This Is Brain Surgery

Just yesterday, I had a case where a child had an anomaly in the skull and in the sagittal sinus - the channel that carries blood away from the brain. Blood flows through there at a very high rate. I told the anesthesiologist to have lots of blood in the room and to be ready for a major catastrophe. Sure enough, when we lifted the bone, a hole opened up and blood was squirting all over the place. It was a mess.

The resident assisting me started to panic. I said, "Calm down. Put your finger in the dike, just like the Little Dutch Boy." Then I showed him how to peel off the tissue, lift the rest of the bone, take a piece of muscle fascia, and sew it over the defect. Something big went wrong. But it wasn't a big deal, because we were ready. I knew what we were going to do before it happened.

Make Pressure a Positive

No matter how good you are at planning, the pressure never goes away. So I don't fight it. I feed off it. I turn pressure into motivation to do my best. Everything you do in the operating room is so crucial - I mean every little movement - that you block out fatigue, noise, and personal problems, and focus on what matters.

Last night, I didn't get home until midnight. I did three operations, the last of which involved untethering the spinal cord of a seven-year-old child. Imagine if someone took a bunch of rubber bands, tied them all together, and put a stick of dynamite in the middle. And the dynamite will explode if you don't unravel the rubber bands in just the right way - meaning, in this case, that the kid could come out with some degree of paralysis. There were 10 people in the operating room with me. I spent hours looking through a microscope, separating out nerve roots from scar tissue, stimulating the nerves. Technicians sat in front of video monitors, watching the brain's electric impulses, and I'd ask, "Where is this going? What is this doing?" You'd see little channels open up, you'd see nerve roots coming apart. The operation took five hours and turned out very well. To me, it seemed to take about 45 minutes.

Be Confident, Not Arrogant

You need an incredible amount of self-confidence to go digging around in someone's brain. But it's possible to be confident and humble at the same time. We've learned more about the brain in the last 20 years than we knew in all of history before that. And 20 years from now, I'll be able to make the same statement. So I'm always interested in what other surgeons have to say. I like to call myself a "technical eclectic." If I get a patient who's had good results from surgery performed by someone else, I'll talk to that surgeon and perhaps integrate what he or she did into my techniques.

The hemispherectomy I do now is a lot different from the one I did 10 years ago. I used to take out the whole hemisphere at once. Now I take it out piecemeal. When you try to remove half of the brain in one piece, you can't help but pull up the other half and, in the process, disturb the brain stem. Early on, we had some patients who didn't wake up right after surgery. One stayed in a coma for a month. I concluded that the brain stem was moving too much. The more of these procedures we did, the more we learned. If you want to improve, you have to keep an open mind.

You need that same kind of humility in the operating room. You can be a good leader without being a dictator. My team includes other pediatric neurosurgeons, anesthesiologists, physician's assistants, several nurses, and the secretarial staff. I see myself as a conductor. I am orchestrating the procedure and the activities around it. That's one reason I can do 400 to 500 procedures a year - more than twice as many as most surgeons do. It's not because I have superior skills. It's because I'm flexible.

Get Real about Risk

The only way to handle risk is to be brutally honest about it. I give the parents the worst-case scenario - not to scare them but to prepare them. If parents aren't prepared for what can go wrong, then we shouldn't be talking about surgery.

Still, people need hope. The mind controls so much of the body. We are much more than flesh and blood; we are complex systems. Patients do better when they have faith that they're going to do better. That's why I always tell my patients and their families not to neglect their prayers. There's nobody I don't say that to.

I once had a patient with a brain tumor. She'd had radiation, she'd been operated on by several people, but nothing had worked. As I was taking out the tumor, she suffered catastrophic hemorrhaging. Her brain was herniating, and we were trying to push it back in. All I wanted was to get her skull closed, so she could die in the intensive-care unit rather than in the operating room - to give her mother a chance to adjust a little.