In which Schucht begins surgery.
The atmosphere is casual when Schucht finally enters the operating theatre. It is easy to forget that this is routine; each day, five to ten operations are carried out by neurosurgeons in this hospital. The scrub nurse who prepares the necessary tools has worked here for fifty years.
She lays the equipment on a table covered in blue paper. Another group of people adjust the clamps to hold the patient’s head steady in its place. Using felt tip pens, lines are drawn behind the left ear, marking out the square that will be operated on. Iodine-based antiseptic fluid is daubed onto the shaven head with cloths and sponges, staining the skin brown. The body is covered with blue sheets, so that the demarcated square is the only portion of the patient’s body left visible. The surgeon’s chair is adjusted so that it is at the correct height for Schucht, who is looking through his phone. He puts on music, jazzy loops that are easy and repetitive – chosen, I guess, to put me at ease.
He begins efficiently: the skin is incised with a scalpel. As he continues to work through the flesh of the head, his assistant uses a transparent tube to suck away the blood, redirecting it to a clear plastic cylinder used to measure blood loss. Once the incisions are deep enough, small hooks like crocodile clips are used to pull the flesh back and allow Schucht a clear view of the skull below. The process has taken about thirty minutes so far.
The challenge now is to prevent excessive blood loss; though there is blood ready for transfusion, its use is best avoided. One method Schucht uses to halt the bleeding is cauterising the open wound, electrifying the flesh with a tool. It gives off a strange smell, reminiscent of burnt hair and cooking meat. Schucht must be careful when working through the skull: if he cuts into the wrong place, he may open a blood vessel and exacerbate matters.
Having finally determined the point of entry, he bores through the bone with a small rotary saw that is mounted on a short pole. A patch of skull is removed and placed carefully to one side; the entire process has taken just thirty minutes so far.
The music is turned off and the lights are dimmed. A spotlight illuminates the square that has been broached and a large videomicroscope is moved to where Schucht sits, peering over. Four of the operating room’s many screens are switched to relay live footage from the microscopes directly. The next stage of the operation begins.
For the onlooker, it is difficult to square the violence of the neurosurgeon’s work with its virtue. To scar somebody, to break through their bone – these are necessary acts. It seems almost monstrous to feel nothing at the sight of a brain exposed, but Schucht cuts through its thin outer membrane as a matter of procedure, using a small saw, a scalpel and scissors. You must become accustomed to this if you are to save your patient’s life.
Even harder to comprehend is the risk. Another neurosurgeon present explains that in order to close the fistula, Schucht will need to use clips – a simple tool, similar to tweezers – to clamp down on exactly the point where the artery joins the vein. His assistant moves the severed membrane out of the way with thin black strings, stitched through the skin to pull it back, so that Schucht can seek out his target. If he were to miss, closing the vein instead, he would cause further bleeding. If the clips close around the artery, the patient would immediately suffer from a stroke.
As Schucht hunts out the fistula, small cotton pads are thrown on to absorb the blood and protect the organ. When they become thick with blood, they are taken off. This continues for thirty minutes, an hour perhaps, as Schucht works around the pads. He has operated for periods of ten hours or more in the past. To continue in this way, you must experience an intense sort of fascination in your work, of excitement. Your entire being must be focused on the task: your reflexes, your memory, your intuition. If this does not come, then you would be better advised to pursue another career.
Schucht does not think of any of these things; he cannot. The fistula should be visible now, on the surface of the second skin of the brain, the dura. But as he continues to remove the outer membrane, it becomes apparent that it is not there. A blue vein is visible and the brain gives off a clear pulse, suggesting there is an artery nearby. But there is no sight of the fistula, no point at which the artery joins a vein.
An hour of this passes before Schucht stands, stepping away from his chair and moving to one side of the room. Another doctor, the hospital’s head radiologist, has entered the room and now confers with Schucht, switching one monitor to show a scan of the brain. As they speak, it becomes apparent that the fistula is of a rare kind: one which sits below the surface of the dura, rather than on top. This is, an attendant explains to me, a complicated case.
Following protracted discussion, Schucht returns to his place. Two more screens within his line of sight are switched to show the new scans. He must now work with these, trusting neuroimaging to guide him toward the point of entry through the second skin.
When the scalpel pierces the fleshy dura, a severe bout of bleeding is ushered on. It is easy to think of leaving but, equally, it feels impossible to turn away. Even as spectator, you do not struggle to comprehend the surgeon’s fascination in his work.
Schucht delves his clippers into the cut, cautiously feeling out the space. They appear to close and he sits back. But the tension in the room does not lift. He stands again, consulting with the radiologist, pointing at the screens. An assistant explains that a portion of the fistula has been closed. But not all. Blood wells up, vermillion, filling the gap before it is sucked away again. Schucht returns to his chair. The process must be repeated.
In this final stretch, it is as though an age passes and no time at all. When Schucht makes a new incision, closing his clippers one last time, I cannot tell whether a grievous error has been made or the operation is a success. But in a flash it is clear: the crimson excess is no cause for concern. The nurses and doctors loosen their postures. The bleeding will stop. The fistula has been closed.
I sit in the passenger seat of Schucht’s car, a convertible Mercedes Benz. It is a vintage model, forest green and furnished with plush leather. The wind whistles through gaps between the windows and the chassis. He bought it twenty years ago, he tells me. I am reminded of his words after he left the operating theatre: twenty years ago, the woman’s condition would have been inoperable – advances in technology meant that, today, she could be saved.
But Schucht does not speak much of his work as he returns home. The conversation is light. It has been a quiet day. Tomorrow, there will be more patients to be seen.
Thanks for reading, hope you enjoyed it. On another note, it’s been a busy schedule lately and I’m going to be putting At Large on hold for a week or two. Don’t worry, there are more stories in the works – expect despatches on crossing the southern US border on foot and a delve into Mexico’s strange affinity with clowns. But, in case you hadn’t noticed this post’s tardiness, I’m in need of a little room to breathe.
On another ‘nother note, an article first published on At Large has happily evolved into a report on BBC Radio 4’s flagship foreign affairs programme, From Our Own Correspondent. You can find the original piece here and the BBC version here, voiced by my own dulcet tones and beginning at 23 minutes in.
Hasta la proxima,