The trauma experiences hardened me to death and the pain patients made me cynical about suffering. I felt my personality I slipping away during this arduous process of becoming “one of them.” Clinical cases no longer evoked the strong emotions they once had. The humiliation of that first unsuccessful nasogastric tube, the panic as B.G.’s fingers died at my command—I looked back upon such mushy feelings with a bemused nostalgia, like a worldly playboy reminiscing about the naive crush on his sixth-grade teacher.
Yet, my emotional numbness was still only partial. I hadn’t progressed to the status of a true surgical psychopath, wherein one’s humanity is placed under general anesthesia. I first learned about surgical psychopathy from the sad case of a man named Andy.
Life had been unkind to Andy from the very beginning. His troubles started before his conception, with a chromosome blunder within the developing eggs of his mother’s ovaries. The blueprint for a human body resides in its chromosomes, our molecular heirlooms, which consist of tightly coiled bundles of DNA passed from generation to generation. As the human egg and sperm are formed, chromosomes are shuffled like poker cards as nature tries to deal the best hand to our offspring. In Andy’s case, the shuffled DNA deck dealt him a loser.
We’re supposed to possess forty-six chromosomes: twentytwo pairs of non-sex chromosomes, and two sex chromosomes consisting of either two X’s (in women) or an X and a Y (in men). Each parent donates half of the total pool of a child’s genetic material: one sex chromosome and one each of the twenty-two different non-sex chromosomes.
Because of a foul-up in making the egg that would become Andy, his mother gave him not one but two copies of chromosome 21. Since one chromosome 21 was also contributed by his father, Andy thus inherited three, not the normal two, copies of chromosome 21’s DNA blueprints, a condition called trisomy 21.
This mistake most commonly occurs during the process of meiosis, when the mother’s chromosomes are packaged into eggs for dispersion to her children, although the error can occur in other ways as well. The likelihood of producing a trisomy egg increases as the ovaries age and the egg-making machinery becomes senile, misplacing chromosomes as an octogenarian might misplace eyeglasses.
DNA has been called the currency of life. Unlike money, however, it is possible to have too much DNA. Trisomy 21 is associated with varying degrees of mental retardation, a high incidence of congenital heart defects, and an increased chance of childhood leukemia. Decades ago, those afflicted with trisomy 21 were called “mongoloids” because of the thick eyelid folds which give trisomies a vaguely Oriental appearance. This offensive label was replaced with the more medical-sounding “Down syndrome.” Some argued that the late Dr. Down should not be so eponymously rewarded. Down’s critics charge that he was a racist who believed that trisomy 21 victims actually were “inferior” Mongolians who appeared sporadically in the Western population. The technical term “trisomy 21” is now most commonly used.
In addition to trisomy 21, Andy was also afflicted with multiple head and neck abnormalities. His ear canals were small and misshapen, making him deaf from birth. A low hairline sat barely an inch above his wide-set eyes. Malformed vocal cords rendered him mute. Unfortunately, this simultaneous clustering of genetic defects is not rare. The opposite situation, people with nothing but stellar genes, also occurs. Who hasn’t known someone born with a royal flush of genes, the high school beauty queen who is class valedictorian and captain of the swim team as well? But alas, for each genetic success story, there is an Andy.
Andy had a social disadvantage as well: he was born in the 1930s, when special education for disabled children was not widely available. Andy did have several things going for him. He was born to loving parents who reared him at home when institutionalizing trisomy victims was the norm. Moreover, he had been spared the ravages of trisomy-related heart defects, and he even had a respectable IQ of 80.
Though he never went to mainstream schools, he still managed to learn sign language, as well as how to read a little. He was emotionally untroubled, passing his time doing odd jobs as they became available.
Andy eventually settled into a job as the janitor of his local Catholic church, where he would spend hours polishing the hardwood pews. He particularly enjoyed preparing the church for holidays. As the decades passed, the task of putting up the decorations for Easter and Christmas became entirely his own, a responsibility he cherished. Andy became the bedrock of St. Mary’s, a fixture at Mass, a benevolent Buddha at summer bazaars and spaghetti dinners. Pastors came and went, but Andy stayed.
As years passed, he became increasingly obese, smoked heavily, and developed diabetes and high blood pressure. One day shortly after his forty-fifth birthday, he went suddenly blind in his right eye from a diabetic retinal hemorrhage, making his left eye his sole link to the world. Timely laser surgery forestalled blindness in that good eye, but Andy knew his vision was failing and he subsequently battled bouts of depression. Despite his health problems, he was at the church shortly after dawn seven days a week.
One humid morning in the summer of Andy’s forty-seventh year, his mother was awakened by the sound of retching in the downstairs bathroom. She found her only child seated by the toilet holding his large head in his hands and rocking slowly back and forth. His broad face was chalklike and glistening with cold sweat. He signed, “I’m sick,” and “Help me, mom” repeatedly before slumping onto his side, unconscious.
I was shooting pool in the residents’ recreational area on the hospital’s tenth floor when my pager went off, disturbing a surprisingly quiet Saturday afternoon. The beeper display read “1667.” A call from the outside. Bad news.
I dialed the extension and was connected to an ER nurse at Suburban Hospital.
“Please hold for Dr. Najarian.”
During the long wait my mind conjured up all sorts of grim possibilities lurking for me in the Suburban ER. Was it one of the pain patients? A head trauma? A bleed?
“Hello, who am I speaking to?” the voice finally came.
“Vertosick,” I replied dryly, “neurosurgery resident.”
“I have a mongoloid in his late forties, history of hypertension, comes in this morning lethargic, found down in his bathroom by his mother after vomiting times one. BP is 230 over 120, pulse fifty-five. He’s deaf and mute, but can communicate with sign language with his mother as interpreter. He’s com plaining of a headache, has no focal deficits. Our CT scanner is down and we’d like to transport him. I think he has a hypertensive bleed.”
“Is he on any meds?” I pulled out a crumpled note card and began jotting down information.
“Inderal, Dyazide. He’s allergic to penicillin. He’s also diabetic, but not being treated as far as I can tell. He’s got partial blindness, I don’t know what from—perhaps from retinopathy.”
“Do I have this right—he has Down syndrome, he’s deaf, he’s partially blind, he can’t speak, and he has a bleed?” Wow. This was going to be a long weekend.
“Yeah, and he lives at home with his parents, who look about a thousand years old. Still, they seem in better shape than he is.”
“What’s his name?”
There was a pause as Dr. Najarian searched his notes. It’s amazing how physicians can remember blood pressures, medications, and allergies, but never something as trivial as a name.
“Go ahead and send him now. By helicopter.” End of conversation.
I racked up the balls again. It would take several hours for the helicopter to arrive.
At 5 P.M. the med flight crew rolled into the emergency room with Andy. Forewarned, I was in the ER when the helicopter team wheeled him into the exam room. Even though he was wrapped in a scarlet blanket, Andy’s obesity was obvious. His eyes were covered with a white washcloth, and an oxygen mask clung loosely to his lower face. His mouth was hanging open, his oversized tongue protruding in typical trisomy fashion.
“Is he awake?” I asked one of the flight nurses.
“Yeah,” he replied, “but I guess you know he’s deaf and mute. His mother says that you can write him notes and he’ll write back, but he won’t keep his eyes open long enough to read anything.”
“How’s his pressure?”
“Still high, about 160 to 190. He got some Aldomet prior to leaving, and some Lasix and Decadron.”
He would need an arterial line and a nitroprusside drip to keep his blood pressure from blowing his brain into the next room.
“Anybody know where his parents are?” I yelled into the room.
“They’re driving down, I think,” another one of the flight nurses volunteered, “but I don’t know when they’ll get here.”
I removed the washcloth from Andy’s face. He winced at the glaring ER light and promptly snatched the cloth from my hand and returned it to his face. Photophobia; the light bothered him. I reached behind his clammy neck and began flexing his head up and down. His arm shot out rapidly to stop me and he made a guttural, almost inhuman, noise. His neck was stiff and sore. Maybe this wasn’t a simple hypertensive bleed. I began to think Andy had suffered a subarachnoid hemorrhage, or SAH.
SAH results from the rupturing of cerebral aneurysms, saccular outpouchings that can occur on the large arteries at the base of the brain. After decades of weathering the incessant pounding of blood, arteries can develop small weaknesses. The weaknesses slowly sprout into thin-walled blebs, similar to the balloonlike outgrowths that form on old inner tubes.
Like the ER doctor, I initially believed that Andy had suffered a hypertensive bleed, an event quite different from SAH. Hypertensive bleeds are not caused by aneurysms on large arteries. They arise instead from tiny arteries that simply “pop” when the blood pressure becomes too great. Hypertensive bleeds occur deep within the brain and, although they can render a patient paralyzed, are rarely fatal. SAH, on the other hand, is quite frequently lethal.
Even though the bleeding during an SAH can be slight and doesn’t damage the brain substance directly, it is a devastating event. A person may silently harbor an aneurysm for years until some stress, such as sexual intercourse, lifting a heavy box, or simply having a violent sneeze, sends a pulse wave of blood pressure that splits the fragile aneurysm sac, spilling a torrent of arterial blood into the space between the brain and the skull. This region is called the “subarachnoid space” because it is below the arachnoid, a cottony substance which covers the brain and which derives its name from its close resemblance to a spider’s web.
The victim of an SAH is felled immediately by a “thunderclap” headache, as if shot by a gun. Vomiting may occur. The body reacts quickly to stem the hemorrhage by sending the blood vessels feeding the aneurysm into spasm, temporarily closing them off. Arterial spasm is the body’s natural defense against hemorrhage—it’s what allows a Kansas farmboy the time to pick up his arm after it has been amputated by a threshing machine and run for help without bleeding to death.
An arm can go hours without blood and survive. The brain’s survival time without oxygen is three minutes. Several minutes after a brain aneurysm ruptures, the feeding arteries are compelled to reopen by chemical signals from the starving brain tissue. If a sufficient protective clot has not formed over the rent in the aneurysm’s wall, the bleeding will resume, with lethal results. If the arteries don’t reopen at all, bleeding will cease but large areas of the brain will die, or “stroke,” with resulting paralysis or coma.
During the first minutes after SAH, the patient’s life teeters on a precipice. The brain’s life-sustaining arteries seek to maintain a level of blood flow which prevents stroke but which will not blow open the aneurysmal tear. Within a two- or threecubic-centimeter area beneath the ailing brain, biochemical processes a billion years in the making converge in a matter of milliseconds—processes such as blood coagulation, already ancient when the dinosaurs roamed. For almost half the victims of SAH, the body’s efforts to save itself are in vain—death follows in days, even hours.
I notified the surgical intensive-care unit that Andy had arrived. We then transferred him quickly to a transport cart. There was little we could do for him in the emergency room, and the faster we got him into the more relaxed environment of a hospital bed, the better. Our trip to the ICU would be detoured through the CT scan room. Andy was given a few milligrams of morphine intravenously and he became calmer, his blood pressure lower. Prior to leaving the ER, I asked the clerk to check with social service about finding a sign-language interpreter.
The scan confirmed my suspicion: the brain was covered with a white frosting around the cerebellum and occipital loves—subarachnoid blood. The location of the bleeding pointed to an aneurysm on one of the arteries at the rear of the brain, the so-called posterior circulation. Such aneurysms are particularly dangerous to treat.
After the scan, Andy was taken to the ICU and the usual monitoring devices were inserted. He was given medications for sedation, blood pressure control, and seizure prevention, as well as some steroids to reduce brain swelling and inflammation. His parents still hadn’t arrived and the hospital had not yet located an interpreter. These situations made me feel like a veterinarian rendering large-animal care. We probed, scanned, and medicated Andy with no way to communicate with him.
Ethically and legally, we had the right—the obligation—to do so, but it still made me feel very uncomfortable. Andy was awake but refused to read the messages we wrote for him. I could only imagine the fear and confusion of this poor deaf man whom we had stripped of all control of his body.
I notified Gary and the on-call attending neurosurgeon, Dr. Filipiano, of Andy’s arrival and condition. Both agreed that Andy should be tucked in for the night and an emergency angiogram be scheduled for the following morning. Once we knew where the aneurysm was, we could better plan our operative attack upon it.
As surgeons, we can do little for the brain injury that a severe aneurysmal hemorrhage can inflict. We can, however, remove the risk of further hemorrhaging by surgically “clipping” the aneurysm. By making a window in the skull and peering at the tangle of blood vessels beneath the brain with an operating microscope, we can dissect the aneurysm sac away from the surrounding blood clot and place a tiny spring-loaded clip across the aneurysm’s neck, the point where it arises from the feeding brain artery. Once the neck is clipped, the trapped aneurysm is rendered harmless.
This is one of medicine’s most dangerous interventions. The lifting of the brain away from the skull base or the delicate microdissection of the aneurysm sac can cause explosive hemorrhage leading to rapid death. Moreover, the aneurysm clip may slip and occlude the parent artery and not the aneurysm, leading to stroke and disability. The brain, bulging and swollen from the hemorrhage, may be quite difficult to elevate from the bony skull. If it is lifted too forcefully, it will be bruised.
Surgery clearly saves the lives of many aneurysm patients, but the timing of such surgery is controversial. Every minute the patient lies in a hospital bed with a “live” aneurysm is a minute inviting another hemorrhage. Consequently, some experts hold that surgery to clip it should be done immediately.
Other experts have argued just as strongly that surgery within the first few days of a hemorrhage carries an increased risk which more than offsets the risk of waiting. During the earliest days after SAH, the brain is too swollen to lift easily and the aneurysm is very fragile to handle. Worse yet, the brain’s arteries are angry and prone to even further spasm when exposed to the air. (You are never the same…) Early aneurysm surgery often means doing it at 3 A.M., when neither the surgeons nor the OR team are up to the task.
A compromise has been reached: early clipping of a ruptured aneurysm should be done only in patients with mild hemorrhages who look and feel relatively well after their initial headache. Andy was not in this group.
Andy’s parents arrived later that evening. They looked to be in their early eighties and, though weathered, nimble and fit enough. Their clothes were rumpled from a long drive made even longer by the search for our hospital in an unfamiliar city. Like many large medical centers, our hospital sat in the middle of an urban university, a noisy and raucous neighborhood designed to confuse an elderly couple from a rural area.
I did my best to explain what had happened to Andy. SAH produces a minefield that the patient must navigate: rebleeding, vascular spasm, stroke, seizures, hydrocephalus, angiograms, major surgery. At any step something might explode, with the possibilities of paralysis, permanent nursing-home care, or death. I covered only the major issues that night, stopping short when Andy’s mother began to become overwhelmed with all the bad scenarios. After having them sign a consent for his angiogram in the morning, I took them in to see their son.
Even though Andy was groggy from medication and his hands were loosely restrained to the bed, he began signing rapidly to his parents. They signed back. This interplay continued for several minutes as I stood outside the room.
I stepped up to the bed and asked them to introduce me to their son, which they did with a flurry of hand movements.
“Tell him he’s going to be all right,” I added. Another flurry. I used them as interpreters to explain to Andy about the upcoming angiogram.
After another fifteen minutes or so, Andy’s nurse ushered them out, but before exiting, his father grasped Andy’s hand and his mother kissed him. No doubt these displays of affection had sustained Andy through the numerous emotional traumas he must have endured in his life.
• • •
“Holy shit!” Gary expressed his usual hyperbolic amazement at the angiogram pictures. We sat drinking coffee on the morning following Andy’s admission and reviewed the pictures as they came out of the X-ray processor. Andy was still on the angiogram table.
“He’s got only a single vert!” Gary continued. The brain is normally supplied by four large arteries going through the neck: two carotid arteries in the front of the neck (the pulse that TV detectives search for before announcing that the victim is dead) and two vertebral arteries, “verts” in resident slang, running along the cervical spine in the back of the neck. Andy had only a single left vertebral artery. There was no sign of either a left or a right carotid artery or of the right vert—a bizarre congenital anomaly.
Gary puffed a cigarette and sipped his coffee. “Not only does he have just one vert, but it’s got three aneurysms on it.” He pointed out the three blebs with his smouldering cigarette tip. After the lone vertebral artery exited the neck and entered the base of Andy’s skull, it branched out to supply the entire brain. Three aneurysm sacs, each about one-half inch in diameter, dangled like grapes from the branches.
Gary looked at me and smiled. “You know, Frank, it reminds me of that story about the obstetrician who goes to the new fathers’ waiting room and says ‘Mr. Johnson, I regret to tell you that your wife has just given birth to a ten-pound eyeball,’ and the guy starts blubbering and says, ‘Oh Jesus Christ, Doctor, what could be worse, what could be worse?!’ The doctor puts his hand on the dad’s shoulder and says, ‘It’s blind.’ “ Gary dragged on his cigarette again. “Well, Andy, you have only one artery in your entire fucking head. What could be worse? It has three aneurysms on it!”
The longer we worked together, the more I realized that Gary and I were kindred spirits. We were both of Slovak descent and from the blue-collar communities surrounding Pittsburgh. This background made us cruder, more blunt and much more prone to foot-in-mouth disease than the typical neurosurgical resident.
Gary was particularly good at getting into trouble with his mouth. One time in the surgeons’ dressing room he repeatedly referred to one of our staff surgeons as “the stone-handed asshole” without realizing that the object of his tirade was just five feet away, relieving himself in one of the toilet stalls. Ever since that episode, Gary would admonish the residents to “check the crapper” before launching into any personal assaults. On some long nights on call, we still had deep discussions about the caliber of the stool if one is defecating and being insulted at the same time.
As a medical student, I often wondered why such incidents didn’t get Gary canned. As I progressed in the program, I learned that it was because he was so good. Gary was the best technician our program had produced, a sort of surgical savant. Like people who can sit at the piano and play almost immediately, Gary mastered the most difficult operations so quickly that as chief resident he could run his operating room virtually unassisted. This enabled a staff surgeon to run two rooms at the same time, thus making twice as much money. The ability to generate staff-level billings on a paltry resident’s salary gave Gary virtual immunity from punishments for his verbal adventures.
“What would you do with this character, Gary?” I asked.
“Me? I’d give him bigger doses of blood pressure meds, keep him in bed for about six weeks, and tell him to go home. You don’t know which aneurysm has blown, so we’ll have to clip all three. If you’re jacking around with the wrong one and the bad one blows, kiss his ass goodbye. You can’t place a temporary clip on his vert; it’s the only pipe to his entire gourd. Too risky. I think trapeze artists call it ‘working without a net.’ Remember the rule: You can always make someone worse.”
A temporary clip is used to clamp off the aneurysm’s parent artery if the aneurysm starts bleeding again during surgery. This stops the bleeding so that the surgeon is not trying to deal with the aneurysm through a river of blood. Since most people have four brain arteries, clipping one of them for a few minutes is usually harmless. But Andy had no alternative routes for blood to get to his brain. Clipping his lone vertebral artery, even for a few seconds, might be lethal.
“So we don’t do him?” I asked.
“I said if it was me, I wouldn’t. It’s not me, it’s Filipiano, remember? He’s aggressive. I bet he goes after these things. Real soon.” Gary unfolded the crowded OR schedule sheet that was the chief resident’s bible. “Like tomorrow.”
As usual, Gary, was on target. Dr. Filipiano came in that afternoon and discussed the situation with Andy and his parents. His presentation made surgery sound like the rational option.
In fact, clipping an aneurysm is a statistical operation. It is entirely possible for an aneurysm to bleed once and then never be heard from again, even without surgery. The statistics show only that SAH patients are more likely to live if they have surgery. Surgery doesn’t guarantee a better outcome.
To operate on a bunion relieves the pain that is disrupting someone’s life. There is no consideration of the “risks” of living with a bunion. Statistical operations, on the other hand, relieve no symptoms; they are done purely to lessen the risk of a disease in the future. For example, a woiman may have an abnormal mammogram in a breast which is causing her no discomfort at all. Statistics show she will live much longer if she has the cancerous lump removed, even though it isn’t bothering her.
The major difficulty with statistical operations is that it is impossible to predict the future of any one patient. It seems obvious that removing a cancerous breast lump is the correct choice for a healthy forty-two-year-old woman, but how about an eighty-one-year-old woman with diabetes, kidney failure, and end-stage heart disease? She may die of her other illnesses long before her cancer spreads, or the operation itself may do her in. The trick is to balance the risks of surgery against the risks of doing nothing, on a case-by-case basis. In Andy’s case, Gary believed that the surgical risk might be greater than the risk of our doing nothing at all.
The course of an illness when doctors don’t interfere with it is called its natural history. Ironically, for many diseases (including SAH), medicine has been fiddling with them for as long as they have been recognized as diseases. We are, therefore, totally clueless about the natural history of those diseases, except for what sparse data we can glean from patients who escape our clutches, either because they are too sick or have stubbornly refused our care.
Given this lack of hard data, a surgeon is left to choose the option for each patient. If the surgeon is aggressive, then the patient will be steered toward surgery. Unlike the bunion patient, who alone knows how much it hurts and how much surgical risk she is willing to assume to alleviate her suffering, candidates for statistical surgery are completely at the surgeon’s mercy. Only the surgeon can provide the arguments for or against a statistical operation. Of course, the final decision rests with the patient and family.
Dr. Filipiano spiced his pre-op talk with graphic images of “bombs” in Andy’s head that could explode and kill him at any instant. When all the talking was done, the shaken parents looked at each other. After a pause, Andy’s father spoke the universal abdication of all who are confused by medical technology.
“Do what you think is best.”
Music to a surgeon’s ears.
The next morning I assisted Gary as he opened Andy’s skull in preparation for the assault on the three “bombs” in his head. Gary let me drill some skull holes and widen them into the needed bony window, using large rongeurs. Just as Tom Sawyer could dupe his friends into believing fence painting was enviable work, chief residents could convince junior residents that this callous-forming drudgery was actually surgery.
After the skull window was fashioned and the posterior brain, or cerebellum, was exposed, Gary wheeled in the giant contraves microscope. Looking like a small crane, with two sets of binocular eyepieces attached to a long, counterweighted boom, the scope was completely draped with sterile plastic sheets. The transparent drapes permitted the surgeon to manipulate the scope controls without becoming contaminated.
The operating microscope was first used for neurosurgery in the 1960s. Modern microscopes, with their fiber-optic halogen light sources, precision balancing, and stereoscopic vision, allow the neurosurgeon a superb view into the depths of a human head. For aneurysm surgery, the microscope was indispensable.
“Let Dr. Filipiano know that the dura is open and we’re going under the scope,” Gary instructed the circulating nurse. This gave the staff surgeon the option to come in as the operation was progressing to its more crucial phases. I had little doubt that Filipiano would come at once. Gary would not do this operation alone.
Gary proceeded by lifting the cerebellum at the rear of the brain, using a thin gold retraction blade fixed to a snakelike metal arm which was, in turn, fixed to the base on the OR table. He then used the hand controls on the scope so that he could see into the wound as he advanced the retractor further under the cerebellum. I watched through the observer’s eyepieces of the microscope while the scrub nurse followed Gary’s progress on a wall-mounted video screen connected to a TV camera within the microscope. The delicate folds and arteries on the cerebellar surface were like the terrain of” some surreal planet under the glare of a fiber-optic sun.
The cerebellar surface was stained a dirty brown from the blood of Andy’s original hemorrhage. Gary moved the retractor blade to the floor of the skull, searching for the main trunk of the vertebral artery as it entered the skull from the neck. With deft moves, he used thin dissectors and delicate knive blades to cleave away the scar tissue that already had begun to form between the brain and the skull.
“Remember, Frank, when we were interviewing to go into neurosurgery? They would look at your medical school grades, your research projects, whether you were an honor student and shit like that? Well—give me a micropatty please—well, none of that was worth a squat. I mean, how can you tell if someone can do this by what grades they made? A guy could have fingers like sausages, but because he got an honors in neuroanatomy they think he can become a microsurgeon. It doesn’t make sense.”
Microneurosurgery is indeed difficult. The surgeon can’t look directly into the wound, but instead looks into the microscope eyepieces. This makes microsurgery similar to operating via remote control. Moreover, the powerful magnification of the scope makes even the slightest hand tremor seem like spastic gyrations. I thought about the agarose droplets.
“Well,” Gary continued, “if I were a program chairman, do you know the first thing I would do when interviewing a prospective resident? I’d get out that Operation game—you, know, the one with all the plastic pieces you have to pick out of small holes in a cardboard patient using electric tweezers? If you touch the patient with the tweezers, his nose lights up and a buzzer goes honnnk and scares the shit out of you. That’s right, I’d say ‘Here you go, pal, get out the fucking funny bone. No, not the breadbasket or the wrenched ankle, those are easy. I want the funny bone.’ If he gets a honnnk before he pulls out the funny bone, I’d say ‘Great grades, now get out.’ If he can get me the funny bone, I know he has the hands for this.”
“Is that fair?” I argued. “I mean, making the poor creep’s whole future rest on that one task? Don’t you think nerves might play a factor?”
“Of course, and that’s the point,” he countered. “In fact, I want them to be nervous. I want them crapping in their drawers. Anyone can have steady hands if they’re relaxed. It’s the ones who are granite under pressure that make the greatest surgeons.” Maggie, the gung-ho cardiac chief, had also told me that pressure was part of the deal. All chief residents must think alike.
Gary adjusted the retractor and slowly pulled the cerebellum further away from the skull. The thick, pulsating vert came into view, and with it the blue, angry dome of the first aneurysm. At six-power magnification, the vertebral looked more like a redwood than an artery.
“How nervous does that son of a bitch make you?” He turned to me and winked.
I saw Dr. Filipiano enter the scrub area and begin putting on his surgical mask. A small man with a gaunt physique and wire glasses, Filipiano, only in his mid-forties, had already established a reputation as a master of complicated aneurysm cases. Like many neurosurgeons specializing in these “commando” cases, he carried a reputation for indifference to the death and destruction he sometimes left in his wake.
He was, as Gary acidly put it, the “prototypical surgical psychopath”—someone who could render a patient quadriplegic in the morning, play golf in the afternoon, and spend the evening fretting about that terrible slice off the seventh tee. At the time this sounded like a terrible thing, but I soon learned that Filipiano was no different from any other experienced neurosurgeon in this regard. He couldn’t mourn every bad result—not without going insane. He handled hopeless cases on a daily basis. After one especially grisly complication, I asked Filipiano if surgery ever got to him. He quoted an old Russian saying: “People who cry at funerals shouldn’t become undertakers.”
Filipiano swung open the OR door and began drying his freshly scrubbed hands. “How’s it going, chief?”
“I have the first aneurysm partly exposed,” Gary said softly without looking away from the scope.
Filipiano was hurriedly gowned and gloved. He then unceremoniously displaced me from the observer’s seat, relegating me to a stool in the corner. I watched the rest of the operation on the monitor.
There was a quiet lull in the OR as Gary and Filipiano tediously dissected the aneurysm away from the surrounding skull and brain, twisting the dome to and fro in search of the neck that joined it to the vertebral. I become hypnotized by the dull whine of the suctions, the soft clicking of the microscope motors, the hum of the bipolar coagulator being turned on and off.
In low murmurs, the two surgeons muttered into their masks: “…No, cut here…Can that take a temporary clip?…Stop that oozing, please…Use a ball dissector for that, goddamn it…Clean the tips of this thing…” I drifted into a twilight world between wakefulness and sleep. With my back pressed against the cold tile wall, I hallucinated about getting out of the hospital for an hour or two that evening. Maybe I’d go to the Black Angus for a hamburger. Although banished from the real action in this case, I was the dutiful junior resident: gowned, sterile, and technically impotent, unwilling to leave the OR for fear of appearing uninterested in what was happening on the fuzzy video screen.
Suddenly, a burst of frantic activity aroused me. Filipiano barked for a larger suction and the nurse-anesthetist pushed her alarm button to summon her staff anesthesiologist to the room. I looked at the monitor. The wound had turned red; the vertebral was gone and the cerebellum was now bathed with pulsatile waves of blood. Gary had slipped and plunged the sharp point of an arachnoid knife into the aneurysm dome.
Gary placed his suction deep into the wound. “Shit, oh shit…,” he moaned. The feeble microsuction did nothing to clear the field as bright blood gurgled audibly from the cranial wound and ran in angulated streams over the drapes.
“Do you want us to take his blood pressure down?” asked the nurse-anesthetist. Lowering the blood pressure with medication sometimes slowed the bleeding.
“No!” Filipiano responded sternly. “We need to temporary-clip and he’ll need his blood pressure up. Just hang some blood, hang it now.”
Working awkwardly from the assistant’s chair, Filipiano jammed a giant glass-tipped suction into the wound and instantly the clear tubing filled with Andy’s blood. On the monitor, I could see the large suction diverting the spewing column of blood sufficiently to see the vertebral artery once again. Gary remained frozen in the surgeon’s chair, still clutching the useless microsuction.
“Give me a fifteen-millimeter straight temporary clip right away, now.” Filipiano reached out with his right hand without looking away from the scope’s eyepieces. The scrub nurse placed a long forceps bearing the open clip into his hand and gently guided it into the microscope’s field of view. He swiftly placed the clip blades around the vessel and squeezed the clip shut. As dramatically as it had begun, the bleeding stopped. The staff surgeon quickly motioned for Gary to vacate the operator’s chair.
“Call me the time, in minutes,” Filipiano said to the anesthesiologist, who had just entered the room, “and load with barbiturates.” The blood flow to Andy’s brain was now ceased. The clock was running on his life. Filipiano had but a few minutes to repair the hole Gary had torn in the aneurysm’s dome, or Andy would die. The barbiturates would protect Andy’s brain somewhat, perhaps give them an extra few minutes.
The surgeon swiftly suctioned away the thick, fresh clot from around the now-collapsed aneurysm sac.
“One minute of clip time.”
Working with reckless desperation, Filipiano tugged and pulled at the sac, peeling it away from the remaining adhesions. He was doing in seconds what would take thirty minutes or longer under more controlled conditions. Such vigorous tugging on the aneurysm ran the risk of ripping it completely away from the vertebral artery, leaving a gaping hole that could not be repaired. Finally, he was able to see the aneurysm’s neck, where he could place a clip without obliterating the vertebral artery itself.
“Fifteen-millimeter bayonetted Yasargil clip.”
The nurse handed him the long forceps again. He glanced at the clip and threw it back to her. “That’s a temporary clip!” he cried shrilly, “don’t kill this man, give me a permanent clip!” Temporary clips, because they are made to be placed on arteries and not on aneurysms, exert less force and cannot be expected to hold an aneurysm permanently closed. The nurse, in her haste, had loaded the wrong clip, wasting precious time.
The nurse rummaged frantically in the large gray tray of aneurysm clips, her hands quaking as she tried to load the requested clip onto the application forceps.
“Clip, clip, clip!” he screamed.
Filipiano finally seized the forceps and clip from her hands and loaded the clip himself. He thrust the clip’s silver blades around the dome as it fluttered in the wake of air and frothy blood rushing up the adjacent suction tip. Slowly, he closed the blades down, killing the aneurysm.
“Four minutes. He’s getting bradycardic.” Andy’s heart rate was falling; his brain was on the brink of oxygen starvation.
“Give me an empty clip applier.” Filipiano removed the temporary clip from around the vertebral and the large vessel billowed once again with incoming blood. The clip on the aneurysm held. The bleeding did not return.
Filipiano decided to abandon the search for the remaining two aneurysms. He did not think Andy could tolerate another temporary occlusion of his vertebral artery, and he was convinced that the one he had just clipped was the aneurysm responsible for Andy’s hemorrhage. He packed some soft gelatin foam around the clip and stepped out of the surgeon’s chair, pulling off his gloves. “Close it up.”
Gary sat motionless for a few minutes, his face pale. After Filipiano had left the room, I moved from my hiding place in the corner and walked up behind the sullen chief resident.
“Hey, Gary,” I said over his shoulder.
He stared at me icily. “Fuck you.”
We closed Andy’s wound and wheeled him to the recovery room. Even after his anesthetic wore off, he remained unconscious and immobile from the large amount of barbiturates he had been given intraoperatively.
Gary sat at the nurses’ station and began writing post-op orders. “If this guy wakes up from this fiasco,” he whispered to me as he wiped his nose with his surgeon’s cap, “I will go and take a dump on Center Avenue in broad daylight. How could his brain have survived five minutes of complete ischemia? Did you see how much back-bleeding there was from that vertebral? Zero.”
I tended to agree with Gary. Five minutes of ischemia, or no blood flow, is usually a devastating insult to the nervous system. However, the effects of ischemia are difficult to predict. Andy was likely to have had some damage, some form of stroke, but where? And how bad would it be? Gary was betting that the damage was so profound as to render Andy forever comatose.
Filipiano told Andy’s family that their son was likely to recover. He believed the episode of bleeding and ischemia was not long enough to cause irreversible injury. Filipiano was the eternal optimist.
We could only wait until the barbiturates wore off, two or three days.
On Thursday morning I met Gary at the door to the neurosurgical intensive-care unit for our usual 5:30 A.M. rounds. I escorted him down the hall to Andy’s room.
“I’ve got something to show you.” We went into the room, where Andy lay motionless, his belly bulging and his eyes closed. He still had a tracheal breathing tube and had not stirred a muscle since his Monday surgery.
“So?” Gary was impassive as he flipped through his index cards of patient data.
I vigorously rubbed Andy’s chest with my knuckles, which prompted Andy to open his eyes and grab at my arm. The chief resident was startled. “Jesus Christ, the poor bastard’s awake.”
“That’s right,” I said, flashing a grin. I pulled a large wad of toilet paper from my white lab jacket and handed it to Gary. “Center Avenue’s ten floors down, but you have to wait an hour or two, since it isn’t broad daylight yet.”
Except for some drooping of his left facial muscles, Andy appeared to have no paralysis. Later that afternoon, when his parents arrived, he even tried to communicate with them in sign language. On evening rounds, Filipiano pronounced the operation a success, hugged the parents, and gave the resident staff a heady discourse on how no blood flow is sometimes better than a little blood flow. Allowing some oxygen to the brain during a period of low blood flow permits the formation of destructive “free radicals,” which does not occur if the blood flow is totally halted.
Over the ensuing days, however, Filipiano’s beautiful freeradical theory was to be spoiled by an ugly fact: we couldn’t wean Andy from the mechanical ventilator. Something was definitely wrong. The operation wasn’t a complete success just yet. Each day Andy became brighter and more alert, passing us notes asking us to remove his breathing tube and allow him to eat. Every time we reduced the ventilator rate, however, he would start to hypoventilate and become lethargic, forcing us to restart the machine. When stimulated by being pinched he would breathe on his own for a brief time, only to stop breathing again when the stimulus ceased.
By the following week we had to insert a tracheostomy into his neck to avoid the complications of a. long-standing endotracheal tube. We tried a variety of medications to make him breathe independently of his machine, including amphetamines, but nothing worked. As long as Andy was stimulated to breathe he would do so, but once his attention wandered, or if he started to fall asleep, he simply quit breathing. Tethered to a ventilator, Andy could not leave the intensive care unit.
Filipiano consulted Dr. Leo, one of the university neurologists. Dr. Leo’s diagnosis: Ondine’s curse.
We caught up with Dr. Leo in the cafeteria and asked him for further information regarding this rare condition.
“Ondine’s curse,” explained Dr. Leo as he peered over his half-glasses, “is a result of a stroke in the medulla, in the lower stem. That’s where the respiratory drive center is located. As you know, we can either breathe voluntarily”—he demonstrated by taking a deep breath—”or involuntarily, without having to think about it. If our respiratory center is damaged, we can’t breathe automatically; we have to think about each breath. Stop thinking about breathing, and we stop breathing. It’s that simple.”
“Who was Ondine? Some Queen Square neurologist?” asked Eric referring to the birthplace of neurology in London.
“No,” laughed Dr. Leo, “Ondine was a nymph of Greek mythology who offended the gods. As punishment, she was sentenced by Zeus to think about every breath. She knew she could never sleep, for to sleep meant death. That’s a great curse, right?”
“Does it get better?” I asked.
“Not really, at least nowhere in the neurology literature. No, I think your friend had better give his ventilator a name. They will be companions for life.”
Dr. Leo’s observation was prophetic. A month passed after Andy’s surgery, then two months, then three. Andy remained wedded to his ventilator. He could stay off it thirty minutes, just long enough to be wheeled to an outside courtyard for a respite from the intensive care unit. Andy had visitors during the first few weeks after surgery: the parish priest and some longtime members of the church’s congregation. They never had much to say to him, but then they probably never had much to say to him when he was well, either. As Andy languished in the hospital for months, his parents were the only people who continued to come.
An ICU is a terrible place to live, a place of no night and no day, just eternal light. Ventilator alarms sound at all hours, night-shift personnel laugh and swap stories, cleaning people roam at all hours. The private tasks of life, like bathing or having a bowel movement, are afforded little privacy. The disorienting effect of the ICU environment can cause psychosis in otherwise normal individuals. Andy’s deafness was probably a blessing in the ICU world. It gave him some peace.
At the time, our hospital had no protocol for managing ventilator-dependent patients outside of an ICU. The rising costs of hospital care would eventually force hospitals to deal with ventilators on regular wards, nursing homes, and even in private homes, but those developments were still a decade away. His years of smoking and chronic pneumonias would have made it difficult for him to leave the ICU for more than a week or two anyway, even if his ventilator were moved to a regular hospital bed.
The ICU became Andy’s home. He dressed in street clothes and tennis shoes and watched television in an easy chair, his ventilator hoses draped across his belly. A large crucifix was hung on the back wall, beside a get-well message from the diocesan bishop.
Four months passed. We pushed the limit of medical technology to help him. A portable, vacuum-driven clamshell repirator was fitted to his body, a modern version of the old iron lung. Andy’s round body did not take well to the machine and it never worked properly.
Andy grew more and more despondent. He became inseparable from his rosary and prayed constantly. One day in early December, the fifth month of his hospitalization, I was summoned to the ICU because Andy was having an outburst. For no apparent reason, he had became violent, crying hysterically. He had overturned his bedside stand and hurled his rosary at one of the nurses.
I wrote him a note, asking him what was wrong. He just shook his large head, made some hand signals, and waved me out of the room. We gave him an injection of the sedative Haldol and located his parents, who had become ICU fixtures themselves, in the hospital gift shop. After communicating with Andy for several minutes, they emerged from his room appearing shaken.
“What’s wrong with him, Mrs. Wood? Is he having pain?”
Her eyes filled with tears and she pointed to a small Christmas tree which the nurses had just that morning set up in the corner of the ICU.
“He didn’t know it was getting close to Christmas; he had lost track of time. He wants to leave here and decorate the church. We told him that he knows he cannot leave, and he said he wants to die.”
“He’s been very depressed…,” I started, but Andy’s father stopped me.
“We know, son. We know you have done everything you could. But we think he’s right.” He stopped and gained his composure. “We want him to die, too.”
Andy eventually calmed down, but he remained sullen and bitter. Christmas came and went. A psychiatrist was consulted and prescribed some antidepressant medications, which helped little. The residents learned a rudimentary sign language, but Andy ignored anyone except his parents.
The left-sided facial paralysis he had suffered during surgery had never fully resolved, but it was not much of a problem until late January, when his left eye turned red and swollen. Because of the paralysis, Andy could not fully close the left eye. He had suffered repeated abrasions to his cornea over the past months, but they had all healed quickly before. This time, though, the cornea became infected and, despite antibiotics, developed scar tissue. His other eye was already blind; now the corneal scarring clouded his remaining vision. By February, Andy was totally blind.
This pushed him over the edge. He began pulling out his tracheostomy and pushing the ventilator out of the room. Soon he had to be continuously tied to the bed and sedated to prevent him from committing suicide. His parents tried making signs against his chest and hands to get him to understand them, but he either couldn’t or wouldn’t sign back. Whenever the hand restraints were removed for him to write a note, he immediately grabbed for the tracheostomy, trying to break the one restraint that bound him to the living. One day on rounds, Gary and I stood and watched as Andy grimaced and strained against the leather restraints while the ventilator pumped unwanted air into his lungs.
“I think it was Wyatt Earp who said ‘Any day above ground is a good day,’” mused Gary, “but Wyatt never met this guy.”
• • •
In late February, Andy’s parents called a conference with Dr. Filipiano. They requested that Andy’s ventilator be turned off. The case was taken to the hospital’s ethics committee, which was nervous about approving this. Andy no longer spoke for himself; how could the committee be sure he wanted to die? The parents asked the ethics committee to come and see Andy, imprisoned in a bed, blind, deaf, ventilated against his will, his lungs wracked with pneumonia. The committee obliged and made a trip to the ICU. Shortly thereafter, they approved the request.
At 11:00 P.M. on the evening after the request was granted, Gary and I met the Woods in the ICU. Andy’s mother kissed him on the forehead and then began tracing something into his hands with her index finger. Andy nodded vigorously. A respiratory technician disabled the ventilator alarm with her key. Gary and I stood looking at each other, wondering who would pull the tracheostomy and be the executioner du jour. Before either of us could act, however, Andy’s father motioned for everyone to leave the room. He then closed the door and pulled the window curtains shut.
I waited for an hour or so but no one emerged from the room. I went to bed. At about four in the morning the ICU called me to pronounce Andy Wood dead. When I arrived, his mother and father were sitting on either side of his giant, lifeless body, still holding his hands, alpha and omega—present at the beginning, present at the end.
His mother stared serenely at her only child through her reddened eyes. There is an old curse: “May you outlive all of your children.” Mrs. Wood now lived this nightmare. She looked up at me and spoke. “They said to put him in a home when he was just a child, but we couldn’t do that. Now, we were afraid he’d end up in nursing home. We couldn’t do that, either. He had a good life. He was a good son…”
Her voice trailed off. The jumbled chromosomes of decades past had turned out to be no mistake to her at all. By her face, I could tell that he would always be the most perfect little boy in the world.
The next morning, Gary and I rounded in the intensive care unit without making further reference to Andy. Gary must have known that his small slip with the arachnoid knife had been as deadly for Andy as a shotgun blast, but the chief resident never spoke about the case again.
Gary’s metamorphosis into a surgical psychopath was now complete. I admired Gary, but he showed not the slightest remorse or concern for his lethal error. He had described Filipiano’s surgical callousness with disdain; he now achieved it himself. Like me, he had entered the chrysalis of residency as the son of a steelworker, little more than a boy out of medical school. In four months he would emerge from his seven years of training with neurosurgeon’s wings. Was this just an act? Was psychopathy part of this transformation? And, I wondered, would I follow his path to indifference? Would my compassion start to slip away?
Perhaps. But perhaps patients didn’t want compassion from brain surgeons. They might prefer Nietzsche to Alan Alda, a superman who would make them better—even if he didn’t give a shit. Unfortunately, Gary fulfilled neither role for Andy.
I would have to learn to quit crying at funerals.