Becoming a Neurosurgeon 1
It is 8:33 a.m. and Dr. Amir Madani, a neurosurgery resident at Mount Sinai, the large teaching hospital on Manhattan’s Upper East Side, is about to perform the final operation in his training as a brain surgeon. A team of doctors and nurses, eight people in all, dressed in blue scrubs and white paper face masks, move around Operating Room #2, preparing equipment, as the patient, a forty-year-old African-American woman, is wheeled in on a gurney. She is transferred onto an operating table in the center of the room, and the anesthesiologist inserts an IV needle into her right arm. He begins a drip of propofol, a powerful sedative. Within seconds, she is unconscious. A nurse, standing between the patient’s legs, places a catheter to drain urine during what is expected to be a four-hour-long operation. The scrub nurse arranges instruments—scalpels, forceps, sponges—on a large table beside the bed. Once all is in readiness, the neurosurgery resident, Dr. Madani, a tall, sad-eyed man in his late thirties, ties a surgical mask over his face and steps over to the sleeping patient.

“Okay,” he says, “let’s do this.”

Neurosurgery residency, the training period for brain surgeons after their four years of medical school, is the most grueling in all of medicine. Trainees work upward of 120 hours a week, often on as little as one or two hours of sleep a night. They do this for seven years, the longest of any surgical specialty. This will be Madani’s 1,807th operation at Mount Sinai, and his 180th assisting Dr. Joshua Bederson, the chairman of the department of neurosurgery.

It is a remarkable case on which to be going out. The patient had been in an accident six months earlier, hit in her car by a pickup that tried to swerve around her at a red light. A minor case of whiplash prompted a CT scan of her head and neck—which revealed, serendipitously, a massive brain tumor the size of a man’s fist in her left frontal lobe, just above the eye. The tumor’s spherical, self-contained shape suggested that it was of a slow-growing type that had, in all likelihood, been expanding for decades. The tumor now threatened to crowd out the healthy tissues (which have little room to expand within the closed box of the skull), inducing swelling that could cause her brain, squeezed like toothpaste in a tube, to “herniate”—to push out through the hole where her skull joins the spine. This would crush the brain stem, the seat of such vital functions as breathing and heartbeat—instantly killing her.

Three months ago, in early March, Bederson, with Madani assisting, had eliminated the immediate danger to the patient by opening her skull, cutting a tiny two-centimeter slit in the surface of the brain, and decompressing the tumor by draining it of a watery yellow liquid that had been building up. They then removed the growth. Such tumors, however, are encapsulated in a thin skin or rind. The patient was now scheduled to have that rind removed, since a biopsy showed that it contained pre-cancerous cells.

The patient had, in the meantime, undergone a complete transformation. For her entire adult life, she had been antisocial, depressed, lethargic, spending the better part of the previous twenty-three years on the sofa watching television. In the months since that first operation, she had begun rising early to exercise and had shed fifty pounds. She now took intense pleasure in every aspect of her life—especially her two children, seventeen and fourteen years old, for whom she had performed parental duties like preparing meals but from whom she had been emotionally isolated and distant. She could now barely restrain herself from constantly kissing and touching them, as if discovering them for the first time. She felt the same way about her husband. They had met when she was eighteen years old and fallen in love, but she had shown little real affection toward him since 1996, when they married.

Neurosurgeons have long known about the changes in mood and personality that can take place through manipulation of the frontal lobes, but rarely does a patient show so dramatic a change in temperament and outlook as had occurred in this case—especially so soon after treatment. While coming out of the anesthetic after the initial operation, she began laughing and pointing at the anesthetist and loudly, playfully proclaiming, “I know you! I know you!” The surgical staff dubbed her “The Giggler” because of her infectious, easily triggered laugh. At the time of her second surgery, to remove the tumor lining, she was making plans to enroll in nursing school. She had given up coffee, after a decades-long “addiction,” and wine. She no longer watched TV—too busy exercising, talking, reading, living. Old texts on her smartphone—messages filled with bitterness, despair, and deep pessimism—mystified her. “I don’t know who that person is,” she said, before going into the second operation. “I know it was me, but it doesn’t seem possible.”

• • •

IN THE OPERATING ROOM Madani tapes a pair of latex-free plastic strips over the patient’s eyes. He talks as he works. “There is a fascinating account of frontal lobe surgery in Penfield’s letters,” he says, referring to Wilder Penfield, the early-twentieth-century physician recognized to be one of the grandfathers of modern neurosurgery. “In the late 1920s, he operated on his sister and removed a frontal lobe tumor. After doing the routine post-op tests in the hospital, he said, ‘Oh she’s doing really well.’ But later, he was at her house and saw that the place was incredibly messy, she couldn’t manage two things at a time. She was confused, disoriented. She’d always been meticulously organized. He realized that the frontal lobe is extremely important, but mysterious. Almost a century later, we’re still so ignorant about what the frontal lobe does—or how it does it.”

The same could be said for the brain as a whole: a three-pound lump of jelly-like matter whose hundred billion cells, and the trillions of electrochemical connections between them, make up the most complex system in the known universe. This system is responsible not only for all motor and sensory functions of the body but for the mystery of consciousness itself and all to which it gives rise: love, hope, memory, fear, music, poetry, art, science—everything, in short, that makes us human. That so little is known about the anatomy and functioning of the brain is one reason neurosurgery is so demanding and so dangerous. Those who expose and cut into the brain’s tissues are, to a very real degree, traveling in terra incognita. Indeed, so fraught with risk is opening the skull and invading the brain—where a millimeter’s error can spell disaster—no reasonable medical professional would perform these interventions save for the fact that patients who end up in neurosurgery wards are already suffering from calamities so threatening to their life and well-being that nonintervention is not an option.

“With this patient,” Madani goes on, gesturing at the woman on the table, “there was a huge mass that we decompressed in her frontal lobe. So the pressure of that tumor was affecting the neuronal communication in a very complex way, and it altered her personality. But how? Who knows? Was the tumor suppressing the electrical activity of the cells by squashing the frontal lobe against the inside of the skull? Maybe. Or maybe the tumor was secreting some chemical agents that interfere. On a molecular level there is so much going on that we cannot see with our imaging tools—and that we’ll maybe never know.”

He wields a hairbrush to make a part in the patient’s hair, exposing a long thin scar from the earlier operation. The scar arcs over the top of her head from temple to temple, about an inch behind the hairline. As he works, he says, wistfully, “This is the last time I’ll do this at Mount Sinai.”

A nurse, who sits in a corner monitoring the patient’s brain activity on a computer, asks what he plans to do next.

“Me?” Madani deadpans, as he brushes an antiseptic gel into the patient’s hair. “I’ll be opening a barbershop. Doing similar stuff, just slightly less stressful.” Laughter fills the room.

“No,” he continues, “I’m going to spend two years in Toronto doing a fellowship in deep brain stimulation.” (DBS involves inserting electrodes into the brain to stimulate areas associated with movement disorders like Parkinson’s Disease and mood disorders like depression.) “That means,” Madani says, “that, by the time I finish my neurosurgical education, I will have been in school for twenty-one years after high school.” This includes four years pre-med in math and biochemistry at Columbia University, eight years of medical school to obtain a combined MD and PhD at SUNY Downstate in Brooklyn, his seven years of residency at Mount Sinai, and the two-year plan for a fellowship in Toronto. “Neurosurgery is the only profession where you’ve started to have arteriosclerosis before you finish your training.”

Madani wields a huge metal clamp, a medieval-looking instrument, with a set of dagger-like points aiming inward. This is a so-called Mayfield device, named after its creator, Dr. Frank H. Mayfield, who made the first prototype in the late 1960s. It is used to hold the patient’s head completely still during the surgery. He positions the points over her temples, taking care not to puncture the band of muscles that encircles this part of the head—to do so would allow her head to shift, disastrously, during the operation. He pushes the clamp together, the points penetrating the skin and touching the bone of the skull. With her head now clamped in the vise jaws, he secures the long extension arm of the Mayfield to the bottom of the bed and tightens the bolt.

“But I can’t complain,” he goes on. “I wanted to do this, and nothing but this, since I was a teenager.” He’d become fascinated with the brain in high school when he saw a TV documentary about Nobel Prize winner Santiago Ramón y Cajal, a Spanish pathologist who, in the early 1900s, perfected the means for staining brain cells. This was a groundbreaking leap: It allowed scientists to define the precise structure of neurons—the central cell body and nucleus, the spidery dendrites and long tail-like axon—and to draw the first blueprint for how these neurons communicate with each other through chemical and electrical impulses that leap across the tiny gap, called a synapse, between them. “I just fell in love with the brain,” Madani says.

Many neurosurgeons are highly competitive superachievers: college athletic champions and Eagle scouts, people driven to take on the most difficult challenges. Madani professes not to be one of those. “I have no other talents or skills,” he says. “This is all I ever wanted. So it’s actually a little scary to think what would have happened if I had not made it into the program.”

The odds of not making it were high. Mount Sinai’s neurosurgery residency program received applications from more than three hundred medical students this year. It chose two.

• • •

PRESENT IN THE OR is a third-year medical student, Rui Feng, a slightly built young woman in her midtwenties. She hopes, one day, to be one of those chosen for the program. Like Madani, Rui is single-minded about neurosurgery. “It’s all I want, too,” she tells him. Her chances of making it seem good. Dr. Bederson, the chief of the department, has recently awarded her a full paid fellowship to do a scholarly year in neurosurgery—one of only two or three such scholarships he awards each year. (“She is destined to be a star,” Bederson says. “If she could sit on my shoulder all day long, she’d do it.”) As a medical student, Rui’s participation in operations, apart from rudimentary actions like using a suction tool to suck blood from a scalp incision as it is being cut, is purely that of an observer. But her appetite for such observation is insatiable. She tells Madani: “A couple of days ago I watched Dr. Yong”—one of Mount Sinai’s full-time attending neurosurgeons—“do a fourteen-hour surgery to remove a tumor. When they got the scans back they realized they didn’t get all of it, so they went back in and operated for another eight hours. Those are my favorites.”

“It’s insane, what you guys do,” says the anesthesiologist, from his position at the foot of the bed, where he will monitor the patient’s vital functions—respiration, heart rate—during the operation. “Actually, I know three different guys—all from Johns Hopkins—who burned out during their neurosurgical residencies. The first guy, he was in, like, year four, and he quit and joined the military—he’s now in the infantry in Iraq.”

“What?” says Madani, incredulous. “Did they scan his head? He might have had a frontal lobe tumor.”

Madani and Rui place long wedges of foam rubber under the patient’s arms, then secure her to the table with a series of seatbelt-like straps that they pull tight over her upper body. They cover her, head to toe, in blue paper drapes, one of which has a small clear plastic window pre-cut to expose only the area on her head where they will be operating.

At 9:26 a.m., Madani is ready to “open”—the term used to describe the surgical penetration of the scalp and skull to expose the brain. Conversation ceases as he takes up a cauterizing needle, a thin blade with an electrically charged tip that simultaneously seals blood vessels with heat as it cuts. He places the tip against the scar that arcs across the upper part of the woman’s forehead and begins to slice. A wisp of smoke rises from the incision and an aroma of seared flesh fills the room. Rui plies the suction tool, a small hollow wand, to suck away the small trickle of blood that seeps from the wound. Madani proceeds slowly, carefully. Once he’s made the long cut from ear to ear, he works his fingertips under the front edge of the flap of skin and muscle and tries to tug it forward over her face. The scalp clings stubbornly to the skull. He uses a flat-ended metal tool and works it under the scalp, like a man using a spatula to free up eggs stuck to a pan. Again using his fingers, he slowly peels the flap up and pulls it over the patient’s face, exposing a large portion of skull, from hairline to eyebrow ridge. The curved expanse of bone is thickly smeared with blood.

Ordinarily, to open the bone, Madani would use a small handheld instrument that looks like a dentist’s drill, cutting a window of a few inches square. That won’t be necessary today. They’ll go in through the opening they made three months before when they decompressed the tumor. That opening is clearly visible, the so-called “bone flap” screwed down with four titanium clips known as “snowflake” clips because of their irregular but symmetrical shape, which indeed resemble snowflakes. Madani uses a screwdriver to loosen the screws, removes the clips and lifts off the skull flap, a slightly curved piece of bone about two inches by three inches in dimension. He hands it to the scrub nurse, who places it in a shallow container on a nearby table.


Pulling back the dura to expose the cortical surface

Madani has one more layer to get through to expose the brain’s surface: a thin, tough protective covering, called the dura, which has a bright silvery look, like a piece of synthetic fabric. It carries a U-shaped scar from the previous operation, but Madani will enter with a new incision—a linear cut down the center. Working slowly with scalpel and miniature scissors (“. . . don’t want to injure any of those cortical veins . . .” he mutters as he works), he makes a vertical cut of two inches. With a pair of forceps, he delicately grasps the edges of the dura and pulls it back to reveal the surface of the brain. It is shiny pinkish-white with a pearly sheen, its thick ridges and folds of cortical tissue glistening, the surface crisscrossed with an intricate network of bright red arteries and thick blue-green veins. It lightly pulses in time with the patient’s heartbeat. Madani has seen this countless times, but the sight never fails to evoke awe. “Amazing to think that that blobby matter is everything that makes us us,” he says.

A couple of nurses roll the intra-operative microscope into place. It’s a large piece of equipment, seven feet in height, on a wheeled base with an arcing, cantilevered arm that, at one end, holds a 150-pound microscope outfitted with a pair of stereoscopic magnifying lenses and a set of handgrips.

Madani sits on a specially designed ergonomic operating chair, which looks like a dentist’s chair, behind the patient’s head and aims the microscope at the opening in the skull. Through the eyepieces, his view is breathtaking. Like a vast alpine range viewed from a low-flying plane, a three-dimensional panorama on which the tiniest structures—squiggly hair-thin capillaries on the cortical surface—appear as clearly as a system of interconnected mountain roads.

The scrub nurse hands Madani a pair of forceps.

To the patient’s left is the so-called “Brain Lab”—a set of computer consoles with screens that project CT and MRI scans made of the patient’s head the night before. An infrared camera at the foot of the bed will track the movement of the surgical instruments, like a kind of Google Maps for the human body, projecting the instruments’ location inside the scan of the patient’s brain, helping the surgeons to precisely target the tumor and avoid dangerous areas of so-called “eloquent” brain—those regions responsible for higher “executive” functions such as thought, speech, memory.

With a retractor—a broad curved tool—in his opposite hand, Madani gingerly pulls to one side healthy brain tissue and exposes part of the pre-cancerous lining that is to be removed. A yellow substance, resembling chicken fat, the tumor capsule is quite different in color and texture from the healthy parts of the brain. Probing deeper, he uncovers a shiny bluish structure behind the pearly jelly. This is the left ventricle, one of the four balloon-like cavities in the center of the brain that generate cerebrospinal fluid, the clear liquid in which the brain effectively floats within the skull and that provides a natural shock absorber for the cortex and spinal cord.

Madani lifts the instruments from the patient’s head.

As one of three chief residents at Mount Sinai, Madani is entrusted with opening and closing the skull. But the bulk of the neurosurgical operations performed in any teaching hospital are the responsibility of full-time attending surgeons from whom the residents learn by up-close observation.

Madani sits back and says, “Okay, we’re ready for Dr. Bederson.”