What am I doing here?

Publish date: May 7, 2004

By:  Sal Iaquinta, MD


2003 Writing Contest


The ink on his medical school diploma was scarcely dry when the author was called upon to do a craniotomy.

I was startled awake by my pager's beep. It was midnight but felt later, as it always does when you're awakened abruptly. I dialed the number without turning on the light in the call room. Maybe it's nothing, I thought hopefully, and I can go back to sleep.

"Hello, Sal?"


"This is Brad. Get down to the CT scanner. Now."

I started to speed-walk. Something lousy is going on when a fourth-year resident pages an intern.

When you graduate from medical school, only two people think you're a doctor: you and your mom. The title "intern" indicates that you know jack squat. I was only 30 days into my internship, so I fit the bill.

I was sure Brad, the chief trauma resident, didn't want me; he wanted my attending and needed me to call him. This was my first day of subspecialty service—urology, neurosurgery, and otolaryngology rolled into one. We worked directly with attending surgeons; there were no residents to oversee us as we bumbled our way through patient care.

While jogging down the hallway to the CT scanner, I tried to think of what I knew about neurosurgical emergencies, but nothing came to mind. Not because I was tired, but because I had never seen a neurosurgical emergency.

The trauma team was huddled around the CT monitors like bar patrons watching the Super Bowl. A lone computer console controlled the scanner in the next room. Brad looked over his shoulder at me. "Who's the neurosurgeon on call?"


"Okay, call him. We'll tell you what to say."

As I paged Dr. Blanchard (I'm not using real names), Brad presented the man in the scanner. He had been punched in the face at a local drinking establishment. It was a knockout. He had come to by the time the ambulance arrived, but on the way to the hospital he lost consciousness again—an ominous sign.

"Yeah, what's going on?" Blanchard answered. Whenever I heard his Texas twang, I imagined a tobacco-chewing cowboy in worn jeans and boots. In person, he looked like an effeminate Englishman, small and dressed like he was going on a picnic.

Brad flipped through the black and white images of the patient's head on the computer screen. He started feeding me the magic words for Blanchard, who was notorious for not coming in while on call.

"There's a 48-year-old man who was hit and lost consciousness, came to, and passed out again en route. His CT scan shows a large subdural on the left with ventricular effacement and a 2-centimeter midline shift. He's intubated and unresponsive." The magic words—effacement, midline shift, and unresponsive—essentially meant the guy's brain was being squished by the blood inside his skull.

"Take him down to the OR. Shave his head. Start the case. I'll be there in a minute." Blanchard hung up.

Start the case? Cut open the patient's skull? Did he know who he was talking to? I was suddenly in a movie—the wrong movie. I was out of character. I didn't know the script. What was I doing here?

Suddenly the naïf is in charge

I hit "0" on the phone.

"Hello, operator 13," a woman answered.

"Can you tell me the pager number of the anesthesiologist on call?"

"There isn't one."

"What do you mean?"

"Nobody reported in today and all the people we've paged say they aren't on call."

I hung up. The trauma team was waiting for my instructions. I didn't have any. I told them, "There's no one on call for anesthesia."

Everyone stood dumbfounded until they remembered that they were talking to a naïf. There's always an anesthesiologist in-house. I hadn't been here long enough to know it.

Another intern, Kendra, took the wheel. "I'll run down to the OR and find out who's here. You bring the patient down." Normally Kendra seems discombobulated, her long hair flying in wild directions and papers falling out of every pocket. But when it comes to crucial tasks, she's unstoppable.

Everyone split except for a nurse, the respiratory therapist, and me. We wheeled the patient downstairs. He didn't look like he had been punched. He looked like an ordinary guy sleeping on a gurney, except for the endotracheal tube coming out of his mouth. The respiratory therapist squeezed the bag at the end of the tube to push some air into his lungs.

I grabbed a blue paper mask and hat as we sped down the hallway. We got the gurney into the OR and moved the patient onto the table. Kendra had done her job; the anesthesiologist was waiting for us.

I put on the mask and hat. The room was full of blue-hatted, blue-masked people with white gloves. An outsider might think we were decontaminating nuclear waste. The patient was lying naked on the bed, his dark skin a stark contrast to the room's sterile whites and blues. A nurse put compression stockings on his legs. Another nurse set up the instrument table.

The anesthesiologist hooked up her monitors and threw a blanket over the patient as Blanchard strutted in. He had the blue hat and mask, but his scrubs were magenta.

"Can't do a case without the films, Sal," he said.

"I'll get them." I ran off to the CT scanner. The films hadn't come out of the printer before we left, but that excuse wouldn't have mattered to Blanchard or any other attending.

When I came back, Blanchard was peeling open the patient's eyes. He asked for my flashlight. The pupils were fixed and dilated; no response to light.

"He's probably already dead, but let's go ahead anyway. Maybe we can salvage his organs," Blanchard said.

What? I thought we were going to save a life. If this is just about keeping organs viable, I might as well have stayed in bed. Aren't we supposed to believe he can still make it? Isn't that why we're doing everything at top speed? What if his family doesn't want his organs donated?

Blanchard went to scrub and I followed silently behind.

Doing neurosurgery—ready or not

"What can I do to help?" I asked when we had returned to the patient's bedside.

"You can do the case," Dr. Blanchard said.

Nothing in his voice indicated he was kidding.

He drew a large, backward question mark on the shaved scalp. "Cut down to the skull on a 90 degree angle on this line."

"Knife," I called, and, unbelievably, the scrub tech put the knife in my hand. I was 25 years old and about to do a craniotomy. I provided traction on the skin with my left hand and inserted the knife. The first cut was like butter. I followed the smooth curve.

"Slow down, it's not a race."

But this guy is dying. He might already be brain dead.

When I was finished, Blanchard pulled at the large flap I'd made. It separated easily from the skull. Everything turned red; the scalp really bleeds. He undermined the skin surrounding the wound and called for the hemoclip.

"Just push in on the skin edge and click." When he pulled the trigger a little plastic clip, about 1/4-inch wide, shot forward and grabbed the skin edge, pinching the blood vessels closed. He handed me the hemoclip and away I went. Clip, clip, clip until the cartridge emptied, then a reload and more clipping. After about 20 clips, hemostasis was achieved.

"Great," he said as I finished. "Drill."

The drill was placed in his outstretched hand.

"See this? It turns at 7,000 rpm, so only put it on something you want it to go through. The pedal is by your foot." He looped the cord around my forearm and handed me the drill.

I was a little kid again, playing with Dad's power tools. But the stakes were much higher now.

He marked off the four corners where I was supposed to make holes. "As soon as you're through, stop. The goal is to not drill the brain."

This is all a dream. This is a game. It's all make-believe. We're just playing doctor.

I couldn't even see a body under all the drapes, just a square of skull with some blood. The only evidence of a live patient was the beeping of the anesthesiologist's heart monitor.

I hit the pedal and the drill whirled to life. It had its own mission: to skip across the smooth skull. But my determination to not mess up prevailed—that, and brute strength. The drill sank into the skull. Blanchard kept the drilling area wet with saline. I pulled up a few times to check my progress. I pulled up once more when the resistance changed. There was a clean, 3-millimeter-wide hole in the skull.

"You're doing great. Next hole."

This time I didn't pull up so often. After I'd made the other two holes, Blanchard called for the electric saw.

"If you angle it properly, it will cut through the skull like air; otherwise it's work."

He handed me the saw.

A saw in my inexperienced hand sounds risky, but it was one of the safer tools at my disposal. It has a guard that prevents it from going too deep.

"Connect the outsides of the holes."

"Ho hum, just sawing the skull. I'm sawing a human skull. I'm sawing a living human's skull!"

"What type of work do you do?"

"I saw human skulls; live people only, of course."

"Really? That must require a lot of training."

"Well, I went to medical school for four years, but I don't remember any lectures about skull-sawing. In fact, I don't remember any neurosurgery lectures whatsoever."

"How do you know what you're doing?"

"See the guy next to me? He's my mentor. When he's quiet, I can assume I'm doing things correctly."

But I didn't think I was. My angle must have been off. My hand was getting sore from trying to cut out the square.

When I finished, Blanchard took a small pick and lifted the cut square of bone. It came right off.

"That's what I like about young skulls. They're so easy to open."

Hmm. I'd never had that thought.

The dura mater, a protective sheath just inside the skull—"dura" meaning hard and "mater" meaning mother—is the only thing separating us from the brain. Blanchard poked a small hole in it with a scalpel.

"Take the scissors and cut out a flap."

"Scissors," I called. The dura wasn't so tough. It felt like I was cutting an al dente mostaccioli noodle.

We folded back the flap. I couldn't see the brain through the dark red clot. Again I thought of food: It looked like cherry Jell-O.

"Be careful with that sucker. Hold it like this," Blanchard ordered. He showed me the proper grip.

"Never use full suction. It will suck up the clot and the brain with it."

I remembered reading that the human brain is the same color and consistency as vanilla custard. Fresh brains are nothing like the stage props I was used to.

We started sucking away the clot with a coffee-stirrer-sized vacuum. I was glad machines are available for that. We went through 1.5 centimeters of clot before we uncovered the brain's mysterious folds. I wished I could have taken a picture. There was something mesmerizing about the spider web of veins covering the pale yellow brain.

It's hard to accept that such an ambiguous-shaped organ has so many functions. The brain is nothing like the stomach. You can look at the stomach and say the food comes in here and goes out there; the muscles jostle food and the glands secrete digestive chemicals. Straightforward and logical. The brain is just a squishy blob. You can't look at a wrinkle and deduce that the area controls leg movements. It would be like looking at the grooves of a record and trying to figure out what sounds are encoded.

"Brain retractor," Blanchard called. "If you use this you can put your sucker right on top of it. Then you know you won't be sucking brain."

He slapped it into my hand. It was a flat paddle of metal, like a steel tongue depressor. I slowly slid it under a clot and sucked above it.

"Go ahead, you don't have to be so gentle. It's soft. It's a brain retractor." He politely omitted the "duh."

I suddenly realized how quiet the room was. The anesthesiologist, scrub tech, scrub nurse, and neurosurgeon were watching me remove a clot from the brain.

"What are the chances of survival for a patient is in this condition?"

"About one in 500."

Well, at least there was a chance. I got a huge chunk of the clot under the retractor and lifted it out. Just below the patient's head was a plastic brain bag, used to catch the dripping blood. I dumped the clot into it, missed, and got some on my shoes. I wished I had put on shoe covers.

Fresh blood poured from under the edge of the clot. I couldn't see the source. It kept bleeding and I kept sucking. Some dripped onto the floor, a bit more onto my shoes.

When I finished we flushed the brain with warm saline. The bleeding stopped.

"Let's get out of here before the brain swells too large," said Blanchard. If that happens you won't be able to put the bone back.

He told me to sew the dura closed. After I did that with a baseball stitch we put the chunk of skull back on. We attached little metal brackets to hold it in place.

Blanchard inserted a long probe through one of the drill holes into the dura and one of the ventricles of the brain. This allowed the extra cerebrospinal fluid to drain as intracranial pressure increased from the swelling.

To close the deep layer of skin, Blanchard used interrupted stitches and I tied them. We closed the outside layer with staples, which hold the skin together with greater strength than stitches. At least that's what they told me in eighth grade when I had to get the back of my head stapled shut. I thought the Frankenstein look was cool.

My patient is someone's brother

As soon as the patient was off the table and I had transferred him to the ICU, I found a cozy desk chair at the nurse's station and started writing the orders. I was in a daze. I had just finished a case that fourth-year neurosurgical residents would have waited in line to do. But it was 3:30 a.m. and I had to think hard to figure out what orders I needed. A neurosurgical patient requires a fair amount of attention. The nurses have to watch for anything that might indicate an increase in intracranial pressure

I looked up to see a woman around 40, wearing a dark blue suit. It was an odd hour for business apparel. She spotted me amid the drab cabinets and counters of the nurses' station and approached me with eyes full of questions.

"Hello, I'm Dr. Iaquinta," I said as I stood up and offered her my hand.

"I'm his sister, Tanya. Are you the doctor who did the surgery?"

"I'm one of them." No way was I taking full responsibility. I needed Blanchard to fall back on, in absentia. No family wants to look at an unshaven 25-year-old and imagine he just performed brain surgery on their loved one.

"How long before he wakes up?"

"He might not. He had a very severe bleed inside his head."

"But it was only one punch."

She was waiting for me to answer.

"It caused bleeding inside his skull. The brain can't tolerate bleeding. It's like he suffered a stroke."

"They arrested the guy who punched him."

I didn't know what to say. The only thing I could think was that a single punch had probably made the guy a murderer.

"What's that tube going into his head?" she asked. She certainly was calm; maybe because she was tired.

"It's a shunt that allows fluid building up around the brain to drain." That part was easy to answer.

She left me to go into the room with her brother. I followed her for a couple of steps. He was covered up to his chin in white blankets. The endotracheal tube protruded from his mouth, attached by a hose to the respirator. A second tube came out the top of his head and was attached to a pressure monitor. His eyes were closed and his face was sweaty.

Her eyes had become glassy. "Why are you always getting into trouble?" Her voice wasn't so much sad as disappointed. Maybe she was the responsible sister and he was the goof-off brother. She moved closer to his bed. I backed up to the nurse's station to finish charting and give her some privacy.

Seconds later, I heard the decisive click of her heels as she left. I was surprised she didn't have more questions. Maybe it was too much for her. That was the moment I realized that my "most exciting case" was someone's dying brother. While his family had been worried about him, I was just excited to cut open his skull.

I was afraid that made me a creep.

Less than two hours remained before I had to do morning rounds. I returned to the call room and flopped onto the plastic mattress. I should have fallen asleep immediately, but my mind was racing.

I wondered how much of a creep I was. Blanchard had taught me how to do a craniotomy. He and I worked in a rigid world that follows a logical course. Tanya, on the other hand, lived in a world much more unpredictable and harder to fathom. I didn't wish anybody harm. When the injured person arrived, I wanted to put Humpty-Dumpty together again. Neither the family nor the attending cared that I was a lowly intern; they just expected me to do the job. And I had done the job, albeit awkwardly.

Maybe I'm not cast in the wrong movie after all. It's just early; there's plenty of time for character development.

I fell asleep and dreamt of sawing skulls.


Sal Iaquinta. What am I doing here? Medical Economics May 7, 2004;81:36.