Heart-stopping brain surgery: a surgeon’s harrowing dilemma

An excerpt from of Paint and Pancakes.

The epicenter of Jane’s cancer occupied some very expensive real estate between Broca’s area and the motor strip. Her ability to speak and form coherent words resided in Broca’s. A little further back was the Motor Strip, which controlled the movement of the right side of her body.

It all looks the same … so damned normal. Mike cleared his throat. High-price real estate. The spasmed muscles in his shoulders and neck felt as if they would rip him in half. If he made the brain cut too far back, he’d paralyze her. Too far forward, he’d wreck her … she’d never be able to speak or understand a word anyone said to her.

Mike rolled his shoulders, grunted, and chose a spot in the surface, the perfectly normal-looking surface, of Jane’s brain. He buzzed through the innermost membrane, the glistening, transparent pia, which clung to the brain’s surface like Saran Wrap. He cauterized half a dozen tiny vessels, each not much wider than a hair, which crossed the cortex.

He cut into the tan-colored grey matter with micro-scissors. He stretched his arm backward. Without a word, Val took the scissors and placed narrow steel spatulas in each of his hands. He tunneled, millimeter by millimeter, through the grey, digging into the snow-white brain substance, the axonal cables.

I don’t see any tumor yet, Mike thought. Am I digging too deep? His mouth went dry. Am I heading in the wrong direction? His heart pounded in his ears. Am I going to wreck Jane’s brain? He said, “Steady now, Mike.” He breathed deeply and slowly. “You can’t throw in the towel.” In through the nose. Out through the mouth.

Mike spread a thin veil of snow-white fibers. There it was: a purplish mass as ugly as Medusa’s head. The last vestige of hope (the tumor might not be malignant; the intraoperative appearance might not be awful) evaporated. He groaned.

He bit the angry tumor with cupped forceps. Blood seeped from the raw surface as if from a wounded animal. He relentlessly buzzed and sucked and cut the beast, not giving it a chance to bite him back. The tumor’s texture, like the color, was distinct from the surrounding white matter. The tumor was stringy and grainy. The surrounding brain, infiltrated by invisible cancer cells, was like a custard.

“Specimen for the pathologist,” Mike said. He handed a pulpy lump of tumor, the color of plum pudding, to Val.

“Frozen or permanent?” She asked.

“Permanent,” he said. Frozen was quicker. Permanent was more accurate. “Knowing the cell type won’t change today’s surgery,” he explained. “Better to let the pathologist take her time and do all her special stains.”

The monster’s bleeding became more vigorous and the color of the blood changed from Beaujolais to cherry-red. “Oh, no you don’t.”

Val leaned as close to him as sterility would allow. She couldn’t tell whether his grumbles meant he needed anything from her.

“Crank the Malis up.”

Joanny increased the settings on the coagulator and Mike buzzed the bleeders, turning them into black char.

“Cupped forceps,” he said. The consistency of the remaining cancer was tougher, as if the strings and grains had weaved together into a shaggy rug. Mike tugged at the beast, “You bastard.” Mike tugged a little harder. Just a touch. The normal brain surrounding the tumor shifted and swelled. If he tugged too hard, he’d be liable to damage a faraway, unseen brain structure.

Mike handed Val the forceps. His unblinking eyes felt like sandpaper. “Gustino,” he said.

Val handed him the Sonopet, the latest weapon in Mike’s never-ending fight. The long, slender tool removed cancer without him needing to tug. It dissolved the tumor by ultrasound and sucked away the liquefied cells. Mike called it the ‘Gustino’ in honor of his friends, Paul and Kelly, who’d donated the funds for its purchase.

“Finally,” he said. The visible and palpable tumor was gone, and a glistening, snow-white cavern remained. But his aching shoulders and cramped hands didn’t relax. Did I take enough out?

“Magic wand,” he said.

He brought the magic wand into the operative site to compare what he saw inside Jane’s head to what the stereotactic guidance system told him.

He looked up at a blank screen.

“Joanny.” He stomped his foot. “The screen.”

Joanny moved the sensor, as she’d done previously, to no avail.

“Is everyone trying to sabotage my surgery?”

“You’ve got crud on your balls, doctor,” Val noted. They would all laugh at that line a few hours hence. In a few months, it would become a classic. No one found it funny at that moment. Val was right, as always. Mike’s balls, spherical fiducials, were splattered with thick drops of opaque blood, which impeded the infrared rays.

“Well. Clean them,” he barked.

Val wiped down Mike’s balls. As if by magic, the image returned and the computer indicated that Mike had completely resected the grossly visible tumor. But he knew there was an invisible army of microscopic cells, feathering out from the blue glob of paint, invading the normal white paint bucket of Jane’s brain.

Mike entered the toughest round of this fight. The one against himself.

Should I call it quits and close up?

It was definitely a gross total.

But the margins … should I go for broke?

He couldn’t get out every drop of blue paint. The glob was hopelessly intermixed, spreading far and wide into the bucket of white paint.

I could get rid of some of that sky-blue.

If he went much further, he’d leave this beautiful, vibrant girl stroked out or, even worse, a vegetable.

Just a touch?

He could make the post-op MRI look as clean as a whistle. All his neurosurgical colleagues would be in awe of the scans.

I’m taking care of Jane, not her damned MRI.

“We’re closing up,” Mike said.

Marc Arginteanu is a neurosurgeon and author of Azazel’s Public House and of Paint and Pancakes.

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