The Brain is Obdurate
A short but thrilling tale of surgical adventure by Edison McDaniels, MD | surgeonwriter.com | fiction
† Time Slows †
A bead of sweat rolled into the surgeon’s eye and broke his concentration. He blinked at the sudden stinging intrusion, but didn’t wipe it away.
The surgeon pushed back from the microscope and sighed deeply. He tilted his head, feeling the reluctance in his neck, and gazed at the clock on the far wall. The simplest of clocks, the elementary school version with big, block numbers. The sweeping second-hand jumped ahead with each tick. He stared through a teary film as it tick-tocked the seconds away. He looked to the circulator, her attention was on the clock as well. After what seemed a long moment, she turned his way and they locked eyes above their masks. She stepped forward, towel in hand, and wiped the accumulated sweat from his brow.
He craned his neck, working his sore muscles. He remained ever fascinated at how sore these cases made him. Hours under the microscope, hands and fingers moving in small arcs, his arms seemingly not at all, and when it was over the stiffness would be worse than his high school days after football practice. He was still a year shy of fifty, but that was old enough he supposed.
Time slows for no one, and ages everyone.
The scrub stood beside the surgeon, fingering a Penfield dissector in her off hand. She worked her jaw, as if chewing gum. Her gaze went to the clock as well, then to the assistant across the table. The assist ignored her, his gaze moving back and forth between the clock and the exposed brain before him. Sweat darkened the front of his surgical cap, but nobody wiped his brow. Blood stained the front of his gown.
The surgeon looked across the drapes to the anesthesiologist standing beside the churning ventilator. A bellows the size of a small loaf of bread moved up and down at one end of the machine. It rasped as it counted the breaths. The doctor held a clipboard in one hand. He turned a knob on the breathing machine and his attention moved to the EKG monitor, to the blip squiggling its familiar pattern across the screen. With each up-down stroke, the unit uttered a stark tone—ping-ping-ping…ping-ping-ping… He jotted a note on his clipboard and looked up at the clock.
Fourteen minutes past two of a Wednesday afternoon.
† The First Minute †
“That’s a full fifteen minutes then,” the doctor behind the drapes said. “BP’s holding. Pulse looks good.”
The surgeon nodded. “Okay then. We best to get this thing done.” He made eyes at the circulator. Her eyebrows went up subtly and she nodded as if in agreement.
The surgeon turned back to the field, where a square of blue towels surrounded a hole several inches in diameter, large enough to sink a fair sized plum through. The edges of the towels were dyed with black, crusted blood. Within the hole, visible to anyone who cared to look, the pinkish-gray brain pulsated in time with the ping-ping-ping of the pulse tracing.
The surgeon peered through the microscope. The various peaks and valleys of the brain came into focus, appearing on a grand scale as if he had a bird’s eye view on an alien, canyoned world. It seemed only natural how the rivers in such a land ran hard and fast with the reddish ochre of blood. He blinked a few times, adjusting his eyes to the intensity of the light. He put a hand out, pinching his fingers to and fro with apparent impatience. “Bipolar.”
The scrub placed the cauterizing forceps between his outstretched fingers.
“Suction,” the surgeon said.
The assist pushed a thin, metal straw into view under the scope. The diameter of a wet spaghetti noodle, the blunt tip could still do damage if yielded imprecisely. The assist pressed a small cotton paddy into place beneath the sucker tip and the slowly accumulating pool of red disappeared up the sucker. It passed up and out of the head, into an attached clear plastic tube, where it crawled toward a canister against the wall.
The brain on the table belonged to a middle-aged mechanic and a minute passed as the two—the surgeon and the assist—jockeyed back into position inside the mechanic’s head. There followed a curious ballet in which they marched along a natural turn of the skull, then squeezed down a corridor between a bony wall on one side and the cerebellum—the ‘small brain’ at the back of the head—on the other. This brought them to the CP angle, a no man’s land in neurosurgical parlance. They only belonged there because they had to be there. Because it was there.
Because the tumor was there.
† The Second Minute †
The surgeon had worked four hours getting to this point, though only later would he realize how much time had passed. Just now, time seemed to labor, with seconds stretching into minutes. He had made only one mistake so far—only one he was aware of anyway—and not obviously a costly one in neurosurgical terms. Obviously was the operative word. In brain surgery, any mistake could be costly.
And any move could be a mistake.
He had been dissecting the tumor off a blood vessel, though hadn’t been quite able to see which vessel at the time. That, in itself, was not a mistake but a fact of the mechanic’s particular anatomy. Patient specific anatomy he told himself, knowing every tumor has it’s own peculiar structure. A tumor invades and pushes and insinuates itself in the midst of what is normal. The normal and the abnormal closely apposed. Sometimes one and the same. It is the surgeon’s job to map these peculiarities.
The unseen vessel had torn. The result was a minor bloodletting, perhaps a thousand cc’s—four cups—of blood lost in the thirty or forty seconds it took to bring it under control. That’s when the clock watching had started: “I’ve packed the bleeder off, give me fifteen minutes by the clock.”
All bleeding stops eventually, the voice of experience whispered in his head.
And so the surgeon and the mechanic had arrived at this moment.
The surgeon took another deep breath. Through the microscope, he ran his eyes around the field for the umpteenth time. He knew what he was about to do would mean everything to the mechanic.
The final ten. The last ten minutes of tumor removal. Everything up to that time was just preamble. The last ten minutes were always the hardest minutes, both on the surgeon and the patient—though the patient would never know it if things went well. If they didn’t? Well, the patient likely wouldn’t know that either.
“Lift here,” the surgeon said.
The assist did as directed, lifting ever so slightly on the retractor. The fold of brain behind it moved, perhaps an eighth of an inch but no more. The brain is obdurate. It doesn’t want to be moved, doesn’t like to be moved.
The final remnant of tumor came into view, but just the edge of it.
“Nice,” the surgeon said to nobody in particular. “Damn thing is just there. Penfield six.”
The scrub passed the number six dissector, a narrow, blunt tipped pointer. The surgeon touched it to the tumor, getting the feel of the growth, wanting to know it’s consistency, it’s texture. He’d been working toward this moment for hours, had most of the tumor out. He had learned most of what there was to know about this particular devil’s peculiarities, but it could still bite.
Another truism he knew from experience. Too much experience. It had thinned his hair but quickened his mind and steadied his hand. Behind his mask, the surgeon bit his lip and held back an expletive.
† The Third Minute †
Using the number six, he defined the interface between the tumor and its surroundings. He developed the three dimensional interface, mapping most all of the remaining devil. He couldn’t see or define the underside of the tumor though.
If trouble was coming—the brain is obdurate, the voice of experience whispered again—it was going to come from the under side.
What’s the worst thing I can do right now and how can I avoid it?
Blunder blindly into something, he told himself. I need to know the surroundings better.
He was three inches inside the mechanic’s head, had ninety percent plus of the tumor out. He looked at the landscape, thought, something isn’t right. Thought, what am I missing?
He took up his own sucker, placing a cotton paddy between it and the brain. He began to work his way over the terrain. At play in the fields of the the Lord, he told himself, thinking there are no atheistic brain surgeons.
He called out the structures as he went. In a half voice mostly, sotto voce. “Seven, eight.” The two cranial nerves crossed the field together, intimate friends, before disappearing into a small opening in the bony wall of the skull base. The tumor had distorted them, but they appeared otherwise none the worse. Same with ‘aica,’ an artery. Just the fact the artery had a name, aica, was enough to suggest it was important, something not to be fucked with. He left it alone out of respect. He found the sixth nerve and followed it’s circuitous path, the longest of any of the cranial nerves, around the periphery of the brain stem.
What he didn’t see, what he hadn’t called out, was the Basilar artery. He hesitated. “Where the hell…”
The large artery came into view just then. A red, pulsating thing, thrumming in exact synchrony with the ping of the EKG. It had an unusual redundant course, turning back on itself as it never should, too curved and twisted for it’s own good. Patient specific anatomy.
He adjusted the focal length of the microscope and the artery moved in and out of focus along its tortured course, worm-like and bloated. “Damn.”
He saw now his worst fear. Or rather his second worst fear. The final remnant of tumor—the very devil himself—had become intimate with the twisted Basilar artery. And the Basilar artery was, of course, intimate to everything the mechanic was.
The brain is obdurate—and the Basilar artery is the most obdurate part of that brain.
The surgeon looked up from the microscope, turned his head. The circulator was at his side on the instant toweling the sweat from his forehead.
The patient, his brain exposed to the elements, lay under the sterile drapes, oblivious to the danger ahead.
Next time on Neurosurgery101—TheBlog: Part II of 2 of The Brain is Obdurate, a short but thrilling tale of surgical adventure well calculated to keep you in suspense, by Edison McDaniels, MD