When the Air Hits Your Brain: Tales from Neurosurgery (18 page)

We would be working near Rebecca’s brain stem, the upper part of her spinal cord. The brain stem, the brain’s chief switchboard, is easily damaged. To monitor its function during surgery, we would use Rebecca’s sense of hearing.

Sounds are transmitted from the hearing nerves into the brain via the brain stem. Thus, hearing can be used as a barometer of brain stem injury. Of course, infants, anesthetized or awake, cannot tell the surgeon whether they can hear, so hearing must be checked electronically.

To do this, small earphones emitting sharp clicking noises are taped to the patient’s ears. Sound transmitted from the ear into the brain stem travels upward into the cerebrum, the “thinking” part of the brain. By attaching electrodes to the scalp overlying
the hearing regions of the cerebrum, neurophysiologists can detect the subtle brain waves that occur when signals carrying the clicks arrive in our consciousness—even if we are asleep or anesthetized. Using an operating-room computer, the neurophysiologist calculates the time interval for the clicking noise to go from ear to cerebrum. Too long a transit time means that surgical injury has occurred to the brain stem or auditory nerves.

Our neurophysiologist for the day was Bob, a small, bearded man with a Ph.D. in electrical engineering, as well as an M.D.—and a ponytail. He looked like he’d just walked out of the 1960s. During the surgery he sat on his stool, gazing at a fluorescent computer screen filled with white waveforms. His warnings would give us time to adjust anything that might be injuring the brain stem before the injury became permanent.

We retired to the scrub sink as Bob finished sewing his electrodes into Rebecca’s scalp and placing earphones into her small ears. We lathered our arms and hands in silence. I gazed through the OR window at the surgical tech as she painted Rebecca’s misshapen head with the gooey orange Betadine. Only weeks into my rotation on this service and I already hated pediatric neurosurgery. Before each case, my mind conjured up laughing babies cuddled by their kindly grandfathers. Everybody’s little bundles of joy. None of them belonged here.

Fifteen minutes later, Dr. Wilson sank his number 15 knife blade into Rebecca’s scalp. The room filled with the highpitched wailing of the suctions. As he opened a four-inch incision down the midline of Rebecca’s head, I quickly placed plastic clips over the skin edges to halt the oozing. An electric knife stripped the neck muscles away from the underlying skull and cervical vertebrae. The muscle sizzled from the heat, flooding the room with the acrid smell of burning human flesh, an odor that has caused more than a few medical students to swoon.
With the bone exposed, a steel Weitlaner clamp spread the wound open.

We drilled small holes into Rebecca’s thin skull and used heavy scissors to pry open a bony window into the cerebellar region. The glistening white dura matter pulsated through the skull defect we had fashioned.

Before incising the dura and exposing the cerebellum, we drilled another small hole just slightly higher than our bone window and inserted a temporary drainage tube into the distended spinal-fluid sacs. Clear fluid spurted from the tube under pressure as I passed it into the brain. We were finally ready to expose the brain. We paused as the circulating nurse put on our loupes, custom-made eyeglasses with telescopic lenses that provide a threefold magnification of vision.

Dr. Wilson grasped the dura with a long forceps and nicked it with a pointed knife until the pinkish cerebellar surface peeked through. We enlarged the dural opening with finetipped scissors, stopping intermittently to place silver clips across small venous channels.

“Evoked potentials have improved,” Bob said softly from behind the wires that engulfed him like technicolor linguini. By letting off CSF with the drainage tube, we had relieved some of the existing pressure on Rebecca’s brain stem. This improvement was to be short-lived.

Rebecca’s tumor showed itself as we peeled the dura away from the left side of her cerebellum. Firmer than the surrounding brain tissue, the mass was a darker pink, almost purple in areas. The dura stuck to it, and tiny rivulets of blood began streaming from the tumor’s raw surface as we stripped the dura away using a metal dissector.

“Cottonoids up, please.” The scrub nurse brought up a gleaming steel basin full of white cotton squares of various
sizes. To each square was attached a long green string. These cottonoid patties stopped our suctions from plunging into the soft brain, like snowshoes which keep feet from sinking into snow. The strings allowed the patties to be identified and removed before the case ended.

Dr. Wilson encircled the tumor with half-inch patties, holding the cottonoids with a forceps in his right hand while using a suction tip in his left hand to push the cotton squares between the tumor and the normal brain. He began developing the “plane” between tumor and cerebellum. In benign tumors, a clear plane exists and the tumor can often be popped out using this encircling technique.

In malignant tumors, however, the cancer invades deeply into normal tissue, obscuring the plane between tumor and brain. Such was the case here. As we tried to separate the tumor away from the brain, the purplish lump disintegrated and the bleeding increased. A small piece of the friable mass was handed off to the circulating nurse in a small plastic cup for a “frozen section.” The pathologist would freeze the tumor and examine it under a microscope to assess malignancy.

The patties were now soaked with blood and the wound swam in the growing ooze. We aspirated the tumor with our suctions in the vain hope that removing it would slow the hemorrhage. Unfortunately, this maneuver only created a deeper hole from which the red blood continued to pour. I glanced at the heart monitor. Rebecca’s heart rate climbed steadily, a sign of her persistent blood loss.

The nurse-anesthetist called for the anesthesiologist to return to the room.

“Trouble?” Dr. Wilson asked.

“Her pressure’s dropping a bit.”

“Do we have blood in the room?”

“No.”

“Get some,” he said sternly while shoving a large ball of cotton wadding into the bleeding brain wound, “and start warming it.” The bleeding was getting ahead of us.

“Evoked potentials, two milliseconds out on the left,” chimed Bob. The hearing impulses from the left ear were taking longer to reach the upper brain regions, the first warning of brain injury.

The surgeon shook his head. “Shit.”

Although the large packing slowed the bleeding, the pressure on the brain stem was unacceptable. If we took out the packing Rebecca might bleed to death; leave it in and the brain stem might be damaged, causing permanent deafness or paralysis.

“Fuck the evoked potentials. I’m leaving this pack in for a while, until they get some blood into her,” Dr. Wilson whispered to me. Several minutes went by.

“Where’s my blood?” Dr. Wilson grew restless.

“Potentials out four milliseconds on the left and the waveform is flattening,” intoned Bob, a voice of doom in the corner, “and the right is now out one millisecond.” The brain stem cried to Bob’s computers, pleading for relief. Dr. Wilson sighed and pulled the cotton wadding from the hole. The bleeding resumed, but more slowly. I grasped the bipolar coagulator, a long forceps hooked to a battery pack which is used to coagulate small blood vessels with heat, and attacked those bleeding arteries I could identify in the soupy tumor bed.

The OR door swung open and a small, squat man dressed in white paper coveralls entered the room. The pathologist.

Dr. Wilson greeted him. “What do you have for me?”

“It’s pleomorphic, highly cellular, aggressive…a PNET, most likely.”

“Yeah, that’s what we thought.”

“Looks like you’re up to your ass in alligators!” The pathologist’s grin shone clearly from beneath his surgical mask as he glanced at the tangled mass of cottonoid strings spewing from the bloody cranial wound.

“It’s a wet son of a bitch, all right,” replied Dr. Wilson as he turned back to the wound, “but we’ll manage.”

“I’m sure you will, John,” the pathologist said over his shoulder as he headed for the door, “but cases like these remind me of why I only deal with dead people.”

We fell into a silent routine, sucking away bits of the tumor, stopping the bleeding, then removing more tumor. The gutted cerebellum collapsed upon itself. I held it away with thin copper “brain ribbons” as Dr. Wilson chased the tumor further and further into the depths of Rebecca’s head. Downward into disaster.

Rebecca had a cancerous brain tumor. The standard methods of dealing with cancer, radiation and chemotherapy, cannot be used in infants. Radiation therapy would destroy the developing brain cells and guarantee that Rebecca would be vegetative before she reached one year of age. The single weapon we could fire at this tumor was our surgery. Removing as much tumor as we could was her only, albeit slim and very risky, chance of meaningful survival. Rebecca became hypotensive and hypothermic, her heart flipped in and out of ventricular tachycardia (one step removed from full cardiac arrest), and yet we pressed on.

“Oh, damn!” Dr. Wilson finally exclaimed as he halted the tumor resection. I peered into the hole left vacant by the excised tumor. At the bottom, spinal fluid welled up and diaphonous strands of severed nerves floated in the watery pool like miniscule bits of white seaweed. He had gone completely
through the cerebellum and into the space surrounding the brain stem, where vital cranial nerves exit on their way to the ears, face, and throat. Some of the nerves were destroyed, meaning that Rebecca might not hear, swallow, or breathe after surgery. The aggressive tumor resection was a gamble which we had lost.

“The left evoked potentials are out completely,” Bob said, his computers verifying the damage we could see with our eyes. The hearing nerve was transected on the left side.

Dr. Wilson put a cotton ball into the tumor bed and squinted at the CT scan hanging on a view box across the room, trying to compose himself. He was motionless for a long time. I have since come to know the agony of those minutes which follow hurting someone badly in the operating room. In those moments, the fear of confronting the family, the panicked thoughts of changing careers, visions of lawyers—all dance through the mind in a flash.

“Surgicel.” He finally stirred and called for the fine cellulose mesh used to fill the tumor bed. Done. Tumor remained in the cerebellum, but Wilson had lost his stomach for this case. With an incompletely resected PNET and several damaged cranial nerves, Rebecca was officially unsalvageable. Outside the OR, in a smoke-filled room, Rebecca’s parents and grandparents waited for good news that would never come. There would be no prom for Rebecca. We packed the brain with wads of surgicel and sutured the dura closed without speaking another word.

We took Rebecca
to the recovery room still asleep and on a ventilator. She made a few decerebrate movements with her arms and confirmed our worst fear: we had damaged the stem. Decerebration, a rigid posture of the limbs, indicates a living, but dysfunctional, brain stem.

We called the family into a more private conference room, away from the crowded OR waiting area. I sat in a corner of the room as Dr. Wilson explained the situation to Rebecca’s parents and maternal grandparents. Unlike television, where people take bad news with explosive histrionics, such news in real life produces only a shocked silence. Families erect a shield of denial almost immediately.

“Rebecca has a deadly form of brain cancer called primitive neuroectodermal tumor,” the neurosurgeon calmly explained, “a name I know you won’t remember. Bottom line? It cannot be totally removed and we have no further treatments we can give her because she is a baby.”

“How does a baby get cancer?” asked her grandmother with an almost cynical tone.

“They’re born with it,” Dr. Wilson continued. “Cancer is not uncommon in infants and children.”

“Will she be a retard?” sobbed the mother. “Can she go to a normal school like other children?”

The grandparents shifted uncomfortably in their seats. Although uneducated, they grasped the reality of the situation far better than their daughter. Dr. Wilson leaned close to Mrs. Hobson’s face and placed his hand on her arm.

“Janet,” he said in a soft but firm tone as he gazed directly into her eyes and prepared to drop the bomb, “Rebecca is not going to school. Rebecca is not going to have a first birthday party. Rebecca is not leaving this hospital. Rebecca is going to die. Probably very soon.”

“No, no, you’re wrong, she’s a strong little girl. I know. She kicked like a mule in my stomach…” She started to cry harder and put her head down on the room’s circular conference table. “…She has such pretty blue eyes…Momma, tell me my little girl won’t die.”

Rebecca’s father sat in the corner opposite to me. He was hunched over, elbows on knees, smoke trailing from a cigarette in his left hand. He looked down at the floor and never spoke. The room fell into an eerie silence broken only by the occasional soft sobs of Rebecca’s mother.

“We’ll talk more later.” Dr. Wilson bolted up and started to exit the room, with me close behind. The grandfather followed us out the door while the grandmother stayed behind to comfort her daughter.

“Doc, can I talk with you?”

We closed the conference room door and moved out of earshot down the hall.

“How long does she have?”

“That’s difficult to say…a few months…,” replied Dr. Wilson. “She isn’t fully awake yet from surgery, but I’m afraid she may be badly hurt. There is a chance she might have some paralysis or that she might not wake up at all.”

“Can we take her home? This is such a long drive and the poor kids don’t even have their own car.”

“I don’t think she’ll ever be able to go home. We might transfer her to a hospital in your own state, but since she’s on medical assistance now and we began treating her here, they may not pay to take her back. Sounds cruel, I know, but she may be stuck here until she dies.”

The old man lowered his head to hide the tears welling in his eyes. “What should we do?”

“Janet may not have formed a truly strong attachment to her child yet. Your daughter is young, she has a lot of time to forget and have another child. My suggestion is that you go home. If you don’t come back, we’ll understand.”