Another Day in the Frontal Lobe (10 page)

As one of my mentors is fond of saying: “Surgery is controlled trauma.” When you see the device we use for drilling holes, this statement becomes clear. We have a special drill, a “perforator,” that is designed to make this hole-making task foolproof. The drill bit is complex in its geometry and formidable in size. Its function, though, is quite elegant. You have to apply firm and constant downward pressure during the drilling process, but the cutting action stops, miraculously, as soon as you’re through the bone, thereby protecting all that is soft underneath. (That’s why we allow the lowly intern to get a piece of the action—it’s really the drill that we trust.) What you are left with is a nice smooth, round, full-thickness hole in the skull, roughly nickel-sized in diameter. Believe me—this was a great breakthrough in the history of neurosurgery.

For all its wonders, though, this drill does have at least one downside. An annoying glitch in the technology makes it nearly impossible to continue using the perforator on the same hole if you stop drilling halfway through. It won’t reengage. Quite disheartening, this is yet another thing that can interrupt the flow of a case, necessitating either chipping away at the remaining bone with a sharp scooping instrument or setting up a different type of drill, with a smaller head, to complete the task. With this glitch in mind, whoever is teaching the intern to use the perforator is tempted to yell “Don’t stop!” above the loud drone of the drill. I have seen, on more than one occasion, the driller stop drilling in order to clarify what is being yelled to him.

A favorite teaching point, passed perennially from professor to resident to intern, involves listening to the subtle differences in sound that the drill makes as it passes through the different layers, or “tables,” of the skull. It requires only a couple bur holes’ worth of experience before you can detect, by sound alone, when the drill is about to stop. This is not rocket science, but it is neat. Again, such knowledge distinguishes us from the guy on the street or at his desk in the office park.

I can’t talk about drilling holes in the skull without mentioning one of my favorite neurosurgical terms: bone dust. You may be wondering (or maybe not) what happens to the core of bone being drilled through. Basically, it piles up along the margins of the hole. However, because the assistant in the case usually drips saline irrigation over the drill bit to prevent it from getting too hot, the bone dust often turns into more of a hydrated bone meal.

Early in my training, I was gently scolded by one neurosurgeon for irrigating too vigorously and washing all the bone away. I didn’t realize that his custom was to collect the seemingly useless bone dust and use it to fill in the holes at the end of the case (theorizing that the hole would seal over faster and more completely). I had learned from others, instead, to cover the defects with thin, round titanium plates—a more contemporary approach. As a trainee, it became clear to me that I needed to learn not just the science and the mechanics, but also the gamut of personal preferences. The best senior residents remember to forewarn their juniors before unleashing them into various operating rooms with particular neurosurgeons: “Don’t forget. This guy saves the bone dust.” Such helpful reminders can prevent the needless reprimanding of one adult by another.

Bone dust has a certain smell. It’s fairly subtle and not really offensive, but you know it when you smell it, especially when the assistant is lax in dripping the saline and the dust remains fine and dry and flies around the room. As a neurosurgery resident, I often returned home late after a day confined to the operating room and had to sneak into bed next to my husband, who was also a neurosurgery resident at the time. If he awoke fully enough and his olfactory skills were sufficiently tuned, he would complain: “You smell like bone dust.” If he fell back asleep right away, I’d be fine. But if he persisted in his complaints, then I was obligated to rinse off in the shower before getting back in bed. Luckily, I always reserved equal rights to complain if he was the one slipping in late, so it never became a source of inequality in our marriage.

In most brain operations, at least a few holes are created and then connected with a different type of drill—one with a foot plate. In this way, an entire “bone flap,” or section of skull, can be removed. This part is usually done fairly rapidly so as to get it out of the way. Once the brain is exposed, things take a turn for the more serious and the pace may slow down considerably. In fact, if the surgeons are listening to raucous “opening music”—usually the younger ones—they may request that the music be changed or turned off. When the hard part is over and it’s time to put the bone flap back on, some will request “closing music,” which is understood by all in the room to be of an even rowdier variety.

I don’t want to leave the impression that neurosurgery is all just low-tech drilling and sucking. From my experience in speaking to guests who visit our operating rooms, the biggest crowd pleaser is one of the more complex devices we use: the 3-D image-guidance system. It’s the kind of cool technology that a layperson expects us to use. There are many competing varieties, with brand names meant to appeal to the techie in every surgeon, like Stealth and BrainLab. These systems, now commonplace, were not widely available several years ago. We now rely on them to avoid the embarrassment faced in years past by our older colleagues: rooting around trying to find a tumor buried deep within the brain, or unwittingly leaving a large portion of it behind.

Although this may be hard to believe, the following exercise can be a challenge for a neurosurgeon: have a patient lie in front of you, hang the patient’s MRI up on the light box, and point, on the patient’s head, precisely to where the tumor should be located. It’s easy to be off by an inch or even two. Why is this exercise difficult? Mainly because the head is round.

Before image-guidance systems were available, neurosurgeons would err on the side of using a large incision and creating a generous window into the skull. By maximizing the playing field, they improved their chances of being able to find the tumor. In the modern era, with 3-D image-guidance, the patient’s MRI scan is downloaded into a computer system in the OR, and these images are linked to a navigation wand. When the surgeon touches the wand to the patient’s head at the time of surgery, a pointer appears on the MRI, indicating the precise location of the wand on the head. This allows us to have a kind of X-ray vision. With the guidance of this magic wand, the incision and the bone flap can be centered directly over the tumor, allowing for the smallest possible opening.

Once the neurosurgeon starts to remove the tumor, the wand can be used again to point inside the brain, within the tumor, in order to gauge how far he or she has gone. This is helpful in preventing a surgeon from being either too aggressive (going beyond the borders) or not aggressive enough (leaving too much behind). With certain types of tumors, it can be difficult to tell exactly where the tumor ends and the brain begins. The MRI may present these margins more distinctly.

I can remember assisting on one of my first brain tumor cases as a junior resident. Once we got into the tumor, my mentor tried to verbalize the subtle differences between tumor and brain, in appearance and consistency, as he worked and I watched. I just didn’t see it. I took his word for it but remained a bit skeptical. Later in the case, when he granted me the opportunity to use the metal suction tip as an extension of my own hand, I understood what he was talking about. Still, it can be a little unclear at times, even in experienced hands.

A few Luddites in our department pooh-poohed this image-guidance technology at first. They worried that the young ones would come to rely on it so much that we wouldn’t think for ourselves and wouldn’t bother to cultivate the innate 3-D capabilities of our own minds. Their fear may have some truth to it, but patients certainly don’t mind us taking advantage of this technology. The Luddites’ perspective would be similar to preferring a bank teller to add all your deposits with a pencil and paper. While certainly possible, it’s always reassuring to see them use a calculator.

Sometimes our desire to have all the latest technology can go a little overboard. When our department found out about a new surgical microscope that incorporated an advanced laser sighting mechanism, we had to have one. It sounded incredible. A special room in the OR was outfitted so that this ultra high-tech (expensive) piece of equipment could be mounted to the ceiling and could descend, electronically, into position when needed. Two of our residents were flown to Europe to get the special training required to use it.

With the OR renovation complete and this formidable multi-limbed, multijointed microscope mounted and ready, the rest of the department went through brief training sessions. In these simulated exercises, the device seemed to work well enough, but there were the small glitches you might expect from anything new, complex, and mechanical.

I remember sitting in the surgeons’ lounge between operations and hearing an onlooker’s account of a case that had just been done with the new microscope. “They might as well have been looking through a cardboard tube!” Apparently, the device didn’t quite live up to everyone’s expectations. Soon after the fanfare of its introduction died down, it tended to remain suspended high up against the ceiling, in hibernation. Case after case, one of our traditional operating microscopes would be wheeled into position underneath it, and after a while, no one even seemed to look up at it anymore. It wasn’t all for naught, though, as it remained an impressive fixture that we could point out to professors and fellows visiting from other, less technically endowed, programs.

Given my sometimes excessive introspection into my own career, I often reflect on the fact that the experience of performing surgery can span the spectrum from pure enjoyment to tedious boredom or even frustration. The most enjoyable cases (for me, at least) involve the greatest number of the following elements: a pleasant, familiar OR team, a “fresh” case (as opposed to a scarred-in “redo”), sharp and well-maintained instruments, a thin patient, glitch-free technology, good music, performance of the case during normal working hours, and a quiet pager. Less enjoyable cases often involve opposite elements. One quickly realizes as a surgeon that only certain elements of the perfect case can be controlled. Given the fact that most surgeons can be classified as control freaks, it can be hard to accept this reality.

For me, I am at risk for boredom when things become overly routine or if I’m not learning anything new, which is a problem, because in surgery, you should strive for routine and a consistent focus. Patients aren’t really looking for a creative surgeon or even an intellectually curious one. The ideal surgeon would be one who doesn’t mind doing the same cases, over and over again, the same way, with the same instruments, year after year, continually enhancing safety and efficiency while building case volume. In such a scenario, although the mind may be at risk of going a little numb, the hands may continue to enjoy going through all the motions that they know and do so well.

I can’t ignore the most obvious benefit of the well-oiled surgical routine: you get to help people. This certainly makes up for some of the downside of routine and can be quite satisfying, emotionally, unless the fear of lawsuits and the compromise of family life cancel out some of this benefit.

The profession of surgery, then, presents an interesting state of affairs: it attracts some of the best and brightest, but is heavily reliant on tools, manual labor, routine, sacrifice, a large support staff, and a narrow focus. This combination can represent, at extremes, the perfect sweet spot or the perfect recipe for burnout.

NINE

Risk

Hooking a fish at the edge of its mouth doesn’t really bother me, even though you have to slide the hook out backward, tugging the pointed barb through the skin, in order to extract it. It’s a necessary part of fishing. I watched my dad do it when I was a kid, and he assured me that the puncture site heals just fine. I would watch the fish swim away after he threw them back in. The small flesh wound didn’t seem to slow them down at all.

Every once in a while, though, a fish will swallow the hook. This is not a simple flesh wound. If the hook makes it into the stomach, it can emerge from the mouth with shiny, dark red viscera trailing behind. Sometimes, the hook can’t be extracted, so the line is cut, leaving the silvery relic inside. I’ve watched these fish swim away, too, but I knew they were doomed. For me, the swallowed hook tarnishes the otherwise carefree game of catch-and-release, at least for a little while.

One of the patients who had the most enduring impact on me was one I knew the least. I didn’t even get to meet her before surgery. She wasn’t my patient. I was just the fourth-year medical student rotating on the neurosurgery service, excited to participate in a cool case. The case was cool because it was big and complex. Risky. Despite my enthusiasm, I didn’t delude myself. “Participate” was too strong a word. At my level, I would be relegated to scrubbing in and watching. The chief resident made me feel like part of the team, though, by discussing the case with me and granting me the dubious honor of placing the Foley catheter in the patient’s bladder, a lowly but necessary task. I also took the initiative to write some orders in the chart based on what I knew she would need after surgery. These orders would turn out to be unnecessary.

I learned from my chief resident that the patient, intubated and asleep in front of me, was a young woman, a teenager really, who decided to undergo surgery only after painful deliberation. Years earlier, she had been diagnosed with a large malformed tangle of blood vessels in her brain (an “AVM,” or arteriovenous malformation). Unfortunately, this AVM was of an extreme type—very large and in a very dangerous location—informally known among neurosurgeons as a “handshake AVM.” As you walk out of the neurosurgeon’s office, a handshake is all he has to offer.

So, for years, the patient and her parents lived in fear, never knowing if or when this malformation would decide to bleed. They knew that a bleed could be fatal. They also knew that surgery could be fatal. They respected their surgeon’s seasoned opinion that surgery wasn’t an option for her. They understood his reluctance to risk having his own hand in her death or, worse, her neurological devastation if surgical removal were attempted.

One surgeon’s handshake became another surgeon’s challenge. When her original pediatric neurosurgeon left town to practice elsewhere, she and her parents sought the advice of another neurosurgeon, one known for both his superlative microsurgical skills and his willingness to take on the most difficult cases. It was unusual for him to turn away a case. In fact, on one rare occasion, in advising a patient against surgery, he was rumored to have told her: “You don’t need me. You need Jesus Christ.”

This surgeon’s way with words was as well known as his surgical skill. In making a teaching point to a resident examining a patient in his clinic once, he wanted to explain how the patient’s disorder was not of the familial genetic variety passed from one generation to the next but was, rather, the product of a random spontaneous genetic mutation. He pointed to the patient and explained: “She’s a spontaneous mutant.”

I suspect the young woman and her parents were impressed by this surgeon’s confidence and reputation. Their impression, combined with the chronic unease that arose from doing nothing, must have tipped their decision toward surgery. In essence, a decision like this comes down to: Do you want to take your risk up front, all at once (surgery), or slowly, over time (wait and watch)? Individual personality, more than science, can be the driving factor in making such a choice.

The operation was a challenge, a technical tour de force. The AVM, which had probably been there since birth, did not give in easily. It had spent its entire existence within the dark confines of her skull, sharing space with her brain, and her brain had unwittingly accommodated its presence. Although a potential threat to her life, the malformation was a native and natural part of her, not a recent invader.

The surgeon worked for hours, meticulously, under the bright focus of the surgical microscope. He closed off one abnormal blood vessel after another, making sure to interrupt the complex inflow to the beast first, knowing that interrupting its outflow too early could provoke a bloody explosion.

The final vessels were closed off and the tangled mass removed. Her brain now remained as the sole inhabitant of her skull. I was surprised by the size of the depression left behind, where her brain had accommodated to the malformation’s presence. Her head was closed up and she was wheeled out to recovery.

After witnessing this surgeon’s skill with my own eyes, I agreed that his reputation, and even his cockiness, was well deserved. If I needed brain surgery, he would be my surgeon. I thought about how satisfying it must be for him to go out to the family, announce his success, and vindicate their most difficult decision. They put their daughter’s life in his hands, and he was able to offer her a life without fear of the malformation that had been so intimate with her brain. Others had warned strongly against surgery, citing unacceptable risk. They went ahead anyway, and could now be grateful that they had made the right decision.

The patient woke up gradually over the next half hour, recovering slowly after hours of anesthesia. She wasn’t awake for long, though, before the nurse noticed early signs of trouble in her neurological examination. Minutes later, she was unresponsive. A stat head scan revealed a catastrophe: massive bleeding into the brain, including the delicate brain stem. The surgeon went through all the right motions of a heroic rush back to the operating room, but the damage had been done and he knew it. The bleed was fatal.

Despite all good intentions and a technically successful operation, her brain could not tolerate the perturbations in circulation that accompanied removal of the large tangled mass of vessels. Maybe an otherwise normal artery in her brain, not used to the new pressure dynamics, broke open. Or, a critical vein near the malformation may have clotted off, leaving too few outflow options for the brain’s rich blood supply. Whatever the explanation, I imagined that this was the AVM’s final demand for respect, with her scan representing a “Don’t Touch” warning to other surgeons tempted to offer others like her more than just a handshake. It was also a tragic introduction to the mantra I would hear again and again through my training: “The patient is the one taking the risk, not the surgeon.”

Years later, as a senior resident, I met another patient with a handshake AVM. She had received only handshakes and had resigned herself to inaction long ago. This woman’s AVM was so large that it extended across the corpus callosum, one of the structures that connects the two hemispheres of the brain. Although she was otherwise a healthy and active woman, in her thirties, she had lived her life with full knowledge of the tangled mass that would always be with her, a cohabitant that would demand extra attention every once in a while.

This woman had never suffered a devastating bleed. Instead, there were a few defined episodes in which the malformation leaked fairly small amounts of blood into the brain. (This scenario is actually fairly typical for the largest of AVMs. The smaller ones are more likely to cause larger bleeds for various reasons.) Luckily, these small bleeds were in the relatively resilient frontal lobes, and the patient suffered bad headaches but no significant neurological sequelae. When I met her, she was in the hospital for a few days after one of these bleeds, and my job was to check in on her and make sure her blood pressure and her headaches remained under good control. That’s about all we had to offer and, luckily, that’s all she needed.

Had these two patients, victims of random developmental circumstance, been given the chance to meet each other, what advice would the elder have given to the younger? It’s clear that the brain can accommodate quite nicely to the overbearing presence of a malformation, but can the mind be trained to accommodate just as well? When inaction is the best action, how do you prevent fear itself from becoming an illness? Does the fear simply wear out, or does it have to be forced out?

Knowledge is power, but it can also be fear. Surgeons are obligated to educate a patient about their condition and treatment options, but then they are faced with managing the anxiety that goes hand in hand with that knowledge. I have found that handling a patient’s anxiety can be more complicated, and sometimes even more time-consuming, than the surgery itself. Some surgeons loathe this part of the job. It reminds them of all the reasons they didn’t go into, say, psychiatry. They prefer patients under anesthesia to patients wringing their hands, crying, and reading off a list of questions from everyone in their family, including their second cousin. Others find those interactions rewarding. I tend more toward the latter camp, but I do empathize with those in the former because I understand the surgical personality and have just a touch of it myself.

Because anxiety management is not always enjoyable, some surgeons don’t spend much time on it. I remember, as a resident, having to recalibrate a patient’s thoughts. She was convinced that she was dying of a brain tumor. She had a small benign tumor, called an acoustic neuroma, on one of the nerves at the base of her brain. She had no symptoms. The tumor was discovered incidentally, when her head was scanned for other reasons. She was elderly, and a surgeon at another institution recommended doing nothing for it. She left his office with this sentiment: “I have a brain tumor and nothing can be done for me.”

I saw her and her extended family a few months later, when a relative urged her to seek an opinion at our institution. She looked around at her loved ones in the room and expressed regret that this would probably be the last Christmas she would be spending with them, as death was near. I glanced down at the name on her chart. Was I talking to the right patient?

I went over her MRI and examined her. I explained the reality of her small benign tumor at the base of her brain (not
in
her brain), and told her that it could have been there for quite a while. Most likely, she would die years down the line of a totally unrelated cause, before this little tumor could even cause a significant problem. I went over all the options and we settled on the one everyone was most comfortable with for the time being: observation. I was happy to be of service as it is always gratifying to extend someone’s life expectancy without even having to pick up a scalpel.

During my training, I took to observing how different neurosurgeons interacted with their patients in discussing the risks of surgery. I knew I’d have to devise my own personal style, but I figured I could pick up on what seemed to work and what didn’t. On one extreme was the warm hand-holder who peppered religious-speak into his counseling, adding blessings to his discussions of what could possibly go wrong. (“We’ll get you through this, with God’s grace.”) I have to be honest. That style did work wonders, especially with the older ladies, but I could never adopt it myself. I wouldn’t be able to keep a straight face. The same surgeon was effective in conversation in other, more creative, ways as well. I observed him discussing a difficult situation with a patient and her very large, extended Italian family. He was trying to get across the fact that the tumor at the base of her brain would be tricky to remove because of all the nerves draped across it. After thinking about it for a few seconds, he explained, “It’s like trying to get at a large meatball when there are strings of angelhair pasta in the way.”

On the other extreme was the guy who, I’m a bit ashamed to admit, was entertaining to watch, in a sadistic sort of way. There’s only one word to describe his style: blunt. Here’s how he would describe the risks of surgery for an aneurysm of the brain, just prior to having a patient sign their consent: “You could have a stroke. (Pause.) You could have permanent brain damage. (Pause.) You could become a vegetable. (Pause.) You could die.” Although these statements were technically correct, the monotone voice with which they were spoken, and the sharklike demeanor that went with them, explained his uncanny ability to make a patient and their family burst into tears.