Muse

hey snappa dappas i'm sharing something special this week it's an episode of the podcast what it's like to be from author dan heath and every episode dan speaks to someone from a different profession a veterinarian an aircraft carrier commander a christmas tree farmer he asks what it's like to do what they do? Like, how does the lineman know it's safe to grab wire carrying thousands of volts? What does the diplomat do when an entire embassy has to evacuate overnight? Or how does an aerospace engineer handle the seven minutes of terror to decide whether a Mars rover lands safely? If you've ever met someone whose work you were curious about, This is the show for you. Here, Dan asks a brain surgeon about the most harrowing part of a brain surgery, why he operates on people's brains while they're awake, and his remarkable path to the operating room. If you dig it, find more episodes of What It's Like to Be, wherever you get your podcast.

How should I refer to you? What do you prefer?

You know, I can go for almost anything. My full name is Alfredo Quiñones Inocosa. Some people can pronounce it, some people cannot. And this is why people began to call me Dr. Q.

Dr. Q is a brain surgeon and chair of neurosurgery at the Mayo Clinic's Florida campus. He's got an absolutely astonishing life story, which we'll get to later. But first, I want to zoom in on one of his surgical days. He says his work begins long before he steps into the operating room.

So the moment someone sends me a picture about their scan, their surgery begins to happen in my brain. The potential complications, the potential dangers, the issues that can become catastrophic.

On every surgery day, he follows a careful routine.

I like to come in early in the morning. I like to review all the films, review my notes about the patient and family.

Most of Dr. Q's surgeries involve removing brain tumors. And in the morning, as he studies the images, he's mapping out the challenges ahead.

It's like when a boxer walks into the ring. It's when the lights are above them. But the real training, the real fight happened in a dark room, in a dark gym, day after day for many, many days before the surgery months. In my case, it's many years of preparation. But that morning, when I'm looking at the films, I am cementing all those years of training into one specific moment where I know exactly what I need to do. and I have an idea about the potential dangers and how to dance around those potential dangers.

I'm Dan Heath, and this is What It's Like to Be. In every episode, we walk in the shoes of someone from a different profession, a hairstylist, a turnaround consultant, an archaeologist. We want to know what they do all day at work. Today, we'll ask Dr. Alfredo Quinones Hinojosa what it's like to be a brain surgeon. We'll talk about how he knows where to cut and not cut, what it's like when the operation does not go as planned, and his own remarkable path to the operating room. Stay with us. On the day of his surgery, after Dr. Q has reviewed images of the patient's brain, he visits them before they're wheeled away to get anesthesia.

We already spoke about the dangers of brain surgery, and I like to keep it positive. I like to make sure that they feel my pulse, the worm of my hand. I like to sit right next to them. I like to ask them what they had for dinner the day before, And I like to ask them about some stories that I could potentially use in the operating room because the majority of my surgeries are with the patients awake and I have to monitor their speech and their function. So the more connections I have with them, the easier it is for them to overcome the fears and anxieties they have.

And do you still get nervous before surgery? Oh my goodness, and every time I am.

About to walk into the operating room, I get nervous. It's that fine line between life and death that gives you the pause, the preoccupation, the adrenaline to make sure that all your senses are hyper, not just acute, but are hyper acute. So time slows down. Your ability to see, hear, multitask, it gets super enhanced. And it's that adrenaline, in my opinion, that allows you to do things that are sometimes considered to be very challenging. For instance, the moment that something goes wrong, which has happened to me after you've done 5,000 surgeries, you know, there's been moments where suddenly something changes quite rapidly. a blood vessel explodes, the vitals change, a patient has a heart attack, the heart stops, you name it, anything. And at those moments, your adrenaline goes through the roof, your heart goes to 180 beats per minute, and yet you have to remain calm.

Paint us a picture of what the operating room is like for you. Is it quiet? Are you playing music? How many people are in the room?

I tell you, this is the operating room for me. It's like an orchestra. It's like a symphony. Because if you listen to the sounds of about 20 to 25 people moving around the operating room quietly, the anesthesiologists, the machine beeping, the machine breathing for the patient sometimes, If you then go on to the side and you look at the neurologists that are helping me monitor the brain function with electrophysiology and you listen to their keyboards as they're entering information or the squiggly lines that are beeping also, it sort of makes some music. And then you listen to the scrub techs, the circulating nurses moving equipment, and that sound is like the percussion, you know, in a band. And if you listen to the steps, you know, of the people moving around quietly in the upper room, where you listen to the scrubs rubbing, you can listen to all that and it becomes the most beautiful music you can possibly imagine.

What are the tools that you have at your disposal? Like, what are you holding or wearing as you operate? Well, several things.

I have high magnification glasses. They're called loops, you know, and a headlight. And once I get deeper into the brain, I bring a microscope that it is more expensive than my house. You know, it gets in there. and it gives me amazing light and a microscope that I can control with my mouth.

Wait, say that again.

Yes, I control the microscope with my mouth. You control the microscope with your mouth? Yes, usually I have a small little handle that is in my mouth that controls this piece of equipment that is over a ton, and I can move it, and it's all the technology then. Isn't that amazing? And I can still talk because I usually use my teeth a little bit, And I can still talk the way that you hear me talking as I'm moving the microscope.

So you're sort of like chomped down on something and you move your head to turn it or you're using like breath in and out or what's the.

I use my head. Imagine you just you just put put a pen in your mouth and you just move in your pen. That's it. That is crazy. Then on top of that, I'm not done yet. Then I use a special chair that has all kinds of controls. You know, in my feet, in one foot, I have about 16 controls that allow me to do things with the chair and the microscope that suddenly I am fully connected to the patient in such a way that the patient, the brain, the microscope and myself were almost one person. So with one foot, 16 controls, with the other foot, about eight controls, and both of my hands are underneath the microscope under high level of magnification. And you have instruments that are finer than the finest pen you can possibly imagine doing microscopic movements to separate a small little blood vessel that is the size of a hair. But you know that that little blood vessel could potentially mean the difference between memories or no memories, speech or no speech, motor function or no motor function. So that's how. your time and your patience and you're listening to the orchestra, the symphony of the operating room, and you're moving your hands and your nurse predicts the instrument that you're going to need a small little microscopic scissors, small little microscopic, very sharp instruments that may look like a little scoop, small little instrument that may look like a little spatula that moves a blood vessel, the brain, or sometimes you use small little devices that cauterize small little vessels. They look like tweezers and you're getting together and

you're moving around. One of the most striking things about brain surgery is, as you said, that the patient is often awake. Why is that important? Well, Dan, the reason why being awake

is important for me and my specialty because I do brain surgery. There are brain surgeons that do epilepsy. There are brain surgeons that do vascular neurosurgery. I do brain tumors. And the majority of the brain tumors that I do are intricately related and adjacent or sometimes invading and penetrating parts of the brain where speech function is important, where motor function is important, where sensory function is important, where vision is important or memory is important. And there's no machine then in the world that can monitor those functions better than the patient's own brain. So what I tell patients when they ask me, why do we need to do this surgery awake? Like I said, because your brain is the best neuromonitoring technique that I have available in the world to be able to do the best surgery for you.

So is the idea that as you're inspecting the site of the tumor that you can, you know, deliver little electrical zaps to different part of the brain and you're kind of monitoring to see, okay, when we zap that, does anything bad happen? Is that the idea?

100%.

I zap this little area and suddenly the patient stops talking. And I know, oh my gosh, I should not take that out. But how, I mean, there's like a thousand different things that your brain does. I mean, how do you sort of monitor for all those things in real time?

So over the years, what we began to realize is that the brain has function, is organized, his eloquence, his parts of the brain that are like oceans where we have no idea what kind of function is there. So the way I deal with my patients, I ask the question. You know, I recently had a patient that mathematics accounting was very important for him. And we needed to make sure that we preserve that function to the max. So before going to the operating room, we did maximum amount of testing to maximize the test that we could do in the OR that will maximize that function preservation. And that's what we do.

Wait, so you were giving him like math questions during the surgery?

Yes, math questions during the surgery. Absolutely. Very complex math questions to which I had no idea what the answer was.

So you had to refer back to his own answers to see if he was getting it right?

Well, I had a neuropsychologist. We had a mathematician, you name it. And then imagine, I had another patient who was a patient that was a music, a classical guitar expert. And he did an amazing job. He had a two-hour concerto that he put together for me. So during my entire surgery, he was serenading me with music from my own country, from Mexico, from the 40s and 50s. You know, music from the United States from the 60s and 70s. So he had a whole two hours because I had to make sure that I preserved. He says, I'm okay if I cannot talk, but I cannot not play music. I need to play my guitar. You know, I had another patient recently that he was important for him. He works at an airport and he directs traffic. So air control. So we set up our computer to simulate what the work would be like. And during the surgery, he was monitoring flights, directing flights, doing all kinds of stuff.

That is so interesting. So it's actually different for different patients. I didn't expect that. That's exactly.

For someone like you, it would have to be probably depend, just listen to you, which make sure that we preserve your voice, your ability to ask all these probing questions in an interview and you name it.

so what are the kinds of classic tests that you're administering as you work? You're looking for speech comprehension,

I assume. What else? Well, there are some baseline things that we have sort of utilized for decades. The ability to read sentences, the ability to understand complex instructions, you know, the ability to produce speech that complements being asked a question and then being able to answer that question. What does the cow do? Will they move? What does the tiger do? And so on and so forth. So there's a lot of questions that are baseline functions. And I follow the best way that I can describe it. The brain has salsa and gyra. The best way that I can describe it, It has roads, avenues, and I go avenue by avenue, road by road, and I begin to stimulate and put in numbers. And when I find an area that has a question, I pause, I keep going, and then I go back to that area a few minutes later and find out, is that area important? Was that just a mistake or was it real? and then I do it at a minimum of three times to confirm that it was not just an oversight because we all make mistakes.

So when you hit a part of the brain that clearly is responsible for some core function and you realize it, how do you realize it?

Sometimes it's so abrupt. You know, let's say that I have a patient and I tell the patient, I want you to count from 1 to 40, and they start 1, 2, 3, 4, 5, and I'm waiting until they get a rhythm, and then when they're like around 10, I go ahead and stimulate a part of the brain, and there is no function. and they keep counting like nothing. If it is a part of the brain where I can literally stop language, the patient stops as the moment I touch the brain with my stimulator, they stop at 10, and they pause. And I got my stimulator on the brain for one second, two seconds, three seconds, making sure that I don't give any seizures. And then suddenly I take the stimulator away from the brain, And the patient continues, 11, 12, 13. And then you ask them, what happened? And they'll be like, what do you mean what happened? I was counting. They don't realize that you have them stop time. Isn't that amazing? That's how beautiful the brain is.

That is completely insane. What is the strangest response you've ever gotten from one of those tests?

Well, the strangest response is eliciting memory. The strangest and at the same time, more beautiful. You know, we're stimulating a part of the brain and suddenly the patient will remember a memory of childhood, a beautiful memory of their parents, a beautiful memory of their pet or something very powerful. And they get either very ecstatic, happy if it's a happy memory, or they get very sad if it's a sad memory. And that to me is the beauty of how little we know about the brain and how much more we need to learn.

This is absolutely fascinating. I mean, what is so striking is that, I mean, here brain surgery is surely one of the pinnacles of human achievement. I mean, the sophistication of the people in the room and the tools and the monitoring. And then adjacent to that is the actual mechanics of the surgery are you're going around poking parts of the brain to see if they're safe to cut out with a knife. You know what I mean? It's like this incredible blend of complexity and almost like plumbing behaviors.

100% I agree with you. And I poke fun at myself. I tell people that I'm nothing else but a highly regarded mechanic of the brain. That's it. That's how I see myself. And of course, I do recognize it, that it is very complex. It's very sophisticated. And it took many, many years to get to where I am. Of course, I've been doing this for over 25 years. But the reality is that there's some level of simplicity that you very eloquently illustrate. You got to roll your sleeves up and you got to get in there. And you have to have sometimes little splashes of blood in your face. You got to get a little bit of that bone dust that comes along when you are removing this skull or sometimes a little bit of the smell of the muscle as it's being, you know, cateurized with electricity and the little smoke that comes out. That's 95% of my work, but a lot of the attention is in the 5% because it is.

It is absolutely remarkable. I got to tell you that the most remarkable thing for me is not what I do as a brain surgeon. It's not the technology, but to me is the fact that a patient and their loved ones are willing to put their lives on the hands of a stranger. And that to me speaks about the power of trust and the power of believing, which is all in the brain. And that to me is remarkable.

After a quick break, what's the most stressful part of a brain operation? Stay with us. What is the track record for the kind of brain surgery that you do? Is it relatively high percentage chance of success or are the situations so precarious that any chance of success is worth trying?

Likely nowadays is extraordinarily high. The chances of complication for a healthy person, you know, are probably in the one to two percent. Really? Wow. Think about this then. 100 years ago, it was almost a 100% mortality with brain surgery.

Yeah.

So we have come a long, long way.

When they brought the leeches out, you know. Yes.

Remember, they used to. So I think the chances of success are very high. Now, having said that, there's still a percentage, 5% to 10%, that you may have an issue, that you may have a deficit, whether it's motor function, inability to move the hand, leg, face or some sort of a speech deficit and at one point you don't know exactly if it was done by the surgery or exacerbated by the surgery or was it just the fact that the air hit the brain and you mobilized things or the disease is moving so rapidly that it's affecting other parts of the brain But nonetheless, luckily, the chances of success are so, so high. Now, every now and then, you will have a patient where you look at the scans and you realize, no matter what I do to this patient, all I am going to do is do a brain surgery, and they're going to spend the last few months of their life in and out of the hospital. So I want to do what is best for this patient and their family. And sometimes what is best is not to do anything. What do tumors look like? You know, in the MRI, tumors look most of the time like a light bulb. And people say, oh, there is the tumor. It should be no problem taking it out. Once you walk into the operating room, many times there is no clear distinction. between what is tumor and what is normal, and most especially at the edges of the tumor. When the tumor begins to invade the brain, and we know there are cancer cells right there and very likely important brain at those edges, but you can't tell the difference. What does it feel like when the surgery is over? Well, first of all, I tell you that for me, the most stressful moment, if everything went well with the surgery, as I expect that it will go, I finish the surgery, I wait around until that patient is awake and moving.

In 2008, ABC's documentary series Hopkins followed Dr. Q at Johns Hopkins Hospital in Baltimore. Cameras rolled as he performed brain surgery.

What do you think we have here? It's a fairly straightforward meningioma. Wonderful news. Thank you.

And the patient is getting extubated at the end of the surgery, and then the anesthesiology is going, show me two fingers. No function. Squeeze my hand. No function. And then I'm looking at this, and I'm getting worried, all right, because I know what that potentially means. So I come in, and I say,

Michael, squeeze my hand. Squeeze my hand, Michael.

Squeeze. And you're literally yelling, because remember, they're coming out of anesthesia.

Squeeze my hand, bud. Squeeze my hand.

At that point, my heart was about... burst out of my chest. I was thinking, did I do something to that patient that that patient is not going to be able to wake up? Wiggle your toes. Can you wiggle your toes? There you go.

Very good. Yes. Yes. It's just great. Just great. I mean, just, this is what keeps me going every

day, you know. I mean, I deal with very bad disease, you know. Brain cancer is tough. But every now and then when you just have this nice, very good news, it's just exciting. Everything went great. So he'll be Mike again. I think so. Thank you. Very good. Okay.

I tell people we are not better doctors than many other doctors. We are not better surgeons than many other surgeons, I think that what makes us special and different, why society has put us where we are, is because we have this amazing ability to emotionally deal with so much uncertainty, and where the outcomes and the stakes are so high every single day between life and death in the operating room.

What is it like when the surgery just doesn't end in a success?

I would say that the most difficult times in my life, the moments where I have landed and got down in my knees where life just puts you down and you feel like there's a fine line between not wanting to do this again and quitting. have been those moments where the surgery didn't go the way that I didn't want it to go. And I cannot tell you that it's never happened to me. Unfortunately, when you have done this for more than 5,000 times, it has happened to me. I think those are the moments that have taken years of my life, Dan. And those moments, I got to tell you, they're not easy for me to get over. It takes weeks, months, years. And I always tell people, I carry those scars in my heart. I have never forgotten the patience that have passed through this life where I have wondered, did I do something to accelerate that demise?

there's a great netflix episode about you and your work we'll put the link in the show notes but at one point you have this quote where you said you went from harvest to harvard in less than seven years tell our listeners what you meant by that it was amazing it's you're talking

about the surgeon's cut that is a quote that most people don't realize i came to this country in 1987, undocumented, from a very poor family in Mexico. They had, my parents had no education. I was undocumented. I was poor. I came to this country undocumented and poor to work on the fields of California in 1987. And by 1994, I was matriculating at Harvard Medical School.

That is absolutely crazy. I mean, what do you attribute that to?

You know, I got to tell you that I wish I could give you the recipe for many. It's now, now. It made me reflect about the miracle. And I attribute this. I'm going to say it. I attribute this to how amazing this country is. This is the country. This is the land of opportunities. Now, don't take me wrong. We still can do a lot for humanity, for our country. But I cannot conceive stories like this happening in too many places around the world. And I still believe they can only happen here in the United States.

Another point in the episode that I appreciated, and correct me if these facts are wrong, but at one point I think you said that you're one of 50 grandkids for your grandfather and that you were the worst behaved of the lot.

I was one of 54 in my father's side. I was not the oldest. I was not the youngest. I was not the smartest. I was not the hard work.

My distinction was that I was the one who got in trouble the most all the time. I had such an inquisitive mind and a curious personality. And when people say no to me, I want to do it even more. So my grandmother and my grandfather played an important role. My grandfather, he was an extraordinarily gifted man in music, and even though he never went to school, he learned how to play many instruments, and he had a wandering spirit. He would allow me to go and explore, and I could do no wrong in his eyes. And my grandmother, she was the opposite. She was the one who was also, by the way, a town healer and a midwife, and I saw the amount of respect that people had for her, the love that people had for her, but she had also a very strong personality, and she was a disciplinary towards me. And nowadays, Dan, if you look at me, if you look at my picture and you look at a picture of my grandmother, imagine that you see me. The more I age, the more I look like my grandmother physically, spiritually, and also in my personality.

How much does being a brain surgeon affect the choices you make in your daily life? Like, are there things you won't do because it might injure your hands, which are, of course, precious for surgery?

you have alluded to something that I had to think about it because remember, I was a migrant farm worker. In 1987, I fixed a 351 V6 Chevrolet engine and so on and so forth. I was working in the field, picking cotton, tomato, driving all these machines. And suddenly here I am, years later after Harvard and after my residency and being at Hopkins, not here at Mayo, where, you know, I have to be careful with what I do. And that came clear to me when I finished Harvard and I went back to California, to the University of California, San Francisco, and I had my pickup truck. It was a 1987, you know, Nissan pickup truck. and the alternator needed to be exchanged. And I proceeded to bring my tools out and exchange it. And it was a little bit rusty and I was struggling. And suddenly one of the ranges slipped and I ended up cutting my hand. And it was for the first time, and I was already a resident in neurosurgery. It was for the first time that I realized that what I did had consequences, but not just on myself, but on the people that I care for in such a way that I couldn't scrub my hands for a few weeks until that wound healed. So that therefore my actions could have a downstream effect on other people that I care for. So, yes, there are things that I think about, you know, and you'd be surprised. So, you know, the Netflix, you saw it, you know that I love boxing. I don't get into the ring anymore. The last time is when I was 17 years old, but I love having my punching bag and exercising. What do I do? I wrap my hands and my wrist in ways that you could never imagine. And I also study for many, many years the way in which I should hit a bag without prompting any injury in my fingers, my wrist, or anything else.

So, Dr. Q, we always end our episodes with a lightning round of questions. Let me fire away here. What is a word or phrase that only someone from your profession would be likely to know? And what does it mean? Show me two fingers. That's the diagnostic that things are okay, right?

That's exactly right. Show me two fingers. But I also have some other connotations, as you know.

I thought you were going to give me some obscure neuroanatomical term or something.

Well, yes, I will do that too. Where is the Indusium Grisium?

Uh, above the neck?

Above the neck, that's right.

What is the most...

thing you could say about a brain surgeon's work. This is so funny that you ask that. I would say that the most insulting thing that you can say is, is not so much about my work, but the profession when someone, because it's actually insulting to the opposite profession. When someone says to you, oh, you're a neurologist and the neurologist gets offended and the neurosurgeon gets offended. The neurosurgeon gets offended because we're not neurologists. We know a little bit of neurologists. We like to think we're not as smart as the neurologist and the neurologist gets offended because they know that they're extremely bright and they don't put their hands on the brain. They work through diagnosis and medications and everything else. So I would say that that's probably insulting both ways to a neurosurgeon, a brain surgeon and a neurologist.

I love that. It's a rare two way insult. That's right. What is a tool specific to your profession that you really like using?

I personally like to use a bipolar coagulator, which is like a little tweezers that allows you to coagulate a small little blood vessels.

Like how small would the action zone on this thing be?

All this would be as small as imagine trying to grab a small little hair. Wow. With these little tweezers. You know, and sometimes the only way you can see that little hair is with the microscope. That's why you use the highest level of magnification.

That you're controlling with your mouth. That you're controlling with your mouth, yes. Is normal life just boring for you after spending hours in that kind of just... Never, never, never, never.

On the other hand, it allows me to see life with such an enthusiasm and such a love and not take anything for granted.

What is a sound specific to your profession that you're likely to hear?

It's the sound of the anesthesia machine beeping. The beep, beep, beep, beep, which is a heart beating. And you want to hear that sound all the time.

And I imagine you're so accustomed to that that you immediately process any deviations from the rhythm if it speeds up or slows down.

100%. And you're attuned. And you remember what I was telling you because you're listening to the music. You listen to the orchestra, the symphony, and if a note is off, you'll recognize it right away.

What's an aspect of your work that you consistently savor?

Oh, I savor every time I finish a surgery and everything goes well, as likely as most of the time. And I put families on the room and I walk into the room. I mean, the first thing that I like to tell the family, everything went well and they all stand up. And before I even get close to them, they're rushing to hug me. And those moments are so private and they're so beautiful. And they are, they touch my heart. They fill me with hope and they give me the energy to keep going, even in those moments of darkness that we talked about earlier.

Dr. Alfredo Quiñones-Inajosa is a brain surgeon and chair of the Department of Neurologic Surgery at the Mayo Clinic's campus in Jacksonville, Florida. He wrote about his remarkable journey to the operating room in the book, Becoming Dr. Q, My Journey from Migrant Farmworker to Brain Surgeon. You'll find a link to that book in the show notes, along with his featured episode in the Netflix documentary series, The Surgeon's Cut, which is brilliant. I can't stop thinking about Harvest to Harvard in seven years. Incredible. As I see it, it's a story with two distinct sides. On one side is Dr. Q's vast potential and talent and drive to have the ability to vault himself upward like that. And on the other side is the ecosystem that allowed that potential and drive to manifest. So if you think about someone you manage, or your kid for that matter, you can ponder that same two-sided story. Are they capable of thriving? And one side is about their personal capacity and drive, and the other is about their environment. Are they in a place that permits them to thrive? It's kind of like a plant and the soil that it grows in. There are no universals with either. Some plants are delighted and...

a hanging planter, and some plants managed to grow 10 feet tall in the desert. How can we find the right soil for the people we care about? Dr. Q found a place to thrive, and thousands of families are lucky to have received his care. Identifying the talents that a patient could not stand to lose. Probing the brain to distinguish invader from host, performing in the symphony of the operating room, and sharing the news with desperate relatives that their loved ones came through okay. Folks, that's what it's like to be a brain surgeon. I hope you enjoyed my conversation with Dr. Q. In every episode of this show, What It's Like to Be, I talked to someone from a different profession. If you're interested in more health care professions, check out my conversation from last year with a hospice nurse. That's episode 45.

So we have to sort of negotiate food and what does it mean to respect the patient's right to not want to eat or I want to eat. I don't care if I'm diabetic. I want a milkshake or I want to eat the slice of cake and to say, just let him eat, let her eat, let her enjoy.

If you want a doctor, but for animals, we've got an episode featuring a veterinarian who is great.

It was a really pivotal moment for me in my life. And I've never stopped, you know, again, asterisks, not mosquitoes or roaches or ants or insects, but other living creatures, I've never stopped caring about them and really wanting the best for them.

And if you want something outside the medical field completely, we've got lots of those. Start with episode two featuring a couple's therapist.

You know, inevitably somewhere I get cornered on long runs, long rides. Anytime on like an airplane, someone finds out that I'm a marriage therapist and it is immediately just like a loss of the next two hours of my life and not getting paid for it.

This episode was produced by Matt Purdy. I'm Dan Heath. Thanks for listening.

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