A 14-year-old girl came into the ER with a prolonged history of vomiting and headaches. I looked at her MRI and saw what appeared to be a medulloblastoma, the most common malignant brain tumor in children. There’s some urgency to dealing with the blockage these tumors can cause; if it’s left untreated, the child can die.
I always make it a point to address patients very directly. For most children, the unknown is actually scarier than the truth—especially for teenagers. I explained to her and her parents that there was a mass that needed to be removed and that we didn’t know exactly what it was made of. The parents had tears at first, but by the time the conversation was over there was confidence we were moving in the right direction.
I scheduled surgery for the girl the following morning. I’d been involved in this particular type of surgery perhaps a hundred times prior to this one, but once you’re out on your own, there is an internal pressure of wanting everything to be perfect. I slept about four hours that night. It was a 7:30 a.m. start time. The patient came in the room, and so did the anesthesiologist. That’s when I went out to scrub. There are times at the scrub sink when you’re chatting about the weekend, but before large cases, I like to scrub alone and play out an operation in my mind. I was nervous, but not nervous beyond the scope of my abilities. It was a realization that this was what I trained for.
Pediatric neurosurgeons spend a lot of time in the back of the brain. To get there, you make an incision and split the muscles in the back of the head. You drill some holes in the bone, then you use a saw to cut a hole out of the skull. You have to be careful because there’s a very big vein that travels just above the area we’re dealing with, and if you cut it, you can have uncontrollable bleeding.
Once I opened the lining of the brain, I was looking at the cerebellum; this tumor was about the size of a peach pit. I took an initial piece of the tissue to send the pathologist and encountered significant bleeding from the tumor. My heart was pounding as I repositioned the microscope to see the remainder of the mass. The bleeding continued—sometimes profusely—but I remembered my mentors coaching me that getting the tumor out was the most effective way of stopping the bleeding. I was able to get the tumor off the brainstem, and all of a sudden, the ultrasonic aspirator— a device that suctions away the tiny tumor pieces—made a loud “gulp” noise as a large chunk of tumor disappeared through the suction. That one gulp happened very suddenly, and the bleeding immediately stopped. It actually startled me for a moment, it was so sudden. I looked around and didn’t see any more tumor. Wow. I think I’m done, I thought. I washed away the residual blood and closed the lining of the brain—very proud but still slightly unnerved. I put the skull back, using titanium plates, and closed up the wound.
There’s a level of anxiety for neurosurgeons between when an operation is finished and when the patient wakes up, because surgery in one area of the brain—albeit rarely—can cause a problem elsewhere in the brain that is not visible to the surgeon. As she was waking up, she started fluttering her eyes, moving her arms and legs. I asked her to hold up two fingers on the right hand and on the left hand. She was perfect. Then the breathing tube came out, and she was wheeled into the recovery room.
It’s an amazing feeling to be able to help a child through a life-threatening situation. There were certainly tears in my eyes as she woke up. I left my magnifying glasses on so my resident wouldn’t notice, and I left the room to wipe them away.