The sound of neurosurgery, one of the more elite medical specialties, is basically banal — it hinges on a lowly suction device, a thin metal tip connected to clear plastic tubing that’s hooked up to a centralized vacuum system.
“We tend to call this instrument the suction or suction tip, rather than the sucker,” explained brain surgeon Dr. Katrina Firlik, 37, noting this crucial surgical instrument is nearly identical to those used by dental hygienists to clear saliva from your mouth during a cleaning.
It “serves two main purposes: to retract against various tissues, including brain, and to continually clear the surgical field of fluids that get in the way, namely blood and cerebrospinal fluid.”
When Firlik removes a tumor or a blood clot, for example, sucking is the method of choice. Operating on an exposed brain, neurosurgeons “tend to look like they are picking at things, sucking things out, little by little, sometimes for many lonely hours at a time.”
Married to a neurosurgeon who quit to become a venture capitalist, Firlik lives in New Canaan, Conn., operates at Greenwich Hospital and teaches at Yale. She came to Chicago recently to promote her memoir, “Another Day in the Frontal Lobe: A Brain Surgeon Exposes Life on the Inside.”
Firlik opens her book thusly: “The brain is soft. Some of my colleagues compare it to toothpaste, but that’s not quite right. It doesn’t spread like toothpaste. It doesn’t adhere to your fingers the way toothpaste does. Tofu — the soft variety, if you know tofu — may be a more accurate comparison.”
The public doesn’t hear much about this branch of surgery or know much about its practitioners. Of the 4,500 neurosurgeons in the U.S., only 5 percent are women. Not for the faint of heart, the highly competitive field is dominated by alpha males, or as Firlik puts it, “as kids, we were the ones who always got a chair in musical chairs.”
According to her, the work requires “a delicate balance between fearlessness and caution.” The neurosurgical mantra, she says, is, “the patient is the one taking the risks, not the surgeon.”
Growing up in Cleveland the daughter of a general surgeon, she never thought of following his footsteps, especially not neurosurgery, which her father warned her was “full of arrogant melagomaniacs.”
“But in college I was drawn to medicine, and my passion was the brain. Other organs can be replaced. The brain, with all its complexity and mystery, makes us who we are.”
Her risky business is reflected in her malpractice insurance premiums ($106,000 a year), and though she has never been sued, she fully expects to be.
“That’s really on colleagues’ minds a lot. Some have decided to just do spine surgery. In fact, some even relinquish their brain surgery privileges, believe it or not. And they do that for malpractice reasons — it means they’re not allowed to cover the emergency room.
“My father was sued near the end of his career, and I saw the turmoil it put him through and the emotional bitterness that ensued afterward. That’s what can make a surgeon bitter, even though so much of the career is uplifting, fascinating and satisfying. The downsides can really weigh on you.”
Making inroads
Her unusually candid book is based on her seven-year residency at the University of Pittsburgh Medical Center — she was the first woman to be admitted to its prestigious neurosurgery program, the nation’s largest — an experience so frenetic she only had time to jot down interesting cases on 3-by-5 cards she carried in her white coat.
She drew national attention after a carpenter walked in with a 2-inch nail in his head, an accident from an automatic nail gun.
“Apart from the nail, he looked great,” Firlik recalled.
After all the necessary scans and examinations, she shaved a small patch of hair, made an incision in the scalp, then drilled a circle around the nail. She carefully lifted the disc of skull with the nail in it and was pleased to find no bleeding coming from the hole it had created in the surface of the brain.
Next she hammered the nail out of the piece of skull, and with the aid of very thin titanium plates, put the piece of bone back in. Finally, she closed the scalp, kept the carpenter overnight for observation and discharged him the next morning.
If this sounds rather mechanistic, Firlik says that issues such as deep thought, personality and consciousness are left to neurologists and psychiatrists, specialists who never actually touch the brain.
A neurosurgeon, she says, is “part scientist, part mechanic,” who cracks open the skull and cuts out aneurysms, tumors, cysts.
“There’s such a huge range of different types of surgery, from sucking out a blood clot, which can be straightforward, to doing very complicated aneurysm surgery at the base of the brain under a microscope. Dealing with an aneurysm is probably the pinnacle or brain surgery.”
Her feelings about her profession waver constantly.
“There are times you work very hard and the patient has a poor outcome and the family doesn’t appreciate what you tried to do. Other times, you feel like you saved someone’s life and brought back their neurological function, and it’s incredibly rewarding.”
The future of neurosurgery will be implanted electrical stimulators, she predicts, both for cortical stimulation (the brain surface) or deep brain stimulation.
The first ones are already entering the culture as medical devices.
“Brain stimulation has gone from putting implants in the brain for Parkinson’s disease to an experimental device for stroke survivors that revs up the area that’s trying to recover. But I think the future will see us implanting devices for depression and language disorders.
Enhancing memory function
“As we learn how the memory works, I can see us implanting a stimulator to enhance memory function. We’d obviously start with patients with serious Alzheimer’s. Still, I can see a plastic surgery of the mind, so to speak, as a potential for normal patients.”
Despite the long years of training and the extreme delicacy of the task, neurosurgery is wrongly thought of as a highly intellectual pursuit, she said.
“Of course, you have to be smart and make quick decisions, but we know what we’re doing. It becomes routine.”
Still, as Firlik attests, the high-pressure work tends to give the rest of life a certain perspective.
“I get mildly annoyed by people who are frazzled by the least important decisions,” Firlik said. “Pulp or no pulp? Skim or 2 percent? I feel like butting in: `Look, you’re not deciding whether or not to pull the plug. Lighten up.'”
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pgorner@tribune.com
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`Apart from the nail in his head, he looked great’
Excerpted from “Another Day in the Frontal Lobe” by Dr. Katrina Firlik. Reprinted by arrangement with The Random House Publishing Group.
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I was paged to the emergency room a few years ago during my training and received the following brief report over the phone: “Carpenter coming in with a nail stuck in the left frontal region of his head … neurologically intact.” …
What I encountered in the ER was a young man, in his thirties, sitting up on an emergency room gurney. Perfectly awake and alert, arms crossed in repose and still in his construction boots, he smiled nervously when I walked in. Was he the right patient? He looked too good.
He was the right one. The carpenter explained that he and his friend were both on ladders along the side of a house. His friend was working a few rungs above. They were driving heavy-duty nails into the siding with automatic nail guns. His friend’s hand slipped upon firing in one of the nails, and the nail entered the left frontal region of my patient’s head below. …
Upon close inspection of his scalp, past his short crew cut, I could see the flat silver head of the nail, not quite flush with the scalp, but a bit deeper. Apart from the nail, he looked great. I performed a quick five-minute neurological exam and found nothing wrong. I sent him down the hall for a CT scan. The nail entered his brain perfectly perpendicular to the surface of the skull. It had been driven a good two inches into his left frontal lobe. Luckily, it didn’t snag any sizable blood vessels along the way. There was no evidence of bleeding within the brain. Unlike the more common gunshot wounds we see, this was a respectably neat and clean penetrating injury.
At this point, my biggest fear — bleeding in the brain from entry of the nail — had been put to rest. Now, do I take a breath and mull over any complex scientific issues at this point? Am I exercising my formidable brainpower as a brain surgeon?…
After calling on the appropriate team, including the supervising neurosurgeon and anesthesiologist, I took him to the OR, shaved a small patch of hair around the nail head, and made a short linear incision in his scalp, down to the skull. There are no how-to entries in our textbooks regarding removing nails from heads, so we improvised using common sense. We drilled out a disc of frontal bone from his skull, with the nail head at the center of the disc. Slowly, we lifted this piece of bone up away from the surrounding skull, bringing the firmly embedded barbed nail with it. Although we could see a small jagged tear in the covering of the brain and a puncture wound on the surface of the brain itself, there was no blood oozing from the hole, and we considered ourselves lucky. (“Better lucky than good” is a favorite slogan among surgeons.)
Then, using large tools fit more for our patient’s line of work, we clipped off the barbs and pounded the nail through the disc of skull, backward. After soaking the bone in an antibiotic solution, we neatly plated it back in place with miniature titanium plates and screws and sewed his scalp back together. … Within less than twenty-four hours, the patient was on his way home, joking the entire length of the hall with the friend who nailed him in the head.
