Page 7
"Well wait for the patient," Ellis said dryly, and there were some chuckles from the Nine Group team.
Ross looked around the room at the seven TV screens. They were of different sizes and stationed in different places, depending on how important they were to the surgeon. The smallest screen monitored the closed-circuit taping of the operation. At the moment, it showed an overhead view of the empty chair.
Another screen, nearer the surgeon, monitored the electroencephalogram, or EEG. It was turned off now, the sixteen pens tracing straight white lines across the screen. There was also a large TV screen for basic operative parameters: electrocardiogram, peripheral arterial pressure, respirations, cardiac output, central venous pressure, rectal temperature. Like the EEG screen, it was also tracing a series of straight lines.
Another pair of screens were completely blank. They would display black-and-white image-intensified X-ray views during the operation.
Finally, two color screens displayed the LIMBIC Program output. That program was cycling now, without punched-in coordinates. On the screens, a picture of the brain rotated in three dimensions while random coordinates, generated by computer, flashed below. As always, Ross felt that the computer was another, almost human presence in the room - an impression that was always heightened as the operation proceeded.
Ellis finished looking at the X-rays and glanced up at the clock. It was 6:19; Benson was still outside being checked by the anaesthetist. Ellis walked around the room, talking briefly to everyone. He was being unusually friendly, and
Ross wondered why. She looked up at the viewing gallery and saw the director of the hospital, the chief of surgery, the chief of medicine, and the chief of research all looking down through the glass. Then she understood.
It was 6:21 when Benson was wheeled in. He was now heavily pre-medicated, relaxed, his body limp, his eyelids heavy. His head was wrapped in a green towel.
Ellis supervised Bensons transfer from the stretcher to the chair. As the leather straps were placed across his arms and legs, Benson seemed to wake up, his eyes opening wide.
"Thats just so you dont fall off," Ellis said easily.
"We dont want you to hurt yourself. "
"Uh-huh," Benson said softly, and closed his eyes again. Ellis nodded to the nurses, who removed the sterile towel from Bensons head. The naked head seemed very small - that was Rosss usual reaction - and white. The skin was smooth, except for a razor nick on the left frontal. Elliss blue-ink
"X" marks were clearly visible on the right side.
Benson leaned back in the chair. He did not open his eyes again. One of the technicians began to fix the monitor leads to his body, strapping them on with little dabs of electrolyte paste. They were attached quickly; soon his body was connected to a tangle of multicolored wires running off to the equipment.
Ellis looked at the TV monitor screens. The EEG was now tracing sixteen jagged lines; heartbeat was recorded; respirations were gently rising and falling; temperature was steady. The technicians began to punch pre-op parameters into the computer. Normal lab values had already been fed in. During the operation, the computer would monitor all vital signs at five-second intervals, and would signal if anything went wrong.
"Lets have music, please," Ellis said, and one of the nurses slipped a tape cartridge into the portable cassette recorder in a corner of the room. A Bach concerto began to play softly. Ellis always operated to Bach; he said he hoped that the precision, if not the genius, might be contagious.
They were approaching the start of the operation. The digital wall clock said 6:29:14 a. m. Next to it, an elapsed-time digital clock still read 0:00:00.
With the help of a scrub nurse, Ross put on her sterile gown and gloves. The gloves were always difficult for her. She didnt scrub in frequently, and when she plunged her fingers into the gloves she caught her hand, missing one of the finger slots and putting two fingers in another. It was impossible to read the scrub nurses reaction; only her eyes were visible above the mask. But Ross was glad that Ellis and the other surgeons were turned away attending to the patient.
She stepped to the back of the room, being careful not to trip over the thick black power cables that snaked across the floor in all directions. Ross did not participate in the initial stages of the operation. She waited until the stereotaxic mechanism was in place and the coordinates were determined. She had time to stand to one side and pluck at her glove until all the fingers were in the right slots. There was no real purpose for her to attend the operation at all, but McPherson was insistent that one member of the non-surgical staff scrub in each day that they operated. He felt it kept the Unit more cohesive. At least that was what he said.
She watched Ellis and his assistants across the room draping Benson; then she looked over to the draping as seen on the closed-circuit monitor. The entire operation would be recorded on video tape for later review.
"I think we can start now," Ellis said easily. "Go ahead with the needle. "
The anaesthetist, working behind the chair, placed the needle between the second and third lumbar spaces of Bensons spine. Benson moved once and made a slight sound, and then the anaesthetist said, "Im through the dura. How much do you want?"
The computer console flashed "OPERATION BEGUN. " The computer automatically started the elapsed-time clock, which ticked off the seconds.
"Give me thirty ccs to begin," Ellis said. "Lets have X-ray, please. "
The X-ray machines were swung into position at the front and side of the patients head. Film plates were set on, locking in with a click. Ellis stepped on the floor button, and the TV screens glowed suddenly, showing black-and-white images of the skull. He watched in two views as air slowly filled the ventricles, outlining the horns in black.
The programmer sat at the computer console, his hands fluttering over the buttons. On his TV display screen, the words "PNEUMOGRAPH INITIATED" appeared.
"All right, lets fix his hat," Ellis said. The boxlike tubular stereotactic frame was placed over the patients head. Burr-hole locations were fixed and checked. When Ellis was satisfied, he injected local anaesthetic into the scalp points. Then he cut the skin and reflected it back, exposing the white surface of the skull.
"Drill, please. "
With the 2-mm drill, he made the first of the two holes on the right side of the skull. He placed the stereotactic frame - the "hat" - over the head, and screwed it down securely. Ross looked over at the computer display. Values for heart rate and blood pressure flashed on the screen and faded; everything was normal. Soon the computer, like the surgeons, would begin to deal with more complex matters.
"Lets have a position check," Ellis said, stepping away from the patient, frowning critically at Bensons shaved head and the metal frame screwed on top of it. The X-ray technician came forward and snapped the pictures.
In the old days, Ross remembered, they actually took X-ray plates and determined position by visual inspection of the plates. It was a slow process. Using a compass, protractor, and ruler, they drew lines across the X-ray, measured them, rechecked them. Now the data were fed directly to the computer, which did the analysis more rapidly and more accurately.
All the team turned to look at the computer print-out screen. The X-ray views appeared briefly, and were replaced by schematic drawings. The maxfield location of the stereotactic apparatus was calculated; the actual location was then merged with it. A set of coordinates flashed up, followed by the notation "PLACEMENT CORRECT. "
Ellis nodded. "Thank you for your consultation," he said humorlessly, and went over to the tray which held the electrodes.
The team was now using Briggs stainless-steel
Teflon-coated electrode arrays. In the past, they had tried almost everything else: gold, platinum alloy, and even flexible steel strands in the days when the electrodes were placed by inspection. The old inspection operations were bloody, messy affairs. It was necessary to remove a large portion of th
e skull and expose the surface of the brain. The surgeon found his landmark points on the surface itself, and then placed his electrodes in the substance of the brain. If he had to place them in deep structures, he would occasionally cut through the brain to the ventricles with a knife, and then place them. There were serious complications; the operations were lengthy; the patients never did very well.
Now the computer had changed all that. The computer allowed you to fix a point precisely in three-dimensional space. Initially, along with other researchers in the field, the NPS group had tried to relate deep brain points to skull architecture. They measured their landmark points from the orbit of the eye, from the meatus of the ear, from the sagittal suture. That, of course, didnt work - peoples brains did not fit inside their skulls with any consistency. The only way to determine deep brain points was in relation to other brain points - and the logical landmarks were the ventricles, the fluid-filled spaces within the brain. According to the new system, everything was determined in relation to the ventricles.
With the help of the computer, it was no longer necessary to expose the brain surface. Instead, a few small holes were drilled in the skull and the electrodes inserted, while the computer watched by X-ray to make sure they were being placed correctly.
Ellis picked up the first electrode array. From where Ross stood, it looked like a single slender wire. Actually, it was a bundle of twenty wires, with staggered contact points. Each wire was coated with Teflon except for the last millimeter, which was exposed. Each wire was a different length, so that under a magnifying glass, the staggered electrode tips looked like a miniature staircase.
Ellis checked the array under a large glass. He called for more light and turned the array, peering at all contact points. Then he had a scrub nurse plug it into a testing unit and test every contact. This had been done dozens of times before, but Ellis always checked again before insertion. And he always had four arrays sterilized, though he would need only two. Ellis was careful.
At length he was satisfied. "Are we ready to wire?" he asked the team. They nodded. He stepped up to the patient and said, "Lets go through the dura. "
Up to this point in the operation, they had drilled through the skull, but had left intact the membrane of dura mater which covered the brain and enclosed the spinal fluid. Elliss assistant used a probe to puncture the dura.
"I have fluid," he said, and a thin trickle of clear liquid slid down the side of the shaved skull from the hole. A nurse sponged it away.
Ross always found it a source of wonder the way the brain was protected. Other vital body organs were well-protected, of course: the lungs and heart inside the bony cage of the ribs, the liver and spleen under the edge of the ribs, the kidneys packed in fat and secure against thick muscles of the lower back. Good protection, but nothing compared to the central nervous system, which was encased entirely in thick bone. Yet even this was not enough; inside the bone there were sac-like membranes which held cerebrospinal fluid. The fluid was under pressure, so that the brain sat in the middle of a pressurized liquid system that afforded its superb protection.
McPherson had compared it to a fetus in a water-filled womb. "The baby comes out of the womb," McPherson said, "but the brain never comes out of its own special womb. "
"We will place now," Ellis said.
Ross moved forward, joining the surgical team gathered around the head. She watched as Ellis slid the tip of the electrode array into the burr hole and then pressed slightly, entering the substance of the brain. The technician punched buttons on the computer console. The display screen read:
"ENTRY POINT LOCALIZED. "
The patient did not move, made no sound. The brain could not feel pain; it lacked pain sensors. It was one of the freaks of evolution that the organ which sensed pain throughout the body could feel nothing itself.
Ross looked away from Ellis toward the X-ray screens.
There, in harsh black and white, she saw the crisply outlined white electrode array begin its slow, steady movement into the brain. She looked from the anterior view to the lateral, and then to the computer-generated images.
The computer was interpreting the X-ray images by drawing a simplified brain, with the temporal-lobe target area in red and a flickering blue track showing the line the electrode must traverse from entry point to the target area. So far, Ellis was following the track perfectly.
"Very pretty," Ross said.
The computer flashed up triple coordinates in rapid succession as the electrodes went deeper.
"Practice makes perfect," Ellis said sourly. He was now using the scale-down apparatus attached to the stereotactic hat. The scaler reduced his crude finger movements to very small changes in electrode movements. If he moved his finger half an inch, the scaler converted that to half a millimeter. Very slowly the electrodes penetrated deeper into the brain.
From the screens, Ross could lift her eyes and watch the closed-circuit TV monitor showing Ellis at work. It was easier to watch on TV than to turn around and see the real thing. But she turned around when she heard Benson say, very distinctly, "Uh. "
Ellis stopped. "What was that?"
"Patient," the anaesthetist said, gesturing toward Benson.
Ellis paused, bent over, to look at Bensons face. "You all right, Mr. Benson?" He spoke loudly, distinctly.
"Yuh. Fine," Benson said. His voice was deeply drugged.
"Any pain?"
"No. "
"Good. Just relax now. " And he returned to his work.
Ross sighed in relief. Somehow, all that had made her tense, even though she knew there was no reason for alarm.
Benson could feel no pain, and she had known all along that his sedation was only that - a kind of deep, drugged semi-sleep, and not unconsciousness. There was no reason for him to be unconscious, no reason to risk general anaesthesia.
She turned back to the computer screen. The computer had now presented an inverted view of the brain, as seen from below, near the neck. The electrode track was visible end on, as a single blue point surrounded by concentric circles.