Monday, October 21, 2013

Best birthday present, ever.

The past few months through the retrospectoscope have been like looking through fog frosted glass while backing up an SUV. My research year was coming to a close, and as I said goodbye to the normal 9-5 work day and life without a pager, I began to have little tastes of things to come. Our residency is scheduled in such a way that we start to cover the compatriot ahead of us when he goes on vacation. Not enough to just see the sword of Damocles looming from above, you're allowed to cut your tongue on its cold steel for one week at a time while still but a servant in the king's court.

Many things were vaguely reminiscent of the life I had somewhat forgotten in the eddies of sleep deprived memories. Working long hours, operating without food or water for half days at a time. But the home call was definitely something new. When you're a junior resident, you sign out and leave your work at the hospital. When you're a senior, you're constantly on pager. No more hitting the bars after a long work day with your buddies to recount war stories from the days prior. No more weekend getaways with your significant other to escape the monotony of blood and brain that permeates every part of your life. No sir. Senior resident equals 24 hours each week where they can't touch you, but aside from that all consults seen by the in-house juniors go through you, and you need to be available at all times to operate on a minutes notice. That adds up to 12 days in 90 when sleep was protected and uninterrupted. Or 78 in 90, when there was a good chance you were the neurosurgical undead.

That said, for the first time you were the neurosurgeon. You ran the service. You decided who to operate on. You determined who could be saved, and who was beyond saving. There's a saying in neurosurgery that once God lays his hands on your patient, you take yours away. Well, I was never really the most reverent one.

She just turned 82. A spritely one they said. A bedside drainage procedure had failed, so we counseled the family and decided to evacuate the hematoma in the operating room. The surgery went well, and through a moderately sized craniotomy we were able to evacuate the majority of the blood that had caused her to get weaker and drowsy. I was at my friend's place after work for about 20 minutes when I got a call that she had blown a pupil. CT scan showed a large rebleed into the surgical cavity. She was doing so well, and it had just happened. Most people would have said to let her go at this point, but she wasn't going to die tonight, not on my watch, and sure as hell not on her birthday. I sped down the 405 and made it to the hospital in record time to see the patient being moved onto the OR table. I tore down her head dressing and positioned her accordingly after I had called my senior and attending and got everyone to start the case. Give her mannitol, keep her CO2s low, guys this a real red line, let's move, NOW. I was making skin incision and extending the craniotomy within minutes and was able to visualize the bleeders. My chief joined me shortly to help, the attending much later. He grumbled, annoyed that he had to come in in the middle of the night to what seemed like a futile situation. The size of the hematoma, her age, all strikes against her. But he didn't account for our genuine desire to make sure she would live.

I saw her in clinic 3 months later and she looked fantastic. She had a little bit of a rocky hospital course, but was now walking, talking and laughing like the spritely young thing the family told us she was. It was worth everything. I had been working for 3 days with only 6 hours of sleep (total) and was literally falling asleep while running clinic when I heard she was there for her follow-up. Seeing her like that gave me an energy that coffee could not provide, a sense of joy that achievement could not afford. This is why we do what we do. And why when we do, we do it damn well.

Thursday, October 18, 2012

Please be happy

Happiness wasn’t so distant, actually. Just a little beyond our fingertips, like grasping mist through a half remembered dream. It wasn’t complicated or endlessly multidimensional like misery, it was quite simple really. It was that moment right before waking, where the angels of slumber gently glide their fingers over your skin as you float within the warm clouds of your bed. It was the beginning of a smile, while the emotion is still raw and isn’t judged, or quantified, or remorsed, but just is. But though simple, happiness was never easy. When our lives are so deeply rooted in those that would love and leave us. When our notion of self worth is a reflection of how others that would belittle and despise us would view our selves. When we live in a world where beauty is skin deep and heroism is celebrated briefly but tragedy consumes us for years. You’re right, happiness isn’t easy. But happiness was always a choice. It’s a choice to acknowledge what you do have, instead of dwelling on what you don’t. It’s a choice to wake up to the freshly created existence of the new day that has never been lived before and be determined to live. And it’s a choice to fill your life with those you love, and those who love you… those that bring you up and those that inspire you. It’s a choice to spend a quiet night finding yourself, and a not so quiet one finding yourself in others. Happiness is a choice because you choose happiness. It’s hard to think that such a choice exists when there are only so many letters in our day to day alphabet soup. But there are 7 billion people in this world, 196 countries to travel to, a few hundred trillion synapses in your brain, and a lifetime ahead of you. If you find yourself in unhappiness, read the unread book, sing the unsung song, take the road less traveled and find yourself in a foreign place where misery has not laid its familiar webs. And somewhere in the cold drink on a summer’s night or the stifled laugh between friends in a quiet hall you’ll find it, because you chose to.

Monday, August 06, 2012

A prisoner on parole

They say that the artist fears the blank canvas, the writer the blank page, and the musician the blank score. Infinite possibilities to create. Infinite possibilities to fail. Previous success, instead of serving as fuel to creation, may be the very paralytic that retards our thoughts and slows our hands. For a year I laid my blog to rest for fear that my life, indescribably more trite than it once was on the front lines of medicine, on the battlefield of emotion, life, death, sadness, bitterness, and an endless list of what would be hyperboles in our day to day but egregious depreciations of the experience of an R2, would not be worth writing about. But over the past year I've continued to learn and continued to see. Despite not being on the forefront of the battle against death and suffering, we've been called back as reserves from time to time enough to boast our share of scars.

One night while on call at the county hospital I was paged regarding a young female with a gunshot wound (GSW) to the head. I had seen my fair share of GSW patients. They had always been fairly easy to triage: either the bullet was just superficially involved requiring only debridement and cosmetic repair of the skin and bone, or the damage was so extensive that you could declare them dead on arrival. Should be a quick consult, I thought. I quickly pulled up the CT scan to see what I was dealing with, and thought, "Oh god. This can't be right." I rushed down to the ER and found my patient, a Korean woman in her mid 40s. She was intubated, and in restraints, both good signs in that her airway was protected and that she was able to move around enough to warrant physical confinement. I grabbed some gloves and went to the head of the bed to where a towel was covering the left side of her face, and lifted it with such apprehension, bystanders must have thought a bomb under this white barrier. And there was. The impact of seeing half of the left side of her brain hanging out of the defect where her skull had been blown off sent me reeling. The brain, when not fixed in formaldehyde as you traditionally see after autopsies (and in TV shows and movies), has the consistency of soft tofu, and would collapse on itself should it be held in real life outside of its home in cerebrospinal fluid. A mess of oozing vessels and tofu-like grey matter fungated from within, entangling itself into her dampened hair. There's no way she's still alive, I thought. But, pupils: reactive, cough/gag: present, motor: localizing... bilaterally?? (With her left hemisphere hanging out of her head, she shouldn't have been able to move the right side of her body. Localization is being able to localize a painful stimulus, and is a good neurologic finding, and did not match her CT scan or physical exam findings - ie brain hanging out). She was losing blood fast from the venous sinus bleeding, and the loss of viscosity in the blood that was pooling on the floor made it clear that she was getting more fluids than much needed red blood cells. We took her to the OR once we realized that resuscitation without concomitant attempts at stopping the bleeding would be futile. I shaved what I could of the hair, trying to avoid the interweaved chunks and bits of brain. We prepped, draped, and cut open the scalp to discover a mess of fragmented bone and bullets. Shotgun to the head, the paramedics had said. Shot by her husband, who then turned the gun and killed himself, successfully I might add. The bleeding was too difficult to control, and despite countless units of blood products she exsanguinated on the table. We called time of death and started to close. What? It wasn't enough for you to kill her, but you had to make her suffer? It was even more difficult to shake the tragedy of this case because she was Korean. I made sure to call my parents the next day to let them know I loved them.

My last 24 hour in house call of residency was like a final exam. An alcoholic man showed up in the emergency room with a subdural hematoma that had gradually accumulated and expanded over the past 2 weeks. These bleeds are oftentimes monitored with close observation if the patient is neurologically intact so a less invasive procedure can be done to wash out the blood once it's broken down to the consistency of water, rather than making a large bony opening to evacuate the clotted blood. His had continued to expand  so he came to the ER. I took his history, reviewed the CT findings with him, and told him we would take care of this now as the hematoma had enlarged to a point where he couldn't walk properly, he was getting sleepier, and his voice and swallowing were impaired. A routine surgery, a neurologically stable patient. Things would be all right, he would do just fine, I told him. While discussing the risks of the surgery, stroke and death were mentioned, but I scoffed that in his case ... in his case it would be extremely unlikely. The surgery went beautifully, the postoperative CT looked pristine. I got him back to the ICU still intubated as he had not fully woken up, but then noticed that his lips were twitching. I checked his pupils, the right was dilated, but reactive. He was seizing. 2mg ativan, and get 2 more ready. Bolus him 1g of dilantin STAT. The subdural drain that we had left in there per routine had stopped flowing. I raised it to see if there was any backflow... there was, at 30cm H2O (this means that the pressure in this head had exceeded 30cm H2O, normal is 0-20. When intracranial pressure gets too high, the patient starts to stroke, and herniate [brain tissue starts to compress other vital brain tissue and you can go into a coma and die]). Versed, mannitol, lasix, 3% normal saline. This guy needs a ventriculostomy. I shaved the left side of his head and prepped, draped and drilled into the side we hadn't operated on. I placed one of the fastest ventriculostomies in my life and was relieved and dismayed when I saw CSF shoot out with the first pass of the catheter. ICPs in the 30s. His ICPs were temporarily controlled, but soon became refractory to the medications and drainage of fluid (you can drain CSF in order to relieve pressure inside the head, but only so much. After like 50ccs you basically drain it dry, and need for it to regenerate). I threw everything I could at him, and watched with despair as his blood pressure dipped down from all the sedation we were giving to reduce his ICP, which still refused to fall within normal range. Start levo (levophed). Increase the versed. Bolus him another liter of NS. Now people, come on. In the 3 years of residency to date my voice had never betrayed any fear or anxiety that I had within, but something about having done every aspect of this patient's care, from history and physical to operating to post operative management... he was MY patient. I told him he would be just fine. My voice bled with urgency as I continued to call for more medications and fluids. This isn't working. Call pharmacy, we need to bolus this guy with pentobarb now (pentobarbital - for chemically induced comas to greatly decrease brain metabolism and reduce ICP). We got his ICPs controlled, his seizures stopped, and his blood pressure stabilized but I felt like I had aged a year in one night. He never recovered and 3 weeks later the family decided to withdraw care. Despite doing everything by the book, I wondered if there was anything I could have done differently, faster, more efficiently. It's interesting how with great surgical skill and medical management a doctor is praised for saving a life. When things go poorly despite doing everything right, we're told "there's nothing more you could have done". Isn't there? Being good isn't good enough anymore. I need to become supernatural.

No longer responsible for taking in house call has allowed me to catch up on life, relationships, and most importantly of all, sleep. I've started having dreams again. Dreams were a luxury I didn't know were absent from my life until they appeared again one night. When you're sleep deprived, your body spends more time in deep sleep (restorative sleep), rather than spending energy on REM sleep (where dreams occur).

I'm starting to forget what it's like to be a neurosurgical resident. I spend most of my days in front of a computer now doing MRI analysis and writing papers and grants. Like a prisoner who finally gets parole after half a lifetime of gen pop life, I'd forgotten what it was like to be able to eat when I want, go to the restroom when I want, and have weekends where I can run errands and sleep in because there aren't 50 patients waiting for me in the hospital. Life has found new meaning, but at the same time I feel like I've lost more than I've found. I itch to hold the drill and scalpel again, to admire an excellent tumor resection or beautiful skin closure. Now just a fish out of water I gasp and wait till I'm allowed to have my purpose again.

Thursday, June 30, 2011

The End

It was the best of times, it was the worst of times. It was a time of tribulations, a time of sorrow. It was a time that weathered our thinning heartstrings, leaving in the wake of untimely deaths and undue suffering, men that were some reason stronger. In every man there is a point of inflection in the tapestry of his life where the threads of youth intertwine to form the cords of manhood. Through baptism by sleep deprivation, hopeless situations, academic intensity and emotional intimidation we became something more than what we were a year ago.

116 overnight calls done.

Through repetition and remembering, our hands that once trembled while accessing the brain have found steadiness. Where once we hoped against hope with the families of loved ones for miracles, we now hold out our hands to catch their crumbling dreams. We do not cry, no, we never did; but now we no longer think of tears. As the number of patients we've touched, saved, and buried grow, our energies are diverted to our ability to save rather than our capacity to empathize. But we have known sorrow, though the chords that move us have changed. Death has become our companion, so we no longer fear him. But abandonment, seen in the brain tumor patient admitted for medical issues, silently choking on his own saliva in the corners of the medical ward; or the wife that leaves unable to handle the despair that comes with a diagnosis of a terminal illness... the consolidation of loneliness in an already lonely profession, in an already lonely world, chills us.

We recognize there is still much to be learned, and still many sleepless nights to be had. But in this year of hazing we hope that we were broken down beyond the imperfections of our upbringing and built into something better. Only time will tell.

And now, we play.

Tuesday, May 24, 2011

The Perfect Game

There's been no shortage of perfect games in the world of baseball over the past few years it seems. But to experience a call night with no consults, no traumas involving neurosurgical needs, and no ER admissions is something akin to the holy grail of a neurosurgery resident's call night at a level one trauma center in the middle of one of the largest cities in the United States. But the gods were kind last night, and for my 101st call as an R2 I had a no hitter. Going into any call you pray that it'll be a light day. With the post operative checks, the 15 patients in the ICU, and the 20 some odd patients on the floor any given call can potentially be a busy one without the steady flow of consults from other services or the emergency department. As a lot of what we do as physicians is innately pattern recognition, my co-residents and I have become increasingly superstitious about our rituals and routines that we perform to ensure a quiet call night. Initially when I started I noted that whenever I brought my book bag to get some reading done, I would be hammered by incessant calls from the ED and direct admissions from clinic. Suffice it to say my book bag has not experienced much use in the past few months. Granted, it's a little healthier and far less harmful than one of my co-residents who believes that the number of chocolate muffins consumed will be inversely proportional to the number of consults he'll get while on call (true story). I don't see them to be correlated to how busy his calls are at all... but now he's addicted and can't stop eating them.

101 calls done people. Only 12 more overnight calls for this academic year. Don't get me wrong, we'll still be doing in house call as a 3rd year, but it'll be more along the lines of 3 times a month instead of every third night.

Wednesday, May 18, 2011

My Chemical Romance

14 calls left.

I don't remember a time when I wasn't a junior neurosurgery resident. Maybe it's because we've worked enough in 10 months to bill for two years; or maybe because we've been awake long enough to have lived two lives. My dreamless nights suffocate under the fatigue of the day, and lacking any visions apart from this reality, my consciousness holds only the threads of this endless toil. As reality blurs into what should be dreams, whilst we sleep still standing and read pages half asleep, intracranial pressure management and surgical techniques overtake every moment of our lives, forcing us to relive our jobs many times over. The compounded whittling of endless nights have shaved us down to emotional cadavers, as our weary minds stumble behind our weathered bodies. At 1AM when the 20th hour of my work day strikes, my judgment fails me as my body cries out for just a moments rest. Oftentimes it's then that I realize I haven't eaten since morning, though my stomach has become accustomed to the constant neglect and abuse of on-call binging. As I'm ready to despair, and let the post op patients go unattended and the nurses pages unanswered for a quick nap, I pull myself together long enough to grab two Full Throttles from the downstairs night cafe. Unashamed of my growing emotional dependence on caffeine I knock one back, and receive the energy to last through my post op checks and the rest of the night's check list of tasks. The other I drink during rounds to keep me awake long enough to sign out my patients and stumble to the downstairs call rooms where I bury myself within the darkness of basement level quarters. By the time I wake and determine it's safe enough to drive home, I've been in the hospital for 36 hours. This year needs to end.

Monday, April 25, 2011

Dead on Arrival

One day during your surgical residency you'll realize that you've come to a point where you yourself can actually save a life. Be it through your split-second diagnostic reasoning that diagnoses an aortic dissection or your expedience in rushing a patient to the OR to evacuate an intracranial hemorrhage. With this power, however, comes the bitter fruit of knowledge that makes you cognizant of when a life could be saved, but wasn't.

He wasn't even 20. But the death of his friend the day before was too much for him to handle. While drinking the sadness of life with the spirits of liquor he suddenly found himself falling, to be reawaken to the piercing pain of reality as the spikes ran through his legs. He lay there, dangling from a fence, the blood in his head squeezing consciousness from him as the twinkling of lights from anoxic brain damage painted the last mobile of stars he would see in this world.

He was unresponsive when the paramedics found him. His left pupil was fixed and dilated when we moved him from the gurney to the recovery suite table. He has a left sided hemorrhage, probably a subdural, I thought to myself. He needs a CT scan and an emergent hematoma evacuation, I continued. He's young, his brain isn't too compliant, he may have herniated already, but we need to give him a shot.

My patience quickly smoldered into helpless rage as I watched them place bilateral chest tubes, multiple central lines and IVs, and turn him to check for spinal injury. Guys, let's get him to CT now. But not knowing how serious his pneumothoraces were, or how indicated the chest tubes were, I couldn't argue with the ABCs (airway breathing circulation) of trauma. Honestly though, it should be airway, brain and CT for someone with a blown pupil. The CT scan confirmed the subdural hematoma, and we rushed him to the OR. As I sawed off the bone and cut open the dura, blood clot shot out of the operative field and I knew the brain underneath was probably already dying from ischemia. The brain continued to rise up like muffin tops in an oven, and as the cortex herniated through our bony window the attending surgeon told us it was futile. Close the skin, he said. There's no hope, he finished. My senior resident and I looked at each other. Maybe we could open more bone, maybe there's more medical management we could do to help reduce the intracranial edema. But we knew as well as he that it was too late. He had probably already stroked his whole dominant hemisphere and even if we did decompress him adequately would remain a vegetable for the rest of his life. He didn't want to live anyway, what right did we have to save him? Still, we could have. To save life, and even return it to those that throw it away, that is a surgeon's power, his duty even, if you will. As I closed his skin, pushing down the brain that still tried to escape out of the boy's scalp, each stitch I wondered how we could have gotten there faster, how if a matter of seconds could have made a difference.

Only earlier we were consulted on a 7 year old boy who's spinal cord was internally severed from a motor vehicle accident. The injury is incompatible with life, I told the peds ICU team. The boy's father had killed himself the year before. His mother had killed him by driving under the influence. She posted bail and made it to his bedside in time to tell me that she thought she saw tears coming from his eyes sometimes. Yes, I thought, wouldn't you cry too if your mother's stupidity resulted in your death?

There will always be lives we cannot save. And sometimes even harder is realizing that by the time they reach you, there is no life to be saved. But for the rare instances where seconds mean another smile, another laugh, another breath of fresh air, we work tirelessly to improve, to be ready, so that when we scrub out of the OR we can look at their families with relief, not regret, and be met with tears of joy, rather than the wails of despair.

Breath of Fresh Air

In the worst of times the breath of our friends becomes the air we breathe.

I finally got my vacation. Thank you so much for the awesome times guys.

After the 48 hours of insanity in Las Vegas I flew out to a neurosurgery conference as I submitted some of my research, which was accepted for a digital poster. Small beans in the grand scheme of things, but not too shabby for someone who barely has time to do his laundry.

The conference was relaxing in it's sleepy schedule with optional conferences and lack of mandatory engagements, but overwhelming in the vastness of knowledge and neurosurgical greatness that I found myself surrounded by. It was nice to see what others in the community were doing, and inspiring to think that one day when the dark days end I too would be able to engage in such life changing, cutting edge work.

But after 7 days of awesomeness I returned to the grind.

Thanks guys for posting on my blog, it means a lot to know that people in the electronic ether find the things I say interesting from time to time.

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About Me

I'm a quixotic idealist that's readjusting to the reality of the world around him. An aesthetic at heart, willing to not shower a week at a time to go camping, exploring, hiking, etc. I love food, poker, and anything that can be turned into a competition.