When the Air Hits Your Brain: Tales from Neurosurgery by Jr. Frank Vertosick Page A

kills swiftly. Faced with tamponade, we must tear out the skin sutures without delay; cut the bone wires to separate the halves of the freshly sawed sternum, or breastbone; and scoop the clot away from the heart. A set of suture-removal scissors and wire cutters sat taped at the bedside of every post-op cabbage for just such a delightful occasion.
    Patients survived—provided the intern recognized the tamponade quickly and opened the chest immediately. There was no time for anesthetic during this emergency maneuver, however. Opening an awake patient’s chest and showing them their own beating heart did not make my top-five list of favorite activities. When closing the chest cases on my call days, I prayed, “Please, dry this wound up, stop the bleeding…no tamponades tonight.”
    Heart surgery is a tough profession. A cardiac surgeon must complete six years of general surgery, followed by a two- or three-year cardiac fellowship. Operations stretched for hours; intraoperative deaths occurred frequently. Because of the hardships of training, cardiac programs attracted people with a Marine Corps attitude, residents so in love with their profession that the suffering became sweet nectar. They sported T-shirts that beamed: THE BEST WORK IN THE CHEST, and hung autographed pictures of Michael DeBakey in their lockers.
    My chief cardiac fellow, Maggie, exemplified the drill-sergeant demeanor. The ER called Maggie and me one night to evaluate an elderly woman flown in from another hospital. The woman was barely clinging to life. A ventilator tethered her to earth, else she would have expired hours earlier. A cardiac catheterization, done at the first hospital, had disclosed a blownmitral valve. The mitral valve, stopcock between left atrium and left ventricle, had stuck in the open position, its mechanism damaged by a fresh heart attack. With each beat, blood drove backward into the atrium, not forward into her body. Unless replaced with a synthetic valve, the broken mitral would kill her before the sun rose.
    Maggie, fresh from two straight cabbage procedures, was clearly tired. She scanned the cath report with a heavy-lidded stare, then shook her head slowly. I expected her to pound her fist with rage, angry at the unceasing workload. I had seen residents in other fields crumble under the onslaught of a neverending day. Instead, she looked at me with a wicked grin. “Frank, we’ve got a mitral valve to do! Oh, baby, this is great…YOU GOTTA LOVE THIS!!” She gleefully pranced to a phone to call the OR. She should take up bowling, I thought, just for a change of pace.
    In the uterus, the fetus breathes through the umbilical-cord blood, not the lungs. The unborn possess an elaborate bypass system which shunts blood away from their water-logged lungs and into the mother’s placenta. At the moment of birth, this bypass system shuts down, clotting off the umbilical cord and diverting blood to the virgin lungs.
    The in utero blood shunt carries two consequences for the cardiac surgeon: The closure of the shunt at birth occasionally fails and must be completed with a knife; and, since the normal circulation of blood is superfluous until after birth, some truly terrible heart malformations pass undetected until the delivery room, requiring the surgeon to rebuild the heart from scratch.
    Although many malformations have been described and named—tetralogy of Fallot, total anomalous venous return,hypoplastic left ventricle—malformations are as individual as fingerprints, hence the less restrictive “fucked-up heart” category.
    Some malformations kill the infant minutes after birth; others are mild, and their correction can be deferred for years. Most deformities, however, fall between these two extremes, producing a heart good enough to sustain life for a month or two but not good enough to last years. In these instances, the surgeon must decide whether the defect is correctable. If not, the child is left to die, or referred to