THE TIMED SCRUB is an operating room ritual, and I’m a little out of practice. Keep
those elbows down, I remind myself, so that the water drips off them rather than running the
other way, from dirty to clean areas. Scrub, scrub. Three more minutes to go on the scrub, then
my grand entrance into the O.R.
Though I have to think about it because I do it so infrequently, this scrub is automatic
for a surgeon, requiring as little thought as riding a bicycle. A surgeon gets ten quiet minutes to
think about the patient, contemplate the novelties of the case, reflect on what the patient said
when asked about preferences. In this type of neurosurgery, there may be a lot of on-the-spot
tailoring of the surgery to the unique aspects of the patient’s brain. And there are often serious
value judgments to be made, ones that the patient will have to live with ever after. Conflicts can
arise, between getting rid of the patient’s epileptic seizures and preserving his language and
memory abilities intact. One of the neurosurgical principles in such matters is, "Better some
seizures than a loss of language abilities." That’s a consideration that could arise later today,
when some of Neil’s brain is being removed.
There is a window next to the scrub sink, and I look into the O.R. to see how things
are going. I see the big blue-green tent, created with sterile sheets, but it mostly hides Neil. I
remember seeing him at the pre-op conference: the one patient, and twenty inquisitive doctors.
Not the usual patient-to-physician ratio, even hereabouts. The conference brings out many people
like me who are interested in how the brain normally works, crowding in with the usual
specialists in treating epileptics.
Before the conference, when Neil and I were talking about writers, he said that he was
becoming a rather specialized kind of writer himself: writing letters-to-the-editor about wearing
seat belts. The skull fracture that caused his epilepsy came from a collision with the steering
wheel fifteen years ago, during one of those quick trips to the grocery store.
Like most epileptics who are surgical candidates, Neil is highly motivated. A long day
of surgery, he said, was nothing compared to coping with a seizure almost every week. And
besides, he added, he had always wondered how his brain worked; maybe he might learn a little.
Unlike many of the mentally ill, epileptics often have quite a bit of insight into their
problem. Seizures are only temporary, with little in the way of problems between them. A single
seizure usually won’t hurt you, unless you are driving a car or flying an airplane. It’s all the
repetitions that make it a serious problem. About one in four epileptics isn’t helped by
anticonvulsant drugs. If the epileptic "pacemaker" area can be identified, and is in a place where
it is doing more harm than good, it can sometimes be surgically removed. This requires a lot of
testing, once the brain’s surface is exposed to the light of day, to identify the troublesome region.
The patient wakes up after the first two hours and, under only local anesthetic, works quite hard,