When the Air Hits Your Brain: Tales from Neurosurgery

8. If It Was Easy, Everyone Would Do It

My junior year of residency was near an end. On a Friday evening in May, Gary, Eric, and I finished rounds about eight o’clock and went to the surgeons’ lounge to change into our street clothes. The intern was “in the house” that night and Gary, who was responsible for backing him up, was in no hurry to head home. An intern can make very few decisions on a specialty service such as neurosurgery, and, as chief resident, Gary never strayed far from the hospital on the nights that the intern took call.

“Who wants some Roma’s pizza?” he shouted down the long row of lockers. Roma’s pizza parlor was directly across the street from the hospital. So many of the residents ate at Roma’s that a direct hospital line had been installed there.

“No thanks,” Eric replied. He had been on call the night before and was anxious to see his wife and children. Eric was dedicated to his work but made a quick exit when the work was done. I never liked to hang around the hospital campus and socialize either, but I decided to go because I hated to see the chief eat alone—even if it meant inhaling his cigarette smoke and bullshit another two hours.

“I’ll go, if you buy,” I agreed.

“It’s a deal,” said Gary, “but you have to obey Gary’s law of eating pizza.”

“Another law?! What’s this one?”

“You’ll just have to wait and see.”

We hurried through the hospital lobby, casting quick glances around corners and down hallways to be sure that we didn’t accidentally bump into any attending surgeons or patient families who might want to discuss business. A chief resident never finishes a workday, he just sort of amputates it. There was always something more to do if he looked too hard. This night, all was quiet. We made our escape undisturbed.

Roma’s was filled with the usual crowd of residents. Every specialty was represented, each identifiable by a characteristic uniform and behavior. Two bulked-up orthopedic residents were taking a break from their anabolic steroids and downing a few calzoncs instead. A general surgery resident, still dressed in surgical scrubs and wearing blood-splattered shoe covers, was slamming his hips into a “Star Wars” pinball machine and cursing.

In the back corner of the pizza parlor a table was crammed with medical residents dithering about some liver syndrome, their stethoscopes draped around their necks and their coat pockets jammed with standard-issue medical resident paraphenalia: the Washington Manual, index cards, photocopies of New England Journal articles, syringes. The pediatric residents were essentially medical residents with small teddy bears wrapped about their pastel-colored stethoscopes and an empathetic gaze permanently welded onto their faces.

As we passed the table of medical residents, Gary glanced back at me and began scratching violently at the back of his right ear with his cupped hand, imitating a dog scratching a flea. This was his own personal code for internists. In resident lexicon, internal medicine residents are “fleas.” The origin of this epithet is unknown, although several colorful theories have been advanced: fat, loud, egotistical assholes; the last creatures to jump on a dying dog.

There is a constant tension between internists and surgeons, the internists viewing surgeons as brainless technicians, the surgeons viewing internists as medical Neros fiddling as patients burn. This internecine feud peaks during residency and eases after a few years in practice. New surgeons soon realize that their patients, and mortgage payments, depend upon internists. Internists soon realize a surgeon isn’t such a bad person to have around when a patient is vomiting blood.

Gary and I ordered a large pizza and found an open booth. The chief lit a cigarette. “Look at those goddamn fleas, jabbering about some disease they’ll see once in their lifetimes. That’s the trouble with fleas, they only like the bizarre stuff. They hate their bread-and-butter cases. That’s the difference between us and the fucking fleas. See, we love big juicy lumbar disc herniations, but they hate hypertension. The pediatric fleas—maybe we should call them gnats?—hate healthy babies. They dream about seeing some poor kid with cystic fibrosis. When we see a guy with pain shooting down his leg, we don’t cross our fingers and hope he’s got a signet cell cancer growing into his parasympathetic plexus like they do. We hope he’s got some garden-variety disc rupture that we can fix and then kiss his ass goodbye.”

He paused to puff his shortening cigarette and quickly changed the subject. “What staff guy is on call this weekend?”

“Fred,” I answered, expecting the chief’s reaction.

“Oh, fuck,” Gary grimaced. “I hope nothing comes in this weekend. I have a month to go and if I can get out of this place without doing another case for that dick-with-ears I’ll be a happy man.”

“He’s a big fan of yours, too, pal, ever since the bone flap thing.” The bone flap incident had occurred early in Gary’s chief year. Fred and Gary were performing a cranial operation to remove a benign brain tumor. Fred had performed the entire operation himself—a grave insult to a chief resident, known as “stealing the case.” After Fred left the OR, further irritating the chief by dumping upon him the tedium of closing the wound, an angry Gary had engraved the phrase “Fred sucks” with the electrocautery knife on the inside of the bone flap, the plate of skull bone that is temporarily sawed away to gain access to the brain. He had then wired the flap back into place, thinking that the inside of the patient’s skull would never again see the light of day.

Unfortunately, the bone flap developed a staph infection and had to be removed a week later. Once contaminated with bacteria, the free piece of skull must be removed to cure the infection. The soft spot is filled in with plastic several months later. Gary coerced me into assisting Fred with the surgical removal of the infected flap. I’ll never forget the almost unintelligible stream of invectives that spewed forth when Fred saw Gary’s skull graffitti. Fred was too embarrassed to send the discarded flap to the pathology department as it was, and we spent an hour drilling the message off the bone before allowing it to leave the OR.

“Screw him.” Gary was characteristically unrepentant. “It was a tiny convexity meningioma and he stole the whole thing. How should I know the flap would get infected?”

“Well, you should be happy he didn’t tell the administration about it,” I said, trying to maintain some fairness.

“Are they going to fire me for one skull-o-gram? Where’s that pizza? You were a physics major, weren’t you, Frank? You know about quantum states? Well, I have two quantum states: hungry and nauseated. It’s a curse. I have to eat until I’m nauseated, or I stay hungry.” Gary had the lanky, wiry build of the chain-smoking, eat-anything-and-everything-and-never-gain-a-pound, type A personality. He could consume vast quantities of food.’

The waitress delivered the pizza several minutes later.

“And now,” I asked, “what’s Gary’s law of pizza-eating?”

Gary pulled the pizza toward him and removed half of it, folding it in two and biting into it like a giant sandwich.

“When I share a pizza with someone,” he replied with a full mouth, “it’s not fifty-fifty—it’s whoever eats the fastest gets the most. That’s Gary’s law. So you better get started.”

I was no match for him. I managed to eat only two of the. eight slices before Gary had devoured the rest. When we were finished, the chief leaned back in the booth and closed his eyes contentedly.

“Nauseated?” I asked. He gave a slight smile and nodded. I probed him about his future plans. “Have you decided what job you’re going to take?”

Gary was silent for a few minutes, as if he was drifting off to sleep. He then opened his eyes and bolted forward, reaching for his nearly empty pack of cigarettes.

“I took that job in upstate New York. You know, the old fart who says he wants to retire in two years and turn his onemillion-a-year practice over to me.”

“Really?” I was amazed. “You interviewed for that job five months ago. When did you decide to go there?”

“Five months ago. I signed a contract when I was there.”

“But you’ve interviewed at a dozen places since then! Why didn’t you tell anyone you were already taken?”

Gary laughed, blowing pulses of smoke. “Naive boy,” he whispered, leaning close, “if you’re a good candidate, people will fly you anywhere to interview. And each interview gets you out of this meat grinder for a day or two. Why the fuck would I tell people I signed a contract five months ago and quit interviewing? Look at where I’ve been since: San Diego, San Francisco, New York—shitty jobs every one of them, but great trips. I didn’t go to Akron, did I? You see, that’s the job of the chief resident, Frank. Everyone thinks we’re here to teach you punks how to sew and tie, but you can learn that shit anywhere. We’re here to teach you really important things, like how to con a dinner at Antoine’s out of a private-practice group in New Orleans that you wouldn’t work for if your life depended on it.”

I was a Buddhist pupil seated in the presence of the Enlightened Master.

“The next five years of your life, Frank, will be hard,” Gary continued, “but always remember this: If neurosurgery wasn’t hard, everyone would do it. Look at those fleas over there. Do you think they really want to write prescriptions for Inderal for the next forty years? Do you think they wake up at night screaming ‘Dialysis! I must dialyze one more patient!’ Maybe a few do, but most of them wanted to be surgeons but just couldn’t hack the work it takes to be one. If a genie popped out of their pizza right now and said he could make them into any type of doctor they would want to be, right here and now, which one of them do you think would say ‘Oh, genie please make me a gastroenterologist so that I could look up someone’s ass all day and my office can be filled with spastic-colon patients wanting to show me Polaroids of their latest bowel movement,’ or ‘Genie, I get an erection just thinking about chronic lung patients coughing up goobers at me.’ No way. They’d all want to be heart surgeons or brain surgeons or transplant surgeons.”

Gary’s beeper went off. It was the emergency room. He dunked his last cigarette into his cup of flat Coke with a hiss and headed for the hospital phone. I watched as he stood hunched over with a finger in his other ear to block out the incessant noise from the video games. He listened for a few minutes, nodded his head, and hung up. He returned to the booth, threw a ten-dollar bill on the table, and grabbed his jacket without sitting down. “Let’s go.”

“Go where?” I asked, bewildered. “I’m not on call.”

“Do you want to learn how to be a neurosurgeon or are you going to go home and watch Gilligan’s Island? You can tell some future patient that you had to skip learning about spine trauma because you just had to see the episode where Mr. Howell decides to put Skipper in his will.”

“All right, all right, I’m coming, but I have to call Kathy first. She’s expecting me.” My future wife was growing used to my last-minute cancellations.

“Call her from the ER. Walter has some guy who rolled his pickup truck and is getting weak in front of his eyes. You know Walter, he wants to be a plastic surgeon. Stuff like this just panics the shit out of him.” Walter was our intern. He was a good intern, but definitely more of a Bel Air boob-lifter than an urban trauma surgeon.

As we were on our way out, one of the orthopedic residents called to us. “Hey, Gary, going back again? Don’t you guys ever leave?”

“Man, this is a tough year for us, Bob,” Gary retorted, “but nothing like those three toughest years in an orthopedic surgeon’s life.”

“Yeah, what are those?”

“Second grade.” We exited into the dark street and headed for the ER entrance.

The ER looked a lot like Roma’s: brightly lit, filled with residents, and humming with electronic beeps and whistles. We tossed our jackets in the nursing station and went to the trauma room. Walter met us there, thin and handsome. An ugly plastic surgeon is about as successful as a fat aerobics instructor. Walter was obviously relieved to see us. Most interns enter our program knowing less neurosurgery then the housekeeping people. When on our service, they wander about clumsily, literally living out the nightmare of being on stage without knowing a single line of the play.

“Walt, my man.” Gary put his arm around the frazzled intern. “What have you got for us here?”

Walt pulled out his crib sheet filled with random pencil marks. “Billy Renaldo, age thirty-three, no prior medical history, was coming home from softball practice when his pickup truck was sideswiped as he came off a ramp onto Route 8…his truck flipped over…Uh, let’s see…his vitals at the scene were—”

“Wait,” said Gary, “do I look like I’m from Haaah-vard? Just the facts. Is he alive, is he awake, does he move anything? Is he really thirty-three and still called ‘Billy’?”

The intern didn’t miss a beat. “He never lost consciousness. He came in about half an hour ago saying that his neck hurt and that his legs felt heavy, but he could move them OK. But now he says he can’t move them at all and his hands are feeling ‘tingly.’ He has no external marks of trauma and the general surgeons are done with him. He really looks pretty good.”

Gary didn’t wait to hear more. He darted into the trauma room. The patient, a tanned, muscular man ‘with a shock of black hair and a black mustache, was strapped to a backboard and still wearing his softball uniform.

“Mr. Renaldo,” Gary began, “I’m Dr. Stancik, chief resident in neurosurgery, and this is Dr. Vertosick and Dr. Schwartz.” He motioned to Walter and me. “Try and wiggle your toes.”

“Call me Billy. And I can’t. I could about ten minutes ago, and now they just won’t do it.”

“Move anything from the hips down.”

Billy weakly rotated his legs at the hips.

“Try lifting them,” Gary instructed as he loosened the restraining belts holding Billy to the backboard. No luck.

“Doc,” Billy continued, “now my hands feel funny. Jesus Christ, what’s happening to me?”

“Don’t panic,” said Gary sternly, “we’ll figure it out.” The chief examined the distraught man completely and then we left the room while some spine X rays were taken.

“He’s got a C7 sensory-level,” Gary whispered to me, “and a nearly complete motor-level as well. He looks good, all right, except he’s paraplegic. Walter’s idea of ‘good’ needs some revision.” C7 referred to the seventh cervical vertebra, at the junction of the neck and chest. Billy’s spinal cord wasn’t working below that level, giving him numbness and paralysis from about his armpits down. Gary thought out loud: “But why is he progressing so quickly? He was moving his legs when he came in.”

“Maybe he wasn’t properly immobilized,” I offered. If his neck was broken, improper movements could injure the spinal cord further.

“Naw,” said Gary, “he looks pretty immobilized to me and, besides, he’s wide awake. If someone breaks his neck and is wide awake, they’re in so much pain you could lift them up by their nostrils and they wouldn’t move their necks. Something fishy is going on here.”

“Maybe he’s having a conversion reaction,” chimed an emergency medicine resident.

“Possible,” mused Gary, “maybe he struck out in the bottom of the ninth and his male pride made him a paraplegic to save face…but don’t call the psychiatrists in just yet.”

The phrase “conversion reaction” is a euphemism for hysteria. The patient “converts” an emotional trauma, such as a failed marriage or, in Billy’s case, the shock of being nearly killed in an accident, into a physical complaint such as blindness or the paralysis of an arm or a leg. Although the symptom has no organic cause, the patient isn’t faking in the conventional sense, either. Malingerers don’t believe that they are ill. That’s why hidden cameras catch them throwing away their wheelchairs when they think no one is watching. The hysteric, on the other hand, is truly convinced that the illness is real, and will continue to manifest symptoms even when alone. A patient with hysterical numbness will let a needle be pushed through a fingertip without flinching.

The word “hysteria” derives from hyster, Greek for uterus and root word of “hysterectomy.” Ancient physicians believed hysteria to be an exclusively female disease. While it remains more common in women, I had seen plenty of conversion reactions in men, too. In fact, anybody can turn hysteric, even people with no obvious mental-health problems.

The X rays were done. I reviewed them with Gary in a back room. The cervical and thoracic spine films showed no evidence of fractures or dislocation of vertebrae.

“See,” the ER resident chided, “I told you, he’s hysteric. Let’s just watch him for a while. I’ll bet you he walks out the door.”

Gary squinted at the film for another few minutes and then wheeled about. “No…no, no, no. He has a sensory-level, ascending paralysis and neck pain. Frank, get on the horn to Fred, let him know what’s going on…Walter, call the radiology resident, tell him we need a CI puncture for a myelogram and CT. And I mean now, as in now and not two hours from now. I’ll call the OR and tell them we’re coming up as soon as the myelogram is done.”

A myelogram involves instilling some iodine dye directly into the fluid space around the spinal cord, followed by X ray’s and a CT scan to trace the flow of the dye down the spinal column. Gary wanted the dye injected at CI, just behind the ear.

“What do you expect to find?” I asked. “His films are normal.”

“I don’t know,” Gary answered, “a disc rupture, a clot, maybe. But we have to look.” In tense situations, Gary’s flippant facade was jettisoned, exposing a tenacious and humorless professional beneath. He reminded me of the bomber pilot from the movie Dr. Strangelove, a buffoonish bumpkin until he receives his orders to deliver a hydrogen bomb on Moscow, at which time he is transformed into a fanatic and competent cold warrior.

We returned to the trauma room and Gary explained the myelogram test to Billy. As we were leaving to head upstairs to radiology, Billy called out: “Doc…”

Gary returned to the bedside. “Call me Gary.”

“Gary,” the man said quietly, “I can’t move my fingers anymore.”

The adult spinal cord is about two feet long and barely larger than the little finger in girth, passing down the middle of our backs encased in the bony armor of the vertebral column. Through this thin ribbon of fatty nervous tissue courses life. The spinal cord is notoriously intolerant of injury. Like IRS agents and Mafia dons, the cord will tolerate a certain level of insult, but wise men don’t push to that level.

While portrayed as the “main nerve” connecting the brain to the rest of the body, the spinal cord is more than just a nerve. In fact, it is a complex organ possessing an intelligence of its own. Stereotyped movements, like standing and walking, are preprogrammed within the spinal cord’s gray matter. This frees up our cerebrums to do those things which it does best, such as writing sonatas and inventing lite beer ad campaigns.

In lower animals, the cerebrum is so primitive that complicated motor behaviors originate in the spinal cord out of necessity. There just aren’t enough neurons in puny nonprimate brains to accommodate the “software” necessary to power all of the fins, wings, and feet. A headless chicken can run about sans brains. Our neurophysiology department once made a few brainless cats for a vision experiment, later giving them away as pets to unsuspecting cat-lovers who couldn’t tell them from intact animals. (“My Muffin is so smart…she know’s her name, she is just too independent and finicky to come when I call her…”)

As any athlete can verify, thinking too much during competition can hurt performance of repetitive tasks. The higher brain is always trying to embellish movements like a tennis forehand or golf drive, when such actions are best left to the spinal cord alone.

In humans, the “brainlike” behavior of the spinal cord can have macabre consequences. Patients with brains killed by gunshot wounds, hemorrhages, or other injuries can dupe family members, friends, even nurses, into believing that they are awake. An arm reaches up to grab a coat lapel, a hand grasps the hand of a loved one, a leg withdraws in apparent pain after a hospital tray is dropped on it—all preprogrammed spinal reflexes. Called “Lazarus movements” for obvious reasons, these reflexes make it difficult to convince a bereaved family that their loved one is, in fact, legally dead and should be removed from life support.

A spinal cord injury is either “complete” or “incomplete.” A complete injury deprives the patient of all sensation and movement below the level of the injury. If the spinal cord is injured in the upper back, between the shoulder blades, the patient will have no movement in the legs, no bowel or bladder control, and no sensation below the nipples. A complete neck injury will produce paralysis involving the arms as well as the legs. When the injury occurs very high in the neck, near the base of the skull, the muscles of respiration will be paralyzed and the patient usually asphyxiates before help arrives. A successful hanging produces this injury.

If the patient displays any movement or sensation below the level of the injury, even the faint wiggle of a toe or a twoinch patch of feeling on the inner thigh, the injury is said to be incomplete. This is a crucial distinction. Complete spinalcord injuries virtually never improve, while incomplete injuries, even severe ones, can reverse with time and proper treatment.

Gary and I walked up two flight of stairs to the X-ray department in silence. His head was down and his brow furrowed in thought. He was agonizing over what to do for Billy. Suddenly, he stopped and turned to me. “Forget the myelogram. Frank, go downstairs and get that guy to sign a consent for an exploratory laminectomy. I’m going up to the OR and make sure they’re set up and an anesthesia resident is available.”

“Why are we skipping the myelogram?”

“He’s going downhill before our eyes; if we wait much longer he’s going to stop breathing, and the horse will be out of the barn. He can’t have just ruptured a disc in his neck, because that shouldn’t cause the weakness in his legs to ascend into his arms. He may be crazy, but I wouldn’t bank on that, either. I’ve seen a lot of conversion reactions and none of them get worse with time. He must have an epidural clot that’s expanding. At least that’s what I think.” Gary turned and began running up the stairs, calling back to me in a feigned British accent: “Hurry, Watson, the game is afoot! Bring your revolver!”

The epidural space lies between the cardboardlike covering of the brain and spinal cord, called dura, and the skull and vertebrae. It is a space densely packed with veins which can be torn during trauma. While epidural blood clots are common in the head, where they compress the brain and cause coma, they are distinctly uncommon in the spine. Gary was guessing. I bet he had never even seen a traumatic epidural in the spine before. If he was wrong, we could be subjecting a man suffering from transient hysteria to a risky and painful operation. If he was right, and we waited to get the myelogram to prove it, the spinal cord might be hopelessly damaged. Gary had decided that a hysteric with an incision was better than a quadriplegic with pretty myelogram films.

I returned to the ER. Billy’s wife was sitting by the stretcher, holding his now limp hand and crying. I stopped short of entering the room.

“Where are the kids?” I overheard him ask.

“With my mom,” she replied, “they’re going to spend the night there.”

“Good, good…I don’t know how long I’ll be here. My bank card isn’t in my wallet, it’s on the ‘fridge…”

Life goes on. Honey, call the plumber and, by the way, I’m paralyzed. I broke in and introduced myself. I examined Billy again. He could no longer grasp with either hand and his biceps were weaker. He still had a few areas of sensation in his legs, although they remained paralyzed. Excellent, I thought, he’s still incomplete.

I explained that the myelogram would take an hour or two to set up and complete and so we had decided to go ahead and take Billy to the OR and explore his spine. If we didn’t do something soon, he might die from the advancing paralysis. After I was through talking, there was a pause. Billy took a deep breath and then spoke. “Let’s do it. But give me a minute with my wife, alone.”

I left the room and closed the door. I found Walter stretched across a tattered vinyl sofa in the ER lounge. “Give them five minutes,” I instructed the intern, “and get him upstairs to the OR. Call Fred back and tell him where we are.” There would be the expected spousal grief when it came time to take Billy upstairs, and I didn’t want to be there. These pathetic scenes, like exposure to X rays, are occupational hazards that take a cumulative toll on a physician’s health. I avoided them whenever I could. I wasn’t a complete psychopath just yet.

I changed back into surgical scrubs and met Gary in operating room eight. Chun, a senior anesthesia resident, was setting up his machines and Lisa, our scrub tech, was opening a package of sterile instruments.

“We’re on our own, buddy,” Gary said through his mask. “Two other rooms are still running and there isn’t any circulating nurse. Do-it-yourself neurosurgery. Help me with this.” Gary yanked a large metal-and-Styrofoam contraption from the bottom of the OR cupboard. It was the laminectomy frame, used to hold patients prone on the operating table.

The circulating nurse assists with setting up the room. During an operation, the “circulator” serves as an all-purpose gofer, answering phones, opening suture material, checking pagers, and so on. When the OR was understaffed, as it usually was in the evenings and on weekends, circulating nurses were pressed into duty as scrub nurses.

Walter arrived minutes later, pushing Billy on his stretcher. Just then the OR phone rang. Chun answered it, then handed the receiver to Gary. “It’s for you.” Gary thrust the frame at me and took the phone.

“Yeah…Oh, hello, Fred…yeah, he must have a clot…No, I didn’t get any studies, but he’s ascending…What? Uh-huh…of course I gave him steroids…I’m going to start at about T3 and work up…OK, we’ll be here. See you later.”

Gary hung up, his eyes narrowing above his mask. “A dickwith-ears, that’s what he is. He’s pissed because we have no myelogram, but he’s going to have to stay pissed. He only wants a myelogram because he’s at the symphony and it would have delayed the case until after he’s heard his fucking Beethoven. He’ll show up two hours late, anyway. Let’s get started.” He then called out to Walter, who was standing in his street clothes outside the OR, baby-sitting Billy. “Get dressed, amigo, we need you to circulate in here.”

Gary and I wheeled the stretcher into the small OR, parking it parallel to the OR table. The patient would be anesthetized on the stretcher and then flipped onto his stomach on the OR table after he was asleep. Gary examined him again. Billy’s large biceps muscles were now both totally flaccid. “Relax, ace, Dr. Chun here is going to put you to sleep. See you soon.” We then sat on stools in the corner and let Chun do his work.

The room was quiet. Contrary to popular belief, operating rooms are not always crowded, dramatic, and noisy. Nor are there choirs of seraphim basking in the glow of a larger-than-life surgeon. The OR can be an insufferably intimate place, an arena where an intensely personal transaction occurs: the bartering of one person’s skill for another’s quality of life. There we gathered, two men from a pizza shop, one man from a softball diamond, and an anesthesiologist, spending a tragic Friday evening together.

Chun glided an endotracheal tube into Billy’s throat and began taping it to the sleeping man’s face. I swiftly placed a bladder catheter into Billy and then the three of us, Gary, Chun, and I, grunted and heaved Billy over onto the Wilson frame and positioned him to our satisfaction. “Shit,” said Gary as he stared down at Billy’s broad, tanned back, now faceup on the OR table, “this guy’s built like a rock. What a waste if we don’t get his cord back.”

After we had scrubbed and draped the operative area, Gary and I took our positions on opposite sides of the table. “Knife,” Gary said softly. Lisa suspended the Bard-Parker blade between us, but Gary didn’t move to take it. He just stood and looked at me. “Well, are you going to take it or not? I didn’t tear you away from the Skipper and his little buddy just to watch me do a case, did I?”


“You’ll be a senior resident before you know it. C’mon, bring this guy’s legs back to life for him.”

I took the knife. Gary placed his right index finger on the nape of Billy’s neck and his left index finger in the middle of the his back, just below the rib cage. “Between here and here…let’s go, don’t be shy.” I slid the knife on a line between Gary’s hands and took the incision deep through the skin and fatty tissues. The incision was over a foot and a half in length. “Now get your hot knife,” Gary continued to instruct me. I grabbed the electrocautery pen and began carving the thick meat of Billy’s back from the spinal bones below. Gary swept away the tissue with large silver scoops as I detached it with the heat. This allows access to the spine, but does no permanent damage since muscle can heal.

About ninety minutes later, we had exposed the laminae of the spine from the neck down to the midback. The laminae are bony shingles which extend along the length of the spine and protect the back of the spinal cord. “OK,” said Gary as he probed under the edge of one of the laminar shingles with a small curette, “get a Kerrison punch under here and get to work.” The Kerrison is a long-handled metal tool with a small biting cup at the tip. It’s used to chip small pieces of bone away, bit by bit. Removing the thick protective bone in this manner is tedious, but it is the only safe way given the delicate organ below. Removing the laminae, a procedure known as laminectomy, is like chiseling through a cinder block to reach an egg encased within—without cracking the shell.

We removed one lamina, at the fourth thoracic level, and found nothing but pristine dura. No clot. I could almost feel Gary’s stomach churning with a mixture of doubt and pepperoni. “Keep going,” he barked, “it’s got to be here. Look, the dura isn’t pulsating.” The lack of pulsations was evidence, albeit weak, that some compression of the cord existed above our laminectomy.

I kept chipping away. Piece by piece, the third thoracic lamina ended up in the silver pan on Lisa’s Mayo stand. Still no clot. “I think the dura is pulsating here,” I observed, trying to be scholarly. Gary was unimpressed. “Keep going, tiger. Higher.”

In and out of the cavernous wound I went, dipping my tiring hand down to the spinal canal, grasping a bite of bone, and then releasing it into a specimen pan. Grasping and releasing, grasping and releasing, in and out, in and out. A widening expanse of translucent dura, the spinal cord visible just below, grew at the depths of the red wound. I had never worked around the spinal cord before and my arms were tense as I painstakingly guided the metal rongeur repeatedly under the laminae. My fatigue was growing, but I could not show weakness. If it was easy, anybody could do it.

Suddenly, just below the cut edge of the second thoracic lamina, a small piece of clot, resembling fresh liver, peeked out around the left side of the spinal dura. “There!” Gary shouted with the enthusiasm of a prospector seeing the glint of gold in his pan. He grasped the Kerrison from my hand and began making swift, sure strokes, slicing through the lamina like a rower slicing through a river. The clot grew larger and larger as the spinal opening proceeded higher. “Oh, sorry,” he apologized, handing the instrument back to me, “you’re doing fine.”

Hour after hour, I pulled bone away as Gary suctioned the thick epidural clot. Fred showed up, peered into the wound, and retreated to the lounge to sleep. At 5 A.M., over six hours into surgery, we reached the top of the clot at the fourth cervical vertebra. To me, scaling Everest couldn’t have felt better. I gave my aching forearm a rest while Gary probed the side of the spinal canal for further bleeding. “Look, Frank”—he gently tugged the spinal cord to one side, showing a tangle of thick, oozing veins—“I think this is where the clot originated. He must have flexed his neck badly when the truck rolled over and tore one of these veins. The slow ooze gave him the progressive paralysis.” He coagulated the veins with the bipolar cautery and packed the area with a small piece of Billy’s back muscle.

Fred came in again at the end of the case and Gary described the findings. “Very good,” said the attending surgeon, who had retreated to the far end of the room and was rummaging in an equipment drawer. Fred came over to the scrub nurses’ table and opened a sterile marking pen onto the field. “What’s that for?” Gary gave the staff man a quizzical stare.

“Well,” observed Fred dryly, “you have such a large area of dura exposed, I thought you might want to personalize it by writing ‘Fuck you, Fred,’ or something like that.” Both men laughed. They looked like colleagues now. I felt more like a surgeon and less like a medical student. In the glow of this male bonding, however, a question remained: How would Billy feel?

As for Walter, he wasn’t feeling anything. He had been sleeping on the OR floor for the past three hours.

Billy was no better the next day, or the day after that. He was transferred to a rotating bed, designed to keep the quadriplegic patient in constant motion and prevent the formation of phlebitis and bedsores. He had regained a little motion in his biceps muscles, but his hands and legs remained paralyzed. He did retain some sensation in his stomach and feet, but not much, and he had lost bladder and bowel control.

He spent his days listening to the radio and talking with his family and friends, all the while turning about like a rack of ribs on a spit. His mood was defiant and upbeat. He talked with his son about the fishing trips they would take. His wife brought in the family finances for his approval and read the newspaper to him daily. He treated his disability as purely temporary and was determined not to let his marriage or his mind wither like his nerveless muscles.

Making rounds on patients like Billy is a difficult task. People complain about the little time their surgeons spend with them, but they should try it from our perspective. What could I say to this man—How are you feeling today? (Paralyzed from the chin down, thank you, same as yesterday.) Small talk begins to look truly small: How about that win by the Pirates? Do you think it’s going to rain this weekend? Hey, time to get those tomato plants in! Eventually, however, doctor and patient find some neutral ground, some subject they can discuss that does not draw attention to the reality at hand. With Billy it was tennis.

Billy’s wife told me that he was an avid tennis fan. One day in June, after Billy had been hospitalized about three weeks, I found him sitting in a stretch chair watching the French Open on TV. His neck was still wrapped in a rigid plastic collar, and his hands and feet were bound in braces to slow the formation of contractures in his lifeless limbs. He was shouting “Just keep it in, just keep it in!” at the screen.

“What are you watching?” I asked.

“Oh, Jimmy Connors playing some kid at Roland Garros. The kid is trying to play serve-and-volley against Connors on clay. Connors isn’t consistent today, and if the kid would just stay back and play some longer rallies, he might do better. Right now he’s getting his ass kicked. You can’t play serve-and-volley on the brick dust unless you’re McEnroe.”

We sat and talked for an hour about pro tennis and our own philosophies about playing the game. I told him I preferred the baseline game, which surprised him. He thought my height favored a net game. He was being kind. In reality, my body habitus favors sitting in the stands with a Sno-Cone.

He grew quiet. “When do you think I’ll hit a serve again?” I told him I didn’t know. It was the truth: I didn’t. From that day on he called me Pancho, a reference to Pancho Gonzales, the tennis great. I called him Bjorn.

Billy’s huge wound eventually fell apart and became infected with pseudomonas bacteria. He developed pneumonia and an infected left kidney. Despite the rotating bed, his legs developed phlebitis. He was young and tough, however, bouncing back from each illness. One day, near the end of his acute hospitalization, something happened. Something small, but very important.

Billy had recovered from his lung problems and was in a regular hospital bed. In another day he would be transferred to the spinal cord rehabilitation unit of West Suburban Rehab Center, about five miles away. The mountains of cards he had received from friends and family had already been bundled together with twine.

“So long, Bjorn.”

“Yeah, see you Pancho.” He was grinning from ear to ear. “There is something I want to show you—I haven’t shown anyone yet, not even my therapists.”

“What’s the secret?”

“Look at my left hand.” I looked. I stared at it for several minutes, and then, quite subtly, almost imperceptibly, the thumb moved. “I think it’s moving,” Billy cried out, “it feels like-it’s moving. Is it moving?”

“Goddamn, Bjorn, it is moving! Centre Court, here you come!”

“It’s not much, but maybe I’ll get enough back in one hand to run a computer. If I can run a computer, maybe I can make a living again…” He began to cry, I think for the first time since his truck had flipped over.

I sat down beside him. “No, Billy, if you can move a thumb, it means your spinal cord is waking up. You never had a complete injury. Who knows where this will lead. You have to work hard. When they write your story in Reader’s Digest and use the old cliche ‘Doctors said he would never walk again,’ don’t include me in that group, all right?”

“Fucking right.” He composed himself. “Fucking right I’ll work hard. Ask anybody that knows me.”

I looked at his wound, still packed with cotton gauze but slowly healing. Putting a hand on his shoulder, I said goodbye and left.

Billy went to rehab, and I didn’t hear anything about him for a long time. In the ensuing months, Gary went on to New York and private practice, while I left the clinical service for a one-year stint in the basic science program. One of the flaws of surgical residency is that it centers on inpatient care. We often don’t get to see the small miracles that occur beyond our hospital walls.

In early January I was in neuropathology, imprisoned six days a week in my cubicle surrounded by glass slides, books, and printed handouts from our instructors. Life in pathology was dull, and I could feel blood coagulating in my veins as I sat for hour after mind-numbing hour staring at Carpenters’ Neuroanatomy text. The pathology viewing room was empty, the attending pathologists were at the V.A. for a staff meeting, and the pathology residents, like mice when the cats are away, had bolted for the local ski slopes. I was half asleep when a tennis ball came bounding into my lap.

I looked up and saw a tall, gaunt man standing in the doorway. He looked into my puzzled face. “What’s the matter, Pancho, don’t you recognize me in the vertical position?”

“Jesus Christ, Billy is that you?” He was right, I didn’t recognize him. The face bloated by months of steroids was now thin; the collar and braces were gone. He turned around, unbuttoned his shirt, and dropped it off his shoulders to show the jagged wound between his shoulder blades I had inflicted eight months earlier. Like doubting Thomas, I felt compelled to put my hand upon the broad scar. “I guess you did work hard, didn’t you?”

“I started improving pretty rapidly after I got out of this place,” he explained. “By October I was walking on the parallel bars. I went home in December. It was the best Christmas I ever had. I’m here to see Fred, and I wanted to see you guys, too. Where’s Gary?”

“He’s in New York making money.”

“And smoking twice as much, I’m sure. It took me an hour to find you.”

“How do you feel?”

“My feet still feel funny, and I can’t walk as far as I would like, but I’m getting better all the time. I return to work next month.” He thought for a while, then continued. “I can never look at my wife or children in the same way. That doesn’t sound right…Let’s say that when Joey asks to play ball, I’ll play ball as long as he wants. I don’t remember everything that happened, except that it happened so fast…so fast. It’s like that sappy Christmas movie, when an angel shows some guy how the world would be without him, and then lets him go back so that he can appreciate everything more. That’s how I feel. Like somebody let me go back and I can never waste a single day again.” He strode away on his stiff legs.

“Somebody let me go back.” Now, who wouldn’t want to do that for a living?

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