The evening Karina’s legs didn’t come alive, I could see her future clearly. When I got the call from the nurses a few hours after surgery had been completed, I was hoping the problem was only that the narcotics from the anesthesia hadn’t cleared. Karina’s legs weren’t moving, but patients often don’t respond evenly immediately after surgery.
Sometimes, arms and legs reanimate differently, as though the patient is drunk. So I asked the questions: Had she woken up from the anesthesia? The nurse said she was wide awake. Do her arms move? I was dreading the response I could feel was coming.
I called the operating theatre for an emergency take-back. A take-back is a return to the operating room for the same patient in under 24 hours. Nothing blares “surgeon error” more than a take-back. I unraveled the stitches I’d made just a few hours before to reopen the cut. Everyone, including the girl’s parents, could sense the disaster. I knew what had happened because during the surgery I’d had to choose one of two routes I could have taken to end the surgery. It was a thought that had floated in my mind—a possibility of failure. The decision I made was to do less in the closing steps of surgery. Doing less work would make the surgery quicker, reducing the chances of complications such as infection, but leaving a possibility that the girl’s spine might be less sturdy. Instinct had been telling me to take the second, longer route. Yet, I didn’t. I went for the quicker surgery. The decision I made was justifiable on paper, but I had ignored my gut and made the wrong choice. An unfixable mistake—a burden surgeons inevitably have to bear.
Karina was 11 years old—old enough for me to be able to explain to her as well as to her parents why were meeting. I first met the three of them in a children’s hospital, decorated as they always are like a macabre Disneyland, with bright colors and cartoon figures. Karina was in possession of a calm and poise not often found even in adults. She was an old soul. Her parents had a positive energy, a devout couple who had finally found a deeply fulfilling life by adopting Karina. They told me they could tell in an instant by the way the three of them looked at each other that they were her parents and she was their child. Biology was superfluous. The connection was profound, spiritual, and regenerative.
Karina stood out to me from the outset because she had something called diastematomyelia. As she grew, her spinal cord was being glacially split down the middle, slowly bisected by a piece of errant bone that protruded backwards from the vertebrae and into the bony tunnel that houses the brain’s exquisitely sensitive tail, the spinal cord. The bony keel had split the spinal cord, but the gradual growth of childhood meant that this had so far occurred only in one spot in the middle of her back, like a giant wave around a lighthouse. The unanticipated dimple and buckled skin in the middle of her spine had alerted the pediatrician to look deeper. An MRI had shown a stalactite of bone right on the midline. Just as we have a left brain and a right brain, there is a left- and right-sidedness to our spinal cord. This is why this girl was, for now, still perfect. Only the midline was split, in a tiny spot. She would most likely be fine, as long as the keel didn’t grow—or she didn’t.
Puberty was around the corner, though, and Karina would certainly grow, and grow fast. A burst of height could tear the spinal cord vertically, stretching against the immoveable bony keel: a vertical guillotine. As she grew taller, the keel would rip the cord beneath it, which would paralyze Karina’s legs. It wouldn’t be a sideways curvature of the spine like scoliosis, which sometimes happens in adolescent girls and is usually managed with a brace or, on occasion, surgery. This would be something more nefarious. The keel would essentially be a small blade that cut her spinal cord down the middle. That’s why she was referred to me. She and her parents met me to discuss whether they should take a wait-and-see approach or get in there and shave the shark tooth down so the spinal cord could stretch unimpeded. Both options carried risks, but her parents were optimistic.
Cases like Karina’s are in many ways more difficult than trauma. In trauma, people come in injured and desperately need immediate treatment. Patients like Karina walk in perfect and the surgeon has to weigh the risks of doing nothing against the risks of performing surgery. It’s a judgement call based on a fraught calculus: which option is more likely to end badly. Karina was my first case of the day. What happened to to her wasn’t a failure to execute a surgical maneuver. This wasn’t about my hands or my technique. My failure was the product of both a loss of vigilance and not allowing my instincts to have their say.
When the skin is cut and the muscles are parted left and right, the spine looks like a lobster tail. The segmented and shingled bony rings allow for protection and movement. The bony protuberances you can feel running down your back are not the spine but the strange vestigial features of dinosaurs, a stegosaurus maybe. They are like a mohawk on the spinal column that can be clipped without issue. Four inches deep into the skin is a bony tunnel, the spinal canal. There, you’ll find the spinal cord, the light-speed communication cables between the brain and the body. Sever or damage these gossamer fibers and the consequences can be both profound and—almost always—irreversible.
What happened to to her wasn’t a failure to execute a surgical maneuver. This wasn’t about my hands or my technique. My failure was the product of both a loss of vigilance and not allowing my instincts to have their say.
The spinal cord is a long, delicate structure and the material in it is the same as in the brainstem. It is the tail of the reptilian brain and, like the brain, it is housed in bone and ensconced in the same dural sheath. The brain and spinal cord both float in the same cerebrospinal fluid. Pathways in the spinal cord look like the folds of a delicate curtain and when you surgically expose the spine’s segmented lobster tail, vertical windows can be drilled or chiseled into it. The pieces of bone are then lifted and set aside.
In Karina’s case, I’d carved out the top of the spinal column with a fine drill in case I decided to replace the bones during the closure. With a sharp knife, I made a vertical incision on the dura covering her spinal cord. The two halves of the dural sheath were held apart with delicate stitches to the muscles that had been separated. The spinal cord is a beauty. You can see serpentine vessels on the back of the bright white, glistening cord. In fact, it’s whiter than the brain, which has neuronal cell bodies that look bluish-grey in the cortical canopy. The spinal cord is mostly tentacles, long extensions from the brain’s neurons that carry signals. These were all tightly tucked electrical highways, and the surface shows the fine ridges.
Karina had been lying face down on the operating table when I removed the piece of spinal column. From this perspective, I thought of it as the roof of her spine. To get her out of the operating room, though, she’d need to be flipped on to her back, and the weight of her body would rest on the spot that had been removed and replaced. This spot would therefore have to bear her weight. The roof of the spinal column would then become the foundation. The thought had crossed my mind that Karina’s spine would need more support. Should I buttress and fortify the closure to ensure there were no grave complications, or should I let it be so that she wouldn’t have to deal with the additional risks that come with extra work? Should I do more or less? The question often comes up in the surgeries I do.
More means more risk, usually, but less means the patient is exposed to a different palette of injuries. There are risks in doing something, and risks in not doing something. I’d thought about this during Karina’s surgery, and I’d decided on less. But when I got that call from the nurses, I knew I had made the wrong call. It was an error in judgement that had left her vulnerable.
When Karina was flipped from her stomach to her back her spinal column settled into itself: the spinal canal collapsed where I had opened the window for surgery. The result was an imploding tunnel. What was inside that tunnel—her spinal cord—was crushed. When I learned that her legs didn’t move after surgery, I knew what had happened. I understood the physiology of the injury, the anatomy of preventable devastation. During the take-back, I lifted off the settled, crushing bone, but the damage to the spinal cord was already done. There was no fixing this mistake. Opening her up a second time confirmed what I already knew, and my dread solidified into something real and permanent, a failure that would change Karina, her parents, and me.
The morning after the surgery, the social workers and nurses were doing their best to keep Karina feeling positive, despite the obvious weight of the calamity. Nothing had changed from the night before when I had received the call from the nurses. Karina reported that her legs were numb, but numbness is in fact a sensation; it’s the feeling of loss.
Karina sat with a blanket from home covering her lifeless legs. A nurse on a break had brought a beach ball into the room. She would throw it to Karina, and Karina would throw it back. The room was quiet—no noisy machines, none of the frenzy of the operating room or the ICU, just one pole with a few drips. She was receiving intravenous steroids for the spinal cord injury, as she would had she fallen off a horse or crashed a motorcycle. The room had an uncommon configuration, with the window behind her head rather than to the side. Karina’s face was in silhouette. I was glad about that, because I was dreading the look in her eyes.
Karina was so young she couldn’t imagine much past the moments in front of her. Her parents were people of deep faith who trusted in the future. I could see the future—hers and theirs—but not mine. Karina’s legs would never move and would, over time, wither and contort. Her bladder would stop working and fill with infections. A hole would have to be made above her vagina as a port to drain the bladder. A bag on her abdominal wall would collect her feces. Her genitals would shrivel and be insensate, despite puberty. Her parents couldn’t imagine this future. What parent could?
Karina’s demeanor didn’t change. She didn’t break from the equanimity she had before surgery. I was spared from seeing her eyes as the light from the window was shining on mine. I was feeling so much. Shame. Self-loathing. Failure. I needed to rein in those emotions to provide some reassurance, a reassurance based on an extremely low chance of her ever walking. Since, on the rare occasion, a patient or two have recovered enough to walk with braces, I took that one-percent statistic as license to offer some hope to the family. I told them what was easiest for all of us in that room to hear.
Karina’s parents were more than kind. They understood the grave consequences and complications that come with choices made in surgery. Never once did the parents look at me with the hate, the disgust, the wrath, I had earned. They remained steadfast in their faith that this was part of a higher purpose, how they came to find her, how she filled their spirit. They were forgiving, accepting, tolerant, deeper, stronger than me. All the things I was not. All the things I couldn’t be. The day they left the hospital I didn’t even go to see them. I could have made time, but I was glad there was surgery scheduled so I could save face. The shame was unconcealable. I was a coward. I remember her parents telling me how Karina filled them with life, an emotional depth and complexity that hadn’t existed before. What I had done during surgery would test that depth with the challenge of a life in a wheelchair, a life in the tragic wake of my individual failure. I’d made a judgement call despite the dissenting voice, my instinct, telling me to do something else.
What does it take to get past an irreversible mental lapse? When Karina’s case was presented at M&M, the weekly Morbidity and Mortality meeting where all the surgeons assemble, it was a strange confessional, but I didn’t feel that my sins had been purged or cleansed. I stood in front of my peers and detailed my mistakes and the thinking that had led to them. My peers let me off easy for my “error of judgement,” following the established practice of protecting one of their own. I should have been held closer to the flame, scorched a bit. I should have been scarred professionally, demoted, relegated to something probationary, but the system protected itself by calling what happened to Karina a “complication” rather than an error.
I knew right away the physical challenges Karina would be facing in the months and years ahead, but I started to wonder about the mental hurdles. How would her sense of self be altered by paralysis? Would she grieve with her parents over the loss of her legs? The brain is not floating alone and independent in a vat of cerebrospinal fluid. It is connected to the body and in constant communication with it. Karina’s body had changed profoundly. I felt like I had got away with something, and it ate at me. It festered inside me, picked at and frayed the loose threads of the narrative of self I’d spent years weaving.
With Karina, here’s what I should have done: I should have taken the time to place some screws to fortify her spine where I’d opened the window into the spinal canal rather than returning the bones I’d removed. I had put the lid back on the jar, but the lid was barely wide enough to bridge the jar’s opening. The thought had crossed my mind that the free-floating bone wouldn’t perch on her spine and could settle into the canal where the delicate cord lay. I could have added tiny screws to make sure the lid was actually reattached to the jar. I had options how to close this box, and I chose the wrong one. I remember vividly running through the reasoning, the pros and cons, of what to do, and I still live with that error in judgement. I didn’t say to myself: Make the move that ensures she doesn’t have the worst possible complication of this surgery. This is what matters most and what should drive decisions most. I got caught up in my own thoughts. I went academic. Never again. I won’t make that mistake again.
I’d love to redo Karina’s surgery from the beginning, but I can’t. It doesn’t work that way. I did want to set what had happened to her right in some way, and so I’ve tried to replace my failure with performance and skill: hurting people less than the other masters of my profession. The risk can never get to zero, but I want to be the one closest to that number. Of all the events of my life, this one experience shook me the most. There are things we can do to reduce the chance of our traumatic memories becoming consolidated, from following us and injecting themselves into our daily lives. I didn’t do any of them at the time. Time heals nothing if we don’t permit it to. Advances in knowledge, in medicine and life, come through failure, with success arriving bruised but victorious on the back of ignorance, rejection, loss, frustration, pain, and death.
The history of medicine, too, is largely one of failure, of trial and error, of learning from mistakes. The advances arrive as the result of its failings, not in spite of them. For surgeons, the goal is to improve our skills and our knowledge as we work to make failure as infrequent as possible. We want to make failure an endangered species, a rare sighting, and when we do fail, we want our shortcomings to be as trivial as possible. If we fall short in the operating theater, we want it to be a hard landing rather than a crash.
Excerpted from LIFE ON A KNIFE’S EDGE: A BRAIN SURGEON’S REFLECTIONS ON LIFE, LOSS AND SURVIVAL by Dr. Rahul Jandial. Copyright 2021 by Dr. Rahul Jandial. Used by permission of Penguin Life, an imprint of Penguin Books. All rights reserved.
Dr. Rahul Jandial, MD, PhD, is a brain surgeon and neuroscientist at City of Hope Medical Center in Los Angeles.
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