Outside, a winter storm brings lashing winds and heavy rain to Houston. But in a surgical suite in MD Anderson's Main Building, Nicolas Salazar is waking up in a hushed room.
Coming out of anesthesia, he recognizes a kind face. David Ferson, M.D., professor in the Department of Anesthesiology and Perioperative Medicine, smiles and gently clasps his hand.
"You're doing very well, Nicolas," he says softly. "How do you feel?"
And with that, the most important member of the team for an awake craniotomy, in which the patient is conscious and talking for a portion of the surgery, has arrived.
'Mapping the brain' before removing the tumor
A 63-year-old insurance broker from Lima, Peru, Salazar is having his second brain surgery in as many months. Diagnosed late in 2011 with a central-brain glioblastoma, he underwent surgery in Lima in December. But the tumor was too difficult for the surgeons to remove, so Salazar and his family came to
The lead neurosurgeon in Room 23 is Raymond Sawaya, M.D., professor and chair of the Department of Neurosurgery, assisted by fellow Lana Christiano, M.D. Before awakening the patient, they opened his skull to expose the brain.
Now they will "map" the brain, with Salazar's help. The awake procedure is ideal for certain brain tumors because the surgeon can trace the contours of the patient's tumor to ensure that areas of the brain that control speech and movement are not involved. The goal is to excise as much of the tumor as possible without harming the patient's ability to think, speak, move or reason.
In such a procedure, the anesthesia team first sedates the patient intravenously, then inserts a laryngeal mask airway for more precise control and delivery of the mix of anesthetics and sedatives. Once the patient is deeply asleep, the anesthesiologist administers a scalp block to completely numb the patient's scalp for the surgery.
After the brain is exposed, the surgeon asks the anesthesiologist to awaken the patient so he or she can answer questions designed to demonstrate that speech faculties are intact.
'What do you see right now?'
Ferson shows Salazar a series of laminated flash cards, and Salazar names what he sees in Spanish and English. "Bull, toro. Train, tren. Shirt, camiso," he says.
On the other side of the drape, Sawaya administers light electrical charges to areas of the brain. Salazar stumbles only once or twice, and Sawaya makes note of that.
Throughout, Ferson offers the patient ice chips, reassures him he's doing well and clasps his hand. He focuses solely on Salazar and Sawaya. Behind him, James "Monie" Perry, certified registered nurse anesthetist, keeps his eyes on the complex machines that indicate the patient's vital signs.
Once the brain is mapped and the tumor is removed, Sawaya asks Ferson and Perry to put Salazar back to sleep for the rest of the operation.