Pleasure is oft a visitant; but pain clings cruelly to us.
Pain is the price we pay for mobility. Since the dawn of life creatures have segregated into two camps: motionless foodmakers and migrating food foragers. Creatures in the first camp learned to draw energy from their immediate environments. Plants turn chloroplasts to the sun and use photosynthesis to manufacture glucose, while deep-sea creatures harness heat arising from thermal vents on the ocean floor.
Creatures in the second camp sprouted tails, legs, fins, and wings and set off to eat the food makers, or each other. Lacking a clever trick like photosynthesis, the food foragers came up with a new invention: the nervous system. To say that the nervous system evolved so that animals could sense and respond to their surroundings is only partly correct. Anything alive, brainy or not, must be able to sense and respond to its surroundings. Bacteria “know” when the ambient moisture is too low, and form into spores which are more resistant to drying. A tree senses when autumn comes and jettisons its leaves as the sunlight fades.
But these responses are relatively simple and slow, taking hours, days, even weeks to complete. Moreover, no-brain creatures such as trees and bacteria have only tiny repertoires of stereotyped responses. The tree adapts to the seasons but, having no place to run, falls victim to sudden, life-threatening events—forest fire, bark-eating deer, beavers’ incisors. As compensation for this helplessness, nature blessed the mindless tree with ignorant bliss. The oak feels no pain from the lumberjack’s saw. The pine does not cry out in agony as lightning bursts its trunk asunder.
Animals, constantly at odds with a changing environment or with other animals, could not survive with the tree’s small number of adaptive mechanisms. Peripatetic organisms need complex responses which can be customized in milliseconds—they need a nervous system. Although sensation and adaptation can occur in the absence of brain tissue, these skills are elevated to a new level of speed and diversity by an organ system devoted solely to cognition. The primordial ganglion protobrains became the digital computers of biology, leaving the abacuslike reasoning of the plant kingdom in the dust.
As always, there was a terrible price to pay for this new technology. Animals dependent for survival upon the complex software of nerve cells and the delicate clockwork of churning limbs are very vulnerable to injury. Yes, the big stupid tree doesn’t know enough to run away from fire—but it can lose over half its branches and live. A squirrel with one broken leg is as good as dead. In the natural world, where any breach of the skin can mean infection and death, an animal must stay out of harm’s way. Like the earliest computers, the earliest brains were pretty dim. The only way to keep animals equipped with “first generation” brain hardware out of trouble was through aversion: dangerous things became painful things. Pain became the taskmaster of the animal world.
Unfortunately, the blossoming of our magnificent forebrains did not free us from the bondage of animal pain. We are now smart enough to learn abstractly that fire hurts without having to experience it firsthand, yet we still endure the agony of burns. The pain pathways that torment us with toothaches, menstrual cramps, and bee stings have progressed little from the days of the walnut-brained stegosaurus writhing in a predator’s jaws. The continuing need for pain in humans no doubt derives from the stupidity of young children, who, as any parent can attest, feel compelled to seek what does and does not hurt for themselves.
The pain pathways have no “off” switch. Pain lingers long after its biological usefulness has passed. Although a pain alerting us to the presence of curable cancer is a valuable torment, cancer pain doesn’t have the merciful sense to cease after the cancer has spread to a terminal stage. The nervous system does possess two means of limiting pain perception: chemicals known as endorphins and a spinal-cord switching mechanism called “gating.” They are far from perfect in their natural state but can be augmented with the help of medical technology.
Endorphins, natural substances related to morphine, are released in times of stress. Like morphine they are very good for acute, severe pain, but not so effective for mild or chronic pain. Endorphins evolved so that wounded animals could function, at least for a short while. Example: a doe, mortally wounded by a car, ignores the pain and crawls away in search of her fawn. Endorphins permit a running back to keep chugging for the goal line oblivious to the fact that his arm was broken on the line of scrimmage.
Endorphins also perform a true mercy service, anesthetizing an animal trapped by a carnivore. Those people who have survived being caught in the jaws of lions or grizzly bears speak of the warm, insensate calm that flowed through them as they succumbed to being eaten alive.
The gating phenomenon is a second mechanism for blunting painful sensations. The spinal cord is like a collection of railway tracks: sensations ascend within it like freight trains running on those tracks. Each sensory modality (pain, temperature, fine touch, heavy pressure) is like freight carried to the brain on separate trains. Access to the brain is limited, however. Only so many trains enter at once, only so much freight is unloaded into our consciousness. When one sensation is dominant, the others are blocked, “gated.”
The gating mechanism occurs with the other senses as well. If, as we are listening to one conversation at a cocktail party, we are then engaged in another, the voices in the original conversation fade into the background. Likewise, we find it difficult to smell two strong odors at once. Many commercial products operate on the gating principle. Bathroom deodorizers don’t remove foul odors; they gate them from our brains by superimposing a stronger, more pleasant odor. Noise “masking” devices for airplane travelers gate out the annoying whine of an airplane engine with a more soothing white noise.
Pain can be gated from the brain by superimposing another sensation. If we scald a hand with hot water, we immediately rub the burned area. We are inately seeking to gate the pain out, to prevent the pain train from pulling into the brain station. Pain gating is the mechanism behind the old coaching aphorism “Walk it off.” Migraine sufferers knead their temples; sufferers of leg cramps knead their calves. Gating underlies the effectiveness of massage, ice packs, heating pads, liniments, and acupuncture. Attempts to gate pain can be taken to perverse extremes. Napoleon, troubled in his later years by kidney stones, routinely burned himself with a candle to divert his attention from abdominal pain.
Neurosurgeons deal in pain on a daily basis. Pain in the head, pain in the face, pain in the arms, pain in the legs, pain in the neck, pain in the back—all, essentially, a pain in the ass for patient and doctor alike. Over two-thirds of all neurosurgical operations are for pain control—or, more properly, the alleviation of suffering.
There is a profound difference between pain and suffering. All animals feel pain. Only humans suffer. Pain is a physical sensation; suffering is an emotional state induced by pain. Suffering is pain coupled with uncertainty, depression, frustration, anger, fear, despair. We can have intense pain but not suffer. A stubbed toe, a shin whacked against a coffee table, a softball to the groin, a paper cut, a mouth ulcer—all may elicit extreme pain with little suffering. We know these pains are temporary. We know that they will go away and that they bode no longterm ill for our bodies.
But what of a woman who thinks she is cured of her breast cancer and then develops a minor backache? Her mind is troubled. Is it the cancer again? Until she finds out, she will suffer greatly. That small backache will become like a nail driven into her spine until she knows what it signifies. When told that all the tests are negative for cancer, she feels better instantly. No pain medications could accomplish this. The pain is the same, but the suffering is eased. In a sense, suffering is pain augmented by a bleak imagination. We construct dismal scenarios for our unexplained miseries: That toothache must mean a root canal; that hand stiffness is rheumatoid arthritis; that heartburn could be coronary artery disease.
Hippocrates once said that the chief function of medicine is to entertain patients until they heal themselves. On the pain service, we didn’t entertain our patients; far from it. We took their pain away as best we could.
Of course, sometimes we had to poke holes in their heads to do it.
The very first morning of my residency, Gary and Eric took me to the neurology floor and introduced me to some of the pain patients on the service. I had little previous experience with the pain service. At the time of my medical student rotation, there were relatively few pain service patients in the hospital. I had avoided even that handful, concentrating instead on the more “interesting” cases like brain abscesses, pituitary tumors, and carotid aneurysms. A medical student can get away with ignoring tedious problems in favor of more challenging ones. But residency was different. Medical school is five parts learning to one part servitude; the ratio is reversed in residency.
We halted at room nine, a private room.
“Room nine,” Eric whispered, “Mr. van Buren. Status postfive laminectomies for ruptured lumbar discs. He’s from Boston, runs an investment company or something. He has chronic right leg pain and has been on oral morphine for the last six months. We put in an epidural spinal cord stimulator yesterday and externalized it. The guy’s now playing with it to see if any of the settings make his pain go away. If not, we yank it. If it does, we internalize it to an antenna and send him to a detox unit.”
Gary explained that the spinal stimulator’s gate mechanism permits pain to be masked by a simultaneous sensation, such as touching or rubbing. Not surprisingly, people with chronic sciatica find it impractical to go around rubbing their legs all day. To exploit the gate mechanism, devices which continuously stimulate the touch nerves have been marketed. The simplest is the transepidermal nerve stimulator, or TENS unit, which consists of surface electrodes taped to the skin and hooked to a portable battery supply. The TENS unit provides a gentle “buzz” to the affected skin, akin to the low-level shock felt when touching the transformer of a toy electric train set. In patients with “failed back syndrome,” or FBS, severe leg pain from a damaged spinal nerve lingers even after one or more “successful” operations to remove a ruptured back disc. Many FBS sufferers can get by with a TENS unit attached to their affected leg all day.
Eventually the TENS unit fails, though, and more masking stimulation is needed. To accomplish this, a thin electrode is threaded under the skin, between the vertebrae and directly over the spinal cord, into an area known as the spinal epidural space (the same area anesthetized during labor and delivery). The electrode is initially brought out through the skin and hooked to a compact control box to allow the patient to experiment with different spinal stimulation settings. If the patient gets relief, he or she is returned to the OR and the electrode is put under the skin and connected to a subcutaneous antenna. The stimulator is then completely internalized and safe from infection. Stimulating signals are broadcast to the spinal cord electrode via a radio transmitter hooked to the belt or worn over the shoulder like a purse.
We entered the room. Mr. van Buren, dressed in expensivelooking pajamas, sat in a chair by his bed. He was a large man with a pleasant, ruddy face and coarse black hair cropped short, almost in a crew cut. On his lap lay a small beige box, the size of a pack of cigarettes, with several buttons and dials on one side. Two thin wires sprouted from the top of the box and disappeared into the front of his pajama top. He looked to be deep in concentration as his thick fingers twiddled the knobs on the box.
“Good morning, Mr. van Buren. Have you had any luck?” asked Gary in his best professional tone.
“I can get it to buzz a little around my butt cheeks when I use the square wave pulse and turn the frequency to…here.”
“Does that help?”
“A little, but it feels like my pants are warm, like I’m pissing myself all the time. I’m not sure that’s any better than the pain.”
“Mr. van Buren, this is Dr. Vertosick,” Eric spoke, “and he’s joining our team for the next six months. You’ll be seeing him every morning now.”
The man looked up from his box and smiled politely.
“Nice to meet you, Doctor.”
“I understand you have had five disc surgeries?”
“Yes…the first was in 1974…but here, let me show you.”
The man reached over to his nightstand, opened the top drawer, and produced a leather-bound folder with the words “Myelograms and records of A. van Buren” stenciled on the front cover in gold leaf. “Have a seat, Dr. Ferblowstick.”
He proceeded to explain the saga of his many operations in great detail, turning the pages with the slow intensity of a newlywed showing off a wedding album. “Look, here was right after the second operation…there was a little scarring around the fifth lumbar root, but no arachnoiditis yet…My surgeon thought that this might be a disc fragment here, and he looked again in 1981…Here the arachnoiditis got bad…”
Among the photos of myelograms and CT scans and operative notes were other memorabilia: labels from bottles of narcotics, letters containing second surgical opinions, insurance forms, articles on holistic healing and the power of positive thinking. He grew more excited as he spoke, spouting his tale of vertebral vivisection at the hands of three surgeons with as much glee as a fisherman recounting his battle with a prize marlin. He didn’t seem to be in any pain at all.
“Mr. van Buren,” Gary interrupted him, “tell Dr. Vertosick what your pain is like now.”
“Oh,” he replied, still grinning, “it’s awful, excruciating. It’s like an army of red-hot earthworms crawling up inside my leg, wriggling and writhing day in and day out. Occasionally, I get a groin pain, over here, that’s like a C-clamp being slowed twisted down on my pubic bone.”
“Thanks, we’ll see you this afternoon…try turning the amplitude down and the frequency up. If that doesn’t work, we may have to take you back to the OR and reposition the electrode.”
We exited the room and walked a little way down the hall. When we were far enough away from room nine, Gary spoke: “Well, class, what did Mr. van Buren teach us?”
“Ah, that the electrode…”
“Forget the friggin’ electrode. Is this guy in pain?”
I was confused.
“Is he in pain?”
“I guess so?”
Gary motioned me over to another room, room eighteen. Lying in the bed was a pale, wasted man. “Hey, Mr. Angelo, it’s Gary. Tell young Dr. Vertosick what your leg pain is like.”
“I dunno.” The man’s voice was thin, weak. “It hurts like hell is all I can say. Right about here. Real sore.”
“Thanks, Mr. Angelo.” We darted back into the hallway again.
“Mr. Angelo has a malignant sarcoma eating into his lower back and right lumbar plexus,” Gary continued, “and he’s in agony. Does he say he has goddamned electric earthworms in his leg or some such shit like that? No. He says ‘I’m real sore.’ He also uses about one-tenth the morphine that room nine uses. Why? Because he has legitimate pain and he isn’t nuts. Another rule of thumb: The more bizarre the description of the pain, the more likely it is to be a psychiatric delusion. Phrases like ‘I have little gnomes with branding irons running all over my face’ or ‘The hooves of a thousand angry horses are thundering in my head’ should immediately make you suspicious that something else is going on. People with real pain don’t say ‘excruciating.’ The word ‘excruciating’ literally means to feel the pain of crucifixation. Since hardly anybody knows what it’s like to be crucified anymore, no one is entitled to use that word, in my humble opinion.”
“Look at that guy!” Eric chimed in. “My kid’s pictures don’t get as much attention as his X rays! He’s becoming his pain. It’s part of his identity. He’ll be in pain until it’s time for him to make the horizontal call from a brass-handled phone booth—which won’t be long if he keeps slurping up oral morphine.”
We proceeded down the hallway to room eleven.
“Room eleven,” said Eric. “Mrs. Rubinstein, atypical face pain. Had a microvascular decompression of the fifth cranial nerve three days ago. Still has face pain, same as pre-op. Wound looks good, no headache—thank God for small favors…Husband Ben by her side, as usual.” A microvascular decompression is the act of padding arteries away from the cranial nerves at the base of the brain using small Teflon sponges; it was the first operation I had seen—or at least started to see until Gary plunged the drill into the patient’s cerebellum and made me flee the OR.
The body has twelve pairs of cranial nerves, so named because they exit from the brain itself, not from the spinal cord. The cranial nerves mediate the sensory and motor functions of the head and neck. The first cranial nerves are the olfactory nerves, which convey the sense of smell; the second cranial nerves the optic nerves, which convey the sense of sight; and so on. The fifth cranial nerve conveys sensations from the face. It is also called the trigeminal nerve, from the Greek phrase meaning “three origins,” because the main nerve branches into three divisions: V1 (called vee-one, even though the “V” is meant to be the Roman numeral five, not the letter), which supplies sensation to the forehead and eyes; V2, which supplies the cheeks, upper teeth, and upper lip; and V3, which supplies the jaw, lower teeth, and lower lip. The trigeminal nerve is somewhat rudimentary in humans compared to the nerves of lower animals, such as mice or cats, which have whiskers and depend upon keen facial sensation for their survival.
“Atypical facial pain?” I asked. “Is that like trigeminal neuralgia?”
“No.” Gary answered sharply. “It isn’t anything like trigeminal neuralgia, or tic. People with tic have stabbing pains in one, or perhaps two, divisions of the nerve. The pains are elicited by sensations in the affected area: brushing the teeth, cold air or water hitting the face, chewing. Atypical patients have pain all the time, describing it as burning or aching and not shocklike.”
“Does surgery help this?”
“Judge for yourself.”
Mrs. Rubinstein, an attractive woman of about forty, wore a sexy nightgown and large, dangling gold earrings. The right earring smacked repeatedly against the shaven, sutured wound behind her ear as she turned her head to greet us. A bald man sat in a chair beside her bed.
“Mr. and Mrs. Rubinstein, this is Dr. Vertosick. As of today, he’s a brain surgeon. How’s your face?”
“Awful just ahhhwful.” She had a heavy New York accent—I wasn’t versed enough to tell exactly what part of the city it was from. “What can I say, it’s worse than it was before, I’m telling you. Like grease from a doughnut frier being poured onto my face all of the time. My God, I thought that this was really going to do it for me. Right, Benjamin?” (A vigorous nod from the bald man.) “The people at the Mayo Clinic and Hopkins told me that this was the place to go, but I don’t know. Doughnut grease, I’m telling you, doughnut grease. One Percocet just isn’t holding me. I told you people that I need two every four hours or I’m not fit to live with. When we were at Cornell, they tried to switch me to Motrin, but what a scene I made!”
“Is it still hurting you…all the way to here?” Eric reached over and gently touched the woman’s hairline at the top of her forehead. She winced.
“But not here.” Eric drubbed his index finger in her scalp, just behind the hairline.
“No, not the scalp…just the face hurts. Doughnut grease, scalding doughnut grease. My God, I swear one day I’ll wake up and big strips of scalded skin will peel off on my pillow!”
“Is your pain excruciating?” I asked.
Gary’s face became stern. “Well, we’ll see what the boss has to say. Good thing the mister’s here to take care of you, huh?”
“Yeah, he’s such a dear.”
“Yes, Mrs. Rubinstein?”
“I’ll have to check with your attending surgeon first; I’m sorry.”
Back into the hallway, Gary started grilling me again.
“Anything funny about her pain?”
“She uses that graphic imagery you were talking about with Mr. van Buren.”
“Uh-huh. But what about the distribution of her pain?”
“It stops at the hairline and doesn’t go into her scalp?”
“Bingo! And where does the distribution of the trigeminal nerve stop?”
“At the vertex of the head, almost back to the occipital area.”
“Bingo again! Society defines the face as being from the hairline down, while the brain considers almost the whole head as the face. Patients with V1 tic have pain extending well into their scalps. I’ve seen patients who haven’t washed or combed their hair on the affected side of their heads for days or weeks because they can’t touch their scalps. Her pain distribution follows a culturally defined area, not an anatomically defined one. Her pain has to be psychiatric in origin.”
“But we did a craniotomy on her,” I observed.
“There is no way to be sure she doesn’t have some component of tic pain,” said Eric. “On the pain service, we have to assume all pain to be real, organic, and that the pain makes people eccentric, not vice versa. In any pain patient, no matter how bizarre the history, may be a kernel of real pain, like a splinter at the bottom of a festering sore.”
“So the pain service doesn’t refuse anybody?”
“No,” answered Gary, “and room twenty-two is a case in point.”
In room twenty-two was a wispy little man in his mid-twenties. He was thin to the point of pathological anorexia, his face covered with blemishes and his hair thinning in random spots. An odd collection of items lined the man’s windowsill, each with a note card taped upon it. Across the top of the window was a large banner that read “Harry Gottlieb’s Museum of Pain.”
After I was introduced, Harry, who had suffered from chronic headaches for year’s, showed me his museum.
“This is the Dodgers cap which used to-take away my pain whenever I wore it. It quit working for some reason. And this…this is the TENS unit they gave me at the pain clinic in Erie. It really didn’t help much at all. I even shaved my head so that the electrode patches would stick better, but that didn’t make any difference. And the patches cost a lot of money, so I quit using it…These are a collection of the pain medications I’ve tried over the past eight years…”
I rummaged through the bottles: Dilaudid, Percocet, Elavil, all the bottles large—and empty.
“Mr. Gottlieb, what’s your headache like?” I asked.
“Like a big railroad spike that some large man is hammering right into the top of my head. And it’s one of those square spikes, not sharp at all. Dull. Pounding right down into the center of my head, right here.”
One of the staff surgeons had recently placed a midbrain stimulator into Mr. Gottlieb. This device is a higher-powered version of the epidural stimulator inserted at the very top of the pain pathways.
“Did your operation help you?” I pointed to the incision on his balding scalp.
“Yes, oh, my yes. The spike feels sharp now, not dull and square, anymore.”
I thanked him for the tour of his “museum” and we went back to our rounds. We left him scurrying about his windowsill, tidying up his Museum of Pain for the next visitors.
I stopped and confronted Gary and Eric before continuing with rounds. “You guys are pulling my leg, right? These can’t be typical patients—the only patient with real pain was that Italian man with the sarcoma.”
Gary stopped me. “Let’s be serious. These people have real problems and we shouldn’t make light of them. And we can’t be sure whether they are having pain or not. If someone ever invents an accurate pain-o-m’eter, then that person should get a Nobel Prize. But for now, the only way we judge pain is by what the patient says. These people are feeling some kind of pain, if only psychic pain. They need help; I’m just not sure if they need our help. But there is no way to know for sure, so we give them the benefit of the doubt. If we fail, we send them to the pain clinic, where the anesthesiologists, psychiatrists, and social workers take over.”
We finished rounds. My mind was troubled. When I first started working in our local steel mill, I thought I’d be making steel, but I’d spent all of my time shoveling grease. I’d entered neurosurgery to help people, but these people seemed beyond help. My mother had once suggested that I not go to medical school, that I stay in the factory, since that was as good a job as any. Was she right?
The pain patients made up only half of the service. The other half consisted of ER consults, trauma victims, and the elective patients of the other university neurosurgeons. We were also responsible for the in-house neurosurgical consults, which were sometimes interesting, sometimes tedious.
The university’s medical center had a diverse patient population, bringing problems ranging from spinal pain in a melanoma patient to brain mass in a liver transplant recipient. The most common consults were for mundane complaints—say, benign backaches, or requests for the neurosurgery resident on call to perform a lumbar puncture, or LP. Because neurosurgeons violate the brain’s natural barriers to infection, any postoperative fever in one of our patients may herald a bacterial meningitis. Fever in a post-op head case mandated a lumbar puncture, known to laymen as a “spinal tap,” so that some of the cerebrospinal fluid, or CSF, could be sent for a white cell count, glucose measurement, and bacteriological cultures. When we were busy, I would do ten to twelve LPs a day. Medical residents, in comparison, might do ten or twelve a year, while other specialties may do less than that in a career. By virtue of our experience and availability, we were the LP mavens of the health center.
The procedure consists of turning a patient on his or her side, numbing a small patch of skin in the middle of the lower back, and plunging a six-inch-long needle into the spinal canal. (It’s best not to show the needle to the patient, I have discovered.) The fluid is left to drip into sterile plastic containers, like maple sap from a tree.
In younger patients, a spinal tap can be trivially easy. Not so in the aged. As we grow older, the small openings in our spines—tiny windows between the vertebral laminae which permit the entrance of the LP needle—are slowly occluded by the advancing bone spurs of degenerative arthritis. This makes LP’s very difficult affairs in elderly patients, sometimes requiring many minutes of blind probing with the needle before a portal into the spine can be located. One patient suggested that a divining rod might be useful, to point the way to watery paydirt.
More often than not, the failed LP was a result of inexperience, of a medical student or an intern’s sticking the needle far off the mark. Patients will tolerate only so much amateur prospecting in their bones and nerves before they order the procedure abandoned. But if meningitis is suspected, there is no waiting for tomorrow: the test must be done immediately. When the medical interns cannot obtain a successful LP, neurosurgery is called to save the day. This was not a pleasant assignment. We frequently had to try again in a hornet-mad patient whose back looked like a sprinkler head. Ah, but the sweet pleasure of passing the needle effortlessly into a ravaged spine in seconds, when other doctors had tried for an hour or more! All I needed was a ten-gallon hat and I was off into the sunset. Shucks, ma’am, ‘twern’t nothin’!
This dire need to obtain spinal fluid in a case of suspected meningitis illustrates how the physician’s job, particularly a surgeon’s, differs from most others. In medicine, results count, not effort. Get spinal fluid. That’s all, just get it. And soon. Nobody cares how tired you are, or how much the patient bitched, or how the hospital didn’t have a long enough spinal needle, or that the patient was a thousand years old or weighed a thousand pounds. Nobody cares that your technique was correct. Just get spinal fluid. Use fluoroscopy. Sit the patient up.’ Stand him on his head. Give him Valium. Do what it takes; just do it. His life may well depend upon success.
My last physics course as an undergraduate was Mathematical Methods in Physics. On the first day of class, the professor informed us that there would be only one test, the final exam, and that it would consist of only one problem. He wanted only the answer to that problem, accurate to four decimal places, written on a scrap of paper above our name. If we were correct to all four decimal places, we’d get an A. If not, we’d fail. Simple. There were immediate howls of protest from myself and others. One test? One answer? Didn’t he even want to know how we set up the problem? If we even knew what we were doing?
“No,” he replied. “Welcome to the real world, where people only want answers—correct, accurate answers. If a bridge collapses and kills forty people, who do you think cares whether the engineers set up the problem correctly? In life, there is no partial credit for being half right. If you want to accomplish anything important, you have to be totally right—and be willing to take the consequences if you are not.”
As the professor argued, all real-world occupations require a certain level of performance. The physician’s performance must be perfect, however, and it must be perfect right now. In a lifetime, a surgeon performs thousands of operations and makes hundreds of thousands of decisions regarding medications, antibiotics, when to operate, when not to operate. Complicating matters is the fact that these decisions often must be made quickly and with incomplete information. Call a lawyer at three in the morning and ask to have a coherent defense strategy laid out right now! Wake an airline pilot from a dead sleep and expect him to pull the plane out of a nose dive right now! Take a car to a mechanic and say fix it right now—not a day from now, or an hour from now.
One night I was summoned for an emergency LP on a young man from the medical service, admitted that day in a stuporous condition and now nearly comatose. His brain CT showed nothing unusual. He had a slight fever and a stiff neck, and the diagnosis of bacterial meningitis had to be ruled out. Both the intern and the resident on the house medical service had tried to get spinal fluid and had no luck. They called for the radiologist to do the procedure under fluoroscopy, but she refused to come in from home until I had given it my best shot. She paged me to ask if I could spare her a night trip to the hospital, as her daughter wasn’t feeling well.
There was the usual bedside scene: a naked man on his side in a fetal pose, his back purple from failed LP attempts, brown prep solution staining the sheets and floor. A dozen blood-soaked gauze sponges littered the bed, the wreckage of a prepackaged LP tray strewn across the patient’s nightstand.
The man was very tan, even in places that shouldn’t be tan, and he had short, bleached-blond hair. Gold chains adorned his neck and right ankle. He had an excellent physique.
“Is he awake?” I asked. “Any sign of trauma?”
“He moans; that’s about it,” replied the medical intern, still wearing her bloodstained latex gloves. “And no, no sign of trauma.”
“He sure looks healthy for a sick guy…What’s the name?”
“Roger Doe? Any relation to John?”
“Everybody who comes to the ER without ID is called Doe. They rotate first names to keep the record room from being clogged with John Does. We’re up to the R’s already.”
“No kidding! Like naming hurricanes. What’s wrong with him?” I asked as I pulled on gloves and began to probe the mauled back in search of a virgin interspace. I immediately detected the error of the intern’s failed attempts: she was far too low and had been skewering the hard sacrum, or tailbone. Nothing but blood there.
“He came in like this, found unresponsive on the street and brought in by the police from downtown,” the intern continued. “He was probably robbed after he collapsed, since he had no wallet or other ID, even though he was dressed pretty well. He’s not a street person, that’s for sure. No sign of a beating or any struggle. The cops took a few quick fingerprints and we might have some idea of who he is by tomorrow. He has a low white count, and some big cervical lymph nodes. A few in the axilla and groin as well. It’s like mono, or cat scratch fever, maybe.”
“Cat scratch fever? When does cat scratch fever make you comatose?”
“We don’t have the toxicology back yet. His alcohol level is zero, but he may have barbiturates or heroin on board.”
“Did you give him Narcan?” Narcan is the antidote for narcotic overdoses.
“Yeah, but that didn’t do anything.”
“Sort of rules out heroin…Here, here we go!” I pushed the needle forward and clear, watery fluid began to drip out. As I was switching collection tubes, the fluid splashed onto my face and eyes. I brushed it away with my coat sleeve. “This fluid looks pretty clear to me. No meningitis here.”
“Thanks much, er”—she glanced quickly at my name tag—“Frank.”
“No problem…(Try learning where the lumbar spine is next time)…Anytime at all. I’d get a stat gram stain on this stuff, anyway. He ain’t like this for no reason. Maybe he has the Black Plague…maybe those groin nodes are really buboes.” The intern blanched a bit. I was only half joking, since bubonic plague still exists in some parts of the country and, for the moment, we had no idea who Roger Doe was or where he called home.
I went back to my evening scut chores and forgot about the LP. Two hours later, the medical intern paged me with a curious bit of news.
“The Gram’s stain,” she said, referring to the microscopic examination of the fluid, “found many organisms resembling Listeria monocytogenes.”
“What the hell is that? I’m a surgeon, remember?”
“A gram-positive rod, a bacteria which causes meningitis, but only in alcoholics and in patients with cancer or leukemia.”
“But he had clear fluid! And no pus!”
“I know. The official white count on the fluid was only three, normal. The glucose was a little low, but the fluid is teeming with bugs.”
I thanked her and hung up. Why does someone have a rare meningitis, with no white cells in his spinal fluid? This was the healthiest sick guy I had ever seen.
Out of curiosity, I stopped into the medical ICU two days later to check on Roger Doe. He now had a name: William Bishop.
Forty-eight hours of intravenous antibiotics had done nothing to lighten his coma and he was now on a ventilator. The same intern who had botched his LP was standing by his bedside, along with a fellow from the infectious diseases department.
“Have you figured out what’s wrong with Roger…er, I mean, Mr. Bishop, yet? Oh, by the way”—I turned and addressed the infectious diseases fellow, a tall woman with hornrimmed glasses—“I’m Frank, the neurosurgery resident who did his LP. The intern here told me he has Listeria meningitis.”
The fellow nodded, her face dour.
“Well, we know several things. He does have Listeria meningitis; also has some form of pneumonia, we’re not sure what type…he’s getting an open lung biopsy this afternoon…and he has oral candidiasis.” Candidiasis, called “thrush” in infants, is a yeast infection that almost never occurs in the mouths of adults unless they have had prolonged antibiotic therapy or have had their immune systems suppressed by disease or drug treatments.
“His family showed up from Ohio,” the diminutive medical intern added, “but they haven’t given us much useful information. It seems Mr. Bishop is a freelance artist and graphics designer who has been in town here for several weeks on a job. They haven’t seen him in months, and he was the picture of health when he left Ohio. He doesn’t do drugs, he doesn’t smoke. In fact, he’s a health nut. Whatever happened to him happened fairly quickly. He must have just passed out in the street one night, was robbed and left there to be picked up by police, who thought he was drunk. His tox screen was totally negative.”
“I wouldn’t say that they didn’t provide us with any useful information,” the fellow interjected. “I got two pieces of information that you didn’t. He’s a homosexual. And he’s been to San Francisco.”
The intern and I screwed up our faces in simultaneous puzzlement. I voiced what we were both thinking: “What difference does that make? I know—too much sourdough bread.”
The fellow removed her glasses and spoke in low tones, as if she was about to convey top-secret information: “There are scattered reports coming out of cities with large populations of homosexual men, San Francisco in particular, concerning a new illness that afflicts only gay men. We’ve known for a while that this group is more prone to hepatitis B and a variety of other unusual things, such as gay bowel disease. Now, however, there seems to be a clustering of weird illnesses—Kaposi’s sarcoma, pneumocystis pneumonia, candidiasis—occurring in homosexual men. Mr. Bishop fits that picture. He’s homosexual, has been to San Francisco several times, has a low white count and several infections that occur only in people without competent immune systems. That seems to be the common denominator: immunodeficiency, or lack of normal immunity. There’s no name for it yet.”
“Is it contagious?” I asked with a shudder, thinking of the CSF I had cavalierly splashed about.
“No,” replied the fellow. “At least we don’t think so. Since only homosexual men are afflicted, it must be transmitted by something unique to their culture or their environments. One theory holds that it comes from the overuse of amyl nitrate, a drug used by homosexual men to heighten orgasm. Another hypothesis is that this is a virulent form of hepatitis B, but that seems far-fetched. Hepatitis B has been around a long time and has never been seen to cause anything like this. Some feel that geography matters, since the disease seems limited to the West Coast and to sections of Florida and the Caribbean—Haiti in particular.”
I shrugged and left. Clearly not a neurosurgical problem. I found out later that Mr. Bishop had died of complications following his lung biopsy. The biopsy itself showed pneumocystis pneumonia. He became the first person reported to our local county health department with the strange new disease of gay men. Shortly thereafter, the illness got a name: AIDS.
Mr. Bishop’s case faded from my memory, his name lost in the sea of names, faces, and diseases that a resident in a large medical center must deal with on a daily basis. Looking over my log book of operations and clinic visits, I once estimated that I took care of almost one thousand new patients each clinical year of my training. That number didn’t include the William Bishops, those patients for whom we performed some bedside procedure or informal hallway consultation.
This is not to say that we forgot patients easily. While people in many occupations—bank tellers, food servers, mechanics, to name but a few—must deal with the public by the thousands annually, the interaction of physicians with the flux of humanity is unique. Bank tellers don’t take personal histories. Food servers don’t say you’ll die within a year. For some reason, though, Mr. Bishop drifted out of my memory.
Years later, at the end of my chief residency year, I was speaking to one of the many insurance salespeople who dog us as we are about to finish our training. He was discussing disability policies and mentioned casually that I would have to be tested for cocaine and HIV before a policy could be issued. This was now standard for physicians. I shrugged it off: I don’t use cocaine and I’m not gay…Then, suddenly, I remembered Mr. Bishop! The night of his LP came back to me in a rush, the few drops of spinal fluid that had splashed into my eyes were now oceans of contagion. In five years I hadn’t developed AIDS, but the latency period between HIV infection and the full-blown clinical syndrome can be quite long.
How many other patients with HIV had I dipped my fingers into, whose bone dust had flown into my eyes and nostrils, whose spinal fluid had drenched my clothes? I had been up to my mask in bodily fluids during the blind era of the disease, when the virus was spreading but no test for it was available and few precautions were taken.
I took some comfort in the knowledge that our medical center was in an urban area with a very low prevalence of HIV. Nonetheless, I deferred getting tested for years, until I foundit unavoidable. Mr. Bishop was never far from my mind during that long week which separated the drawing of the blood and the phone call informing me of the negative result.
But nothing would ever be the same again. The next person to roll into the ER could be the one who kills me.