I was getting ready to leave for the day and walked up to the operating room charge desk to say goodnight. The charge nurse hung up the phone. He looked at me and asked, “Can you stay late? We have an emergency crani. coming in.” I shrugged and said, “Sure, I can stay. Do we have any details about the case yet?” “They have an MVA coming into the E.R., a 30-year-old female. She has a bad head injury. They think she may have a bleed. Can you get room nine prepped?” He asked me. I ran over to room nine and pulled in the emergency crani. cart. Some techs and nurses came into the room to help prepare for the case.
I scrubbed in, then a flurry of sterile packages were opened onto my table in every direction. They begin bringing neuro equipment into the room, and multiple people are firing questions and answers all around me. “What is his glove size? Do you have everything? What else do you need?” They ask me. Anesthesia is prepping their station with meds. The surgeon passes through to make sure we are getting the room ready. I call out to him to ask him about the case. “Dr. Smith, can I ask you some questions?” He walks over and looks at me. “Are you doing a flap or just burr holes? What do her scans look like? Do you want a drain?” I asked him. He carefully answers all of my questions. He tells me that her bleed is acute and the brain is already starting to herniate. She has a Subdural Hematoma. He will be doing a flap, and he needs a ventricular drain set up. As he walks away, I turn my attention back to the pile of sterile supplies on my table and begin inventorying what I have and what I still need to get. I start spouting out the supplies that I need to the nurses and techs around me. “Hey guys, can you get me a ventric. drain and more patties? I need Floseal too. Thanks!”
I begin to organize my set up. Each step has to be systematically laid out to ensure the surgery will go smoothly. At this time of night Dr. Smith did not have his P.A. or an assistant, so it would just be him and I. I would need to stay five steps ahead of him and assist in the procedure as his second pair of hands. My set up had to be perfect to enable me to do this. As I was running through the steps of the procedure and organizing my table, the nurse asked me to count. I counted all my sponges and sharps with her. All of this activity, the chaos, and preparation happened in less than 20 minutes. My heart was pounding. My pupils were dilated; everything around you seems to slow down as you focus in preparation for emergency surgeries.
The patient was wheeled into the room. My back was to the patient as I continued focusing on my current task. I start to hear distant sounds of beeping from the monitors and the murmur of people giving commands to each other about meds and positioning. They get the patient on the operating room table, and anesthesia goes to work putting in central lines and connecting EKG cables. Dr. Smith walks in again to put on the Mayfield positioner. The Mayfield is an essential and crucial positioning device that holds the head stable while the surgeon works on the brain. One jolt or slight bump during surgery could be fatal. The Mayfield latches onto the skull clamp or “Gardener Wells Tongs.” They look a bit like an ancient torture device. The three steel, razor sharp pins are inserted into the skull clamp and then clamped down onto the head. They pierce straight into the skull to keep the head completely stable. It is brutal but necessary.
I hear the “click” “click” “click” of the skull clamp being placed onto the patient. Then, I hear the electric razor. They started to shave the portion of her head where the surgeon will make his incision. I turn around as I hear this and as I watch, long thick locks of dark hair float to the O.R. floor. I think of my mother, my aunt, and my sister. I think of this woman’s family. It weighs on me. I start to feel her humanity and the sadness a tragedy like this brings. I see a small tattoo on her shoulder. I start to think of her and what she may be like. No! Stop it! Focus!
I quickly turn around and shut out my feelings. I need to be laser sharp right now. Dr. Smith was not a very patient surgeon, and her bleed was severe. I must be robotic and mechanical. No matter how hard we try it is difficult for people who work in surgery to not feel empathy and become overwhelmed with the fragility of human life. In surgery we must not let our emotions affect us, we must stay focused to do our jobs. So, we push away the thoughts of their children, their memories, or their lives to do what we need to do to help them to see another day. It is a strange emotional balance that all operating room staff has to maintain. We must feel to stay sensitive and human, but we must press that invisible button in our minds to turn off emotion when we need to see and do grotesque tasks to save a life.
The nurse cleans and preps the patient’s head. It is time. Dr. Smith walks in, hands out-stretched and dripping from his surgical scrub. I look into his eyes. I can see thoughts of the systematic steps being checked off in his mind that he is about to perform. I gown and glove him. One last glimpse of the patient’s hair and her face, one final thought of who she was and who she may be to someone. Stop. Focus.
The sterile towels are placed on her head. He uses a stapler to secure them in place. “Kerchunk.” Kerchunk.” “Kerchunk.” The sound echoes in my ears as he presses each staple into her scalp. The sterile craniotomy drape goes on. I take a deep breath. No more shiny dark locks of hair, no more long eyelashes. That invisible switch flips in my brain and my mechanical mind takes over.
We all do a surgical time out, and I hand him the ten blade. I grab a suction as he incises. The scalp has so many capillaries that it bleeds more than any other part of skin on the body. I chase his incision with my suction tip collecting all the blood to keep it out of his view. He starts using a sponge and his fingers to separate the skin from the skull. It peels with ease like peeling an orange rind. I hand him some raney clips to pinch the edges of the skin to provide hemostasis while not damaging the tissue. He peels the flap of skin back and secures it to the drape so it will not flip back and get in his way. I place a wet sponge on top of it to preserve the delicate tissue and keep it moist. I hand him a Lagenbeck elevator to scrape the remaining tissue away from the bone.
That is when you see it, the hard protective bone of our skull that protects our being. It is the one final barrier guarding our thoughts, our functions, and our existence. This white, smooth, rock hard shell encapsulates the most precious part of who we are as humans. In a world filled with prejudice and racism, it always fills me with anger and frustration when I see the internal workings of our bodies. If only everyone could see it? If only every person in this world could see the undeniable similarities that make us human, reguardless of skin color, race, or gender. Once you see that skull with the skin peeled back the meer thought of one person being treated differently from another due to what they look like becomes incomprehensible.
I handed the perforator to Dr. Smith. The huge drill looks horrifying as it moves towards the patients head. Medical technology has advanced so much over the years. At one point, it was a hand crank drill which was slow and hard to keep steady; once they made it motorized, creating burr holes became a thing of ease. The hard part for the surgeon was knowing when to stop drilling. Their training and practice taught them how to feel this. Times of emergency, high stress, or lack of experience allowed for mistakes to be made. So, today there is an automatic stop on the perforator drill when it has reached the edge of the bone. Regardless of the technology, it still looks massive and barbaric to anyone watching.
He presses the perforator down, creating two, three, or four holes, whatever is needed to create the correct size of bone flap. I grab the bulb syringe and irrigate the bone away from the hole as he burrs. The bone slivers and flakes build up around each hole as it would when drilling a hole into a plank of thick wood. He completes his burr holes and I hand him a penfield 3 to dissect the dura off the bone edges of the hole. He takes small balls of bone wax and smears them on the bleeding edges of the bone. The skull has now transformed from a smooth and uninterrupted casing with beautiful fissures and varying characteristics to looking something like a cream colored bowling ball with finger holes cut into it.
I switch the drill to a cutter. The surgeon needs to connect the holes that he made to remove the flap. The guarded cutter slips into the burr hole and begins to create a line from one hole to the next. I irrigate and suction while he cuts. The bone dust slides down off the edges of the cut into the pouch that is connected to the drapes. Blood is pouring out of the burr holes. Yep. There is a bleed alright and we are getting close.
He peels back the bone flap as I irrigate. The slurping and crunching sound it makes is similar to the sound of opening an oyster shell. He hands me the bone flap. I rinse it off, wrap it into a wet sponge and clamp it to my instrument tray to keep it safe. The responsibility and weight that a scrub tech feels when handed a piece of someone’s body is overwhelming at times. You, and you alone, are holding a piece of that person’s body. You cannot drop it, lose it, or damage it. You are being entrusted with a priceless and irreplaceable item. It doesn’t matter how long someone has been scrubbing or working in the operating room. I genuinely believe that all of our hearts skip a beat every time we are handed an organ, bone, or piece of tissue. What a gift, yet what a burden it is. A surgeon once told me that if I dropped the bone flap, he would take mine to give to the patient. He said this to me in order to scare me into being cautious. So, accepting and securing the bone flap is one of my most focused moments in any craniotomy.
After securing the bone flap to my tray to keep it safe, I began to irrigate the brain. Blood was oozing out, and blood clots were clinging to the brain’s surface. As I suctioned to help Dr. Smith to see the brain and find the bleeder he asked me for patties or cottonoids. He lined these small sponges all around the edges of the skull where the bone flap used to be. We are starting to make progress. He asks me for the bipolar and I realize he has found the bleeder. Irrigate. “Buzz.” “Buzz.” “Buzz.” Irrigate. “Buzz.” “Buzz.” “Buzz.” Then Dr. Smith mumbles, “Half by half.” I load one on a bayonetted forcep and hand it to him. “Dammit!” He shouts. He had found the vessel, but he could not get it to stop bleeding. Irrigate. “Buzz.” “Buzz.” “Buzz.” Irrigate. “Buzz.” “Buzz.” “Buzz.” Then Dr. Smith mumbles again, “Brain spatula.” I place the malleable retractor inside the brain to gingerly pull aside the brain tissue. It feels soft and spongy, almost like retracting a piece of angel food cake. My thoughts drift to the complex network of nerves and small blood vessels inside the tissue that I was retracting. How incredible this soft spongy tissue was that controlled our whole body!
He found it! Dr. Smith found the bleeder. “Patty and Floseal” He says to me. I hand it to him and he dabs the vessel. No oozing. Then we wait and watch. He examines the rest of the brain making sure he did not miss any other bleeders. He irrigates and suctions all the old blood. While he was doing this, the brain tissue started to reveal its beauty.
The coils and swirls of pink and grey tissue wrapping around each other like a labyrinth. The tiny vessels were weaving in and out of those coils and swirls like ivy vines. It had a sheen now, a slight shimmer under the O.R. lights. As I watched it, it slightly pulsed. To this day it is one of my favorite sights. To see a brain pulse with life inside of someone’s head is such a life-changing experience. It’s complexity and power is overwhelming. It is like a pearl, a fragile pearl guarded by a hard armored shell. It is so soft and susceptible yet controls everything that we are and makes us who we are. Though all of us look alike inside, like a pearl, our brains are unique and signature. It is our guarded treasure. So, every time I see those intricate swirls and the pulse of life when I look at a brain, it humbles me and enlightens me. What incredible creatures we are!
The patient’s brain appeared dry. It had stopped bleeding. Dr. Smith was able to save this pearl, this brain, this mother, aunt, or sister. I began to hand him 4-0 neurolon sutures for him to close the dura. The thin, delicate tissue of the dura slides back on top of the brain like a satin sheet tucking it in for the night. Each stitch securing the dura tucks the brain in tighter and tighter. Good night precious pearl, stay safe and warm.
I count all of my sharps and sponges with my nurse and start gathering the closing supplies. Dr. Smith and I place small screws and plates onto the bone flap to attach it back onto the skull. I hand him the bone flap, relinquishing my guardianship of the patient’s precious piece of bone. I give him small screws to secure the bone. Good night pearl. You are safe now. The hard skull resumes its duties of protecting the woman’s command center.
All of it is covered again but one burr hole which Dr. Smith uses to place the ventricular drain to monitor the ICP levels of the brain. Dr. Smith slowly puts the skin flap back on top of the skull and sutures it on. Goodnight hard shell. Keep that pearl safe.
We wipe the incision site and begin to pull back the drapes. There she is again, the 30-year-old mother, sister, aunt? Her long dark locks of hair, her long eyelashes, her small tattoo. Dr. Smith takes off the Mayfield and releases her from the skull clamp’s death grip. “Click.” “Click.” “Click.” We all work together to get her onto the hospital bed, carefully guarding drains, I.V.’s, catheters, and monitors. The nurse covers her up with warm blankets. Other than the small ventricular drain coming out of her head it was as if we were never there.
The switch flips back on in my brain to feel again. I looked down at her and smiled. Your going to be ok. Your going to live another day. I say to the patient in my mind. Live well girl, live well. It is a strange feeling to look at someone’s face and know that you have seen the innermost part of what makes them who they are. You feel as though you know them even though you have never met them.
As a scrub tech, you carry these moments with you every day.
The gift. The responsibility. The burden.
Today was a good day. Another fragile pearl was saved, to hopefully change the world around it.
Sending you all love and light,
**All details and names have been changed to protect the identities of people in this story including the patient**
**Images were all taken from online public sites**
Crani– an abbreviated term for Craniotomy or making an opening into the cranium (the skull)
MVA– Motor vehicle accident
Herniated– when something shifts the brain due to pressure
Ventricular drain– a drain put into the ventricles to monitor CSF and ICP in the brain
P.A.– Physician’s Assistant
Central lines– an I.V. placed into a large vein
EKG– An Electrocardiogram. It monitors heart function
Mayfield– A positioner used in neurosurgery
Skull Clamp– A device that secures the cranium to the Mayfield
Raney clips– Clips used in surgery to pinch the tissue to stop bleeding
Perforator– A type of drill used in neurosurgery
Penfield 3– An instrument used for dissection in neurosurgery
Bipolar– A forceps that cauterizes between the two tips of the instrument only
Patty or cottonoid– a small sponge with a string on it, used in neurosurgery
Dura– the layer of tissue that encases the brain
4-0 neurolon– A type of suture used in surgery
ICP– Intracranial pressure
Subdural Hematoma– When blood gathers between the inner layer of the dura mater and the arachnoid mater of the brain.
Bone wax- A wax used in surgery to stop bleeding on bone
Lagenbeck elevator- an instrument used to scrape in surgery