If I Ready to Do Neurosurgery?

"What can I do to help?" I asked when we had returned to the patient's bedside.

"You can do the case," Dr. Blanchard said.

Nothing in his voice indicated he was kidding.

He drew a large, backward question mark on the shaved scalp. "Cut down to the skull on a 90 degree angle on this line."

"Knife," I called, and, unbelievably, the scrub tech put the knife in my hand. I was 25 years old and about to do a craniotomy. I provided traction on the skin with my left hand and inserted the knife. The first cut was like butter. I followed the smooth curve.

"Slow down, it's not a race."

But this guy is dying. He might already be brain dead.

When I was finished, Blanchard pulled at the large flap I'd made. It separated easily from the skull. Everything turned red; the scalp really bleeds. He undermined the skin surrounding the wound and called for the hemoclip.

"Just push in on the skin edge and click." When he pulled the trigger a little plastic clip, about 1/4-inch wide, shot forward and grabbed the skin edge, pinching the blood vessels closed. He handed me the hemoclip and away I went. Clip, clip, clip until the cartridge emptied, then a reload and more clipping. After about 20 clips, hemostasis was achieved.

"Great," he said as I finished. "Drill."

The drill was placed in his outstretched hand.

"See this? It turns at 7,000 rpm, so only put it on something you want it to go through. The pedal is by your foot." He looped the cord around my forearm and handed me the drill.

I was a little kid again, playing with Dad's power tools. But the stakes were much higher now.

He marked off the four corners where I was supposed to make holes. "As soon as you're through, stop. The goal is to not drill the brain."

This is all a dream. This is a game. It's all make-believe. We're just playing doctor.

I couldn't even see a body under all the drapes, just a square of skull with some blood. The only evidence of a live patient was the beeping of the anesthesiologist's heart monitor.

I hit the pedal and the drill whirled to life. It had its own mission: to skip across the smooth skull. But my determination to not mess up prevailed—that, and brute strength. The drill sank into the skull. Blanchard kept the drilling area wet with saline. I pulled up a few times to check my progress. I pulled up once more when the resistance changed. There was a clean, 3-millimeter-wide hole in the skull.

"You're doing great. Next hole."

This time I didn't pull up so often. After I'd made the other two holes, Blanchard called for the Medical Electric Saw.

"If you angle it properly, it will cut through the skull like air; otherwise it's work."

He handed me the Medical Electric Drill.

A Medical Electric Saw & Drill in my inexperienced hand sounds risky, but it was one of the safer tools at my disposal. It has a guard that prevents it from going too deep.

"Connect the outsides of the holes."

"Ho hum, just sawing the skull. I'm sawing a human skull. I'm sawing a living human's skull!"

"What type of work do you do?"

"I saw human skulls; live people only, of course."

"Really? That must require a lot of training."

"Well, I went to medical school for four years, but I don't remember any lectures about skull-sawing. In fact, I don't remember any neurosurgery lectures whatsoever."

"How do you know what you're doing?"

"See the guy next to me? He's my mentor. When he's quiet, I can assume I'm doing things correctly."

But I didn't think I was. My angle must have been off. My hand was getting sore from trying to cut out the square.

When I finished, Blanchard took a small pick and lifted the cut square of bone. It came right off.

"That's what I like about young skulls. They're so easy to open."

Hmm. I'd never had that thought.

The dura mater, a protective sheath just inside the skull—"dura" meaning hard and "mater" meaning mother—is the only thing separating us from the brain. Blanchard poked a small hole in it with a scalpel.

"Take the scissors and cut out a flap."

"Scissors," I called. The dura wasn't so tough. It felt like I was cutting an al dente mostaccioli noodle.

We folded back the flap. I couldn't see the brain through the dark red clot. Again I thought of food: It looked like cherry Jell-O.

"Be careful with that sucker. Hold it like this," Blanchard ordered. He showed me the proper grip.

"Never use full suction. It will suck up the clot and the brain with it."

I remembered reading that the human brain is the same color and consistency as vanilla custard. Fresh brains are nothing like the stage props I was used to.

We started sucking away the clot with a coffee-stirrer-sized vacuum. I was glad machines are available for that. We went through 1.5 centimeters of clot before we uncovered the brain's mysterious folds. I wished I could have taken a picture. There was something mesmerizing about the spider web of veins covering the pale yellow brain.

It's hard to accept that such an ambiguous-shaped organ has so many functions. The brain is nothing like the stomach. You can look at the stomach and say the food comes in here and goes out there; the muscles jostle food and the glands secrete digestive chemicals. Straightforward and logical. The brain is just a squishy blob. You can't look at a wrinkle and deduce that the area controls leg movements. It would be like looking at the grooves of a record and trying to figure out what sounds are encoded.

"Brain retractor," Blanchard called. "If you use this you can put your sucker right on top of it. Then you know you won't be sucking brain."

He slapped it into my hand. It was a flat paddle of metal, like a steel tongue depressor. I slowly slid it under a clot and sucked above it.

"Go ahead, you don't have to be so gentle. It's soft. It's a brain retractor." He politely omitted the "duh."

I suddenly realized how quiet the room was. The anesthesiologist, scrub tech, scrub nurse, and neurosurgeon were watching me remove a clot from the brain.

"What are the chances of survival for a patient is in this condition?"

"About one in 500."

Well, at least there was a chance. I got a huge chunk of the clot under the retractor and lifted it out. Just below the patient's head was a plastic brain bag, used to catch the dripping blood. I dumped the clot into it, missed, and got some on my shoes. I wished I had put on shoe covers.

Fresh blood poured from under the edge of the clot. I couldn't see the source. It kept bleeding and I kept sucking. Some dripped onto the floor, a bit more onto my shoes.

When I finished we flushed the brain with warm saline. The bleeding stopped.

"Let's get out of here before the brain swells too large," said Blanchard. If that happens you won't be able to put the bone back.

He told me to sew the dura closed. After I did that with a baseball stitch we put the chunk of skull back on. We attached little metal brackets to hold it in place.

Blanchard inserted a long probe through one of the drill holes into the dura and one of the ventricles of the brain. This allowed the extra cerebrospinal fluid to drain as intracranial pressure increased from the swelling.

To close the deep layer of skin, Blanchard used interrupted stitches and I tied them. We closed the outside layer with staples, which hold the skin together with greater strength than stitches. At least that's what they told me in eighth grade when I had to get the back of my head stapled shut. I thought the Frankenstein look was cool.