Anatomy of a dream

Week One:

I was stripping off layers of my brain when the dream returned to me.
I held a brain in my latex-gloved hands. My brain wasn’t covered with blood or gore like I’d imagined it would. It smelled like vinegar, having been picked in formalyn for several weeks after being removed from an undeserving skull. It looked like a Play-doh model of a dinosaur shaped by the pudgy hands and borderless imagination of a three year old. It was gray and lumpy, about the size and weight of a honeydew melon.

I had stripped off the grey cortex of the insula, the island between the temporal and parietal lobes, with a broken popsicle stick. Underneath were the nerve fiber tracts of the internal capsule, which looked like white, damp hemp. These tracts ascended to become the corona radiata, connecting the cortex and subcortical structures. Heaven and earth. Telephones lines between man and God.

Seventy white-coated figures surrounded me, all bent over brains similar to mine. We were in the basement of the medical building, trapped in a room with no windows, lit only by dead florescent lights. The silence of the tomb was broken only by the murmuring of tutoring describing brain structures and the clink of scalpels dropping on steel tables.

It was our first week at the Sackler School of Medicine in Tel Aviv University. We had toiled thousands of hours in eight a.m. physics lectures, foul-smelling chemistry labs and midnight reviews for the MCAT in order to be here. We had made our pilgrimage to the land of the Living Bible to become student-doctors.

It seemed as if the lights dimmed, or moved far away, as my mind drifted back to the dream. The world was empty, quiet and dark. A shape appeared against the backdrop of darkness, a shape of arms and legs and an inhuman head. A bird-man. He was tall, broad in the shoulders, and covered head to toe in robes. He had a long beak like an ibis and enormous cloth eyes. In his hand he carried a staff of wood, thick as a baby’s wrist.

He looked familiar, as if I had seen him somewhere before.

Thus Spake Zarathrustra surged in the background. The powerful concert piece started with three trumpet calls, each ascending higher than the last.

The bird-man raised his staff. The dark world quieted, as if awaiting him to speak. Wisdom radiated from him like an invisible sun. He opened his mouth to enlighten me and his first words were--

“BEEP-BEEP-BEEP!”

The alarm clock had cut him off. Whatever wisdom that he had was denied by eight am Neuroanatomy. I had struggled to awaken, as I now struggled to come back to reality.

“Aren’t you going to identify the arms of the internal capsule?”

Josephina, my lab partner, stood with her hands on her hips looking impatiently at me. Her high-pitched voice brought me back to the lab, back in the world of white and chrome, Greek and Latin, brains and scalpels.

***

Preparing for a career in medicine was a process of neurosurgery. At the University of California at Berkeley, close enough to hear the hum of the cyclotron and the discontented murmurs from the homeless, I learned to slice midsaggitally down my brain. Parts of the tumor called identity were resected, quivering bits of individuality that were discarded in the bin marked BIOHAZARD - BODY PARTS ONLY. Facts were sewn in. The wound was closed with catgut of childhood dreams, of smiling doctors in white coats and nubile nurses and perfect patients.

We were premeds: brilliant, determined, ideological. We were the best of the best, who wanted to save the world, to heal in others what we could not heal in ourselves. Premeds. A word synonymous with competitive, ruthless and anal retentive. We knew that only one out of three of us would be accepted to medical school. We were competing with the sharpest minds in the best Universities. We were competing with each other.

Like our Cell Physiology professor said “If it can’t be measured, it doesn’t exist.”
Medical school applications are quantified at every level: MCAT scores, grade point averages, and extracurricular activities, measured in hours per week. They even have a score for brown-nosing measured by letters of recommendation. You become a number, which is measured against the numbers of your peers. The biggest wins. Size does matter.

The lucky few were priviledged to display themselves in front of admissions committees. Making a central slice down the skull, I pulled away layers of bone, dura, arachnoid, and pia mater, to reveal the gleaming pathology inside me. It is a process of exposing yourself aggressively, even violently, like flashing old ladies on the street wearing only tennis shoes and a trenchcoat.

My scars were approved. I was accepted.

But the biopsy proved that the cancer had spread dangerously. The operating room was ready. Bit by bit, my diseased identity would be cut out. Shiny, perfect facts would be put in its place.

Medical school would begin.

Week Three

We began sectioning the brain in vertical slices to see the structures underneath. In one slice we saw the amygdala, the almond that gives us the ability to fear, and the head of the caudate nucleus, which lets us move without flailing our bodies like disco dancers. The next slice showed us the hippocampus, named after a seahorse, which allows us to store memories, to realize the significance of each moment and know that it was different than the last. Slice: the thalamus, the gateway of the senses. Slice: the corpus collosum, connecting the two hemispheres of creativity and precision.

I knew intellectually that this was a human brain, supposedly the seat of consciousness and the soul, but it was hard to reconcile those lofty ideas with the corpulent structure in front of me. The slices looked like olive loaf or hog’s head cheese, neatly arranged on the side of the tray as if in the butcher’s display window. It was hard to be sentimental about something that looked like lunchmeat. I felt like Frankenstein.

The Chef walked over to examine my work. The Chef was a portly Russian lab assistant who wore a white paper chef’s hat. He didn’t speak much English, but he knew his brains well. According to rumor the Chef had been a famous neurosurgeon in Russia, but had fallen to a lowly anatomy lab technician after immigrating because of his lack of facility with Hebrew.

“Visual signal in one eye, cross over…contralateral side…” he explained in heavily-accented English.

“Through the optic chiasm, right?,” I said.

“Good! Good! Yofi!,” the Chef replied enthusiastically while pointing with a scalpel. I tried to be appreciative of his complements while dodging the brain-stained blade.

The Chef turned back to his brain, “Look here now, optic tracts…”

With the Chef’s guidance, that mundane lump of neural tissue took on magical life once again. Time faded away and space narrowed into a tiny tract of land no bigger than a football, but with all the landmarks and pitfalls of darkest Africa, as we continued our cortical safari. We followed the optic tracts into the back of the thalamus known as the lateral geniculate bodies, into six layers of processing, then through the optic radiation into Meyer’s loop which lead us into the primary visual cortex in the occipital lobe and later to other association areas...

Hours passed. I smudged some brain off of my notebook and yawned. Any subject, no matter how fascinating, loses it’s brillance after two or three hours of intense study. We’d been in class for a total of seven hours that day. Ground brain congealed on my stick. Little bits of brain were spattered here and there. I rubbed my temples. The gyri and sulci were starting to swim around like waves in the ocean. My own brain hurt. I could feel the synaptic connections being severed and resewn, as the experience was starting to mold me.

***

The sun was exploding fire into the Mediterranean sea as I left the Sackler building. The fire spread across the sky, leaving behind the blue newness of dusk. Palm trees swayed in ocean breezes, exotic treeliths warbled, woodpeckers pecked. I took a deep breath, trying to expel the toxins from my lungs. It was a strange transition from the fluorescent lights and fomalyn smell of the Neuroanatomy lab to the beauty of Tel Aviv in late autumn.

Natural beauty was only a part of the scenery. Brice, a brash Canadian that looked more like a hockey player than a medical student, called Israel ‘the land of milk and honeys.’ The white sand beaches beaches and grassy parks were thronged with slim, tanned and scantily-clad Israeli women. Vending machines outside the supermarket rented raunchy porn videos. The sidewalk cafes were lined with hip youngsters in black like Paris or Milan, drinking their espressos and talking politics. The only difference here was that along with cello cases or notebooks, the young Israelis carried M16s and special forces berets.

When I first considered medical school in Israel my main concern was safety. Every time I turned on CNN in the U.S. it seemed there was another terrorist bombing in Israel. The reality is that Israel was perhaps safer than most major U.S. cities. My wife felt comfortable walking alone downtown in the middle of the night. My biggest worry was crazy Israeli drivers.

Week Five

I had my first hospital shift that week, with a smiling British endocrinologist I nicknamed the Surfing Rabbi. Dr. Niven’s fat fingers dropped the insulin pen several times while demonstrating its use, but he knew how it worked. He was gentle with his patients and seemed to care about his work. I admired him and wanted to be like him.
He took us on a tour around the hospital. He showed us the tiny babies in the nursery, no bigger than puppies, grimacing and thrashing their way into life. He showed us the Emergency room, where sluggish patients roamed around waiting to have stitches taken out or children’s fevers checked. Then we encountered our first real patient.

She had sixty-seven years of life in her. She had survived Jewish pogroms, two husbands, had bore three children and eight grandchildren. Now she was as helpless as a child. The oxygen mask helped her to breathe, medications kept her heart rhythm stable, but no one could talk to her. She only spoke Russian.

I felt as helpless and frightened as she. I knew techniques for stabilizing trauma, for bandaging wounds and massaging dying hearts back to life, but I had nothing to ease her pain. I couldn’t even speak Russian. The only thing I could do was to sit next to her and hold her hand.

We are made of blood and spit, shit and piss. Illness can drain a person of everything they recognize about themselves. In the hospital, technicians poke at them with needles, nurses order them around as if they were children, and even their own bodies rebel against them like petulant children. The first treatment the patient needs is not medicine or surgery, but rather dignity and humanity. To realize that grey lump of jello is not jello but is somehow something more.

The bird-man had come to me that night, except that his face was the old lady’s face. Instead of speaking, it sang a lamenting song.

“All that was immortal, inspired, innocent and fresh,
is now chained to Earth by cracked bones and torn flesh.
swollen with agony, gouted with spite.
rocked by the thundering of each heartbeat,
pierced and splintered by each ray of light.
I am no neurochemical engine simple and clean;
no jellied goo of cells and molecules, impulses and streams.
I am the gaunt spirit in the haunted house;
The doomed ghost in the mortal machine.”

I tried to get the song out of my mind but I couldn’t. I kept seeing her face. Her face, with the bird-man’s body.

I was back in lab, staring at the brain again. I rolled it over and over in my hand, identifying various lobules. Instead of looking at tiny sections of brain, I wanted to get the big picture. Holding up the brain, it didn’t seem like much on the outside. The frontal lobe, the seat of higher intellect. The parietal, the sensual lobe that coordinates cognition with experience, occipital lobe, the movie screen in the back of your head which makes sense of electrical signals that come from your eyes. cerebellum, pons, midbrain, medulla.

Was this the sum total of a human being that had lived and died? Was his or her personality still somehow trapped within? Did he or she die young of severe leukemia, or perhaps much later in life of a broken heart?

I started to learn Russian.

Week Seven

Phrenology was a branch of neuroscience quackery from the nineteenth century. Phrenologists believed the brain pushed out on the skull, and therefore careful examination of the skull could determine a person’s personality. For example, if you had two little bumps on top of your skull like horns, they thought you were possessed by evil.

Now we know it’s the other way around, that the skull pushes in on the brain to make the lumps and folds that are unique to each person. Like life. Freud said we only grow by frustration. When we reach the walls of our little reality, we sort of conform to fit them, but each of us comforms in our own way.

Medical school is the skull that crams us all in together under high pressure, and we learn our personalities in relation to each other. Like learning the names of esoteric structures that are all different and yet somehow alike, I have to learn the names and personalities of my fellow students. We were crammed into a very short space, constantly bumping elbows in the classroom, the library, the lab. We soon learned our relationships to each other.

George was the class clown. He has a deep voice sort of like a radio jockey, and he wanted to go into the Air Force. Then there was Julia, blond and long of limb, who could easily pass for a Nordic stewardess. Julia liked learning languages. ‘And I like steak,’ she would say. ‘I could eat a steak for breakfast and another for lunch’.

Some of us were even farther out. Byron has a Ph.D. in jellyfish studies. Janice had been a graphic designer. Wallace had been a professional dominator, complete with whips, leather and female submissives. Hell, I used to be a Taoist priest.
It wasn’t as strange as it sounds. Doctors are really a fanatical monastic order ordained by the AMA. Who else but monks or medical students would give up the best decade of their lives working ten to eighteen hours a day, forsaking food, sleep, even sex? Why was I memorizing irrelevant structures on the inside of the brain that ninety-nine percent of humanity had no knowledge or interest? I started to wonder what the hell I was doing there.

Finals Week:

Dr. Gantrow, a thin severe man with a Germanic adherence to punctuality, stood way at the front of the room. After he finished chewing us out for coming to class late, eating, he began his lecture on the cranial nerves. He was staring to drone like the adults in the Charlie Brown cartoons. “the ninth cranial nerve, the glossopharangeal, exits from the medial side of the medullary olives….wah, wha-wah-wah-wah,…”

Gantrow leaned a little bit from the weight of his own self-importance. Even his phrases took a little time in each breath to reflect on their own wisdom. Meanwhile I was trapped on four sides by the damn little blue plastic seat that was putting a nasty kink in my back. My head was lolled forward and my eyes half-closed, but I couldn’t concentrate and I couldn’t sleep.

I wondered what the students at Harvard were doing at that moment. If Sackler was flying economy, Harvard was first class. They had just returned from lunch at the gentlemen’s club, and were happily digesting in leather recliners. A stewardess floated from row to row with complementary drinks.

“I’ll have a bloody Mary,” a student would exclaim with a girlish giggle. The whole class would laugh politely. “How droll!”

I let my eyes unfocus and daydream about what I’d be doing if I wasn’t in medical school. Perhaps I’d be a writer: living in a sleazy dive in Istanbul, banging away on the never-finished novel on my portable computer, rubbing noses with British expats in white tweed, smoking hashish in coffee shops with walls stained brown from smoke. Maybe I’d special agent of the FBI, poring over computer files of suspected terrorists, coordinating with local sheriffs to find terrified kidnap victims in Kentucky, or hunting down tax evaders. I still have my FBI application on a shelf somewhere, but they’d never let me in because I smoked pot more than the maximum 15 times allowed. They even use a polygraph to make sure you don’t lie about it.
I wasn’t like the others. My parents weren’t doctors. I wasn’t a particularly good scientist, nor was I interested in golf or country clubs. I never wanted to own a BMW. Why was I here? What had I done to deserve this torture?

The daydream wandered of its own volition through time and space. In preschool, hoarding the Tonka trucks and Legos in our special corner of the playroom, we asked each other what we wanted to be when we grew up. Fireman, policeman, doctor, or lawyer? I wanted to be a Luke Skywalker. I wanted to be a hero. This was the last of my thoughts as my eyes closed, my head lolled to the side, and the world became dark.
My world was empty and quiet once again. The bird man stepped out of the shadows. His staff clacked against the ground as he approached me. As he drew closer, I realized where I had seen him before. It was in an old book on the history of medicine. The costume was worn by English physicians during outbreaks of plague. They kept sweet-smelling herbs in their long beak, which they believed protected them from the foul demons of disease.

The bird man opened up his skull and removed his brain. He tucked the top of his skull in the crook of his arm, and held the brain out before me. His voice was soft but seemed to fill the world.

“Sometimes an event has a history and a personality all to its own. It is decisions and consequences, it is past wounds and future possibilities.”

Sitting under the metallic white light, bathing in formalin breezes that had filtered through artificial chambers down into the basement, I remember that moment and I let it free. I let it free, and I set myself free.

I was six years old, riding up the tow robe, with skiers on all sides. I was so excited! Skiing was going to be fun, skiing was going to be so great! Then I felt my leg twist, as it caught on another girl’s skiis. I will always remember her face, cherubic and blank, as if she knew she were nothing more than an agent of destiny. My leg was pulled backwards, while my frozen fingers were locked on the icy steel tow cable. The pain and terror was bewildering. I was so scared I started to cry, as the sky and ground whirled. Confusion, confusion, pain and fear.

Then they came. They wore red and blue parkas, smiling faces, they took me and they ended the confusion. Put my leg in a cast, told me everything was going to be okay. They brought order from chaos, security from fear. They were my heroes.

The experience had made its mark. From then on, perhaps not openly but in my secret heart, I knew I must become like them. Talismans of health and healing.
In the dark of night, when the innocent have fallen asleep in their beds, you will find me in the libraries and in the laboratory, in the secret rites of preparation with the old masters ready to pass on their cowls. I will become the masked man in the white coat who arrives from nowhere to rescue humanity from insanity. Those who have no voice but the hiss of the respirator, the peaks of an EEG, they will find voice in me. I will be the cry for help finally answered.

I will become a doctor.

***

It was the night before the big neuroanatomy final, and my mind was churning. I laid in bed unable to sleep, tossing back and forth in anxiety. The facts and figures, structures and functions, lumps and folds, they all whirled in my mind without pausing to try to make sense. I was speaking in tongues to myself.

In the darkness I was flying, like in astral travel, wind whipping through my hair and nothing under my feet and I felt fantastic and free. I didn’t see the bird man anywhere, but I wasn’t concerned. I turned over and over again, soared through the free black air, without boundaries or inhibitions.

Far away I saw a planet.

As I got closer, I saw that it was an enormous ghostly skull. Through the bone, I saw the surface of an enormous brain spewing out of the spinal cord like a great grey ocean in slow-motion photography. It boiled upwards inch by inch until it splashed against the white cliffs of the skull. As it pressed inward, lumps and valleys were formed.

As I swooped down towards its surface, the skull faded away to leave the brain exposed. Flashing across the hills and valleys like a bird over treetops, I saw images. Memories of my life, playing like disembodied TV sets…shouting To Ho Ka Mi Eh Mi Ta Me at the top of my lungs, swinging a blue-painted iron bell filled with steel bearings louder than God, together with fifteen other white-clad priests, feeling my legs on fire but praying the Universe would speak to me…getting propositioned by a soft skinned hard edged Japanese hooker in a crowded bar on the seventh floor of a thin building like a bacon strip reaching for the Kyoto skyline…riding with the head paramedic Linda in the back of the ambulance bumping over rocks at seventy miles an hour with a kid on the stretcher who looked like he was made of white sticks who said he drunk eighty beers, shouting at Linda “you stupid bitch you whore you fucking whore let me go,” so she slammed an NT tube into the kid’s nose and he screamed and taped an oxygen mask to his face so that he couldn’t shout at her anymore flying over the handlebars of my beloved Yamaha at forty miles an hour in the rain with the pavement rolling like a grindstone under me and not being scared but thinking ‘oh, shit’…getting the acceptance letter from Sackler and screaming to myself ‘I finally did it I finally got into medical school’…

I saw an unformed section of brain: medical school. Flat and featureless, but fertile with potential. A host of experiences waiting to be molded. To mold me. Let the tests come, I thought with a rush of freedom. Let the long nights and ungrateful patients and big loans and bad coffee come.

I am ready.

-e2k