Tag: aneurysm

Part I

The speed with which medical conventions can domesticate the most outlandish requests, or re-frame even grotesquely violent behaviors, is an under-appreciated marvel of modern social life. In virtually every other setting—for instance, at your workplace—, it remains inappropriate for me to approach you, hand you a Dixie cup, and request that you fill it with your excrement. Work conventions rightly disallow this behavior, which would appear out of place, out of bounds, and downright weird.

However, if I approached you in my hospital office, handed you a paper cup with a wooden spatula, and there asked you to fill it with a stool sample, the request would be rendered perfectly normal because the conventions in that setting make it okay to require unacceptable things of you. In the right context, one of my colleagues might insert his finger into your anus, peer wisely into your vagina, thread a camera up into your colon to take pictures–or even cut you open from your collarbone to your pubic mound, slice out your heart, and put it in an ice chest. Only temporarily, mind you, because the promise is that someone will put it back when the time comes.

Although hospitals do their best to disguise the fact by building routinized, institutional facades (look at the architecture of the hospital pictured with this article), they are nonetheless the wildest places I can think of—far crazier than prisons, science laboratories, or military compounds, though they may share aspects of each of these establishments. Hospitals are the licensed institutions in which we hide the uncanny things of the world, chiefly by erecting conventions that suspend our incredulity. Hospitals assert the commonplace, affirm routines, profess the customary, declare humane incentives: just mundane practice going on in here, another ordinary day of saving lives, move along, nothing to look at. And in fact, you will not be allowed to look behind the closed doors.

But let me tell you, if at some point in your life, you discover that you need to be frightened–that you want to challenge your complacencies in ways you do not control beforehand–then hospitals are where you want to be. Nowhere else have I routinely touched people, circumstances, fates that otherwise I never would have imagined.

I never would have thought, for example, if left on my own—never thought to step behind the Senator showing me and my friends around the White House, and try to give him a bear hug. I am just too inhibited that way, and I don’t like Republicans. But Andrew, an adolescent high school student from one of the blue New England states, was comfortable with open displays of good feeling, and felt obliged to make a public declaration of his patriotism by embracing the natty senator addressing the New England Debate Club.

Naturally, Andrew called down upon himself the hordes of Secret Servicemen positioned throughout the building. The event I am writing about happened years ago at this point, well before 911, but even then the Secret Servicemen didn’t take chances–and given the initial urgency, it is to their credit that they pretty quickly recognized this was not a criminal assault, there were no bombs involved, and that everybody was safe, after a fashion. They had no idea what was really going on, but their expertise was with threats and violence, which they were trained to recognize when they saw them, and Andrew’s behaviors fit neither category.

For one thing, he was pretty disorganized in his attempt–not hesitant so much as uncoordinated in a weird way. He was also spouting a sort of ‘word salad’ that might have been mistaken at first for an unknown foreign language–except recognizable, though misused, words in English were mixed in. He wasn’t hard to deter from his intended purpose, the teacher-chaperones intervened with the government men, and eventually one of them took him back to his hotel room.

By report, he seemed to improve over the course of the afternoon, though his parents were called nonetheless, and arrangements were made to whisk him back home–in the course of which, however, he suffered another, more severe and persisting disturbance to his language production and his mental organization. He never made it home per se, but was taken directly to my Medical Center and admitted through the ER, where he was taken for a CAT scan. He had an aneurism in his left middle cerebral artery, which had begun to leak, causing disturbances in his language and motor control over parts of his right bodily extremities.

If he had been 75 years old, I think the symptoms would have been recognized more quickly than his were, because mid-adolescence is not typically an age at which to develop strokes. Though no one said anything, my sense at the time was that the adults around him all were assuming he had been taking some recreational drug, and his goofiness was the result. In truth, he would have been better off if he had simply been wasted on something fun, the effects of which were temporary. But instead of merely needing de-tox, he was awaiting brain surgery to clip the artery.

I was enlisted to evaluate him to establish a portrait of his current level of cognitive performance, which would provide a baseline for his post-surgical therapies. Accordingly, I visited over two afternoons as arrangements were made for his surgery. There were the formal portions of the evaluation, which mapped out memory, attention span, visual-spatial organization, executive planning, and of course his linguistic functioning, which looked pretty decent even with the aneurism. There were also the informal parts of our interaction that let him tell me, off and on, that he liked political science, that he was an only child, and that his favorite band was Tool or Nirvana, depending. I preferred Alice in Chains to either one of them–which no way could he believe, man, because Cobain was such a great guitarist, and the best writer. And besides, Courtney Love was hot.

This could be a fun job. For two days we definitely had the best music going on the floor.

Part II

Other days, on other units, were less musical. On Thursdays we had neuropathology rounds at 7 a.m. in a group of inter-connecting rooms in the basement sub-floor near the morgue. There the neurosurgeons, the radiologists and the neuropsychologists (i.e. me and two others) would assemble among the pathologists to engage in Brain Cuttings: an instructive event during which the brains of persons who had died would be sliced in coronal sections to allow the group of us to examine the gross pathologies, before the sections would be given to other pathologists in other rooms to stain and photograph. Often there would be two or sometimes three brains trussed up in a vat of formalin, where they had been immersed in order to solidify and preserve them for the cutting.

In themselves, brains are remarkably fragile–which is the reason they each float in the cerebrospinal fluid inside each of our respective skulls. Suspended in that salty fluid, they weigh about one fifty-sixth of what they would on land, so to speak. The brain’s own weight would be lethal otherwise; it would collapse fatally on itself simply by the pull of gravity, squashing the life out. So it is a delicate thing to remove the brain from the braincase, and slide it into the fixative that will solidify it enough to allow manipulation. It takes a sensitive and dexterous hand–governed by the attentive mind of a sociopath. Here we’d be standing by this large butcher’s block, on which the pathologist would set the brain he just fished out of the formalin tank, and in the adjoining room, separated by a kind of shower curtain, we could hear the whirr of the diamond saw as the other pathologist was cutting off the top of a recently-deceased-person’s head. It took some getting used to. Hannibal Lecter might have trained in a place like this.

There were two pathologists: a male and female team. The man–call him Dr. Taft–always chose to cut the brains; the woman–call her Dr. Adler–had the knack of extricating the slippery cerebral mass from its protective layers of skin, bone and meninges without brutalizing it, and getting it into the formalin with minimal damage. I don’t know if she ever knew whose forehead it was into which she pressed that whirling saw blade, but the rest of us had to know. Otherwise we could not relate whatever pathologies we saw in the fixed brains to the particular medical histories that proved so fatal to our patients. That meant that each brain, which was labeled by the kind of tag you might find dangling on an appliance in Sears, could be connected to a clinical history, which one of us would read to the group while Dr. Taft prepared to start cutting slices.

You cannot believe some of the stories. One brain I remember looked as if it had been shot with a spray of ice. This had been a young pregnant woman who, some time during her third trimester, had been engaged in love-making with her husband. Given the size of her huge gravid womb, the couple had chosen to have oral sex. Unbeknown to either of them, as the poor guy was going down on his wife, his excited heavy breathing was introducing air into her vagina, up the birth canal, through the dilating cervix, and into the placenta, where it was absorbed through the immense plexus of blood vessels there. Their sexual excitement, in other words, fed multiple air bubbles into her blood stream, which abruptly killed her when her pumping heart shot all those emboli into her brain. She never knew what hit her.

You can imagine what it must have been like. For one second or so he thought he had brought his wife to climax, only to realize that, no, something was stunningly wrong. By the time he had called 911, she was already dead, and by the time the EMT’s arrived, they had lost the baby too. The group of us stood there in numbed silence, not making eye contact, and waiting just to get the session over with.

I never went to neuropathology rounds without preparing for them. The fundamental premise was, of course, that someone had died–which, naturally enough, occurs with some frequency in hospitals. But it nonetheless required a sort of steeliness, a resolve to take it all on, to walk into that room and slice up someone’s brain. It wasn’t for everyone. We strolled down unadorned corridors toward restricted rooms where, like it or not, our Thursday exercises assumed religious proportions. After all, our rituals required human sacrifice. With the permission of the deceased, whose organs we were using, we called up the gods of science, and retrieved truths as we found them in the literal world of the dead. We had mortality itself on the cutting block, and took the opportunity to dissect the accidents of disease and infirmity, tease out vital membranes, and prepare as best we could against the onslaughts waiting for every last one of us.

These were perilous ceremonies, requiring perhaps a sort of ancient Mayan sensibility. Mercy wasn’t in it. Dr. Taft accidentally inflicted a vicious wound in his hand with the knife he was using to transect one of those brains, and though he survived the resulting systemic infection, it was a very near thing. He was ill for a prolonged time, and he wound up losing some of the function in that hand.

My own changes came some months before Taft’s injury, and had a different provenance all together. As we gathered around the ceremonial block that Thursday, and as Taft prepared to make his first cut at the frontal pole of a male brain, I heard someone–one of the interns, probably–begin reading the clinical history of the specimen we were about to study: The patient was a 17-year-old adolescent male named Andrew, the voice intoned,  a neurosurgery patient with an aneurism, who post-surgically bled out in the recovery room. Oh man. Oh man. I could see the extensive, black irregular pool of blood that had guttered into the left parietal lobe, the left anterior temporal lobe. I didn’t want to see the rest of the ugly stuff in the lateral ventricles, once Taft cut back to them.

I was looking instead for the place where Andrew kept Kurt Cobain’s music, the place where he knew the words to Lithium, Aneurysm, Heart-Shaped Box–the secret area where he stored his version of Nirvana. Everyone would have, if they had known him.