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

depression, frustration, anger, fear, despair. We can have intense pain but not suffer. A stubbed toe, a shin whacked against a coffee table, a softball to the groin, a paper cut, a mouth ulcer—all may elicit extreme pain with little suffering. We know these pains are temporary. We know that they will go away and that they bode no longterm ill for our bodies.
    But what of a woman who thinks she is cured of her breast cancer and then develops a minor backache? Her mind is troubled. Is it the cancer again? Until she finds out, she will suffer greatly. That small backache will become like a nail driven into her spine until she knows what it signifies. When told that all the tests are negative for cancer, she feels better instantly. No pain medications could accomplish this. The pain is the same, but the suffering is eased. In a sense, suffering is pain augmentedby a bleak imagination. We construct dismal scenarios for our unexplained miseries: That toothache must mean a root canal; that hand stiffness is rheumatoid arthritis; that heartburn could be coronary artery disease.
    Hippocrates once said that the chief function of medicine is to entertain patients until they heal themselves. On the pain service, we didn’t entertain our patients; far from it. We took their pain away as best we could.
    Of course, sometimes we had to poke holes in their heads to do it.
    The very first morning of my residency, Gary and Eric took me to the neurology floor and introduced me to some of the pain patients on the service. I had little previous experience with the pain service. At the time of my medical student rotation, there were relatively few pain service patients in the hospital. I had avoided even that handful, concentrating instead on the more “interesting” cases like brain abscesses, pituitary tumors, and carotid aneurysms. A medical student can get away with ignoring tedious problems in favor of more challenging ones. But residency was different. Medical school is five parts learning to one part servitude; the ratio is reversed in residency.
    We halted at room nine, a private room.
    “Room nine,” Eric whispered, “Mr. van Buren. Status postfive laminectomies for ruptured lumbar discs. He’s from Boston, runs an investment company or something. He has chronic right leg pain and has been on oral morphine for the last six months. We put in an epidural spinal cord stimulator yesterday and externalized it. The guy’s now playing with it to see if any of the settings make his pain go away. If not, we yank it. If it does, we internalize it to an antenna and send him to a detox unit.”
    Gary explained that the spinal stimulator’s gate mechanismpermits pain to be masked by a simultaneous sensation, such as touching or rubbing. Not surprisingly, people with chronic sciatica find it impractical to go around rubbing their legs all day. To exploit the gate mechanism, devices which continuously stimulate the touch nerves have been marketed. The simplest is the transepidermal nerve stimulator, or TENS unit, which consists of surface electrodes taped to the skin and hooked to a portable battery supply. The TENS unit provides a gentle “buzz” to the affected skin, akin to the low-level shock felt when touching the transformer of a toy electric train set. In patients with “failed back syndrome,” or FBS, severe leg pain from a damaged spinal nerve lingers even after one or more “successful” operations to remove a ruptured back disc. Many FBS sufferers can get by with a TENS unit attached to their affected leg all day.
    Eventually the TENS unit fails, though, and more masking stimulation is needed. To accomplish this, a thin electrode is threaded under the skin, between the vertebrae and directly over the spinal cord, into an area known as the spinal epidural space (the same area anesthetized during labor and delivery). The electrode is initially brought out through the skin and hooked to a compact control box to allow the patient