Another Day in the Frontal Lobe (2 page)

A swollen brain is another matter. There’s not much room for it to swell. Swelling within a fixed container leads to elevated pressure, and unchecked pressure can lead to a cascade of events—namely a last-ditch shifting of delicate intracranial contents—that can be fatal. So as neurosurgeons, we do whatever we can to maintain a normal pressure within the skull when things go awry, such as in a serious head injury.

Although this is “brain surgery,” the options we have for treating high pressures within the head are relatively simplistic and mechanistic: drain off cerebrospinal fluid from within the skull, shrink the brain tissue itself with a temporary dehydrating agent, or constrict the blood vessels in the brain via hyperventilation (although this one can be dangerous in situations when the brain needs all the blood flow it can get). If these options fail, there are more extreme measures, as a last resort: remove a portion of relatively “unimportant” brain tissue to create more room, or remove a section of skull to allow the brain to continue to swell. The decision as to which of these extreme measures you choose is largely a matter of who your mentor was and what he or she preferred to do.

As an example, here is how I handled such a decision recently. It was a warm sunny Sunday afternoon and I was sitting at an outdoor table at an Italian restaurant with my husband. We were eating salad and waiting for our Margherita pizza, content in our idle people-watching and discussing what we wanted to do after lunch. Our contentment was interrupted by my pager. It was one of the medical interns at the hospital: “Dr. Firlik, we need you to see a patient in the ICU, soon as you can. He had a stroke a few days ago and now he’s herniating.”

“Herniating” refers to the end-stage shifting of the brain in response to increased pressure. The word puts everyone into crisis mode, including my husband who, overhearing my conversation, had our pizza boxed up so he could eat it while sitting in the passenger seat of my car as I sped down the highway. He is also a neurosurgeon but, because of his passion for innovation and entrepreneurship, pursued a career in venture capital. He has always been interested in challenging cases, so he still likes to offer his two cents when it comes to critical decision-making.

“So what are you going to do for this guy?” he baits me, between bites, his smile glistening.

“I don’t know. I haven’t seen him yet,” I answer, stating the obvious, not interested in debating the pros and cons of surgical intervention as we have done on so many other occasions with each other and with colleagues, to the point where it feels that we are following a script.

“Well, just call me if you’re going to the OR. I’ll leave my cell on.” He gives up and pulls a second slice out of the box while wondering out loud what he should do to amuse himself while I’m busy. He’ll probably go to a café and read a couple newspapers, further broadening his understanding of the world we live in.

We arrive at the hospital and my husband assumes the driver’s seat. I leave the car, enter the hospital through the automatic glass doors that seal shut behind me, walk down the hallway to the ICU, and prepare to immerse myself in a very small, intense, and isolated world.

I have three priorities: evaluate the scan, evaluate the patient, and then step back for a gestalt, big-picture view of everything. The patient’s scan is a textbook example of a major stroke that has swollen aggressively. An “ischemic” stroke—due to blockage of blood flow to a portion of brain—causes part of the brain to die. (Just as a heart attack causes a portion of heart muscle to die.) Dead brain tissue swells. If a large portion of the brain has died, such as in a complete middle cerebral artery stroke, the swelling can be quite impressive, to the point where it causes the brain to shift within the skull, threatening the viability of the remaining normal brain and brain stem.

Where I trained as a resident, a “strokectomy” was advocated in certain life-threatening situations. In a strokectomy, a portion of dead brain tissue is surgically removed in order to leave more room for the remaining, unaffected brain. The concept is somewhat controversial and the practice is not widespread, but it truly can be a lifesaving procedure. The question, of course, is whether or not the life in question
should
be saved, given concerns of quality over longevity, and that’s where the decision can get tricky.

I did a brief neurological exam on the patient while the family waited outside the room. He was clearly in dire straits. I ordered a stat dose of mannitol to be given through the IV to buy us some time. This would temporarily lower the intracranial pressure by dehydrating his brain a bit. The effects don’t last long but it’s perfect for such a situation. I would have a few minutes to talk to the family, the neurologist, and the internist in order to get the critical big-picture view, as this was my first time meeting the patient. What was he like? What would he want? What do we want?

A living will doesn’t always give clear direction. I remember seeing one in a patient’s chart that included a few lines at the end that the patient had added in his own words. It said, in large, almost childlike, handwriting: “I do not want no machine hooked to me. Soley to keep me alive.” Unfortunately, I couldn’t extract any further meaning from these words apart from what was already in the legal text, but the handwritten words were far more endearing.

Conversations like this require as much listening as talking, if not more listening than talking, and this is when the neurosurgeon is neither scientist nor mechanic. After holding court with all parties, the decision was clear: no surgery. The patient was elderly, and fragile in so many ways. His neurological deficits were significant, and his outlook was bleak, even with a technically successful emergency operation. Everyone agreed to no “heroic” measures (an odd term in a situation like this, as sucking out dead brain tissue in a frail elderly man seems more pathetic than heroic).

In the instant the decision was made, the intensity that had stricken that small world vanished. The nurses moved more slowly. The looks of panic, fear, and confusion on the family members’ faces were replaced by a simple sadness. The neurologist and internist left the ICU to attend to other concerns. I lingered for a few moments in an attempt to soften the blow, as if I could somehow soften the blow.

In thinking like a neurosurgeon, not everything comes down to a mechanistic evaluation of the intracranial contents. You do have to know about everything that can go wrong, and then about everything you can do to fix it, but then you also have to know when to do nothing. Certain decisions come down to a judgment call based on the gut, and that’s when both the scientist and the mechanic step aside.

I returned to the nurses’ station and dialed my husband’s cell phone. He answered and I heard music in the background. I could picture him in the café, sipping a latte and flipping through
The New York Times
“Week in Review” section.

“Can you come pick me up?” I asked him.

“Sure. No surgery? Let’s enjoy the afternoon then,” he said, matter-of-fact.

And I did enjoy the afternoon, strangely enough. Because, in thinking like a neurosurgeon, you also have to know how to make a decision in the face of tragedy and then just move on.

TWO

Small World

Sometimes I wonder why I chose such a strange career. I don’t always have a satisfying answer for myself, but I can accept this lack of clarity from time to time. When other people pose the same question, though, I feel obligated to have a clear answer, so I have developed a respectable dinner party response that takes only a few seconds, something about neurosurgery being the best way to combine my interest in the brain with an interest in doing things with my hands. This answer, though, is admittedly dull and perfunctory, and probably disappointing.

Luckily, most people don’t linger over my lackluster response because the “why” question is typically followed by a “what” and a series of “hows”: so
what,
exactly, do you do, and
how
do you do this or that? I suspect that other professionals, like teachers, lawyers, and even other doctors, don’t get these “whats” and “hows” quite so often, and I think I may know why. The bottom line is, there aren’t many of us out there. Not only is the job unusual, it’s also extremely uncommon.

I love watching the Parade of Nations during the opening ceremonies of the Olympics. As the athletes stream into the stadium, I read off the name of each country and remark on how many athletes follow along behind each sign. I have a special affection for the smaller nations with smaller representation, like Malta and East Timor. I root for those athletes. In the world of medicine, neurosurgery is one of the smaller countries with fewer athletes trailing behind its sign. Internal medicine, pediatrics, obstetrics, and gynecology, to name just a few—those are all much larger. There’s no need to feel sorry for us, though. We’re well trained. As a nation, we don’t struggle that much. Neurosurgery is similar to one of the Scandinavian countries—small but elite and with an impressive gross domestic product relative to its size. In fact, at large academic medical centers, our economy often helps support the more populous but less economically sound Sudans of medicine. You might consider rooting for one of them.

There are about 4,500 neurosurgeons in the United States. As a visual person, I picture that number as, roughly, all the kids in my high school times two. This means that there is, on average, one neurosurgeon for about every 66,000 people or so in this country. (Compare that to the African continent where the ratio is one neurosurgeon per 1.4 million people. If you exclude Northern Africa and South Africa, the ratio is closer to one neurosurgeon per 6 million people! One piece of advice: avoid a head injury while on safari.) As for the boy-girl ratio, it’s still heavily weighted toward the boys. Only about 5 percent of neurosurgeons in the United States are women, but that is changing, slowly, as more presumably intelligent women are willing to subject themselves to a career of demanding and frustrating lifestyle inconveniences.

If an American has never traveled to Scandinavia or is not well acquainted with world geography, he may have difficulty in distinguishing between Norway, Sweden, and Finland on a map. Similarly, unless you have personally dealt with a neurosurgeon before, you may not be able to distinguish between neurosurgery, neurology, and maybe even psychiatry. This confusion stems from the common focus on the brain. The specialties, though, are quite different and each has a strong national pride. Neurosurgeons tend to wince at the mistaken identity. They joke that one good MRI scanner can replace a hundred neurologists. The snobbery here revolves around the assumption that a surgeon’s skills cannot be replaced by a machine (at least not yet). I can’t comment on whether neurologists are subject to the reverse mistaken identity, but I can attest to the fact that most would consider themselves brighter than surgeons. They are also more likely to have a beard or wear a bow tie, by the way.

Because our jobs are unusual, I need to clarify what we do, who we are, and who we aren’t. The “surgery” part is a clue. Neurosurgeons operate. Neurologists and psychiatrists do not. For that reason, neurosurgeons focus on disorders amenable to surgery, which constitute a relatively small subset of all brain-related disorders. That is one reason for our small numbers. Brain tumors can pose a serious threat to individuals, but they are not public health menaces.

So, for instance, Alzheimer’s disease seems to be on everyone’s mind. Neurosurgeons don’t treat Alzheimer’s disease because no one has ever designed an operation for it. Consider schizophrenia. It affects 1 percent of the population, but, again: no operation for schizophrenia, so no role for neurosurgery. If you ask me about schizophrenia, I can tell you what I learned in medical school a decade ago or, better yet, what I read most recently in
The New York Times.
I will certainly be conversant, but not an expert. What about these disorders: autism, attention deficit, and Tourette’s? Again, these are not within our surgical scope, but I do find them to be a fascinating read.

Neurosurgeons are true experts in brain trauma, brain tumors, aneurysms, congenital brain anomalies, hydrocephalus (“water on the brain”), and brain hemorrhages, among other things. All of these problems have at least the option for a surgical solution. The borders between us and our nonsurgical colleagues, though, are porous in spots. Some diseases can be treated by both a neurologist and a neurosurgeon, like Parkinson’s disease or certain forms of epilepsy. A neurologist may refer such a patient to a neurosurgeon when it becomes clear that medication alone is ineffective, or if medication side effects are too much of a problem. Surgery is usually a last resort.

Classically, neurosurgeons complain that neurologists wait too long and try too many medications before sending patients over. Neurologists complain that neurosurgeons are too aggressive in recommending surgery. Such grievances keep things lively.

Leaving the brain aside for a moment, you may not realize this: the majority of neurosurgeons spend the majority of their time operating on spines rather than brains. This may be a minor disappointment, because the spine tends not to inspire the same degree of intrigue and appreciation as the brain. The predominance of spine surgery is simply a reflection of what’s out there in the population (and, some cynics would argue, what tends to reimburse well). You probably know someone with a “bad back” or a “bad neck” and may even be a victim yourself. Arthritis of the spine (or degenerative spine disease, as we like to call it), unlike brain tumors,
is
a public health menace.

Because of this broader focus on both the brain
and
spine, we don’t refer to ourselves as “brain surgeons.” The term is too narrow. Also, it sounds silly for some reason, so it’s hard for us to say it with a straight face (although I have heard of neurosurgery residents using the term as a pickup line in bars). Likewise, rocket scientists don’t actually call themselves rocket scientists, but I’m not clear on what they do call themselves.

One man is historically credited with having inspired the enduring “brain surgeon” image in the public eye. Harvey Cushing is the widely acknowledged father of neurosurgery. To give you a sense of the field’s youth, Cushing was born in 1869 and died in 1939. He was really the first person to perform brain surgery in a thoughtful and systematic fashion despite the overwhelming surgical mortality rate at the time. Most surgeons were intimidated by the thought of operating inside the skull. Cushing, though, was a pioneer and a bit of a renegade. The techniques he developed and the rigor he brought to the discipline made brain surgery a reasonable endeavor for others to pursue. Neurosurgery is its own specialty largely because of Cushing.

What made Cushing even more remarkable, though, was that he was more than just a pioneering neurosurgeon. Although his clinical skills made him famous among physicians, it was his literary skill that was instrumental in his recognition by the larger public. He won a Pulitzer Prize for a biography that he wrote about another famous physician, William Osler. This and his later writings made him a well-known entity in the literary world and gave him coverage in popular publications like
The New York Times, Newsweek,
and
Time.
¹

After Cushing’s death, his own biography was written by one of his protégés, John Fulton. I have an original copy of the book, published in 1946. I bought it at a used bookstore in Cleveland—my hometown—the city that Cushing grew up in.
²
  On the inside cover, written in pencil, is the following: “Abram Garfield, from Hope & Ted, Xmas ’46.” On a whim, I looked up Abram Garfield in the index when I bought the book, and noted four separate pages listed after his name. The former owner of my book was Cushing’s friend.

Cushing’s biography is over seven hundred pages long. Although I have never read through the entire tome, I did make sure to read the last couple pages which, I discovered, are of particular significance to neurosurgeons. In true surgical style, Fulton describes Cushing’s autopsy in a fairly matter-of-fact clinical fashion:

“Drs. Milton Winternitz and Harry Zimmerman reported that the brain showed no sign of atrophy but the arteries were here and there sclerosed; and in line with the superstition that physicians sometimes fall victim to the diseases in which they specialize, a small colloid cyst, one centimeter in diameter, was found in the third ventricle.”
³

A colloid cyst! Harvey Cushing, father of neurosurgery, harbored a colloid cyst deep within his own brain. (I don’t think even many neurosurgeons know this.) A colloid cyst is a quirky little entity. It’s completely benign in the sense that it’s not a tumor or cancer, but it is associated with the possible risk of sudden death. It sits at a critical crossroads of cerebrospinal fluid circulation in the brain such that if the cyst grows large enough, it can block this flow and cause a dramatic and rapid increase in the pressure inside the head. Luckily, colloid cysts are pretty rare. In Cushing’s case, the cyst was an incidental finding. He probably died of a garden-variety heart attack. He was a smoker.

Colloid cysts are fun to remove. A gelatinous goo often oozes out from the center after you pop through the cyst wall. I say this with the realization that most people wouldn’t want to think of their neurosurgeon as having “fun” (or marveling over gelatinous goo). But you have to have some fun with your job, or why do it? As a junior resident, I was privy to an unusual conversation between one of the academic neurosurgeons and a woman with a newly discovered colloid cyst. The neurosurgeon explained that he was going to have to refer her to a colleague in the department who was more of a specialist in the endoscopic technique recently advocated to remove such cysts. He then added: “But don’t get me wrong…. I’d love to take that sucker out!” The woman appeared dumbfounded as the neurosurgeon patted her on the back and walked out, leaving us in the room together alone. An awkward silence lingered. Some things are better left unsaid.

Cushing was buried at Lake View Cemetery, a historic cemetery in Cleveland that is also the final resting place of J. D. Rockefeller and former president James Garfield. When my husband and I were still medical students, we wandered around the cemetery in search of his grave. We found it only after consulting a cemetery map, as it wasn’t one of the most impressive tombstones. As eager medical students, we had become Cushing groupies, several decades too late.

I can assure you that, as a kid, extracting a nail from someone’s head or wandering around a cemetery in search of a neurosurgeon’s tombstone were not activities I would have envisioned for my future. I was, though, privy to the world of surgery well before I made a single career move, and this must have affected the wiring of my brain in ways undetectable to my child mind at the time.