psychosis. But the institute had a limited number of beds on locked wards, and the ubiquitous schizophrenics were quartered in any empty beds.

Closet psychiatrists lurk everywhere, anxious to render armchair analyses of coworkers and friends. The workaholic in marketing, he’s manic. Margaret next door sank into depression when her daughter went away to school. And John down the street—he’s schizophrenic, totally bonkers. Amateurs toss these diagnoses about with no insight into their true manifestations. After encountering my first bona fide depressed, manic, and schizophrenic patients, the magnitude of their mood changes and aberrant behaviors shocked me.

Is that man in marketing manic simply because he’s the first one into the office and the last out? How about a housing contractor I encountered who read the Bible, rode an exercise bike, dictated a letter to his secretary, and expounded on the dangers of having too many Jews in government—all at the same time?

Is the homemaker next door clinically depressed because she gets teary-eyed every morning looking at the photo of her daughter boarding a bus for college? How about a grandmother of three I saw, who spent eighteen hours a day sitting on her haunches, banging her head on the floor and repeating “God, kill me now” over and over again?

And the oddball down the street—is he schizophrenic because he wears black socks with white tennis shoes and talks to his tuberous begonias? How about a nurse’s aide who plunged a bread-knife into her vagina and partially cut away her own uterus because Satan told her that Julius Caeser’s baby was in there?

Of all the illnesses I witnessed at the institute, the most fascinating was schizophrenia, a cruel and enigmatic disease which robs us of our most human quality: our reason. The word derives from the Greek for “split mind,” and many still confuse schizophrenia with the very rare condition known as split, or multiple, personality disorder. Ironically, a schizophrenic barely posesses one complete personality, let alone two or more. Although many subclasses of the disorder exist, they all share common characteristics: apathy, deranged thought processes, the tendency to leap chaotically from topic to topic during a conversation (flight of ideas), feelings of persecution, and, finally, hallucinations—both auditory and visual (although the former are more common).

Schizophrenia stems from an imbalance in the brain chemical dopamine, the same chemical involved in the movement disorder Parkinson’s disease. Prior to the introduction in 1952 of chlorpromazine, which normalizes the dopamine balance in schizophrenic brains, treatments of the disease ranged from the merely inane (dunking the patients in ice water) to the dangerous (lobotomy). Although a family of effective chlorpromazine-like drugs, known as antipsychotics, has been developed over the past forty years, the treatment of schizophrenia remains imperfect. Many patients become resistant to the medication, refuse to take it, or develop a Parkinson-like disability as a permanent side effect.

Some believe that schizophrenia is a modern illness, since ancient historians don’t mention it. Others contend that earlier societies ignored schizophrenics—or treated them as possessed. How could such a dramatic syndrome be ignored, discounted into nonexistence?

Today, almost one in every hundred people in the United States is schizophrenic. One percent of the population suffers from the illness, yet its profile stays low and, on a dollars-per-new-case basis, schizophrenia* receives few government research funds. Given that they are virtually invisible now, the exclusion of schizophrenics from history becomes believeable.

Years ago, the great medical essayist Lewis Thomas wrote a poignant treatise on dead birds. He noted that we rarely see dead birds, certainly not in the numbers one would expect. The summer skies fill with live birds, pigeons choke our cities like rats with wings, gulls hover like been around ships and beaches—yet their dead vanish. Aware of their impending demise, dying birds instinctively hide themselves away, perhaps to avoid contaminating the world of the living with their carrion. Schizophrenics do likewise. Like dead birds, their obscurity belies their swelled ranks. They seek heaven on street grates, in halfway houses, in prisons, in attics.

The first schizophrenic I met face to face was Jake, a street dweller who wandered into the institute’s evaluation center (a gentler title than “emergency room”). A winter evening had caused Jake to see refuge from the cold…and “the wolves.” The chief psychiatry resident instructed me and two other thirdyear medical students to chat with Jake in one of the interview areas. She handed us a three-inch-thick hospital folder marked “Jacob N. Guy.” Jake was apparently a regular patron of the evaluation center.

The interview room was a cozy alcove with blue walls, soft chairs, and a long table of fake wood. Jake sat leaning his elbow on the table. He appeared to be about forty. Matted, filthy brown hair draped over his hunched shoulders, his tangled beard showed traces of gray. He wore a tattered spring jacket suited for April, not January. His face, white as Elmer’s glue, had unremarkable features save for the eyes. Those wild eyes, unblinking black lasers, looked straight through me.

As we entered the room, my two colleagues pushed Jake’s chart into my hand and then madly scrambled for the two chairs behind him, leaving me the sole chair facing him. My “friends” then waved their hands as a signal for me to proceed with the interview, as they smiled and held their noses. The room reeked of stale urine, and odor growing stronger as I leaned forward to introduce myself. I extended my hand to him, but Jake ignored me.

Thumbing quickly, through the chart, I read that Jake had been a troubled child who had dropped out of school in the tenth grade. He drifted around Pennsylvania and Ohio, holding odd jobs until his behavior became too erratic even for menial work. A car wash in Steubenville fired him because he dried the same car a dozen times, fearing that the owner might die of germs unless he wiped them all away. A small landscaping company in Altoona could no longer deal with his bolting the lawnmower and cowering behind a tree for hours. A supermarket used him as a bag boy for less than a day.

Finally diagnosed as a schizophrenic at the age of twentyfive, Jake had been committed by the state to Woodville Mental Hospital, then released to a halfway house at the age of thirty-three. He spent less than a year there before taking to the streets, where he had lived ever since. He presented to the evaluation center every six months or so, when the weather outside got too formidable or when his most-feared hallucination, the wolves, haunted him. He would get a shot of Prolixin, an antipsychotic drug with effects lasting a month or more, and then be sent away. Rarely, he was admitted for a week or two.

I began timidly. “Jake, can you tell me why you are here to see us today?”

He said nothing for a few minutes as he sat and stared around the room, his mouth twisting and contorting—a side effect of the the antipsychotic drugs. He then erupted with a single word:



“Yeah, shit, the wolves are out there, you know. They like us street meat. Christ, they chewed me up last year…If I had my gun, man, I could fight ‘em…naw there’re too many.” He became more animated, his speech flowing in a rapid monotone. “They chased me down Grant Street last night and then they ate my buddy, Tommy. They go for the guts first, you know, flip you right over on your fuckin’ back and start digging, like this”—Jake scraped frantically at the table with his nicotinestained fingernails—”and then just pull your guts out and eat ‘em. Shit and all. Poor Tommy, goddamn it…If I had my gun, he’d…but they don’t let shitheads like me carry a gun anymore. Not since Nam. No sir—”

“You were in Vietnam?”

“I was in Vietnam, Russia, Cuba…the CIA sent me everywhere. Special Forces. Hamburger patties, that’s all we are out there for them wolves. Yeah, Tommy and I were in Nam. That’s when the wolves got wind of me. The Cong sent the wolves, and the bastards have been after me since 1971. Gook wolves, wolf gooks. Shit, let me in here so the gooks don’t get me. Put me in a cage, I don’t give a damn.” The crazed look in his eyes faded into a sincere look of desperation and fear.

Jake’s flight of ideas continued for another ten minutes, his thoughts ricocheting from subject to subject like a pinball. In Joseph Conrad’s novel Lord Jim, Marlow observes that extracting truth from Jim was like trying to find out what was in a sealed metal box by beating upon it with a stick: you got a lot of noise, but no useful information. An excellent description of psychotic speech.

I broke off the interview and exited the room to seek out the psychiatry resident. We found her watching TV in the lounge.

“Well,” she said upon seeing us, “what did you think of Jake?”

I related the story of the wolves and Tommy and Vietnam and the other observations I had hurriedly jotted down on his progress notes. “He’s a little scary,” I concluded.

“Schizophrenics are like rattlesnakes,” she observed dryly. “They look scary, but they’re far too frightened of you to be really dangerous. Personality disorders are a whole lot scarier, trust me. Tommy is Jake’s brother, a systems analyst for CocaCola. Jake talks about him, although they haven’t spoken in years. Tommy was wounded in Vietnam while Jake was institutionalized. When Jake has an acute episode he usually says wolves are after him. Two years ago, it was a pack of dogs—the hallucination is being upgraded all the time. It’s hard to tell if he really is afraid of his hallucinations or whether he just wants a night away from his cardboard box. I think it’s the hallucinations—they can be frighteningly real to these people, like a waking nightmare. If he just wanted to be admitted for a few days, he could threaten violence or suicide and try to get a 302 that way—but he never has. Not yet, anyway.” A 302 is an involuntary commitment to a psychiatric hospital, which can be imposed on patients only if they are perceived as an immediate physical threat to themselves or others.

The resident gave Jake his shot of Prolixin and returned him to the street. I watched him walk jerkily through the automated front doors, his gait bending under the weight of the brain-altering drugs, which had done little for him except make his movements as distorted as his thoughts. A wispy snow fell about him, dusting the walkways like confectioner’s sugar. Jake pulled his spring jacket around his neck and wandered off into the blackness to face his wolves alone.

• • •

I graduated from medical school in May and began my surgical internship that July. Like medical school, internships consist of different rotations, providing the broadest possible experience before our careers funnel into single, narrow specialties. My first assignment as a full-fledged M.D. was cardiac surgery. The chest team at last!

Our cardiac service included both adults and children. A curious thing about illness: it strikes the very young and very old—but few in between. On the cardiac service, patients were either seventy years old and undergoing coronary artery bypass grafting (CABG, or “cabbages,” as the residents affectionately called them), or three days old and undergoing a repair of a congenital FUH (fucked-up heart).

Interns did nothing of any consequence on the cardiac service. Not that we didn’t work hard; there was a massive amount of inconsequential nothingness to do. To be stuck in the hospital for two or three days at a time was not unheard of. Every year, the police ticketed at least one cardiac intern for falling asleep at a red light while driving home.

Our purpose was to take night calls and to be human retractors in the operating room. During the day, I held quivering hearts upside down so that a vein graft could be sewn into their backsides. Immersed in iced saline during cardiopulmonary arrest, the hearts froze my fingers, and only hours after surgery did my frostbitten fingers regain their feeling.

The nights on call terrified me. Cardiac patients destabilize in an instant, and my knowlege of cardiac surgery bordered on the nonexistent. Opportunities for sleep were rare—the few moments between beeper pages were spent searching for drug dosages in the pocket-sized Washington Manual. We might be called to administer drugs to a 300-pounder one minute, and to medicate a four-pound infant the next.

I lived in constant fear of a patient “tamponade,” when a blood clot forms around the post-op heart and smothers the life from it. If left untreated, even for a few minutes, tamponade kills swiftly. Faced with tamponade, we must tear out the skin sutures without delay; cut the bone wires to separate the halves of the freshly sawed sternum, or breastbone; and scoop the clot away from the heart. A set of suture-removal scissors and wire cutters sat taped at the bedside of every post-op cabbage for just such a delightful occasion.

Patients survived—provided the intern recognized the tamponade quickly and opened the chest immediately. There was no time for anesthetic during this emergency maneuver, however. Opening an awake patient’s chest and showing them their own beating heart did not make my top-five list of favorite activities. When closing the chest cases on my call days, I prayed, “Please, dry this wound up, stop the bleeding…no tamponades tonight.”

Heart surgery is a tough profession. A cardiac surgeon must complete six years of general surgery, followed by a two- or three-year cardiac fellowship. Operations stretched for hours; intraoperative deaths occurred frequently. Because of the hardships of training, cardiac programs attracted people with a Marine Corps attitude, residents so in love with their profession that the suffering became sweet nectar. They sported T-shirts that beamed: THE BEST WORK IN THE CHEST, and hung autographed pictures of Michael DeBakey in their lockers.

My chief cardiac fellow, Maggie, exemplified the drill-sergeant demeanor. The ER called Maggie and me one night to evaluate an elderly woman flown in from another hospital. The woman was barely clinging to life. A ventilator tethered her to earth, else she would have expired hours earlier. A cardiac catheterization, done at the first hospital, had disclosed a blown mitral valve. The mitral valve, stopcock between left atrium and left ventricle, had stuck in the open position, its mechanism damaged by a fresh heart attack. With each beat, blood drove backward into the atrium, not forward into her body. Unless replaced with a synthetic valve, the broken mitral would kill her before the sun rose.

Maggie, fresh from two straight cabbage procedures, was clearly tired. She scanned the cath report with a heavy-lidded stare, then shook her head slowly. I expected her to pound her fist with rage, angry at the unceasing workload. I had seen residents in other fields crumble under the onslaught of a neverending day. Instead, she looked at me with a wicked grin. “Frank, we’ve got a mitral valve to do! Oh, baby, this is great…YOU GOTTA LOVE THIS!!” She gleefully pranced to a phone to call the OR. She should take up bowling, I thought, just for a change of pace.

In the uterus, the fetus breathes through the umbilical-cord blood, not the lungs. The unborn possess an elaborate bypass system which shunts blood away from their water-logged lungs and into the mother’s placenta. At the moment of birth, this bypass system shuts down, clotting off the umbilical cord and diverting blood to the virgin lungs.

The in utero blood shunt carries two consequences for the cardiac surgeon: The closure of the shunt at birth occasionally fails and must be completed with a knife; and, since the normal circulation of blood is superfluous until after birth, some truly terrible heart malformations pass undetected until the delivery room, requiring the surgeon to rebuild the heart from scratch.

Although many malformations have been described and named—tetralogy of Fallot, total anomalous venous return, hypoplastic left ventricle—malformations are as individual as fingerprints, hence the less restrictive “fucked-up heart” category.

Some malformations kill the infant minutes after birth; others are mild, and their correction can be deferred for years. Most deformities, however, fall between these two extremes, producing a heart good enough to sustain life for a month or two but not good enough to last years. In these instances, the surgeon must decide whether the defect is correctable. If not, the child is left to die, or referred to the heart-transplantation waiting list.

Baby girl McKenna had entered the world with a small right ventricle. This pumping chamber receives depleted venous blood from the body and flushes it into the lungs, where it is replenished with oxygen. A month premature, she had arrived before her parents could agree upon a name. Her condition had deteriorated rapidly after birth, and she was sent to our pediatric heart service during one of my nights off. When I arrived in the pediatric ICU to make rounds at 5 A.M., little B.G. McKenna, a blue blob on maximal life support, awaited the next operating-room slot. Maggie sat in her surgical scrubs and rocked slowly in a large wooden rocking chair—known as the chair by cardiac interns.

“I don’t know what we can do for this munchkin,” she said, sipping from a vending machine cup. “Hartley and I are doing her as soon as they finish the trauma patient that’s in the heart room.” Hartley was the chief of pediatric cardiac surgery.

That’s great, I thought. I was on call for the night. B.G. and I were sure to have a fun time together. Babies this small can’t tolerate the heart-lung machine, and are done instead under “profound hypothermia.” Packed in ice until suspended animation occurs, the infant’s heart is stopped and repaired as quickly as possible.

Certain species of frogs and fish can be frozen solid and rethawed with no apparent injury. But babies are neither frog nor fish. Without the protein antifreezes that circulate in those animals, they emerge from profound hypothermia near death, their blood-clotting mechanisms deranged, their livers reeling, their brains dysfunctional. I looked at the chair, now occupied by Maggie—the command seat for the pediatric heart patients in the children’s ICU. We spent many nights in it, wrapped in an afghan and rocking nervously, watching patients too unstable to be unattended.

B.G.’s surgery commenced later that morning and finished around five o’clock. Having scrubbed on cabbages until about eight, I finally wandered down to the pediatric ICU for signout at nine. Maggie awaited me, anxious to sign out B.G. before leaving. The service was quiet…except for B.G. As I expected, the problem for the night.

Surgical soap stained her scrawny little body orange from her neck to feet. Heating lamps dangled above the bed, to restore warmth to her frigid body. She looked like a little cornish hen roasting under the heat lamps of a delicatessen.

Maggie handed me an index card. “Here, I’ve calculated the doses of the resuscitation drugs for her weight. I think everything is there—epi, bicarb, bretylium…The nurses know the defib settings, they’ll help you with that. You’ve taken infant CPR? Good. You’ll need it. She’s going to have a rough night, but if she makes it twelve or twenty-four hours, she has a shot. The parents have just left…We’re all counting on you. I want her alive tomorrow morning. You know how to reach me if you get up to your ass in alligators…So long.”

Maggie left. I dragged the heavy rocking chair beside the rotisserie bed and plopped myself in for the night. Gazing at the monitor, I watched the little squiggles that B.G.’s damaged heart traced across the fluorescent screen. So far, so good.

I dozed for a short time. A nurse shook me awake. “Her pressure’s falling,” she whispered.

I cleared the cobwebs from my head and ordered an infusion of albumin and an increase in her dopamine, an intravenous drug which stimulates the failing heart muscle. (The drug dopamine is the same as the brain chemical dopamine which is deranged in schizophrenics. The human body uses many chemicals in multiple roles.) B.G. stabilized for an hour before her blood pressure dipped precipitously again. Despite more albumin, the pressure bottomed out completely and her heart fibrillated wildly.

I jumped from the chair and started cardiac compressions on her tiny chest with my index and middle fingers. I order a bolus of epinephrine (also known as adrenaline) and the fibrillation reverted to a normal rhythm. The blood pressure went up to ninety. Breathing a sigh of relief, I went to the nurses’ station and called Maggie at home, informing her of the successful resuscitation.

“What do you want, a medal?” she croaked. “What is it, two A.M.? You got hours to go before she’s stable…and go easy on the epi; her perfusion is poor as it is and I don’t want her fingers to die. Push the fluid harder.”

My ego deflated, I went back to the chair. Maggie was right about the epinephrine. B.G.’s fingertips grew more discolored by the hour. Like Mephistopheles, epinephrine will do your bidding—for a price. The increase in blood pressure and heart contractility after an epi infusion comes at the expense of blood flow to the limbs. Too much epi and the hands and feet will become gangrenous.

Another hour passed before the hypotension and fibrillation returned. More CPR, more albumin. Some lidocaine and bretylium. A blast from the miniature defibrillator. Nothing worked. I gave yet another bolus of epi. Again, the pressure shot up, the heart rhythm stabilized. B.G.’s fingers and toes became darker and more mottled.

To prevent another round of hypotension, I increased the intravenous infusions drastically, but her lungs filled with fluid and the oxygen level in her arteries fell dramatically. To counteract this, I gave her Lasix, a strong diuretic. The Lasix, had no effect. The urine output slowed, no doubt due to lack of blood flow to the kidneys: another side effect of the epi.

The fibrillation came again.

They are all counting on me. The words rang in my tired brain. Her mom and dad, Hartley, Maggie…they are counting on me to keep this baby alive. I ordered another bolus of epinephrine. Take this child’s fingers, Satan. Faustus selling his soul for another hour of stability, another hour of fitful sleep in the chair…

The epi kept the devil’s bargain: the blood pressure soared and a sinus rhythm once more hammered its way across the monitor screen. I glanced at the clock: four-thirty. Time for rounds soon. My eyes closed.

Maggie grabbed my arm. Disoriented, I jumped from the chair and to B.G.’s bed. Empty. The heat lamps dark. Looking again at the clock, I realized that I had been asleep for over two hours! Panic overcame me. What had I slept through? They had been counting on me.

Maggie chuckled at my frenzy. “Relax.”

“Where’s the baby? Did she go back to the OR?”

“No, I shut off her ventilator an hour ago. She’s in the morgue. Actually, her parents wanted her shut off last night before I left, but I forgot.”

“In the morgue? You forgot what? What do you mean, they wanted her shut off last night?” I was confused, furious.

“Hartley met with them after surgery. You see, we couldn’t repair the right ventricle. All we could do was enlarge it with a Teflon patch, but Teflon doesn’t pump blood, you know. We knew she was a goner when she left the table. The family was very reasonable—the mother’s an ER nurse across town—they couldn’t see prolonging things and they gave us the okay to halt support. I just figured we could wait until morning to do the deed.”

“Why didn’t you tell me all this last night? Why did you let me sit in this fucking chair all night thinking I was making some baby’s fingers drop off?”

Maggie’s smirk vanished. “Your night wasn’t such a waste, was it? You learned how to resuscitate a baby, how to face crisis, what drugs to use and what problems they can cause. I bet you won’t forget the doses of those drugs for a while, either. They are burned into your brain. You did a good job. Not many people can keep a Teflon heart beating for ten hours. Now I know I can count on you to handle a baby with a real chance of living.”

“You could have told me that she was a goner—I was crapping in my drawers.”

“No. Then you wouldn’t have been under the gun. Pressure’s part of the deal. Anybody can sing in the shower, but how many can sing in front of an audience, huh? Pressure makes all the difference in the world.”

* See William T. Carpenter Jr., and Robert W. Buchanan’s excellent review article, “Schizophrenia,” in The New England Journal of Medicine 330 (1994): 681-90.

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