Giant shoulders

10 hours to my birthday I was standing in the room of a lady we operated on the day before. She had just said something that will keep me going for a long time. People say all kinds of things after surgery, and some of those words never go away. She told me, with a smile, that this was the first time in 3 years she was sitting up without a headache.  

I had woken up at 4.30 am to join a team to do the surgery that removed the tumour in her head. Suddenly it all seemed so worth it. Suddenly, in the music of those words there was a tonic to keep me going. It did not matter that her story of tolerating headaches for 3 years without seeing a neurosurgeon, broke my heart. It did not matter that my cases for the next day had been canceled because of absence of staff. I had drank a full gallon of hope’s elixir in this room. It would suffice, for now.  

This is a hard road that one has to travel, neurosurgery. In our briefing with the client before the knife, we talked about so much that could go wrong, because it was our duty to do so. We spoke numbers. We discussed how dangerous the surgery is. Small instruments fitting into the nostril, to chase a 2cm wide target, have only a small margin of error.  Every dot must connect to the next for ultimate success. Each dot and it’s subsequent connection has been handed down from teacher to student over decades. There have never been any guarantees, because every person is different, every skull is different. One can only trust, that the expertise and experience of the giants on whose shoulders we stand, the hours we have spent studying the anatomy and its variations, the skill, the equipment all click together to ensure that the client goes home better than he or she came. 

More than a hundred years ago a surgeon decided that he had studied enough of a route through the nose to the pituitary gland to to use instead of making a huge hole in the head and pushing healthy brain aside to get to the pituitary in the centre of the skull base. This was before CT scans, before MRIs, before ultrasound, even before the widespread practice of anaesthesia the way we know it today. I shudder, just to think about the bravery of those surgeons, jumping into the chasm of undiscovered territory. Their prayer then, is our prayer now. One never really knows when that instrument taps a blood vessel which carries blood at high pressure, and ends the patient’s life on the table.  There is always that moment that is a make or break and the mastery of surgery is that awareness of when to push on, and when to stop. 

The approach we used was first described 40 years ago. We used high definition cameras, 4 mm diameter tubes with independent light sources, and high end instruments angled exactly to overcome the nostrils’ internal architecture and do the job where needed.    I learnt the approach 5 years ago, my teachers were American. I am still learning. My colleague ENT surgeon had South African and Israeli teachers. Surgical specialty skill acquisition has become a global enterprise, and we have not joined the table, not yet. We still live in the era of yesterday when infectious disease was king, and antibiotics were all one needed to buy.  

Now even yesterday’s challenges are raging back to haunt us in the future. The same lack of strategy that has ensured that we only have 22 neurosurgeons and only 5 who do this kind of surgery, has manifested a vaccine shortage. Measles, rubella should not haunt us in 2023. They vaccine has been around for 60 years. It is wrong to let a country run short of such precious medication. Decisions decide life and death. For now, one person has gone home smiling. So I will bask in the wake of one success. 

 After all, I can only do one surgery at a time.