Life, Love and Neurosurgery

Michael Schulder once removed a tumor on a patient’s pituitary gland. Not technically part of the brain, the gland, which regulates hormonal levels, is located at the base of the organ and right behind the optic chiasm, the part of the brain where the optic nerves partially cross. That day, Schulder performed the surgery through a transnasal approach, a minimally invasive procedure whereby the surgeon makes a small incision in the back wall of the nose. After making the cut, he entered the sphenoid sinus, situated behind the bridge of the nose. For this surgery, the sinus constituted Schulder’s tunnel for reaching the tumor. But once he made it there, he discovered he had “limited exposure” and accidentally poked his surgical instrument too far in.

The clock in the operating room was ticking, but time froze, and Schulder with it. His unshaken hands had slipped and for several minutes left him hanging, anxiously. Later he would recall it feeling like an eternity. His instrument was stuck on the optical nerve. He understood that his hands had to do the right thing, or else he would blind his patient.

“I didn’t say anything to anyone,” Schulder said. “When things are at their hardest, that is when I have to be the calmest. But my heart was in my mouth.” He eventually made the right move, and his patient woke up tumor-free and with his sight untouched.

Schulder is a neurosurgeon at the North Shore Hospital on Long Island. When he decided to make a profession out of brain matters, he effectively committed to two careers: that of a scientist who celebrates the inner manifestations of the organ through a lifetime of research and that of a mechanic who fixes it when it’s broken.

The brain haunts him, but not all the time. It remains for Schulder a feast of wonders, a complex organ that, despite all the scientific advances in knowledge as to its workings, retained much of its mystery. To Schulder, and to so many of his peers, that mystery is exquisite. But to do his job, and to do it well, Schulder has to be tough and confident. That is because the brain, soft as it may be, is never easy on him.

Neurosurgery as it is practiced today is a young and small domain established in the late 19th century by a bold and tough man with a prestigious academic background. To this day, neurosurgeons have kept their realm at the top of the medical world. They have maintained their pedigree, gathering around the idea that they stand above all physicians. They have embraced a reputation of narcissism and austerity, a historical sameness in which the character of neurosurgeons goes unchanged and unchallenged. While each medical specialty adheres to its own stereotypes, this is a phenomenon particularly true to neurosurgery, says Deborah Benzil, one of the few female neurosurgeons in the United States. “People feel more comfortable training people that are like them,” she said. “If they are tough, and the only successful neurosurgeons they know are tough, anyone who isn’t tough won’t fit. This tends to perpetuate a certain culture or a certain personality. But is there really a personality that makes the best neurosurgeons?”

My husband, Teddy, once wanted to be part of the neurosurgical elite, but he never will. Not that he wasn’t bold or tough. He had a thick skin and the confidence that most neurosurgeons possess, which translated into steady hands, a gift noted by his mentors. But he was never much of a megalomaniac and, most importantly the brain, while an interest of his, wasn’t what he wanted his life to revolve around.

Teddy saw the brain for the first time in his early twenties. He was an undergraduate at the time and worked as a pharmacy technician at his hometown hospital, in Bloomington, Illinois. He befriended neurosurgeons and eventually got to see them save the life of a 35-year-old woman who had a bulging aneurysm in her brain. It was a ticking bomb, a balloon filled with too much air, and without the surgery it would have popped, causing her to bleed and die.

“I was captivated,” Teddy told me. “I wanted to make that kind of difference in people’s lives. I had been on the fence about going to medical school, but after that experience, I was set upon going and becoming a neurosurgeon – to be the one taking care of this woman.”

Teddy’s favorite organ, however, was the heart. Yet when it came to unraveling mysteries, the human mind stole all his intention. He liked the brain’s color – the pearly white shade, as he described it. He talked about it as a thing of beauty, as a dazzling work of electrical engineering. He loved to see it pulsate in syncopation with each beat of the heart. But most importantly, Teddy wanted to save lives, and to do it where the stakes are high, where life hangs in the balance, and where he would have no choice but to stand steady in the face of death.

Like most aspiring neurosurgeons, he took some time off of school to do research in the field. A month before his research came to an end, however, Teddy had doubts. He saw a prominent neurosurgeon ask one of his students to pick up his children from school because the surgery he was conducting took longer than he had originally planned. He saw residents too exhausted to continue on with their training. He saw others sticking with it, but dissolving into bitterness. He attended conferences and Christmas parties where the holiday spirit faded into brain talk. The brain was already lurking in every conceivable corner of his life, making him realize that neurosurgeons had no other choice but to eat, breathe, and sleep neurosurgery and relegate everything else in life to second place.

So when he met with his mentor in the summer of 2009, Teddy asked for advice. His mentor told him that if he couldn’t be happy with neurosurgery alone, if he couldn’t give up the 14-mile runs he did for fun, if he couldn’t let go of his guitar, and if he wasn’t okay with the possibility of losing me to the harsh and demanding world of neurosurgery, then he wouldn’t be happy.

To him, Teddy had too bright of a soul, and if not ready to marry the brain, for better or for worse, that soul would be darkened.

I couldn’t help but wonder, why did he say this? What world was he protecting Teddy from?

I got to meet a few neurosurgeons when Teddy was still doing research. My encounters with them remained quick and in the realm of small talks, and my understanding of who they were superficial. They seemed self-assured, their posture upright and handshakes strong. They talked only about the brain, in spite of themselves it seemed, as though neurosurgery came with an endless loop of talk of tumors and strokes. As brain talks bounced from one gathering to the next, I realized that marrying a neurosurgeon meant that I would have to battle against the brain for even a little of his attention.

My second encounter with the field came later, through books dissecting the lives of neurosurgeons – many of which were written by neurosurgeons themselves. Many of these books did not limit themselves to the everyday routines of the neurosurgeon’s life. Instead they toured the labyrinth that is the human brain, as if to remind me that it is indeed all they think about. As Katrina Firlik wrote in her memoir, “The issue of the brain texture is on my mind all the time. Why? I am a neurosurgeon. The brain is my business.”

As it turned out, nearly all of these autobiographies and personal accounts of and by neurosurgeons shared another guiding spirit: the tale of the pioneer of modern-day neurological surgery and nastiest surgeon known to the field, Harvey Cushing.

Cushing died at the age of 70, most likely from a heart attack. Despite being a husband and father of five, he spent most of his life in the operating room. He was, by all accounts, a hostile and unsociable man who would scowl at anyone and anything standing in the way of his success. He was a poor loser, was often cruel to his subordinates in the name of perfection, and to this day endures as the embodiment of a tradition of abusive surgical training.

“He was a nasty person,” Schulder said. “He was a genius and a demanding pioneer who was willing to try things that no one else did. He would take on the worst clinical cases. You have to have a pretty tough ego and a strong stomach to do that. And you sure have to be total megalomaniac.”

Cushing’s curriculum vitae might have been the spine of his ego. After graduating from Yale University, he studied medicine at Harvard Medical School, did his internship at Massachusetts General Hospital, and completed his residency at Johns Hopkins Hospital. Thereafter, he worked incessantly, to the limit of his strength and beyond. He lived for and by the brain, so much so that when he learned about one of his sons’ death, he informed his wife and continued with the operation he was about to perform.

Cushing now lies underground, at Lake View Cemetery, in Cleveland, and, despite his nastiness, rests in most neurosurgeons’ hearts as the man to look up to. He was eager to pass on his knowledge and break in new people. His pupils were, in a sense, the surrogate children that he bred in his own image. And thus was born the proud and stoic family of neurosurgeons.

When I arrived at Café Lalo, Schulder, the first neurosurgeon I met since my husband changed career paths, was already there, still standing up and diligently folding his brown coat before draping it on the back of his chair. I was a minute late; he was obviously on time. He remained up and inquisitive, giving me a steady stare as I zigzagged my way through the crowd of patrons. We shook hands rather firmly, sat down rather quickly, and without further ado started to recount the tale of his career.

Schulder was redolent of the past, as he talked more about Cushing’s surgical prowess than he did his own. In many ways, he even seemed to have carried on with Cushing’s philosophies and ways of life. This may be no coincidence, as he is (and prides himself for being) his surgical great-grandson – something my husband’s mentor also took pride in. “I was trained by a surgeon who was trained by a surgeon who was trained by Cushing,” Schulder said with a subtle hesitation on when to stop. Cushing and he aren’t blood, but his excitement when going up the genealogical tree suggests they may as well be.

Much like his forebear, Schulder seemed abstemious. All he wanted for brunch was muesli with yogurt and fresh fruit. He is a simple man when it comes to food, he confessed. He avoided any topics that made him squirm, like death, and when he talked about his own surgical cases, he kept coming back to his most challenging, but successful ones. To him, the long hours spent in the hospital, while exhausting and painful, are an inevitable testament to his commitment to his patients. Working less, he said, is caring less. But a neurosurgeon also ought to be tough and shouldn’t abide by, as he called it, “all that mushy gushy stuff” that patients can get from other members of the hospital staff, like nurses, pediatricians or other physicians on the case.

“It’s not bad for me to be sympathetic,” he said. “But it’s a distraction. It’s much better for my patient that I spend all the time I can taking out a tumor than it is for me to hold hands.”

Schulder pokes at brains that have been pushed around by tumors, or blood clots, or strokes. The brains he sees are at their most vulnerable; and it’s when brains are at their most vulnerable that he needs to be at his strongest.

“You have to have a strong stomach,” said Schulder. “You have to deal with some bad problems. Most of them, hopefully, are not of your own making. But at some point, some of them are of your own making and then, what are you going to do? Are you going to quit? Are you going to crawl into a fetal position and never emerge from your room? You can. But in the end, everyone can have complications, and you have to learn from them, become a better surgeon, and move on.”

Like my husband, it took Schulder one glimpse at the brain and one surgery to get hooked. But he had to go through a rigorous training to learn toughness. During the seven-year long tunnel of medical residency, his bosses yelled and stomped their feet; hours never ended and sleep never seemed to come; he taught himself to love coffee because it was the only thing that made it all sweeter. To make his marks, Schulder had to show confidence. He had to grab the scalpel, take the lead, and talk back to the physicians in charge. Only then would he gain the respect of his peers.

He married during his third year of residency, but any other semblance of life that didn’t fit with his scrubs was an afterthought. Sleeplessness left him in a recurrent haze. He dozed off at the dinner table and behind the steering wheel. He worked 100 hours a week, if not more, and quickly understood that his spare time was just for sleep.

After those seven years Schulder graduated from the status of apprentice and in time became more than a neurosurgeon. He is now a teacher, a researcher, a committee member and an editor for a neurosurgical journal. His curriculum vitae fills over 50 pages, and a snippet of it – framed diplomas, prizes, and awards – hangs on his office’s largest wall as a brash reminder of his accomplishments.

On April 8, 2013, I spent the day at the hospital with Schulder, trying to catch through his office window as much sunlight as I could. When not in his office, I was under the bright, artificial lights that traveled through the hospital’s hallways into the patients’ rooms and into the operating room.

That day, I didn’t see the sunrise, nor did I see the sunset. But I did, for the first time, see the human brain. It was not quite as pearly as my husband had described it. Rather, it was more of a salmon pink fading here and there into a greyish white and looked very much like a chewed piece of gum – at least the part that I saw from the tiny incision that Schulder made during his operation.

It didn’t take me long to figure out that in being a competent neurosurgeon, timeliness was of the essence, but hastiness wasn’t. As Cushing once wrote, “There should be a legal penalty imposed for speeding in brain surgery.”

Schulder entered his OR – room 8 – at 7:30 a.m. sharp. The surgery that he was about to perform, a deep brain stimulation, which aims at treating patients with movement disorders such as Parkinson’s disease, was going to last six hours, he warned me. His patient had writer’s tremors, which means that he couldn’t write – not even his name. Every time he tried to grasp a pen with enough strength to write something onto a page, his hand would convulse capriciously from left to right, drafting clumsy, childlike doodles. Schulder planned on making him write by introducing electrodes that would fire electrical charges deep into his brain and stimulate the nerves responsible in regulating abnormal impulses.

To do that, the patient had to have his head screwed to a thick, coppery frame, which was shaped like a drum shell, but looked more like a torturous device. He was awake through the entire surgery, but was sedated and locally anesthetized. So the screws digging into his forehead didn’t seem to bother him as much as they bothered me. The frame was then attached to the bed to keep his head stock-still.

The patient kept going back and forth from mumbling to snoring. When the anesthesiologist placed a catheter up his urethra, he instantly woke up from his doze. He had to pee, he said, which the anesthesiologist swiftly dismissed as a natural response to the clear tube traveling bladder-bound. Somewhat reluctantly, the patient made peace with his urge, or the illusion of it, and went back to rest.

The preparation was the part of the surgery that felt the longest. But it was also the part that smelled the best. There was so much antiseptic product involved, it smelled like those sanitizing hand wipes that people get after eating oysters. Once Schulder and his resident drilled the skull open, however, a cloud of fumes formed above the patient’s head, and a whiff of burning flesh crept up on my nostrils. That stink was, thankfully, the goriest part of the surgery and didn’t last for too long.

Schulder and everybody else barely spoke throughout the surgery, letting the EKG machine monitoring the patient’s heart rate set the mood. It was as if they had rehearsed, as if everybody knew exactly where to stand or what to do. There was a mechanical composure to every move involved, which made the operating room feel like a safe place to be. The scrub nurse passed the instruments to Schulder; the resident suctioned out the blood to better Schulder’s visibility; and the anesthesiologist, who was the only one able to sit down for most of the operation, made his eyes sway from the anesthetic machine to the heart monitoring machine, making sure that the patient remained stable and in a sufficient daze.

Once the electrodes were placed, they woke the patient, asked him to write his name and draw a spiral, and simultaneously made him talk to check for any speech impairment or other damage that the electrodes, if misplaced, could have caused to the brain. That was the most crucial part of the surgery. Everyone but Schulder – the scrub nurse, the resident, and the anesthesiologist – stared at the patient’s hand. Schulder kept his eyes on the screen that showed the depth of the electrodes. At first, the patient’s hand was still shaking and producing scribbles, so Schulder had to slide the electrodes a tad deeper. And after a few trials, the patient’s hand stopped shaking; the spiral started to look like a spiral; and his name like his name.

The success of the operation was welcomed, if at all, with little enthusiasm and little more interaction, as if it were normal, or even expected. The team was happy with the results, but still had to introduce a pacemaker into their patient’s chest, which, connected to the brain by a thin wire traveling up from the chest into the neck and to the head, would monitor the electrical charges that the electrodes would fire up. This required another surgery, which was scheduled three weeks later. All that was left to do was to close up the scalp and free the patient of the torturous frame, which Schulder allowed his resident to do before he left the operating room and changed back into his business suit.

Aside from surgeries, Schulder does the rest of his job – mainly seeing and checking on patients – garbed in a suit. Scrubs, he tells me, just don’t look professional enough. He took me along with him to visit some of his most critical patients. He quickly fell back into the hard reality of being a neurosurgeon, which that day lay unconscious four floors below his office, in one of the beds of the hospital’s oncology department.

Many of the patients there hung between life and death, and the entire floor was sinking in a confused limbo where an overall sentiment of hope mingled with an excruciating anticipation of loss. The cacophony of beeping from all the patients’ EKG machines instilled a feeling of chaos, reminding me that some patients were probably running out of time.

Schulder’s patient was one of them. She was a 45-year old woman with a brain tumor that grew too fast and took over her body, leaving her with multiple blood clots and too little energy to stay awake. Once we entered her room, Schulder explained to her husband that he was, for once, too late, that the surgery was too risky and pointless. She had, he informed him bluntly, a few days to live.

“You have to take it to the most practical narrow, focused question,” Schulder said. “If you ask me whether the surgery should happen today, my short answer is no. It wouldn’t be good to anyone.”

Silence broke and time stopped, letting the beeping of the patient’s heart monitoring machine deepen the agony that had already permeated the room. Throughout his conversation with his patient’s husband, Schulder showed compassion, but remained distant. He knew he had to let go because while he has to know about everything that can go wrong and everything that he can do to fix it, he also has to relinquish the mechanic in him and, in the face of a tragedy, know how to do nothing.

“You have to separate what’s in the hand of God and what’s in the hand of man,” he said. “It may be painful to watch, but you have to learn what you can from it, do your work, and move on.”

I don’t know if Schulder saw his wife that night. But after a 13-hour workday, he and I didn’t head to our respective homes right away. Rather, we met with 16 fellow neurosurgeons for dinner and stayed at the restaurant until about 10:30 p.m.

They didn’t talk much about the brain. But they didn’t talk about much else either. Rather, they talked about themselves and where they and their field stood in the world of medicine. They were, they said, still the jewels of hospitals and needed to demonstrate the worth of their procedures, to figure out a way, as one of them put it, “to have [hospitals] value [them] more than just for [their] good looks.”

As he drove home, Schulder confessed that some of the surgeries that were once exclusive to neurosurgeons are now shifting into the hands of other physicians. Orthopedic surgeons, for example, get to operate on the spine as long as they complete a spine fellowship. Just like radiologists that do additional training in endovascular techniques and are able to repair aneurysms; some orthopedic surgeons have become hybrid physicians, to which neurosurgeons are increasingly losing some of their most valuable surgeries. Ultimately, Schulder and his peers concluded that they would be fine, that all they needed to do was to follow what they loved rather than the money. The job market for neurosurgeons, they said, had never been better.

“I’ve heard this speech for so long,” Schulder said. “Twenty-five years ago, when I was finishing my training, one of my attendings told me that there was no job out there. It was simply not true. I don’t know why we think that way. Maybe because we have this gloom and doom about us, this constant pessimism because we keep having hard cases with patients. But we do tend to think the worst.”

I now understood that it might not just be the brain that neurosurgeons are married to. It might not just be their patients and all the complicated cases they are worried about. It might well be neurosurgery itself – its place in the world of medicine and whether they could continue as neurosurgeons shining in the light that Cushing had lit.

Before Schulder walked back into his apartment building that night, he told me he had to go straight to bed. The next day, he would have to wake up at 5 a.m. and do it all over again. So as we parted, I couldn’t help but wonder, what if it were Teddy? James Gardner, another prominent neurosurgeon, referred to neurosurgery as a “jealous mistress.” Teddy is now in his third year of anesthesiology residency, which is busy, but not all-consuming. Had he become a neurosurgeon, I wondered, would I have grown into a jealous wife?