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

trauma faster than any other word. Leaning close to her face, I smelled her alcoholladen blood—a nauseating aroma unique to emergency rooms.
    “Shirley,” I spoke directly into her ear. She slowly opened her eyes.
    “Yes?” she answered, her voice muffled by the green plastic oxygen mask draped over her mouth.
    “Shirley, my name is Frank. You’ve been in a car accident and you’re in the hospital. I don’t think you have been badly hurt, but we have to do a bunch of things here. It’s going to be a long night. Can you wiggle your toes and fingers for me?”
    After a brief delay she obeyed, feebly, and then closed her eyes again. Although I was encouraged that she was not unconscious, I remained skeptical about her chances for survival. I had seen “talk and die” patients before, those who have a short period of wakefulness followed by a slow descent into coma and brain death. Just as a sprained ankle may not bruise and swell until hours after being twisted, the injured brain may not succumb to edema until several hours after a lethal impact.
    The skull is a best friend and worst enemy to the gelatinousorgan within. During normal daily activities, the brain sways to and fro in a watery sea of spinal fluid, tethered to the bone by small veins. During rapid acceleration and deceleration, such as during a car crash or during the vigorous “shaking” of a crying infant (one of the leading causes of infant murders), the brain slams into the skull and rips loose from its venous moorings. Blood oozes from the torn veins, forming compressive clots known as subdural hematomas, while edema fluid collects in the bruised areas of the brain. Trapped within the skull’s bony confines, the swelling brain chokes off its own blood supply and strangulates. In a trauma, the skull turns from a brain’s protector to its murderer, and, finally, to its coffin.
    The surgeon can intervene by removing blood clots and giving drugs to reduce brain swelling, but the damage is often irreversible. Surgeons in Japan tried removing the top of the skull in these patients, allowing injured brains unlimited space in which to swell. The skull’s “lid” was stored temporarily in a refrigerator, to be replaced when the swelling subsided. In some cases, unfortunately, the brain swelled to monstrous proportions, making the patient’s head look like something from a bad science-fiction movie. The patients died anyway and the practice has been abandoned.
    In desperate cases, large sections of the brain can be hacked away to make room for more swelling—a kamikaze strategy. In a macabre sense, Shirley was performing this type of surgery upon herself by squeezing her swollen brain tissue through the open skull fracture. The continuous decompression of dead, liquefied brain matter from her wound may have been the only thing keeping her alive at the moment.
    “Shirley, you have a cut on your head from the windshield and this young doctor is going to put some stitches in your head.” I instructed the general surgery intern to suture thelaceration using a quick layer of running nylon. Since I was likely to reopen the wound in the operating room in a few hours, a cosmetic closure was unnecessary. “It doesn’t have to be a Rembrandt; just stop the bleeding. And try to keep her hair out of the wound.” He grimaced at the sight of a growing mound of brain exuding from the wound. I wiped it away with a gauze sponge. “Memories of third grade,” I whispered, “but don’t let it bother you; she won’t miss it.”
    Bill, the senior surgical resident, examined the woman’s chest and abdomen while his junior residents performed other standard chores: drawing blood samples for the lab, inserting large intravenous lines, feeling along her arms and legs for any palpable fractures or lacerations, debriding the skin of dirt and glass.
    “Type and cross her for six units of blood,” Bill instructed a trauma nurse, “and see if they can send down some