{"product_id":"another-day-in-the-frontal-lobe-isbn-9780812973402","title":"Another Day in the Frontal Lobe","description":"Katrina Firlik is a neurosurgeon, one of only two hundred or so women among the alpha males who dominate this high-pressure, high-prestige medical specialty. She is also a superbly gifted writer–witty, insightful, at once deeply humane and refreshingly wry. In Another Day in the Frontal Lobe, Dr. Firlik draws on this rare combination to create a neurosurgeon’s Kitchen Confidential–a unique insider’s memoir of a fascinating profession.\u003cbr\u003e\u003cbr\u003eNeurosurgeons are renowned for their big egos and aggressive self-confidence, and Dr. Firlik confirms that timidity is indeed rare in the field. “They’re the kids who never lost at musical chairs,” she writes. A brain surgeon is not only a highly trained scientist and clinician but also a mechanic who of necessity develops an intimate, hands-on familiarity with the gray matter inside our skulls. It’s the balance between cutting-edge medical technology and manual dexterity, between instinct and expertise, that Firlik finds so appealing–and so difficult to master.  \u003cbr\u003e\u003cbr\u003eFirlik recounts how her background as a surgeon’s daughter with a strong stomach and a keen interest in the brain led her to this rarefied specialty, and she describes her challenging, atypical trek from medical student to fully qualified surgeon. Among Firlik’s more memorable cases: a young roofer who walked into the hospital with a three-inch-long barbed nail driven into his forehead, the result of an accident with his partner’s nail gun, and a sweet little seven-year-old boy whose untreated earache had become a raging, potentially fatal infection of the brain lining. \u003cbr\u003e\u003cbr\u003eFrom OR theatrics to thorny ethical questions, from the surprisingly primitive tools in a neurosurgeon’s kit to glimpses of future techniques like the “brain lift,” Firlik cracks open medicine’s most prestigious and secretive specialty. Candid, smart, clear-eyed, and unfailingly engaging, Another Day in the Frontal Lobe is a mesmerizing behind-the-scenes glimpse into a world of incredible competition and incalculable rewards.Katrina Firlik was the first woman admitted to the neurosurgery residency program at the University of Pittsburgh Medical Center, the largest–and one of the most prestigious–neurosurgery programs in the country. She is now a private practitioner in Greenwich, Connecticut, and a clinical assistant professor at Yale University School of Medicine. She lives in New Canaan, Connecticut, with her husband, a neurosurgeon turned venture capitalist. Visit her online at www.katrinafirlik.comChapter 1\u003cbr\u003e\u003cbr\u003e1\u003cbr\u003e\u003cbr\u003e    Scientist and Mechanic\u003cbr\u003e\u003cbr\u003e    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. If you cut out a   sizable cube of brain it retains its shape, more or less, although not   quite as well as tofu. Damaged or swollen brain, on the other hand, is   softer. Under pressure, it will readily express itself out of a hole in   the skull made by a high-speed surgical drill. Perhaps the toothpaste   analogy is more appropriate under these circumstances.\u003cbr\u003e\u003cbr\u003e    The issue of brain texture is on my mind all the time. Why? I am a   neurosurgeon. The brain is my business. Although I acknowledge that the   human brain is a refined, complex, and mysterious system, I often need   to regard it as a soft object inhabiting the bony confines of a hard   skull. Many of the brains I encounter have been pushed around by   tumors, blood clots, infections, or strokes that have swollen out of   control. Some have been invaded by bullets, nails, or even maggots. I   see brains at their most vulnerable. However, whereas other brain   specialists, like neurologists and psychiatrists, examine brain images   and pontificate from outside of the cranium, neurosurgeons boast the   additional manual relationship with our most complex of organs. We are   part scientist, part mechanic.\u003cbr\u003e\u003cbr\u003e    The scientist in me revels in the ethereal manifestations of the brain:   the mind, consciousness, memory, language. The mechanic in me is   satisfied by the clear fluid that rushes out of the end of a tube I   insert into a patient’s brain to relieve excessive pressure. In   everyday surgical practice, the science may take a backseat to the   handiwork, and that’s okay. If you have an expanding blood clot in your   head, you want a skilled brain mechanic, and preferably a swift one.   You don’t care if your surgeon published a paper in Science or Nature.\u003cbr\u003e\u003cbr\u003e    I’ll give you an example of a most straightforward and manual case. I   was paged to the emergency room a few years ago during my training and   received the following brief report over the phone: “carpenter coming   in with a nail stuck in the left frontal region of his head . . .   neurologically intact.” What is going through my mind at this point? Do   I hark back to my studies of frontal lobe circuitry and mull over the   complex neural networks involved in language and memory? No. I’m   thinking concrete, surgical thoughts: nails are sharp; the brain is   full of blood vessels; the nail may have snagged a vessel on the way   in. These thoughts are instantaneous, of course. I spell out the simple   logic here purely for effect.\u003cbr\u003e\u003cbr\u003e    What I encountered in the ER was a young man, in his thirties, sitting   up on an emergency room gurney. Perfectly awake and alert, arms crossed   in repose and still in his construction boots, he smiled nervously when   I walked in. Was he the right patient? He looked too good.\u003cbr\u003e\u003cbr\u003e    He was the right one. The carpenter explained that he and his friend   were both on ladders along the side of a house. His friend was working   a few rungs above. They were driving heavy-duty nails into the siding   with automatic nail guns. His friend’s hand slipped upon firing in one   of the nails, and the nail entered the left frontal region of my   patient’s head below. For the first few moments after impact, the   carpenter doubted what had happened. Although he noticed a stinging   sensation within a split second of his friend’s slip of the hand, and   heard the loud expletive coming from the same direction, there was no   trickle of blood and he felt nothing unusual as his fingers frantically   searched the top of his head. He wasn’t sure if it went in. His friend   knew otherwise.\u003cbr\u003e\u003cbr\u003e    Upon close inspection of his scalp, past his short crew cut, I could   see the flat silver head of the nail, not quite flush with the scalp,   but a bit deeper. Apart from the nail, he looked great. I performed a   quick five-minute neurological exam and found nothing wrong. I sent him   down the hall for a CT scan. The nail entered his brain perfectly   perpendicular to the surface of the skull. It had been driven a good   two inches into his left frontal lobe. Luckily, it didn’t snag any   sizable blood vessels along the way. There was no evidence of bleeding   within the brain. Unlike the more common gunshot wounds we see, this   was a respectably neat and clean penetrating injury.\u003cbr\u003e\u003cbr\u003e    At this point, my biggest fear—bleeding in the brain from entry of the   nail—had been put to rest. Now, do I take a breath and mull over any   complex scientific issues at this point? Am I exercising my formidable   brainpower as a brain surgeon? When people say, “it doesn’t take a   brain surgeon,” they refer to the assumption that we are the smartest   ones around. Have I demonstrated this superior intelligence so far?   Again, my thoughts return to the practical and concrete. We need to get   the nail out of this guy’s head. It didn’t cause any bleeding on the   way in. We need to avoid bleeding on the way out.\u003cbr\u003e\u003cbr\u003e    I walked out to the waiting room. His wife was there and so was his   friend, who was pale and despondent, looking down at the floor. I tried   to cheer them up a bit. Yes, the nail entered his brain, but his brain   function, as far as we could tell, was normal and the nail caused no   bleeding. Without looking up, the friend opened his hand and offered me   a large silver nail that had been warming in his palm, the same type   embedded in my patient’s head. “I don’t know . . . it might help you   guys to have one of these . . . so you know what you’re dealing with.”   I hadn’t been able to tell from the scan that the nail had two   copper-colored barbs sticking out from the shaft at acute angles. I’m   not a carpenter, but I figured that the purpose of the barbs was to   ensure a strong hold. I thanked him and pocketed the nail in my white   coat. On my way back to the ER, I ran my fingers over the pointy barbs   and thought about the issue of bleeding again. Avoiding and controlling   bleeding are elementary and pervasive themes in surgery—not quite the   stuff of rocket science, but critical nonetheless.\u003cbr\u003e\u003cbr\u003e    After calling on the appropriate team, including the supervising   neurosurgeon and anesthesiologist, I took him to the OR, shaved a small   patch of hair around the nail head, and made a short linear incision in   his scalp, down to the skull. There are no how-to entries in our   textbooks regarding removing nails from heads, so we improvised using   common sense. We drilled out a disc of frontal bone from his skull,   with the nail head at the center of the disc. Slowly, we lifted this   piece of bone up away from the surrounding skull, bringing the firmly   embedded barbed nail with it. Although we could see a small jagged tear   in the covering of the brain and a puncture wound on the surface of the   brain itself, there was no blood oozing from the hole, and we   considered ourselves lucky. (“Better lucky than good” is a favorite   slogan among surgeons.)\u003cbr\u003e\u003cbr\u003e    Then, using large tools fit more for our patient’s line of work, we   clipped off the barbs and pounded the nail through the disc of skull,   backward. After soaking the bone in an antibiotic solution, we neatly   plated it back in place with miniature titanium plates and screws and   sewed his scalp back together. Actually, rather than suture, we used   surgical staples from a staple gun to close the final layer of his   scalp, unaware, at the time, of the subtle irony in that move. Within   less than twenty-four hours, the patient was on his way home, joking   the entire length of the hall with the friend who nailed him in the   head.\u003cbr\u003e\u003cbr\u003e    When I recounted this story to my family and friends after dinner one   night, they all nagged me with the same question: “How could he be   normal? This went into his brain.” Finally, here’s where the scientist   in me gets to pontificate a bit, settling into a fast-paced   question-answer session in the comfort of my own home with a captive   audience. I am not just a mechanic, after all, and the brain is not   just tofu.\u003cbr\u003e\u003cbr\u003e    How could he be normal? First of all, his brain function was considered   normal based on our typical bedside examination, which is, admittedly,   a bit coarse. His speech was fluent. He answered simple questions   appropriately. I asked him to remember three objects over a five-minute   time span, and he did. His pupils reacted when I flashed a light in his   eyes and his eyes moved symmetrically. He had no drooping of his face.   The strength in his arms and legs was normal and so was his sensation.   His reflexes were fine. He was capable of rapid and coordinated hand   movements. In other words, his five-minute neurological examination was   perfectly satisfactory.\u003cbr\u003e\u003cbr\u003e    But the frontal lobes harbor quite sophisticated functions, more   sophisticated than the relatively simple ones I tested. The frontal   lobes make up the largest section of the brain and are the most   recently evolved. Compare the forehead of an ape to the forehead of a   human. One slopes, the other bulges. We can thank, or blame, our   frontal lobes for much of what we consider to be our personality and   intelligence. Damage to the frontal lobes can be subtle, including   changes in insight, mood, and higher-level judgment (“executive   function,” in the professional lingo). I’m not going to detect such   changes in the ER during my five-minute exam before he is whisked off   to the CT scanner. I’m just the neurosurgeon here. We would need to   consult a neuropsychologist to help us evaluate these more complex   brain functions.\u003cbr\u003e\u003cbr\u003e    “So why didn’t you send this poor guy for more sophisticated testing?”   my dinner audience asks in a confused and mildly accusatory tone. Why   did I simply proclaim him “fine” and send him on his way? I explain   that the foreign object was a nail, not a jackhammer. A relatively   minuscule portion of brain was violated. The large frontal lobes, in   particular, can be quite forgiving, especially when only one side is   involved. It’s not unusual to see a frontal lobe tumor, for example,   grow to impressive citrus fruit proportions before the patient even   detects a problem. In fact, the patient often does not detect a problem   at all. It is frequently a spouse or friend who insists on the doctor   appointment, explaining: “He’s just not right, but I don’t know what it   is.”\u003cbr\u003e\u003cbr\u003e    There is a redundancy and resilience to certain brain functions. What   is compromised in one portion can sometimes be compensated for in   another. (A remarkable ability referred to as “plasticity.”) Even if   the brain doesn’t compensate directly, the patient often can cope   indirectly, without even realizing it. If a person develops minor   difficulty with memory, for example, he may start to write more things   down, thereby maintaining the otherwise seamless flow of his existence.   There are limits, though, to the power of plasticity. Damage to a   single frontal lobe is frequently well tolerated (the opposite frontal   lobe can compensate to some degree), whereas damage to both sides is   often irreversibly devastating.\u003cbr\u003e\u003cbr\u003e    Getting back to our carpenter, we were confident that the very narrow   swath of injured brain in only one frontal lobe would be   inconsequential. Even if a faint cognitive deficit could be identified   with detailed and time-consuming neuropsychological testing, would the   patient really care? Would he, or anyone else, even notice the problem?   Would his life as carpenter, husband, or friend be affected? Doubtful.   On a more cold-blooded and practical note, would the patient or the   hospital be willing to pay for these tests? His insurance would   certainly balk at the cost and question the necessity. Besides, given   my confidence in the resilience of his frontal lobes, my biggest   concern was not sluggish thought but sluggish carpentry. What if he   gives up the automatic nail gun altogether?\u003cbr\u003e\u003cbr\u003e    And with this final thought, the mechanic in me reclaims the front   seat, as the scientist heads again to the back.\u003cbr\u003e\u003cbr\u003e    It doesn’t necessarily take a brain surgeon to think like a brain   surgeon, especially when it comes to the fundamentals. Consider this   elementary notion: there is a limited amount of room inside the skull.   Another central truth, directly related to the first, is: the brain is   not the only thing inside the skull. The brain, in fact, makes up about   80 percent of the intracranial contents. The other 20 percent is split   about evenly in volume between blood and cerebrospinal fluid. Once you   master these central tenets, a good deal of seemingly complex   neurosurgical decision-making becomes transparent.\u003cbr\u003e\u003cbr\u003e    Neurosurgeons learn to care just as much about the 20 percent as they   do about the 80 percent, even though everyone else is blinded by the   mystique of that 80 percent. I get plenty of wide-eyed questions about   the brain, but no one ever cares to ask about the cerebrospinal fluid,   a real nonissue as far as the public is concerned. Neurosurgeons care   about the cerebrospinal fluid because if there’s too much of it, the   brain could be rendered next to useless.\u003cbr\u003e\u003cbr\u003e    In learning to think like a neurosurgeon, you have to take these   thoughts one step further: given the rigid, fixed-volume container of   the skull, and the 80\/10\/10 balance of its contents, what can be done   if the equation is disrupted? This tips us more into the realm of   mechanic than scientist.\u003cbr\u003e\u003cbr\u003e    Consider what would happen if you were punched in the eye. The area   around the eye becomes swollen and is free to swell as much as it needs   to. Aside from the social and cosmetic downsides of having a puffy,   swollen eyelid and face, the swelling itself is usually not dangerous.   It’s not constrained. It goes down after several days, and the skin and   underlying soft tissues recover nicely.\u003cbr\u003e\u003cbr\u003e    A swollen brain is another matter. There’s not much room for it to   swell. Swelling within a fixed container leads to elevated pressure,   and unchecked pressure can lead to a cascade of events—namely a   last-ditch shifting of delicate intracranial contents—that can be   fatal. So as neurosurgeons, we do whatever we can to maintain a normal   pressure within the skull when things go awry, such as in a serious   head injury.\u003cbr\u003e\u003cbr\u003e    Although this is “brain surgery,” the options we have for treating high   pressures within the head are relatively simplistic and mechanistic:   drain off cerebrospinal fluid from within the skull, shrink the brain   tissue itself with a temporary dehydrating agent, or constrict the   blood vessels in the brain via hyperventilation (although this one can   be dangerous in situations when the brain needs all the blood flow it   can get). If these options fail, there are more extreme measures, as a   last resort: remove a portion of relatively “unimportant” brain tissue   to create more room, or remove a section of skull to allow the brain to   continue to swell. The decision as to which of these extreme measures   you choose is largely a matter of who your mentor was and what he or   she preferred to do.[quote]--The Oprah Magazine","brand":"Random House Trade Paperbacks","offers":[{"title":"Default Title","offer_id":46303936446693,"sku":"NP9780812973402","price":19.0,"currency_code":"USD","in_stock":false}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/1842\/7735\/files\/9780812973402.jpg?v=1767721642","url":"https:\/\/k12savings.com\/products\/another-day-in-the-frontal-lobe-isbn-9780812973402","provider":"K12savings","version":"1.0","type":"link"}