‘Part scientist, part mechanic’
Dr. Katrina Firlik describes triumphs and tribulations of operating in male-dominated world of neurosurgery
by Peter Gorner
September 21, 2006
The sound of neurosurgery, one of the more elite medical specialties, is basically banal — it hinges on a lowly suction device, a thin metal tip connected to clear plastic tubing that’s hooked up to a centralized vacuum system.
“We tend to call this instrument the suction or suction tip, rather than the sucker,” explained brain surgeon Dr. Katrina Firlik, 37, noting this crucial surgical instrument is nearly identical to those used by dental hygienists to clear saliva from your mouth during a cleaning.
It “serves two main purposes: to retract against various tissues, including brain, and to continually clear the surgical field of fluids that get in the way, namely blood and cerebrospinal fluid.”
When Firlik removes a tumor or a blood clot, for example, sucking is the method of choice. Operating on an exposed brain, neurosurgeons “tend to look like they are picking at things, sucking things out, little by little, sometimes for many lonely hours at a time.”
Married to a neurosurgeon who quit to become a venture capitalist, Firlik lives in New Canaan, Conn., operates at Greenwich Hospital and teaches at Yale. She came to Chicago recently to promote her memoir, “Another Day in the Frontal Lobe: A Brain Surgeon Exposes Life on the Inside.”
Firlik opens her book thusly: “The brain is soft. Some of my colleagues compare it to toothpaste, but that’s not quite right. It doesn’t spread like toothpaste. It doesn’t adhere to your fingers the way toothpaste does. Tofu — the soft variety, if you know tofu — may be a more accurate comparison.”
The public doesn’t hear much about this branch of surgery or know much about its practitioners. Of the 4,500 neurosurgeons in the U.S., only 5 percent are women. Not for the faint of heart, the highly competitive field is dominated by alpha males, or as Firlik puts it, “as kids, we were the ones who always got a chair in musical chairs.”
According to her, the work requires “a delicate balance between fearlessness and caution.” The neurosurgical mantra, she says, is, “the patient is the one taking the risks, not the surgeon.”
Growing up in Cleveland the daughter of a general surgeon, she never thought of following his footsteps, especially not neurosurgery, which her father warned her was “full of arrogant melagomaniacs.”
“But in college I was drawn to medicine, and my passion was the brain. Other organs can be replaced. The brain, with all its complexity and mystery, makes us who we are.”
Her risky business is reflected in her malpractice insurance premiums ($106,000 a year), and though she has never been sued, she fully expects to be.
“That’s really on colleagues’ minds a lot. Some have decided to just do spine surgery. In fact, some even relinquish their brain surgery privileges, believe it or not. And they do that for malpractice reasons — it means they’re not allowed to cover the emergency room.
“My father was sued near the end of his career, and I saw the turmoil it put him through and the emotional bitterness that ensued afterward. That’s what can make a surgeon bitter, even though so much of the career is uplifting, fascinating and satisfying. The downsides can really weigh on you.”
Her unusually candid book is based on her seven-year residency at the University of Pittsburgh Medical Center — she was the first woman to be admitted to its prestigious neurosurgery program, the nation’s largest — an experience so frenetic she only had time to jot down interesting cases on 3-by-5 cards she carried in her white coat.
She drew national attention after a carpenter walked in with a 2-inch nail in his head, an accident from an automatic nail gun.
“Apart from the nail, he looked great,” Firlik recalled.
After all the necessary scans and examinations, she shaved a small patch of hair, made an incision in the scalp, then drilled a circle around the nail. She carefully lifted the disc of skull with the nail in it and was pleased to find no bleeding coming from the hole it had created in the surface of the brain.
Next she hammered the nail out of the piece of skull, and with the aid of very thin titanium plates, put the piece of bone back in. Finally, she closed the scalp, kept the carpenter overnight for observation and discharged him the next morning.
If this sounds rather mechanistic, Firlik says that issues such as deep thought, personality and consciousness are left to neurologists and psychiatrists, specialists who never actually touch the brain.
A neurosurgeon, she says, is “part scientist, part mechanic,” who cracks open the skull and cuts out aneurysms, tumors, cysts.
“There’s such a huge range of different types of surgery, from sucking out a blood clot, which can be straightforward, to doing very complicated aneurysm surgery at the base of the brain under a microscope. Dealing with an aneurysm is probably the pinnacle or brain surgery.”
Her feelings about her profession waver constantly.
“There are times you work very hard and the patient has a poor outcome and the family doesn’t appreciate what you tried to do. Other times, you feel like you saved someone’s life and brought back their neurological function, and it’s incredibly rewarding.”
The future of neurosurgery will be implanted electrical stimulators, she predicts, both for cortical stimulation (the brain surface) or deep brain stimulation.
The first ones are already entering the culture as medical devices.
“Brain stimulation has gone from putting implants in the brain for Parkinson’s disease to an experimental device for stroke survivors that revs up the area that’s trying to recover. But I think the future will see us implanting devices for depression and language disorders.
Enhancing memory function
“As we learn how the memory works, I can see us implanting a stimulator to enhance memory function. We’d obviously start with patients with serious Alzheimer’s. Still, I can see a plastic surgery of the mind, so to speak, as a potential for normal patients.”
Despite the long years of training and the extreme delicacy of the task, neurosurgery is wrongly thought of as a highly intellectual pursuit, she said.
“Of course, you have to be smart and make quick decisions, but we know what we’re doing. It becomes routine.”
Still, as Firlik attests, the high-pressure work tends to give the rest of life a certain perspective.
“I get mildly annoyed by people who are frazzled by the least important decisions,” Firlik said. “Pulp or no pulp? Skim or 2 percent? I feel like butting in: `Look, you’re not deciding whether or not to pull the plug. Lighten up.'”