What it’s like to be a neurosurgeon?

What It’s Like to Be a Neurosurgeon? A Working Podcast Transcript.

What It’s Like to Be a Neurosurgeon? A Working Podcast Transcript.

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April 27 2017 11:33 AM

The “How Does a Neurosurgeon Work?” Transcript

Read what Dr. Harry Mushlin had to say about pediatric brain surgery.

Pediatric resident Harry Mushlin
Pediatric resident Harry Mushlin

Jacob Brogan

This is a transcript of the April 21 edition of Working. These transcripts are lightly edited and may contain errors. For the definitive record, consult the podcast.

Jacob Brogan: This season on Working, we’re taking a trip to Baltimore to chat with some of its residents about the various ways they make a living there. We’re hoping to learn a little about how Baltimore shapes their work, and about how they’re shaping Baltimore by working.

The Johns Hopkins Hospital is one of the institutions at the heart of Baltimore. In the hopes of getting a better sense of what goes on there, we talked to Harry Mushlin, who’s currently a University of Maryland neurosurgery resident doing pediatric residency shifts at Hopkins, while also treating victims of violence at the University of Maryland’s Shock Trauma Center. In this episode, Mushlin tells us about his daily life leading us through the basics of residency, but also discusses the more astonishing experience of seeing and working on a human brain. And of course, he talks about what it’s like to operate in Baltimore itself.

Then, in a Slate Plus extra, Mushlin talks to us about what it’s like to operate in the shadow of the city’s most famous neurosurgeon, Dr. Ben Carson.

What is your name and what do you do?

Harry Mushlin: My name’s Harry Mushlin, and I am a neurosurgery resident.

Brogan: That sounds awesome, but what does it involve exactly? What kind of neurosurgery do you do?

Mushlin: “Resident” means you’re in training like an apprentice, so I’m halfway through. It means I’m under the guise of an attending doctor, and what my job is day to day is taking care of patients and operating. That’s where I am right now.

Brogan: What sorts of surgery are you doing? What kind of neuro work are you involved in?

Mushlin: Residency is everything, the goal is to learn how to do everything. Being a neurosurgeon actually is spine and brain. You are a spine surgeon and a brain surgeon as well, and so it’s the nervous system. Throughout residency you take seven years, and each stage you learn something a little bit different and it builds on itself. Right now, where I’m at right now is doing my pediatric rotation. So I’m doing pediatric neurosurgery.

Brogan: Meaning ...

Mushlin: For kids. But kids have a wide range of problems. You have tumors, you have spine issues, you have problems with fluid on the brain that you have to divert. There’s a wide range of issues in pediatric neurosurgery.

Brogan: How did you settle on neurosurgery? How did you come to that?

Mushlin: In college I did neuroscience, so I knew I liked the brain. I then went to medical school and in medical school I was like, “I know I like brain surgery, but I’ll keep my options open.” Then I just fell in ... you try out everything, and you kind of go back to where I thought I’d be. And that was doing neurosurgery.

Brogan: Are you at the point in your career now where you are actually there in the room to perform surgeries?

Mushlin: Yeah, now my life is day-to-day coming in, seeing the patients we operated on, seeing what happened overnight, making a plan, discussing the plan with the boss, and then going to surgery during the day. You’re the assistant surgeon, there’re different parts that you’re responsible for. Pediatrics is a little more tiered, so the attending’s always there. There’s a fellow, then there’s me, and a resident. But yes, I’m in the OR every day.

Brogan: Can you give us a specific example of something that pulled you into the OR recently?

Mushlin: Yesterday we had two cases that came overnight, one that was planned that’s just for simple CSF diversion. They’re called shunts.

Brogan: What is that?

Mushlin: The sort of bread and butter of pediatric neurosurgery. It’s a way your brain makes fluid that we all absorb normally, and then some people, and the pediatric population for multiple reasons, are predisposed to not having proper absorption of fluid, so you have to divert it from the brain to somewhere else. Because if it builds up in the brain, you get sick.

So these kids have had infections, or bleeds, or these congenital disorders that don’t allow them to drain fluid. So we have to drain the fluid somehow that you and I would somehow absorb into your body to another portion of the body. You have tubing that goes from inside the brain, and then it has a little tube—

Brogan: This is a tube that you put in?

Mushlin: Put in, yeah, we put in the tube, it’s not born with the tube. It’s a little tube goes into the brain, where the caves inside the brain hold this fluid. Then there’s a little valve on the skin that goes underneath the scalp, and then you have a tube that goes all the way down to your abdomen, and you put the tube into the abdomen, into the abdominal cavity, so it sits on top of the organs, and that absorbs the fluid. It sounds kind of crazy if you don’t know what it is, but that’s what it is.

Brogan: How do you get a tube like that into a child’s body?

Mushlin: You make an incision, you have to drill a hole through the skull, and you stick a tube through the skull, through the covering of the brain, into the brain, into those caves that hold the fluid. And then there are special instruments that allow you to place all the tubing.

Brogan: It sounds like this is not something that would usually happen on an emergency basis?

Mushlin: No, it does if you need to ... there are reasons why people are very sensitive to needing that diversion, so you have to emergently do it.

Brogan: So a patient could just come in and everyone has to scramble and assemble—

Mushlin: Yeah, exactly. Neurosurgery in particular has a lot of emergencies, so if we had a trauma a few weeks ago where someone came in that needed the bone taken off the head because there’s a lot of pressure—

Brogan: Like the whole—?

Mushlin: No, just part of the bone. If you’re doing that, the OR always has staff ready to go if you need an emergent room.

Brogan: OK, let’s take a step back. What’s the actual shape or your day like when you are, as you are right now, in this pediatric rotation?

Mushlin: Sure. I wake up at between 4:30 and 5:00—

Brogan: A.M.?

Mushlin: A.M. To me that sounds normal, maybe other people—

Brogan: That does not sound normal to me, but I applaud your ability.

Mushlin: I wake up and half the days I quickly shower, make some lunch, walk the dog, and then I come in. Then you go—

Brogan: What time are you in?

Mushlin: Between 5:30 and 6.

Brogan: And you’re in scrubs now, are you in scrubs when you come in?

Mushlin: I come in in scrubs, yeah. I come in in scrubs, I wear this. You come in and you get signed up from the person who is covering the hospital that night. So anything that acutely happened, they update you. The initial work is looking at a paper list, a list of everyone’s names. And then you have to look at the computer, because the computer has the medical records now. Then you sort through that, and then once you have your list updated, imagine you are updating a list every day relative to the things that have happened, you then walk around and see every single patient.

Brogan: You’re going on rounds through the hospital?

Mushlin: Rounds through the hospital. This is before your big meeting with the attendings has even happened, so you’re getting all your information, coming up with all your plans, that’s how you learn to be a good clinician. You’re like, “I saw this, I want to do this,” and then you’re going to tell someone what you think we’re supposed to be doing, and then they confirm or deny that that’s the right plan, and come up with a plan to do for the day.

Brogan: Just for each of the patients?

Mushlin: Each patient, yeah, each patient.

Brogan: All right, so you’ve looked at this list, you’ve updated it, you’ve made your rounds, and then you have this big meeting with—

Mushlin: There’s another meeting, you have a daily meeting, all the pediatric neurosurgeons sit around the table, you go through every single patient, you pull up all the imaging, if there’s any relative imaging when you’re a surgeon.

Brogan: Imaging of their brains?

Mushlin: Brains, yes.

Brogan: MRI imaging?

Mushlin: Yeah, MRI, CAT scans, and X-rays are what we use. With kids you use MRIs a lot, because CAT scans have a lot of radiation.

Brogan: So you’re putting all of these scans up on screens around the room or something? Can you paint us a picture?

Mushlin: Yeah, nothing’s done with those traditional slides you put up anymore. Everything’s computer.

Brogan: That’s a shame, because that’s a pretty cool-looking thing.

Mushlin: It looks cool, but you have no idea when you get the actual films, it’s like 50 of them and you have to put them up individually.

Brogan: All right, so you’re looking at all of these computerized imagings of brains and spinal cords I assume, as well?

Mushlin: Yes. Let’s say a new patient came in, you’re like. “Is something wrong?” And you get the picture to help you figure out what was wrong, is there a brain tumor? Let’s look at the brain tumor. There’s a problem with that fluid issue I was talking about.

Is their brain changed in size or caliber? Was there a bleed or a fracture or something like that that we have to look at? Has it changed over time?Because we wanted to monitor it over a period of days and hours, so we’re constantly following up on stuff like that.

Brogan: Yeah. What comes out of that meeting? Are people getting assignments? Are you figuring out next steps?

Mushlin: Yeah. That meeting, now we have a plan for every single person, that’s the day’s goal. And that’s been sanctioned by the attending and off you go.

Brogan: What time in the day are we?

Mushlin: This is 7:30.

Brogan: So you’ve been here for two hours at this point?

Mushlin: 7:45 is their meeting, yeah.

Brogan: So what happens after that?

Mushlin: Now you go to the OR.

Brogan: How much of your day do you actually spend in the OR?

Mushlin: It’s varied. Yesterday we had three cases and we were done being in the OR, probably done around 3:30, or something like this.

Brogan: So you’ve been there for ...

Mushlin: Hours, but the cases roll over. The case finish, you wait, you have 45 minutes until the next patient gets in the room. So it varies. Some days are long, some days you have a case that’s six, seven hours. Some days you have a case that’s maybe an hour. Maybe you have a combination of those.

Brogan: And you work with kids right now, some of them probably very young, do you interact with them at all? Or are you totally on the post-anesthesiology encounter?

Mushlin: Yeah, I’d say there’s a conscious effort to make sure that before surgery, the parents see the attending, not the resident. They know that we’re part of the team, because you’re at Johns Hopkins, you’re at a university, a university doesn’t function without residents. But we are not the star of the show before surgery. The interaction with the kids is after surgery we check up on them, say hello, then they know who we are. But not right before.

Brogan: Are you able to build relationships with patients over time?

Mushlin: Of course. Some are more receptive than others, I’ve realized. Even the babies you have a relationship with that can’t communicate with you, but you’ve been seeing them every day. You feel a connection to taking care of them. That’s part of the process of being a physician is having that connection.

Brogan: Yeah. And what’s it like to have this personal interaction with someone whose neural tissue you’ve seen exposed?

Mushlin: It doesn’t seem so taboo to me. You get desensitized. There’s no other way around it, because I would think the other way to rephrase that would be not their tissue, but who are so sick. You’ve either tried ... you’ve done your best surgically to help someone who still ends up being very neurologically devastated, and so you see them every day, like a young boy, a young girl who can’t talk, can’t move half their body, is ventilator-dependent, you get desensitized.

Not that you aren’t aware of the tragedy of it, but you are able to objectively deal with how to help them versus being—every day’s not a new “Oh my God, I can’t believe this happened to the person.” You’re the physician, you learn how to deal with it.

Brogan: Do you interact at all with parents, or is that just something the attending ...?

Mushlin: No, we interact with the parents.

Brogan: What’s that like? When you have someone who just so desperately wants you to help their child, but also maybe who doesn’t even fully grasp what’s happening?

Mushlin: The last part of your question is good because that’s the key. For sick people, everyone reacts differently to grief. In my head, there’re some people whose reaction is to know everything. They say, “I want to know all these things, I want to be very detail oriented, in my kid’s care,” and try to be rational.

And sometimes it hasn’t hit even if it’s been there for a long time. I can’t speak, it’s never happened to me, how do I know how I’d react? Everyone’s different, and your job is to gauge how to present information relative to what the parent is able to, I think, obtain. Or comprehend, and expecting. It can be a complex process.

Brogan: The brain is such a complex and subtle system, and so much can go wrong with it. Is it ever difficult to really help people understand the vagaries of what’s wrong with their children?

Mushlin: Yeah, I think that’s hard to capture. Because you break a bone, it heals.

Brogan: Yeah, we all understand things like breaking a bone.

Mushlin: The other issue, I think, is with children—talking with the attendings and getting their wisdom as well, adults are a little easier to predict who might not do well or what’s going to happen. Children really act differently. Sometimes it’s a little harder to say exactly what’s going to happen, and that mystery changes the way you talk to families. It’s hard for some people to fully ... that would be philosophical to get into how people understand what makes them them.

I have my own thoughts, I think you are your brain and you damage that tissue, there’s not some secret you hiding out in the soul somewhere waiting to come out. That’s just the way, unfortunately, you’ve been injured. That concept of what created you is not altered forever, and that’s hard to capture for some people.

Brogan: In that light, with thinking about the brain as the soul, seat of the self, does that, for you, ever increase your sense of the burden, or the importance of your work? You literally have someone’s selfhood in your hands when you’re operating on them.

Mushlin: You remember, that’s part of the seriousness, and not just the brain, if you’re operating on the spine, anything that can change who you are. Functionality, part of our training, the way you become a surgeon is to appreciate, especially in neurosurgery, a small mistake can be a huge mistake. So a small thing can be forever gone, and you are conscious of that. You aren’t going to take that vein, it can cause a stroke. You aren’t going to touch that and cause bleeding there, because that could give them a different type of stroke. There’re things that you’re thinking about that you should never do, yeah.

Brogan: You’re listening to neurosurgeon Harry Mushlin. After this brief break, Mushlin talks about working at Shock Trauma Medical Center, and shares some thoughts about what it’s like to see a brain up close.

* * *

Brogan: How late are you here? After all that time in the OR, after going around checking, what else happens?

Mushlin: The day usually ends by six o’clock.

Brogan: And do you go home at that point?

Mushlin: I go home.

Brogan: Your days are like 12-, 13-hour days?

Mushlin: Yeah, that’s fair. Some days are a little more, some days are a little less, but yeah, that’s the day.

Brogan: When you hear sometimes about residents working these 24-, 25-hour or more shifts, is that just not something that happens at this hospital? Or is that not a neurosurgery thing?

Mushlin: No, it’s a neurosurgery thing. It’s complex because it has to do with how call is taken, and on the weekend I occasionally do shifts that are 24 hours. That’s the weekend coverage, I do that at Shock Trauma, I’ll cover a 24-hour shift. That’s how that happens. The way they’ve changed all that stuff has to do with how they allocate residents to cover the hospital. You don’t do that as often anymore. I’m sort of a mid-level now, the junior guys are doing that kind of overnight stuff that I only have to do occasionally now.

Brogan: How does your day differ when you’re here for that huge 24-hour period or longer?

Mushlin: How is it different? You eat a lot of cafeteria food and you find ways to nap. When you’re working a long shift, it’s rest when you can, do some extra work when you can, and you pace yourself out. Your concept of time changes a little bit.

Brogan: We’re in a call room in the hospital now which has a bed in it, it’s like a little, super-spare hotel room, almost. Is this the kind of space you would nap in?

Mushlin: Yeah, you have a little room with a bathroom and hopefully a computer, it’s kind of nice.

Brogan: No computer in this one.

Mushlin: This one has no computer, this is the lower-end one. Yeah, it’s like a little office with a bed. Which is nice, the truth is sometimes you’re very tired, you have call and you’re not getting anything for a few hours, you can rest up and then you go back to go in to work. I think people’s concept sometimes is that the physician in a 24-hour shift stretches.

Imagine doing one thing the entire time, and that’s not true. It’s just someone has to be there in case there’s an emergency. Sometimes you get worked like a dog, and you are running around and you didn’t sleep. But there’s always a little sleep here, a little sleep there, to get you through.

Brogan: Do you ever get giddy?

Mushlin: Yeah, if you’ve been up for that long, you get a certain mania. Some people get really tired, some people get grumpy, I’ll admit on record I can get a little grumpy, I don’t know who doesn’t. Your personality changes a little bit.

Brogan: Did you do anything to keep yourself entertained? Do you read, play a game, watch a movie when you have downtime?

Mushlin: Yeah, downtime I watch a lot of TV. There’s a setup where I have these nice two screens. You can do a little work and watch TV at the same time. Sometimes I’ll do some work if it’s time before a test that I have, you can study during that time for your boards. But usually it’s that, or if it’s not board studying—that’s been for my last two years. Or it’s Amazon and Netflix and stuff like that.

Brogan: If you’re on one of those overnight shifts and you doze off for a little bit, is there any trick to making sure that you will wake up and be focused when a call comes in when you get paged?

Mushlin: There’s no trick to being focused, but there are times if you don’t get paged enough, your body wakes itself up to make sure that it’s working. Because you’re so used to maybe getting called that if it isn’t going off—remember, the pager makes a lot of noise. I can’t sleep through a pager, it’ll be beep, beep beep, really loud. I can’t sleep through that, but your body—maybe if you’re exhausted you’ll sleep through, but if I go through a few hours and no one’s called, I probably just wake up and check it to make sure it’s still on because the battery didn’t die or something like that.

Brogan: How do you maintain focus, though? Presumably you still need to be on ...

Mushlin: You have a job to do. I think personally, I’m not great at paying attention without being forced. Surgery and medicine is forced attention. People ask that, that’s the job. I don’t know any other way to say it, that’s required of you so you get it done. Forced stuff makes you do stuff that maybe you thought you couldn’t.

Brogan: You said you were doing crash trauma during those times?

Mushlin: I said “Shock Trauma.”

Brogan: Oh, Shock Trauma.

Mushlin: Shock Trauma’s the big hospital downtown in Baltimore.

Brogan: Oh, it’s an actual facility?

Mushlin: Yeah, it’s the trauma hospital.

Brogan: That’s a pretty badass name.

Mushlin: Yeah, it’s a cool name. I think they thought about that. That hospital is just a big trauma hospital.

Brogan: And you’re of course trained for all sorts of stuff?

Mushlin: It’s everything. When you train neurosurgery you learn everything.

Brogan: Are you looking at ER stuff when you’re in those kinds of situations?

Mushlin: Imagine it’s like extreme ER. The stuff that you might see on TV that go to the ER, dying, terrible trauma, icepick to the head, or some crazy car accident, really ends up in a place like a trauma bay, which is really run by trauma surgeons. Maybe in the community stuff ends up in ER. In a big city, it ends up in the trauma hospital. Hopkins has a trauma section, University of Maryland has Shock Trauma, so you’ve got to think about it a little differently.

Brogan: What kind of stuff do you see when you’re there?

Mushlin: At Shock Trauma? You’ll see some crazy stuff. A lot during the summer, it’s a lot of gunshot wounds. Especially last summer when it was particularly violent. Last year was a lot of gunshot wounds to the head, you’re getting MVC accidents, old people who fall get easily injured in the head. You’re getting spine injuries, sometimes from young kids doing dumb things like jumping off into shallow pools. The range is pretty wide. But, yeah, sometimes it’s quiet and sometimes it’s bustling, but you’ll get a wide range of pretty significant injuries mixed in with the ones that are benign.

Brogan: And the homicide rate as I understand it is pretty high in Baltimore?

Mushlin: Yeah, it was pretty high last year. You sensed it. I remember last summer there was the Freddie Gray, all that Freddie Gray stuff, and the aftermath lasted a while. Particularly in the summer, it’s already a violent time because people are out and about and drinking or doing whatever they’re doing, winter people are holed up a little more.

Brogan: What’s it like to experience that as a medical professional? It’s one thing to read about it in the papers, it’s another thing to see it in the streets, but to experience the aftermath of violence must be—

Mushlin: See it? For a neurosurgeon in particular, you’re treating a lot of these people. You’re treating them, but it’s pretty, sometimes devastating, hits to the brain, so you’re kind of doing your best, but it’s a little beyond the pale. Sometimes you do good work and you really do save them, and the person has a good outcome. Think about things as a good outcome. You sense the violence. Like I said, you do get desensitized to seeing brain coming out of someone’s head, which most people might vomit at. For me, that’s part of the intimacy of the work. It’s the macabre part. You’re involved in that most raw part of human life sometimes, and sometimes that involves violence. So you get to see that part of human nature that maybe people don’t see every day.

Brogan: Was there ever a time in your training before you were desensitized that it was hard to see that stuff, or you shifted pretty quickly?

Mushlin: No, how can I even know, I never saw a gunshot to the head before I was a resident.

Brogan: What was your reaction the first time you saw brain?

Mushlin: It’s an excitement, because you feel as though you’re somewhere you’re not supposed to be. And the process of even getting to the brain or the spine is hard. It’s covered by bone, nature wants that to be the most protected part of your body. Skin, muscle, bone, thick bone, and then there’s another covering that covers your central nervous system. And when you open that, then there’s the actual nervous system.

When you get there, it’s excitement because you’re somewhere very special. It’s the hub of who we are, and what makes you you, and makes you move, it’s delicate, and when you look at it, it is pretty beautiful. But I remember that first time they took off the bone on the head, and there, the opened the covering of the brain, and there was the cortex, with all the little vessels, and the grooves, it’s very pristine. It’s very clean. Like the cleanest thing you can imagine ... it shines. That’s pretty exciting, I remember that.

Brogan: I’ve read, I don’t know if this is bullshit, but that the particulars of a given brain, the way that it folds and so on, are like a fingerprint that is unique. Does that resonate with your experience?

Mushlin: Yes and no. Everyone’s is shaped differently, but the things are supposed to be where they’re supposed to be. The part that is sensory is sensory, the part that’s for vision is vision, the part that controls motor is motor, the part that does hormones is hormones, so it’s kind of bullshit. Yeah, that’s bullshit.

Brogan: That’s fair.

Mushlin: It looks a little different, but that doesn’t mean much to me.

Brogan: We’ve got a quick message here for you, but after this brief break, neurosurgeon Harry Mushlin leads us through the details of performing a surgery.

* * *

Brogan: Can you tell us a little about the actual, practical experience of doing one of these surgeries? The skull, as you said earlier, the skull is incredibly thick bone. What do you do? Do you have to saw that open?

Mushlin: Yeah, it’s pretty barbaric. You’re scalping a human. You’re cutting the skin. You’re keeping it from bleeding too much—

Brogan: Peeling it away?

Mushlin: But you can bleed out, the scalp is unbelievably vascular, so you can bleed —actually, people can die if you cut enough of the scalp, and you can bleed out and die. You can lose all your blood. So you’re opening the skin—

Brogan: Well, how do you prevent that from happening? What kind of care do you take?

Mushlin: You’re buzzing it, you’re burning stuff. You’re burning little vessels.

Brogan: You’re cauterizing it?

Mushlin: Cauterizing. You see, you know better than me. You’re cauterizing it, and you’re putting special clamps on the skin that squeeze down and prevent flow from coming out. Those are called “Raney clips,” and those go on to the scalp. Then, you’re using instruments that help peel away the muscle and the special covering of the bone. And that reveals the bone.

Then once your bone is revealed, with planning, I won’t get into all that, but you’re planning where your incision is going to be, and you have an idea of how much bone you want to take off.

Brogan: How long does this whole process usually take you?

Mushlin: That’s quick. Once you’ve set up the room and you know where you want to go and you have the patient positioned, getting down to skull is, I don’t know, a few minutes. Five minutes. It’s very quick. Getting the bone should be quick. It can be very quick. Then you’re using power tools, using special drills to go through the bone, and using little jigsaws to connect your dots. Imagine connecting your dots on a shape that you’ve created on the skull is where you remove.

Brogan: So you just remove a section of the skull, you’re not taking the whole top of their skull off?

Mushlin: Oh, God no, we don’t take the whole thing off. You’d get fired. You’re taking off a segment, a little corridor that allows you to access the part that you want.

Brogan: You’ve revealed—

Mushlin: You’ve taken the skull off. Now the next part is to open the covering of the brain, and that’s called “dura,” it’s a little leathery covering.

Brogan: Like a cuticle for the brain?

Mushlin: A cuticle—more like a skin for the brain.

Brogan: OK.

Mushlin: There’s a covering of the brain, and you have to open that up very gently. Now you’re being more precious. Skin and bone you can move a little quicker, now you’re being careful. You’re opening the covering of the brain, and then you’d be looking at the brain once you open that up. But everything’s in stages to keep things organized. There’re ways that we package everything and pull stuff out of the way.

The skin is held back with special instruments so it’s out of your way. Then you’re tenting up the dura to keep it out of the way, or to keep it moisturized out of the way. And now you’re—it’s all about making sure that your view is kept nice, and no bleeding. My program director would say, “No bleeding.” Different people have different allergies to blood, but your goal should be to have a complete allergy to blood, I think.

Brogan: Just absolutely—

Mushlin: Before you start going into the brain, there should be no blood going into your field. You take your time, figure out what’s bleeding, fix it. The little covering of the brain’s got little vessels, you buzz, you cauterize. Then you can start what you’re going to do.

Brogan: Are you taking any other precautions while all this is going on to make sure nothing gets on the brain? I don’t even know how to ask this question.

Mushlin: I think you could ask, “What else have you done?” The positioning of your head’s important, and the anesthesia is important. Medications you can give pre-op are important to make the brain more slack, you can give special medication for that depending on your objective. There’s no other special precautions other than a sterile OR.

Brogan: I assume that the procedure is going to be different each time.

Mushlin: Yeah.

Brogan: What are some things that you could do once you’ve opened up the skull?

Mushlin: Very varied. I’ll tell you the big things we do. You remove blood clots. You clip aneurysms, those are abnormal outpouchings of the vessels inside your head. You remove tumors.

Brogan: How do you remove an aneurism?

Mushlin: You don’t.

Brogan: Sorry?

Mushlin: You obliterate it. You can go in and imagine you had a tunnel, but if that tunnel was a blip because the wall of the tunnel was affected. If water’s going through that tunnel, it can go into that blip in the tunnel wall.

Imagine it’s a little balloon, and sometimes that can rupture or not rupture. But if you want to get rid of it, imagine you put a clip, a very powerful clip around the base of that, and reconstruct the tube so nothing’s going into that blip. That’s how you do it. That gets rid of the aneurism, but it’s not a resection like a brain tumor, it’s more of an obliteration.

Brogan: You’ve got tumors as well, that you’re taking off, taking out?

Mushlin: That you’re taking out. As much as you can. Sometimes tumors you only can debulk, and they’re palliative, people are sick but you’re going to do your best.

Brogan: Remove some of the tumor—

Mushlin: Remove some of the tumor.

Brogan: Which takes away some of the pressure, I guess, from the brain?

Mushlin: Exactly, takes away some of the pressure that could be affecting parts of the brain and making you weak, or having trouble talking, or trouble seeing.

Brogan: Because it’s putting pressure on one of those areas that’s responsible for those various areas of cognition?

Mushlin: Exactly. That’s why I answered earlier, that answer’s bullshit, because it’s not like it’s a mystery where your vision center is, it’s not a mystery where your arm center is. Then you take tumors out completely or partially.

Brogan: So you’ve done this, you’ve obliterated the aneurysm, removed or palliated the tumor, what’s next? You’re closing up the brain now?

Mushlin: Yeah, imagine going backwards. You’re working backwards.

Brogan: You’re putting that —what was the layer?

Mushlin: The dura.

Brogan: You’re putting the dura back?

Mushlin: Yeah, you’re sewing the dura back.

Brogan: You literally sew it?

Mushlin: Yeah.

Brogan: With just stitches that are going to biodegrade?

Mushlin: Exactly, very special small sutures that you sew back and then patch. There are special things that we do when that dura’s integrity has been altered, there’s a hole in it, or there’s not enough of it to cover the brain, we have special material that we use to cover the brain.

Brogan: Synthetic dura?

Mushlin: Synthetic. Some of it’s actually cadaveric.

Brogan: What does that mean?

Mushlin: Dead people’s skin, I believe.

Brogan: OK. Sorry, got queasy for a second. What about putting the skull section that you removed back?

Mushlin: Sure, that part’s easy. There’re little titanium plates and screws just like an orthopod puts metal into your leg, or pins or screws, we use little titanium plates that span the bone that we took off to the native bone, and then you use little screws to screw it back together.

Brogan: At some point are you going to come and take that off?

Mushlin: No, that stays forever.

Brogan: That stays forever? So you don’t want to have too many brain surgeries?

Mushlin: Well, for many reasons.

Brogan: And then you sew the scalp back in?

Mushlin: And then you suture the scalp back together in layers.

Brogan: Suture?

Mushlin: Suture.

Brogan: What do you mean in layers?

Mushlin: It’s not like you just put the skin back on, there’s a bottom layer.

Brogan: You put the bottom layer, suture that—

Mushlin: And then the skin.

Brogan: You had done the cauterization of some of those blood vessels—

Mushlin: No, that comes up. As you close you’re making sure you have hemostasis.

Brogan: What does that mean?

Mushlin: Control of bleeding.

Brogan: Are you opening them back up, or you just let those vessels reform?

Mushlin: Oh, these little tiny vessels? No, they’re just burned. You’d be amazed. Imagine a huge tree. There are major vessels that feed your skin that you avoid, but we’re talking these little feeders.

Brogan: All right. And then?

Mushlin: And then the patient gets—sometimes, answering for neurosurgery, I’m sure all surgery, there’s such a wide range, but if it’s a very sick patient, usually they go to a neuro ICU, and are cared for by a neurosurgery team, and an intensivist helps manage the patient.

Brogan: You’ll check in on them occasionally?

Mushlin: All the time. There’s a full squad. It’s 24 hours a day, seven days a week.

Brogan: What are you looking for when you’re checking in on a patient after a surgery?

Mushlin: After a neurosurgery is most important to your exam. How are they doing?

Brogan: How are they performing cognitively, or ... ?

Mushlin: Yep, all of that. Cognitively, yeah. We’re looking for functionality in cognition.

Brogan: Are you looking at lot more scans, MRIs and such?

Mushlin: Yep, there’s post-op scans depending on what you did, you’re looking at your work.

Brogan: What’s the medical community like here in Baltimore? How did you end up in Baltimore?

Mushlin: Just like all physicians, I do a match. A computer program spits you out, and I matched into neurosurgery, University of Maryland. But I wanted to go there, it was one of my top choices, so I was happy to come.

Brogan: Why were you attracted to Baltimore for neurosurgery in particular?

Mushlin: I really liked the people in the program and I thought it was a good fit. When you’re going to be somewhere for seven years, it has to be a good fit. I felt a certain connection with the people there, the professors there, and the type of program they were running, so it was good for me.

Brogan: What about the social elements of being in residency in a place like this? Is it Grey’s Anatomy?

Mushlin: I did marry a doctor. I did marry a urologist. It’s not as juicy, but sure. There is an element of being in a very intense bubble, and that bubble can be a lot of your life, especially early on, I think for some people. I met my wife in the hospital. I came here single, and I met her there. I didn’t have some inappropriate love affair like they do on Grey’s Anatomy, but there was getting to know each other through—I paged her through a paging system to go get lunch the first time, and that’s probably something most people don’t do.

Brogan: I don’t think most people do that. Are there friendships, rivalries?

Mushlin: There is competition when you’re in survey or medicine in general, sure.

Brogan: What are you competing over?

Mushlin: Everyone wants to be good, have good hands, be smart, publish, be respected, sure. I think that can get out of control at some places, there’s probably that sense of every man for himself a little too much. Where I go, I don’t have that feeling. I think it’s overall not that kind of place, where everyone’s just trying to stay on top and be the shark, but surgery is still surgery, and it is competitive in nature.

Brogan: What will be next for you? Where will you go—you have a full year in this pediatric part of your education?

Mushlin: I have four months total.

Brogan: Four months total, OK.

Mushlin: And then I’m actually done with pediatrics. Unless you wanted to be a pediatric neurosurgeon, I would then do a fellowship. For me, I go back to Maryland, and I’m going to do a [inaudible] spine clinical.

Brogan: University of Maryland Hospital?

Mushlin: University of Maryland Hospital. Which is across downtown. I go back there. I finish residency in 2020, and then I’ll do a year of fellowship, so I’ll be done in 2021. I’m only halfway through the tunnel.

Brogan: Where do you want to end up? Would you want to stay here in Maryland, or do you see yourself ultimately landing in another city, another hospital?

Mushlin: If I do an academic job, sometimes you have to go where the job is. I like New England, and I like D.C. I do like Baltimore, actually. East Coast.

Brogan: Has being in Baltimore shaped your experience as a doctor particularly?

Mushlin: Well, yeah. Every place has a population they’re serving. Every place you’re going to have a different experience. Some people serve more of a VIP clientele, some people serve more of the people of the city they live in, we’re probably more of that group, which is good, I think. I think that’s a good training to see all different types of walks of life.

Brogan: Do you feel like you’ve gotten a sense of the city and its people?

Mushlin: Yes, absolutely. Particularly Maryland, if you’re from the coast of Maryland, it’s very different from being from Baltimore. You can sense that. Southern Maryland is very different from northern Maryland, it’s a different little culture.

Brogan: Do you think that your job, your experience of it is different here than it would have been if you had been in another city? If you had been in Boston, or some city like that?

Mushlin: Sure, if I was anywhere it would be different. Philosophically. Baltimore has a very “Baltimore proud group,” and there’s a certain personality that’s with Baltimore than I did not know existed. Everyone’s like “I want to be a New Yorker, or a Bostonian,” but Baltimore is more—people are from D.C. or L.A., it’s like two of a mishmash, but Baltimore has a true essence to it.

That has been unique to being here is getting to know what that was. Baltimorian is a Baltimorian. There’s actually a little accent, I can’t even try to do it because it’s true, there’s this little thing. You love the Orioles, you love the Ravens, you have a place you go eat crab, there’s people who are born and bred here, you know that. Just like I thought if you’re from Boston you know that person’s really from Boston. There’s that thing for Baltimore as well.

Brogan: Do you feel like you know—if I can ask a really cheesy question—the Baltimorian brain?

Mushlin: No, I don’t know the Baltimorian brain.

Brogan: Thank you so much for taking the time to talk to us today.

Mushlin: Sure, thank you, I hope you learned something.

Brogan: I learned a lot.

* * *

Brogan: In this Slate Plus extra, Harry Mushlin tells us what it’s like to operate in the shadow of Ben Carson, Baltimore’s most famous neurosurgeon.

Baltimore of course had one particularly famous neurosurgeon, Ben Carson.

Mushlin: I’m currently in his department right now. He used to work at—he’s a Hopkins Pediatric Neurosurgery.

Brogan: Does he still work here?

Mushlin: No, he’s the head of the Health and Human Services, right? No, that’s the wrong word, HUD.

Brogan: HUD.

Mushlin: Health and Urban Development.

Brogan: Health and Human Services would have made sense, I suppose.

Mushlin: That might have made—

Brogan: More sense. I ask about Carson because he’s a particularly famous. He may be our most famous—

Mushlin: Me, after this interview.

Brogan: After this interview, you will be our most famous neurosurgeon. At present, Ben Carson certainly is. And he is from Baltimore. Does the shadow of a particularly famous neurosurgeon linger of a program like this?

Mushlin: I will stress that I am not a Hopkins resident, but do you sense that he was here? Of course. Particularly a place like Hopkins has many famous people in their history, especially neurosurgery. You guys have never heard of some of these people I’ve mentioned, but there’s a keen sense of what the history of neurosurgery is because it’s small. And it’s not that old. So we’re talking, there’s a lineage of [inaudible] that’s not that distant for all of us, even though you don’t really know it. It’s a small community.

Neurosurgery is a small community. The giants in the field, you know who they were, you know who trained whom a little bit. And Dr. Carson, a place like Hopkins, you know he was here partly because he’s famous too. He’s in the news, and he comes up, and he had a lot of patients treated by ... patients you get here that were treated by Dr. Carson.