From Publishers Weekly
The brain is my business," says Connecticut neurosurgeon Firlik. "Many of the brains I encounter have been pushed around by tumors, blood clots, infections, or strokes that have swollen out of control. Some have been invaded by bullets, nails, or even maggots." In these pages, a carpenter with a nail in his left frontal lobe goes home within a day of surgery; a boy develops a raging bacterial meningitis because his New Age mother gave him herbs instead of antibiotics for a routine ear infection; and an infant with hydranencephaly looks cute despite the absence of brain matter in his skull. Along the way, Firlik muses that a healthy brain has the consistency of soft tofu, and she flies solo in the OR for the first time as she saves an 18-year-old victim of a car accident who didn't buckle up. A woman in a male-dominated specialty, Firlik doesn't get worked up over minor things that can be construed as sexist; she finds that handling a patient's anxiety can be more complicated than the surgery itself, and she expects to be sued someday for malpractice. This witty and lucid first book demythologizes a complex medical specialty for those of us who aren't brain surgeons. (On sale May 2)
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved. --This text refers to an out of print or unavailable edition of this title.
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved. --This text refers to an out of print or unavailable edition of this title.
From Booklist
It doesn't take a brain surgeon to wonder what it's like to poke around beneath somebody's cranium. It does take a brain surgeon, however, to explain what makes a person want to drill into another person's skull. At that Firlik excels in her sometimes grisly, sometimes amusing (in a dark-humorous way), always informative, personal (father was a surgeon), and professional ("part scientist, part mechanic") story of becoming a neurosurgeon. In many ways she is what you might expect, but in others she is the rarest of the rare. There are a mere 4,500 neurosurgeons in the U.S., and a scant 5 percent of them are women. While Firlik has had some of the predictable and standard hassles and worries (what to wear to a job interview?), she has never had to storm out of a room because of male chauvinism. From a day-in-the-life sketch of a neurosurgery residency to an astonishing report on a performance-enhancing procedure to improve brain function, Firlik maintains a highly personal and engaging style. Donna Chavez
Copyright © American Library Association. All rights reserved --This text refers to an out of print or unavailable edition of this title.
Copyright © American Library Association. All rights reserved --This text refers to an out of print or unavailable edition of this title.
Product Description
Katrina Firlik is a neurosurgeon, one of only two hundred or so women among the alpha males who dominate this high-pressure, high-prestige medical specialty. She is also a superbly gifted writer–witty, insightful, at once deeply humane and refreshingly wry. In Another Day in the Frontal Lobe, Dr. Firlik draws on this rare combination to create a neurosurgeon’s Kitchen Confidential–a unique insider’s memoir of a fascinating profession.
Neurosurgeons are renowned for their big egos and aggressive self-confidence, and Dr. Firlik confirms that timidity is indeed rare in the field. “They’re the kids who never lost at musical chairs,” she writes. A brain surgeon is not only a highly trained scientist and clinician but also a mechanic who of necessity develops an intimate, hands-on familiarity with the gray matter inside our skulls. It’s the balance between cutting-edge medical technology and manual dexterity, between instinct and expertise, that Firlik finds so appealing–and so difficult to master.
Firlik recounts how her background as a surgeon’s daughter with a strong stomach and a keen interest in the brain led her to this rarefied specialty, and she describes her challenging, atypical trek from medical student to fully qualified surgeon. Among Firlik’s more memorable cases: a young roofer who walked into the hospital with a three-inch-long barbed nail driven into his forehead, the result of an accident with his partner’s nail gun, and a sweet little seven-year-old boy whose untreated earache had become a raging, potentially fatal infection of the brain lining.
From OR theatrics to thorny ethical questions, from the surprisingly primitive tools in a neurosurgeon’s kit to glimpses of future techniques like the “brain lift,” Firlik cracks open medicine’s most prestigious and secretive specialty. Candid, smart, clear-eyed, and unfailingly engaging, Another Day in the Frontal Lobe is a mesmerizing behind-the-scenes glimpse into a world of incredible competition and incalculable rewards.
From the Hardcover edition.
Neurosurgeons are renowned for their big egos and aggressive self-confidence, and Dr. Firlik confirms that timidity is indeed rare in the field. “They’re the kids who never lost at musical chairs,” she writes. A brain surgeon is not only a highly trained scientist and clinician but also a mechanic who of necessity develops an intimate, hands-on familiarity with the gray matter inside our skulls. It’s the balance between cutting-edge medical technology and manual dexterity, between instinct and expertise, that Firlik finds so appealing–and so difficult to master.
Firlik recounts how her background as a surgeon’s daughter with a strong stomach and a keen interest in the brain led her to this rarefied specialty, and she describes her challenging, atypical trek from medical student to fully qualified surgeon. Among Firlik’s more memorable cases: a young roofer who walked into the hospital with a three-inch-long barbed nail driven into his forehead, the result of an accident with his partner’s nail gun, and a sweet little seven-year-old boy whose untreated earache had become a raging, potentially fatal infection of the brain lining.
From OR theatrics to thorny ethical questions, from the surprisingly primitive tools in a neurosurgeon’s kit to glimpses of future techniques like the “brain lift,” Firlik cracks open medicine’s most prestigious and secretive specialty. Candid, smart, clear-eyed, and unfailingly engaging, Another Day in the Frontal Lobe is a mesmerizing behind-the-scenes glimpse into a world of incredible competition and incalculable rewards.
From the Hardcover edition.
About the Author
Katrina Firlik was the first woman admitted to the neurosurgery residency program at the University of Pittsburgh Medical Center, the largest–and one of the most prestigious–neurosurgery programs in the country. She is now a private practitioner in Greenwich, Connecticut, and a clinical assistant professor at Yale University School of Medicine. She lives in New Canaan, Connecticut, with her husband, a neurosurgeon turned venture capitalist. Visit her online at www.katrinafirlik.com
From the Hardcover edition.
From the Hardcover edition.
Excerpt. © Reprinted by permission. All rights reserved.
Chapter 1
1
Scientist and Mechanic
The brain is soft. Some of my colleagues compare it to toothpaste, but that’s not quite right. It doesn’t spread like toothpaste. It doesn’t adhere to your fingers the way toothpaste does. Tofu—the soft variety, if you know tofu—may be a more accurate comparison. If you cut out a sizable cube of brain it retains its shape, more or less, although not quite as well as tofu. Damaged or swollen brain, on the other hand, is softer. Under pressure, it will readily express itself out of a hole in the skull made by a high-speed surgical drill. Perhaps the toothpaste analogy is more appropriate under these circumstances.
The issue of brain texture is on my mind all the time. Why? I am a neurosurgeon. The brain is my business. Although I acknowledge that the human brain is a refined, complex, and mysterious system, I often need to regard it as a soft object inhabiting the bony confines of a hard skull. Many of the brains I encounter have been pushed around by tumors, blood clots, infections, or strokes that have swollen out of control. Some have been invaded by bullets, nails, or even maggots. I see brains at their most vulnerable. However, whereas other brain specialists, like neurologists and psychiatrists, examine brain images and pontificate from outside of the cranium, neurosurgeons boast the additional manual relationship with our most complex of organs. We are part scientist, part mechanic.
The scientist in me revels in the ethereal manifestations of the brain: the mind, consciousness, memory, language. The mechanic in me is satisfied by the clear fluid that rushes out of the end of a tube I insert into a patient’s brain to relieve excessive pressure. In everyday surgical practice, the science may take a backseat to the handiwork, and that’s okay. If you have an expanding blood clot in your head, you want a skilled brain mechanic, and preferably a swift one. You don’t care if your surgeon published a paper in Science or Nature.
I’ll give you an example of a most straightforward and manual case. I was paged to the emergency room a few years ago during my training and received the following brief report over the phone: “carpenter coming in with a nail stuck in the left frontal region of his head . . . neurologically intact.” What is going through my mind at this point? Do I hark back to my studies of frontal lobe circuitry and mull over the complex neural networks involved in language and memory? No. I’m thinking concrete, surgical thoughts: nails are sharp; the brain is full of blood vessels; the nail may have snagged a vessel on the way in. These thoughts are instantaneous, of course. I spell out the simple logic here purely for effect.
What I encountered in the ER was a young man, in his thirties, sitting up on an emergency room gurney. Perfectly awake and alert, arms crossed in repose and still in his construction boots, he smiled nervously when I walked in. Was he the right patient? He looked too good.
He was the right one. The carpenter explained that he and his friend were both on ladders along the side of a house. His friend was working a few rungs above. They were driving heavy-duty nails into the siding with automatic nail guns. His friend’s hand slipped upon firing in one of the nails, and the nail entered the left frontal region of my patient’s head below. For the first few moments after impact, the carpenter doubted what had happened. Although he noticed a stinging sensation within a split second of his friend’s slip of the hand, and heard the loud expletive coming from the same direction, there was no trickle of blood and he felt nothing unusual as his fingers frantically searched the top of his head. He wasn’t sure if it went in. His friend knew otherwise.
Upon close inspection of his scalp, past his short crew cut, I could see the flat silver head of the nail, not quite flush with the scalp, but a bit deeper. Apart from the nail, he looked great. I performed a quick five-minute neurological exam and found nothing wrong. I sent him down the hall for a CT scan. The nail entered his brain perfectly perpendicular to the surface of the skull. It had been driven a good two inches into his left frontal lobe. Luckily, it didn’t snag any sizable blood vessels along the way. There was no evidence of bleeding within the brain. Unlike the more common gunshot wounds we see, this was a respectably neat and clean penetrating injury.
At this point, my biggest fear—bleeding in the brain from entry of the nail—had been put to rest. Now, do I take a breath and mull over any complex scientific issues at this point? Am I exercising my formidable brainpower as a brain surgeon? When people say, “it doesn’t take a brain surgeon,” they refer to the assumption that we are the smartest ones around. Have I demonstrated this superior intelligence so far? Again, my thoughts return to the practical and concrete. We need to get the nail out of this guy’s head. It didn’t cause any bleeding on the way in. We need to avoid bleeding on the way out.
I walked out to the waiting room. His wife was there and so was his friend, who was pale and despondent, looking down at the floor. I tried to cheer them up a bit. Yes, the nail entered his brain, but his brain function, as far as we could tell, was normal and the nail caused no bleeding. Without looking up, the friend opened his hand and offered me a large silver nail that had been warming in his palm, the same type embedded in my patient’s head. “I don’t know . . . it might help you guys to have one of these . . . so you know what you’re dealing with.” I hadn’t been able to tell from the scan that the nail had two copper-colored barbs sticking out from the shaft at acute angles. I’m not a carpenter, but I figured that the purpose of the barbs was to ensure a strong hold. I thanked him and pocketed the nail in my white coat. On my way back to the ER, I ran my fingers over the pointy barbs and thought about the issue of bleeding again. Avoiding and controlling bleeding are elementary and pervasive themes in surgery—not quite the stuff of rocket science, but critical nonetheless.
After calling on the appropriate team, including the supervising neurosurgeon and anesthesiologist, I took him to the OR, shaved a small patch of hair around the nail head, and made a short linear incision in his scalp, down to the skull. There are no how-to entries in our textbooks regarding removing nails from heads, so we improvised using common sense. We drilled out a disc of frontal bone from his skull, with the nail head at the center of the disc. Slowly, we lifted this piece of bone up away from the surrounding skull, bringing the firmly embedded barbed nail with it. Although we could see a small jagged tear in the covering of the brain and a puncture wound on the surface of the brain itself, there was no blood oozing from the hole, and we considered ourselves lucky. (“Better lucky than good” is a favorite slogan among surgeons.)
Then, using large tools fit more for our patient’s line of work, we clipped off the barbs and pounded the nail through the disc of skull, backward. After soaking the bone in an antibiotic solution, we neatly plated it back in place with miniature titanium plates and screws and sewed his scalp back together. Actually, rather than suture, we used surgical staples from a staple gun to close the final layer of his scalp, unaware, at the time, of the subtle irony in that move. Within less than twenty-four hours, the patient was on his way home, joking the entire length of the hall with the friend who nailed him in the head.
When I recounted this story to my family and friends after dinner one night, they all nagged me with the same question: “How could he be normal? This went into his brain.” Finally, here’s where the scientist in me gets to pontificate a bit, settling into a fast-paced question-answer session in the comfort of my own home with a captive audience. I am not just a mechanic, after all, and the brain is not just tofu.
How could he be normal? First of all, his brain function was considered normal based on our typical bedside examination, which is, admittedly, a bit coarse. His speech was fluent. He answered simple questions appropriately. I asked him to remember three objects over a five-minute time span, and he did. His pupils reacted when I flashed a light in his eyes and his eyes moved symmetrically. He had no drooping of his face. The strength in his arms and legs was normal and so was his sensation. His reflexes were fine. He was capable of rapid and coordinated hand movements. In other words, his five-minute neurological examination was perfectly satisfactory.
But the frontal lobes harbor quite sophisticated functions, more sophisticated than the relatively simple ones I tested. The frontal lobes make up the largest section of the brain and are the most recently evolved. Compare the forehead of an ape to the forehead of a human. One slopes, the other bulges. We can thank, or blame, our frontal lobes for much of what we consider to be our personality and intelligence. Damage to the frontal lobes can be subtle, including changes in insight, mood, and higher-level judgment (“executive function,” in the professional lingo). I’m not going to detect such changes in the ER during my five-minute exam before he is whisked off to the CT scanner. I’m just the neurosurgeon here. We would need to consult a neuropsychologist to help us evaluate these more complex brain functions.
“So why didnR...
1
Scientist and Mechanic
The brain is soft. Some of my colleagues compare it to toothpaste, but that’s not quite right. It doesn’t spread like toothpaste. It doesn’t adhere to your fingers the way toothpaste does. Tofu—the soft variety, if you know tofu—may be a more accurate comparison. If you cut out a sizable cube of brain it retains its shape, more or less, although not quite as well as tofu. Damaged or swollen brain, on the other hand, is softer. Under pressure, it will readily express itself out of a hole in the skull made by a high-speed surgical drill. Perhaps the toothpaste analogy is more appropriate under these circumstances.
The issue of brain texture is on my mind all the time. Why? I am a neurosurgeon. The brain is my business. Although I acknowledge that the human brain is a refined, complex, and mysterious system, I often need to regard it as a soft object inhabiting the bony confines of a hard skull. Many of the brains I encounter have been pushed around by tumors, blood clots, infections, or strokes that have swollen out of control. Some have been invaded by bullets, nails, or even maggots. I see brains at their most vulnerable. However, whereas other brain specialists, like neurologists and psychiatrists, examine brain images and pontificate from outside of the cranium, neurosurgeons boast the additional manual relationship with our most complex of organs. We are part scientist, part mechanic.
The scientist in me revels in the ethereal manifestations of the brain: the mind, consciousness, memory, language. The mechanic in me is satisfied by the clear fluid that rushes out of the end of a tube I insert into a patient’s brain to relieve excessive pressure. In everyday surgical practice, the science may take a backseat to the handiwork, and that’s okay. If you have an expanding blood clot in your head, you want a skilled brain mechanic, and preferably a swift one. You don’t care if your surgeon published a paper in Science or Nature.
I’ll give you an example of a most straightforward and manual case. I was paged to the emergency room a few years ago during my training and received the following brief report over the phone: “carpenter coming in with a nail stuck in the left frontal region of his head . . . neurologically intact.” What is going through my mind at this point? Do I hark back to my studies of frontal lobe circuitry and mull over the complex neural networks involved in language and memory? No. I’m thinking concrete, surgical thoughts: nails are sharp; the brain is full of blood vessels; the nail may have snagged a vessel on the way in. These thoughts are instantaneous, of course. I spell out the simple logic here purely for effect.
What I encountered in the ER was a young man, in his thirties, sitting up on an emergency room gurney. Perfectly awake and alert, arms crossed in repose and still in his construction boots, he smiled nervously when I walked in. Was he the right patient? He looked too good.
He was the right one. The carpenter explained that he and his friend were both on ladders along the side of a house. His friend was working a few rungs above. They were driving heavy-duty nails into the siding with automatic nail guns. His friend’s hand slipped upon firing in one of the nails, and the nail entered the left frontal region of my patient’s head below. For the first few moments after impact, the carpenter doubted what had happened. Although he noticed a stinging sensation within a split second of his friend’s slip of the hand, and heard the loud expletive coming from the same direction, there was no trickle of blood and he felt nothing unusual as his fingers frantically searched the top of his head. He wasn’t sure if it went in. His friend knew otherwise.
Upon close inspection of his scalp, past his short crew cut, I could see the flat silver head of the nail, not quite flush with the scalp, but a bit deeper. Apart from the nail, he looked great. I performed a quick five-minute neurological exam and found nothing wrong. I sent him down the hall for a CT scan. The nail entered his brain perfectly perpendicular to the surface of the skull. It had been driven a good two inches into his left frontal lobe. Luckily, it didn’t snag any sizable blood vessels along the way. There was no evidence of bleeding within the brain. Unlike the more common gunshot wounds we see, this was a respectably neat and clean penetrating injury.
At this point, my biggest fear—bleeding in the brain from entry of the nail—had been put to rest. Now, do I take a breath and mull over any complex scientific issues at this point? Am I exercising my formidable brainpower as a brain surgeon? When people say, “it doesn’t take a brain surgeon,” they refer to the assumption that we are the smartest ones around. Have I demonstrated this superior intelligence so far? Again, my thoughts return to the practical and concrete. We need to get the nail out of this guy’s head. It didn’t cause any bleeding on the way in. We need to avoid bleeding on the way out.
I walked out to the waiting room. His wife was there and so was his friend, who was pale and despondent, looking down at the floor. I tried to cheer them up a bit. Yes, the nail entered his brain, but his brain function, as far as we could tell, was normal and the nail caused no bleeding. Without looking up, the friend opened his hand and offered me a large silver nail that had been warming in his palm, the same type embedded in my patient’s head. “I don’t know . . . it might help you guys to have one of these . . . so you know what you’re dealing with.” I hadn’t been able to tell from the scan that the nail had two copper-colored barbs sticking out from the shaft at acute angles. I’m not a carpenter, but I figured that the purpose of the barbs was to ensure a strong hold. I thanked him and pocketed the nail in my white coat. On my way back to the ER, I ran my fingers over the pointy barbs and thought about the issue of bleeding again. Avoiding and controlling bleeding are elementary and pervasive themes in surgery—not quite the stuff of rocket science, but critical nonetheless.
After calling on the appropriate team, including the supervising neurosurgeon and anesthesiologist, I took him to the OR, shaved a small patch of hair around the nail head, and made a short linear incision in his scalp, down to the skull. There are no how-to entries in our textbooks regarding removing nails from heads, so we improvised using common sense. We drilled out a disc of frontal bone from his skull, with the nail head at the center of the disc. Slowly, we lifted this piece of bone up away from the surrounding skull, bringing the firmly embedded barbed nail with it. Although we could see a small jagged tear in the covering of the brain and a puncture wound on the surface of the brain itself, there was no blood oozing from the hole, and we considered ourselves lucky. (“Better lucky than good” is a favorite slogan among surgeons.)
Then, using large tools fit more for our patient’s line of work, we clipped off the barbs and pounded the nail through the disc of skull, backward. After soaking the bone in an antibiotic solution, we neatly plated it back in place with miniature titanium plates and screws and sewed his scalp back together. Actually, rather than suture, we used surgical staples from a staple gun to close the final layer of his scalp, unaware, at the time, of the subtle irony in that move. Within less than twenty-four hours, the patient was on his way home, joking the entire length of the hall with the friend who nailed him in the head.
When I recounted this story to my family and friends after dinner one night, they all nagged me with the same question: “How could he be normal? This went into his brain.” Finally, here’s where the scientist in me gets to pontificate a bit, settling into a fast-paced question-answer session in the comfort of my own home with a captive audience. I am not just a mechanic, after all, and the brain is not just tofu.
How could he be normal? First of all, his brain function was considered normal based on our typical bedside examination, which is, admittedly, a bit coarse. His speech was fluent. He answered simple questions appropriately. I asked him to remember three objects over a five-minute time span, and he did. His pupils reacted when I flashed a light in his eyes and his eyes moved symmetrically. He had no drooping of his face. The strength in his arms and legs was normal and so was his sensation. His reflexes were fine. He was capable of rapid and coordinated hand movements. In other words, his five-minute neurological examination was perfectly satisfactory.
But the frontal lobes harbor quite sophisticated functions, more sophisticated than the relatively simple ones I tested. The frontal lobes make up the largest section of the brain and are the most recently evolved. Compare the forehead of an ape to the forehead of a human. One slopes, the other bulges. We can thank, or blame, our frontal lobes for much of what we consider to be our personality and intelligence. Damage to the frontal lobes can be subtle, including changes in insight, mood, and higher-level judgment (“executive function,” in the professional lingo). I’m not going to detect such changes in the ER during my five-minute exam before he is whisked off to the CT scanner. I’m just the neurosurgeon here. We would need to consult a neuropsychologist to help us evaluate these more complex brain functions.
“So why didnR...
