Urgency Redefined: Neurosurgical Perspective and Poise in the Age
of COVID-19

Neurosurgery residents
at Mayo Clinic
Rochester, MN

This essay is part of our series, Flattened By the Curve, which features the voices of doctors, nurses, healthcare workers, and others on the front lines against COVID-19. For information on how to submit, click here.

Neurosurgery is a peculiar profession. Almost daily, we muster the unsettling combination of confidence and humility required to look a stranger in the eye — often in the presence of their loved ones — and suggest that their life will be substantially improved, should they consent to our proposal that we saw their head open. For most, this is a practiced art, and its successful refinement takes as given two interesting philosophical conceits.

The first is the essential horror of neurosurgical diseases, which share the corporeal devastation of all the body’s banal malfunctions, while simultaneously threatening the mind and its foundations. Brain tumors, aneurysms, neurotrauma, hydrocephalus; ours are maladies that don’t simply kill you, but often first stamp out who you are, after which the dirty work of disposing with the body seems almost trite.

The second is the unpredictable expression of futility-cum-heroism that describes so many neurosurgical treatments, which stand prominently among medicine’s most quixotic interventions. Each neurosurgeon has witnessed at least as many remarkable recoveries as shocking declines, and yet our ability to successfully predict the combinations of patients and treatments most likely to reach a favorable outcome is frustratingly confounded at best.

In practical terms, these nuanced spectra of disease and cure, of benefit and risk, resolve into a simple calculus: Left to their natural histories, most neurosurgical diseases will quickly progress to far worse outcomes than the unlikely complications of our operations, and so we cut, quickly, and confidently. Philosophically speaking, for many of our patients, even though their operations will be scheduled, they understand fundamentally that there has never really been such a thing as ‘elective neurosurgery.’

And yet, in the wake of medicine’s own ‘Black Swan’ event — against which none of us was prepared — we have learned that our concepts of urgency and emergency no longer apply, fully subjugated by the raw violence of an insidious plague. Neurosurgery is a humbling affair, but there is no comparison to a pandemic so incapacitating it has essentially collapsed any diseases not liable to kill you today into an irresolvable mishigas. There is no ‘survival benefit’ or ‘quality-of-life’ to be discussed when the intervention is inseparable from a deadly exposure; to our overwhelming surprise, natural history has won the upper hand. And so we have abandoned our confidence, our heroics, our philosophical resolve. In this foxhole, there is room for humility alone, and a curve that has flattened us all.

Avital Perry is a Skull Base Neuro-oncology Fellow, originally from Israel, who is looking forward to the day when she can visit home again.

Christopher Graffeo is a Neurosurgery Chief Resident in Neurosurgery in Minnesota, who did not have this in mind when he wished for clinic to be cancelled.