On brain surgery

This week, on the neurosurgery service, I have seen some wild stuff.

On Tuesday, I wandered into an OR. The neurosurgery coordinator told me to find one of the attendings. After changing into scrubs and getting a bit lost around the operating rooms, I found the correct one. Looking through the windows, I saw the patient on the table and the anesthesia team beginning to put her under.

I walked in and tried to get a sense of the room. I couldn’t tell if the attending was actually in the room, but I did find one of my fellow medical students by the door and I asked for her help. She knew the patient from the internal medicine service and wanted to follow along. She also pointed me to the attending and I introduced myself to the curt older surgeon with an Italian accent.

I asked my friend what brought this patient to the OR. She told me the basics of her history: 50-something female with a one week of headaches. No neurological deficits or seizures. Upon admission, imaging revealed a large 3-4cm tumor in the left temporal region of the brain. The purpose of the surgery: get a sample of the mass, obtain a diagnosis, and remove as much of the tumor as possible.

The head was held in place with a vice-like device that utilized spiked points to grab the skull. The hair shaved down with medical electric razors. Creating the sterile field looked similar to previous procedures that I had witnessed, like a cesarean section or breast reduction, except on the head: flowing blue drapes that covered everything except for what they needed to access.

The uncovered section, a 3″x3″ square of flesh over the patient’s left temple, became the neurosurgeon’s canvas. He removed the overlying flap of skin and then began to drill into the skull with a small electric tool at four specific locations. In determining the placement for the holes, the surgeon asked for a tool that looked like a stake that you would use to kill a robot vampire: a long, thin spike of metal with three prongs on the opposite end topped with a small 0.5 inch ball on each prong.

He then placed the spike on the skull and peered at a screen facing him. As he manipulated the tool, I realized that the spike was represented on the screen. The tool was overlaid on MRI images taken before the surgery. He was utilizing virtual reality to accurately determine the margins of the tumor, much like some consumer products like the Xbox Kinect or VR headsets.

Then, with the holes allowing access to the inner aspects of the skull, he connected the 0.5″ holes with a small jigsaw thus allowing the entire section to be removed in one piece. He placed the skull section in some saline water and began the work.

As he began to resect the layers of dura, the protective sheaths encasing the brain matter, I appreciated not just his skill but also his patience. Compared to a c-section or breast reduction, the field of surgery for this operation was like watching TV on a cell phone versus a movie projector.

When coaching movement the years before I entered medical school, I would often tell my athletes that if you can move slowly then you can demonstrate mastery. If you must blast past some range of motion as you squat down, or pull an oar, or transition from one yoga pose to another, then I’d bet that you are hiding some sort of weakness or instability. Move slowly and with great care and you expose both your strengths and weaknesses.

From what I have seen in the OR, something similar can be said for surgical procedures. The smaller the field, the higher the skill required. I watched this neurosurgeon carefully retract and set his field to expose the brain. A stark contrast to the large movements and  broad incisions of an emergency c-section. And of course, not to downplay the skill required of an OB/GYN to extract a healthy infant from an ailing mother, but the differing scales require differing levels of attention and a distinct skillset.

When down to the level of the brain, he then began to remove the tumor. As he setup the large microscope, we students were directed to a screen on the side of the machine and handed a set of glasses. The screen projected a double image until I put on the glasses, then the image resolved into a three-dimensional view of the surgical field.

Much like the glasses needed for 3D films at a local movie theater, this allowed us to appreciate the depth in the area that the surgeon worked. Alternating between the cautery pen and suction, he burned off the vessels to limit bleeding and then suctioned away the dead tissue. He sent off a sample to the pathologist to make a diagnosis and worked as he awaited the response.

When the pathologist called and the nurse put him on speakerphone, so that the entire OR could hear the results, I remember being curious but not concerned. I don’t know who this lady is, I have never met her while she was awake, and I had no connection to her. To me, she was basically a question stem: 50yo F presents for headaches and CT reveals ring-enhancing lesion of the temporal lobe.

When the pathologist said GBM, glioblastoma multiforme, I hummed and thought, “yeah, that sounds about right.” No moment of empathy, just a clinical piece of the puzzle fitting into place. The neurosurgeon told us that the average survival time after diagnosis for patients with GBM was about 18mo. Almost always fatal because the cancer spreads quite aggressively and in thin strands, so complete resection is practically impossible.

After a few more hours of careful cauterization and suction, he neurosurgeon handed off the case to his PA, who then stitched together the skin flaps and wrapped up in the OR while the surgeon prepared to deliver the news of the terminal diagnosis to the awaiting family members in the post-op area. I remember walking out of the OR being incredibly impressed with the technology available. This is the future, we have practical applications of virtual reality and 3D imaging at our fingertips.

But, we also have to deliver tragic news to family. And I was also shocked at how little this affected me. I watched as a woman’s life changed forever, but I was more curious than compassionate.

Why? I think because I didn’t know the case going into it. Perhaps my classmate was more affected by the negative news than I was. Maybe the novelty of the technology distracted me from the human struggle in front of me.

After this week on the neurosurgery service, I doubt that I will see another brain surgery for the rest of my life. I leave with a deep appreciation for the technical level of skill required for these tasks. I’m just glad that I will be peering into the mind as a psychiatrist, not cutting into the brain.

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