A neurosurgery resident contemplates his everyday work.
“I CAN SEE BRAIN,” the trauma surgeon said. “This one’s for you.”
I was covering the neurosurgery night shift and had been seeing another patient in the resuscitation unit when the trauma team consulted me on a new admission.
Twenty years old, found down, and he appeared to have a hole in his forehead.
I examined him. He was in a deep coma and his pupils were large, not reacting to light.
A rapid CT scan of his head revealed, in unfeeling white-and-gray pixels, a foreign object lodged in the back of his skull. A bullet, a vestige of a heinous act, had entered and torn through the middle of his brain, damaging life-giving structures.
I reviewed this with my attending, but I knew. There was no neurosurgery, no medicine that could help him. He was devastated, the prognosis was grave.
The trauma surgeon and I walked to the waiting area to talk to his mother and father, who had just arrived. They didn’t expect to be here, at this hour, for this reason. That time, before they heard what parents fear most, felt dilated.
We introduced ourselves. We asked what they already knew. I listened.
After a pause, in plain language, I explained what had happened, how he was.
You don’t forget a scream like that. It cleaves your soul. She just learned her son will soon be no more. His life had just begun.
Tragedy is not rare. We diagnose a child with a life-changing brain tumor; a mother suffers a brain aneurysm rupture, stealing her wit; a husband’s cancer metastasizes to his spinal cord, strangling his strength and independence. Death and disability precede me.
Triumph is common, and I’ve reflected on it. There are many saves. We open the skull or the spine, pressure is relieved, and life or livelihood is restored. Most of our patients get better, rehabilitate, and move on.
I knew what neurosurgery was when I chose it. I’m not surprised. I would choose this life again every time.
But by its nature, my work does give one a privileged exposure to the human condition, and in the moments between moments, you sometimes dwell on it.
The definition of human must be one who suffers.
The mayfly suffers less. It emerges from its larval state and dies all in a one-day cycle, in a mad dash to reproduce and perhaps catch a glimpse of the sky. These ephemera, short-lived fliers as the ancient Greeks called them, repay their genetic debt, then retire forever.
You quickly become impervious to suffering.
A man in a coma. He is on blood thinners for his cardiac arrhythmia and has a history of poorly controlled hypertension. Imaging reveals the price: he has suffered a grievous hemorrhage in his left thalamus and midbrain. He can no longer converse or comprehend, and his right body is paralyzed. He’ll never be the same.
“How old is he?” one of us asks.
“Eighty-one,” the other answers.
A head nod.
Somehow we might feel less badly if it occurs at an advanced age. We silently rationalize misfortune, or try to. I can see the same thought travel through different minds: he was near the end of life. Ageism doesn’t make it less painful for him or his family. It mollifies us. We want suffering to make sense, or at least lead to inevitable closure.
As I reflect, I consider what my undaunted colleagues would think of this introspection. In medicine, we have all pondered our personal predicament at some point or the other, regardless of our outward resolve. We’re surrounded by more signal and less noise. Every patient’s worst moment is our everyday. One has to wonder. We press forward.
Tragedy in neurosurgery, and in medicine, differs by temporality. A trauma is instantaneous. Family and loved ones have little time to accept the reality. A brain tumor can be the beginning of a slow demise. There can be initial triumph, but many tumors are obstinate. A new normal settles in.
The frailty of human life is evident, perhaps too much so. Human life itself is improbable, and can seem insignificant. We live on “a mote of dust suspended in a sunbeam,” Carl Sagan aptly described in his book Pale Blue Dot.
Somehow, in the vast nothingness, on a remote rock, we scrape out a life. We have desires, jobs, loves, children, conflicts, adventures, and failures. We write poetry, cure disease, climb mountains, and hurt
each other. The cost of this improbability
is entropy and decay. Free radicals, friction,
and fibrosis always win.
A middle-aged, Portuguese-speaking patient was in a high-speed rollover on the interstate. His wife and child were passengers. The trauma team consulted me for his cervical spine fracture.
As I entered his room in the resuscitation unit, I found him on the phone. He had just learned his family didn’t make it. With one turn, what mattered most was lost.
There was agony in his voice. I gave him space. More entropy, more pain.
His strength and sensation were intact. He didn’t need surgery. With time, his bones would heal.
A woman was transferred to the neurological intensive care unit from a local hospital. She was experiencing headaches for the past month, eventually earning her a CT of the head, and then a contrast-enhanced MRI of the brain.
She was otherwise intact, without any change in her vision, strength, sensation, cognition, or language. It could be any other day in her life.
As I reviewed her imaging, it was clear this life was forever affected.
Her corpus callosum—the bundle of 200 million nerve fibers that allow the left and right brain to communicate—was invaded by a foreign mass, an irregular, space-occupying lesion, causing adjacent swelling.
Where it occupied, the brain’s natural barriers had fallen, allowing, among other things, gadolinium contrast to enter.
It was most likely glioblastoma, and could not be fully removed with surgery without causing significant, lasting damage. Though unlikely, it could be an infection or inflammatory disease, if she were fortunate. I discussed this with my attending. At the least she needed a biopsy.
I spent time with her, collected her understanding, then reviewed with her what we knew, what we didn’t, and the further workup we needed.
Rarely genetic, possibly environmental, but mostly unknown factors allow glioblastoma, a malignant tumor of the brain that is often fatal, to maraud our most personifying faculties.
A cruel insult to our humanity.
A young woman in the emergency room had been enduring piercing pain from her back to the bottom of her left foot. An MRI of her low back revealed the cause. The disc between her fifth lumbar vertebra
and first sacral vertebra, at the base of her spine, had slipped backward, irritating a nerve root, inciting pain. She had tried exercise, physical therapy, pain management, and steroid injections with no relief. The pain was winning.
I admitted her.
Later my team would discuss options with her. She elected surgery. They took her to the operating room, drilled through a little bone, and removed the offending disc, letting her nerve breathe. She would leave the hospital the next day, back to normal, back to her life. She likely would not need us again.
When I walk from one corner of my hospital to the other, from one consult to the next emergency, I often listen to music. On this walk, Hans Zimmer’s peerless score for Christopher Nolan’s masterpiece Interstellar met my thoughts.
In this future, humanity is forsaken, the Earth has become arid and uninhabitable, and we must leave. A cadre of scientists and astronauts resolves to save the human race by transporting embryos to a distant planet to establish a new colony. By the reliable hand of hubris, an airlock on the ship carrying the embryos explodes, and the ship’s precious remnants are in free fall. The last hope for our species to endure is spiraling in outer space to a dull end, to the sound of a ticking clock.
Even in health, so vulnerable are we.
Yet, in these final moments, a lone astronaut, in a show of valiance and virtue, narrowly rescues the ship and saves this desperate effort to last.
My patients remind me, lest I forget, the human spirit is persistent.
The sun is starting to rise. The Earth rotates at 1,000 miles per hour, and the work of Rev. Thomas Bayes encourages us that the dawn will come. New light painting the walls and hallways shifts your perspective, even if temporarily. Signs of human activity again become apparent.
The mayfly has its own predicament. It may suffer less, but it never feels a second sunrise.
Though we are diurnal creatures, much of the human narrative unfolds in the twilight hours. I give the oncoming resident sign-out as such.
On my walk to the parking garage, I can hear the chickadees and finches chirping. I can smell spring. From somewhere, energy is invested in this improbable place, in us, for a time, a taunt to the Second Law. Do not go gentle.
It’s a zero-sum game, and the game
I’ll be back tonight.