When the Air Hits Your Brain - Frank Vertosick - Reflections on Pressure, Ethics, and the Emotional Reality of Medicine

ref. When the air Hits Your Brain, 1996, Norton

When the Air Hits Your Brain is a book about tales from neurosurgery. In this book, Frank recounts his experiences during his years as a neurosurgeon, beginning with the early stages of his career. He describes moments like witnessing his senior accidentally drilling too deep into a patient’s skull, or the humiliation of being a confused ‘newbie’- made to feel like a complete fool when a junior resident laughed, saying it looked as if  "he started his goddamn medical career this morning”. 

These fresh experiences for Frank explore the countless lessons a doctor encounters throughout their career. Frank recounts a moment when he failed to properly insert a nasogastric tube into a patient’s stomach, which resulted in profuse bleeding from both nostrils. The patient’s patience, gratitude and lack of anger shocked Frank. It was then he realised his white coat was no ordinary piece of clothing, stating that if the same procedure had been performed on the street, it might have been considered as an assault- yet in the context of medicine, he began to understand the inevitability of complications. 

Following a surgical complication with a ruptured aneurysm, Frank found himself reflecting deeply- and it was then that he remembered a piece of advice that had stayed with him. 

‘ You didn't kill him, you were just asked to step in and prevent him from dying on his own……and you couldn’t…… There will always be people better than you and worse than you. If you worry about not being as good as someone else, why don’t you just give up every case right now? Just set up a phone hot line and sit in an office and match people with the very best surgeons in the whole universe. No point in cursing humanity with your own sorry skills, is there …... .do the best you can with those who ask for your help….. You have to care about the patients, but not too much. It’s unethical to operate on our wives, Why? Because we’d be too likely to choke, to get nervous and fuck up if it’s our own family on the chopping block. The very fact that medical ethics forbids treating your immediate family is proof that we shouldn’t get so involved with a patient that we are made nervous by the possibility of failure. Patients want us to care about them, but they want us to perform with the nerveless demeanour of someone slicing bologna in a deli at the same time. It’s one of those unexplained paradoxes we just accept…’(Vertosick, 1996, p.223).

This taught me that failure and complications are obstacles that can drive many to their lowest point. It’s important to acknowledge that these situations will happen - yet as doctors, we should not succumb to failure. Patients and their loved ones often have high expectations for success; after all, who doesn’t want to see their friends, children, parents live a healthy life? The fear of death and suffering is one of the greatest fears we all share. As doctors, our role is to separate our own expectations from those of our patients. If we don’t, we risk seeing every failure as a beating instead of a lesson. A doctor’s expectations are grounded in scientific facts - and only we truly understand the real possibilities of an outcome. Recognising this is central to what makes a good doctor: we must be honest with ourselves about our limitations, and honest with our patients about risks, outcomes, and uncertainties. The GMC’s guideline on professional values emphasises this balance - encouraging doctors to be open and realistic while respecting patient autonomy and supporting shared decision-making. In doing so, we remain compassionate without being crushed by expectation, and committed without being blinded by perfectionism. 

Pressure

Frank first learnt about the weight of pressure in medicine when his senior asked him to look after a baby - without telling him that the baby had already been agreed to be taken off life support due to an irreparable right ventricle. Being kept unaware of the full clinical context left him unprepared and emotionally unsteady. When he questioned the situation, his senior responded with a stark truth: 

 ‘Pressure’s part of the deal. Anybody can sing in the shower, but how many can sing in front of an audience, huh? Pressure makes all the difference in the world.’(Vertosick, 1996, p.69)

Reading this has taught me that pressure is an inherent part of medical practice, and that we should never think little of it. Yet, learning to remain conscious, focused and professional under pressure is what distinguishes truly great doctors - it is a quality that earns them trust, respect, and responsibility in the most critical of moments. 

Pain

Shortly after explaining endorphins and the gating phenomenon as mechanisms for blunting painful sensations, Frank delves into the distinction between pain and suffering. 

‘There is a profound difference between pain and suffering. All animals feel pain. Only humans suffer. Pain is a physical sensation; suffering is an emotional state induced by pain. Suffering is pain coupled with uncertainty, depression, frustration, anger, fear, despair.’ (Vertosick, 1996, p.74)

He then illustrates this difference through his patient’s change of attitude.

‘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.’(Vertosick, 1996, p.74)

Later in the chapter, Frank talks about the idea of pain as a psychological affliction on one’s body. 

‘The more bizarre the description of the pain, the more likely it is to be a psychiatric delusion’ (Vertosick, 1996, p.79) 

This raises questions about clinical judgement: how does a doctor discern between physical and psychological pain? This distinction highlights that medicine is not only rooted in science, but also in empathy, listening, and an understanding of human complexity. A patient’s mental and emotional state can drastically shape the way they experience illness - and doctors must tune into those subtle signs. Small details cannot be ignored if we are to truly meet a patient’s needs. 

Ultimately, Frank’s reflections remind us that doctors don’t just treat conditions- they treat people. The act of listening becomes not only a diagnostic tool, because after all, it’s the patient who is living the experience, not the doctors. Listening, truly listening, is what allows doctors to act with compassion and clarity. 

The book also reflects on the nature of dedication in medicine. One neurosurgeon draws a clear line between those who endure and those who don’t:

‘Most of them wanted to be surgeons but just couldn’t hack the work it takes to be one.’(Vertosick, 1996, p.149)

This contrast underscores that becoming a doctor takes more than knowledge, it demands persistence, emotional strength and an unwavering sense of purpose. 

Medical Terms I’ve learned:

Conversion reaction

A psychological condition in which a patient unconsciously converts emotional stress or trauma - such as a car accident - into physical symptoms, such as blindness, paralysis etc. 

Ondine curse

A.K.A the central hypoventilation syndrome, it is a rare condition, often resulting from damage to the medulla ( part of the brain that controls involuntary breathing etc.) In healthy people, breathing is controlled both voluntarily (e.g. taking a deep breath when you want to) and involuntarily (your brainstem keeps you breathing even when you’re sleeping). However, In Odine’s Curse, the involuntary drive to breathe is removed. So unless you’re awake and actively thinking about breathing, your body won’t do it on its own. 

Ref. 

Vertosick, Frank. When the Air Hits Your Brain: Tales from Neurosurgery. W. W. Norton & Company, 17 Mar. 2008.