No Ifs, Ands or Buts 

The  Craniotomy

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When they roused me at 5:00 a.m. they asked me if I had eaten anything or drunk water. It didn’t make any sense. How could I eat or drink when I was sound asleep? I dutifully went to the bathroom to shower with the red soap, which didn’t lather up very well and had the effect of drying out the skin when I rubbed it in. The more I rubbed, the more the moisture was sucked out of my pores by the red soap. By the time I toweled off and popped the seal on the freshly sanitized hospital gown I was starting to feel nervous about what was going to happen in the long hours I’d be laid out on the operating table. Just a little jittery, trying over and over again to tie the gown behind my back. Brain mapping, they said. I’d have to be awake for the first part of it.

A large blonde nurse was waiting for me by the bed with a syringe. I asked what was in it and she said, “Your insulin, of course. Thirteen units.”

“What? Do you mean thirteen units of regular insulin on an empty stomach? I’ve never taken thirteen units at once, not even before a big meal when my blood sugar was sky high!” My right hand fluttered and started to feel numb. “I’ll be fasting during the operation and if you give me that much insulin now it’ll kill me!”

She gave a knowing smile as if I was a little boy refusing to swallow my cough medicine. “It’s on the chart, honey. Dr. Ringgold wrote thirteen units pre-op, and he knows all about your condition.”

I bent over backward to be kind and respectful to the nurses and the hospital staff, partly because my father was on the faculty of this teaching hospital, but more importantly because I wanted to face my fate with dignity and grace. But this was too much. I’d been seen by a half-dozen doctors in the past two days and this Dr. Ringgold was not one of them. He wasn’t the kindly endocrinologist, Dr. Nelson, who went over my diabetes management in detail the day before. I asked to the see the chart and it was as she explained. A lethal dose of insulin.

“Put the Goddamned needle away,” I barked. “I’m not going to let you put me into a coma on the operating table.”

“Now calm down, please,” she said, changing the tone of her voice to stern authority. “You’ve got to take it. It’s on your chart.”

I got up and walked out of the room to the nursing station and asked to see the attending physician on the ward. In my most arrogant and outraged foreign correspondent’s voice I demanded he get my neurosurgeon on the phone. It was an effective outburst. He connected me to the resident on duty, who said she wasn’t sure what was on my chart but it was hospital rules that you don’t overturn an intern’s order. “What! An intern? You’re going to let a fucking intern kill me so he can learn from his mistakes!” The conversation that followed was not pleasant, but she finally agreed to patch me through to my four-star neurosurgeon who phoned my father and the endocrinologist, and we brokered a deal. They agreed to give me a basal drip of insulin through an IV and monitor my blood sugar continuously through the operation, and I, in turn, would calm down.

I couldn’t believe that I had to jump in and save my own life in an institution that was supposed to heal me. But in eleven years as a diabetic I had learned the hard way to take responsibility for my own health, aggressively if need be. And this Doctor Doogie had taken the Hippocratic Oath that says first, you idiot, do no harm. I was ready to strangle the young man with tufts of his blond hair when he came to my bedside to re-examine the chart, which had been changed moments earlier by the resident. Poor fellow, he had to endure the shame of being overruled by a patient. He left the room, sheepishly, without looking at me or saying a word.

The operation had to be delayed an hour because of my little rebellion, but I was relaxed and ready when they strapped me securely and taped down my head to keep it steady for the saw. I can’t recall what the anesthesiologist said he was giving me, but it did exactly what he said it would do: ßNumb my entire body to kill the pain but keep me awake and alert to allow me to hear and speak. I was vaguely aware of what they were doing back there when they sliced open the sheath of skin and muscle covering the bone and peeled it back. It was the most amazing sensation when they started drilling into my head to make four holes where they could insert the router to cut through the skull, stopping precisely at the surface of my brain. I heard the blurry sound of power tools and felt the reverberation of saw on bone that went on for eternity as they carved out a square hatch over the left parietal lobe. It was amusing, not frightening. “Are you all right, Billy? Roger? Is your name Gus? What was your name?” the neurosurgeon said. “Very funny,” I replied. “My name is Barlow, Raul Barlow, I take my martinis shaken, not stirred.”

Then we played the game of Where’s the Tumor? Whack-a-mole with electrodes. It was all mapped out on the computer and now they were going to map it on the brain itself, probing with electrical stimuli while asking me questions and listening to my responses to see what circuits fired up and when. I was an experimental dog. They kept asking my date of birth and my home address and I’d answer and then they’d ask me again, probing different places in the left parietal lobe where they suspected the tumor was hiding below. Once in a while I’d try to answer but couldn’t. I thought the answer but my tongue didn’t obey. They’d found a marker. Then they did things that made the fingers on my right hand twitch uncontrollably, then came the backward counting, start at 99 and count backwards, please, and I did so, anxious to please. I’d keep counting and realize my voice didn’t accompany the numbers, and then I’d hear it again, 79. 78. 77, and suddenly it would all melt away into total confusion. I wasn’t sure where I was but I heard a faint murmuring of conspiratorial voices that reassured me that I was still among the living. Then the fog lifted and I was fully conscious again. They said keep counting, please. “Where was I, 61?” They laughed. And while I continued the counting would slow, then speed up, and I’d mumble like a drunk, slide into confusion, come back. They’d found a trigger in my brain with their electrode stingers and were toying with haywire ganglia, tracing a path to the guilty malignant cells.

The last thing I remember was “No ifs, ands or buts.” They asked me to repeat the phrase over and over again until it became a brainteaser, an annoying mantra, tonguing its way in and out of forced articulation.

“Okay, stop.” It was the voice of the neurologist, the one with the moustache that made him look like Kurt Vonnegut. I wondered if he had a surgical mask covering his moustache. Of course he did. “Now resume,” he said. “No ifs, ands or buts,” I’d say, then stop saying, then saying again. It was the strangest conversation I ever had. Then it fell silent, and I knew it was time to start slicing into the tissue where X marked the spot. “You did great, Raul,” I heard the surgeon say. “Are you ready?”

Less than a minute later, it seemed, I returned to consciousness. The room was uncompromisingly white, and there was a machine next to me pumping air in and out of plastic sheaths on my legs, kneading my calves. I tried to say hey, it’s my brain, not my calves that needs the massage. But the words came out as little dry squeaks from the throat. I looked up to see the neurosurgeon beaming a radiant smile, totally out of character, a smile that said, you’re in luck. “I don’t think I’m dead, am I?” He couldn’t hear me, but he answered anyway. “It’s just lymphoma, Raul. We did the biopsy and it’s very good news. Malignant, potentially lethal, but we can beat it. Your prognosis is good. Maybe you’ll meet your grandchildren, assuming you don’t get run over by a car.” He nodded and walked off while I thought of something to say in response. Thank you, or that’s great, or where am I? The cogs of cognition were turning slowly, trapped in medicated gelatin. I felt giddy. I thought about being run over by a car after going to all the trouble of having my brain fixed, and had to laugh.

I soon discovered where I was, not in a whitewashed heaven but in an intensive care unit, and it was the end of the day. where dusk showed itself in the windows, not the bright morning light I’d imagined. They came in groups of two and three, my wife and my two brothers, my parents, a parade of my father’s colleagues, who puzzled over my condition before the operation, all smiling effusively. I wasn’t going to expire anytime soon. It seemed I had my visa to the world stamped and renewed. I could live forever or die tomorrow, but it wouldn’t have to be on account of mutinous killer T-cells in my left parietal lobe.

They say there are about ten billion cells and one hundred billion neurons in a single brain, plenty to waste, and that the generation and regeneration of each brain cell goes back 550 million years – way before Adam and Eve and the apes and the restless fish who decided to crawl on shore and spawn humankind. The first brain cells belonged to flatworms. Whatever is left in my brain can’t be measured or counted, but the odds are I’m going to have to make do with less. I’m not asking for much. I’d still be happy with forty or fifty billion neurons. I’m not greedy. My hematologist told a great story about a patient of hers who had an MRI taken after complaining of headaches, and the scan revealed a very small brain – about twenty percent the size of a normal brain – tucked into a corner of his skull. The rest was salt water. Other than size, it was a healthy and perfectly functional brain. The man went to law school, passed the rigorous California Bar exam and prospered as a high-powered attorney, but he couldn’t accept the fact that he accomplished all this with such a small brain. Size doesn’t matter, the doctor told him, but he was so angry he went off to seek a second opinion and presumably the rest of his missing brain, never to be seen again.



The coroner came up for air. He resumed drinking his forgotten Tecate and noticed the thin man at the bar watching with steely eyes, as though he was prepared to draw a knife and slash his throat if he made the wrong move. Maybe it is about time I should leave, he thought, even I am imagining malice out of my own paranoia. I will read to the end of the notebook and finish this last beer before nodding in respect to the men at the bar and departing this sanctuary, its odors of spices, carnitas and refried beans, and the glow of its quiet light.

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