Another Day in the Frontal Lobe (19 page)

This boy’s mother explained to us that if he had a seizure while eating, he would continue eating but would stuff everything in his mouth, reflexively, maniacally, including chicken bones or whatever else happened to be on the plate. We were hoping to curb that sort of thing.

We sat down with the young boy and his parents. The parents listened in from the sidelines, as their son was the one we were really trying to connect with. He was earnest, bright, and curious. He listened intently to the surgeon’s entire explanation: an incision in the neck, another one under the collarbone, thin electrodes up here, a small battery down there, everything should go smoothly, a little pain medication for a few days, overnight for one night in the hospital. The boy nodded and took it all in.

Then he got to look at the actual device, one that we kept for teaching purposes. He fingered the thin electrodes and the battery pack. He turned it over in his hands. “Do you have any questions?” the professor asked. The boy continued to feel the electrodes and then paused.

“Yes,” he said, looking up. “The ’lectrodes…they’re a little bit sticky.” (They were coated with a thin layer of insulation, and had been touched by countless other hands.) It was more of a statement than a question. He waited for the response.

“Yes. You’re absolutely right. They are a little sticky,” my mentor replied.

And with that simple confirmation, the boy was satisfied, ready to go forward with surgery, and the consent form was handed over to his parents to sign on his behalf. Given the same operation, different patients will fixate on different concerns. One thing I’ve learned is that regardless of what the surgeon assumes is most important, what a patient thinks is most important
is
what’s most important.

The personalities of certain patients with chronic epilepsy make me wonder: How much is the person, and how much is the disease? In other words, how much of what I’m seeing in a person is a result of their seizures versus how much is just their inherent personality and abilities? This is often impossible to answer, which is why I like the question. There is one patient I can remember, though, in which the answer did become quite clear, but only after surgery.

Consider the life of a child growing up with medically refractory epilepsy (not well responsive to medication). For one, she is probably on more than one medication, maybe even three or more. Each medication has its own potential side effect profile, perhaps a vague and generalized slowing or fatigue.

She may have seizures during school. It may be a challenge to make and keep friends. Seizures interrupt the day, the lessons, and the learning. She falls behind. She has seizures at home, and this interrupts homework and family life. So, her grades are a problem, her social life is lacking, and her family is frustrated. She has poor self-esteem and a worrisome future. Certainly, the seizures and the medications can be blamed for much of this. What would her abilities and personality have been like if she had never developed epilepsy?

We evaluated such a girl in her early teens. She had had poorly controlled epilepsy for years, with her seizures occurring mainly at night, interrupting sleep (nocturnal seizures). She had a twin sister who was completely normal, who did not have epilepsy. Her twin was considered by everyone to be the older sister, and her family even referred to them as older and younger. Even though they were the same age, the patient was far less mature, more impulsive, and a much worse student compared to her sister. She had a short fuse and was a challenge to her parents and teachers.

Her original brain scans, performed years prior, revealed nothing abnormal. Medications were her only hope but none worked well enough. She tried numerous drug combinations. Her neurologist didn’t want to give up on her, though, so he referred her to the academic A-team for further testing. She was put through an extensive evaluation: inpatient monitoring over several days, continuous EEG, updated brain imaging, and neuropsychological testing.

Imaging technology continues to improve. The MRI that we obtained during her evaluation was of significantly better quality than the one she had had years prior. We agreed that her old MRI
did
look normal, but something wasn’t quite right on her new, high-resolution one. There was a hint of something amiss in the right frontal lobe, but the finding was extremely subtle, and maybe even an artifact, maybe not even a true finding. The team persisted and ordered a specialized variant of an MRI in which a coil is placed over one part of the head, accentuating only that one area while the rest of the brain fades into less detail. That was the ticket. There
was
something in the right frontal lobe, probably a very small focus of cortical dysplasia.

We took her to the OR, found that little spot, and took it out.

Fast-forward a few months to a follow-up visit in the office. The girl is beaming, wearing a T-shirt, incidentally, that announces across the chest
i love boys.
The mom is beaming, too, not because she condones the message on her daughter’s T-shirt but because “I have a new daughter.” She hadn’t had a single seizure since surgery.

According to the mother, the patient had now become the “older sister”—the more calm, conscientious, and mature one—even to the point of looking after her now “younger sister.” She had been transformed. Her outcome was more impressive than I would have ever expected. While I was confident that the surgery would control her seizures, I didn’t expect any miraculous personal transformation.

“Why do you think…?” I asked my mentor.

“No more seizures. She’s getting a full night’s sleep every night,” he answered.

At first I was incredulous—the explanation was too simple—but then I realized that it all made sense. If you mess with a kid’s sleep every night, year after year, she’s going to become a certain type of person. The disease will actually mold her. If you fix the disease, then the true person, submerged for so long in a fog of seizures and chronic sleep deprivation, can finally blossom into her true self.

I wish all the stories from my fellowship year could have been so happy.

My husband and I joke about the “old sneaker phenomenon.” When you wear a pair of sneakers over a long period of time, they develop a worn-out appearance, and that worn-out appearance, at some point, reaches a transition point between being acceptably worn out and unacceptably sloppy. When you’re in college, sloppy is fine and maybe even desired. When you get older, though, sloppy is usually just embarrassing.

The funny thing is: the person wearing the sneakers becomes too familiar with them, and cannot always detect when that transition point has been crossed. That’s one advantage of being married. We’re always honest about alerting each other as to when it’s time to throw out “an old pair of sneakers.” Neither of us takes it personally. We understand our own susceptibility to this universal human phenomenon.

In the epilepsy surgery clinic we carried around a black bag full of educational models, including a detailed life-sized brain that we could show to patients. The other material—sample electrodes that we implant over the brain and a sample vagus nerve stimulator—was stored in individual plastic bags. These bags would have been fine except for two things. One, they were biohazard bags, marked with an orange “biohazard” sign, of the type meant for transporting possibly infectious material like blood and urine samples. And two, they had become all crumpled up and worn out from sitting at the bottom of the large black bag, often squashed by the plastic brain model.

If I were a patient, I might be a little suspicious of anything that a surgeon took out of a crumpled-up biohazard bag, so I eventually took it upon myself to replace the bags with new ones. I suspected that the old sneaker phenomenon had been at play for a while.

This fresh switch, though, came too late for one particularly sensitive patient. She was pleasant, intelligent, and overwhelmingly in touch with all things holistic, alternative, and organic. She had numerous dietary issues, unrelated to any true allergies per se, but more related to various beliefs and psychosocial sensitivities. She insisted on bringing her own small refrigerator into the hospital. She would eat only her own food.

Her epilepsy came about after a neglected infection had affected her brain. She had been hesitant to seek traditional medical care despite several days of an unusually severe headache. Now, several years later, after her reluctant trial of numerous antiseizure medications, she would undergo an evaluation to see if we could localize her seizure focus and, potentially, offer her a surgical solution.

Unfortunately, her case was not straightforward and we were going to have to implant a series of electrodes over the surface of her brain—“invasive monitoring”—if we were to have any chance of helping her. She had a number of questions for me regarding the electrodes, so I fetched the black bag to facilitate my answers.

That’s when I had to reach for the crumpled biohazard bag. I tried to shield the “biohazard” but it was so large and so orange. She recoiled. I pulled out a thin electrode strip, made up of a series of small platinum discs embedded in a silicone material. The wire trailing from it was a bit kinked in spots along its length. I explained that we would be implanting a series of these in order to capture a detailed recording of her seizures.

“So…these aren’t natural…are they?” she asked me, already knowing and fearing my answer. I told her what they were made of. Her brow furrowed. I wished I could have offered her an organic soy and rice paper version.

“Honestly,” I told her, “everything is natural, if you think about it. Are there really any unnatural things? Everything has to originate from something natural, something from the earth.” My brief, pathetic soliloquy was completely unconvincing, but she ended up consenting to the placement of the electrodes anyway, even more fed up with her seizures than with the tragic state of the inorganic world.

Her frailties and hypersensitivities aside, I really got to like her. She maintained a cautious optimism. With the amount of controlled torture we were about to put her through, I couldn’t bear the thought that there was a chance we might not be able to help her. Over the next several days, she endured the surreal experience of implantation surgery and then the epilepsy monitoring unit, with twenty-four-hour cameras watching her behavior, dozens of wires exiting her shaved monk head, and a parade of specialists tracking in and out, day and night.

In the end, though, we were forced to admit to her that we couldn’t pinpoint the focus of her seizures. We couldn’t offer her a surgical solution. We had put her through all of that and had come up with nothing. We took her back to the OR, took out the electrodes, and closed everything back up, defeated. I looked down at her head before wrapping it in white gauze. It was going to take a long time for her hair to grow back. At that moment, I wished she had fled from that crumpled biohazard bag, back to her organic world, never to be seen again.

Some people are lucky enough to be able to spend their entire career—their entire adult life even—in a singular pursuit of a singular focus. They have such a passion for just one specific thing, one disease, one treatment, one musical instrument, one social ill, that they are content to leave all other possibilities aside. This is a good thing. A life with a singular focus is a setup for excellence.

What I am passionate about, more than almost anything else, I’m afraid, is learning something new. If I could somehow benefit society and make a good living as a professional student, crossing disciplines as I went, I’d be tempted—very tempted. I love life on the learning curve and my curiosity is broad. This can be a double-edged sword, though, when it comes to settling on a career. Although it’s true that in any given specialty, no matter how narrow the focus, you’re “always learning something new,” as every good mentor says, my suspicion was that I would always want to find out what, exactly, that new something was in the next conference room, operating room, or country on the other side of the world.

I would have to obsess over these abstractions later. This particularly cerebral year in my training had ended, and there was one more to go, but one that would not allow for quite as much time to think.

SEVENTEEN

Chief Concerns

The seventh and final year of neurosurgery training is the “chief year,” when a resident is finally dubbed “chief resident.” This year comes not only with a new title but also with new responsibilities. For one, you’re in charge of trying to keep the peace among the other residents on the team. (All young and male, in my case. I’ve joked that I should have written a book entitled
Gorillas in My Midst.
) You don’t want little problems to become big problems. You need to solve them before they grow large enough for the chairman of the department to take notice. In addition to your role as peacekeeper, you run morning and evening rounds, delegate items on the daily to-do list, try to keep all the attendings happy, and get everyone to the OR on time, by 7:30 a.m.

This year does have its perks. You get to choose the best cases. The attendings allow you more free rein in the OR. You tend to be shielded from minutiae because the other residents take care of much of the grunt work. You finally settle on some of your own opinions—how’re you’re going to handle a particular type of case, what approach you will prefer to take, and how you will speak with a family. You cement your own style. For all these reasons, the chief year is memorable for any neurosurgeon. In my case, though, there was one other factor that will always mark it as hard to forget.

My year as chief resident was the year of the World Trade Center attacks. I was in the operating room at the time. I was performing a craniotomy with a foreign-born neurosurgeon who happened to be from the Middle East. We were about to remove a cystic tumor from a patient’s brain, and our world was about to change.

The technician who was monitoring the patient’s brain waves for us had gone out for a break and was in the OR lounge, while the junior tech covered the monitors. We had a connection to the outside world.

“A plane just hit one of the Twin Towers!” our tech announced on his return to the OR. This set off a buzz around the room: What was going on, how could such a thing happen, who among us knew someone in New York? He peeked over his colleague’s shoulder at the computer screen and went right back out to gather more information. We kept working.

Not too long afterward, the OR door swung open again, with a second announcement: “The other tower was hit!” We had opened the dura by that point and were entering the brain. We said nothing for a few moments while we continued to work. My attending was the first to speak and said to me quietly, without shifting his gaze away from the task at hand: “This is terrorism.”

In my relative innocence, I had thought only “freak accident” during those silent seconds. My mentor, more realistic and wise to the world, knew better. He had already figured it out. Once he introduced the word, of course, it seemed obvious. It had to be terrorism.

Never before in my memory had current events entered the isolated cocoon of the OR with such urgency. A few years earlier, I remember listening to a live radio program during a case. Everyone wanted to catch the O. J. Simpson verdict in real time. There was a collective gasp in the room at the pronouncement of innocence, and then back to work. Other than that (and, on occasion, the announcement of important sports scores by an enthusiastic anesthesiologist), the feeling is usually that the news can wait.

(By the way, there is no need to worry about the patient’s safety here. There are key moments of concentration during certain cases when everyone in the room knows not to talk—such as when an aneurysm at the base of the brain has just been isolated and is about to be clipped—but surgery does not otherwise demand absolute silence, and discussion does not have to be limited to immediate surgical concerns. The OR can be a lively social environment, unless the surgeon is in a rotten mood.)

Later, we would find out that another plane was missing somewhere in airspace not too far from us, and I even heard rumors that our hospital was on alert in case we were needed. The tragedy, of course, was that we weren’t needed. Regardless, at least one of our neurosurgeons postponed his elective afternoon cases until later in the week, not because he was told to, but because he felt he just had to.

Once we finished the critical part of the operation and began the routine of the layer-by-layer closure, I let my mind wander. My husband was working in Connecticut, just outside of New York City. For career purposes, we needed to spend this one year apart, in different cities, seeing each other only on weekends. I was sure there was no reason for him to be in New York that day, but I would call him from the recovery room, just to make sure, as soon as we wheeled our patient out there.

He was in his office in Connecticut and watching the news with business colleagues from Seattle who would soon realize they were stranded. I thought about my brother. He was a starving artist in Brooklyn, living an unstructured bohemian life. The World Trade Center was the last place I’d expect him to be, but I called my mother from the recovery room right after talking to my husband. She told me that my brother was in Manhattan but not downtown, and was making his way back to Brooklyn, on foot.

Then the ICU paged me, so I left the recovery room and walked over there. Televisions were on in every room, flashing unbelievable images at the bedside of each comatose patient. Everyone in the ICU who was conscious—nurses, critical care fellows, respiratory techs—tried to catch bits and pieces of the news as they went about their routines. I attended to whatever minor crisis it was that required attending to and pulled a chair up to one of the televisions, watching and listening over the sounds of the ventilator and heart monitor attached to the patient next to me.

I didn’t linger for long. As the chief, I wanted to check on what the rest of the team was up to during this strange time. I walked over to the office and found half the department in the conference room watching the large screen that we used for our multimedia presentations. We had television access through this system, so the conference room had been transformed into CNN central, with my colleagues walking in and out as their pagers went off, vying for their attention.

There are isolated moments, turning points, in a life when a certain loss of innocence is realized. As the oldest of four kids in my family, I can remember feeling conflicted at times when I realized that one of my younger siblings was no longer just an innocent little kid. It’s not that I didn’t want them to grow up, wise to the reality of a sometimes harsh world, but more that I knew I was going to have to change the way I thought about them, and that’s what was difficult.

Before I started medical school I even had fleeting thoughts about the fate of my own happy-go-lucky innocence. Did I really want to expose myself to suffering, trauma, and death as a routine part of my job? I’ve always been known as a generally upbeat and happy person. What would several years of surgical training do to me? Would I be the same person and, if not, would that be for the better or worse?

In deciding to become a surgeon I promised myself one thing: I would never become the bitter female surgeon. Better to make a radical career change, if necessary, than to lead a stable but bitter life. It’s not that bitterness is uniquely female in any sense. Believe me, I know plenty of unhappy male physicians. It’s just that I had come across a couple bitter female surgeons along the way and they scared me a lot more than the bitter male ones did.

It could have been that the selective few I had met were older and had gone through their training during a different era, when the idea of women in surgery was still relatively new and not wholly accepted. Still, I resolved never to let myself fall down the slippery slope of harsh behavior, easy profanity, and loss of femininity that I imagined might lurk in the dark corners of a male-dominated specialty.

Now, after four years of medical school and into the seventh and final year of my neurosurgery residency, I was sure that I hadn’t been irrevocably tarnished in any way. Plus, I had gotten to know plenty of other young female surgeons who were reasonably content, women who I knew would be excellent role models, the type of role models that female surgeons of the previous generation may not have had.

Certainly, a few distinct things did embitter me along the way—taking care of drunk drivers for one—but I had otherwise come through largely intact. I wasn’t a totally different person, just more knowledgeable and experienced. One of my colleagues even mentioned that, whereas he had limped across the finish line, I was finishing strongly.

Still, I did have lingering concerns looking forward, concerns that I knew others shared and also sometimes repressed. Would I really want to do this for the rest of my life, the same tragedies, the same procedures, over and over again? What about being tied to a pager? I can tolerate the three a.m. call to a trauma now, but would I continue to tolerate getting out of bed for a drunk driver at age fifty? What about the need to plan my life around a call schedule? How would things change if and when we added kids to the mix? And perhaps worst of all—how bitter would I become with my first lawsuit? My trusted friends out in practice warned: “You
will
be sued, no matter how good, careful, or thoughtful you are.” Nice, I thought, something to look forward to.

I remember being in a pediatrician’s office as a kid and checking out a piece of artwork hanging on the wall in the waiting room. It was a cartoon type of drawing of a female pediatrician at work with chaos all around: children running around and screaming, tugging at her white coat, overstuffed charts falling off of shelves. The doctor was portrayed as positively harried, with slightly unkempt hair, glasses a bit askew, and a weak, tentative smile. The drawing was personalized, with the pediatrician’s name on her white coat pocket. I imagined it was probably a gift, from a family member or a grateful parent. I think it was supposed to be endearing—a very human portrait of a busy working woman trying to keep it all together—but it was unsettling to me, even as a kid.

I couldn’t fully intellectualize this gut feeling of mine until I grew up. Here’s what I figured out I must have felt: Why would a woman intentionally choose to portray herself to the world as frazzled? Even if she does feel overworked and frantic from time to time, why would she want that image hanging on the wall? Why would someone create that kind of portrait as a gift? Maybe there is a comforting solidarity in expressing one’s frazzled nature (assuming that every other woman must be in the same boat), but that’s a little sad. Why glorify it? It reminds me of when smart women intentionally act dumb. I, for one, don’t find that cute. Does the male equivalent of the frazzled doctor cartoon exist? I doubt it, but if it does, you’d probably never see it hanging proudly, as art, in his office waiting room.

One of the responsibilities of the chief resident is to run M&M. Morbidity and mortality conference (the official name, rarely used) is where complications, deaths, and other such problems are aired, formally, in an educational and sometimes contentious environment. It can be fun. M&M conference is when we get to see our mentors butt heads and our fellow residents get “pimped” (asked difficult questions) on a weekly basis. Along with the responsibility of running the show comes a small amount of power. Although others might recommend which cases should or need to be presented, the chief resident usually makes the final call.

Years before I had become chief, one of our attendings was fired and the residents always wondered if they had partly fueled the decision by weighing down M&M with his cases. Every neurosurgeon has vexing cases, complications, and patients who end up dying for various reasons—especially in a big academic institution that receives the most high-risk cases—but we only have time to present two or three patients each week. Only some cases get the spotlight and the third degree.

Most of the morbidity and mortality was due to the patient’s own disease process, trauma, or just plain “poor protoplasm” (an unhealthy body with a natural tendency toward disaster), but actual mistakes were made on occasion. These were aired and discussed with particular gravity. Different surgeons have different styles in discussing their own mistakes, from spreading the blame to humble admission of singular guilt.

I will always remember how impressed I was as a young medical student in the audience of a neurosurgery M&M conference, listening to the chief resident at the time admit a technical error of his own. He was well respected by the staff and fellow residents for his combination of skill, judgment, and intelligence. During one particular operation, in an unlucky moment, he veered just a little too far to one side in dissecting the tissues at the junction between the back of the head and the top of the neck, an area where the vertebral artery—one of the critical blood vessels that supplies the brain—is located. There is some variability in the position of this vessel dictated by its tortuosity and the exact path that it takes in any given individual patient. Getting into this vessel is a known but uncommon risk of certain procedures in that area.