Sunday, 15 January 2012

Half a head


A very productive week this week, spending my time on a neurosurgery placement. I got to see a number of surgeries, which were the highlight of the week really, and spent the rest of the time on the wards and in clinics. A much busier week than many of my previous weeks, which was something I really enjoyed. It reminded me a lot of my third year, with all of the contact time with the patients and doctors, and helping out on the ward, the way I am sure I learn best. The surgeries I saw varied from operations to the spine, to operations on the brain and skull, and lasted for hours and hours each. I was a little disappointed that they were not more complicated, though. I was expecting 'Neurosurgery' to be very complex (everyone assumes it is) but really it just seemed very similar to the rest of the surgeries I have seen. Perhaps rocket science is equally as over-rated.

Before I get into my post, though, I would like to thank the people who run who, in compiling a list of who they think the top medical student blogs are this year, were kind enough to put mine at the top. I am touched that they thought it was that worthwhile-a-read, and its always good to know what you are writing is appreciated. 

Getting back to my week, saying all I did about neurosurgery not being as complicated as I expected, it doesn't mean that I didn't enjoy the operations, or the time I spent in the theatre. I spent half a day in theatre on Monday and a whole day on Wednesday. When I say I spent a whole day, this means the surgical list running from 9AM to 7PM. While the surgeons may be seen as the 'jocks' of the medical world, they sure do seem to work hard! I was with another medical student for both of these sessions, and we were not allowed to 'scrub in' as we have done for other operations previously, letting us hold things for the surgeon and generally help out. This is probably due to the increased risk of infection, and the fact that most of the operations are done down a sort of microscope, meaning the surgeon could look at the minute anatomy more easily down the eye pieces, but there is no room for medial-student-help. The operations were shown up on a screen, making it easy to see what the surgeon could see, but also giving you the feeling that you could just be watching something similar on youtube at home...

Despite all of the time I spent in surgery, I only saw three and a half operations, as they tend to take a long time. On Monday, there was one operation all day for one complicated case, a patient with a meningioma (a type of brain tumour), which was in the posterior fossa of the brain where the cerebellum sits. A complicated operation where part of the skull needs to be removed, and the tumour searched for in the brain meant that this would take a whole day. Unfortunately I was only scheduled in for the afternoon, having lectures in the morning that I couldn't miss. This did mean that I missed the portion of skull being removed, which could have been interesting, but I did get to see the removal of the tumour and everything being put back on again. Seeing the surgeon search for the cranial nerves so they didn't get accidentally cut reminded me why my anatomy was so important, and I regret the fact that I have forgotten so much of the anatomy I had to learn in my first and second years! Interestingly, if the skull cannot be put back immediately (for example, because they think that there will be inflammation in the brain, which will cause it to swell and they don't want it to swell up inside the closed skull causing injury) the part of the skull cannot be kept and given back to the patient at a later date as it used to be. Because bone is a structural material, they used to be able to remove it, sterilise it and give it back at a later date. Laws relating to the use of human tissues mean that this is no longer possible, and instead the skull always needs to be kept with the patient. This means the portion of the skull is kept inside the abdomen along side your guts, where the patient carries it inside them until it needs to be put back (when the inflammation has gone down). The skull can shrink slightly because of the body's macrophages (immune cells) having a little munch on the edges, meaning if it is left in there for some time it can become too small for the original gap, but this is a very interesting concept! 

As I said before, my part in the neurosurgery involves standing by the edge and watching what happens. On Monday this involved standing up from 12 'il 6.30 straight, which seemed like a long time, but on Wednesday I was standing from 9 'til 7, though I did get small breaks as they switched the patients around. Working for this long means you have to be tough to be a surgeon, but at least they and the anaesthetist get to sit down as they work. I feel sorry for people like the scrub nurse who have to stand for the whole day! On Wednesday the three operations I saw were the changing around of a spinal cord stimulator, the removal of a pituitary tumour via a transsphenoidal route (via the nose) and the replacement of most of someone's skull which had been removed in a traumatic accident. A long day, which I shared with my fellow medical student and an osteopath who was a friend of the surgeon and had come to watch and learn.

The spinal chord stimulator replacement surgery was pretty simple and only took a few hours. Because there was already one in place, this was more about replacement of the unit which had run out of batteries for a new one. This machine is inside the body, and has a small battery with wires in the spine. The patient is given a remote with which they can control how much voltage is put into their spine. Rather than being the terrifyingly painful experience I would imagine it to be, supposedly it is a great pain killer for chronic pain, working by blocking the pain signals going up the spinal chord. 

After this surgery was the surgery for a woman who had been diagnosed with a pituitary tumour. The pituitary gland is a small gland in the brain which controls most of the bodies hormones. Tumours here are usually benign, but they can cause the secretion of many hormones, or interfere with vision as the nerves from the eyes run next to the pituitary gland, and if it gets enlarged it can interfere with these. This surgery is done via the nose, using a similar method to that the Egyptians used to remove the brains from the skull before mummifying their ancestors. This is because the pituitary gland is right behind the nose, and going in this way means you do not need to go through brain, though it does mean that the entire operation is done while looking down one of the nostril! Impressive that this can be done, but it did involve watching a screen for ages as the surgeon fiddled around in the nose. A little more interesting than my experiences of TURPs previously, but only just.

Transsphenoidal surgery route - pretty clever huh! An approach favoured by Harvey Cushing, whose name has become associated with a number of medical syndromes and diseases

The best surgery of the day, and the reason I stayed 'til the end with only a cheese and pickle sandwich keeping me going was the man who had had a serious head injury in April and was having his skull reconstructed. Back in April, he had been hit in the head by a large part of a car while at work, which was travelling at about 70 miles an hour. This had crushed half of his skull, and on admission to hospital he was not expected to survive. Fortunately, with some dramatic surgery, he had recovered and had been living in a rehabilitation home until now. His skull had not been put back on at the time, hough, because of all the inflammation, and because of the large loss of one of his cerebral hemispheres (half of his brain) his head was a very strange shape, missing about a quarter of the top part of his head. It had skin over it, which was growing hair, but he looked distincly different, and wanted to go back to looking more normal, which was the purpose of the operation. A metal plate had been constructed to fit the shape of the skull, and this was going to be screwed in.

I saw him the day before when I was on the ward, to clerk him before the surgery, and was surprised with how well he seemed. Obviously, for someone who was missing half of their brain, he was not perfectly healthy, but other than slow slurred speech, and slight confusion when I asked him to carry out slightly more complex tasks. On physical examination, his body was neurologically normal other than brisk (increased) reflexes across the body. Amazing the sort of injuries the brain can deal with and bounce back - a very plastic organ! Either way, I build up a good rapport with him on this day, and I felt that he really appreciated my presence in the operating theatre before his anaesthetic (he was understandably nervous). As someone who had been a helicopter pilot on the army about a decade ago, this injury had clearly changed his life hugely, but he seemed so determined to do as well as he could. It really puts my problems in perspective! Either way, the surgery went well, the highlight being when the surgeon noticed the surgery lights shining on the plate he was about to insert cast lots of glittery reflections around the walls. He ordered the main lights to be turned off and created a disco... This may seem a little insensitive, but a nice break after hours of painstaking dissection around the edges of the remaining skull. The fact that I really enjoyed talking to the patient about his story (and the theatre-disco) and didn't really care so much about the surgery reiterates to me that I don't think surgery is the sort of speciality for me. It is clever and technical, but so is being a car mechanic.


  1. I've always thought the trans-sphenoidal route for pituitary tumour removal was really innovative, although it sounds like a boring surgery from your description. I'm glad I only did general surgery as a med student, as I had a hard enough time standing through the 2- to 3-hour-long surgeries. I think neurosurgery might've done me in.

  2. Brilliant writing! Very interesting about the skull reconstruction.

  3. Wow, glad you pointed me towards this post! Really interesting stuff...

    It does make me want to go back and look at my guys abdomen to see if I can find the other part of his skull though :P Seems crazy that his neuro obs would come out like that though. I just don't see how that can happen! Makes me think neuro is even more interesting (although, as you say, maybe not the surgery part)