Quality of life. This seems to be very important to most people when making decisions about a lot of things. Whether it is renovating a kitchen, taking a dream vacation or deciding whether to pursue various therapies for a medical condition that may or may not be curable.
In general, I operate on patients because their quality of life has been impacted negatively. Perhaps they experience pain from a ruptured disc in their neck or lower back. Perhaps they have developed severe weakness due to a brain or spinal cord tumor.
Sometimes, however, instead of improving a patient’s quality of life, surgery itself, may have an adverse impact leaving the patient worse off than before.
In particular, when I am removing a brain tumor, the dilemma I often find myself in is balancing this quality of life issue with my own ego.
You may find such a thought absurd, because of course a patient’s quality of life would always come first. But what you must understand is that it is because of my ego that I am able to do what I do. As such it is my ego that makes it possible for me to be focused and aggressively treat these life threatening tumors which would otherwise destroy the quality of my patient’s life anyway, and in the worst case scenario take it from them.
However if I go too far, the patient’s quality of life can be made worse, not better. Unfortunately, knowing where that cut-off point is… is not always clear.
Recently I took care of two patients where this was apparent in very different ways. Tom Davis had a large benign brain tumor that technically was so difficult it took me all day to remove it; and Paul Kinsey had an equally large but malignant tumor that extended so deep into the brain it took me nearly as long as Tom’s surgery.
After my initial surgical exposure of Tom’s 2 ½ inch diameter tumor, it quickly became apparent that the tumor was literally stuck to the brain. Not only that but it was densely adherent to the blood vessels that were responsible for providing circulation to the motor area that controlled the left side of Tom’s body.
So I knew I would be spending many hours with my eyes glued to the oculars of the surgical microscope tediously removing the tumor from theses vital structures.
It was perhaps half way through Tom’s surgery that I was becoming discouraged as I began to realize I might not be able to completely remove his tumor. This weighed heavily on my heart since he was only 36 and if I was not successful in doing so, the tumor would recur and very likely prevent him from being the father that his young children needed.
I was also becoming fatigued and as I had learned all too well when you become tired it is very easy to make mistakes that could have profound consequences. So, I stopped momentarily, closed my eyes and prayed to God that He would give me the strength and perseverance I would need to remove Tom’s tumor without causing any injury to the critical areas of his brain.
Roughly, ten hours after I began my attempt to remove Tom’s tumor I had successfully removed 98% of it with only a small amount of tumor adherent to two large blood vessels.
In fact when I zoomed out the microscope to get an overall view of the operative field, I was astounded. It appeared as though the tumor had simply rolled off the brain surface without any damage or discoloration of the brain cortex. I smiled as I shook my head, realizing I had just participated in a small miracle.
Tom did great following surgery and was discharged from the hospital four days later feeling better than he had in a while.
Two days later I operated on Paul and the difficulty I had was no less than I encountered with Tom’s surgery. The difference of course was that Paul’s tumor was a malignant astrocytoma and as such I knew there was no possibility that I could remove it completely. In addition, Paul was 66 and not 36.
So, at face value it would appear that the complete removal of Paul’s tumor was neither possible nor imperative. However, I also knew that Paul’s overall survival would be directly related to how much of the tumor I did remove.
In addition, Paul’s wife knew me and she had requested that I be the one to operate on him rather than my partner or the other neurosurgeon on call who was initially consulted to take care of him. So in reality I felt more than the usual amount of pressure to remove as much of the tumor as I could… safely.
And that is the ‘operative’ word here, safely.
In general the appearance of this type of tumor is distinctive compared to the normal surrounding brain tissue. The problem is it is not always easy to determine when ‘enough’ tumor removal is actually, ‘too much’.
So as I was operating three inches deep into Paul’s brain I contemplated how much more of his tumor I should remove. To a great degree my decision is based upon visual and tactile cues I get, but there is also a ‘sixth sense’. And this is when I pray to God to help me ‘know’ when enough is enough.
Postoperatively, I am not always satisfied with the extent of my resection based on the follow-up MRI. Nevertheless, I have to trust that I did my best. Although more importantly, however, I have to trust that I did what was best for the patient and for the quality of the life of that patient that remains.
In Paul’s case his postoperative MRI looked quite good and in fact he was playing a round of golf two weeks after his surgery. That knowledge made me feel good, as I smiled once again, realizing that I was part of another small miracle for the second time in the same week.
