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What really goes on inside an operating room? If you suspect that neurosurgeons listen to their MP3 players and secretly enjoy sawing open skulls, you are right. Neurosurgeon Katrina Firlik set out to write the brain-surgery equivalent of Anthony Bourdain鈥檚 infamous restaurant trade expos茅 Kitchen Confidential, and has managed to provide a candid behind-the-scenes peek into the OR and the body鈥檚 most fascinating organ, which she describes as 鈥渟oft like tofu鈥�. Amanda Gefter talks to the woman who delves deep into grey matter

What are the biggest misconceptions about neurosurgery?

People think of neurosurgery as something highly intellectual. They use phrases like 鈥渋t doesn鈥檛 take a brain surgeon鈥�. Of course, you have to be smart and make quick decisions, but, in part, a neurosurgeon is a kind of mechanic. We cut heads open, we use drills. On a daily basis we are thinking about practical things like, how do I get this nail out of this guy鈥檚 head? You have to love the brain and also love working with your hands.

Why do you like the brain?

It is still so mysterious. And it makes us who we are. There is nothing else I would want to specialise in. The kidney, liver and lungs can be replaced. You can get somebody else鈥檚 and still be the same person. I also love the aesthetics of the brain, the architecture. As a whole, you might think it looks like a blob, but when you dissect it, it is unbelievably intricate. The pattern of the blood vessels at the base of the brain is so weird, like a strange creature.

What is the most fun part of your job?

To be in the operating room and to expose the brain. It is something we get used to but it is still fun. The camaraderie in the OR is great. It is not as serious as you might think. There is a lot of joking around, music playing and people are talking about what they are doing for Thanksgiving. You might think that is dangerous, but it is not. We are like mechanics working on a car. We know what we are doing, it is a routine.

What kind of music do you listen to in the OR?

Usually the surgeon gets to choose. That is an unwritten rule. But I like to give other people the choice so I will listen to anything other than heavy metal or music that is disturbing. When I choose, I like to listen to jazz because it is soothing. Usually we have the anaesthesiologist bring in his iPod and we put it on random play.

Have the boys given you any trouble for being a woman?

People expect this would be a really big deal, and there were small instances when I was the butt of a few light-hearted jokes, but I was lucky to work with a bunch of guys who were pretty progressive. A senior neurosurgeon asked me at an interview, how do you know you will be able to handle the big drills? It turns out that I breezed through even easier than some of the guys did.

What about patients?

That is a more interesting question. I think I get questions that the guys don鈥檛 get. For instance, I can spend 45 minutes with a new patient going into detail about the operation and at the end you wouldn鈥檛 believe how many people say, 鈥淪o, who is actually doing the surgery?鈥� They expect me to be an intermediary or something. It is usually the older people. I don鈥檛 think it is sexism per se. It is a generational thing.

What was your most bizarre case?

A guy came in with a long-neglected tumour on his scalp. It should have been very easy for a dermatologist to fix in an office, but he had a psychiatric disorder and he just ignored it, and was destitute so didn鈥檛 have any medical care. Over a period of years, the tumour had eroded through his entire scalp and skull, and he ended up with his frontal lobe exposed to the air and spinal fluid dripping down his face. By the time he came to us, a huge portion of brain was exposed and there were maggots in the wound. That was an extreme case.

What is the most rewarding part of the job?

Seeing someone improve. Something that is starting to come out of the woodwork is the ability to recognise a condition called NPH (normal pressure hydrocephalus, or excess fluid in the brain). It is one of the only treatable, reversible forms of dementia. I have had patients who are in a wheelchair, barely able to speak because of what had been assumed to be Alzheimer鈥檚. Then someone thought, maybe it isn鈥檛 Alzheimer鈥檚, maybe it is NPH. Then you put a shunt in to drain the fluid, and there is a miraculous transformation. Within five months they are back home, getting a driver鈥檚 licence again and reading The New York Times. To be the one who puts the device in, to see them transform and to see their family鈥檚 reactions, it is really amazing.

Do you think of the brain as a resilient or a fragile organ?

Both. I鈥檓 amazed by how, for example, kids bounce back from what seems like a devastating head injury. They have so much resilience and so much drive compared with adults, who often mull over things, thinking 鈥渨oe is me, I was in a car accident鈥�. Partly because of their attitude and partly because their brain is young, they can damage a large portion of the brain and make a full recovery. On the other hand, if someone has a tiny injury in the brain stem, that can put them in a locked-in state where they can only communicate by blinking. In that way the brain is exquisitely sensitive. The Achilles鈥� heel of the brain is that it matters where the injury is. Damage to the frontal lobe might not make a huge difference but a tiny brain-stem injury can be devastating.

What do you see for the future of brain surgery?

Implanted electrical stimulators. A device for stroke survivors is under development that has been effective in early studies. A small electrical implant revs up the area that is trying to recover. It is still experimental, but I think in the future we are going to be implanting devices for depression and language disorders. It is going to be a whole new field, helped along by functional MRI work, that shows which parts of the brain control which functions to help us target where to place implants. That will be an alternative to drugs.

What about dementia?

Enhancing cognition will be a wide-open field that neurosurgeons will participate in. Memory is a big one. Baby boomers are starting to worry about Alzheimer鈥檚. People do brain teasers and things to try to pump up their brain functioning, but if there鈥檚 a way to enhance memory or language skills electrically or by some other means, even though it sounds very invasive 鈥� and it certainly is 鈥� people will be more amenable to it than you might think.

鈥淓nhancing cognition will be a wide-open field for neurosurgeons鈥�

After seeing so many head injuries, do you have any advice?

This is common advice, but I can鈥檛 stress it enough: wear a seat belt. People who get ejected from a vehicle are a total wreck, missing half their scalp because they were thrown through the front windshield. There is no excuse.