THE VIRGINIAN-PILOT
Copyright (c) 1995, Landmark Communications, Inc.
DATE: Tuesday, December 5, 1995 TAG: 9512050284
SECTION: FRONT PAGE: A1 EDITION: FINAL
SERIES: BRAIN SURGERY: THE OPERATION
SOURCE: MARIE JOYCE
STAFF WRITER
LENGTH: Long : 303 lines
Sheri Clark, Jack H. Pearce Jr.'s oldest daughter, buries her head in his shoulder. She casts a teary glance at Laurie, Jack's wife, standing at the foot of his bed.
Laurie's eyes turn red. ``Don't you start,'' she says, pointing a finger at her stepdaughter.
It's dawn, Aug. 23. Jack is smiling at his family and joking with Linda Vaughn, the nurse who is clinical coordinator of Sentara Norfolk General's Comprehensive Epilepsy Program.
Jack has suffered from epilepsy since a head injury in 1976. Medicine hasn't rid him of the seizures. Today, a surgeon will remove a damaged part of his brain, in hopes of curing him.
``When I get out of here, am I going to be bruised in the face?'' he asks Vaughn.
``Only if I hit you,'' Vaughn says.
``You'd do it while I was under,'' he says.
A man comes to wheel the bed into pre-op.
Laurie kisses him. ``Don't act up on that table.''
Jack grins up at the man. ``Hey, I've been pushed around all morning.''
He smiles, beatific, as his bed rolls toward surgery.
Laurie and Sheri hold hands and stride solemnly behind the bed.
``Cute,'' says Laurie.
``Yes, he is cute,'' Sheri replies.
``Like a litte boy,'' says Laurie. They reach the doors to the waiting room and have to turn away.
Dr. Jonathan P. Partington scrapes a disposable razor over Jack's head, folding the right ear out of the way. He always does the shaving himself, right before the surgery. He wants it done right, and if a hair follicle got infected, he couldn't operate.
Jack has dozed off somewhere between pre-op and this room. A tube snaking down his throat works his lungs for him. A heated air mattress covers his legs - the OR stays cold to stymie bacteria.
Linda Vaughn has followed him in here. So has Robin Roth, a nurse who works for the epilepsy program. They stand a few steps back, since they have no official role.
Partington cradles Jack's head while the staff slips off the headrest and replaces it with a metal clamp. At the end of three silver arms, the thick prongs glisten with antibiotic gel. Partington turns Jack's face toward the left. The clamp is tightened until the nails bite into the skull.
Soon, a 5-foot-high tent of blue surgical drapes hangs over instrument tray that juts out over Jack's stomach.
Inside the tent, Jack communicates to the outside world through figures on monitor screens. Numbers show his heart rate and blood pressure. A spikey graph - that's the beating of his heart. Bellows pump like a concertina and mark his mechanical breaths. Soon, all that remains visible is a small patch of skull.
From the CD player on a shelf along the wall, Hootie and the Blowfish croon, ``I only want to be with you. . . '' Partington likes his rock n' roll. He bounces up and down a bit in time. ``Everyone thinks I'm dancing. I'm just doing my varicose veins exercises.'' His surgeon father developed veins like pipes.
It's time.
Partington dons a head lamp. The brain, more than other parts of the body, doesn't tolerate a misstep.
He cuts an elongated C on Jack's skin and pulls back a muscle. The exposed bone is tinged yellow and scored with lines from the Bovie, the hot instrument he uses to strip the muscle and cauterize tiny blood vessels. Partington runs a gloved index finger lightly over the bone, feeling for the top of the cheekbone, one of the landmarks he'll use to guide his passage.
He points to where he'll drill guide holes, then traces an arc, to show where he'll cut.
``Hey, the rock n' roll hall of fame in Cleveland is going to be opening Sept. 4,'' he says.
``Who's going to be inducted?'' asks someone.
``I don't know,'' says Partington. ``They didn't consult me.''
A golden-handled drill churns through the skull, sending up a puff of smoke and a smell like a wood fire in the distance. An assistant dribbles saline from a baster to cool it. The drill tip sizzles.
Now a tool like a jigsaw, a long bit with four cutting edges spinning at 80,000 revolutions per minute, connects the holes. A small plate fitting under the saw tip keeps it from cutting into the tissue below. A fine, white dust settles on Partington's gloves, the surgical drapes, the folded-back flap of skin and muscle.
The skull comes up with a faint protesting crack. For a hushed moment, the group can see the white dura mater, ``hard mother,'' the thin, leathery layer that covers the brain. Linda steps on a metal stand to get a better look. Robin leans forward. Blood seeping from the skull's marrow fills the hole.
A nurse holds the skull fragment lightly in her hands. For the next few hours it will rest in a blue plastic dish, in a pool of antibiotic wash.
``How many grams of brain tissue will you take out?'' asks an assistant.
``Uh - probably a couple hundred,'' Partington replies.
The drape around Jack's head is already soaked with bloody saline.
With a small blade, Partington slices - with fine, delicate strokes - through the dura, slipping a tiny paddle underneath to protect the surface of the brain. A clear liquid seeps through the slit. Spinal fluid. The brain floats in an ocean of it. The dura pulls back like a layer of plastic wrap, and there's the brain.
White and glistening, pulsing slightly with each beat of Jack's heart. Blue veins and arteries line the surface.
It looks wrong. Where there should be healthy, pristine tissue, there's a mass of sticky, cobwebby stuff. It should be pinkish white, but it's stained faintly yellow from iron deposits left when blood pooled there years ago. There's a cavity, big enough to hold a couple of marbles, where there should be brain. When the brain is injured, it just melts away.
That injury. A simple misstep off the curb 19 years ago. He smacked his head on his car, got a massive cerebral hemorrhage. After that, seizures that a pharmacy of medicines couldn't control.
Through tests, doctors have pinpointed the area where they think the seizures start - the right temporal lobe, which extends in a horizontal strip above the right ear. By removing that, doctors hope to end the seizures.
``This old brain has been beat up,'' Partington says. ``This is a temporal lobe only a mother could love.''
It's 10 a.m.
A shriek fills the room, a high-pitched sucking noise. Partington holds an instrument that look like a pen with a tube attached. The CUSA, an ultrasonic aspirator.
Its tip vibrates thousands of times a second, pulverizing tissue without hurting stuff a millimeter away; it doesn't tug on surrounding tissue like a scalpel would do. So precise, it will disrupt the brain tissue without destroying the blood vessels that snake through it. Then Partington can cauterize and cut those vessels. The machine sucks up the remains.
White chunks and blood race through the clear vacuum tube. The brain feels wrong. It's too soft. It gives away far more easily than undamaged tissue would.
Small blood vessels are torn open. Partington pauses and uses the bipolar, an instrument with tiny insect claws, to grab the vessels and singe them shut with a jolt of electricity. Assistants wash down the tissue with saline and vacuum up the liquid.
As Partington moves deeper into the brain, he skirts the choroid plexus. Bright yellow and fern-shaped, the structure, which produces cerebrospinal fluid, contains a critical artery that supplies blood to certain parts of the brain. There is no other blood supply for that area. If Partington cuts that by mistake, Jack may be paralyzed. Partingon lays pieces of gauze over it to protect it.
Partington tells the staff to page Dr. Joseph Hogan, Jack's neurologist.
Deep within the brain, behind the choroid plexus, Partington can see a pearly white structure, curved like a sleeping tadpole. The hippocampus, which controls short-term memories.
This is one of the pieces damaged by Jack's accident years ago. Tests show that, like the rest of the right temporal lobe, it doesn't work any longer. Its functions have been taken over by a the hippocampus on the left side. It could be the part of the temporal lobe that's causing the seizures. Most of it has to go.
The group Guess Who on the CD player, ``These eyes cry every night for you. These arms long to hold you again. . . .''
Hogan arrives. ``Thought you might want to see a hippocampus up close and personal,'' says Partington. Hogan stands on a stool and gazes into the hole, now several inches deep. He spends every day working with patients who have brain problems, but he's not a surgeon, so he seldom gets a live look at the stuff inside his patients.
In the waiting room, ``The Price is Right'' blasts from the television set. A hysterical woman shouts ``625!''
On a table under the TV, Betty, Jack's stepdaughter, and Sean, his son-in-law, play cards. Jack's father and mother chat with Laurie and Sheri. His younger daughter, Wendy, was here early this morning, but Jack told her not to miss her college classes.
Jack's dad stands up when he sees Linda stride into the room, a white lab coat draped over her sugical garb to keep it from getting contaminated. Laurie leans forward, clutching her foam coffee cup.
``We opened everything up,'' Linda says over the din from the television. ``They're taking the area out . . . he's doing fine . . . there's a lot of damage in there.''
There's silence for just a second, then Ruth, Jack's mom, says, ``Well, he does have a brain, huh?'' and everyone bursts into laughter.
In the operating room, Seal is singing from the CD player: ``There's a light outside the room . . . ''
Partington steps back. Lights dim. The staff rolls a spindly contraption, tall as a man and draped with plastic. It hunches over the table, and its microcscope eye looks into the hole in Jack's head, illuminating it with a bright light. Two eyepieces allow Partington and an assistant to peer in. The scope also feeds a live picture to a television set by the door, so everyone else can see, too.
``Could you turn this up please?'' Partington asks, then amends that. The music, he says, not the setting on the CUSA.
He's working around the hippocampus. Just below the tip of his instruments lies the ``floor'' on which the temporal lobe sits - the arachnoid membrane, a filmy layer that separates structures of the brain. Normally, it looks like cellophane. This one is thickened and opaque because of Jack's old injury. It's a wall Partington can't cross.
Just on the other side is the brain stem, the seat of all basic functions. Breathing, circulation. Mess with that and Jack might not wake up tomorrow.
The aspirator sucks up the gooey white strings of damaged brain tissue. Up close it looks like gristle. The brain is full of fat, the myelin that surrounds the nerve cells and insulates them, like wrapping on an electrical cable, to keep them from getting their signals crossed.
Linda Vaughn, the nurse, can't help laughing a little bit. ``Yuck,'' she says to Robin and Tommy Altman, a technician and program coordinator of the epilepsy program, who has stopped by and perches on a stool by the door.
Severed arteries shoot tiny streams of blood until the bipolar grabs them. The cauterized tissue turns dark. Saline droplets flash brilliantly in the intense light before they're vacuumed up by the suction tube.
Over and over, timelessly.
Suddenly, ``We're done with the resection.'' It's almost 11:30 a.m.
An assistant fills the hole with saline, and Partington looks for rivulets of blood. They siphon the liquid, and Partington seeks out the stray blood vessels and singes them shut. Again and again, fill, check, siphon and cauterize.
The walls of the hole throb with the heartbeat, glisten under the bright light, white tissue with tiny red vessels.
Small white squares of synthetic cellulose are dropped in there for a time, to help close off any remaining wounds. Little patches of white webbing that look like gauze are laid on the walls. They'll stay there, clotting minor bleeding, eventually being asborbed by body.
Partington hesitates to use the bipolar too close to the posterior cerebral artery, a large, purple vessel on the brain stem, just on the other side of the arachnoid membrane. The heat could damage it, cutting off blood supply to sections of the brain. So he waits for the patches to take effect, turning blue-black as they attach themselves to the tissue. Most areas of the body can handle a little post-surgical oozing. Not the brain. Partington rocks from side to side, suction tube in the left hand, bipoloar in the right.
``Lights on! Scope up, please!'' he says. He taps his foot to Seal's ``Prayer for the Dying''
Eventually, cerebrospinal fluid will fill the hole in Jack's brain. For now, the surgical team fill it with saline. Partington pulls the dura tight over the watery cavity and sews it down. His gloves are encrusted with dark blood. His fingers fly.
``Bone plate, please.''
The yellow disk is fished out of its blue plastic pool. He threads the sutures through holes he made earlier.
The Seal CD ends its second play-through, and the earnest singing is replaced by the thumping rhythms and hard, wild guitars of Living Colour. Partington folds over the skin flap and staples it down.
It bothers him that the incision slopes onto Jack's forehead. There'll be a scar there. No choice.
The drape is pulled away. There's Jack, face slack in sleep, tube in his mouth, eyelashes glinting with a lubricating gel. Just a tiny bit of blood crusts in the hair on the left side of his head, which wasn't shaved.
``Turn the radio off, please,'' says Partington. ``Jack's going to wake up with his foot tapping, and he won't know why.''
Partington holds Jack's head carefully in his right hand while the staff helps him unscrew the brace. The doctor tilts his hips foreward and rests Jack's head on his stomach, wrapping it in gauze.
More than three hours since they started removing the brain tissue. It's over. People on the operating team call to Jack:
``Mr. Pearce! Open your eyes!''
Jack moves fitfully. He twitches his left arm. There's a clip on the index finger to measure blood oxygen level, an IV tube in the back of his hand, a hospital bracelet on his wrist.
``Jack, wake up!'' Linda joins in. She knows he dreads waking up with that tube in his mouth. He told her before the surgery.
``Mr. Pearce - Do you want this thing out of your mouth?'' asks the nurse anesthetist.
He nods. Linda laughs.
The tube comes out.
``Ugh.'' Jack tosses his head to the side, furrows his brow and frowns like he's bit into something rotten. ``Ugh.''
Partington leans over and puts his mouth by Jack's left ear.
``Jack?'' he calls, loudly
``Yeah?'' Jack whispers.
``Everything went fine.''
``OK.''
Jack is wrapped in a white blanket. He'll spend the night here, in the neurological intensive care unit, watched closely. An oxygen mask covers his nose and mouth, giving out a puff of white vapor every once in awhile. He snores like a freight train.
``Dad, it's Sheri. Laurie's here too, Dad.'' Laurie wipes her eyes.
``Dad, you wanna talk to us?''
``No,'' Jack grunts.
``You wanna sleep?''
``Yeah.''
``You want us to let Grandma and Granddaddy come back? Jerry's here.'' Jerry is Jack's brother.
Jack snores loudly.
``I'll tell them you said that.'' Sheri laughs. She ducks under one of the cables hanging by the bed to plant a kiss on his cheek. Laurie leans over and kisses the bridge of his nose. They hold hands and gaze at him.
Somehow, he doesn't look as beat up as he did after the last operation, when he had the electrodes planted in his brain for monitoring.
``He looks good compared to last time,'' says Laurie. ``It really tore me up, but he looks real good this time.''
It's about 3 a.m. when the phone call pulls Laurie from sleep. Dr. Hogan. Jack has suffered a bunch of bad seizures.
No reason to come before morning. There is nothing she can do.
Laurie calls Jack's parents. She waits for dawn. MEMO: TOMORROW: Jack Pearce lay in a stupor, his face wide and swollen. The
machine that breathed for him wheezed every time his chest fell. There
was only one sure way to know if the operation was a success: wait.
ILLUSTRATION: MARTIN SMITH-RODDEN / The Virginian-Pilot
[Color Photo]
Jack Pierce, in an operating room at Sentara Norfolk General
Hospital, is being prepared for the surgery that he hopes will cure
a nearly two-decade struggle with epilepsy.
MARTIN SMITH-RODDEN / The Virginian-Pilot
Jack's wife, Laurie, hugs Sheri Clark, his oldest daughter, in the
neurosurgical intensive care unit soon after the surgery.
Dr. Jonathon P. Partington prepares Jack to leave the operating room
following his surgery.
A nurse checks Jack's pupils following his surgery. The surgery took
about five hours.
KEYWORDS: SERIES BRAIN SURGERY EPILEPSY by CNB