Another Day in the Frontal Lobe (6 page)

Even though neurosurgery is a small specialty, you can’t lump all neurosurgeons together. Some neurosurgeons tend toward the more brainy, nerdy end of the spectrum, whereas others are more of the jock or frat boy variety. Some love to spend all day in the OR whereas others prefer to spend extra hours in the lab. A few superstars do it all, via liberal delegation, collaboration, and little sleep.

Such distinctions can introduce a funny quirk into the academic system: a lay person might assume that a surgeon with his name on the greatest number of papers, or the one with his name in the
New England Journal of Medicine,
is
the
guy to go to for a certain type of surgery. While this certainly may be the case, and I don’t discourage this type of thinking outright, the reality could also be that this is the guy who spends far more time in the lab than in the OR. A great mind for science and great hands do not necessarily go together.

Some renegade neurosurgeons have taken on research projects that have gone down in history—as much for inciting ethical debate as for pushing the envelope. In addition to being inspired by Harvey Cushing, my husband and I were also influenced by another neurosurgeon from Cleveland, but a living one we actually got to meet: Robert White. White became famous for many things, but perhaps most of all for his head transplant work, which he preferred to call a “body transplant.” He actually performed a head transplant on a primate in 1970, connecting all the blood vessels required to perfuse the new head. The transplanted head was fully functional, but, with no way to connect the two ends of the spinal cord, the new being was quadriplegic. However, White envisioned that this experiment, however macabre, might someday pave the way for extending the lives of people with healthy brains but deteriorating bodies, such as those who are already quadriplegic or nearly so.

White kept popping into our lives at various times, sometimes unbeknownst to him. My father knew him from years earlier and set up a meeting—all four of us—when Andrew and I were still college students. We checked out the historic transplant lab. A year or so later, Andrew and I spent a summer month in Spain together. While staying in a rundown apartment in Valencia, we had a knock on the door one day. An animal rights activist was handing out flyers. It featured animal abuse “horror stories,” including a description of White’s work and the lab we had seen. We laughed, not at the purported abuse, but at the fact that our Cleveland buddy had made it to Valencia, to our little apartment.

Years later, White was nice enough to attend our wedding. And, upon buying our first car together and driving it off the lot, we just happened to turn the radio on to the sound of White’s voice on a talk show. White has become legendary, especially in Cleveland, where he is perhaps best known not for his research, but for his connection to the late Pope John Paul II, for whom he served as a medical adviser. My father—a general surgeon who told me long ago that neurosurgeons are known for being megalomaniacs—likes to tell the following joke that circulated around Cleveland at one point. The joke goes: A crowd is gathered at the Vatican, with everyone looking up at the balcony, where two men can be seen. One random onlooker says to another: “Who is that guy standing next to Dr. White?”

You might think that neurosurgery as a profession is specialized enough, but we’ve managed to break it down into even smaller bits. And, as with any culture, stereotypes abound, some fair and some unfair. Vascular neurosurgeons, for example, are the “cowboys” whose lives revolve around aneurysms and other blood vessel–related brain abnormalities. Aneurysms are weakened bubbles on blood vessels that can burst, sometimes leaving neurological devastation in their wake. Emergencies are the norm. The vascular guys are known for having the worst lifestyle. Aneurysms seem to present themselves at the most inopportune times, like Friday evening or Thanksgiving afternoon. They often require a trip to the OR to prevent a rebleed. The spouses and children of these cowboys may file for neglect. On the bright side, vascular neurosurgeons do some of the greatest cases—intricate and technically demanding—the kinds of cases that attract young medical students to the field in the first place.

Spine specialists are a different breed. They work with screws, rods, and bones. They may be mistaken for orthopedic surgeons (some of whom do spine surgery also, but only if they’ve undergone special fellowship training). They are courted by instrumentation companies that hope to entice them with new products, like modified screws or updated screwdrivers. Spine surgeons are the ones who usually bring in the most cash, to put it bluntly. There are a few simple reasons for this: (1) the population is aging, (2) aging spines can be painful, (3) there’s a growing trend toward fusing painful, aging spines, and (4) fusions reimburse well (better than most brain operations).

Picture this. A haggard vascular neurosurgeon comes in at midnight, Friday night, to do an emergency aneurysm case on a deathly ill patient. He monitors the patient for a week or two in the ICU and another week or two on the floor. He fears the potentially devastating complications that can occur even several days after a flawless operation. He answers frantic phone calls in the middle of the night. He holds family conferences. He checks scan after scan. He will be compensated reasonably well for the operation itself, depending on the patient’s insurance plan, assuming that the patient actually has insurance. (Otherwise, he works for free.) However, he receives nothing additional for all the work required after surgery.

The spine surgeon, on the other hand, performs an elective spine fusion on a healthy patient on a Monday morning (after his office staff has confirmed insurance coverage). He checks on the patient once a day for a few days in the hospital, sends the patient home, and receives a multiple of what his vascular colleague received. This disparity, although seemingly unfair, has become an entrenched part of our culture. I introduce this disparity not as a crude exposé of our finances, but because these issues are on our minds all too often. Ask almost any neurosurgeon.

Neurosurgeons come in many other varieties: pediatric, functional (for movement disorders such as Parkinson’s disease), tumors, trauma, epilepsy, and peripheral nerves. A small subset of neurosurgeons focus on anything that requires surgery at the base of the skull. These “skull base” neurosurgeons are famous for their maximally invasive approaches. Their cases may take all day, sometimes extending into the next day. For the longest operations like large, complex tumors at the base of the brain, neurosurgeons sometimes work in shifts, so that one surgeon can leave to use the bathroom, eat, and explain to their spouse why they won’t be home, while the other one works. To many young residents, this complex and demanding field can be quite attractive…at first.

Radiosurgeons are in a rarefied class of their own. They perform stereotactic radiosurgery, a slick noninvasive technique that involves focused radiation to treat brain lesions. Their patients are usually quite pleased because they avoided having their heads opened—the more traditional alternative. Their procedures are not performed in the OR, so they have certain liberties that other neurosurgeons cannot share, like drinking specialty coffees during their cases. They’re often the smartest ones around, partly because they have time to read.

The wide spectrum of technical approaches in our field, from minimally invasive to maximally invasive, and even noninvasive, inspired one graduating resident to offer this tribute at his graduation speech: “I thank Dr. X for teaching me to operate through a keyhole, Dr. Y for teaching me to operate through a manhole, and Dr. Z for teaching me to operate through no hole.” This quote has been passed down, year after year, at my training program and I can’t even remember now who should get the credit.

Neurosurgeons of all types, nationwide and even worldwide, convene at our annual neurosurgery conventions. These meetings are designed to strengthen our social bonds and keep us up-to-date on the latest scientific advances (in that order). Our two major organizations, the AANS (American Association of Neurological Surgeons) and the CNS (Congress of Neurological Surgeons), each hold a separate meeting. Most neurosurgeons belong to both.

Each organization has it own corresponding journal. The AANS publishes the
Journal of Neurosurgery
and the CNS publishes
Neurosurgery.
Although both are equally well regarded, the younger
Neurosurgery
is more colorful and has more pictures, provoking the nickname “the cartoons” by its rival. Among the more senior neurosurgeons, the older journal is known as the “white journal,” based on the cover, and the newer one is the “red journal,” further reflecting the divergent emphasis on color.

My first annual meeting was in Chicago, when I was a junior resident. Finally, after hearing about all the big names in neurosurgery around the country, I was able to match faces with names. (Their faces are not exactly featured in
People
magazine; neurosurgery is a very small sea. Once the big names set foot outside of the convention center, they become relatively anonymous again, unless they forget to remove their convention badges.) As I went up escalators and walked down hallways, the senior residents would lean over and whisper to me:
The guy with the mustache is Spetzler…that older guy is Yasargil…the big guy over there is Rhoton.
These were the neurosurgeons typically asked to give the “How I Do It” talks, like “How I Do It: Giant Aneurysms,” or that type of thing. The same talks tend to be featured year after year, which didn’t dawn on me until my second or third meeting.

One of the most unusual aspects of these gatherings is the massive, open, sterile convention room filled with specialty vendors. I’m not talking about food vendors. I’m referring to companies that sell things like surgical instruments, medications, textbooks, and multimillion-dollar pieces of capital equipment. They vie for attention with colorful, educational displays and freebies such as pens, candy, customized Post-it notes, and squeeze toys in the shape of a brain. At some of the booths, you can try out the equipment. If you’re so inclined, you can, for example, test the performance of a cautery device on a piece of raw steak. You can look at fine newsprint through the lens of the latest surgical microscope. You can peruse the gamut of OR tables that fold over, orgami-like, in various ways. These tables often feature live models in black leotards lying motionless, simulating a patient about to undergo spine surgery. The models are always women.

Residents get to eat well at these meetings, which is much appreciated in the context of a chronic hospital cafeteria diet. Dinners at the best restaurants are sponsored every night, either by our academic department or by a company representative. Expensive steak-houses are favorites. As a petite woman, I usually can’t finish the entire piece of steak, but it never goes to waste. There is always at least one guy in the pack who is willing to wolf down the rest. Someone asked me once whether there were any particular advantages to being a woman in the male-dominated field of neurosurgery. I mentioned this one.

The scientific information at an annual meeting is presented in various formats. The studies deemed most important, like the results of large, multicenter trials on aneurysms, brain tumors, or spine surgery, are presented in the biggest rooms during exclusive times when nothing else is going on, so the maximum number of people can attend. Talks that are deemed important, but a little less important, are also granted time slots, but the talks are shorter and have to compete for attention among the other sessions. Everything else is presented in poster format. Apparently, most posters that are submitted are accepted; relatively few are rejected. This ensures maximum attendance, as a potential presenter might skip the meeting if his poster is rejected, leaving the organization with one less registration fee. I didn’t know this when my first poster was accepted. I was thrilled that it had surfaced to the top of what I had envisioned was a highly competitive weeding-out process.

A poster always presents a dilemma: What do you do with it when the meeting is over? Some departments are willing to devote some hallway space to it, but if not, it’s a toss-up whether or not to haul the unwieldy tube back home on the plane. After the devotion of so many hours, it seems a waste to throw it out. That’s probably the best option, though, because few spouses would encourage its display in the living room or bedroom.

The slogan at my first annual meeting was “Winds of Change.” It was displayed in large print on banners and on the cover of our meeting programs. The slogan was fitting, given the constant evolution of our profession and the host city of Chicago. The society president gave an uplifting talk at the opening of the meeting, reflecting on the recent unique “winds of change” in our profession. I was proud to be a new member of the society, sitting among thousands of other residents and neurosurgeons from around the world.

On the last day of the meeting, I walked through the length of the convention center on my way back to the hotel. I could see that a national hardware chain was preparing for their own annual meeting, scheduled to follow ours. As I walked, I noticed more and more name tags bearing the logo of the hardware chain, while the neurosurgery badges thinned out. They were taking over the space I had come to consider ours. Upon leaving the building, I saw their banner hanging proudly at the main entrance. I paused when I saw their slogan: “Winds of Change.” I imagined their opening talk to be equally uplifting.

SIX

Routine

“Don’t go into neurosurgery unless there’s
absolutely nothing else
you could ever see yourself doing.” In other words, unless you’re fanatical about it, it’s not worth the sacrifice. I received this advice from elders in the field, as did other medical students hoping to enter the specialty. For some, the advice triggers introspection, which is the whole point. For others, the gravity of the message and the solemnity of the delivery only enhance the aura of exclusivity surrounding the profession. For those starry-eyed medical students, the thought of joining a tribe of devoted and single-minded practitioners—a tribe that others are not passionate or qualified enough to join—makes the decision even easier. The warning is pure enticement.

I was in the more introspective camp. Unfortunately, though, the warning continued to haunt me even after I had made up my mind, extending my introspection through seven years of residency (and beyond). I am convinced that most neurosurgery residents question their decision at least once or twice during the prolonged training period. Regarding those who didn’t—the ones who claimed an unwavering confidence in their career choice—my feelings alternated between suspicion and jealousy. Some seemed to have been born into the role. I, on the other hand, smiled and got through the training just as deftly, not so much because of a natural fit, but, at least partly, because of my innate tolerance (and, usually, fondness) for hard work. I took it in stride but I didn’t always like it.

The decision to become a neurosurgeon places you on a track that runs, unabated, through a seven-year tunnel. This begins only after completion of the prerequisite four years of college and four years of medical school. This means that the average neurosurgeon is in his or her early thirties by the time the “real job” begins as a fully fledged surgeon with a decent salary and independent decision-making. If you tack on a one- or two-year fellowship (or worse—a Ph.D.), then you’re talking mid- or even late-thirties. (By that time, a good deal of interest has piled up on student loans.) At the end of the tunnel, the formerly undifferentiated M.D. emerges as an exquisitely super-specialized neurosurgeon, squinting at the rest of the world—a rare animal dominating a small niche within the ecosystem of medicine. At that point, you feel unqualified to do anything else, even if you had any lingering thoughts about a career change. It pays to listen to the elders before entering the tunnel in the first place.

Neurosurgery is marked by labor-intensive routine sprinkled with brief highs. The highs keep us going, so we hope they aren’t too brief or spaced too far apart. Popular portrayal of surgery on television usually focuses on these highs: saving a life, removing an ugly tumor from an otherwise young healthy brain, separating conjoined twins fused at the head. The laborious routine is far more representative, but not as enticing. (Only a very small handful of neurosurgeons, by the way, have ever separated conjoined twins, including one who wrote a book entitled
Gifted Hands,
about himself.)

In the traditional culture of neurosurgery, the puritanical work ethic reigns supreme. Our routines require long hours, especially during residency. Because we’re stuck with these long hours, we turn the long hours themselves into a source of collective pride. We tend to make fun of the “softer” specialists who never get called to the ER and who make it home in time to help their spouses chop vegetables for dinner.

One morning during residency, at our usual post-rounds seven a.m. team breakfast (after arriving for duty a couple hours earlier), my colleagues and I were joking around—and fantasizing—about the life of dermatology residents. One of the more contentious members of our group decided to put them to the test. He called the hospital operator and requested a stat overhead page to the dermatology resident on call.

Five seconds later, to the amusement of the entire hospital, the unprecedented page came through: “Stat page, dermatology resident on call, 4072. Stat page, dermatology resident on call, 4072.” We erupted into uncontrolled laughter. Assuming that the dermatology resident was still at home (making pancakes?), we laughed even harder when he actually called back, promptly. According to my colleague, the guy on the other end of the line displayed a mixture of confusion and excitement in his voice, and was genuinely disappointed to learn that there was no dermatologic emergency.

Although team camaraderie, in addition to the brief and scattered highs, helps get us through the routine, the routine is still often a chore. Consider what a typical day is like in the life of a junior neurosurgery resident, based on my experience from the not-so-distant past.

I wake up at 4:30 a.m. in order to make it to the hospital by about 5:15. After a very brief shower, I get dressed in a fresh pair of scrubs and apply undereye concealer to try to mask the dark circles. I don’t waste time with any other makeup. No blow-drying or other styling, of course. I’m satisfied with the plainest of looks in the interest of efficiency.

The one nice thing about getting to the hospital so early is that there are plenty of spots in the parking garage. I jog the short distance across the street between the garage and the hospital. I’m always rushing. I’ve never liked the feeling of having to rush, but there’s no good alternative. We have to be on time. Before joining the rest of the residents at six, I need to get the overnight update on my patients. I need to check their vitals and their labs, do a quick neurological exam, leave notes and orders in the chart, and speak to the nurses. As a junior resident, I am in charge of the head and spine injury patients in the trauma ICU. Sometimes I come in ten minutes later or earlier, depending on how many patients were in the unit the night before. Coming in a little later, though, can be risky if a new “stealth admit” came in overnight. Then I really have to rush, as being late for rounds is strongly discouraged. It can screw up the entire team.

I have five patients to see on this particular morning, which may not sound like a lot, but it is when you consider the complexity of their care and the fact that I have less than ten minutes to spend on each patient. (On principle, I’m not willing to get up much before 4:30 a.m.—although a few residents do—in case you’re wondering why I don’t just come in earlier.) I see that there is one new guy from last night: a typical motorcycle crash, no helmet. I’ll need to spend a couple extra minutes on him and skimp a little on another patient who’s more of a “chronic player” (a patient who’s been in the hospital a long time).

As soon as I enter the unit, two nurses start firing off questions about their particular charges, even though they know that I’ll be going through each patient, systematically, one at a time. Yes, go ahead and repeat the potassium on that guy and, fine, I’ll unclog the drain on that guy when I get to him. Some residents are cordial in answering urgent requests on nonurgent matters and others bark at the nurses for poor prioritizing. It can depend on how much sleep we got the night before.

I walk to the nurses’ station to gather the charts. I notice greasy pizza boxes containing half-eaten crusts from the night before and a large open bag of Doritos that has probably seen more recent activity. (When you round in the ICU the morning after a holiday, a cold leftover potluck of casseroles, bratwurst, and fried chicken usually awaits.) Mildly nauseated, I walk to the end of the unit and start with the first patient.

I get bogged down on this guy because his exam is not quite as good as it was the night before, when I last examined him on evening rounds. The change could easily be due to the fever he developed this morning, but I can’t make any assumptions. I look at his nurse and she fears what’s coming: he needs to go down for a scan of his head. I call radiology and she starts to “pack him up” for the ride down, which requires disconnecting all of his tubes and monitors and getting a respiratory therapist to “bag” him (pump in artificial breaths by squeezing a large plastic grenade-shaped device connected to the tube in his trachea) on the way to the scanner while he’s off the ventilator. It’s a real pain, and I get all the usual grumbling. Although I can’t say that the scan truly needs to be done stat, I know that if it’s not done now, then no one will look at it until we’re out of the OR much later in the day.

Of equal importance in my mind in placing the order “stat” is the fact that aggressive action is a highly valued trait in a neurosurgical resident. My early morning order allows me to announce on team rounds: “His exam was a little worse, so I sent him down for a stat scan. I’ve already checked it out and it’s fine.” Otherwise, if the problem isn’t resolved, the chief is likely to say, “So what did you do about it?” and consider you weak. A lesson learned early on is that a sin of commission is better than a sin of omission. Better to do too much than too little. If you appear weak or indecisive, people will walk all over you.

I check my watch and rush through the next four patients before running down to meet the team. I don’t have time to reflect on the fact that none of my patients are conscious enough to speak to me. I don’t know them as people, but rather as complex data sets and problem lists. As they start to awaken, they slowly emerge as individuals. At that point, though, they’re transferred out of the ICU and replaced by new data sets and problem lists.

The team gathers around the glow of a large computer monitor in the dark, windowless radiology department to review all the scans performed overnight. Our group consists of an intern, two junior residents, two senior residents, and two chief residents. One of the residents is still wearing his red outdoor fleece, which means he was running late and didn’t have time to get to the office to change into his white coat. (We heckle him about another “fleece day.”) Everyone else is wearing scrubs and white coats. According to official hospital rules, we’re supposed to wear our “street clothes” to the hospital and change into scrubs in the locker room. That’s a precious waste of time, though, at five a.m. Everyone just takes their scrubs home with them, in defiance of a rule made by someone with more time on his hands.

We have about ten minutes to examine the new scans, and the senior resident who was on call overnight “drives,” selecting the appropriate images on the appropriate patients from the computer. (In the modern era, films are no longer printed out and read on a light board.) The review is perfunctory and solemn until we get to the scan of a patient who required placement of an emergency ventriculostomy, a tube placed in the brain to relieve pressure.

One of the chiefs pipes up: “Wow! Who put that one in?” Everyone laughs heartily as the senior resident driving the computer lays claim to the job: “It’s working just fine, so I don’t even want to hear it from you guys.” These drains are placed freehand, often under duress, through a small hole in the skull, aiming for a certain spot deep within the fluid spaces of the brain. There are numerous ways in which the tip of the catheter can end up a little off from the desired target. This is typically of no consequence to the patient, so the images become a fertile but largely harmless source of ribbing among the residents. The ridicule is heightened, though, if the case does become complicated and the scan is reviewed on the big screen in our conference room, in front of the entire department. (These drains can be not only a source of social embarrassment, but also the cause of interrupted sleep when they become clogged in the middle of the night and you are called to the ICU to flush out whatever is clogging it, like small bits of brain—affectionately known as “brain guppies” in our program—or blood.)

We rush en masse from radiology up to the first ICU that we need to cover, and the resident responsible for this group of patients presents them in the ritualized, efficient manner that everyone is accustomed to. If the resident deviates too much from this form, the chief is likely to demand a course correction. Sloppiness and inefficiency are not tolerated. Everyone else on the team needs to take notes for themselves, and a disorganized presentation screws everything up on our sheets.

Here’s an example of a typical presentation on rounds, in written form as would be found in the hospital chart: “Joe Blow. PBD 8, POD 7, SAH, L. PComm. Levaquin #4/7 (lung?). AVSS, Tmax 38.2, SBP 120s–140s. I/O 4.2/3.1. D5 1/2 NS @ 100. Na 140, Hct 35. AA Ox2 (“1998”). PERRL. Speech normal. No drift. Strength 5/5. A/P: Neuro stable; Tx 5G, d/c Foley, cont. nimodipine.” The presentation takes less than one minute and the chief is then free to add to or subtract from the plan, to praise or to criticize. The chief’s other task is to keep the team moving. There are too many other patients to see, and we can’t get bogged down on any particular one.

This brief presentation supplies the entire team with all the pertinent details required to cover the patient. Equally important, it allows any resident to speak intelligently to any attending about any patient when accosted in the hallway. (The sight of an attending usually prompts a reach into the white coat pocket for our notes from the morning.) In the case of Joe Blow, any resident can be confident in the knowledge that the patient suffered a bleed from an aneurysm located on the posterior communicating artery in the brain. The bleed occurred eight days ago, the surgery was seven days ago, and he’s been on antibiotics for four days (with plans for seven days), for presumed pneumonia. He had no fevers over the past twenty-four hours, his blood pressure is fine, and his fluid balance is fine. He’s still on intravenous fluids. His pertinent lab results—sodium and blood count—are normal. He is alert and oriented to his own name and place, but not to the year (he thinks it’s 1998). His pupils respond to light, equally. His strength is normal. The overall assessment is that he is neurologically stable. The plan is to transfer him from the ICU to the step-down unit, to remove the catheter from his bladder, and to keep him on a medication to help prevent spasm of the vessels in his brain.

Despite our best efforts, there are numerous threats, lurking around every corner, that can potentially derail our efficient morning routine. Sometimes the threats are minor, like a chart falling apart, scattering dozens of pages across the floor. (The intern or the nurse will scramble to put it back together, while the patient is temporarily passed over. Given our penchant for superstition, someone might mention that the chart explosion foreshadows a poor prognosis for that patient.) More serious, a head injury could arrive in the ER during rounds, which means that someone has to “fall on the sword,” peel away from formation, and run down to check it out (and maybe have to skip breakfast, leaving him hungry all day in the OR). A nurse from the preoperative holding area may call about a missing surgical consent form. This one is particularly annoying. It’s purely a paperwork snafu, but it demands our attention because it threatens to delay an operation. The guy lowest on the totem pole is usually sent down to sort it out.