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Faculty Focus

he's still learning the fine points of the profession. "First thing," she asks him, "is this surgery indicated?" In other words, Should we be doing this operation? Radwan hesitates, so together they run through the details of the case. The girl's cerebellum—the part of the brain in the lower back of the skull—is misshapen. Instead of being rounded, it's elongated and descends into the opening to the spinal canal. The misshapen cerebellar tissue, known as a Chiari malformation, puts pressure on the brain stem and spinal cord, which can cause various neurological problems. This afternoon, Duhaime and Radwan will cut open the back of the girl's head and insert a synthetic patch to enlarge the membrane enclosing her brain. "I'll be honest. I'm not sure this surgery is going to help her," says Duhaime.

"I think it's a soft indication," adds Radwan, meaning that the reasons for performing the surgery are debatable.

Duhaime had told the girl's neurologist and parents the same thing. She is always frank with her patients and their families about the possible benefits and dangers of surgery. Earlier in the week, she met with a family that was considering invasive monitoring—the placement of electrodes on the brain—in an effort to track down the source of their child's epileptic seizures. Sitting with them in her cozy office, which often smells of mint tea, Duhaime detailed the limitations of invasive monitoring and the pain that their child would be likely to experience after the surgery. "There is no parent that goes into this that on the second or third day doesn't doubt that it was the right thing" to do, she told them.

Being a pediatric neurosurgeon is not all about surgical talent. "With this field, you have to like dealing with kids," Duhaime says, "but you also have to not mind dealing with parents." Parents of children facing surgery can be frantic, demanding, unreasonable, and pushy, she admits. Yet she cherishes the intimate connections she forms with her patients and their families. The human side of medicine is what drew her to the field in the first place.

As an undergraduate at Brown University in the mid-1970s, Duhaime wanted to be a psychologist. She was interested in

During residency, Duhaime was determined not to go into pediatric neurosurgery "because that was the girly thing to do." But she found kids to be so much fun, she couldn't resist.

what makes people tick. It was one of her three older brothers, an oral surgeon, who pestered her to apply to medical school. "If you really want to study humans, you have to go into medicine," she remembers him saying. "You will not get an adequate education in . . . how the brain works without having a medical-scientific background."

In medical school at the University of Pennsylvania, Duhaime found her niche in neurosurgery. "I was taken under the wing, just by chance, of the chairman of neurosurgery," she says. "He used to let me first-assist on intracranial cases." She liked seeing "the results of what you did to the brain showing up in how the person was afterwards." During residency, Duhaime was determined not to go into pediatric neurosurgery "because that was the girly thing to do." But she found kids to be so much fun, she couldn't resist. "With adults, you examine them," she says. "With kids, you play with them." She was physically suited for the subspecialty, too. In pediatric neurosurgery, she explains, "if you have big hands, they get in your way."

Almost an hour into this afternoon's surgery, Duhaime asks if anyone has called the girl's mother in the waiting room to let her know how things are going. She and Radwan have been cutting deeper and deeper into the girl's neck, but the going is slow. Duhaime is standing on a stool so she can easily reach the patient's head, while Radwan is hunched over the other side of her head. The tissue covering the area they need to get to is so tough that Duhaime jokingly calls the procedure a "gristlectomy."

"This is not elegant" surgery, she says, "but it exemplifies how careful you have to be." Only a soft membrane protects this part of the girl's brain. "This is a very healthy, athletic kid," Duhaime adds. "We have a lot to lose if we mess up.

"So we did call up to her mother, right?" she asks again.

Duhaime is now doing the most delicate cutting while Radwan uses a suction tube to keep the open area clear of blood and other fluids. Perhaps trying not to look idle, he is suctioning continuously. "Whatever you have in your hand does not mean that's what's needed," Duhaime scolds. "The hardest thing for a surgeon to do is nothing."

Finally, after more than an hour of clearing away tissue, the grayish, purplish brain is visible. Radwan suggests using a different instrument. At first, Duhaime ignores him, but he repeats the suggestion. "And how many of these have you done, big guy?" she teases, and everyone bursts into laughter. Duhaime and Radwan then prepare the area for the patch. When it's in place, Radwan sews a neat stitch at the top of it. "Oh, that's nice," she tells him. "Beautiful."

Call out to her mom," Duhaime tells the nurse. "Tell her we're closing up." When the last stitch is in place, Duhaime sheds her gloves and checks in with her office assistants. She returns a phone call and then dials into the hospital's transcription service. Duhaime dictates all of her patient notes by phone. Her dictations are extraordinarily detailed. She mentions, for example, a brand of patch she tried but abandoned because she didn't like the way it handled. And her notes about office visits often refer to toys the child played with. She reads all the transcripts once they're finished, too, to make sure they're accurate and even to fix grammatical mistakes.

When she hangs up the phone, Duhaime notices that Radwan is pulling the elastics out of the girl's hair; a few strands of hair dangle from one. "Can we get some scissors over here to cut these rubber bands?" she calls out. "He's sliding them, but it's gonna hurt."

Finally, Duhaime, Radwan, and the rest of the team gently roll the patient off the operating table so she's face up on a stretcher. Duhaime calls for some soap and water and begins washing the girl's hair and face, paying special attention to some streaks of dried iodine on her forehead. When she's done, she pats everything dry with a white towel. And runs her fingers one last time through the girl's hair.

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Jennifer Durgin is Dartmouth Medicine magazine's senior writer. Certain identifying details in this article have been changed to preserve patient confidentiality.

If you'd like to offer feedback about this article, we'd welcome getting your comments at DartMed@Dartmouth.edu.

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