Another Day in the Frontal Lobe (9 page)
Again, there is no role for thinking here. It had been drilled into my head by the more senior residents that I ask for two things in this situation, automatically: a large piece of gel foam and a large cottonoid. While an assistant keeps a suction device in the field to siphon off the ongoing bleeding, you try to plug the hole with a large piece of spongy material (gel foam) and then cover that with a large cottonoid, which looks like a strip of felt. I placed these items over the hole but still, for the first several seconds, I was certain the bleeding would never stop. There was just too much of it. That thought wasn’t helpful, though, so I kept working at it.
It took me a minute or so, but I got the bleeding under control and called for assistance in completing the rest of the opening, which was more laborious than usual. We had to avoid disturbing the rather tenuous floodgates where the hole had been patched. All told, the patient probably lost about 200 cc of blood (eight-tenths of a cup) before I stopped the bleeding. Although this is a relatively small amount, it occurred over a very short time period and was enough to raise the heart rate (my heart rate, that is).
Total human blood volume is about 5 liters, so 200 cc of blood loss would make up only about 4 percent of the total blood volume. A heart-lung transplant surgeon would laugh at this. So would many orthopedic surgeons. Neurosurgeons would argue, though, that blood coming out of the head is distinctly different from blood coming out of the leg.
Despite the tear in the sinus, the patient did beautifully. She didn’t need a blood transfusion and was home in three days. The torn sinus was not technically a complication, but I did have to blame my technique, even though I knew it could happen to even the most senior and experienced of surgeons.
I attribute the punctuation in evolution here not only to my control of the bleeding, but also to the response of my fellow residents. After the case, I removed my bloody shoe covers and walked into the residents’ office. A few of the senior residents were lounging around and asked me how my case went. “I got into the sinus. The drill just ripped it open.” I must have looked dejected.
They all smiled and one piped up: “Did you have your hip waders on?” Riotous laughter followed. They had all been there before. They weren’t making fun of me, but instead were inviting me into the club. There is solidarity in adversity, and the fact that I handled it just fine made me one of the guys.
EIGHT
Tools
Neurosurgeons are practically worthless without their tools. In order for neurosurgeons to do their job well, these tools need to stay organized. Almost nothing irks a neurosurgeon more than when a surgical instrument can’t be found or handed over quickly enough. This can happen because (1) it is buried in clutter, or (2) the scrub nurse is new. I especially pity the new and disorganized scrub nurse. This fatal combination can bring out the worst in a surgeon.
This became obvious to me when I scrubbed in with a slick senior neurosurgeon known for his efficiency in the OR. We were doing a straightforward spine case and he had a tee time scheduled to follow. He was not in the habit of being late for a tee time. The nurse was new. The word was that she was a former exotic dancer, which, believe it or not, is actually marginally relevant to the story.
About one minute into the case, I could tell that he was getting antsy. There was too much delay between him speaking the word “Cobb” and the instrument hitting the palm of his hand. He couldn’t get into his usual rhythm. He glanced up at the clock on the wall and said, “Let’s stop right here for a second.” I knew this was trouble.
He looked Ms. Former Exotic Dancer in the eye and then, in the softest of tones, explained: “Pretend this is your makeup counter. You would have things organized, right? Your mascara goes here, lipstick there, eye shadow over there.” He pointed to different areas of the instrument table.
It was strange to hear a surgeon like this say a word like “mascara.”
“So, we’ll put our kerrisons here, Leksells here, and periosteals there.” He arranged the instruments for her in neat little rows. “Now let’s get going.”
All concerns of sexism aside, I was happy to see that this little tutorial actually worked. The case went smoothly from that point on, and the surgeon had plenty of time to get to the golf course. Not only that, the nurse seemed genuinely grateful for the advice. (I knew that the surgeon intended no offense. I had already judged him to be a genius in speaking to people on their own terms and in their own terms. I accompanied him once to see a patient who was a librarian. He greeted her with: “So, what’s new with the Dewey decimal system, huh?” Maybe a little old-fashioned, but you had to love him.)
Because neurosurgeons spend a large portion of their professional lives in the operating room, it’s not surprising that we can develop a certain affection for the tools we use. Although I admit to having my own favorites (I like the simplicity and versatility of the slim, no-frills Penfield #4 dissector), some neurosurgeons go a bit overboard, assigning cutesy nicknames to their favorites, names that seem a bit out of character in the macho world of surgery.
One attending I worked with, in the middle of performing the mechanical grunt work on the skull necessary for invasive skull base surgery, would ask the scrub nurse for “my little nipper.” This is not the instrument’s given name. It is his, and only his, nickname for a diminutive variant of a tool properly called a “rongeur” (the
g
here being the French type), designed to bite off pieces of bone. New nurses are expected to know, a priori, what “my little nipper” is, and some actually figure it out, without prompting, by scanning the table of possibilities and reading the surgeon’s mind. Others don’t even try, raising their eyebrows and asking: “You want the
what
?” After swallowing my pride, I gathered up the courage to ask for “my little nipper” when working with this neurosurgeon, assuming that consistency within the team was important.
Claiming possession of an instrument that you don’t own or that you didn’t invent can rub people the wrong way. One neurosurgeon I know made frequent use of a dissecting instrument called a “freer,” which is pronounced in two syllables, as in to free something up. Case after case, use after use, he started to ask for “my freer, please” rather than just “freer” or “the freer, please.” In the setting of a long, multihour case, this subtle shift in nomenclature annoyed one of my fellow residents so much that, when that neurosurgeon stepped out of the room during an operation, the resident turned to the scrub nurse and said, in a mock-serious tone, “I’ll take the ‘myfreer’ please,” as if it had become one word. Long hours in the OR have a special way of magnifying trivial annoyances.
Other nicknames are just cute abbreviations, like “pitute” for “pituitary rongeur,” and some instruments have names that are already so cute they don’t need a nickname, like the “peapod” instrument we use in disc surgery. Certain well-established nicknames make no sense, like the “bunnies” whose proper name is “Adson forceps.” (I refuse to ask for “bunnies.”) When it comes to requesting an instrument to retract against the brain, I have my choice of three different names (brain retractor, malleable retractor, and brain ribbon) for the same instrument. I prefer “brain ribbon” because it is, by far, the most poetic.
Although I’ve never claimed an instrument as my own and I’ve never coined any affectionate nicknames, I do have a soft spot for surgical instruments in general, partly because of my upbringing and partly because I like design, and so many instruments are a perfect coupling of form and function that I’d say are worthy of display in the Museum of Modern Art.
I was in an antique store recently with my husband and he pointed out an interesting artifact in a glass case that he knew I’d love. It was an old hand drill used to make holes in the skull, long before the era of the slick power drills we use today. As I’d seen with other antique instruments (and been amused by), there were even a couple ornamental elements, a touch of design beyond what was required for function, almost as if it were meant for display.
My first impulse was to buy it. But then, my husband and I started thinking: What would we actually do with it? Would we display it in our home as a morbid conversation piece? Could I display it in my office, or would that be completely inappropriate, prompting nervous questions by already nervous patients? Our indecision, combined with the price, made me pass on the opportunity, and I kind of regret it now, although I still don’t know what I’d do with it.
A small hospital that my father used to work at closed several years ago, and the OR was throwing out tons of outdated and broken equipment. They must have felt the stuff wouldn’t even have been worthy of donation to a third world country. My father—a natural tinkerer with an inventive mind—picked through some of the “rubbish” and brought several selected pieces home with him. For months, you could come across an old used endoscope here and there, in the family room or the library, and you might wonder what orifice it had last been pushed through.
After a while, the novelty of using the scopes to look under bookcases wore off, and our family found no further use for them, until my brother came home one day with a brilliant idea: eBay. He had become accustomed to foraging through my mother’s long-forgotten basement treasures, Hummel figurines, and once-precious china, selling the goods on eBay to help pay his Brooklyn rent. The endoscopes then, transferred from the hands of a tinkerer to the hands of an opportunist, made their way into cyberspace and were quite a hit. They sold like hotcakes. (Who bought them, I wondered, and for what potentially subversive reasons?)
I guess it’s okay to profit off of someone else’s trash, but it does give me pause. I have to think of it this way: it would otherwise have ended up in a landfill. But do you owe anything to the person or organization that was throwing the “trash” away? My mother would answer with this famous story of hers. She was leaving a friend’s home, driving down the driveway, when she noticed an old worn-out oriental rug lying on top of a garbage pail, awaiting pickup by the garbage truck. She went back and asked the friend if she could take it. Her friend, of course, had no problem with her taking it—it was trash.
My mom used the rug in our garage for a while, but my father tired of it and requested that she get rid of it. My mom cleaned it up and donated it to a local philanthropic organization that automatically had it formally appraised—at a value of $1,000. A while passed before she decided to tell her friend, but they both had a good laugh, and watched what they threw out from then on.
Although the variety of tools that we have to choose from is enormous, we tend to use certain ones over and over again, from case to case. This does cut down on the confusion a little. A favorite saying of one of my mentors—“Ah, the sound of neurosurgery!”—refers to the sound made by the most commonly used instrument in modern brain and spine surgery, an instrument we deem absolutely essential. We demand two for every case: one for the main surgeon, one for the assistant. We rely on this instrument throughout the entire operation and use it to perform the most basic and the most complex of functions.
Granted, neurosurgery is a technically advanced field, but in this case I’m not referring to lasers, robotic assistance, or holographic imagery. I’m talking about the lowly suction device: a thin metal suction tip connected to long clear plastic tubing that’s hooked to a centralized wall-based vacuum system. This instrument is nearly identical to the one used by dental hygienists to clear the saliva out of your mouth during a dental cleaning, except that their suction tips are usually plastic and disposable. We reuse ours.
During an operation, the surgeon’s nondominant hand is nearly always occupied by holding and manipulating the suction, while the dominant hand controls other instruments, such as the drill, the bipolar (a coagulating device), scissors, or a dissecting tool (of which there are over a dozen to choose from). We tend to call this instrument the “suction” or “suction tip” rather than “sucker.”
The suction serves two main purposes: to retract against various tissues, including brain, and to continuously clear the surgical field of fluids that get in the way, namely blood and cerebrospinal fluid. (Hence the omnipresent, somewhat annoying, sound of fluid being sucked through the system, the “sound of neurosurgery.”) The suction tip can also be used to help push things into place, such as when packing various materials into a hole to stop bleeding. The suction, though, has more than just a supporting role. When removing a soft brain tumor, the bulk of the work may be accomplished by the lowly suction, even in this modern era.
Other surgeons have been known to make fun of us for our strongly suction-centric ways. (All surgeons use a suction device, but not quite so extensively.) While general surgeons, cardiothoracic surgeons, and orthopedic surgeons toil over abdomens, chests, and limbs, you will notice more cutting, sewing, and tying. In short, they look like they’re doing surgery. Their hand movements are grander. They may even have to get their elbows and shoulders involved for the bigger moves.
Neurosurgeons doing brain surgery, on the other hand, tend to look like they are picking at things, sucking things out, little by little, sometimes for many lonely hours at a time. Once the grunt work of bone removal is done and the brain is exposed, the microscope is wheeled into position. The moves are small and delicate. Elbows and shoulders remain still.
Despite, or maybe because of, their simple tubular structure, suction devices are not foolproof. They are a leading source of mundane frustration for the neurosurgeon in the OR. Pieces of tissue or clotted blood often clog the suction tip or the tubing, requiring the surgeon to interrupt the flow of the case, hand the device over to the nurse, and have it flushed out with saline irrigation. When that fails to clear the problem, all eyes turn to the large canisters by the wall. Are they full? Or, perhaps the quiet and unsuspecting medical student standing in the background is the culprit: Is his foot on the tubing that runs along the floor? If so, he is forgiven, but only once. He’d better not step on it a second time, or the surgeon may start to question his worth as a human being.
If the suction is our number-one most basic instrument, the drill may be number two. That’s how we get into the head. Obviously, drilling holes in the head is one thing that distinguishes neurosurgery from the typical desk job. Not so obvious, though, is that the drilling of a hole can be more meaningful than you think. The honor of placing the first “bur hole” of an operation is a gift, of sorts, that we sometimes grant to our eager interns who plan to give themselves over to neurosurgery. We present them with a freshly exposed portion of skull, scalp retracted off to the side, and then ceremonially hand over the weapon. The honor of having drilled into a live human skull then affords the intern bragging rights: “Yeah, I placed a bur hole today. The guy’s fine.” The intern may say something like this, nonchalantly, to his colleagues who are bored stiff from checking labs and writing orders all day.