Part II: On day of surgery, Fort Worth surgeon's steely resolve helps ease mom's fears

Second in a five-part series

The series so far: A terrified mother, Leticia Gutierrez, consents to brain surgery for her young son to alleviate his worsening epilepsy. When she meets Dr. David Donahue, head of neurosurgery at Cook Children’s Medical Center in Fort Worth, he is not at all what she expected

Tuesday, April 27

After a sleepless night, Leticia Gutierrez carries her young son through the predawn to the family car. She keeps 6-year-old Roberto on her lap instead of strapping him into the back seat, because on this day, the day of his long-dreaded brain surgery, the mother wants to hold him for every last second.

Her fiance, a construction worker named John, is behind the wheel for the short drive from their home in west Fort Worth. A block from Cook Children's Medical Center, the reality of Roberto's looming operation becomes too much.

Leticia starts to cry and pleads with John to turn around.

"I can't do this," Leticia says. "Let's go home."

But the epileptic seizures that have afflicted Roberto since he was a toddler have become more frequent and violent. Medication is less and less effective. For any respite, doctors say the only real option is to try to cut out the short-circuiting parts of the boy's brain, part of a multisurgery process that is scheduled to start that morning.

"You know he needs this," John says, driving on.

Inside the hospital a few minutes later, nurses and technicians hurry in and out of the room where Leticia, her fiance, and other friends and relatives gather around the drowsy boy. Leticia's pastor blesses Roberto, and he is placed on a gurney. Leticia fidgets in her chair, crossing and uncrossing her legs, feeling lightheaded, like she will collapse if she stands up. Seconds before Roberto is wheeled away, Leticia finally makes it to her feet, weeping again as she says goodbye to the youngest of her four children.

"We'll take real good care of him," nurse Abby Morse says.

Intense focus

As brain surgeries go, that day's operation on Roberto is not considered particularly risky. Dr. David Donahue, head of neurosurgery at the Fort Worth children's hospital, will perform a craniotomy, removing a section of the boy's skull and then placing a grid of electrodes against Roberto's brain. Electrode grid placement is a procedure that Donahue has done scores of times. If all goes well, he will be in and out of the operating room in a few hours.

But no brain surgery is routine. No matter the procedure, it is always delicate and humbling, involving hours of intense focus as Donahue works within millimeters of arteries and nerves and cerebral tissue that control human function.

From the time of his childhood, Donahue had been a cautious person, a worrier, and as a surgeon that has not changed. He has also never been able to shrug off the tragic aspects of his profession. His longtime surgical assistant, Rosa Leos, will always remember the surgery about eight years earlier when Donahue lost a young patient on the operating table, the only time in his long career that has happened.

The patient was a boy less than a year old who had been injured in a fall. During that operation, to repair the boy's head injuries, unexpected bleeding started from a large vessel in the brain. Ultimately, there was nothing Donahue could do.

"He apologized to the staff for not being able to save the child's life," said Leos, who has worked beside Donahue for 11 years. "He was probably thinking, 'Was there anything I could have done differently to save the child?' He took it hard for a long time."

So even after three decades and thousands of procedures, Donahue spends the quiet hours before his operations in his Fort Worth home, alone in the middle of the night, brooding over brain scans on his laptop or rereading journal articles. He will go to bed at 9 p.m. sharp, then wake up and study. More than once, Donahue's wife, Angela, has found him asleep in a chair or on a sofa with a medical textbook open on his chest.

The night before Roberto's surgery is no different. Donahue stirs awake, and surgical risks associated with even a relatively simple procedure crowd into his consciousness. While performing the craniotomy, a surgeon could drill too far and damage the brain. While removing the section of skull he could tear a big vein that could cause a child to bleed to death. These things were highly unlikely, but possible. If the worst comes to pass and Donahue hasn't thought about it beforehand, he will not be as ready to respond.

Donahue rises for good at 6 a.m. and eats his regular breakfast of fruit, an English muffin and decaf coffee with lots of cream and sugar. It is just before 8 when he pushes through the door of Operating Room No. 5 on the hospital's second floor, wearing scrubs and a surgical cap, a brown backpack dangling over his shoulder.

Leos has just finished shaving Roberto's head. The boy lies anesthetized on the operating table next to a monkey made out of a sock.

"That's a good look for him," Morse, the OR nurse, says of Roberto's new haircut.

"I think so," Leos says. "It's almost summertime."

"We ought to have an outdoor operating room today -- it's so pretty," Donahue says, removing his laptop and a camera from his backpack. "We could have a bunch of people standing around with flypaper to suck away all the bugs."

Members of the team smile at the surgeon's remark, a typically offhand Donahue comment that seems to come from nowhere. They return to a familiar preoperative choreography. Nurse anesthetist Oscar Fimbres inserts a breathing tube into Roberto's throat and attaches the young patient to several intravenous lines. Nurses place foam padding beneath Roberto's arms and legs, then drape his body and most of his head in a sterile blue sheet.

Donahue flips open his laptop and moves to the operating table, where he bends over Roberto's head, carefully adjusting it on a support that extends from the table. Once satisfied, he takes up his camera and snaps off several photographs of his supine patient, part of Donahue's own pre-surgery ritual.

Leos sterilizes Roberto's head with a yellow solution. With a felt-tip marker, Donahue etches a wavy line across the boy's scalp, because a wavy incision tends to heal better, and the scar will be less obvious when Roberto's hair grows back. The surgical team turns its attention to Morse, who notes the time and the patient's name, and confirms that the procedure is a neuro-grid placement. That part of the surgical process is mandated by law to avoid catastrophic mix-ups.

"I agree," Donahue and the others say unison.

Before he takes up a scalpel, there is another decision to make.

"Did you bring your iPod?" Morse asks Donahue.

"Yeah, plug in some music," Donahue says. "Drown out all this whining."

It is another wry poke at his surgical team, who almost never complain.

"What are you feeling like this morning? Steely Dan?"

"Steely Dan sounds good," Donahue says.

The surgery begins

Leaning over Roberto's head, Donahue makes a long incision from one side to the other, tracing the wavy mark with the scalpel. Working across the operating table, Leos dabs at the blood with white gauze.

"I was never good at staying in the lines," Donahue says, humming along with Steely Dan.

The incision complete, Leos peels the scalp from the skull and folds it back, revealing bone, smooth and off-white. She holds the scalp back with a series of hooks and rubber bands attached to the sterile sheet that covers the patient. She hands Donahue a drill that the surgeon uses to bore four small holes in the corners of Roberto's skull.

"You have blood ready?" Donahue says.

"We have two units," Morse says.


Using a different attachment on the drill, Donahue slices horizontally through the skull, then vertically, connecting the four holes. When finished, the surgeon pries off a thin, rounded, 3-inch-square piece of Roberto's skull, which he hands to a nurse, who wraps it in a damp sponge and places it in a plastic tray near the operating table.

The removed section of skull exposes a grayish membrane, the dura. Cerebrospinal fluid seeps out when Donahue makes an incision, which Leos suctions away. Donahue uses surgical scissors to clip a 2-inch-long slit in the membrane, carefully feeling his way beneath the dura to avoid cutting nerves and vessels. In the process, he uncovers a small part of Roberto's brain, pulsing and white, traversed by a delicate network of red vessels.

"It's beautiful. It's incredible," Donahue says. "This is a screwed-up brain, and it's still beautiful."

Inserting the electrodes

Dr. Angel Hernandez enters the operating room. A tall man, he towers over Donahue as he takes a place at his shoulder. It was Hernandez, a neurologist and head of Cook Children's epilepsy unit, who diagnosed Roberto more than five years before with a rare genetic disorder called tuberous sclerosis. Noncancerous growths called tubers irritate the surrounding tissue in Roberto's brain, triggering his seizures.

"He would be walking and then just drop down," Hernandez says. "He's worn a helmet, but as hard as she tried, his mother couldn't keep an eye on him all the time."

As Donahue clips open the dura, a nurse removes plastic, color-coded strips of electrodes from cardboard boxes. Long white leads dangle from each strip, 10 in all. Donahue lifts the dura and gently coaxes the grids beneath, resting them against the brain. Hernandez sketches the electrodes' position in a small notebook.

The grid placement takes less than an hour. When they are in place, Donahue lightly massages Roberto's brain, feeling the big tuber on the left side just below the surface.

"It feels like a rock," he says. "This kid has rocks in his head."

Members of his team roll their eyes. Typical Donahue.

"How's the blood loss?" Donahue asks.

Fimbres, the nurse anesthetist monitoring the surgery from Roberto's feet, replies that it was minimal.

"Good," Donahue says.

They are ready to close. Donahue and Leos stitch the dura, closing it around the protruding white leads. The section of skull is retrieved, put back in place and secured to the rest of the skull with a series of screws. The leads stick out from the edge of the skull flap. Leos punches holes in Roberto's scalp, threading the white wires through the holes.

When the scalp is folded down and sutured, the sleeping boy looks like a character from an old horror film, with the leads streaming out of his head like thick strands of hair. In the intensive care unit, the leads will be attached to monitors. Then the doctors will wait for the seizures to resume.

"The general anesthetic will protect him for a while, but he's been taken off his anti-seizure medication," Donahue says. "I hope he starts seizing tonight, or soon. We got good coverage [with the electrodes]. It will be fascinating."

Two hours after the surgery began, Roberto is wheeled from the operating room. Leos extinguishes the intense lights over the operating table.

"Thanks, everybody," Donahue says.

"Doctor, it was an honor and a pleasure to serve you," Fimbres says, smiling while removing his mask.

As the others leave, Donahue sits down on the floor of the OR, leaning against a wall, dictating surgical notes into a telephone. The janitorial staff moves in to gather up bloody bandages and gauze and mop the bloody floor.

Donahue finishes his dictation and chats with the janitors, clearly pleased that the procedure has gone smoothly.

"Let's go talk to the family," he says.

'He did fine'

In the three hours since her son was taken away, Leticia Gutierrez goes back and forth to the chapel, and her heart stops every time the telephone rings in the waiting room. It's the nurse, Abby Morse, calling Roberto's mother with hourly updates.

At 10:30 a.m., Morse calls with the news that Roberto is out of surgery. But the mother's heart thunders when she sees Donahue appear through the door of the waiting room, still in his surgical garb. Oh my God, she thinks. How did it go? What will he say? But the surgeon is obviously happy and relaxed.

Leticia sighs with relief.

"He'll be in recovery for a little while," he says.

"Everything went smooth then?" Leticia asks.

"Yes. Pretty dull," Donahue says. "He did fine. We'll monitor him really close, and as soon as we get the seizures, we'll do the other operation. We've done all the opening and heavy lifting. Now we just have to do the fine stuff."

"So the major stuff is out of the way?" a relative asks.

"It's all major," Donahue says, smiling. "If they don't think it's major, they can't charge you enough. But anyway, he should be good. We'll just have to watch him. Bleeding and stuff like that can louse us up."

"As long as you're keeping an eye on him," Leticia says.

"Don't worry," Donahue says. "Thank you for letting us take care of him. See you guys."

Leticia slumps back into her seat in the waiting room, relieved and exhausted. She didn't know it then, but it is just the beginning of a long and difficult week for the mother, her son and the surgeon trying to fix his brain.

Tim Madigan, 817-390-7544

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