"Good luck." Such was Dr. Wang's advice on Day 1 concerning getting the attention of my clinician, Dr. Philip Stieg. I had to admit, I could only smile and nod at the time - three weeks of attempting to contact the Chairman of the Department of Neurological Surgery and all I really had to show for it was the knowledge that he had a very helpful secretary, executive assistant, and nurse that had about as hard a time getting his attention as I did. But going on the age-old assumption that if you are persistent, good things will come, I dove headlong into the chaos that is a hospital on Monday and came out with several things: my mentor's schedule for the week, an invitation to see my first surgery at 7:30 am on Tuesday, and the knowledge that I would need scrubs.
While the latter piece of information seemed mostly trivial at the time, Tuesday morning proved me rather wrong. Suffice it to say, I showed up at 7:30 am at the OR believing that it was as simple as asking a friendly nurse at the front desk for a single pair to get me through the day, and an hour later I was still running around on a mad quest to find someone, anyone, that could clothe me in that wonderfully flattering surgical green. So as to not implicate the very friendly people involved in the end, I will merely say that by 9:00 I had managed to find enough flexibility within the rules to be finally dressed and ready to go. For the next 9 hours, I found myself fully engrossed in my first two surgeries, both craniotomies for aneurysm clipping. It was a fascinating experience for many reasons, not the least of which was learning that it is apparently okay to gently but dramatically pull apart the lobes of the brain to reach all the way through the precious organ and clip off a life-threatening aneurysm. Though it wasn't until several hours in that Dr. Stieg casually looked up from his work, said "Are you Joseph? Nice to meet you!", and promptly went back to his task, I can hardly complain given how engrossed I was in the surgery. I had always heard surgery was brutal, more hack-and-slash than science. But this was like art - gently melting and nudging away connective tissue with a cauterizing probe called a bipolar, carefully avoiding vessels, and ultimately saving a life as minimally invasively as possible (you know, given the fact that the brain was indeed staring the surgeon in the face). Now, that's not to say that gluing and drilling the skull cap back on and sewing the scalp back together while rocking out to Lady Gaga's "Bad Romance" wasn't a little less than medically professional, I was definitely overall impressed. And honestly, why not have a little fun when you just pulled apart a living brain, fixed a life-threatening medical condition by clipping an aneurysm as if you were just casually clipping laundry to a clothesline, and then put it back together as if nothing had gone wrong?
The second craniotomy was interesting for different reasons: it was interesting to see what happened when things didn't quite go right. Ultimately the procedure was quite similar in the beginning (again, it was a right frontal craniotomy for an aneurysm clipping), but there was a crucial difference: this was a correction of a failed aneurysm clipping. And when the correction was finally and painstakingly made, the brain allowed to close back up, and an on-table angiogram was called, things began to seem very different from the first surgery. Instead of the angiogram lighting up the whole matrix of blood vessels in the brain like in the first surgery, only half of the brain seemed to be being perfused. As more and more complicated imaging positions were called upon, with the patient's brain still open on the table, the engineering truth that we all know quite well that you just can’t build something for every situation began to show even for the amazingly advanced instrumentation they had in this particular OR, with the multi-joint robotic X-ray scanner straining and struggling around the operating table to meet the demands of increasingly unsettled surgeons. When I finally left the room, the decision had been made in the end to close her up and hope for the best. While I was compelled to agree there weren’t exactly many other options, I was left feeling a little emptier than after the first surgery.
If the first day of surgery was my introduction to the elegance of neurosurgery, the second day was to be my introduction to its own take on the aforementioned hacking and slashing, as well as its own inherent risk for tragedy. Wednesday was a day for more frontal craniotomies, this time for the purpose of removing meningiomas, rarely-malignant tumors formed from the meninges that have the unfortunate habit of putting a damaging pressure on the brain. So this time, after the scalp had been peeled back and hooked into place, and the skull had been carefully opened with a combination of a diamond drill and a little bit of good old fashioned leverage, it wasn’t about persevering tissue; it was about annihilating it. With a mixture of ultrasonic bombardment and suction, brain tumor tissue that to me looked only mildly different from functional tissue was destroyed and removed. While it wasn’t exactly a subtle procedure, there was certainly still a good deal of intelligent intent behind it – just because I couldn’t tell the difference between tumor and brain didn’t mean the surgeons couldn’t. Unfortunately, the surgery was not destined for flawless success. Just as the lower wall of the tumor was being reached, the brain suddenly began to swell. This was not microscopic swelling either, this was the most complicated organ in the body swelling like a balloon and pushing its way a full inch out of the skull. Honestly, I’d never witnessed a more startling silence followed quickly by the heated noise of urgency. First came the rapid commands from the surgeon: elevate the head thirty degrees, induce hyperventilation, infuse manitol (as a diuretic to help pull fluid back into the blood vessels). But when this failed, the hard call had to be made – the device that had been removing tumor was suddenly turned on the swelling brain tissue, healthy frontal lobe rapidly being sucked away in a simple yet startling attempt to fix the swelling before it killed the patient. I will be honest, I was not prepared to see a high-stress decision being made in a split second that could mean the death or serious handicap of the patient on the table, as my jaw’s intimate acquaintance with the floor of the OR likely indicated to the zero people who had time to notice the helpless observer standing in the corner. Many hours later, well beyond the scheduled time for the surgery, the swelling had abated, radioactive seeds were placed in the cavity, and the skull was closed. And the patient, still alive only because of that split-second decision, was unfortunately not waking up. There were other surgeries I saw that day – a procedure where two cranial secretory tumor cysts were drained in a single procedure using advanced real-time imaging neuronavigation to produce a full 60+ mL of fluid, another where a pituitary tumor was removed with the help of a 3D endoscope via surgical entry through the nose. Both were very interesting and mostly successful (with a couple on-the-spot decisions making things a little more interesting). But the first 7-hour surgery of the day stuck with me, because it forced me to learn an important truth about an intrinsic component of surgical medicine, particularly neurosurgery: every moment could bring a critical decision that could have very serious consequences, and there was no way to ever be fully prepared. And yet the engineer inside of me couldn’t help but see it all unfold, see the human body as a complicated yet rational network of information concerning perfectly logical and predictable action and reaction, and feel there must have been a better way to know, and to act.
Thursday and Friday saw me sitting in on the other side of the surgery, i.e. when the patient is more than an unconscious subject of a surgeon’s concentration. Thursday I attended in-office visits with patients who mostly were just coming back for 6-month follow-ups, the vast majority of them having nothing to complain/joke about except their inevitable march into old age. It was, at the least, a nice break from the more stressful side of surgery. Friday I opted to instead get a medical perspective on neurological surgery cases as they unfolded on a more meaningful timetable by attending neurology rounds. It was an interesting contrast to the surgery world – singular approaches and split-second decisions were replaced with discussions of myriad methods of medication prescriptions and the shocking insinuation that maybe, just maybe, it was okay to wait and see if the body could heal itself. I have to admit, however, that I came out honestly preferring the surgery world. Maybe it was simply because a stroke or a tumor is easier to deal with when it is merely a complicated biological puzzle to solve with your wits and cool instruments, rather than having to go face-to-face with the fact that it also involves a struggling, seizing patient who has difficulty meaningfully discussing anything due to the overwhelming pain. But I like to think that it was also that personally, if ever given the choice, the realm of surgery simply was a more exciting world to apply what certainly seemed like an equivalent amount of amazing quantities of medical knowledge.
That being said, it’s only the first week. I look forward to growing not only my knowledge base of medicine and the medical world, but also my perspectives and insights. I’ve even managed to have a short discussion or two concerning a project that would involve me in an ongoing clinical trial concerning ultrasonic disruption of the blood brain barrier for delivery of anti-ischemia drugs, a revolutionary technology that ironically one of my projects back at the lab in Cornell seeks to completely replace with a much less destructive and invasive nanotechnology drug delivery approach. Always good to see the competition I guess!
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