Daddy always told me not to put my hand out of the window of the car when it was moving… He told me that a boy had his “cut clean off at the elbow” once when his mother drove too close to a fencepost. I glanced over at him to see if he was looking, saw that he wasn’t, and eased my right hand out and over the partially rolled-down thick safety glass.
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I opened my fingers out wide, and let the wind whistle through them… then, I put them together, and let the force of the wind push my partially cupped hand backward until my forearm bumped into the door frame… open — forward.., closed — back.., open — forward.., closed — back… I looked at my palm, and that made me think about my baseball glove… that in turn made me think about the baseball game that I wouldn’t be able to play on my little league team that evening. I frowned.
Baseballs aren’t as big as some other things… like a football, or a basketball… or softball, even… They’re a little big to be inside of your head, though… I think…
I reached up with my left hand and felt the back of my head, and asked absentmindedly, “how much further, Daddy?”
He glanced over, “put your hand back in the car, son… you know better…”
My father and I were traveling to Houston, about three hours south from my small hometown, so that I could see my mother for the first time since her operation — removal of a baseball-sized tumor from her brain. She had been an inpatient in our local hospital for several months prior, with what was thought to be a mental disorder, and had been transferred down to the Texas Medical Center to die. Her weight had drifted down to a skeletal sixty-four pounds, and several shock therapy treatments had effectively managed to relieve her of a significant amount of her memory — but not her unrelenting headache.
The psychiatrist that accepted her in transfer performed a neurologic examination in addition to the usual salvo of questions that one might expect to be asked of a crazy woman that had managed to almost starve herself to death, and called my father that night to tell him that “I don’t think her problem is psychiatric… I actually think she has a brain tumor”. She was in the operating room the following day.
This part of the brain where the tumor was located is called the cerebellum. All parts of the brain are obviously important and none necessarily “dispensable”; however, this region is of particular importance as it is what allows us to more or less control ourselves within our environment — what we cumulatively call “coordination” (speech, walking and other “motor” skills such as feeding yourself). As I had overheard my father telling other adults, almost half of this part of her brain had to be removed to lift the tumor up and out of her skull.
“Is mommy still sick?” I asked.
“No son, not really, but she isn’t well enough to come home yet”.
“Will she remember me? She won’t forget me again, will she Daddy?”
Tears welled up in my father’s eyes as he perhaps recalled the shock treatments, and his consent to allow them to take place… “no…no… she has most of her memory back, okay big guy? But she’s still weak and won’t probably look the same”.
“Oh”, I said, as I looked out absentmindedly at the passing fields, wildflowers and cows grazing along the farm-to-market road. My six year old concern took leave of me… it drifted up and out of the open passenger side car window I was looking through, and lodged itself in the branches of the twisted live oak and mesquite trees that framed the pastures we drove past…
“Okay, Daddy”.
It was overcast and raining as we entered the city. The buildings we drove past were frighteningly immense — the tallest structure in my hometown, the county courthouse, was just a little over two stories. I was fascinated by the fact that that the raindrops hitting the windshield of our car would stop, then start, then stop again — I didn’t have the higher order reasoning to understand that the tall buildings were responsible. Turn this corner — rain…, turn that corner — no rain…, turn another — rain again. I slumped down in the slick braided rayon front passenger seat of our car, trying to see the tops of them as we drove past.
My father parked our car on a side street across from the hospital, in front of a medical uniform store. I immediately noticed the female mannequins with scrub suits and tailored white labcoats and thought that they looked pretty — fashionable and thin, leaning back with their motionless elbows bent outward, hands on hips. There were several of them lined up in a row across the half-block length of the display, and each had a tight blonde, brunette or red bouffant hairdo, heavily painted blue or green eye shadow and smiling red lips. They made me think of my mother, the way she stood and the way she wore her hair — but admittedly well before she left me months prior. I remembered why we were there, and the anxiety that had wafted out of my body miles back turned its evil head my way, and sensed an opportunity, despite the distance. It crawled down like a snake from the branches and vines of the trees along the road where I had left it, followed our path down the highway, into downtown Houston, and around the tall buildings to find me standing there. Fear slithers up on little boys from behind — silent and sinister, so that it can’t be noticed or avoided. It bites them at the nape of the neck, where the skin is soft and yielding, and the venom acts quickly.
What would she look like? Daddy had said she might look different… How, like a monster? Would she really remember me? Would I have to look at blood? Would she have one of these white coats on like the mannequins in the window, or pajamas? Even more terror for a moment when I contemplated she might not be wearing clothes at all. Will they make me look at her if I don’t want to? Will I have to talk to her if I don’t want to? What will I say to her? I stared in the storefront window at the pretty plastic representations of what my mother used to be, but knew she no longer was. I stood trembling, my palms on the thick green glass, fogging it a little with each halting breath, until my father came around the car and took one of my hands in his — a welcomed antidote to the serpent’s poison.
We crossed the street briskly, and entered the hospital through a side door, into a small room with some chairs, some signs on the wall with big words that I couldn’t read, and a closed window. Daddy has been here lots, I think, to know where to come.
My father walked us up to an opaque sliding-glass window. He rapped, and one of the shiny panels was pushed aside by a woman who was sitting behind it. She was older, and wearing silver-blue rhinestone cat’s eye glasses. Her hair, approximating the color of her glasses, was pulled back so tight on her head into a bun that it looked painful, and she was wearing a little white paper cap with a black stripe running across the bottom. I only could get intermittent glances of her face above the ledge on which my father leaned from my vantage point, but could see the paper cap the entire time — bobbing back and forth and up and down as she spoke to my father — tt looked as if it were alive, moving the head beneath it. She was telling him that my mother had been transferred out of the intensive care unit a couple of days before, and was now in what she called the “neuro step-down unit”. I didn’t understand what any of this meant. I anxiously shifted my gaze from the magic hat to my father’s face and looked intently for a signal. To my relief, he was smiling.
This particular area of the hospital was safer for my mother, my father explained while we were walking to a nearby elevator, “because the nurses can do nerve tests — to make sure she’s alright”. I didn’t know what a “nerve test” was, but it sounded scary. I imagined the Frankenstein movie I had watched the previous Halloween, with lightening bolts coming out of the sky, down into the laboratory and directly into the monster’s body, whereby he lurched in agony under the thick leather straps holding him down. I also remembered a scary looking man with a hump on his back limping around excitedly next to someone that was wearing a white labcoat — he looked a lot like a doctor.
I tried hard to keep from crying as the elevator doors closed and hugged my father’s leg tightly. There were other people on the elevator, including some wearing white labcoats. I wondered which one of them was going to give my mother the Frankenstein nerve test. All of them looked like they could be evil enough to do it, except for one old man who was leaning forward on crutches. He smiled at me, but I wasn’t sure… I inched around to the back my father’s leg and checked the man’s back for a hump.
We stepped out of the elevator and walked down a corridor. I was fascinated by how shiny the ceramic tile floors were, dark colors in the hallway and lighter pastel shades inside the patient rooms we walked past. Holding my father’s hand, I walked with my head down so that I could see everything, including me, reflected up from the surface. No one else seemed to think it was a big deal — maybe they were too far from the ground to notice? I was worried that the new, uncomfortable black shoes that my father had taken me to buy specifically for this trip would slip on the slick floor, and that I might hit my head and be put into the hospital like my mother. The soles were smooth and hard, and I had trouble when we would turn a corner keeping them under me just right, taking extra shuffling steps in a larger arc around my father’s like someone roller skating for the first time, looking up at him and hoping he wouldn’t think that I was doing it on purpose and get mad at me.
The smell in the hospital was terrible — it reminded me of a mixture of rubbing alcohol that my mother used on me from time to time when I had a fever, and some brown “medicated” cough drops that my grandma loved. She offered me one once, and it made me queasy to think about the horrible taste. Where did the smell come from? My mother would spray something in the air at home to make it smell nice, and sometimes when she would wax the wooden furniture, it made everything smell like lemons.
Did they spray this smell into the air? Why would they do that if it smelled so bad? Do grownups like this smell? Is this sick people smell?
I was completely engrossed with these important thoughts when we stopped at an open doorway and my father said, “Roy, this is your mommy’s room.”
I froze. I didn’t want to turn my head and look into the room for fear of what I might see. After a little tugging on my arm, and a few words of encouragement from my father, I entered the room, but didn’t dare venture too far, stopping just past the doorway. As soon as he let loose of my hand, I sunk into the corner, at a maximum distance from my mother’s bed at the opposite end of the rectangular room. I had my head down, and was looking up at her without lifting it — the way that children look when they are interested in something, but trying to disappear from the consciousness of adults.
She’s so skinny… I could see both of the bones in her bruise-covered forearms, even from my distant vantage point. She had a large white gauze bandage wrapped around her head, and beneath her eyes were both swollen — the left one was no more than a slit with a large purple bruise encircling it. Why did she look so bad? Why did she have a black eye!? Did someone hurt her? My heart was racing and I felt like I needed to pee. I wanted to go into the bathroom immediately adjacent to where I was now squatting down, shut the door, close my eyes and forget everything — this day, the thousand days leading up to it, this place, my uncomfortable black slippery shoes — everything. Then, my mother spoke.
Her speech was garbled and slow, and I couldn’t make out anything she said except what sounded like my name, but it wasn’t scary. This was my mother’s voice, a voice that I had only heard in my dreams these last few months. It was the voice that had spoken to me before I was in the world, and had soothed me as an newborn when I didn’t know her as anything other than just that — her voice, when my eyes were still unfocused. In her arms, during countless feedings and diaper changes… when I cried, when I was happy, when I was sleeping… I heard this voice. I heard her as only a son can hear the voice of his mother — not changing over time despite age or illness. A rhythm, a cadence, a tone, a certain inflection, or even a wavelength perhaps that the genes she passed to me allowed me to hear differently from all others.
She was okay.
I stood up from my crouching position and looked her way, but I wasn’t about to move. I opened my mouth a little, to speak, but nothing came out.
The room’s door then suddenly swung open next to me and a thin, tall well-groomed man in a dark suit walked past and into the room, without noticing me. He had short “slicked back” dark brown hair and sharp features, and was followed into the room by a couple of other men, who looked younger. I didn’t know it at that moment, but this was Dr. Sharkey, a nationally-respected neurosurgeon who had removed the huge tumor from my mother’s brain. He shook my father’s hand vigorously, hugged him, and walked over to my mother’s bed. I heard him say her name, and put his hand gently on hers. He was speaking quietly and slowly to her, but I couldn’t make out what he was saying. As they finished up their conversation, he and my mother both chuckled, and then without warning he spun around and looked right at me.
“And… who do we have here?”, he asked.
I just stared back at him. I was now a statue.
“You must be Roy… I’ve heard an awful lot about you young man”, he offered.
I didn’t respond.
My father leaned in close to the doctor’s ear and whispered something.
The doctor then tried again, “your mother sure has missed you, and she is doing just fine… just fine. She has talked about you non-stop, and I see why now. Why don’t you come over here and say hello?”
The impulse to go in the bathroom and shut the door returned, and I now considered the option of just running out of the room into the hallway. He hesitated for a moment longer, turned and said goodbye to my parents, and then moved toward me. I shut my eyes. I heard his footsteps stop right in front of me. He stood there for several seconds, and then leaned over and spoke to me — almost in a whisper.
“Roy, how would you like to take a tour of the hospital… you know, see the operating rooms and the radiation area where your mother was treated… some neat medical equipment, that sort of stuff?”
He stood back up and told the others that had accompanied him that he would catch up with them later, after giving them what sounded like instructions. The words and phrases sounded foreign and exotic — not the same language I spoke, but one that I curiously wanted to understand. I heard his footsteps pass by me, and he patted me on the shoulder as he walked by. I opened my eyes and turned my head to see him standing just outside the doorway, beckoning me to follow, and to my own amazement — I did. I looked back at my father expectantly. He smiled and waved me on.
The next hour was an exhilarating blur. Dr. Sharkey put his hand gently on the back of my head, and we walked back down the hall to the elevators. We got out at the main hospital lobby, where he showed me an ancient medical instrument display. It housed a large collection of rusted and somewhat garish-looking knives, drills, saws and other instruments from Surgery’s past. One of the drills looked like it had a large hollow circular bit on it, and Dr. Sharkey told me that it was a “trephine” — an instrument that neurosurgeons in previous times would use to do brain surgery. He assured me, however, that nothing like it had been used on my mother, and that it was old and outdated approach. I got “butterflies” in my stomach as I peered down at it, and contemplated the circular hole that it must have made in people’s skulls that were like my mother in the past, but I was still fascinated.
He then took me the “radiation suite”, where he showed me a big metallic, very complex-looking machine in the center of the large room. It was painted a pretty pastel green color, with a large arm suspended out from it and over a stretcher. It looked like something that I might see inside of a spaceship at the movies, but I thought it was beautiful. He told me that this was the “cobalt machine” where my mother would receive “X-ray therapy” to “kill any of the cancer that might still be in her brain”. He added that, “We don’t think there is very much there, we just want to be careful”, and reassured me that this sort of treatment “didn’t hurt”. That didn’t make sense to me, but I believed him.
Finally, he took me up another elevator and to the operating room area, where as we approached, a large double metallic and glass door opened automatically — “CLICK! — WHOOSH!”. We stopped just inside where could peer across the hall and into one of the operating rooms. There were a lot of big shiny metal machines scattered about, and a bed in the middle of the room. It looked very complicated, but once again — fascinating. I thought of a million questions to ask, but I was much too shy to do so. My head was spinning by the time he deposited me back at my mother’s room. I felt giddy, and brave.
“You were gone a long time… did you have fun?” my father inquired.
I turned to see Dr. Sharkey give him an “okay” sign, wave at me, and then leave. I then walked right up to the edge of my mother’s bed, and hugged her neck, hard. I stood up and recounted in mind-numbing detail all the things I had seen with Dr. Sharkey, my speech rapid, and pressured. I could barely get the words out fast enough. My mother was smiling with tears in her eyes, holding my hand the entire time as I spoke.
My father laughed at my manic recounting, and asked, “so what did you think about all of that, buddy?” I replied, with no hesitation while looking at my mother and grinning broadly, “Mommy…, Daddy…, I’m going to be a doctor”.
§§§§§§
The professor moved through the last names of the forty or so students in the classroom, and finally reached the S’s. I stopped daydreaming for a minute and tuned him in.
“Sable, Tom”, he inquired.
“Here”, someone behind me replied.
“Sanchez, Tracy?”
“Here”.
“Sessions, Michael?”
“Right here”.
“Sharkey, Paul”.
“Yo!”…
My head snapped reflexively to my left from where the last student had responded, and I scanned the faces, locating the most likely one. Sharkey? Paul Sharkey? Are you kidding me? I must have heard it wrong. How common could the last name Sharkey be? How common could the name Paul Sharkey be?
My mother’s neurosurgeon from thirteen years earlier was named Paul Sharkey, the man who took me on a tour of the hospital, and who had as a result had sparked an interest in medicine. I now sat in an advanced biology class as a college sophomore pre-med student.
What are the chances that this Paul Sharkey is not his son, or at least a relative? I stared over at him.
“Smythe, William?”
“Smythe, William?”
“Hello? is Smythe, William here?
“Last call, William Smythe?”
“Oh”, I answered, my face suddenly feeling hot, “sorry… here!”
I tried, but didn’t hear most of that first day’s lecture. At the end of class, as everyone was filing out, I meandered between desks and approached the person that had answered to “Sharkey, Paul”. He looked athletic, and was wearing a baggy soccer shirt and shorts. He had long blond hair and scruffy goatee. He didn’t look at all like my memory of my mother’s neurosurgeon — I remembered him having dark hair, and looking much more conservative. The likelihood that it was a weird coincidence seemed increasingly likely.
“Are you Paul Sharkey?”, I asked.
“Yeah,” he replied, “and you?”.
“I’m Roy Smythe” I answered, “where you from?”
“Houston,” he replied, “all my life, man…”.
“Hey,” I asked nervously, “I know it might seem weird for me to ask, but is your Dad a doctor?”
“Yeah, he’s a doc… in Houston… how would you know that, man?” he asked smiling and now curious.
“Is he a neurosurgeon?” I asked.
“Yeah!”, he answered, “you’re freaking me out a little…”
I went on to explain that his father had operated on my mother, and that I had fond memories of him. I didn’t go into detail about the hospital tour, or his impact on me, as it wasn’t the sort of things that guys in college talk about.
We were now approaching the lobby of the science building. The late summer sun was streaming through the two story glass windows that made up the front of the edifice, on either side of the front doors leading outside. We stopped momentarily, reacting to the bright light. Paul put his hand on his brow and shaded his eyes, looking at me as I squinted.
“Well… guess I’ll see you around, man, “ he offered.
I hesitated before answering… “yeah… yeah, that’s great. Say, can I ask you one more question?”
“Sure.”
“Are you a sophomore?”
“Yeah.”
“Are you like, nineteen?”
“Yeah…”
I stood and squinted at him for several seconds, without saying anything. I felt the corners of my mouth moving upward into a subtle smile.
After a few moments, he became noticeably uncomfortable… “Are you… are you okay, man?”
“Yeah… yeah… great… I’m fine, sorry… something just made a sense to me for the first time, something that happened a long time ago.”
He looked a little confused, but not agitated, and nodded his head, “okay… okay… that’s cool…”
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We shook hands, and walked outside. I stopped after a few steps. and watched him trail away on the sidewalk toward the library building, his long blonde hair and backpack bouncing off his shoulders with each step. I closed my eyes and thought back to the moment when his father, a busy neurosurgeon had stood over me whispering… asking me if I wanted to tour the hospital.
I laughed to myself… we’re the same age… we were the same age…
§§§§§§
My plane bumped to a stop on the tarmac at the gate in Houston. I had traveled there to attend a national surgical meeting where I had been asked to present some of the research work I had done at the University of Pennsylvania medical school, where I was a surgical trainee. It was my first time in several years that I had traveled back to Texas, where I had graduated from medical school, so even though I was tired, I was excited. I had come in on a late flight and a rainstorm had forced the pilot to circle the airport, as best as I could tell, at least twenty times before finally landing.
I flagged down a taxi, and around midnight, made it to my hotel — situated right in the middle of the Texas Medical Center. I unpacked, and I sat down at the little desk and looked at the tiny drops of water beading up on the window in my room, remnants of the tropical Houston storm that had passed through. The droplets looked like little Christmas lights, reflecting the red light from an emergency room sign across the street, and the whites, blues and greens emblazoned on plastic and neon signs beaming up from the innumerable hospital and medical school buildings scattered up and down Fannin Boulevard. It reminded me of a rainstorm I had experienced here more than twenty-five years earlier — on this same street.
I got ready for bed and crawled under the sheets, but wasn’t sleepy. My mind wandered… I thought about my childhood, my mother’s illness, and her many stays in the hospital where her brain tumor was removed, the Methodist Hospital, which I could also see from my hotel window. Dr. Sharkey’s office had been nearby as well, in a building located in the same block and on the same side of the street as my hotel. I closed my eyes and remembered clearly our first clinic visit back after my mother had finally been released from the hospital. I remembered Dr. Sharkey’s office as being somewhat palatial, or at least it appeared that way to a seven year old boy from a small town — red leather chairs, a big walnut desk, stained wood dark paneling on the walls, ornate built-in shelves lined with books and plaques, dark green plush shag carpet, and beautiful paintings. His looked like a movie star — dark hair slicked back and parted on one side, always wearing well tailored dark suit when not in his white coat, and sporting a wide, loud 1960’s print tie. I think I remembered that particular visit and so many of the details involved due to the fact that he had told my parents and I while we were there that he would be soon taking his family on vacation — the idea of that terrified me.
Although I had only been paying partial attention, I stopped daydreaming and listened intently as he began to talk about being out of the country. I stopped swinging my legs in the fancy chair I was sitting in adjacent to his desk, and inched forward to the edge of the cushioned seat.
“We have a house in South America,” he said, “and we go there each summer for an entire month. I will be turning my practice over to my partner while I’m gone, because I will not be able to be reached when I’m there. We are without telephone or any other means of communication except mail when we are down there.”
What? I panicked. I thought to myself, worriedly — what does he mean he can’t be reached? What if there’s a problem? What if my mommy needs him? What if she gets sick? No one else knows how to do this to my mommy! WHAT IF THE BIG SCAR ON HER HEAD OPENS, AND SOMETHING COMES OUT? To my parent’s and Dr. Sharkey’s surprise, I jumped up, and screamed, “NO!” , and then threw myself face-down on the soft green carpet, sobbing.
I lay in bed, now almost in twilight sleep as the day’s travel-tightened tension-spring gradually relaxed. Wonder how old Dr. Sharkey actually was back then.., at the time of my mother’s operation? It was hard to tell. His son was the same age as me, I knew that, but was Dr. Sharkey about the same age as my Dad? If he was, it would make him only sixty or so, but I remembered that he looked a little older, maybe a lot older… He could have been ten or more years older than my parents, how could I know? That would make him seventy. Was he still practicing? Surely not. Was he still in the medical center? I shook off the first stage of sleep, sat up on the edge of the bed and turned on the nightstand lamp. A Houston phone book, seven or eight inches thick, was in the drawer under the phone. I grabbed the white pages and turned to the seemingly million S’s — no luck. I put it down on the bed and grabbed the yellow pages. There were the same number of pages of doctors under “physicians, medical and surgical” that would encompass all of the businesses for a medium sized city. Again, no luck. Had he died, or retired? Even though it was one in the morning, I knew from personal expreience one other place to check, so I picked up the phone and dialed the main number for the Methodist Hospital.
The operator answered cheerily, “Methodist”, as if it were ten in the morning.
“Yes,” I said, “can I have the page operator?”.
“Sure, connecting sir.”
After a few rings, an answer, “page operator, Methodist Hospital.”
“This is Dr. Smythe,” I said, knowing that she would not know whether or not I was on staff there, or on the planet Mars, but that she would likely respond favorably if I said it with confidence.
“Yes doctor, what can I do for you?” she asked.
“Can you page Dr. Paul Sharkey of neurosurgery for me?” I asked, again as if I had spoken with him the day before, perhaps outside a patient’s room, or at the scrub sink before a case with which I would be assisting.
She replied, “One moment please”, and a few seconds later, “I’m sorry doctor, we don’t have a pager for him, but I do have an office number. Dr. Sharkey doesn’t take call for the neurosurgery group anymore, but he still has an office listing. Do you need me to page the resident on call for neurosurgery for you, doctor?”
“No, that will be fine, but thanks”, I said, “say, would you mind giving me that office number? I need to speak to him about an old patient of his tomorrow if possible”.
After the my research presentation was over the next morning, I walked down to the lobby of the hotel and asked the concierge if I could make a call to the nearby outpatient clinic building, where Dr. Sharkey’s office was located. I dialed the number and a woman answered, who told me she would be happy to arrange for me to meet with Dr. Sharkey at about three that afternoon if I would be available at that time. I agreed, and went up to my room and packed up. At a little before three, I walked down Fannin and entered the front door of the building where many of the Baylor College of Medicine faculty offices and outpatient clinics were located.
An elevator took me to the fifth floor, and I walked down to a doorway that had a sign stating “Baylor College of Medicine Department of Neurosurgery” offices. The waiting area was very nice, not quite as ostentatious as I remembered Dr. Sharkey’s office to be in the 1960’s, but medicine had changed a bit since then. Patients were now usually seen in non-descript clinic rooms, rather than personal offices. I could see down a hallway to the left of the reception desk; however, and into what must have been one of the faculty member’s offices — fairly spacious, dark furniture, plaques on the wall, and other decorative items. Again, this wasn’t as nice as I remembered, but attractive, and opulent compared to the “academic” offices at Penn where I was training — those were little more than closets with desks in them.
“I’m here to see Dr. Sharkey,” I said to the receptionist, “I have an appointment”.
She looked up from her work, and smiled, but somewhat quizzically. “Dr. Sharkey?”, she asked, a little incredulous, but trying to be tactful, “are you, ah, a patient?”
“No,” I said, “I’m just an old friend”.
“Okay,” she laughed, “I’m really sorry, but he doesn’t see patients anymore, well, I guess with the exception of some much older folks that he operated on years ago, and he gets few other visitors. C’mon, then, follow me.”
She opened a door to the area behind her desk, and walked into what looked like a back office area for assistants and clerical staff — filled with copy machines and filing cabinets. The floor was covered in scuffed ceramic tile, and the overhead lights were fluorescent and harsh. We walked past a couple of women who were talking and putting patient charts together at a paper-strewn desk, and a young girl putting files away in a large filing cabinet. In the very back corner of this large, crowded and somewhat dingy work area was a small metal desk, and behind it was a old man in a flannel shirt with white unkempt hair, and a bushy white beard.
I whispered to the receptionist, and asked, “are we going to see Dr. Sharkey?”
The look of incredulity returned to her face, “I thought you were an old friend. That is Dr. Sharkey, she whispered, “ right over there behind that desk — Dr. Paul Sharkey.”
“Oh.., okay… I just, uh, haven’t seen him for a while.”
We walked up, but he didn’t notice us approaching. His he was bent over reading, his nose about an inch from the pages of a medical journal. I stopped for a moment and looked around. It was disheartening. He had been completely marginalized. No office, no secretary, just a little unadorned corner in the filing area in a dented metal desk.
“Dr. Sharkey, you have a visitor,” the receptionist announced, a little louder than I thought necessary — maybe he was hard of hearing?
He put the journal down slowly, and stood up, a little stooped. Our eyes met, and I recognized him. It was him. They were the same eyes I had looked up and into as a child.
The receptionist walked away, and we were left alone. He smiled, and offered me a seat on a folding metal chair.
“Please,” he said, “please, please… have a seat.”
I sat down, trying not to stare at his face.
“What can I do for you, young man?”
I hesitated, not really knowing where to start. Where should I start? “Dr. Sharkey, you probably don’t remember any of this, but my mother was one of your patients, a long time ago.”
“Yes!”, he said, smiling and shaking his head in an exaggerated fashion, “am sure that’s true, yes, yes.”
Had he gone mad? He looked a little like a caricature of a mad professor. Surely they wouldn’t want him around if so… here amidst the secretaries, so close to the patients coming in and out, and bothering the busy neurosurgeons…
“My name is Roy Smythe,” I said, “and…”
Before I could complete the sentence, he interrupted, “Peggy! Peggy, my sweet, sweet Peggy. Was Peggy Smythe your mother?”
“Yes, yes… she was,” I replied, surprised.
He sat back in his chair and looked up at the ceiling, rubbed his beard pensively, and shook his head. “Peggy, Peggy… she was a redhead… yes… and a painter, right? “ He looked back down at me, “she painted several things for me, I kept one in my office, when I had a real office, you know… for quite some time… yes… Peggy, I remember her very, very well. I remember your father too, nice man, very kind and easy to deal with even though it was a tough business, your mom’s case. He loved her very, very much… very dedicated, unusually dedicated. Yes, yes.., wonderful to remember… wonderful. Now, what brings you to see me young man, what brings you to see me after all of these years? I’m obviously not still operating, and barely hanging on here.” He chuckled nervously, and I thought he suddenly looked sad.
I hesitated… How do I tell him what I desperately want to say. What is it, exactly, that I want to say? I decided to just start, and see where it went.
“Dr. Sharkey, you first operated on my mother when I was six years old, twenty seven years ago. I know you don’t remember this, but the first time I came to see her, after her first major operation, you spoke to me…. you actually took the time to take me on a tour of the hospital.”
“Really?” he said, smiling again, “that’s great, eh?”
“Well,” I continued, “it is a bigger deal to me than you might realize.”
I told him about my attending medical school, and training in surgery at Penn. I spoke about the genetic research I had been engaged in, and the academic accomplishments I had worked for and had been fortunate enough to achieve along the way — trying not to sound too proud, but just wanting very badly to share with him how well I had done, how motivated I had been to work so hard, and how much I still planned to do.
“Fantastic,” he gushed, “just fantastic. Say, as a matter of fact, you must be about the same age as my son, he went to medical school too, you know”. I told him that Paul and I had gone to Baylor together.
“Amazing,” he said, “simply amazing. You have got to be kidding me… small world, eh, really small world!” He laughed, “your father must be very proud of you, like I am of my son.” I didn’t bother to tell him about my father’s premature death just a year following my mother’s, when I was eighteen — it wasn’t material … I also felt that I had been here long enough without actually getting around to the reason for the visit — I needed to tell him… I wanted him to know, even if it didn’t mean anything to him — it was important to me
“I wanted to tell you something, and I hope that you don’t think it is strange or disingenuous,” I said. I was nervous, but the compulsion to finish what I had literally dreamed up the night before was killing me.
“I’m not sure, but it seems to me that children exposed to serious illness take one of two paths. Ninety-five percent of them are suspicious and avoidant of all things medical, and the other five percent, or maybe a lot less… maybe they’re attracted to it.”
He rubbed his beard again, a serious expression on his face, “yes… I could agree with that, sounds logical…”
“When I was six years old, you took the time on a particular day — the first time I had been to see my mother after her operation — to give me a tour of the hospital. You took the time to try to diminish a terribly scared little boy’s fears. I decided on that day, and because of your gesture, that I wanted to be a physician, and I never changed my mind. All I have accomplished up to now, and all that I might do in the future is because of you, and your kindness to me on that one day. I came today to thank you, to thank you for all of it. You are, in fact, the reason I’m a physician, and I feel as if I can’t thank you enough for that. For allowing me this privilege… to do what I love to do.”
He looked at me intently, as if confused at first, and then put his head down on his hands, on the little Steelcase desk, and wept, quietly. I cried a little as well, rubbing my eyes with the back of my hand and chuckling.
After a few moments, he raised up his head, still smiling, beaming, his cheeks moist with tears, and red with emotion, in sharp contrast to his white beard.
“Thank you so very much, so much,” he raised his hand in a sweeping gesture as if to show me the space he now inhabited compared to where he had been in the past, where he knew I knew he had been in the past… a famous surgeon, now banished to the copy room. His lower lip trembled, and for a moment he fell silent, looking down at the marred desktop, his palms down on the surface. I looked down at his hands, the same hands that had given my mother ten more years of life… the hands that had gven me a mother for ten more years… The knuckles were enlarged and misshapen with age.
He wiped his eyes with the back of one of those hands, and said, sighing… “you just never know, do you? You just never know, Dr. Smythe… you just never… do… know…”
He put his head back, and from somewhere down deep inside, laughed heartily, and for so long and so loudly that of the secretaries milling around stopped what they were doing in that dingy little space, and stared at us. I laughed as well.
I dedicate this true story to the memory of Dr. Paul Sharkey, and to all of physicians who have given small children more time with their mothers and fathers — precious gifts of immeasurable value.
Copyright @2012 by William Roy Smythe. All Rights Reserved
This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
This article describes the trepan technique for treating single segment ossification of the ligamentum flavum (OLF) using an endoscope. OLF is the most common cause of thoracic spinal stenosis. The most common surgical procedures involve semi‐lamina or full‐lamina resection and decompression. However, considering the anatomical structure of the thoracic spinal canal and the combination of OLF, traditional surgery has higher risks, more complications, and greater technical requirements. In the past ten years, with the development of endoscopic technology, spinal endoscopy has been increasingly applied for the treatment of intervertebral disc herniation and spinal canal stenosis. The present study demonstrated the effectiveness of visual trepan decompression under spinal endoscopy used for patients with single segment OLF. This surgical procedure had many advantages, including a shorter operation time, minimal trauma, less expenditure, and better functional recovery over the conventional open surgery.
In the past ten years, with the development of endoscopic technology, spinal endoscopy has been increasingly applied for the treatment of intervertebral disc herniation and spinal canal stenosis 4 , 5 . However, few reports have focused on using spinal endoscopy for thoracic vertebra OLF. The present study discusses the clinical efficacy of visual trepan decompression under spinal endoscopy for patients with single segment OLF. We describe the procedure of this operation in a typical case and introduce the specific use of visual trepan. In this case, we examined the safety and efficacy of this operation. We observed and compared the sensation, muscle strength, Japanese Orthopaedic Association (JOA) scores, and visual analogue scale (VAS) scores preoperation, during operation, 1‐month postoperation, and 6 months post‐operation. The operation time, time in bed, blood loss, complications, symptom relief, and postoperative neurological and functional recovery were also recorded. This study evaluates the application value of this new surgical method, and provides a reference for treatment choices for single segment OLF.
Ossification of the ligamentum flavum (OLF) is the most common cause of thoracic spinal stenosis 1 . Considering its complicated and atypical clinical manifestation, patients may delay treatment due to misdiagnosis, resulting in irreversible spinal cord damage and nervous lesions. At present, the thoracic posterior wall resection and decompression method is the main approach used to treat single segment OLF. The most common surgical procedures involve semi‐lamina or full‐lamina resection and decompression and have an excellent therapeutic effect 2 , 3 . However, considering the anatomical structure of the thoracic spinal canal (narrow lumen and limited spinal cord buffer space) and the combination of OLF, the thoracic spinal canal is even narrower. Any instrument in the vertebral canal is likely to cause dura mater tears and intraoperative neurovascular injury, leading to obvious dysfunction. As a result, traditional surgery has higher risks, more complications, and greater technical requirements.
Here, 15 mL lidocaine, 10 mL ropivacaine, and 20 mL normal saline mixture was used to perform infiltration anesthesia through the skin, subcutaneous tissue, and muscle layer at the entry point of the T 9 vertebral plate. The skin was cut to a length of 0.6 cm, and then the puncture needle was used to fix it to the T 10 vertebral plate. The dilating catheter was installed step by step and a protective case was installed, after which all catheters were removed. The micro‐endoscope was installed and the radio‐frequency electrode was used to clean soft tissue; the superior and inferior T 10 vertebra plate, the spinous processes of the lamina migrate, and the T 10,11 zygapophyseal joint were visible (Figs , , ). After the first trepan was slowly rotated into the sclerostin from upper third of the T11 hypozygal medial border vertebral plate (head inclination of 30° and backward inclination of 40°). The sclerostin showed a slight sense of loosening during the rotation of the trepanl. The right hand lightly broke the sclerostin using the trepan, and then lightly rotated the trepan to remove the bone block. Meanwhile, myodynamia changes of patients were investigated. After electrode hemostasis, the surgeon exposed part of the dural sac and the medial margin of the superior articular process of the contralateral T 11 . The annular tube, was moved to the same side, revealing a T 10 inferior articular process. The second trepan was inserted in the superior part of the inferior articular process of T 10 on the same side. Medial sclerostin of the inferior articular process was gently removed (1/3 horizon space was reserved in the trephine). The superior border of the spinous process on the T 10 vertebral plate was exposed. The third trepan gently removed the spinous process basilar part and the inner plate of the contralateral vertebral plate from the upper T 10 spinous process and vertebral plate (tail inclination approximately 10° and back inclination approximately 30°). At least 1/3 of the horizon space was reserved in the trepan. After taking out the bone block, the dural sac, the contralateral T 10 pedicle, and the superior articular process were exposed. Finally, the annular tube was moved to the same side to expose the lower inferior articular process of the T 10 on the same side. The lower inner margin sclerostin of the inferior articular process and the superior articular process inner margin sclerostin on the T 11 were removed. The dural sac was explored to reveal the ideal range for the laminectomy decompression. The power system and vertebral plate rongeur under the endoscope were used to remove residual sclerostin in the inner margin of the superior and inferior articular process, sclerostin of the lower basilar part of the T 10 spinous process, and the upper margin sclerostin of the T 11 vertebral plate (Figs , ). The ideal decompression range for up and down and both sides of the vertebral canal was explored. The dural sac was loose and had no pressure. Pulsation of endorhachis was good. There was no active bleeding in the vertebral canal. Finally, the incision was closed. The operation time was 160 min and the blood loss was 20 mL.
The surgery was performed in a prone position. G‐arm positioning marked the posterior midline of the spinous process and the T 10, 11 intervertebral space horizontal line (Fig. ). The insertion point marker was located at the left posterior midline, approximately 3 cm away from the left midline, with the head tilted by approximately 30°.
A 48‐year‐old male patient presented with numbness and weakness in both lower limbs for 20 days; he had experienced difficulty standing up and walking independently. Physical examination revealed tenderness in the chest and back; numbness of the skin occurred when acupuncture was applied below the left inguinal plane; hypoesthesia was observed when needling the skin in the saddle area. Muscle strength of lower limbs was grade III, and the patient had high muscle tension. Muscle strength of left and right femoral quadriceps muscle was grade III and grade IV, respectively (Table ). The tendon reflexes of bilateral biceps and triceps humerus are normal. Ankle clonus and patellar clonus were positive, and the pathological reflex Babinski sign was positive. Thoracic CT and MRI suggested that the yellow ligament of the T 10, 11 was thickened and calcified, and the spinal canal was severely narrowed in the corresponding plane (Fig. ). Diagnosis on admission of this patient was T 10, 11 segmental thoracic OLF. The operative method was thoracic canal enlargement and decompression by using visual trepan under an endoscope (Fig. ).
The visual analogue scale (VAS) score was 5 and the Japanese Orthopaedic Association (JOA) score was 6 before the operation; 1 month after surgery, the VAS score was 2 and the JOA score was 11, and the muscle strength of both lower limbs was grade IV and the numbness was significantly reduced. The area of the spinal canal was 10% before the operation and nearly 100% after the operation. When the patients were followed up at 6 months after the operation, the sensation of both lower limbs had returned to normal, and the muscle strength of both lower limbs was grade IV+; the VAS score was 0 and the JOA score was 14 (Table ).
Postoperatively, mannitol, and hexadecadrol were used for 2–3 days. Antibiotics were used for infection prevention for 1–2 days. Meanwhile, analgesia and trophic nerve drugs were given as symptomatic treatment. The patient was bedridden for 1 day after the operation without complications, and moved with a brace on the second day after surgery.
Ossification of the ligamentum flavum is the primary cause of thoracic stenosis. For concealed onset and the slow development of illness, it is often ignored, meaning that it causes oppression of the nerve and spinal cord. Therefore, spinal cord blood is reduced, resulting in irreversible damage. Patients often show numbness of the lower limbs, paresthesia, and dysbasia. The thorax and abdomen have zonesthesia, and quality of life is affected. When there is a spinal cord injury, surgery is the only therapeutic option; thus, it is extremely important to diagnose and cure OLF in a timely manner.
It is difficult to achieve favorable results through conservative treatment. Operative decompression is the only effective means of treatment before irreversible damage. Posterior full‐lamina or semi‐lamina decompression is the traditional operative method for the treatment of OLF. Multiple studies have demonstrated that thoracic vertebra wall excision is the safest and most effective operative method to cure thoracic vertebra OLF6, 7, 8, 9. Wang et al.7 used the en bloc surgical method centrum posterior column to cure 18 OLF patients. It was found that after the operation, patients showed good neural functional recovery, but the amount of bleeding was greater, with an average of 691.1 ± 443.3 mL. Leakage of cerebrospinal fluid is the most common complication. Park et al.8 used vertebral plate decompression to cure 8 OLF patients. The JOA score before the operation was less than 5, but after the operation, it was improved by between 3 and 10. Back pain, zonesthesia, and paresthesia of the lower limbs were relieved to varying degrees. However, the operative procedure was needed to excise the vertebral plate and zygopophysis, peel off paravertebral muscle, excise the posterior column structure, and totally expose the intraspinal structure; thus, muscle injury risks were increased. Meanwhile, the operative incision was large, which could easily lead to poor spinal stability and induce a series of complications, including incision pain, myasthenia, and incision infection. Moreover, after removing the protective structure from the back of the nerve, the nerve and dura mater would be disturbed by the surrounding scar tissue, resulting in iatrogenic stenosis or postoperative chronic back pain. In addition, postoperative myasthenia and amyotrophy caused by paravertebral muscle might result in chronic back pain.
The question remains: How can the maximum operation result be gained with the minimum trauma? With the in‐depth knowledge of anatomical structure attained and the development of endoscopy, minimally invasive spinal surgery emerged at the right moment. Particularly in recent years, studies on various minimally invasive technologies have been published successively. From the traditional micro endo disc system (MED) to an intervertebral aperture mirror, and from minimally invasive spine surgery‐transforaminal lumbar interbody fusion (MISS‐TLIF) to extreme lateral interbody fusion (XLIF)/oblique lumbar interbody fusion (OLIF), various diseases requiring spinal surgery have been covered. On the basis of a preliminary study, on the philosophy of endoscope surgery, the traditional open operative steps can be completed under endoscopy to reduce operative difficulty. In this study, the combined work channel of the endoscope was used to remove OLF under an endoscope without peeling off or excising the paravertebral muscle. The work channel, with a diameter of 8.4 mm, could directly situate in the vertebral plate to protect the nervus vascularis and reduce bleeding. In addition, the 7.5‐mm visual trepan was used to replace the traditional vertebral plate rongeur, to reduce intrusion for the narrow intraspinal structure, and to effectively prevent dura mater tearing and intraoperative neurovascular injury. Other advantages include the clear surgical field, less bleeding, and fewer complications. At present, few studies in the literature have reported on the treatment of thoracic vertebra OLF under full endoscopy. Chen9 used percutaneous microchannel microscopic surgery to cure 68 patients with focal OLF. After surgery, the improvement in the JOA score was obvious. Recovery rates were good (up to 97.06%). The improvement rate was also increased, up to 90.86%. The procedure was performed by visual trepan under endoscopy (Fig. ). At the 6‐month follow‐up, the JOA was obviously increased. In addition, spinal cord function was improved to some degree. Patient function recovered considerably (Table ). Moreover, there were no relevant complications.
Relevant biomechanics and clinical studies have demonstrated that when the vertebral plate or zygopophysis incision is less than 50%, the stability of the spinal segment is not affected10, 11. Our finite element analysis (not yet published) also proves that using trepan decompression under endoscopy (four‐trepan) does not result in any obvious instability of the spine. In our opinion, this technology can be used for thoracic vertebra OLF and OPLL.
The spinous process and laminar junction were drilled to the contralateral articular process
The vertebral plate and inner margin of the inferior articular process were drilled on the same side.
The residual spinous process on the same side and the laminar junction to contralateral zygapophyses were drilled
The residual vertebral plate was drilled on the same side
Visual trepan provides a new surgical method to treat OLF under an endoscope.
The visual trepan technique is feasable and is superiority in treating single segment OLF.
Visual trepan decompression has the advantages of less trauma, faster recovery, and less expenditure.
For more information, please visit visual trephines.