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patient lies asleep and intubated on the operating room table under the surgical drapes, his head held in place with pins secured to a Mayfield head clamp that holds the skull rigidly in place, his head turned towards the left shoulder. With the aid of the Leica operating microscope, I am looking deep within the confines of the skull through an opening the size of a quarter at a wedge-shaped recess known as the cerebellopontine angle. To my right lies the protuberance of the pons, the largest segment of the brainstem that is positioned between the midbrain and medulla oblongata. To my left the shiny surface of the dura mater covering the petrous bone glistens before me. Between the two, I see the tiny filaments composing the cochlear, facial and vestibular nerves traversing the recess, accompanied by twisting and turning arteries and veins, the clearest fluid imaginable, the cerebrospinal fluid, bathing the entire area.
As I increase the magnification of the microscope to its maximum, sixteen times what the naked eye can perceive, I see deep to the recess a diaphanous veil of billowing tissue, the arachnoid membrane, covering the trigeminal cistern. With bayonet microscissors, the blades only a few millimeters in length, I slide the shaft of the instrument over the surface of the cottonoid protecting the cerebellum and section this veil, carefully avoiding any nearby vessels and pause.
A faint tingling sensation travels up my spine. A hush seizes the personnel in the operating room as they look up at the large plasma screen on the wall, the image of what I am seeing in three dimensions through the oculars of the operating microscope appearing to them in two dimensions. The lights in the room are already dimmed. The only sounds heard are the bellows of the respirator and the monitor registering the patient's heartbeat. Beneath the translucent veil of the arachnoid lies the trigeminal nerve, one of the largest of all cranial nerves, emerging from the brainstem and composed of a multiplicity of fascicles running in parallel like the silk threads of a tassel. I move the microscope ever so slightly to one side to examine the inferior edge of the nerve and there it is: a loop of the superior cerebellar artery, wedged underneath the nerve, caught between the brainstem on one side and the emerging trigeminal fascicles overlying it.
If I am to succeed in relieving this patient’s trigeminal neuralgia (the “suicide disease” as it is commonly known), for whom a variety of medications have failed to bring the excruciating symptoms of lightning-like pain under control, I must ever so gently tease the arterial loop from underneath the nerve and insert a tiny felt pad, strategically placed between the two. To fail to achieve this means that the operation is all for naught. To kink the vessel while trying to dislodge it runs the risk of a devastating brainstem stroke for this patient, a human being whose life lies in my hands.
The muscles in my body that are stiff begin to relax, requiring a minimum of tension. I become aware of my breathing. Ever so gently, a blunt right-angled micro nerve hook is slid underneath the vessel loop. As I start to exert pressure on the vessel, its beating action readily palpable, I listen for any changes from the monitors registering the patient’s heartbeat, prepared to momentarily stop if bradycardia, a slowing of the heartbeat, should ensue. Then, very deliberately, ever so gently, I slide the loop out from underneath the nerve watching for the presence of a tethering vessel that might be compromised or, worse still, shorn at its point of penetration into the brainstem. A felt pad, tailored in size to the anatomy of this patient’s needs, is then slipped with micro forceps between the arterial loop and the underlying trigeminal nerve. I breathe a little more easily. I hear murmurs in the operating room. The anesthesiologist confirms there have been no changes in the patient’s vital signs. The technician monitoring the patient’s cranial nerves confirms that the evoked potentials are unchanged. So far, so good. Everyone breathes a sigh of relief.
But like a mountain climber who has reached the summit, what counts is the getting down, alive and unharmed. Too flippant and relaxed, bathing in the exaltation of having achieved the goal, all this good work can be erased: bleeding from the surface of the cerebellum that has been shifted in order to reach the anatomical target, brain swelling in the hours postoperatively, surges in blood pressure, spinal fluid leakage: the list of potential complications is long. All the more important to remain vigilant as I move towards the last phase of the surgical procedure.
Carefully, I peel back the cottonoid from the surface of the cerebellum, looking for any signs of oozing from the surface veins. I irrigate the operative bed copiously to ensure that there are no signs of active bleeding coming from the depths. The expected pulsations of the cerebellum are noted. All is quiet. And like a thief who has tiptoed through the house to claim the jewels while the residents are sleeping, I begin the process of retreat: the dura is closed with fine sutures, the quarter-sized hole that was drilled through the skull is sealed with a bone cement, the muscles reapproximated with sutures and the skin closed with a running absorbable suture. Only when the patient is finally awake and moving in the recovery room do I walk away to meet the anxiously awaiting family.
What is this attention that allows me to function within these extreme confines, where another individual’s life depends on my ability to execute the operation flawlessly in such a way that his or her symptoms are relieved without incurring a devastating complication? Where does this attention originate from? In these moments I am reminded that all parts of myself must come together to serve a higher purpose: a stillness that takes over the body, the feeling of being connected to a deep and powerful energy that permeates my being, demanding that I be fully attentive and, most importantly, realizing that I am not always able to achieve the goal I have set for myself, that I must accept that there are instances when the wisest course of action is to acknowledge that not every circumstance lends itself to a surgical solution. As one of my neurosurgical teachers used to say: “the mark of a good neurosurgeon is not how far he can go, but when to stop.”
How then do I take these lessons and apply them to my life: to be vigilant, to be attentive, to be receptive to what is taking place around me without losing myself through the process of becoming identified with the object? These are questions that I return to from time to time, for whom answers are not necessarily readily available, but questions that ultimately need to be asked and, most importantly, lived. The privilege of being a surgeon into whose hands a patient places their trust is first and foremost the responsibility to place the well-being of another individual’s life above all else, to serve that higher purpose regardless of the circumstances that may pull one in multiple directions at once.
Viewed from a larger perspective, it is a calling that requires a sacrifice of one’s own personal interests for the interests of another human being, regardless of whether I happen to “like” that individual or not. As we are reminded, the patient chooses us and not we who choose the patient. Needless to say, as physicians we all fall short of this calling, the ego being inflated by the successes the surgeon multiplies whilst deliberately glossing over his failures. But contrary to the popular depiction of the neurosurgeon as an arrogant, self-centered, autocratic narcissist that the media delight to portray, the neurosurgeons who made the deepest impression on me during my training, and since, were those who were humble before their many accomplishments, who shunned the limelight and strove to set a standard of excellence first and foremost for themselves as an example for others to follow, and remind us of the higher cause we serve as physicians.
One of the founding fathers of neurosurgery, Harvey Cushing, famously wrote, “If a doctor’s life may not be a divine vocation, then no life is a vocation, and nothing is divine.”[1] How to understand this “divine vocation”? In the light of inner work, how do I translate what I experience under highly specific conditions that occur in the sanctum of the operating room into conditions I create for myself?
Here is where I see how fragile and fleeting is this very fine attention that can vanish when the slightest perturbance ruffles the environment in which I inhabit. Not so, when another’s life and well-being hang in the balance. And even then, despite years of practice and thousands of operative interventions, disasters occur. Perfectly executed operations can be followed by devastating complications, some seemingly avoidable with the clarity of hindsight, others for reasons that defy explanation. To understand this is to understand the fragility of life, a reminder to remain vigilant, as at any moment catastrophe can strike.
The French surgeon, René Leriche, a pioneer in the surgical management of pain disorders, once wrote “every surgeon carries within himself a small cemetery, where from time to time he goes to pray, a cemetery of bitterness and regret of which he seeks the reason for certain of his failures.” [2] Recognizing these failures, as well as coming to terms with them, is a fundamental necessity for every surgeon even if the reasons for these failures are not always evident, this despite the many strides that have occurred over the decades since Leriche wrote La Philosophie de la Chirurgie. As someone who carries the responsibility for the life of another human being, I am haunted by my failures, whether they were the result of surgical mishaps or whether they were a result of my inability to alter the inevitable outcome of a patient’s illness. However, I am ultimately reminded that it is precisely these failures—and not the successes—that act as the fuel to return once again to the task of placing myself at the service of a higher calling, to “attend” to the other person—my patient—while not forgetting the person who is directing this attention.
How does all this relate to inner Work? What is this attention? As Madame Jeanne de Salzmann so eloquently stated, “I believe I need to pay attention when, in fact, I need to see and know my inattention”[3] (my italics). As a neurosurgeon, my inattention has the potential for devastating complications in another human being. But paradoxically, when it comes to myself, my inattention seemingly has little consequence: I simply remain in a state of sleep, that is until a shock momentarily jolts me into a state of awareness.
What is evident, what is clearly seen now, is that the energy of attention is what connects me to another world, a world that becomes alive when I am centered, and not a prisoner of recurring thoughts or emotions that remove me from a reality far greater than what I could possibly imagine, a reality that reveals the divine nature of the world that surrounds us. It is precisely in these moments when I experience the energy of attention flowing through me, that the presence of that higher energy is experienced: I am alive both to the world that surrounds me, as well as to my inner world, suspended between the two.
I head to the intensive care room where my patient is seated in bed conversing with his nurse, his head wrapped in a thick gauze, the monitors registering his oxygen saturation, blood pressure, and cardiac rhythm. I ask him how he is feeling. “I have a slight headache” he replies. “And what about your facial pain?” He opens and closes his mouth, gently touches the side of his face to see if the usual triggers prompt a sudden jolt of excruciating pain, looks at me, and says “it’s gone.” I smile. Our eyes in an instant lock on each other. No need for further words. □
At the age of twenty, Alain C. J. de Lotbinière was introduced to Mme. de Salzmann. He subsequently became a pupil of Michel de Salzmann and participated in New York groups with Lord Pentland and Paul Reynard. Dr. de Lotbinière earned an undergraduate degree in neurobiology from Columbia University, after earlier studies in philosophy and comparative literature at the University of Edinburgh. Upon completion of his medical training at McGill University in Montreal, Quebec, he was recruited by Yale University to start a program of Stereotactic and Functional Neurosurgery, spending seventeen years building the program. Since 2006 he has practiced with Brain & Spine Surgeons of New York, focusing on patients with pain disorders.
[1] A statement by the renowned American neurosurgeon Harvey Cushing, found in his 1926 graduation address, Consecratio Medici (The Consecration of the Physician).
[2] René Leriche, La Philosophie de la Chirurgie (1951) Paris: Flammarion. English translation of quotation found in memoir of British neurosurgeon, Henry Marsh, Do No Harm: Stories of Life, Death and Brain Surgery (2014) London, Hachette.
[3] Jeanne de Salzmann, The Reality of Being: The Fourth Way of Gurdjieff (2010) Boston: Shambhala, p. 21.