Another Day in the Frontal Lobe (20 page)

The chief resident on the hot seat at that moment, seven years my senior, stood at the podium and discussed the case, very matter-of-fact. He discussed his technique in detail, how he ventured out laterally, and how he injured the vessel, ultimately having to sacrifice it altogether to control the profuse bleeding that ensued. Luckily, the patient had enough overlap in circulation from the paired vessel on the other side that a major stroke did not occur, but that was pure luck. The same complication could have had a much different outcome in a different patient.

What impressed me was this guy’s confidence and honesty. He wasn’t the type to make careless mistakes, but mistakes sometimes happen, even to the best. He was appropriately apologetic in a professional way, without groveling, and did nothing to diffuse the blame or come up with convoluted explanations as to why it couldn’t have been avoided. The funny thing was: afterward, there was no discussion, no questions, no contentious accusations. There was no need, and he continued on to the next case.

Seven years later, it was my turn to run the show, this form of medical theater and internal policing. Our M&M conference adhered to a time-honored ritual. The chief resident, of course, stood up front at the podium. The department chairman sat in the front row, in a corner seat, with the black three-ring binder that held a list of all the neurosurgery operations performed that week, including who was involved in each case and whether or not there was a complication. There was otherwise no formal assigned seating, but the residents tended to favor the back of the room (the post-call resident might try for the last row, allowing him to rest his head against the wall).

Logic would dictate that if you hid yourself well enough in the room you wouldn’t be “pimped,” but logic was proved wrong again and again as the chairman would crane his neck and body into extreme contortions to make sure he saw the guys in the back who were trying to hide. They were sure to get grilled. Still, exposing your flank, right up front in the open, seemed even riskier, so we all persisted in playing hide and seek.

Here’s how a presentation would go. The chief—me, in this case—would present the first patient in the formal medical parlance and format, the same exact style used by generations of surgeons before us:

“L.M. is an eighty-five-year-old woman with early dementia who complained of a headache and then developed a dense right hemiparesis, confusion, and aphasia.” (In other words, she couldn’t move the right side of her body and couldn’t speak.)

At this point the chairman might jump in with a question, usually for the youngest resident on the team. He was good at asking age-appropriate questions, pimping the intern or junior resident on basic anatomy, physiology, and pathology questions and reserving detailed inquiries regarding the pros and cons of various surgical approaches for the senior or chief residents.

“John: What do you think is going on here?” the chairman would ask.

“Uh…could be a bleed, stroke, tumor…infection,” John might answer.

“Infection? Come on now. You don’t really think this is an infection. Why do you guys always feel obligated to give us the most comprehensive list? Tell me what you really think this is.”

“A bleed, sir.”

“Good, go on.”

(It’s hard for a resident to win this game. If John had simply said “a bleed” with bold confidence from the start, the chairman very well could have answered “Is that it?” and chided him for neglecting to list other possibilities.)

The chairman would leave John alone for a minute and would turn his attention back to me as a sign to continue with the case.

“Her past medical history was significant for hypertension, peripheral vascular disease, depression, and heavy smoking. She was on aspirin, Prozac, labetalol, and Lasix. She presented to the ER where a stat head CT was performed, and we were consulted.”

“All right, back up,” the chairman would say. “What about her exam?”

“Okay,” I’d continue, “in the ER she was awake but sleepy, nearly flaccid in the right arm and leg, unable to follow commands and unable to speak.”

“Pupils?” he’d ask.

“Equal and reactive.”

The residents always wanted to get to the visuals as quickly as possible: the scan of the brain, the money shot that would give us something to work with. The attendings would annoy and taunt us by questioning us on details of the neurological exam in an effort to teach us a thing or two, or to criticize us for failing to check for a specific esoteric finding. In reality, we usually saw the scan before we saw the patient, but we would make an effort to follow the rules of formal medical presentation anyway, with history and exam first, then scan, albeit artificial in the modern era. After a few nitpicky questions about the exam, followed by my perfunctory answers, and maybe another question lobbed over to John about what the scan might show, the chairman would give in:

“Okay. Show us the scan.”

I would flash her head CT scan up on the screen, cut by cut, from the bottom of her head to the top. Then I’d take the initiative to pick on a resident myself and ask him to take us through the findings. This is how the conference would go; a step-by-step unveiling of the story punctuated by pointed questions to the audience. The best part would be the debate that followed.

I liked to request: “A show of hands for those who would recommend taking her to the operating room.” Maybe a third of the room would be in favor. “And who would
not
operate?” The majority was in this camp, but a few didn’t vote, so I would single out one of the unlucky few who couldn’t decide.

“Mike, you didn’t vote. What are you going to do here? You have to make up your mind.”

Mike was one of the younger guys, unsure of the right decision here.

“Well, she’s eighty-five, a big smoker, not the healthiest, she’s probably not going to do well. You might not be able to get her off the ventilator. But…the bleed…it’s huge. She’ll probably end up dying if you don’t take her to the OR. Maybe you just go in and take the clot out, hope for the best, but—”

“Mike, make up your mind,” one of the senior attendings pipes up. “You’re on call. You’re in the ER. What’s your recommendation over the phone to your attending?”

“Okay, okay,” Mike answers, a little flustered, “I’m taking her to the OR.”

“So, you’re taking an eighty-five-year-old hypertensive smoker to the OR?” one of the pediatric neurosurgeons asks. “I thought we all knew the data on intracerebral hemorrhage in the elderly. You might improve her short-term outlook, get her off to a nursing home in a few weeks, but she’ll end up doing very poorly in the long run, just the same. You’re just prolonging the inevitable.”

“Wait a minute!” One of the vascular neurosurgeons jumps in. “I’ve had plenty of families who have thanked me for taking their loved ones to the operating room in this type of situation. Patients don’t always follow the rules. Some can do quite well. Come to my clinic, you can meet a few.”

“Your idea of ‘quite well’ is in a nursing home with a feeding tube!” the pediatric attending says. The room erupts in laughter.

The chairman tries to maintain some order. “Okay, that’s enough. Let’s hear what happened to this poor lady.”

I continue: “The recommendation was made to send her to the ICU, stabilize her, but not to operate. The entire family was okay with this plan except for the daughter, the one from out of town, of course. She asked for a second opinion and had heard of Dr. Jones through a friend of a friend. Dr. Jones saw her the next morning and said that surgery was an option and that he would actually be in favor of it. The rest of the family finally gave in to the daughter, and the patient ended up in the OR within twenty-four hours of admission.”

“Hmm…sounds a little complicated. How’d she do?” the chairman asks.

“Well, she woke up after surgery, more alert, and was starting to move her right side within three days. We couldn’t get her weaned off the ventilator because of her lungs, and she ended up with a pneumonia.”

“Big surprise there!” I heard one of the more cynical senior residents mutter under his breath.

I continued. “Finally, after serious debate, the family decided on the trach and PEG route (tracheostomy and feeding tube surgically inserted through the stomach wall), and now we’re awaiting nursing home placement.”

“Nice case,” concludes the pediatric neurosurgeon. “Next?”

In a department made up of over twenty neurosurgeons, as was the case at my training program—one of the largest in the country—you will see the entire gamut of clinical decision making, from the most conservative to the most aggressive. As a chief about to go out into the real world, I felt lucky to have been able to sift through the large collective experience of all of my mentors and develop my own set of philosophies and leanings that would inform my recommendations going forward. But that was the scary part of anticipating the end of the chief year: soon, the buck was going to stop with me. No longer would I be able to suggest a strategy to my attending over the phone at three a.m., discuss the pros and cons, and then have him look over my shoulder as I carried out the plan that he approved.

The interesting thing is, different residents, drawing from that same collective experience, may come up with different views of the vast array of neurosurgical options by the end of it all. Medicine is a human endeavor. Here’s a secret, then: what happens to you on admission to the ER for a neurosurgical problem may not be based purely (or even mainly) on science. The science regarding a particular situation may well be scant or conflicting. The individual philosophy of the neurosurgeon who happens to be on call that day may be of equal influence. As evidence, M&M conference is chock full of debate, often the same debates over and over again, back and forth, especially the “operate versus don’t operate” variety.

The burgeoning elderly population—prone to falls, catastrophic bleeds from blood thinners or worn-out vessels, and brain metastases from recent or remote cancer—ensures, unfortunately, that there will be no shortage of cases to be debated. (Over the course of a two-day period recently, I was asked to consult on three patients in the hospital. Their ages: eighty-five, ninety-three, and ninety-nine years old. All involved some form of blood in the head.)

You can’t always state a treatment philosophy with absolute certitude (except maybe the one I learned in pediatric neurosurgery: if the mother thinks her child isn’t quite right, then the child isn’t quite right, even if he looks perfectly normal to you). There are so many variables to consider in difficult cases, especially in the older patient: Is the person a frail eighty-five or a hearty eighty-five? What is their baseline quality of life like? Are they demented, and to what degree? What preferences had they expressed ahead of time? What are their family’s wishes? How complicated are the possible interventions? How much “torture” are we willing to put a person through and for what possible outcomes?

It can all boil down to this question: What constitutes a life worth living? This is where it gets messy, philosophical, and personal. Consider life in a nursing home at age eighty-five, unable to speak or move one side of your body, and unable to care for yourself. One colleague of mine told me that as long as he could hold his grandchildren on his lap, then that would be a life worth living. Another responded, when presented with the same scenario: “No way! Spare my family the anguish.” Our recommendations to others can very well be colored by what we feel would be an acceptable life for ourselves.

How much value do statistics play in these sticky decisions? What if one study concludes that 10 percent of elderly patients operated on for large bleeds have a “good” outcome, broadly defined. What if another study says it’s only 1 percent? What if you think those studies, probably uncontrolled and retrospective, are no good to begin with (as many studies are)? What about the one-in-a-million miracle case from the news or the tabloids that families always ask about, the person who came out of a vegetative state after ten years, still bed bound but able to smile and utter a few words like “hi” and “Pepsi”? Those stories make our jobs more difficult.

Once a decision is made to take someone to the OR, when the situation is not black and white but gray, and when the ultimate outcome after surgery remains uncertain, you almost have to say “we did the right thing” no matter what. If not, you risk casting doubt on the decision, inciting feelings of guilt, and deflating everyone’s morale.

I remember taking care of a patient who traveled from several states away for consultation regarding a very rare and vexing problem: intractable hiccups. This was no joke. The patient was quite elderly but otherwise reasonably healthy. His hiccups started soon after coronary artery bypass surgery a few years earlier, and they were ruining his life. He had already tried everything and had had every scan of every possibly implicated body part. His family did the research and found out that one of the star neurosurgeons in our department had a reputation for curing unusual and often mysterious ills that may have their origin at the brain stem, and a couple cases of brain surgery for intractable hiccups had actually been written up as case reports in the medical literature.