When air hits the brain - tales from neurosurgery
- Feb 11, 2018
- 4 min read
How I came across this book: It is considered a ‘must-read’ before starting surgical training, so I finally decided to read it after finishing my training.
Favorite Line from the book:
Failure instructs better than success. A single death shapes the surgeon’s psyche in a way that fifty “saves” cannot.
Pressure is part of the deal. Anybody can sing in the shower, but how many can sing in front of an audience, huh? Pressure makes all the difference in the world.
Nietzsche: whatever does not kill me makes me stronger.
The book aptly stated in the first line, ‘neurosurgery is an arrogant occupation.’ Most medical doctors would tend to agree with that line. In fact, there is a direct correlation between the importance of an organ you play with routinely in the operating room and your testosterone level (p<0.00001). Some surgeons will argue that the testosterone level increases in a specific order when it comes to surgery - plastic surgeon (skin) -> orthopedic surgeon (bones) -> gastrointestinal surgeon (bowel) -> HPB surgeon (liver and pancreas) -> transplant surgeon (HPB surgeon on steroids) -> cardiac surgeon (heart) -> neurosurgeon (brain). In the eyes of a neurosurgeon, a plastic surgeon is a wimp, whereas in the eyes of a plastic surgeon he is doing the most important ‘job’ while the neurosurgeons are unnecessarily killing the patients by messing with their brains and wasting tax-payers money. Welcome to the arrogant world of surgery where everyone is trying to show the size of their biceps. New York based medical oncologist, Siddhartha Mukherjee writes in his fascinating book, ‘the emperor of all maladies’: surgery is a profession sealed to the outsiders, to change surgery, one must be a surgeon. I am often asked, ‘why did you become a surgeon’ or ‘did you always want to become a surgeon?’ On most occasions, I give a diplomatic answer, so it does not turn out to be a long stretched out discussion.
Frank Vertosick gives a short account of his surgical training including events, which led him to become a neurosurgeon. He describes some of his memorable and anecdotal experiences during neurosurgery residency from his internship year to his chief year (final year in surgical training) in Pittsburgh. From a baby born with cerebellar tumor to a pregnant woman paralyzed from frontal lobe tumor - every chapter makes you emotional and shows medicine at its best and its worst. The book wraps around the events, which led Dr. Vertosick to become ‘one of them,’ a psychopath, emotionless, narcissist, surgery thirsty, workaholic neurosurgeon, all the features necessary to show you have the biggest biceps of them all. He describes all these characteristics necessary for the job, some of them you possess before you enter surgical training (the reason why surgical bosses think you have the potential to become like ‘one of them’) and some of them, you acquire over the course of multiple years of rigorous surgical training. A lot of Dr. Vertosick’s experience comes from his interaction with his senior and chief resident. While the chief resident taught him a lot about surgery and life; he notes how all these years of training had metamorphosed his chief resident into ‘one of them.’
Dr. Vertosick was sent to the London hospital (now Royal London Hospital) during his residency as part of his training. He felt the stark contrast in the medical system across the Atlantic but learned a lot about patient care in the process. The training era described in the book is from the eighties. A lot of surgical and medical practice has changed (thank god!). Open lung biopsy, injecting epinephrine directly in the heart for a patient with cardiac arrest, routine open clipping of a cerebral aneurysm (dilatation of a blood vessel in the brain) are things of the past. Dr. Vertosick states that a surgeon after multiple years of repeated practice starts to operate from his spinal cord reflexes (muscle memory). The spinal cord reflexes are important for a surgeon but the concept of operating purely by ‘muscle memory’ is not entirely true. As my transplant boss (the charismatic and legendary surgeon Dr. Tzakis) would often remind me, ‘surgeons operate with their brains, not with their hands.’ Muscle memory is just a term and the ‘activity’ to be done is a combination of ‘reflexes’ (activity within the spinal cord) that is evoked by the ‘program’ or that is executed by the cerebrum but further modulated by the ‘code’ in the cerebellum. As we get better as a surgeon, the ‘program’ improves, but the code within the cerebellum gets updated too. Just like an iPhone update leads to a better performance in the operating system (spinal cord reflex) of the phone but the direction of improvement is governed by the Apple engineers (cerebrum) in turn listening to customers demand/feedback (cerebellum). This beautiful analogy was explained to me by my cousin ‘BR Chaudhary,’ who happens to be a neurosurgeon himself.
The book gives an honest and humane inside view of surgical training. Reading through the book reminded me about my surgical training over the course of last decade and how much I learned primarily from my colleagues, senior residents/registrars, and chief residents. Today, each one of them is an excellent surgeon saving lives in different parts of the world. Surgical residency is an integral part of a surgeon’s experience. There are periods when you suffer from emotional desensitization and start to feel like ‘one of them’ while there are periods where you are feeling on top of the world after saving a life or two. The book is a fascinating read for anyone (medical or non-medical) as long as you are ready to tolerate all the profanity (very often used in the surgical world) in the book. Dr. Vertosick finished the book by quoting how he slowly transformed into ‘one of them.’ The reasons why I went in surgical training have changed over the course of last decade after working with some truly caring and inspiring mentors. From someone who was fascinated by taking care of the patient with his knife to someone who feels passionate about taking care of the disease, from someone who wanted to prove the world that they are wrong (I have what it takes) to someone who feels passionate as an innovator and wants to prove that we can win the battle in medicine, at least on most occasions.
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