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Medical Fiction Question #3: A Question So Easy a Brain Surgeon Could Answer It (Oh Wait…)

Q: (edited to remove specifics about the manuscript)

In the book my one lead character – a Brain surgeon – will be performing two major surgeries during the life of the book, one on [an animal], and the other she will be performing a radical operation on the male lead. Could you in as short as possible give me an overview of what happens during such a surgery, the big picture and any suggestions you could give me that would make the scenes believable. Even if you can point me at a website where I can read up about brain surgery – any videos would help as well, I am not squeamish about blood etc… so don’t worry about that side (more fascinated by the whole process). Any help would seriously be appreciated. Thank you in advance. Regards RB

A: While I saw lots of surgeries during my 12-week surgery rotation in medical school, ranging from cholecystectomies (gall bladder removal) to liver transplants to cardiac surgeries to breast implants, I didn’t see any brain surgeries (and I especially didn’t see any veterinary sugeries! So I can’t comment on that part of your question). The reason I didn’t see the brain surgeries was that the surgeons wanted you to be there for the entire surgery and brain surgeries can take a really long time. For example, I heard of one brain tumor removal taking 6 hours (and a quick search of the web reveals people who report their brain surgeries having taken more than 12 hours–not sure if they’re counting recovery time). Performing and assisting surgeries for long periods of time requires stamina, dedication, and patience. Alas our hospital didn’t have a surgical theatre like on Grey’s Anatomy where people could eat lunch, gossip, and come and go as they please while watching surgeries.

While I haven’t seen a brain surgery, the very basic timeline of surgeries are generally the same:

  1. The patient is wheeled into the sterile operating room (OR) and transferred to the operating table. Everyone in the room (besides the patient) is required to wear a face mask, a hair covering of some kind, scrubs, and shoe covers.

  2. The anesthesiologist sedates the patient (sometimes this is started in the pre-op area). During some brain surgeries, the patient is kept awake for portions of the surgery (so they can monitor the patient’s brain functions by having the patient do different things during surgery) while in others the patient is intubated and kept under general anesthesia the entire time.

  3. The patient is positioned appropriately for the surgery. Parts of the body that aren’t being operated on are covered up. The patient’s head is shaved (or at the very least the part that they are operating on I should think).

  4. Meanwhile the surgical team “scrubs in” (i.e. they go to a separate room attached to the OR to thoroughly clean their hands/arms up to the elbows and then return to the OR where they are helped by surgical technicians and nurses into sterile gowns and gloves, all the while making sure not to touch anything that isn’t sterile). Sterile coverings (which are usually all blue) are draped everywhere so that people who are “scrubbed in” don’t accidentally touch non-sterile things. People who aren’t “scrubbed in” aren’t allowed to touch anything in the sterile field. Keeping things sterile and clean is key.

  5. The surgical area is “prepped” (i.e. cleaned).

  6. Surgeons and surgical techs do a “time out” and double check the patient’s name and the procedure being done and the area being operated on.

  7. The first incision is made.

  8. The surgery is performed. :) (see below–I’ve kept it separate for the squeamish)

  9. Tools are all counted by the surgical tech. (During long surgeries, this may happen several times throughout.)

  10. The surgical site is “closed” i.e. stitches are put in, the wound is dressed.

  11. The patient is wheeled to the post-operative area (“post-op”).

–>>Note: If you’re squeamish stop reading here!<<–

As far as what would exactly happen during the brain surgery, it’s hard for me to say because I don’t really know what kind of surgery your fictional patient is having. But most basically, the surgeon first cuts into the patient’s scalp, exposing the skull. They drill open and remove a portion of the skull, then cut into the dura (a membrane surrounding the brain) to expose the brain. Then the surgery is performed (depends on the type of surgery). At the end of a craniotomy, the skull is reaffixed using screws or other techniques (though in a “craniectomy” it is not replaced).

This website goes into some specifics about what’s involved during different brain surgeries (has a lot more information than you want or need!). Make sure to scroll down to the bottom for some nice images.

Searching YouTube for “Craniotomy” brings up a whole bunch of relevant brain surgery videos. If you have an idea what specific kind of surgery your fictional surgeon is performing, there’s probably a video of it on YouTube.

But as far as things that would make your story believable, I think this video of an awake craniotomy is excellent. You get views of the room, the equipment they use, the patient, the doctors and others in the room, and the surgery itself. Very nice.

This video isn’t quite as self-explanatory, but shows a surgery where the patient isn’t awake and where a special microscope is used during the surgery.

When writing, I’d try not to get too bogged down in research and details–you’ll bore yourself and your readers to tears. I’d focus on getting the more overview type things right–what people are wearing, what people are doing–rather than specifics of the surgeries, because it’s the simple things that will make your reader question your credibility as an author. For example, knowing that your surgeon will already have her face mask and hair coverings on before she enters the OR and that she’d keep these on the entire time she in there is something that anyone who has seen a surgery would notice. Whereas choosing the wrong type of scalpel, or the wrong kind of anesthesia, would be overlooked by most people.

I hope this helps, RB. If not, please let me know if you have any specific questions I can answer!

Got a medical fiction question? Email me (amitha [at] amithaknight [dot] com), comment on my blog, or send me a tweet. I’ll try my best to answer! (Note: This blog post is meant to be writing advice only and should not be construed as medical advice in any fashion whatsoever.)

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