I’ll Be Learning To Operate ’til the Day I Retire

My son Jack just started driving.  I gave him my 2007 Jeep Wrangler, having removed the lift kit to lower its center of gravity.  Anyone growing up in the 80’s will tell you that Jeeps were vilified in the media.  Right or wrong, the notion that they “rolled over easily” left its scars.  Aside from spending long hours in the passenger seat rendering instruction to my son and subjecting him to the awkwardness of piloting the local driving school’s Gremlin, there were few other things I could do to mitigate risk.  This was one of them.  Ultimately we as parents have to let go, however, comforted by the fact that we have utilized every available resource to safeguard our children.

Neurosurgery residency chairmen undoubtedly harbor similar feelings when they sign off on their graduating chiefs annually.  There’s only so much knowledge one can impart to their “children” prior to their journey into the fray.  The unknown.  Truth be told, it is during the first several post-residency years that a graduate becomes a “surgeon.”  Residency is an apprenticeship, a time-tested derivation of medieval times, with an equal amount of torture.  You get your hands dirty (pun intended), learn the technical considerations of trephination, and, during seven arduous years, gain an appreciation of the complexity, beauty, and fragility of the human nervous system.  Sleep-deprived, you make every effort to assimilate the ocean of neurosurgical knowledge into practical skills, etching these memes into your brain until they become instinctual.  My chairman used to tell me that the operating room was “no place to think,” that it was a place “only for execution,” excluding the patient of course.

Then reality sets in.  You’re on your own, driving down the interstate, first time out.  Cars passing at high speed, blood spurting from freshly cut skin.  Perceived chaos.  Or not.  Nothing has changed in the 13 years since graduation.  The human heart still pumps blood at an average systolic pressure of 120 mm Hg.  The drapes still become saturated with blood upon making the incision.  The brain still has the friable consistency of undercooled Jell-O, except it bleeds.  Whether or not these physiologic truths register or come to awareness (modulated by the brain’s “thalamus”) is simply a matter of signal-to-noise ratio.  With experience, one develops more robust filtering mechanisms that essentially devalue all previously considered “alarm” stimuli.  In essence, there is more noise and lesser signal.  And the noise is simply filtered out.  Do you hear cars passing while driving?  Do Manhattanites notice the ambient city noise?  No.  Same phenomenon in the OR.  What “sets” the filter threshold ultimately?  No one knows for sure.  Certainly, however, MINDSET is integral to the tuning of our sensory systems.  How one interprets incoming experiences (or signals) is a function of mindset.  I’ve witnessed senior surgeons hurl bloody instruments across the room in response to trivial bleeding during brain tumor operations.  On the opposite end of the spectrum are those who fail to be rattled by even the most daunting of intraoperative events, like a truck suddenly swerving into their driving lane for example.  There are those with ice in their veins and others that require beta-blockers to slow not only their pulse, but also blunt their response to external stimuli or “change their filter threshold.”

And while I use beta-blockers on a daily basis, they are only in the context of cardiac protection.  The OR is my solitude.  There I am isolated from the outside world, yet amidst the perceived chaos.  I’ve been driving for years.  My mind is clear.  The procedure at hand has been well thought out.  The music is playing.  The data suggest that music has a positive effect on OR performance.  Of course, surgeons have known this anecdotally for decades.  You listen to music while you drive, right?  Same thing.  It’s soothing, regardless of the genre, to you.  It alters your MINDSET.  It is one of many factors that enhance your ability to withstand the long hours sometimes demanded by complex cases.  These can last 6-8 hours.  Heck, I’ve stood in cases for over 12 hours.  Rigors of the job…

These I was well exposed to during my neurosurgery training at NYU.  Having trained prior to the advent of the capitated 88-hour workweek, I was quarantined at one of three resident-staffed first avenue hospitals for days on end.  At times miserable, I developed my true grit while manning a battery-operated pager for literally thousands of hours, tending to an equal number of patients and fielding a myriad of family questions, let alone operating at all hours of the night.  The experience, inclusive of the downing of the World Trade Centers, in the wake of which Bellevue Hospital was deemed the Command Center, was unparalleled.  More mentally than physically taxing, residency is one of those necessary evils.  Remember, many of the technical aspects of neurosurgery are straightforward.  It’s the critical thinking and judgment amidst boiler-room pressure that develops during those critical 10,000 hours.  An iron MINDSET: That’s what you glean from neurosurgery residency, particularly in the years predating the Libby Zion verdict.  The thousand-plus hours of additional experience, inaccessible to today’s residents, made us harder and smarter.  And the data suggest this as well, highlighting an increased complication rate since the introduction of workweek-hour limitations.  Spurious?  Unknown.  This will be borne out ultimately, however.

As a neurosurgeon with a high monthly call volume at a Level I Trauma Center, I am thankful to have trained in the mid-90’s. There is not a single week during which I have not called upon the grit earned during those long dark hours, at times with limited supervision.  The 3AM motorcycle accident victim with a severe head injury in need of a craniotomy or the infant that was dropped by a parent or sibling.  One may need a delicate brain operation, the other a non-surgical treatment plan.  No matter.  Both decisions are of high acuity.  Patients’ lives are often on the line.  We are expected to function at the highest level, time-independent, brain-fueled with food or not.  For me, it’s not unlike residency.  Except I have no residents.  But it makes me all the stronger mentally.  I’m still accumulating experience, constantly learning by virtue of both good and bad judgment, striving for betterment in performance and efficiency, and further tuning my filter.  The more I see, the more the stimulus becomes the “noise,” demanding less energy and thought to generate corrective action.  And that frees up “processing time” to address higher-level problems while concomitantly sparing my coronaries.

Last week, I saw a surgeon become unhinged in the OR.  And for what?  The scrub tech passed him an incorrect instrument.  Despite years of experience, his attitude remains sophomoric, and his mindset is equally unrefined.  Often times, this is a reflection of confidence, sometimes not.  Invariably, however, these individuals age poorly, weathered both physically and mentally, having not developed that all-important filter.  Aging is a preventable disease, one that begins in the mind.  It’s common knowledge that a healthy mind begets a healthy body.  The converse is true also.  Instead of lashing out at the scrub tech or chasing after the car that cut you off in error, use mental fortitude to temper your pre-inclined notions of retaliation.  Build your filter.  Calm your mind.  It will serve you well amidst the perceived chaos:  performing surgery or riding motorcycles at high speed (both of which I routinely do).  What was once a Jeep is now a CBR 1000.  What’s next?  I am unsure.  It’s certainly not a discrete goal but instead one of continued progress, of an ever-developing mindset.  If you’re reading this, you probably know something about that, right?