The Brain is Obdurate, Part II of 2
A short but thrilling tale of surgical adventure by Edison McDaniels, MD | surgeonwriter.com | fiction
Read Part I here.
† The Fourth Minute †
The patient, his brain exposed to the elements, lay under the sterile drapes, oblivious to the danger ahead, to the final ten minutes of tumor removal.
The surgeon studied the scene through the microscope, learning its intricacies. He had one chance to get this right. Everything the mechanic was—and everything he would ever become—depended on it.
But it was more than that too. The surgeon held to the ancient belief we are, each and every one of us, the sum of all those we touch. These touches are both big and little, some having more impact than others but all contributing to the whole. A mistake at this point, even a small one, and the mechanic would likely never consciously touch another human being again. This, of course, would change the course of history, since we all touch, are touched, by thousands of others in a lifetime.
He knew all of this and dwelled on none of it, of course. Sitting at the microscope and looking inches deep into the mechanic’s head—the mechanic’s brain—he had no time for such introspections. No time even for hesitation. Years of experience informed his every move, had taught him to be decisive.
“Ten,” the surgeon said, holding his hand out to the scrub.
She passed another penfield dissector to him, this one with a small, flat beveled edge to it. He turned to his assist. “Whatever happens, you just keep sucking. Visualization is everything and I can’t see a goddamn thing if this field fills with blood. Don’t move the goddamn sucker around, don’t try to improve my view. Just suck. Got it?”
The assist nodded. He blinked an eye repeatedly, like a man with a tick that had suddenly acted up.
The surgeon turned to the anesthesiologist. “Let me know if anything changes up there.”
“Will do. Rock stable just now.”
The only sound in the room was the rasp of the bellows and the ping-ping-ping of the EKG.
The surgeon took up his own sucker in his off hand, prodding it against the tumor, feeling the pulsations of the nearby artery. He prodded gently at first, and then with greater force. As he did this, the tumor began to come away from the Basilar artery.
Delicate, tedious work. The wall of the Basilar artery was muscular, but still thin enough to see the blood swirling past with every contraction of the mechanic’s heart. The surgeon’s own heart seemed to work overtime with the work, and, like a man digging ditches at the roadside, his own chest heaved with every breath.
His hands were rock steady though.
He stopped periodically to suck away pooling spinal fluid. An occasional wisp of blood clouded the otherwise clear exposure, turning the watery fluid a red so thin he could have read newsprint through it. The tumor, looking ever more dusky, came away in fits and starts as if not wanting to give itself up. But the surgeon was persistent.
He had pulled half of the remaining tumor away from the artery when the ping-ping-ping of the EKG tracing slowed down. An instant later, the pings stopped altogether.
† The Fifth Minute †
“He’s bradying down—asystolic now,” the anesthesiologist hollered over the drapes.
The surgeon relaxed his pull on the tumor. It settled back against the Basilar artery, which in turn settled back against the brain.
Behind his mask, the surgeon pushed a wad of spit around his mouth.
The ping-ping-ping resumed, slowly at first, then with greater gusto. Ten, Twenty, Twenty-five beats per minute.
The anesthesiologist put his clipboard aside and reached for a prepared vial on the countertop. He injected it into the IV tubing. “Atropine going in.”
Thirty-five, Fifty, Sixty, Seventy-five beats per minute. The up-down squiggles on the EKG display sped up. “He’s back.”
The surgeon waited for the atropine to circulate fully, a long minute or more, then replaced both the dissector and the sucker against the tumor. The monitor hiccoughed, then became regular again.
The surgeon and the assist looked through the microscope. The usual small amount of spinal fluid bubbled into view, enough to keep things moist. A good thing.
Still no bleeding, he thought.
The tumor, which had been pink going on red when they started the day, was now decidedly blue. Deprived of blood, the devil had gone dusky. The thing was dying.
“Almost there,” the assist said.
The surgeon didn’t answer. Almost don’t count for shit, he thought.
† The Sixth Minute †
The surgeon bent to the microscope, his vigor and determination clear. “Let’s get this damn thing out and all go home,” he said.
Again he tugged on the tumor, this time using the sucker to lift the growth while he looked for trappings between it and the artery using the dissector. The heart rate ping-ping-pinged steady at eighty beats per minute.
He cut away at the last piece of tumor and of a sudden the operative field bloomed red. Blood flooded the mechanic’s open head in the instant before the assist reacted with his own sucker. The blood rose like water over a cofferdam.
“Suck here now,” the surgeon said. His voice was the definition of calmness. “Right here, right now.”
He took up a cotton paddy and placed it under his own sucker, then submerged the sucker tip in the bloody lake. The move was more precise than it appeared.
“More paddies. I need cotton paddies.”
He began to insert them one at a time into the depths of the wound, working around all of the delicate nerves and vessels passing through the mechanic’s CP angle. He did this by rote memory, using the mental map he had been constructing so meticulously all day. He moved with purpose, without wasted motion in even the tiniest action. He moved too with precision.
The flood continued unabated.
On the instant, the scrub rolled back one of the covering blue towels and passed the third sucker to the assist, who now held one in each hand. He placed them into the head, the surgeon all the while directing him. The blood diminished and the tumor floated into view.
The surgeon placed one last cotton paddy over what he envisaged to be the source of the bleeding. It trickled and he adjusted his pressure slightly. The bleeding stopped.
He picked up the final nubbin of tumor, the size of his little finger tip, with his other hand. “The devil’s out.” He gave it to the scrub. “How’s it going up there?” he asked the folks at the bellows.
† The Seventh, Eighth, & Ninth Minutes †
“Shit,” the doctor said. “I got 60 over palp for BP.” He had his hand of the plastic IV bag, squeezing saline into the mechanic’s arm as fast as it would go. “Heart’s racing at 130. You about done there?”
“He damn near bottomed out,” the anesthesiologist said.
“But he didn’t,” the surgeon said. He sat on his stool and waited. He had time now. They all had time now.
The mechanic as well. He had all the time in the world.
† The Tenth Minute †
The surgeon waited two minutes by the elementary school clock, watching the sweep of the second hand jump through the seconds.
Experience—no substitute for it—had whispered to him yet again. The worst is over.
He had seen the color of the blood coming out of the mechanic’s head, dark red, and had known that whatever was bleeding it was not the Basilar artery. The Basilar artery would have bled bright red—and stopping it would have proved a fruitless gesture.
It would have stopped eventually of course, but only because all bleeding stops eventually.
A Curious Thing
The curious thing about working inside someone’s head is this: the longer you work, the deeper you get. And the deeper you get, the harder it becomes. This is because while you might be working through a hole the size of a plum on the outside, that hole cones down to a grape or even a pea somewhere deep—sometimes very deep—in the distant hills and valleys of the brain. That, of course, is where the fun really begins, because you have to be at your best when you are most tired.
And remember, the brain is obdurate. It doesn’t shift easily and doesn’t like to be moved about. The cost of this is visualization. Despite the light afforded by the operating microscope (one of the greatest advances in brain surgery in the past fifty years), one is always fighting to see into the crevices and around the many rocks and boulders strewn about.
And one false move in one of those crevices, places never meant to see the light of the surgeon’s microscope—packed with bundles of nerves, arteries, and veins—and the patient might wake up devastated.
Or might never wake at all.