Messing Around With The Brain Is Serious Business

It’s hard for many who know me to believe – and it is even hard for me to believe – but from a very early age, I loved the brain.

Looking at my professional path, one can see that everything I’ve done has been related to the brain (with a few side trips, of course). I tell most people now that my change from neurosurgery that ultimately landed me in psychopharmacology was a result of personal maturation. After all, I once believed that most medical problems had mechanical, or near mechanical solutions.

The OBT (Olivier-Bertrand-Tipal) frame -- Conventional stereotaxy makes use of a frame attached to the patient's head.

I once believed that a hematoma drained, using squishy squeegie apparatus, just like my mother of blessed memory would have used to baste the Thanksgiving turkey.

The truth of the matter is that I had become convinced slowly that a brain, once touched or handled, changed in immeasurable ways. My own dexterity seemed piteously inferior to the task of brain manipulation.  It was not fear — at least I do not think it was.  It was more a sort of reverence for the complexity of that which I struggled to lay my hands upon – literally to manipulate.

Ah, the sensations and hopes and dreams that would change in ways I did not know and could not measure once I had attempted to do neurosurgery on someone’s brain! Still, I loved the brain and still do.

I remember a discussion with a beloved avuncular Canadian elder statesman of the neuro-surgical profession.  He was as fine a gentleman as I had ever known, and he knew how much I loved the brain (and all medicine to boot) and he offered to help me down a different path.

I was in his office with him alone; a rarity, as he was a busy man. I remember the collection of hunting trophies, for this was a man who had often answered the “Call of the Wild” — a Canadian value I had never done a very good job of buying into — and had the skins and heads on his wall.

He said that if I stood with the kind of manual dexterity based surgery that neurosurgeons usually considered as the bread and butter of their profession, I would be a “chicken surgeon” – an inside reference to a doctor who only operates on backs and necks. We agreed that I would be unhappy going in that direction, for I had always had a passion for digging into the cranium with all of it’s gray-matter filling, or at least, the surgery of the cranial nerves.

He was very clever and suggested that I might enjoy getting into stereotaxy and related fields.  I had the neuro-anatomy knowledge, and I could work with a computer system, and I would be able to develop with the new technologies, and do wonderful things.

It sounded exciting, but not terribly practical. I was not as sure as he that neurosurgeons would be in the lead here, but I thanked him profusely for his caring — a trait rare in surgeons. I have thought a great deal about neuro-anatomy, but relatively little about the technology of stereotaxy, until now.

A recent report is upsetting for a number of reasons.  Of course personally I am glad I was never involved with this particular technology.  I mean, I knew it was being developed at centers other than where I was.  The chances of an outlier like me getting involved with something this much on the forefront then were realistically pretty small, I think, so really my avuncular preceptor was flattering me.  Whatever, these reactions are purely personal so they must be brushed aside.

Looking at the reality of the situation there are lots of things that have gone wrong with the development of this stereotactic technology. Lots of mistakes have been made and lots of people have been made worse.

The New York Times has done exactly what it should have done. They have chosen a single case, that of a 50 year old woman who had to date an active and productive life, and not only chased but also photographed her rapid descent into the category of “nursing home patient.” About the one person who seems to have been lost in this story is the neurosurgeon.

I do distinctly remember locating the ganglion that seems to be responsible for the horrific pain of a trigeminal neuralgia, and, under the less-than-one-foot-away supervision of both a senior neurosurgeon and a neuroradiologist, “frying” said ganglion to some sort of a functional death.

In general the patients were so grateful that if there were a little sensory loss — a little part of the cheek where they could not feel — they did not care a fig. Of course, the other people were responsible, in the final analysis — the senior neurosurgeon for verifying my placement of the apparatus, the knowledge of the neuroanatomy; and the neuroradiologist for the “numbers” — that is, for the intensity of the “frying.” As far as I can figure here, the “frying” was done by a biophysicist — a PhD technologist, perhaps.

I remember a course in biophysics in medical school.  It was early — second year — because, someone who had worked on the curriculum once told me, they had to get us while we still were thinking (at least a little) like a general scientist.  This would have been a carryover from previous training — a scientific baccalaureate for them; a bachelor of science for me.

I remember learning how to write a prescription for eyeglasses and how the electrical impulses of the heart translated into an electroencephalogram.  I learned about the electricity of seizures, but not about the electricity of ablative surgery, as used here, simply because the technology was still in its infancy.

I believe that the erroneous use of the technology and the poor patient outcomes are the result of the financial pressures of modern medicine.

First – The trend to use anybody other than a doctor (meaning a cheaper technician).  A biophysicist is still a technician. The final check on any procedure, especially a delicate one, should be with the physician. In this case, the neurosurgeon.  They may cost a bit more, but this is no place to scrimp.

Second — A biophysicist may simply “sign-off” on technologies that are very different from that which he or she has been trained.  This is a little surprising since most companies that make this sort of machine actually train the operators in the procedure.  It helps them sell machines.  However, the important thing in any medical system is to get paid – and there is always a requirement for someone of a certain level to sign-off.

The problem here is that the one whose signature is on the “sign-off” form is the one who gets sued for liability.  That’s why I constantly refuse to sign off on anybody else’s work or on patients I haven’t personally seen.  Most doctors (and other professionals) don’t seem to worry about this and most would sign their own death warrant if a sufficiently threatening administrator insisted.

Of course, most places make patients sign waivers of liability which are egregiously unfair to them, but they aren’t in any condition to read the fine print or to argue – they are desperate.

I’m not sure what the story was in this particular case.

Third — Medical devices have been historically easier to get through the FDA approval process than drugs.  This seems to date from the times when less complex technologies reigned.

Fourth — There is a constant pressure to reduce costs by not only reducing length of hospital stay but also getting more things done at an outpatient level. The procedure described is definitely an outpatient procedure.

So the heck with access to health care. Let’s go for health care that may actually work.