One evening several years ago, a 93-year-old man was brought into the emergency room where I was on call. When my chief resident told me about the patient, who was in serious neurological decline, his advanced age concerned me. I thought he would be too old to undergo an operation.
A little while later, the CT scan showed a significant brain bleed that explained his symptoms, and I went to the man's family, fully expecting them to tell me not to pursue an aggressive, risky operation.
I encountered a spry woman, his wife of 70 years. She was 94 and in perfect health; she took no medicines and had driven her great-grandkids to school earlier that day. She told me that her husband, my patient, was an avid runner and worked part-time as an accountant. His 63-year-old son called him “a whiz with numbers.” The man's brain bleed occurred after he fell from his roof while blowing leaves. These nonagenarians were healthier than most of my patients — of any age.
I took the man to the operating room for a craniotomy. I drilled into his skull and used a sawlike device to remove a flap of bone. I removed the blood pool and coagulated small remaining bleeders. All that was left to do was to close the dura mater, reposition the bone flap and suture the skin.
Before I proceeded, though, I took a few moments to inspect his brain. What I saw surprised me. Given how sharp he was, how active and cognitively intact, I expected to see a large brain pulsating robustly and appearing healthy. But this looked like a 93-year-old brain. It was more shriveled, sunken with deep wrinkles indicative of his age.
Now, if this sounds disheartening to you, it should not. In fact, it should sound just the opposite.
There is a truism in medicine: Always treat the patient, not the test results. If someone had described his brain to me before the operation, I probably would have been even less inclined to operate. But this was a reminder that it didn't matter what his brain looked like — it mattered how it performed. The brain, perhaps more so than any other organ in the body, may reliably grow stronger in some ways throughout life and become more robust than in years past.
I won't forget that experience. There seemed to be a total disconnect between the brain I was staring at and the man whose skull it inhabited. I was eager to see how he'd wake up from the operation and what his recovery might be like. Did I make the right decision? Had I prolonged his life or hastened his death?