Another Day in the Frontal Lobe (21 page)

We don’t see this kind of thing every day, or even every year. No one does. Despite the uncertainty over whether or not surgery would help, that’s what the neurosurgeon recommended to this elderly gentleman, who quickly consented to the procedure, with very little to go on except for a couple previous cases worldwide and the confidence of a single senior surgeon. He was desperate. And, truth be told, the neurosurgeon in question was one that I would put in the genius category, albeit of the mad scientist variety, and if anyone could help this patient, this surgeon could.

The patient had a rough recovery. The operation had sapped his strength. His hiccups did improve—somewhat—but they did not go away, at least not during the time I knew him, while he was still in the hospital. Before sending him back home, across the country, his neurosurgeon hoped the patient would tell his story at the weekly teaching conference that we shared with our neurology and neuropathology colleagues. He would be a great teaching case, and he presented the perfect opportunity to highlight a complex and delicate operation. The patient agreed, and I was chosen to present his story and treatment in the usual format, with the patient up in front of the room facing the audience and the attending neurosurgeon seated in the front row, available for comments and questions from the audience.

The only wrinkle in our plan was that the patient looked and felt as if he had just been put through the wringer. He was elderly and hadn’t yet bounced back after this major ordeal. He had already stayed in the hospital longer than we had predicted. He was still too weak to walk long distances or to stand for any length of time. I would need to transport him to the conference in a wheelchair.

The neurosurgeon had arrived at the conference room a few minutes early, and I showed up not too long afterward, wheeling the patient along. Upon our arrival, my attending jumped out of his seat and rushed over to us. He whispered to me: “We can’t have him sitting in a wheelchair like that in front of everybody. Let’s have him stand.”

“But he’ll have to stand for half an hour and—” I protested.

“He’ll be okay,” my mentor replied.

So I led the patient, arm in arm, to the front of the room and hid the wheelchair somewhere down the hallway, before most people had shown up. I had the patient stand right in front of a desk at the front of the room so that he could lean on it if he needed to.

I got started with the presentation in front of a full audience, breaking at one point to have the patient recount his own hiccup saga. His voice was a bit weak. I watched him closely. He was starting to lean more and more against the desk, first one arm and then two, and I worried he might collapse if I didn’t finish the presentation quickly.

I rushed through the rest of my talk, going over the history of hiccup treatments and the rationale behind a somewhat controversial operation. The patient was now trembling, exhausted, and trying his hardest to suppress his intermittent hiccups in front of the audience and his surgeon.

I ended the talk a little early and ushered our patient out of the room and back into the wheelchair, feeling as if I had just been an accomplice to something a bit subversive, something that felt strange. I don’t know, in the end, if we really did the right thing for this kind gentleman, but I certainly knew what to say, encouraging him as I wheeled him back to his room: we did the right thing.

I’m thirty-three years old when my chief year ends.
Thirty-three.
I’ve been in some form of education or training up until this point: college from age eighteen to twenty-two, medical school from twenty-two to twenty-six, neurosurgery residency from twenty-six to thirty-three. My friends who aren’t in medicine have been out in the workplace for years already. I hear about CEOs of Silicon Valley start-ups who are younger than I am. I read the occasional news story about a popular new mayor—my age—elected to office. Hollywood actresses in their thirties are nearing the ends of their careers, which is okay, because they’ve already earned millions. Many professional athletes, at the apex of their professional life, are younger than I am. My parents had a houseful of kids by the time they were my age. I feel as if I have some catching up to do.

I recall the warning we all received when interviewing for our seven-year apprenticeship: “Don’t go into neurosurgery unless there’s
absolutely nothing else
you could ever see yourself doing.” This warning should also come with the reminder that “You won’t emerge from this tunnel until you’re in your thirties.”

I hear about other professionals “reinventing” themselves from time to time, trying out a different career, pursuing their intellectual curiosity to various ends, or taking a few months off between jobs to, say, trek in the Himalayas. That type of thing doesn’t go over so well in medicine—particularly surgery—which is often seen as a sort of “calling” and not as amenable to professional wanderlust. Here’s what people would say to a surgeon who wanted to take a look around: “After all those
years
?”

But we reassure ourselves by recalling all the things we’ve experienced that our white-shoe friends in business haven’t, the things that get our hands and shoes dirty and that make a difference in people’s lives. We can always regale in those highs, and look forward to more. At the same time, though, it’s easy to be haunted by the very experiences that most starkly set our job apart.

EIGHTEEN

Endings

Looking back at seven years, I have had my hand in saving lives and I have had my hand in helping to end them. I’m not talking about murder, of course. I’m talking about helping people die; people who already have their toes at death’s door but are about to cross the threshold in a very unpleasant and—to use a catchword—very undignified way, the type of way that would burn a horrifying imprint into the family’s collective memory. Some might argue that this is never a doctor’s duty, but I would beg them to take another look, with their eyes open.

Take the eighty-seven-year-old woman who collapsed in her kitchen while spending a pleasant day with her granddaughter. She arrived via ambulance at our ER in a coma but was still able to breathe on her own, somewhat. Her family showed up a short while later. With no advanced directives to go on, she was intubated by an ER physician, put on a ventilator to assist her breathing, and sent for a scan. She had suffered a massive spontaneous intracranial hemorrhage. Our best guess, based on her age and the location of the blood, was that she had had an “amyloid bleed,” a type of bleed particular to an elderly brain with worn-out fragile blood vessels that are prone to breaking for no particular reason. No trauma is required and it’s not well understood. The dreaded “why” question is not fruitful here.

I met the family in the ICU waiting room. I explained everything: the scan, her exam, her dismal prognosis. I had already spoken to the attending in charge. He was in favor of no intervention. We wouldn’t even offer the option of surgery. He had taken a peek at the scan and the patient and then left me on my own to do the right thing.

One of the daughters was a veterinarian. I showed her the scan, holding it up to the fluorescent overhead lights of the waiting room. That’s all she needed. She told me that her mother wouldn’t want to live like this. She had spent a great day with her granddaughter. We should end things on a happy note. No one disagreed.

I led the family down the hallway to the end of the ICU where the patient was lying immobile, comatose, on the ventilator. I left them alone and told the nurse to page me when the family was ready. My pager went off soon afterward.

I returned to the ICU and took the veterinarian daughter aside in the hallway. I wanted to run something by her. The area of hemorrhage was quite high in her brain, and her brain was markedly atrophied, given her age. In other words, there was a lot of room in there to accommodate all the blood. For those reasons, there was no real pressure on her brain stem, the part of the brain that controlled breathing. She might very well breathe on her own after being detached from the ventilator, maybe for hours, maybe for days or even longer in this unconscious limbo.

I had seen such things before, and it can be horrifying: an elderly patient sent to the floor for what is thought to be their final hours, and the hours turn into days. The patient gasps and sputters with irregular breathing (giving the appearance of distress), foul odors collect in their mouth and throughout the room, a pneumonia and a bad urinary tract infection set in, no one wants to hold vigil by the bedside, family members visit less frequently, and when they do they prefer to mill around in the hallway. I wasn’t going to let that happen. I swear, sometimes we treat our dying pets more humanely.

I told the daughter that, with the family’s permission, I would order a morphine drip, to be used as needed. She understood perfectly, and thanked me profusely, far more than most families do, even after a successful save, after several hours in surgery.

I spoke to the nurse, found the patient’s chart in the rack at the nurses’ station, and scribbled the final orders: “1. extubate patient. 2. MSO
₄
gtt titrate prn for respiratory distress. 3. CMO.” The “comfort measures only” order made things official, ensuring that no other well-meaning members of the team would come by and complicate things by ordering lab tests, medications, or follow-up scans.

The “titrate” addition to the order for the morphine drip meant that we had the flexibility to escalate the dose as we saw fit based on her breathing pattern, knowing that progressively higher doses would mean progressively slower and shallower breaths. In this way, the dying process could be curtailed and made more humane for both the patient and the family. (More humane, I think, than the “passive euthanasia” of withdrawing food and water. Most people wouldn’t consider starving the family dog as a way of “putting it out of its misery.”)

Shortly after extubation, with the clear drip running through her IV, our patient’s life ended—calmly—with her family encircling her bed, with fresh memories in their minds of the woman she had been just hours before.

The first gift I ever received from a patient or, actually, from a patient’s family was as a junior resident working at the Veterans Administration hospital. It arrived wrapped very neatly in brown paper. I had never received any sort of personal package at any hospital before. I was only a transient worker bee at the VA, doing time on my required four-month rotation, and I was a bit surprised that the package had actually found its way to me through the unwieldy government system of the hospital.

The gift was a Whitman’s Sampler box of chocolates. The thoughtful gift giver was the wife of a former patient of mine, a patient of very humble means, a war veteran who had died while under my care. At the time of his hospitalization I had felt fairly impotent, unable to offer anything but a dignified death in the face of advanced metastatic cancer. This simple box of chocolates, of the finest variety to my new way of seeing things, made me realize that “nothing left to offer” wasn’t quite true.

Sometimes, in dealing with a difficult reality, I am struck by how well art has imitated that reality, if not in every detail, then at least in overall feeling. A perfect evening for me is dinner and a good movie, and I especially love when a movie haunts me, provoking heated discussion with my husband at a café afterward, late at night. I’ll always remember the raw, provocative, and morally ambiguous scene in a Spike Lee film from several years ago that really got us talking. One of the main characters is a minister. His son has gone bad, having fallen prey to the primitive biological forces of drug addiction, and now he’s past the point of no return, the chemicals and his need for them having taken over his brain with a force too powerful to be defeated. In his unbridled quest for money to buy drugs, he has stooped so low as to terrorize his parents in their own home, and his parents now fear for their lives, and rightly so.

It’s almost as if a rabid animal with a virus-laden brain had been set loose. The fear and violence escalate to the point where the parents are forced to defend themselves or risk death, and the minister ends up shooting his own son, ending both his son’s life and the tragedy of the end-stage drug abuse that had threatened so much else.

I once admitted a patient who I thought, by the family’s account, could have been the inspiration for the character of the minister’s son. He was in his fifties, which, after meeting him, I felt was amazing in and of itself. From the looks of him I would have expected him to self-destruct much earlier. He looked at least seventy. He had had a very hard life of alcohol, cigarettes, and cocaine and he had failed all attempts at rehabilitation. He had done time, a few times. He had been violent. His toxicology screen on admission was positive for cocaine and alcohol, and the smell of alcohol emanating from him was so concentrated that it was nauseating.

He had fallen many other times before in similar drunken and drug-induced stupors, but never like this, from the top of the stairs. He tumbled all the way down and ended up at the bottom, quadriplegic, no movement from the neck down. He couldn’t breathe, as his diaphragm had no input from the spinal cord.

The paramedics saved him on the scene, packaged him up, and handed him over to us, a gift. Now what?

The X rays of his neck told us all we had to know. He would be quadriplegic for life. The fracture and degree of dislocation at the top of his neck were impressive. We were surprised at how light and osteoporotic-looking his bones appeared on X ray, especially for his relatively young age. (Another reason, by the way, to avoid smoking at all costs—it’s not just lung cancer, various other cancers, heart attack, and stroke that you have to worry about. Osteoporosis is also more common in smokers, and it only takes one broken bone to ruin your day, especially when it’s in your neck.)

What were we going to do with this guy? You
always
want to give a patient the benefit of the doubt, if there’s any hope at all. Maybe we’d be able to get him off the ventilator eventually, manage all his withdrawal symptoms, ward off the bed sores and infections that patients like this are prone to, and get him off to rehab, one day, where he would find religion and, via dictation to a dutiful nurse, write an inspirational book that would influence thousands and perhaps become the basis of a movie. Maybe not. His family certainly didn’t think so and they knew him quite well.

His body didn’t take well to the quadriplegia and we had difficulty controlling his dangerously low blood pressure. To begin with, his heart wasn’t strong and his lungs were shot. What’s more, a combination of low blood pressure and ratty carotid arteries (again, smoking) left his brain underperfused at times, his mind unavailable to us or his family. In his intermittent fully awake states, he could nod his head yes or no reliably. When I asked him whether or not he wanted us to keep him going in this state, he shook his head no, every time.

I spoke at length to the family, on multiple occasions, and they visited dutifully despite their mixed feelings toward him. He had burned many bridges over the years, but they were still family. His closest sister was a Baptist minister. After several days in the ICU, with his health failing further, she asked if we had to continue with all this care, leading nowhere.

In a case like this—a relatively young man intermittently awake and on a ventilator—I can’t recall now if the ethics committee was involved in our collective decision making, but they probably were. Even so, they may have had nothing much to add. The decision to terminate life support was unanimous among everyone: the patient, the family, the physicians, the nurses. This was not the type of case to hit the media, and there were no demonstrators carrying signs outside the hospital in support of continuing aggressive (and free) care at all costs.

Before taking him off the ventilator, the family gathered in his room and sang church hymns, led by his sister. They left quietly and then we pulled the curtains and slipped the breathing tube out of his throat. His eyes remained closed while I stood at the head of the bed with his nurse, watching the heart and oxygen monitors. We waited several minutes. Despite the fact that he was not able to breathe, his heart kept beating, weakly, and his oxygen level dropped more slowly than I had expected. Then, without warning, his eyes shot open for a second—wide open—then closed again and that was it. I walked out to spend a moment with the family and, again, they thanked me with more warmth than I was used to.

His room now emptied out and disinfected, his family now back home, both sad and relieved, we accepted another patient into our filled-to-capacity ICU without skipping a beat, refocusing our energy and resources on this fresh new person who would have no knowledge of all the weight that had just occupied this very bed.

All it took was a single drop of blood to remember a patient I otherwise would have forgotten. It’s easy to forget a patient whom you never really got to know, especially during residency when the pace is hectic, the volume tremendous, and the memories fleeting. In a really busy week, head injury victims might arrive daily, and one or two might not make it, but you have to move on.

Some victims arrive as “Doe” if the paramedics are unable to find ID. Family notification is delayed until someone can figure out who the patient is. We do whatever we need to do on an emergency basis—surgery, aggressive measures—without obtaining anyone’s consent. In most cases we learn the patient’s name later that day, but that doesn’t necessarily mean that we get to know them any better.