2 days ago I had an experience that will stay with me forever. I almost lost a patient on the operating table for the first time. Never before had I been as terrified and it seared into me the incredible responsibility that we have as we take people’s lives in our hands. As a physician we are taught to “do no harm” however as a neurosurgeon we are often operating on pathologies to prevent a problem, not necessarily to treat an active problem. The patient was diagnosed with a cerebral aneurysm, a small balloon or blister that grows from a larger vessel of the brain. Should I treat the aneurysm or let her live with it and hope that it doesn’t bleed? The lifetime risk of a ruptured aneurysm this size for my patient was approximately 20% with an attendant 10% risk of death. The risk of surgery for an aneurysm like this was less than 5% with a negligible (<1%) risk of death. The odds of surgery were in her favor. We decided to go ahead. I brought her to the OR to repair her small aneurysm which emanated from the proximal right internal carotid artery, one of the dominant arteries of the brain. She had had a prior bleed from an aneurysm of the left carotid artery so despite the fact that this aneurysm was somewhat small and relatively low risk to bleed, I recommended treatment due to her prior bleed which theoretically puts her in a higher risk group. She delayed the surgery for a few months until she was ready, appropriately fearful of a brain surgery. On the morning of surgery I spoke to her prior to taking her to the OR and we discussed when she would go home and how presumably straightforward that the surgery was. We talked about her small haircut and she smiled and laughed, happy to be finally getting this over with. I walked away and waited for the OR to call me when ready. I returned to the OR 40 minutes later and she was asleep, blissfully unaware of what was taking place. We placed her head in a Sugita stabilizing frame, a small shave, surgical prep and then she was draped. Her body completely covered, dehumanized, with the exception of a small window over her right forehead where the incision and craniotomy would be. We made the skin incision and the operation continued no different than the hundreds of other aneurysm surgeries that I have performed. I easily exposed the aneurysm, a small mushroom of tissue growing from the carotid artery, its thin wall holding back the swirling blood within. All had gone to plan. I was under the microscope lowering the clip onto the 3mm blister of vessel, slowly closing it on its base, confident and relaxed, when something went wrong. As I was closing the clip on the aneurysm a little bleeding began around the clip. Nothing terrible at first just some oozing. I inspected the clip and it appeared to be fine. I carefully looked around the sides of the clip and saw some pulsatile bleeding coming from below the clip blades. I opened the clip slightly and tried to cinch it lower but the bleeding continued. Then the bleeding worsened. I had a major problem on my hands. Significant bleeding at high magnification. If I don’t stop the bleeding she will bleed to death on the table. No blood pressure. no pulse. No good way to stop the hemorrhage with a beautiful 40 year old woman on the table, asleep. Her husband in the waiting room, very much awake. I have never lost a patient on the table, not once. It can happen but I have been lucky enough to not have had that experience. I have been in dire situations before but never one where the patient died in my hands. No one can prepare for that. There is no course in medical school or residency to prepare you for that. This suddenly became a horrible possibility. Neurosurgery cases run the gamut from the most difficult and high risk to the banal. Unruptured aneurysm surgery of small aneurysms is not “easy” but generally, one sleeps well the night before. The stress and risk levels are usually quite low and patients do remarkably well. When challenges occur in high risk cases, they are expected and subconscious thoughts remain restrained and compartmentalized. When disaster strikes in low risk cases, I find compartmentalizing much more difficult. I find that the detachment from the humanity of the patient, so vital in treating high risk disease, is harder to maintain. Doctors are human beings. We feel emotion. We laugh. We cry. As a neurosurgeon we are confronted with difficulties and emergencies where these emotions get in the way of action. One cannot allow fear to invade our thinking for it only negatively impacts our ability to act. As I struggled to get control of this horrible bleeding, fear did begin to creep in. Fear for the patient and fear for myself. I was able to remain calm and it seemed like I was making progress when the unthinkable happened. I had my suction tube at the depth of the opening against the bone edge where the aneurysm rested, staring it down through the lenses of a high magnification microscope when the brain began to swell. I was losing access to the bleeding as the brain itself closed my window to the bleeding point. I was falling behind. There was nothing more that I could do. I was losing control of the patient and began to lose control of my mind. I began to think of my patient as a human being. My detachment was lost. I began to think of her as a mom, wife and friend. I have never lost a patient on the table and now I was about to for the first time. What would I tell the husband? What do I tell her young children? I began to think about my own wife, my kids. I felt my heart racing. The room felt hot. My throat tight. I could feel the angst of the people in the room. I was the only one who could do anything and I was failing. I had almost given up when something remarkable happened. The bleeding stopped. I could only get one instrument into the field because her brain was so swollen but as I pulled back there was no more blood. Her vital signs were stable. The anesthesiologist could catch up on her blood loss with transfusions of blood products and fluid. She would survive this surgery. As we began to close the case, I realized how truly exhausted that I was. Hours had passed but it seemed as if time was nonexistent. Everything had happened so quickly. “Dr.Langer, the patient’s husband is calling from the waiting room and asking if everything is ok” said my circulating nurse. “Tell him that I will be right out to talk with him” I said. As difficult as the surgery had been physically, this next task was more difficult emotionally. I had to talk to her husband and explain how something had gone wrong. How she will survive the surgery but how she may have had a stroke. She may not recover to the way that she had been before the surgery. She may not be the same. I certainly won’t.

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