When the Air Hits Your Brain: Tales from Neurosurgery Read Online Free PDF Page A

diagnosed over three-quarters of the time by the H & P alone.
    Every patient admitted to the hospital must have an H & P written on the chart. On a busy day, the neurosurgical service admitted twelve or more people. Even an uncomplicated H & P took thirty minutes to perform, and the task of getting them all done before nightfall was daunting. Only Gary and Eric did H & P’s; the senior and chief residents considered them menial chores. Gary lived in the OR, leaving Eric saddled with six to twelve hours of H & P’s a day. Taught the fundamentals of history taking and physical examination in our second year, any third-year student could do a passable H & P. I became an H & P machine, cranking out four to six every day.
    Of course, nobody read them. Clinical decisions did not turn upon my findings. The attending surgeon, having performed a very directed history and physical in the office, made the required decisions after some careful thought long before the patient ended up in a hospital. My H & P’s were essentially bureaucratic exercises. With one fateful exception.
    Harvey Rathman, a man in his late fifties, was admitted for the removal of a herniated cervical disc in his neck. His “chief complaint” was right-arm pain, increasing in severity over several weeks. Physical therapy had proved ineffective, and he now ate narcotics just to sleep at night. At an outside hospital, Mr. Rathman had undergone a myelogram: thick dye was injected into his neck to visualize the shadowy outlines of his spinal nerves on X-ray films. The test had disclosed that one of his neck’s discs, the fibrous pillows between the vertebrae, had ruptured, “pinching” a nerve between a disc fragment and the bony spine.
    While totally incapable of interpreting the X-ray picturesmyself, I managed to find the printed radiology report which accompanied the patient’s file. At the bottom of the report, it read: “Impression: small central to left-sided disc herniation, C56.” Left-sided? But the patient’s arm pain was on the right. How does a pinched nerve to the left arm cause pain in the right arm? I showed this paradox to Eric, who shrugged it off. He said that misprints occurred frequently, and that the staff surgeon must know that the disc had really ruptured to the right side or he wouldn’t have brought him in for surgery. “The radiologist probably just goofed up when dictating the report.”
    I accepted this explanation and strolled down the hall to see Mr. Rathman. It was nine in the evening when I entered the dark room. Mr. Rathman sat in his bed, his gaunt, lined face betraying his discomfort. He managed a contorted smile and said in the hoarse voice of a career cigarette user, “May I help you?”
    “I’m Frank Vertosick, Mr. Rathman.” I extended my hand, but he declined to raise his ailing arm and simply waved with his left hand. “I need to ask you some questions and do a brief examination, for the record. Now…” My voice trailed off.
    “Is something wrong?” the man asked.
    Something was wrong. As I glanced closely at his face, it struck me that his pupils were grossly aymmetrical. The right pupil was tiny, but the left pupil was huge, saucerlike. What was going on here? In an instant, a flash of insight burst into my head from nowhere. Deep in the recesses of my memory, brain demons below the level of my consciousness pieced together the man’s diagnosis from the disjointed bits of knowledge garnered during my first two years of medical school. The arm pain…the smoker’s rasp…the thin face…the unequal pupils…it all crystallized for me in a rush. This man did not have a ruptured disc! I stood over him, frozen by the thought that onlyI knew what was causing his arm pain. But I couldn’t say anything to him. That was not my place.
    “No, nothing’s wrong. Now, tell me about your pain…when did it start?” So it went. I finished the H & P, thanked him, and left. I immediately grabbed Gary, who had just