A neurosurgery case that this medical student won’t forget

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After the last elective case of the day, the neurosurgeon I was shadowing told me that he was on overnight call that evening, and that I could stick around to observe more surgeries if I wanted to. “Yes,” I responded. “Absolutely yes.”

My fascination with surgery stems from its ability to provide immediate results to a patient by cutting out, repairing, reshaping, or bypassing the problem. It’s exciting and tactile, and I find that very appealing. What’s more thrilling is emergency surgery, when an operation becomes the last-ditch intervention that hopefully saves someone from imminent death.

The first case of the night was the draining of a brain abscess in a 60-year-old man, followed by the evacuation of a symptomatic subdural hematoma in an elderly lady. As the surgeon was closing the scalp incision on the second case, the OR phone rang. It was the emergency department, asking to speak to the neurosurgeon immediately. The nurse put the phone on loudspeaker, and the surgeon took the call. We were informed of a patient being transferred to us from a small regional hospital, needing urgent neurosurgical intervention. The patient, whom I’ll call Ms. H, was a 50-year-old woman who presented with a sudden severe headache, nausea, and vomiting. Brain imaging revealed a subarachnoid hemorrhage from a ruptured internal carotid artery aneurysm, with signs of elevated intracranial pressure. An aneurysm (the abnormal out-pouching of a blood vessel wall) that ruptures in the brain can be rapidly fatal if not treated immediately.

After the call, I glanced at the clock on the wall, noting that it was already 2 a.m. I had been awake since 6 a.m. the previous day, but I wasn’t tired or sleepy. The thrill of being part of the surgical team — along with some caffeine — was keeping me going. However, my role as a medical student on summer break carried little to no responsibility: I was only there to observe the surgeries while occasionally getting to assist when safe and possible. The neurosurgeon I was shadowing, however, was responsible for performing all the procedures, managing inpatients on his service, and taking consults from the ER. With just one junior resident assisting him that night, working efficiently was critical.

Ms. H arrived at our hospital. On assessment, she was awake and oriented, but her headaches had been getting much worse. She was stable on examination with no signs of focal neurological deficits. After the surgeon explained her condition and the details of the aneurysm clipping procedure to her, Ms. H signed the forms and consented for surgery. Meanwhile, the ER staff was frantically trying to get hold of her family, but neither her husband nor her daughter could be reached.

Soon afterwards, Ms. H’s level of consciousness declined rapidly. She became lethargic, confused, and her speech became slurred. The surgeon explained that the pressure in her brain must have risen even further, causing compression of her brainstem against the bottom of her skull. The brainstem contains the respiratory control center of the brain, as well as the reticular activating system, which is the part of the brain responsible for awareness and consciousness. Compression of the brainstem can be fatal within minutes. The OR was promptly booked, and she was taken for surgery.

The team moved quickly. As I walked into the OR, nurses were already scrubbed in and opening up equipment trays. The anesthesiologist was putting in arterial and IV lines, preparing to intubate Ms. H. Porters were rolling in the surgical microscope. The neurosurgeon and his resident were planning details of the procedure using the imaging sent over from the regional hospital. I stood there for a minute, taking it all in. I found myself thinking about how this was likely the worst day of Ms. H’s life. She was brought to a distant city because her town doesn’t have a neurosurgeon, and was now really sick and getting really confused. Worst of all, none of her contacts were aware of her whereabouts or what had happened to her. Had she not been so delirious, she would have been downright frightened.

Eventually everything was ready, and the first incision was made. The neurosurgeon cut and retracted the scalp then drilled out a circular flap from the bony skull, immediately relieving the tremendous pressure the brain was under. With a series of delicate yet masterful movements, he put in a ventricular drain to decompress the brain further. He then found the offending aneurysm and, under microscopic guidance, placed a tiny metal clip over its base to seal off the source of the hemorrhage. I breathed out a sigh of relief just then, but I knew that only time would tell if there was any permanent brain damage. The operation complete, the craniotomy was closed, and Ms. H was taken to recovery.

It was now 8 a.m. and the overnight call was over. On the drive home, I replayed all of the night’s events in my mind. The thought of Ms. H’s family not knowing about her condition was haunting me. How horrible would it be if the next time they see her she had debilitating brain damage, or worse, was no longer alive? The procedure went well with no complications, but she wasn’t out of the woods yet. Her recovery would be long-drawn, requiring intensive care and monitoring.

Medical school started up again for me, and I soon became busy with my second-year classes. A couple of weeks later I ran into the neurosurgeon, who shared some bad news. Ms. H had woken up and was fine after her surgery, but she developed severe vasospasm a couple of days later. Cerebral vasospasm (the abnormal constriction of blood vessels in the brain) is a serious complication that can follow subarachnoid hemorrhage. Its prognosis is poor despite aggressive treatment. As it turns out, Ms. H passed away a few days later in the ICU.

Though I was initially shocked, I was relieved to learn that Ms. H’s family was eventually tracked down and she was able to see them before passing away. It must have been difficult for her husband and daughter to see their loved one become delirious and slowly lose consciousness, eventually becoming brain dead. They then had to make the arduous decision to withdraw life support.

Disease can be isolating for the patient. It is in times of illness that personal relationships with our loved ones become the most valuable to us. Being able to share her last few moments with her family did not change Ms. H’s medical outcome, but on a personal level it must have made a world of difference to her. What could have been a lonely period of fear and uncertainty became, I hope, an emotionally trying yet meaningful last bit of time spent with family. Tragedy can strike any of us at any point in our lives. Despite the advances of modern medicine, death remains a distinctly human experience, made more meaningful by the presence of those we love.

Basheer Elsolh is a medical student.

Image credit: Shutterstock.com

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