What motivates and frustrates four trailblazing women in neurosurgery.
You get the call. A 35-year-old comatose patient has just arrived with a subdural hematoma and cracked skull following a high-speed motor vehicle crash. You need to be at the hospital within 30 minutes. Your daughter tears up because she was looking forward to family movie night later. At the hospital, you perform emergency surgery to give the patient the best possible chance at survival. And you meet with the family members and see the fear in their eyes as they go through some of the worst hours of their lives. Eventually, you head back home to rest. But it’s not over, because you’ll be on call again in three days.
For neurosurgeons who take trauma calls, 24-hour availability and readiness are critical. Recent research on molecular mechanisms of acute neurological insults has shed new light on the value of earlier inventions to prevent secondary insults after neurotrauma.
Whether it’s one night a week or a week each month, being on the neurosurgical trauma schedule is part of many neurosurgeons’ core responsibilities. And it’s not easy. We talked to four neurosurgeons, in varying stages of their careers about how they handle the neurotrauma schedule, the toughest parts of being on call and what they say makes all the sacrifices worth it.
The Neurosurgical Trauma Schedule
Taking trauma calls can mean different schedules and responsibilities depending on location. A 2019 study of practicing neurosurgeons of the American Association of Neurological Surgeons and Congress of Neurological Surgeons revealed that:
- 6% take trauma calls every night
- 12% are on call every other night
- 22% every third night
Dr. Charles Prestigiacomo, a neurosurgeon for more than 20 years, is professor of neurological surgery and director of endovascular and neurovascular surgery at the University of Cincinnati College of Medicine. He says that being on the neurosurgical call schedule for nearly half of each month means staying close to home—never more than 20 minutes from the hospital.
“It’s not like I’m just staring at the phone for 48 hours,” he says. “My wife and I do things around the house. She does her cross stitch. I try to build things. We clean the house; we take care of the garden or watch a TV series or cook. Knowing that if I need to leave, she can take over.”
Yet the schedule can be draining. “Sometimes it’s not just about the tension of waiting for the phone to ring or the pager to go off,” Dr. Prestigiacomo says. “It’s also that if you have to go in, it sucks up hours of time and there may be another case waiting for you. You may be there operating all day on Saturday, plus the rounding that you have to do with the residents to make sure that all patients are doing well.”
The neurotrauma schedule doesn’t faze Dr. Raul Cardenas, a third-generation neurosurgeon at Semmes-Murphey Clinic in Memphis. He’s been practicing for 11 years and takes trauma shifts for about one week every month. When he’s on call, he ends up heading into the hospital about a third of the time he’s called for a consult.
“This has always been my lifestyle, so it doesn’t really affect me that much,” Dr. Cardenas says. “Trauma’s one of those things where it’s busy all summer long, but then it slows down dramatically in December and January.”
Being on call means you must be able to travel to the hospital within 30 minutes, says Dr. Richard Williamson, Jr., director of the Allegheny Health Network Cerebrovascular Center in Pittsburgh. A neurosurgeon for 13 years, he’s on call for neurotrauma every six days. Of those, he’s called into the hospital about every third shift.
The 2019 survey revealed that most neurosurgeons—86%—take trauma calls. “I knew this schedule would be part of the job. I knew what I signed up for,” Dr. Williamson says. “But what attracted me to the field was the acuity of the patients. We’re making life and death decisions. There’s no time to waste. You’ve got to get into the operating room and help them right now. You can just see the fear in the family’s eyes when you’re talking to them about their loved one who may or may not make it through this.”
Taking Trauma Calls Means Thriving in Chaos
When the phone rings and you’re called into the hospital for a neurotrauma emergency, you will often tackle the most complex cases.
“You’re going through the crisis of that moment together,” Dr. Cardenas says. “There’s that sense of ‘Hey, drop everything because this person needs us. Everybody sort of perks their ears up and starts paying attention because they want to help the patient in the best way they can. It’s about doing their best and being in the moment and making sure that we have everything we need.”
Dr. Cardenas grew up with both a father and grandfather who were neurosurgeons. He laughs about television dramas that make the trauma surgeon lifestyle seem so dramatic. “It’s kind of like everything in life,” he says. “If you like to do it, you’re always blessed to be stressed. If you like your job, it shouldn’t stress you out. You should be able to do it well and try to help people as best you can.”
Of course, not every patient can be saved. And sometimes the trauma team’s efforts benefit the patients’ family the most.
“You’re giving them closure, letting them know that everything that was done was not in vain,” Dr. Prestigiacomo says. “The families can go home and reflect on it years later. Whether the injury was from violence or a bad car accident or something else, at least the family can look in the mirror and know that everything that could be done was done and that no stone was left unturned. That’s really important.
“The bottom line is that if you do it enough times, you will save people,” he continues. “And you have to learn to be able to let go and know that you’re not going to save everyone. You can’t change the rules of life. But you can certainly try to bend them a little. And that’s what makes people move ahead and do it again and again.”
The Emotional Toll of Trauma Calls
Dr. Enyinna Nwachuku, director of neurotrauma at the Cleveland Clinic Foundation and a neurosurgeon for seven years, says you have to be comfortable with what the job is going to entail—time, energy and stress.
“This is a job that takes more than it gives, and you have to be ok with that,” says Dr. Nwachuku, who is on the neurosurgical trauma schedule up to eight times a month.
He says a trauma call can look chaotic—like everything is happening all at once—but it’s an organized chaos. “Maybe 10 things that are happening, but only seven or eight are actually vital to making you successful in that environment,” he says, “so you have to forget about two or three of those things. That’s what trauma experience gives you: The chaos becomes more normal, and you live in that chaos quite well.”
Sometimes you’ll have the most miraculous saves, but other times the patient won’t survive.
“This is where the rubber hits the road,” Dr. Williamson says. “Patients come in, whether it’s a traumatic brain injury or a traumatic spine injury and we have the potential of reversing that injury. You see some of the biggest saves. But then we have a certain percentage of people, who, despite us doing everything right, will have a bad outcome just because of the severity of their injury. You have to take the good with the bad. You have high highs and low lows.”
Patient emergencies rarely happen at opportune times, and Dr. Cardenas considers neurotrauma duty both a blessing and a curse. “You are taking care of people at their time of need, but at the same time, that may be at an inconvenient time for you,” he says.
Dr. Prestigiacomo’s wife has told him she sometimes feels like an exhausted single parent raising four children. Dr. Cardenas recently bought movie tickets for his family but had to back out at the last minute due to an emergency.
Dr. Nwachuku remembers just starting out, he was given the lion’s share of on-call shifts and went six months without a full weekend off. He worked on Thanksgiving often enough that he began a family tradition of celebrating the holiday the weekend before.
“When you’re on call you really can’t plan your life out to a T,” he says. “Work life balance becomes a big problem sometimes, but I think it helps when you have great partners and a great staff who help to mitigate that for you. And I think eventually you become accustomed to that life and make life work around that schedule.”
How to Still Have a Life When on Call
Taking neurotrauma calls can take a toll on family life, but Dr. Williamson said it often just takes careful planning. “If we have to go out or take the kids somewhere, my wife and I have to drive separately,” he says. “It’s always in the back of my mind, thinking, ‘If I get called, what’s my game plan here?’ It’s probably not a good time to go out to dinner with your family or take your kids to a ball game.
“We say, ‘Okay, we’re going to hang out at the house and watch a movie tonight because dad’s on call,’ he continues. “My wife and my kids are supportive of that. But we have three kids with activities and a lot of stuff going on. Honestly my wife probably bears 95% of the responsibility of that and obviously I couldn’t do it without her.”
Dr. Cardenas tries to spend time with his nine-year-old twins whenever possible, sometimes between cases or in his elective schedule. “In the summers, if I have time, I’ll come home and spend time with them,” he says. “We play ping pong, get in the pool, draw, play piano or kick the soccer ball around.”
Dr. Nwachuku says his family has adjusted to his schedule, but he makes sure to prioritize the time they do have together. “When you’re not around often enough, you make the time that you are there count. My wife and I are mindful that everything else may be chaotic, but we try to be deliberate and keep our time together as constant as possible.”
For Dr. Prestigiacomo, the sacrifices are part of the job. “Do I miss not having been at the soccer games for my kids?” he asks. ‘Do I regret having missed the plays? Do I regret not being there when they had their first step or their first words? Of course I do, I’m a dad.
“But back then, if I wanted to be a neurosurgeon, I knew I had to make those sacrifices. Having a wife who’s in the field—she’s a pediatrician—makes it a little easier because she can explain it to the kids. That helps tremendously, but it’s important that I don’t take advantage of that.”
Decompression Is Critical
Neurotrauma emergencies mean family members and patients are having some of the worst days of their lives, but for the attending neurosurgeon, such high stakes and tension are a daily routine. To sustain that, it’s critical to deliberately manage the stress of taking trauma calls.
“Whether it’s going out for a run, hanging out with your loved ones, reading a book or something else, you need to have that balance to be able to decompress,” Dr. Prestigiacomo says. His own methods have changed over the years—from reading, photography and building model ships to spending time with his family. Now an empty nester, he prioritizes quality time with his wife.
“We make sure that every Friday night that I’m not on call we go out to dinner where the phones are away, and we have a change of scenery,” he says. “We catch up with the week and catch up with each other, without the bills on the kitchen table and all of the other stuff that’s usually around.”
After a tough case, Dr. Nwachuku tries to decompress before coming home to his family. He can still recall the case of a 23-year-old involved in a scooter accident who suffered a massive subdural hematoma and was close to death when he arrived at the hospital. Despite emergency surgery, the patient died.
“It’s hard when it’s a young person,” Dr. Nwachuku says. “I’ve seen it before, but this one bothered me for several days. In such situations, I always ask myself, ‘Did I do my best?’ ‘What could I have done differently and would someone else have done anything differently?’ That doesn’t make everything go away but allows you to know that you did what was in your power. Once you can alleviate any uncertainty, it allows you to get back on the horse and do it again. You allow it to affect you emotionally, but not cripple you.”
Because it’s often busy at the hospital, Dr. Williamson has found his own schedule for decompressing after emotionally draining trauma calls.
“My routine is, before I go to sleep, I reflect on the cases of the day and think about how it’s affecting my own wellbeing and thoughts,” he says. “I use my wife, who is a primary school teacher, as a kind of a sounding board. She really helps me sort through my thoughts because she doesn’t necessarily see things from a clinical perspective. She knows enough about medicine because my life is absorbed in it, but she has a healthy outside perspective that helps balance it.”
Family is where Dr. Cardenas finds support. “I love coming home, and if the kids want to do something, that takes my mind off of things,” he says. “I play the drums and sometimes we have a jam session. One of them will play the keyboard and the other one’s starting to play the guitar. And if it’s too late and they’re asleep, I’ll just drink a cold glass of water or something like that.” He also talks to his wife, a urologist who also takes trauma calls. “She’s always very interested in knowing what I did that day,” he says.
The Future of Neurotrauma Coverage
The U.S. is facing a shortage of neurosurgeons with experts projecting a deficit of 1,200 neurosurgeons by 2025. Meanwhile only 160 new graduates join the neurosurgical workforce each year, according to an AANS workforce analysis estimate.
“This is particularly important at a time when there is an increase in the need for acute neurosurgical intervention in trauma and in stroke,” wrote Dr. Jefferson Chen, a neurosurgeon at the University of California-Irvine, in a 2019 issue of Neurosurgery. “Additionally, with an aging population, there is the expected increase in the need for urgent neurosurgical interventions for chronic neurosurgical problems (i.e., sequelae of ground level falls).”
Other medical specialties also face shortages, but Dr. Nwachuku said the scarcity of neurosurgeons is intensified because more graduating physicians prefer more control and routine in their lives, i.e. work life balance, which neurosurgery doesn’t abundantly provide.
Having a strong support system is imperative to managing a neurosurgical trauma schedule, says Dr. Prestigiacomo, so you can jump immediately into action when needed. “In trauma, you have to break into your salvage mode,” he says. “You have to turn the switch and say, ‘We need to save the patient’s life, and we will figure out what comes next.’ You need to think about medicine on a global scale and on a societal scale and you need to think about it from the perspective of the patients and their families.”
The neurotrauma schedule can be unpredictable and entail long hours, but it’s important to find time for yourself, says Dr. Williamson. “We’re dealing with some pretty heavy stuff, and you need to take time to reflect on what you’re doing and the emotional and mental toll it takes on you,” he says. “I think you can run into a trap of bottling everything up and then not even realizing how much it’s bothering you.”