← 🎙️ Interesting Humans Podcast![Ep. 33: Brain Surgeon - Behind the Scenes [WARNING] — 🎙️ Interesting Humans Podcast cover](https://storage.buzzsprout.com/yzzdkab5n3hy1e4ki8l347h9npfe?.jpg)
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- [00:00]
A
All right, folks, welcome back to another episode. I have Dr. Jay McCracken. Doc, thanks for being here with me today.
- [00:07]
B
Absolutely.
- [00:07]
A
Doc is a brain surgeon. So I am just. It's one of those subjects that I know it's a little. We don't want to talk about it. We don't want to examine it sometimes because it's frightening. But I have always been blown away and fascinated by this, and I am just excited to get into the interview today. We're going to talk all things. What does it look like for, like, a day of work, Some harder cases that you may have worked on, and then just gradually get into, like, did you wake up one day and just decide to be a brain surgeon? So we're gonna have a great episode. And just as a quick reminder, everything here is raw, and I love to do these episodes unedited. So we're not doing a lot of chopping up and taking stuff out. When I press play, the interview starts. I like the feel of sitting in a coffee shop and having a conversation. So let's get right into it. So, Doc, did you. Did you just wake up one day and it was crystal clear of, I want to operate on people's brains or how does it work?
- [01:09]
B
Yeah, I don't think it was ever like that. I mean, I think, you know, in all the way back to high school, I had, you know, a lot of interest in science and anatomy. And, you know, I think my mom really pushed me towards sort of exploring that. I was very fortunate to. When I was in high school, I broke my ankle really badly when I was playing football and met just the coolest orthopedic surgeon that helped me out. And he was very kind to be able to say, well, if you ever want to come see what it's like a day in life of the surgeon, come shadow me. And so after that, kind of the summers between high school and college, I spent several weeks with him in the operating room. Loved surgery, loved the patients that, you know, we treated. And so I really thought I was going to be an orthopedic surgeon. I really thought that that was going to be my path and took that with me through college and then getting into medical school. And then when I got to medical school, I really felt like it just. There wasn't. There wasn't enough for me there that I wanted to do it every day.
- [02:19]
A
Right? Yeah. Yeah.
- [02:20]
B
And so we went through our neuroanatomy courses. I love the anatomy of the brain. I loved all the connections of the brain. So I started shadowing some of the neurosurgeons in medical school and realized that every case was different. You had to be creative. You had these patients. It was the worst day of their lives. So you really could help people in a tremendous way. And so that really helped me sort of gravitate more towards neurosurgery, and so I sort of shifted gears towards that.
- [02:46]
A
Yeah. So where'd you grow up? And where was that practice, that ortho practice that you worked at?
- [02:51]
B
So I grew up in Alpharetta, Georgia. Okay. I went to Milton High School, and that was over at North Fulton Hospital and Resurgence Orthopedics.
- [03:00]
A
Okay. Okay. Resurgence.
- [03:02]
B
Yeah. Yeah. So Jeff Albert was the. Was the orthopedic surgeon, and he's a tremendous guy, one that I have, you know, enormous respect for.
- [03:11]
A
Yeah.
- [03:11]
B
And he still practices over there.
- [03:13]
A
Yeah. What was life for you growing up? Siblings, parents? What did they do? Sort of unpack that.
- [03:19]
B
So I had one brother, my younger brother Alex, who's 20 months younger than me, and then my mom and dad. And it was. For us, it was a lot of sports. I mean, I played football. I wrestled, played baseball, Kind of did a little bit of everything.
- [03:34]
A
Yeah.
- [03:35]
B
You know, really involved in our community. And then I ended up going to the Naval Academy to go play football out of high school.
- [03:45]
A
Yeah.
- [03:46]
B
And then it was kind of a combination of things that brought me back to Georgia. My mom got. Unfortunately, she got really sick and ended up having a liver cancer my freshman year. And then on top of it being very difficult to go to medical school from the Naval Academy, I ended up transferring back to the University of Georgia so I could be kind of closer to family, but also pursue medical school.
- [04:11]
A
And when in your life did you decide medical school was for you, or.
- [04:17]
B
Was it always, like, you know, I always. I could never find anything else I wanted to do more. Right. I mean, it was always one of these things that I love the idea of. I love the idea of being a doctor. And there was just. Despite being exposed to so many other things, I just. I couldn't find anything else I wanted to do more than that.
- [04:33]
A
Yeah. So you had, like, a. You were born into it. Now, were your parents?
- [04:37]
B
Yeah, my dad was in the Air Force for, you know, 25 years. My mom was an interior designer. We didn't really have many other doctors in the family, and so it was kind of. I didn't really have anybody to talk to or kind of help, you know, shepherd me in.
- [04:51]
A
Yeah, I'm always curious by that. Like, was there a show when you Were young that you loved or, like, how did it.
- [04:57]
B
Yeah. I don't know if it was ever a show. I think I really credit, you know, my mom towards pushing me, you know, into that and really helping me explore that side of things and, you know, take anatomy courses and, you know, really get into science. I was always good at science, and I always really liked that.
- [05:11]
A
So were you natural at it, too?
- [05:14]
B
I think so, yeah. I mean, I think I was natural at school in general. Like, it just kind of came easier to me, but I just. I really loved, you know, the science, the anatomy side of things.
- [05:24]
A
Yeah. What you. You mentioned a bunch of different sports. What did you excel in? What did you like?
- [05:29]
B
I mean, I, you know, I think I did pretty well at most of the sports that I played. I mean, I was, you know, captain of the football and there are wrestling team and, you know, competed for, you know, state titles and in both and, you know, obviously got recruited to go play football, you know, in college, and then ultimately settled on the Naval Academy. So, you know, sports was a huge part of our life. And I just. I grew up playing since I was a kid and kind of played, you know, three or four different sports.
- [06:01]
A
What's Naval Academy like?
- [06:03]
B
The Naval Academy is hard. It is a great place for people who want to go, you know, serve in the military and ultimately become an officer on a, you know, a plane, a ship, a sub, things like that.
- [06:16]
A
Yeah.
- [06:16]
B
You know, but I think it's one of those places that you really have to want to do that. Right. I think for me, you know, I went there as a. As a way for me to sort of. I still want to go play football, but it would give me the opportunity to still do medical school if I wanted to. And all those things are just very difficult up there. Right. I mean, you know, I was playing football, so I didn't have the chance to really, you know, excel and be a part of, you know, the military side of things.
- [06:41]
A
Sure.
- [06:41]
B
And that really limited, you know, their ability to let me even apply to medical school. Right. So it would have been very difficult for me to do that.
- [06:49]
A
Yeah.
- [06:49]
B
From the academy.
- [06:50]
A
Did dad. Did dad go to naval academy or.
- [06:53]
B
No, he was in the Air Force and he didn't do any of the service academies. But he really, obviously, he was very proud that I went.
- [06:59]
A
Yeah.
- [07:00]
B
And supportive of that.
- [07:01]
A
Sure. Did you. Do you bounce. Bounce around a lot as a kid?
- [07:06]
B
Oh, you mean.
- [07:07]
A
Sorry. Yeah.
- [07:08]
B
Like, I mean, we started. I was born in Fort Worth, Texas, and then we moved to Omaha, Nebraska, and then To Georgia. So not a ton. A couple. A couple different places. Just three hops.
- [07:19]
A
That's pretty. And all, I'm guessing, for Air Force. Air Force, like reinsign, reassignment or re.
- [07:25]
B
That's right.
- [07:25]
A
Yeah.
- [07:26]
B
Yeah.
- [07:26]
A
And that's awesome. All right, so. So you go to. So you go to medical school. You're in med school. Something had to happen there. That goes. And I know you touched on it in the beginning where you said, ooh, I'm not getting enough over here, so I want to start pursuing over here. Unpack that for me a little bit.
- [07:45]
B
You know, to go into neurosurgery.
- [07:46]
A
Yeah.
- [07:47]
B
I think we. You know, it was really. I don't want to say it didn't challenge me enough, because that's not the case at all.
- [07:55]
A
Yeah.
- [07:56]
B
I just felt like, you know, orthopedics. I felt like I was doing sort of the same thing a lot of cases. Right. Even though it was. It was. You were helping people. You know, I think I wanted something that had a little bit more. A little different nuance for every. Every case. And that's what I really loved about. About neurosurgery, especially brain surgery, is that, you know, with every patient, you know, there's tumors in every different parts of the brain. So you really had to figure out creatively, how do I get to that area without causing damage.
- [08:26]
A
Right.
- [08:26]
B
Or how do I safely clip this aneurysm? How do I, you know, safely, you know, attack this. The spine issue. Right. And so it's so very different for every case. And to me, I. I really love the creativity of it.
- [08:38]
A
Man, that sounds. That just sounds incredible. All right, so you're in med school. You make the change over to neuro, and then what did that look like? Was that more schooling for you, or.
- [08:48]
B
Yeah. So you finish. You know, so in medical school, you're doing different rotations to kind of get, you know, your feet wet, and so multiple rotations and away rotations. I spent a month at Emory.
- [09:00]
A
Okay.
- [09:01]
B
And then I spent a month at Duke. And so you're spending time at these other places to figure out where you want to go and to get a sense of what you want to do. And then I ultimately match. So there's a match process where you match for a residency slot. I matched into Emory, which was my top choice, and I was thrilled to go there.
- [09:18]
A
Wow.
- [09:19]
B
Yeah. So I was. You know, I love the guys. I love the training program. Obviously, it was close to home. My wife and I had gotten married in 2010, so it was kind of right after we got married, we had a lot of family in Atlanta, so it was a wonderful place for us to stay and have family support too. And so went to Emory. And it's a. It's a fantastic training program because we have five hospitals that you get to rotate through. So there's two children's hospitals, Grady, which of course is sort of the, you know, the Community Trauma Hospital, Emory Hospital, and then Emory Midtown.
- [09:55]
A
Okay.
- [09:56]
B
So you do a lot of training amongst, you know, all five places where you really get a good sense of what academics is like, what private practice is like, what, you know, trauma hospitals like, and then pediatrics. So not a lot of the training programs in the country had, know that same experience.
- [10:11]
A
Sure.
- [10:12]
B
So.
- [10:12]
A
So what was it like, you. The first time you walked in the or, I'm guessing you were under residency and you were. You were going to be part of a. An open skull craniotomy, brain surgery.
- [10:26]
B
Yeah. I mean, I think, I think you're terrified, right? I mean, I think. I think you are truly scared that, I mean, number one, you don't know what you're doing. You probably feel like a fraud, like you shouldn't be there, you don't deserve to be there. Right. You know, you're terrified, am I going to touch something and. And cause a problem.
- [10:43]
A
Right.
- [10:44]
B
And so you're trying so hard just to sit in the corner and just. And absorb it and not pass out and, you know, things like that. So, you know, but then it. Then you kind of go, God, this is kind of cool. I mean, you know, I see what they're doing and I don't understand it, but it looks. It looks great.
- [11:00]
A
Right.
- [11:01]
B
You know, and I think one of the challenges for us is translating what we see on an MRI or a CAT scan. Right. 2D image. Right. And sort of saying, how do I recreate that and figure out what that's doing, you know, in a real person?
- [11:14]
A
Right, right.
- [11:15]
B
And how do I attack that problem, you know, based on what a CAT scan shows me?
- [11:19]
A
Yeah.
- [11:19]
B
So learning that is very difficult. Right. And. But it's. It's what we do every day, but gradually you get used to it. And I think in residency, especially at a place like Emory, they allow you to keep doing a little bit more and more, you know, as you progress. And so, you know, you start off by scrubbing in and sitting there quietly and doing nothing.
- [11:38]
A
Right.
- [11:39]
B
To being able to start making incisions and close wounds. And all of a sudden, you know, as you're progressing, you're. You're drilling into the skull and taking the bone off. And then as you get more and more, you're taking the tumor out or taking the blood clot out or whatever it may be. Right. Until, you know, the goal is to get you. By the time you finish, to be able to operate independently and make decisions independently and be a, you know, a real doctor in the world.
- [12:02]
A
And that takes how long roughly?
- [12:04]
B
So it's seven years. Okay. So various programs are different, but six to seven years.
- [12:09]
A
Yeah.
- [12:10]
B
Some people will do a fellowship where they specialize in one particular area. So I did a fellowship in oncology, so neurosurgical oncology, where we spent a year learning about and really focusing on brain tumor patients.
- [12:22]
A
Okay.
- [12:23]
B
And so I did an extra year in that. But a lot of people do that for spine, for vascular, for pediatrics. So there's a bunch of different specialties sort of within neurosurgery.
- [12:33]
A
Yeah. So that very first time that you walk in, you're nervous. I like how you said that. You feel like a fraud. I can only imagine how many. How many people are there?
- [12:44]
B
I think for every surgery, you're probably anywhere from, you know, five to 10 people in an operating room. Right. You've got the anesthesiologist, you've got your scrub tech, you've got your nurses. You know, you've got multiple physicians. So. And sometimes there are multiple people doing all those jobs. You've got. You've got reps who are, you know, with different companies showing you different instruments or devices that you're using. So.
- [13:10]
A
Right.
- [13:11]
B
It can be a big. It can be a big production. I mean, I've been in some cases where we're trialing a new product and there's 20 people in the room. Right. Trying to figure out, you know, is the product working well? Is it going okay? You know? Yeah.
- [13:23]
A
So have there been advancements made? I mean, is that even the right question? Like, are we.
- [13:29]
B
Yeah.
- [13:29]
A
I mean, getting. Are we moving down the field, do you feel?
- [13:32]
B
Yeah. I mean, I will tell you this, you know, you know, industry is a massive part of medicine. Right. And, you know, we cannot advance any field of medicine without having industry support. And that takes a lot of input from physicians to be able to say, hey, this is a problem. Right. I see this problem. How do we overcome this problem? And a lot of times it's partnership with industry to be able to say, you know, I need. I want to create a product with you to solve this problem. And so there's a lot of innovation that goes on, and I Will say, you know, the field of what we do is so different now than even what it was when I graduated residency 70 years ago to what it was 15 years ago. I mean, you know, the devices and the techniques that we're using, you know, are, are changing every, every day, every, every year.
- [14:19]
A
Robotic stuff.
- [14:21]
B
So we use robotics for a lot of it is precision guided, you know, biopsies or resections of things, mainly in spine. Right now are robotics being used for placement of, you know, screws into the, you know, the vertebral, you know, column for stabilization and fusion of spine. Yeah, we haven't gotten to the point where, like the, like the da Vinci robot is what they use a lot for abdominal surgery, prostate surgery, things like that. Yeah, we haven't gotten to the point where we can use that in the brain yet, but I'm sure, I'm sure it's coming.
- [14:54]
A
Is it also, is there going to be a day where you don't have to do the craniotomy part of it?
- [15:00]
B
I wouldn't doubt it. I mean, I wouldn't doubt that you're able to, you know, tell a machine, this is what, you know, this is the size I want. This is where I want it. And it goes in there, opens the skin, drills the bone, takes it off safely. You know, I wouldn't be surprised at all if that happens. Hopefully not anytime soon because I'd be out of a job. But, you know.
- [15:20]
A
Well, somebody's got to tell the machine what to do. Right? Right.
- [15:23]
B
I mean, at some point there will be advances where, you know, we're, you know, it takes sort of the human fiddle factor out of it, I'm sure.
- [15:30]
A
Yeah, yeah, yeah. Now you said industry. So what are some of those, I guess, are companies, right? Are they the ones we know? Is it like Bristol Myers and stuff like that?
- [15:40]
B
Yeah, I mean, some of the bigger ones like Medtronic, Stryker, Globus, you know, there are a bunch of medical companies that make devices that we use, anything from, like, for us, neuro navigation, which shows us kind of in a 3D model where a tumor is within a patient's brain. So I know how to get there.
- [16:01]
A
Yeah.
- [16:02]
B
You know, there are implantable devices. Specifically, I work with a company, GT Medical, that makes an implantable radiation device that we put in patients after a tumor has been removed.
- [16:13]
A
Yeah.
- [16:14]
B
You know, everything from the suction, you know, that we use and the forceps and, you know, everything that we use has been, has been developed by, by a company to make your job easier.
- [16:26]
A
Yeah. So the Big, like when you say company. So it's the companies we know, like the Medtronics, that are publicly traded and stuff like that.
- [16:32]
B
And a lot of them are. They start off as small devices or small companies that get acquired by bigger.
- [16:37]
A
Companies that get acquired. Where would you say, like, what's an advancement that comes to mind since you, since you came in, since you got started?
- [16:46]
B
I would say that one of the biggest things that comes to mind is what we call lit or laser interstitial thermal therapy. So it's one of the newer things within neurosurgery that allows us to. So for sort of deep seated tumors or tumors which are not surgically removable, you can actually place these small wires that have an electrode catheter at the end stereotactically. So we place them under the guidance of a robot with navigation that allows us to burn the tumor deeply without having to physically go in and take it out. So it allows us to do things for tumors that potentially would have caused a lot of harm. Yeah, basically going into surgery, right. You can place little tiny, you know, wires and you know, to burn a tumor, that's incredible.
- [17:37]
A
Do you have to open up to do that or are you going through.
- [17:39]
B
Usually they're very minimal holes that you're able to place these very tiny, you know, wires through. So, you know, it's amazing. So it's kind of a minimally invasive approach.
- [17:48]
A
Yeah, still done. Obviously, in an operating room.
- [17:51]
B
In the operating room, typically under MRI guidance. So, you know, these patients ultimately go to the MRI machines. We're able to take pictures while we're doing it and confirm that we're in the right location and not causing any trouble. Things like that.
- [18:04]
A
Yeah. Oh my goodness. That's incredible. All right. Day in the life. So walk me through. You're driving to work and you have a case. What time are you getting there? What's going through your mind? Just all that.
- [18:17]
B
Yeah, I mean, I'd say typically, you know, patients, cases start about 7:30. We have them get there hour and a half, two hours beforehand. They go to a pre op area where they get checked in. You know, the nurses place IVs, we start giving them medication. You know, all walk in about seven, check them in, make sure they're doing okay. You know, they'll go back to the operating room, they get put to sleep by anesthesia. And then we come in and we position the patients. Right. So it's up to us to make sure that we know, you know, say we're operating on a tumor, you know, Sort of in the. In the left parietal lobe. I've got to position them so that, you know, I have a good working area. Yeah, that's up to us. And so, you know, we'll. We'll position them, we prep them, you know, plan our incision, you know, clean the head, and then we go through the surgery. Some days we'll have two or three surgeries at once. You know, so we'll finish that patient while the next patient's getting checked in, go out and see them, and just kind of. Kind of keep moving. So. Yeah. So and then the most I've ever done is five surgeries in a day. And that's a lot.
- [19:19]
A
All brain.
- [19:21]
B
And sometimes that involves us with, you know, two operating rooms where we're finishing one case while another patient's already being brought back. We'll go to that one and then kind of, kind of go back and forth.
- [19:30]
A
Oh, my gosh.
- [19:32]
B
Five in a day. And then that's. And then that's balanced by clinic. Right. I mean, so we do clinic, and that's to see patients, you know, in the outpatient setting, either pre op or post op. And so they'll come and see us in the office. And so we do that two days a week as well.
- [19:45]
A
Two days a week. Okay. So that's somebody who had a surgery.
- [19:50]
B
Either had a surgery or they were referred to us by, say, their primary care physician.
- [19:54]
A
Okay.
- [19:55]
B
You know, guy goes to see his primary care physician, he's been having headaches. The primary care orders an MRI and finds a. Finds a brain tumor and says, you know, go see Dr. McCracken in clinic. And so that's how we see patients.
- [20:06]
A
Yeah. Okay. Are all tumors like, is it absolute surgery? As soon as somebody knows they have a tumor? It came on the mri. Is it always surgery? Are there any other road.
- [20:20]
B
There are so many different kinds of tumors. Right. There are benign tumors. There are malignant tumors. There are a lot which are operative, and then there are a lot which are non operative. Right. I'd say we see quite a bit of benign tumors, more incidental findings. Where in this day and age, it's so easy to get an MRI and a CAT scan on somebody that we're picking up on some of these more incidental tumors than ever before. Right. And so some of these benign tumors that we'll find, we just say that doesn't need surgery. It's not growing, it's not causing symptoms. Let's just watch it. Check another scan in three months and just kind of keep watching It. And then if it ever does grow or cause symptoms, we can take it out.
- [21:00]
A
Yeah.
- [21:00]
B
And then there are some, there are some tumors that come to us that we say, you absolutely need surgery. Let's do it next week. Right. Or tomorrow.
- [21:06]
A
And what would dictate that, like right now, like, you need to go today or tomorrow.
- [21:10]
B
Yeah, I'd say, you know, a lot of those patients who come in very sick come in through the er, right. They've either had a seizure at home, you know, they've lost consciousness, or, you know, they developed acute neurological symptoms Right. Where they can't move their arm or leg, they have aphasia where they can't speak. Right. And they come in and we find these tumors which are very symptomatic. Large tumors, large magnet tumors. And we say, you know, usually within 24 to 48 hours, you know, we need to get you to the operating room and get it out.
- [21:42]
A
Or it can cause, like.
- [21:44]
B
Yeah, they can either keep deteriorating or. Yeah. Or it's such a, you know, we presume it's going to be a malignancy. We don't want it to keep growing to the point where.
- [21:52]
A
Yeah.
- [21:53]
B
It becomes an inoperable.
- [21:54]
A
Right. Issue. Now, there's a whole nother side of this, too, which I'm, I dread as a human being, but I also want to talk about, I want to learn about what, what's going on. So when a person hears the words, you have to go have brain surgery. So you're going about your day, something happens. Mri, you got to have brain surgery. Yeah, I can't imagine that's like, oh, great, let's go have brain surgery. Like, what?
- [22:25]
B
Yeah, I mean, it's, it's, it's terrifying because, you know, even as, you know, as a human being, myself, I mean, you know, we are all at risk for developing, you know, medical issues, including brain tumors in our life. And so, you know, that's not the first thing we typically think about. Right. And somebody, oh, I have a headache or I've had. I'm dizzy. That's not the first thing that we think about. Right. But it's, it's, it's terrifying. And I, you know, I'm reminded of a young guy that I treated just a couple weeks ago where, you know, I mean, he was, you know, king of his world. Right. And ended up having, you know, a seizure and, you know, was found to have a malignant brain tumor. Right. And so that's, that's a life changing diagnosis. Right. At 42 years old. You know, and so you know, but what I am, the way I look at it, is that I'm glad that there are people like me out there who can calmly and safely address that problem for somebody. Right. And so, you know, when you have, you know, say you have an issue, you know, you want to go find somebody who can, who can take care of that for you.
- [23:34]
A
Sure.
- [23:36]
B
And, you know, it's not the first time they've seen it. It's not the first time they've taken care of it. And they go, yes, it's a. It's an issue, but we can take care of it.
- [23:43]
A
Yeah.
- [23:44]
B
And so I think, you know, the ability for me to be able to provide, you know, confidence and reassurance to somebody that, yes, we can take care of this safely is what. Is what I really, you know, enjoy about the job, too.
- [23:57]
A
Yeah, I'll bet. So the malignant and the benign, can you tell that before going in and getting a sample?
- [24:04]
B
Not always. I can tell you with, with a lot of certainty. Looking at mri, I have a pretty good guess about what things are going to be. Right.
- [24:12]
A
Yeah.
- [24:13]
B
Sometimes it is necessary for us to, you know, you know, we will talk to the patients about that, but you still have to say, well, you know, we don't want to shatter somebody's, you know, you know, complete sense of optimism prior to surgery.
- [24:27]
A
Right.
- [24:27]
B
Say, listen, let's go get it out. We'll figure out what it is, you know, even though you may know kind of what it's going to be. Right. You know, the benign stuff, it's pretty easy. You know, we'll tell folks, ah, this is likely a benign tumor. It's more the malignant stuff, which really, I think you can't. You can't crush somebody's hopes right before.
- [24:46]
A
Right.
- [24:46]
B
I mean, I think you have to really work up to that with, with folks. Right.
- [24:50]
A
Yeah.
- [24:50]
B
And. And sort of deliver it to them in small doses, you know, until. Until you get the final diagnosis.
- [24:57]
A
Get it out first. That makes sense. So get it out. Let's see what it is.
- [25:00]
B
Right.
- [25:01]
A
Okay.
- [25:01]
B
And I've been wrong. I mean, I've been wrong plenty of times. Right. I've. I've guessed something's, you know, a malignancy, and it turns out to be not. Right.
- [25:09]
A
Yeah.
- [25:09]
B
You know, it turns out to be, you know, an issue related to Ms. Or an autoimmune process or an infection. Right. So there are a lot of things that can mimic, you know, malignant brain tumors will end up not being tumors, too.
- [25:22]
A
Can you have a tumor inside of you now, this is spine as well. So when I say like spine and brain. But to me, this brain is just so, so fascinating. Can you have a tumor is true. You can have a tumor inside of you and have no symptoms at all.
- [25:37]
B
Yeah.
- [25:37]
A
You really. Okay. Is that one in a thousand?
- [25:41]
B
I'm not sure. I put a number on it. I mean, there are a lot of benign tumors called meningiomas. Okay.
- [25:46]
A
Okay.
- [25:47]
B
There are meningiomas, there are pituitary adenomas, there are vestibular schwannomas, lipomas. There are. There are a lot of different benign tumors which I consider, you know, non malignant. They're not going to spread, they're not going to grow, you know, rapidly. Things like that, that can go for years and years and years and never cause any trouble.
- [26:08]
A
Right.
- [26:09]
B
Those are the tumors that we love to see. Because I can give you great news and say, this is nothing. Don't worry about it. I'll check you in a year and we'll just keep an eye on it.
- [26:16]
A
Right. Wow.
- [26:17]
B
So there are a lot. Those are fun visits. Those are good visits.
- [26:20]
A
Right.
- [26:21]
B
And I think for the patients, too, they breathe a sigh of relief and go, oh, thank goodness. I don't have to have.
- [26:30]
A
Is there medicine at that point or just sometimes.
- [26:33]
B
I mean, sometimes there are certain types of pituitary tumors which can respond to medication. So we don't have to do surgery, radiation, anything.
- [26:40]
A
Yeah.
- [26:41]
B
You know, or, you know, not every tumor that we see has to be treated with surgery. We have tremendous radiation capabilities now, too. Right. So we can very, you know, stealthily treat some tumors with radiation and never have to go in with surgery.
- [26:57]
A
Really? And would that matter if it was benign or malignant? It could be either.
- [27:04]
B
We treat both. So we treat both with radiation.
- [27:07]
A
Okay.
- [27:08]
B
Some malignancies that, if we already know the diagnosis, and these are small spots within the brain, and those are typically metastases. Right. So say somebody has a lung, colon, or breast cancer and it's spread to the brain, and we already know what they have, small tumors which we find on screening MRIs that are minimally symptomatic. Then we'll treat those with this, what we call stereotactic radiosurgery, which is almost like sort of spot welding in the brain to kind of burn and kill those tumors.
- [27:36]
A
Is that pretty new? Fairly?
- [27:38]
B
No, it's been around. I think it's been refined quite a bit over the past several years. But some of the earliest radiation was what we call gamma knife radiation. And that was developed, you know, 60, 70 years ago.
- [27:51]
A
Right? Yeah.
- [27:52]
B
It's gotten better and better over time.
- [27:53]
A
Right.
- [27:54]
B
And much more safer over time.
- [27:56]
A
Yeah.
- [27:57]
B
Yeah.
- [27:57]
A
Okay, so I heard of, with the golfer Gary Woodland. I. I remember reading that he had a brain lesion. What's a brain lesion?
- [28:09]
B
I mean, sometimes it's semantics. Right? Okay. You know, I mean, it's hard to say. I mean, sometimes we'll talk, well, it's a lesion because we don't know what it is. Or, you know, or, you know, we find a lot of stuff in the brain that we don't know what it is. Right, sure. And we go, well, I don't know, that's an abnormal spot. And, you know, it doesn't need surgery, but let's just watch it, you know, and if it becomes more of an issue, then we can go in and get tissue or treat, whatever it may be. But there are a lot of times we find little tiny spots that we just don't know what they are. And we just, we just watch.
- [28:40]
A
Yeah. Just let them go. And.
- [28:41]
B
But a lot of it is semantics. We say, well, you've got a spot, you got a lesion, you've got a mass, you got this and that. Right?
- [28:47]
A
Yeah.
- [28:49]
B
You know, it's kind of how you choose to, you know, choose to describe it.
- [28:52]
A
Sure. So between the spine and the brain, do you have a, do you have a favorite to do a surgery?
- [28:59]
B
Yeah, I mean, I, I love spine surgery, but kind of my passion is really brain, you know. You know, and we, and I treat all sorts of, you know, both malignant and benign tumors. Yeah, we also do a lot of other, you know, surgery that's not necessarily oncology. So, you know, we'll, you know, traumatic wise, we'll treat, you know, traumatic brain injuries and, you know, traumatic, you know, subdural hematomas, blood clots in the brain from falls. You know, we treat hydrocephalus, which is an abnormal accumulation of spinal fluid within the brain. You know, we treat pretty. We. There can be pretty severe facial pain called trigeminal neuralgia. Yeah, you may have heard of that. And a lot of times that's treated with surgery to physically decompress the trigeminal nerve from a blood vessel, pushing on it. Okay, so that requires surgery to do. Yeah, so we do a lot of other non oncological surgery as well.
- [29:53]
A
Okay, you do. Okay. What about your run of the mill spine? I threw out my C5.
- [30:01]
B
Yeah.
- [30:01]
A
Like, is that you or is that somebody different?
- [30:03]
B
No, that's, you know, we have some tremendous spine surgery. Surgeons that work with us, and that's more, you know, what we call sort of degenerative spine issues. Right.
- [30:11]
A
Okay.
- [30:11]
B
And get arthritis and, you know, stenosis of, you know, the frame and around our nerve roots or degeneration of the. The discs and things like that. Yeah, I don't really do that as much anymore, but it. It is. There's absolutely a place for it. And, you know, we have some really great surgeons that I work with that do great work on that.
- [30:32]
A
Yeah, makes sense. So the. The day you got. I'm gonna use the word training wheels, the day you got your training wheels off and you, like, first surgery that you had, what. What was that like?
- [30:47]
B
You know, I think, you know, in. In residency, you know, you're very protected because you always have your attendings who are your. Your teachers.
- [30:57]
A
Yeah.
- [30:58]
B
They're the ones who ultimately make the decisions. Right. You can come to them and say, doctor, so and so, you know, this patient came in. I think we should do that. And they go, okay, well, we're not going to do that. We're going to do what I want to do and do it this way. And in the same vein, it also may be, Jay, that's a great plan. Let's do it. But you've always got them sort of behind your shoulder. They're always sitting there watching. When you get out into your own, you don't have that anymore. Right. And you don't have anybody to bail you out if something goes wrong. Right. And so that's the scariest part is going, I'm now responsible for this patient. Right. They've entrusted their life in my hands. I've got to be really conservative about what I do and do a really, you know, do a nice, easy job. But, you know, when you first start out, you're still calling your attendings, and, hey, what do I do with this? Hey, what do I do with that?
- [31:47]
A
Sure.
- [31:48]
B
And, you know, being able to have a partner that you can rely on to help kind of come help you out. And so I think when I started, I had a partner that I was worked with quite a bit just to make sure that we were on the same page. I wasn't doing anything that I shouldn't do. And then gradually, you gain confidence. Right. You say, well, I've done that, and I've seen that, and I can do that. And so as you get further and further along, I think you do that less and less, you know, as you kind of gain confidence in what you're doing.
- [32:15]
A
Yeah. Is. Is every procedure a new thing? Is it always new?
- [32:21]
B
I think, I mean, every procedure is new in the fact that every patient is different. Right. I mean, the same tumor you took out on a 35 year old, healthy, you know, you know, female, maybe, maybe very different than the 80 year old diabetic with heart failure.
- [32:36]
A
Yeah.
- [32:37]
B
You know, that has the same tumor.
- [32:39]
A
Right.
- [32:39]
B
There's a lot of risks are different, tolerances are different, you know, you know, I've taken out, I've done a perfect surgery on an 80 year old and they, you know, never wake up because their just body can't handle it. Right. Or, you know, the same thing where you feel like, you know, you did a horrible job and somebody does great. Right. So I mean, it's hard and it's a very humbling profession because, you know, you can feel like you did an amazing job in a surgery and then, you know, somebody has a complication post op and you're devastated. Right. Has a seizure, has a brain bleed, has a stroke, has this and that and stuff. And that, you know, may not have been directly related to what you did, but just, just happens.
- [33:20]
A
Yeah, sure. What about some of the other stuff? Non tumor related, like there's aneurysm, there's other related things. What are, what are some of those? And do you treat that, do you do that stuff too?
- [33:30]
B
Yeah. So I mean, you know, in the, in the realm of neurosurgery, there's cerebrovascular neurosurgery, which is treating all blood vessel, you know, disorders, aneurysms, AVMs, stroke falls into that for sure. Okay. You know, and that's where a lot of, you know, industry has, has really changed the way we treat those. A lot of the aneurysms in the brain were typically treated with a craniotomy and, you know, a small clip where you used to put a clip over the neck of the aneurysm to prevent it from rupturing. Now all that's done intravascularly. So we're going through the groin or the wrist and they're actually putting, you know, coils or stents to sort of block all those aneurysms out now.
- [34:08]
A
Wow.
- [34:08]
B
So. So that's changed tremendously over the past decade. Or there are things for epilepsy and Parkinson's disease where we're treating patients with what we call deep brain stimulators. So you're actually putting small electrodes into the part of the brain that control things like your movement and your shaking to sort of stop those or stop seizures. And then that's more of what we call functional neurosurgery. There's pain, so a lot of, you know, people treat pain or peripheral nerve. That's also sort of falls into the realm of neurosurgery, too. So it's a truly fascinating field that has, you know, just such a breadth of what we do in our specialties.
- [34:53]
A
Right. What does it mean when there's a. I saw an ad for a hospital group in Chattanooga that I pretty sure it said leaders in stroke, whatever management or stroke. Like, what does that mean when you're a leader in.
- [35:09]
B
Yeah, I mean, I think. I think now, and this is something that we've recently done at Piedmont, which I think we're really proud about, is, you know, stroke is a tremendous problem, especially here in Georgia and throughout the South.
- [35:21]
A
Right.
- [35:22]
B
And when I say stroke, there's a couple kinds of strokes. So the main form is what we call an ischemic stroke.
- [35:28]
A
Okay.
- [35:28]
B
Which is typically a blockage of a blood vessel to the brain, which ultimately leads to death of that portion of the brain if that part of the brain doesn't get blood supply. And so it's changed over the past couple years where, you know, a blood clot will develop and go to the brain. You know, we still give medications which can break up the clot, you know, but now we are much more aggressive. And some of my cerebrovascular colleagues who do it, you know, they'll actually go into the groin and actually suck out the clot to sort of, you know, you know, maintain blood supply to the brain. And so now, you know, they are developing these comprehensive stroke centers, which basically, it's really an outcome driven designation. Right. Where you can say, hey, we treat this many patients, we're able to, you know, save this many patients or help this many patients and, you know, get them in in a certain amount of time. So it's a lot of outcome driven care. And so I think for what you were mentioning, it's probably a hospital which has really met a lot of the milestones to say, sure, you know, we are an excellent comprehensive stroke center, can treat those patients, you know, very, very quickly and effectively.
- [36:39]
A
Yeah. What are the other layers of strokes, then? So you said the one ischemic, most serious.
- [36:47]
B
I think they're all serious. The other. The other kind is called a hemorrhagic stroke.
- [36:51]
A
Okay.
- [36:52]
B
And that's when you actually have a rupture of a blood vessel within the. The brain. So as opposed to a lack of blood flow, it's a rupture of blood into the brain. And that can be just as devastating and immediate where, depending on where the rupture of blood is, I mean, it can very quickly take out your ability to lose one side of the body to see, to speak, you know.
- [37:13]
A
Right.
- [37:13]
B
And those are, those are harder to treat. You can't just go suck out a blood clot.
- [37:17]
A
Right.
- [37:18]
B
Occasionally we will go in and physically remove a blood clot if it's really causing somebody to really deteriorate quickly. Yeah, but some of them are small and you can't treat them with surgery. You just, you just manage them very, you know, very critically in the icu. And a lot of it's blood pressure control or. Yeah, so those can be, those can be just as devastating.
- [37:43]
A
Right. Okay. So that's, that's the two main. Two mankind. Okay. Two man kind of stroke. Is it all the same, same symptoms that we hear, like if you're numb on a side of your face or. And what are some of those? Let's.
- [37:56]
B
Yeah, So I mean, the, you know the acronym is fast, right. So it's, it's face, arm, speech and time. Right. So if you see somebody with a drooping face, they're not moving their arm, slurring their words, you know, the quickest thing you want to do is call 911 as quickly as possible because the longer that goes on, the more irreversible that can be. So those are the things that we think about to get, you know, to get them help very quickly.
- [38:22]
A
Yeah. You know, okay. What about lifestyle? I know there's recommended things, obviously, don't smoke. That seems to be connected to everything. I mean, are we making any advances there in medicine? Like.
- [38:34]
B
Yeah, I mean, I think, I think it's kind of the stuff that you've, you've heard of for years, right? It's. Yes. Manage your blood pressure. Right. Manage your cholesterol, all those things. Can smoking, all those things contribute to developing plaques and things that can break off and go to the brain? Same thing with heart attack. It's the same process almost as a heart attack too.
- [38:54]
A
Is it?
- [38:55]
B
So exercise, don't smoke, control your blood pressure, try to eat healthy. Those are some of the modifiable risk factors that we have. But there's going to be non modifiable risk factors. Right. So your genetics play a part of it. Right. So you know, you know, do you have, you know, blood vessels which are prone to doing that sort of things?
- [39:20]
A
Right.
- [39:20]
B
Did your parents have that, you know, are you prone to things like diabetes? You know, so there are Certain things that you just can't. You can't change. But the things that you can change, you should. And you should work on it.
- [39:33]
A
Yeah, you should work on it. Now, you mentioned inoperable, operable. What is. What is all that and what makes something inoperable?
- [39:42]
B
Yeah. So that's. That's always a challenge for us. So when we, you know, depending on the type of tumor that we see, you know, we know from decades of data, for most, we'll just talk about malignant brain tumors.
- [39:55]
A
Okay.
- [39:55]
B
Okay. So for most malignant brain tumors, you know, especially ones that start from within the brain itself, and, you know, the broad term for that is glioma. Okay.
- [40:05]
A
Glioma.
- [40:06]
B
Glioma. And those are infiltrative tumors of the brain, which basically take over normal portions of the brain.
- [40:12]
A
Okay.
- [40:13]
B
We know from decades of data that the more that you can remove safely, the better people do. Okay. So there's a big difference between if I can only take out 50% of the brain, 50% of the tumor versus 95% of the tumor. Right. Okay. That person is going to do better who has more of the tumor.
- [40:30]
A
Right.
- [40:30]
B
Removed. Because that typically means the less hard adjuvant therapy, things like chemotherapy and radiation have to work. Okay, got it. So as a surgeon, when an MRI comes across our desk and we are figuring out what can I do to help this person, is it. Can I take this tumor out safely and provide them benefit? And a lot of it has to do with the size. Right. Is it a area that I feel like I can, you know, get to safely, or is it the entire, you know, half of the brain? Right. Is it in an area that I can take it out and not cause somebody a neurological deficit? Right. In our minds, that's probably the biggest issue. Right. Because technically we can take out anything in the brain, right?
- [41:16]
A
Yeah.
- [41:16]
B
The problem is, is that, am I going to leave you with function so, you know, in an area and a patient has a tumor that's next to their speech area.
- [41:28]
A
Right.
- [41:28]
B
Or their arm motor area. Okay. The challenge for us is figuring out, can I take that out safely and provide them benefit by not. But not cause them harm? Right?
- [41:38]
A
Yeah.
- [41:39]
B
So, you know, case in point, I saw a patient today in clinic where he's got a tumor that is very close to his receptive speech area. Okay.
- [41:48]
A
Okay.
- [41:48]
B
So he's having difficulty generating words and understanding speech.
- [41:52]
A
Speech. Okay.
- [41:53]
B
If I go take that entire tumor out. Right. He'll probably never be able to do those things again. Okay.
- [41:59]
A
Really?
- [41:59]
B
So we have to figure out a Way to safely do that. And a lot of times we do that with intraoperative mapping or with what we call an awake craniotomy. So I offered this guy an awake craniotomy where we will actually map out his language function during surgery. So he will actually be awake during the surgery with his brain expand exposed. And then we will physically. We will ask him questions, and then we stimulate the portions of the brain that we think are where the speech centers are, and we can actually break those connections. And so we can. We can very accurately map out where the language center is and stay away from those. And then take everything, you know, that's not in that area, like, literally.
- [42:39]
A
But not awake that he knows it.
- [42:41]
B
Oh, yeah, yeah, they're awake. I mean, they're. They're. They have to fully participate in what we're doing. And so a lot of times it's. They're answering questions. They're simple things like I would ask you what color is the sky? And you would say, blue. Right. Or count backwards from 10, or repeat this phrase. And all while you're doing that, I'm stimulating the surface of the brain to sort of break those connections to get you to stop talking so I can figure out where that part of the brain is. So you're fully awake and you understand what we're doing. Cause you have to participate.
- [43:12]
A
Can you feel anything?
- [43:14]
B
I mean, very. Thankfully, the brain surface itself has no nerve endings, and so you can't actually feel what I'm doing up there. We actually numb up the scalp and the skin tremendously well, so you don't feel that. And then the anesthesiologists are excellent about giving IV pain medication as well. So nothing that knocks you out, but enough to kind of give you some pain.
- [43:38]
A
Wow. And that's only for a particular type?
- [43:42]
B
Well, I mean, that's. You know, we will use that technique for any tumor that we feel like we are close to a language or a motor center that we want to preserve.
- [43:51]
A
Okay.
- [43:52]
B
So, you know, for a lot of these patients that have, you know, tumors deep within a motor area, we'll also do the same thing and ask them, you know, to move their hand or squeeze a ball, whatever it may be, while we're mapping that area out to also preserve motor function, too.
- [44:07]
A
Oh, my goodness. So what is a. What is the serious one? Like glioblastoma?
- [44:13]
B
Yeah, so glioblastoma is a. Unfortunately, is one of the more common tumors in adults, but it's also, you know, one of the most devastating. So it's a. It's a malignant tumor that grows very rapidly, it's infiltrative into normal tissues. And so you have to. You do have to take out normal tissues along with the tumor, and it comes back. Right. And so despite surgery, despite chemotherapy, radiation, these things always will progress and grow. You know, whether it's months, you know, or a year or two later, they always do come back.
- [44:47]
A
Low survival rate, I would think.
- [44:49]
B
Yeah, I mean, I'd say the, the average survival rate now is anywhere between 15 to 18, 18 months. But we do have some patients that live years. A lot of that depends on how they respond, you know, to chemo and radiation. So there are some that do for sure. And, you know, I think some of the advances that we have now with surgical techniques, the clinical trials, the radiation therapies that we're using, we have patients that are living well beyond that. You know, we'll be on that 15 to 18 months. We have patients living out to 24 to 36 months.
- [45:19]
A
Months.
- [45:19]
B
And so I do think we are making strides.
- [45:22]
A
Right.
- [45:23]
B
But it's not. It's. It's still a pretty tough disease to treat.
- [45:27]
A
Tough. Back in episode one or season one, I think it was around episode six or seven, I was introduced to somebody who's on year. At the time it was 12. Now it's 13. Year 13 survival glioblastoma. And I remember talking about the numbers, and they were so extreme. Like seven to eight months is basically.
- [45:48]
B
And that's really hard to. We really. Unless a patient really presses you, we really don't like to get into statistics because you truly don't know how somebody's going to respond until they respond. Right. You know, unfortunately, I think most people go to Google and they'll start, you know, Googling things, which I always, I always caution. I always caution people don't do because it's just going to scare you and you're gonna. You're gonna hate it. And so, you know, a lot of the stuff in Google may not apply to you, so don't, don't try to do it. Right. But it's human nature for us to want to know and figure out, especially when it's our own body or our loved one. And so, you know, but there are patients who respond tremendously well. And I say, see, I told you not to worry about that. You're at two years now. And you know, oh, that's awesome. And then we have some patients who, who obviously who don't do as well. Right. You know, but, you know, Our job is to give them, you know, good quality of life, you know, and. And give them as much time as we can with their families.
- [46:47]
A
Yeah.
- [46:48]
B
Yeah.
- [46:48]
A
Let's talk about a case that stands out for you. Maybe one of your most. More difficult or harder to navigate.
- [46:56]
B
Yeah. I mean, I think some of the challenging ones either come from accessibility to. How can I. How can I physically get to that tumor? Right. It's in a very difficult location with a high chance of morbidity. Right. You know, one thing that stands out to me is a recent patient who did have a glioblastoma, but he came in and he was very weak on his left side. And I told the patient's wife that, you know, I will try to get out as much as I can, but we may have to stop. And I remember we got in to the. To the case. We had mapped everything out. I found the tumor, but everything was within the motor fiber tracks of his. The left side of his body. And I stopped and I called the wife on the phone, and I said, well, what do you want me to do? I said, I can either get out of here but preserve his function, or I can take it out and he'll probably never use, you know, the left side of his body again. She said, I want you to take it all out. Right. And so that's not something that. That's not a decision that I should make. Right. Like, that is. That should be up to the patient and their family. And I had prepared them for that, and so they were ready for it. But it's never an easy thing for me to know that I'm gonna go take that out and cause somebody harm. Right. That's a very difficult thing, you know, and tumor came out, you know, and as expected, you know, I mean, he, you know, never move the left side of his body again. I think they're at peace with their decision. Right. Because they did what they wanted to do.
- [48:31]
A
Yeah.
- [48:31]
B
That's very difficult. Right. Knowing.
- [48:33]
A
Sure.
- [48:33]
B
Knowing that you're. Knowing that you're going to harm somebody.
- [48:36]
A
Yeah.
- [48:37]
B
You know, regardless of the oncological outcome.
- [48:40]
A
Oh, but still had a quality of life or. I mean, is it just a lesson?
- [48:48]
B
I mean, I mean, I. You know, I mean, you think about yourself. I mean, if you weren't able to. To walk. Right. Or, you know, use your left side.
- [48:56]
A
Oh, you're talking, like, left leg and everything. Okay. Everything left.
- [48:59]
B
So, I mean, if you. If you're unable to use your entire left side, I mean, think about what your quality of life would be. Right. I mean, you can't. You know, for me, I can't play golf. I can't go ski. I can't play with my kids. I mean, it's a.
- [49:11]
A
Okay.
- [49:11]
B
You know, I mean, it would be a devastating injury.
- [49:13]
A
I didn't even think about that. The leg.
- [49:17]
B
We also think about the things that people. People enjoy. I mean, you know, we have, you know, people who are professional singers. Right. And they want to preserve language function or, you know, athletes who want to preserve balance and things like that.
- [49:31]
A
Right.
- [49:31]
B
And so, you know, you always have to weigh a lot of those. A lot of those things because it's. It's not. It's not easy.
- [49:37]
A
Right. Do you think the. Has the medical community made a stance one way or another on these things?
- [49:45]
B
Phones on phones?
- [49:46]
A
Yeah.
- [49:49]
B
I mean, I think. I think besides the fact that we are. We are all too wrapped up in our phones and addicted to them, which, you know, I'm guilty of just like anybody else, you know, I don't think anybody's proven that, you know, we've, you know, they cause tumors or anything like that. I mean, the data may change, but, you know, I think in general, we are all too addicted to our phones and need to break away from that. I. It's funny, I. My daughter just. She got an iPhone, and I realized you can control everything on there and limit app use to certain, you know, 30 minutes a day or 45 minutes a day. I feel like I should do that for myself, too, that, you know, we're.
- [50:25]
A
The ones that need it.
- [50:26]
B
Yeah. I mean, I feel like, oh, my gosh, I'm worse than she is. I should probably, you know, limit my own use on this stuff.
- [50:33]
A
So I know I lifted mine up and now I'm like, oh, I want to see what's on it, because I know there were messages. All right, so you're in the. You're in the. Or you got somewhere between five and 10 people. Is it game on every minute that you're in there for? These are seven plus hour surgeries. Do you ever, like, break? Do you. What do you do? Do you sit down? Do you scroll through your phone? Like, what does it look like?
- [51:00]
B
I. I think, you know, very thankfully, you know, most of our surgeries are not seven hours.
- [51:06]
A
Right.
- [51:06]
B
Okay. You know, I did a simple surgery today, was a biopsy. Probably took me 45 minutes. Right. You know, I'd say the majority of our surgeries are between an hour and a half to three hours. You know, and a lot of it's routine, too. So the opening and closing is kind of routine, Right. So, you know, at that point, you know, we're. We're talking with each other, we're joking with the team. We've got music playing, you know, because you can't be laser focused at all times because you'll go crazy.
- [51:36]
A
Right.
- [51:36]
B
So, you know, I think in my mind, I can do the opening where I open the skin, I open the bone, I open the covering of the brain. To me, that's kind of mindless work. Right. I mean, it's so routine. It's something we have done thousands of times, you know?
- [51:50]
A
Yeah.
- [51:51]
B
But then when it's like, all right, we're ready to take the tumor out, right? That's when you lock in. That's when you focus.
- [51:56]
A
Okay.
- [51:56]
B
That's when you do your work. And then once that's done, everybody kind of relaxes, Right. And that's closing everything up. And that's also kind of a routine process. Close it up, put the bone on you, close the skin, and wake up. Right. So you can't be so rigid because you'll. You'll go crazy doing that. Right. And so you have to be able to. You know, we're very fortunate to have a great team that works well together, that we're able to ask about your weekend and joke about things. And, you know, and so you're. You're doing things to kind of keep things light, even in a, you know, potentially a grim situation, because I think you have to. Otherwise, you know, doing this every day, thousands of surgeries. You'll go crazy.
- [52:37]
A
You'll go crazy. So when you say a biopsy, what. What does that mean?
- [52:41]
B
So today we just did a needle biopsy. So in a gentleman that just wanted to. He didn't want a bigger surgery. He just wanted to find out what the tumor is. And so that involves still going to sleep, but just making a tiny stab incision in the skin, drilling a very little, tiny hole through the skull, and then passing a needle through the bone into the tumor, obtaining tissue, and then getting out of there.
- [53:05]
A
That's it.
- [53:05]
B
That's it.
- [53:06]
A
So what does that look like? So you said it's about an hour and a half.
- [53:10]
B
That took me about 45 minutes. That was pretty quick.
- [53:12]
A
Okay, and then. So when the patient wakes up, is he going home that day?
- [53:15]
B
No, we usually keep people overnight. Okay. So for something like that, we'll still keep you overnight to make sure that, you know, there's no issue. You don't have a seizure afterwards, your blood pressure's controlled, things like that. And then he'll go home the next day.
- [53:29]
A
Pain?
- [53:30]
B
A little bit, but, I mean, the incision's tiny, you know, maybe a centimeter or two. So that's all it is. It's minimal. Yeah.
- [53:36]
A
So can you do a bigger surgery? If I'm saying this the right way, can you do a bigger surgery and still only go through a smaller hole? Or is it, like, the bigger the surgery, the bigger the hole?
- [53:46]
B
Yeah, so it depends. I mean, there are some surgeries where we're taking off the entire scalp. Right. And you have to open the entire scalp, take off the entire bone. You know, there are a lot of surgeries that we do for stuff, what we call the anterior skull base and in the pituitary gland that we actually go in through the nose. We'll take cameras just through the nose, you know, which is.
- [54:06]
A
And not have to open the skull.
- [54:08]
B
Yeah. Which is amazing. And so, really, a lot of that depends on the position of the tooth tumor and where it is. Right. So but for tumors that we can access endonasally, we like to. Because obviously, it's not a big scar. And, you know, we're able to do it with kind of our cameras and instruments, which is pretty amazing.
- [54:24]
A
Yeah. What are, like, some of the areas. You said one area is dedicated to speech. What are some of the other areas of the brain? How does it all work?
- [54:32]
B
Yes. I mean, we have areas, you know, sort of in the left frontal. So speech is a complex, you know, you know, situation. So you have speech areas in the left frontal lobe and the left temporal lobe. We have vision, which occurs in our occipital lobes in the back.
- [54:47]
A
Is that where you're okay?
- [54:48]
B
Yep. We have. We have motor and strength that kind of runs along, you know, the entire frontal lobe from here to here. We have sensory behind it. You know, balance is located in our cerebellum, kind of in the posterior portion of our brain. There's a lot of sort of, you know, interwoven connections where you break one, and it affects multiple systems.
- [55:07]
A
Sure.
- [55:09]
B
It's a truly amazing organ, and you have to be really familiar with kind of the intricacies of it.
- [55:14]
A
And I'll bet.
- [55:15]
B
And know, you know, that if you go there, you know, you're going to cause this deficit and be able to be able to counsel patients. Right. And say, hey, I can technically get to it, but I'm going to cause this problem. Or, yes, you are having symptoms because of where this is located.
- [55:30]
A
Right, right.
- [55:31]
B
And I can fix that by taking this out.
- [55:33]
A
Yeah, makes sense. Is There like an. A team that is looking at an. That's how I envision it. Like an MRI is hanging up, and then there's a team of docs, and you're all talking about it, or what does that look like?
- [55:46]
B
Yeah. I mean, I would say that in the operating room, you've kind of made the decision. Right. We've already made the decision where we're going, and that's what we're doing. Right. We're going in there to do the one job and then get out.
- [55:57]
A
Right.
- [55:58]
B
We do have a tumor board consisting of things like our neuro oncologist, radiation oncologist, neurologists, you know, anywhere between five and six different specialties, where, if it's a very challenging case, we may present it all at our meeting and say, how would everybody tackle this? Right. I'd say, well, I want to take it out with surgery. And they go, well, that's dangerous. Why don't we just radiate it? Or why don't we just do that, Just get a biopsy and give chemo? And so, you know, we use that time for us all to be able to come to a consensus about how these patients should be treated.
- [56:30]
A
Yeah.
- [56:31]
B
And sometimes it's very complex. Right?
- [56:33]
A
Sure.
- [56:34]
B
And sometimes it's difficult for us to say, well, we don't really know what we're doing with this patient at this particular time. Let's recheck a scan in four weeks and see how the tumor progresses and then make a decision. Right. So it's a big team sport, and it's something that we really rely on the colleagues that work with us to really deliver the safest care for these patients.
- [56:56]
A
Yeah. What's the percentage breakdown of needing it to be in front of one of those teams or clear as day? You look at it, you're like, boom, I know exactly what has to happen. Go.
- [57:09]
B
I'd say the majority are pretty clear, especially when they first present before. They've never had any treatment. I think the challenge really comes to somebody who's on their say. In a glioblastoma, the tumors now come back a second or a third time. Right. And they've exhausted a lot of the other options. They said, we've already maxed out on the amount of radiation I can give somebody. Right. Or we've already gone through the first two or three chemos. I don't have another chemo to give this person. Right. Or what's another option? Because we don't have anything else to get. That's where it becomes really Challenging.
- [57:39]
A
Oh, I mean, so you can max out on those. You're only allowed, what, two rounds of chemo?
- [57:44]
B
It's. It's not. It's. It's. Sometimes it's, you know, for radiation. It's. We've already delivered a certain amount of radiation to the brain. The brain will not tolerate more radiation.
- [57:55]
A
Got it.
- [57:56]
B
Or we've already given. They've already failed these first two chemotherapies. It's still progressed. What else can I give them? Well, I could give them this chemo. Well. But I can't because it may hurt their kidneys or their white blood cell count. Or I could give them this chemo, but it has these side effects. And so that's kind of where the art of medicine and sort of the team think really is important.
- [58:16]
A
Yeah. What are some of the stuff, like some of the things you see with the spine?
- [58:21]
B
So the stuff that we'll see, sometimes you'll see gliomas. So the same gliomas that can form in the brain can also end up in the spinal cord. Those are very challenging because those are primarily treated with radiation. Oftentimes they need a biopsy from us to know. Figure out what it is.
- [58:40]
A
Yeah.
- [58:40]
B
But if you. If you take that out, I mean, you're going to paralyze somebody from the. From the spinal cord. Right. So you got to be very careful with those. Sometimes you see a lot of benign tumors called meningiomas that are just pressing on the spinal cord.
- [58:51]
A
Yeah.
- [58:51]
B
Those are tremendously gratifying because you take that away and patients get better. Right. You can take those. Take those out.
- [58:57]
A
Are they easy to take out something like that?
- [58:59]
B
Again, it depends on where it's located and how big it is. Right. But those are tremendously gratifying because somebody who can't walk, you take out a meningioma pressing on the spinal cord, and. And amazingly, they're within months, they're doing better. Right. You know, and then there are some very. You know, we also see tumors that can spread up and down the spine. So it's not uncommon for somebody who's got metastatic breast cancer to the brain to end up having tumor, which goes in the spinal fluid itself and sort of covers the nerves and the nerve roots in the spinal cord. That's not something you can take out. Right. That's something that we say somebody may be very symptomatic and we're treating just with chemo or radiation alone.
- [59:39]
A
Right. And is that. That's. I guess that's just keeping them comfortable to A point.
- [59:44]
B
Yeah. I mean, I think once it gets to that point, those, those patients are in. In a tough situation.
- [59:49]
A
Yeah, yeah. What about. So you don't do anything with kids.
- [59:52]
B
That's not anymore. We'll see some younger kids, like, you know, 15, 16, 17 years old, but the majority of those are still treated at the pediatric hospital.
- [60:02]
A
Right. What I was, I'm always curious in like the St. Jude's like, what. Have you ever seen anybody you had a send over there or that's real small kids. What's the cut off like?
- [60:13]
B
Well, I think, yeah. I mean, for the majority, especially in Atlanta, I mean, we have such great care at Children's Healthcare of Atlanta. Right. So, you know, we will typically defer towards them and especially if they have a real malignancy. I mean, a lot of it is, you know, they have protocols and clinical trials specifically designed for children.
- [60:30]
A
Right.
- [60:31]
B
And so a lot of those patients should be treated in a pediatric hospital.
- [60:34]
A
Right.
- [60:35]
B
Sometimes as, as, you know, kids are older, you know, their late teens, early 20s, you know, we're happy to take care of them, but for the real little kids, I mean, they really should be treated at the pediatrics.
- [60:45]
A
Yeah.
- [60:45]
B
Yeah.
- [60:46]
A
Okay. What is, what does life look like on a daily basis when you are not in the operating room or not at work? What are you doing?
- [60:54]
B
I mean, I. So I've got two younger kids, 8 and 11 years old. They're both pretty heavily involved in sports. They're both playing basketball right now. And so, you know, a lot of our nights are spent going back and forth to the rec center, you know, for practice and games. You know, I, I'm an avid golfer. We, you know, I try to play, you know, three or four times a month as much as I can. You know, our family, we love to. We love to ski. We love to be on the boat at the lake. So we try to do a lot of outdoor things and a lot of sports, which I think is great.
- [61:31]
A
Yeah. Your wife in medicine as well?
- [61:34]
B
So she. I will say kind of. So my wife, Courtney has a PhD in biostatistics. And so for the longest time she was working in research at a couple. She worked at Children's Healthcare of Atlanta and then at Kaiser, where she was helping design research, studies and, you know, publications. And then she actually made a tremendous sacrifice for our family where we were really trying to get our kids into a charter school where we live.
- [62:03]
A
Yeah.
- [62:03]
B
So she recently took a job teaching at our charter school so our kids could go to school there. So.
- [62:10]
A
Yeah.
- [62:10]
B
So she's Doing that right now.
- [62:11]
A
That's fascinating. Is there any. Is there any nugget or nuggets you would leave people with as far as, like, maybe here's some stuff, you know, about studies that are happening. Like just if you're gonna do something or don't do something, here it is right here. Don't smoke. You know, whatever.
- [62:30]
B
I. I would say, I mean, you know, as. As humans, we tend to think the worst when we have a symptom.
- [62:37]
A
Right.
- [62:37]
B
I'd say the vast majority of people don't have a brain tumor. Right. When you have a headache, when you're dizzy, when you're this and that, you know, don't jump right to the thinking that you have a brain tumor. The majority of people do not in the grand scheme of things. They're rare things that happen.
- [62:51]
A
Yeah.
- [62:53]
B
You know, most of the time it's, you know, well, I stared at my phone for too long or I didn't get enough sleep or I didn't have caffeine or things like that. Right. You know, but I will say, you know, to the people who end up having, you know, to brain tumors, you know, you want to find a place that has tremendous experience treating those things and has a wonderful team around them, but more, you know, more on top of that. I mean, some of the things that we do now in medicine, you know, patients are living so much longer and we're providing so much more benefit and quality of life than we were able to five, 10 years ago. So, you know, while some of these diagnoses. Diagnoses can be devastating, there's still a lot of hope to be had.
- [63:35]
A
Sure.
- [63:36]
B
And, you know, and that, that really comes from finding a team who can, you know, who knows their way, you know, around these diseases, can usher you through them very safely. And so that's what I would. That's what I would leave people with.
- [63:50]
A
Yeah, that's good. That's good. Good hope, good encouragement. Well, that was probably the fastest hour.
- [63:57]
B
Was it an hour?
- [63:58]
A
I can't believe it's actually over an hour already. I can't believe it. But just so intrigued by it. So, folks, hope you found hope in this story. Dr. McCracken, thank you. I mean, thank you so much for coming and spending this time with us. So as always, if the, if the show brought value to you, appreciate if you would subscribe to the channel and share your thoughts below. Thanks for joining us.