08 January 2011

"It’s not Brain Surgery"… okay…actually…. it is.

I saw a woman’s brain today. I didn’t touch it – not even the intern, MD,PhD in neuroscience – did. But I was standing there, inches away, peering over the table and into her cerebellum. The surgeons were pointing with instruments – there, there. There’s the tumor (metastasis). There’s her normal brain. The cerebellum looked like I imagine mitochondria look on the inside, the maze of cristae folding back on each other. Or, the stacks of thylakoids in chloroplasts* Beautiful, regular, waving folds, just like in the pictures and the models. I’ve seen brains before. I’ve held a brain in my hands – we had them in anatomy lab. I’ve dissected a cadaver’s head to get to the brain, and I’ve dissected brains whole.

* Disclaimer – had to look up the words, I just remembered the pictures. It’s been… not sure how many years since I did any plant biology. Perhaps 10.

I didn’t dissect this brain. I didn’t even touch it, not this time. But I looked into a woman’s brain today. And she was alive.

I’ve decided that neurosurgery is perhaps the worst career in the world. Even as 4th year med students (not me) and certainly as residents, you’re on Q1.Q1. Q refers to call schedule, and the number refers to how many days between calls. In residency, Q3 or Q4 is common. Q3 means on call one night (overnight), post-call the next day (ie go home around 1pm, theoretically), normal day the next day, and then you’re on call again (you slept two nights between calls). Q2 is fairly common for neurosurgery residency as well – you sleep every other night.
Q1, you live at the hospital. The resident can stay home, but realistically he gets called for something at least once every night, likely many times, and almost always has to come in. Work hour rules (currently) state you have to have an average of one day off per week, or four per month. So there are some of those. But you’re basically taking care of (on our team) 30-35 patients, yourself, your pager is going off every few minutes  (it makes me nervous and jumpy and I’m not even wearing it!), and – it’s brain surgery – there are emergencies. Lots of them. Having a neurosurgeon on call 24 hours is what qualifies a hospital as a Level One trauma center, actually, and I’m at a Level One. (there’s a House episode on that issue).

Tree rings...yosemite. Another kind of inside intimacy.
I wonder what correlating hours are for rocket scientists.

They were in the woman’s brain and somehow, later, after she was all put back together, she woke up. They were in her brain and she survived – maybe normal. Maybe-ish. They took out a large tumor from the cerebellum, about the size of a walnut, a friend described it as. Metastasis. They sent the frozen section to pathology in the middle of the surgery. We waited. We waited. “Metastatic carcinoma” came the phone call. It wasn’t a surprise. The most common brain tumor is a metastasis from somewhere else – breast, lung, lymphoma. And if cancer has metastasized and spread to your brain, it’s already pretty bad. The surgeries, then, are often palliative. Not going to be cured. Maybe a few more months, maybe a year (?!) but they were inside your brain and they took out pieces of it. You don’t always survive that, and when you do, you don’t always survive as the same person.

And there are scissors and microscissors and wax and hemostatic foams and sutures and bovie (cauterizers) in your brain. And you wake up and part of you is gone. You give this amount of power, this amount of trust to someone who has gone through, yes, that many years of training in that special kind of lack of sleep. (Terror? Hell? Torture? Not going to judge). Somehow, the group of neurosurgeons (interns, residents, attendings) are, on average, perhaps the coolest group of doctors-in-a-specialty that I’ve worked with, and one of the groups I’d most like to hang out with. Very laid back. This…surprised me. And maybe it’s not true everywhere. But they’re all very casual (in a good way), easy-going. If you thought all day about how you were in people’s brains, maybe you would go mad with the stress. I might. They don’t – at least not for now. And the ones who have completely burned out would, by definition, not be there for me to meet.

I would trust them as much as I would trust anyone to be inside my brain. And I’m not sure I’d trust anyone.

A general surgery resident remarked on why she didn’t want to be in neurosurgery – “The patients don’t leave the hospital walking. They might have come in walking. They don’t leave that way.”

(Yaounde, my walk to work summer 2009. Capital city yet such beautiful views..I will continue to be random...)

And today I saw the inside of a man’s neck, I saw the surgeon remove parts of his spine, and I screwed bolts into metal rods millimeters from his spinal cord. Unbelievable, unbelievable chutzpah. And yet… this is why surgeons are known as arrogant. They have to be (and these, somehow, doing arguably the most high stakes/dangerous work, are the least arrogant I have met). You can’t hesitate. You have to make decisions with confidence. Or someone dies. You have to work quickly and confidently or they could be paralyzed. They could be comatose. They could wake up being someone else. Or, they could wake up, be able to move again, be awake and alert again, and regain their own personalities and selves (see: man who regained a language).

But the point is….medicine is the only career in which the thing that we use in our work is the same exact thing that we work on. We use our bodies to work on other bodies. They are thinking, intently, while working inside the part of a patient that makes them, that allows them to think. Hand surgeons use their hands to fix someone’s hands. This is what has marked me most in my personal practice (hands being very important to me. Which is the other point and why we can’t ever separate… we’re not different than our patients. We are them, at times, and they are the people we know). Holding my cadaver’s hand in my hand while I dissected it. Thinking about my own tendons and bones as I uncovered hers. This summer, examining a patient, newly diagnosed with lupus, on her swollen joints and arthritic hands. My aching joints (not nearly to any similar degree) holding her, turning them, without being able to tell her. Not always. Sometimes. Sometimes.

This is the unbelievable intimacy. I have seen the inside of people. I have spoken with them, I have examined them, I have met their families, I have talked to them about their fears, and I have seen the inside of them and touched it. Last night, when one of the lamina (back part of the vertebral column, protecting the posterior part of the spinal cord) was removed, I held it in my hand, cleaning it carefully, and turning it over and over and over. My sterilized hand, enclosed in two layers of sterile gloves, was cradling and examining part of what had protected this patient his entire life, what had been such a crucial part of who he was. Is. This patient had broken his neck, in the literal sense, and somehow the cord hadn’t been touched, yet, though some was beginning to show signs of compression. I saw the inside of a woman’s brain and I talked to her before and afterward.

I have seen, I have touched parts of patients that no one close to them has ever seen. No parents, no lovers, no children (usually). And maybe they don’t care and maybe it doesn’t matter to them. But I’ve seen the parts that keep them alive, that are working all the time, that have grown and changed as they have grown and changed and show signs of wear, of injury, of things no one else knows. This is where pain has come from and been felt. This is the heart that speeds up, or slows down, or sometimes feels like it’s about to burst out of their chest. This is the organ where they think, and we don’t understand how that happens (I don’t, at least) – but we know where it is. We talk so much about hearts and brains…I’ve seen them. The loci, maybe not really connected to the feelings about them. And maybe so.

And this is where I see poetry. (the thesis and strong connection * may * because I’m  currently trying to convince grad school admissions committees of why they are the same, and why being a writer will make me a better doctor and vice versa). My favorite quote about writing is: “Writing poetry is easy. All you have to do is find a vein and open it.”

Nothing is more true to me. And this is why writing real, writing good poetry…hurts.

And this is why there’s an incredible sort of intimacy in writing workshops. It’s different than anything else I’ve experienced. The poems are not about the specific thing they are describing or talking about, exactly; they’re what it means. They are the most exact, precise way to describe it in the fewest words and spaces and pauses and line breaks. Friends may know what or whom I’m writing about, depending on the details and depending on when I write it. They are either wrong or right or, more likely, some of both. The person I’m writing about or to may recognize it, or not. I don’t know. Maybe the particular details that marked me so deeply and crucially…didn’t. Maybe I wrote it years later. Maybe they’ve forgotten entirely.

I write about myself in first, second, and third person. Depending. As in – the “I”, “you,” or “she” might be me. Sometimes I write in the voice of other people as “I.” This is why I/we try to remember to separate speaker and author. Often the same? Sure. Not always. And what’s written is usually not exactly what happened. In the moment or directly after, I usually write too many details and too “exactly” what happened. Over time it’s easier to cut and change – it doesn’t hurt as much to change and remove lines I’m attached to – it’s not where the poem is. Often not. For now.


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