Tuesday, December 28, 2010

Blood stains and bleach

It only takes one patient to make your call night busy.

I was already four consults deep when they called a code trauma. Man fell from 30 feet onto his head, GCS 3 (basically non-responsive). Well this can't be good. Usually when I get the trauma page I like to place bets on the likelihood of me actually having to stay and being involved. When he rolled in on the gurney, blood gushing from his forehead and spewing from his mouth as he was being mask ventilated, thoughts of catching a quick afternoon nap eloped with my appetite and the adrenaline kicked in.

Face shield. Isolation gown. Gloves. Neuro exam. I made my way to the head of the bed and tried to pry open his eyes, already swollen from his multiple facial fractures. Minimally reactive. No response to verbal command. I made my way down to his arms, no fractures... he must have broken his fall with his head. No bueno. He didn't flinch when I mashed on his nail beds, poor prognostic sign, and likely indicator of spinal cord injury. I went back to the head of the bed to see if he was responding any more, and was quickly recruited to help secure the airway. The ER docs had their hands full as blood gushed out of the patients mouth like a geyser. I bag masked the patient as they prepared for the intubation, and found my facemask splattered within seconds. The patient's jaw was crushed, making the intubation tricky, but they got it and we rushed him next door to CT. I took off the isolation gown to find that my white coat was splattered like a bad Jackson Pollock. Damn... I had just washed this.

His CT didn't show too much intracranial blood, but the bony damage was horrific. It looked like the front of his skull had exploded, and the number of disjointed bone fragments floating in the soft tissue of his face were too numerous to count. He wasn't going to do well, but with active bleeding from his face and abdomen we had to give him a chance so we rushed him to the OR to fix the abdominal bleeding first. The trauma surgeons cut him open and repaired what they could of the liver laceration they found on CT, and packed it with gauze to tamponade the bleeding and closed with ioband (a sticky film like seranwrap) knowing they'd have to go back in after the bleeding had stopped to remove the packing. He needed intracranial pressure monitoring though since we didn't have an exam. While they were finishing up I shaved the head and cleared out a sterile space to place my ventriculostomy. By the time I was making incision the trauma team was done so I had an audience of about 15 people. Crap. I don't remember ever being nervous about placing a ventriculostomy, but just having a panel of other residents watching you is pretty intense. His skin was 2 cm thick from the swelling, and cutting down felt like I was slicing into a bad steak. I drilled cautiously given all his skull fractures, and luckily the bone I found didn't sink in while I was boring out my entry hole. I passed the catheter and squirt, the CSF burst out. Whew. First pass. Way to shine when it counts.

After some angio embolization of his liver bleeders we got him to CT again. His brain had burst into a bloody mess, and with his physical exam findings his prognosis was very poor. We got him to the ICU and I was notified that his family was waiting in the surgical waiting area. This was going to be a difficult conversation, but I had told family members bad news before. I guess I just wasn't ready for a whole family. Sons, daughters, wife, nieces and nephews were all there. I told them what had happened... what we had found... and what he was like now. The eldest son was the spokesperson. As I told him the news, he didn't cry, but you could see the helplessness fill his face as the reality of the situation was painted so dismally before him. The faces of the women who understood English started to flush... and the eyes of those who didn't looked around anxiously wondering what was wrong. I told them they could see him soon in the ICU, and left the area and walked out of the hospital into the cold night air, somewhat overwhelmed by the collective sorrow I had just stirred. God my job sucks sometimes, I thought. There wasn't anything we could do, I told them. We weren't going to offer surgery because prognosis was so poor, we had decided. I agreed with our decision, but knew they didn't understand the why of the situation. When the wife was finally at bedside, wailing for her husband to wake up, to open his eyes though they were swollen beyond human recognition, and then kissing his dusty feet lovingly, washing them with her tears as we only read of in scripture, I thought to myself again, man my job sucks.

Before I left the next morning, I sheepishly skirted past them, ashamed that I had breached the topic of withdrawing care given the situation. But realizing I was being an idiot, and that they needed whatever support they could get, went back and asked them how they were doing and if they needed anything before I took off. Neurosurgery is a field of hopeless situations. But again, I guess it's about making hope when there is none, comforting when all life delivers is despair, and being the kind angel of death when the gates of heaven and hell open with their unrelenting beckoning.

Afterword: I spent an hour trying to wash the blood out of my white coat. Hydrogen peroxide and toilet bleach seem to work pretty well...

Saturday, December 25, 2010

Even brain bleeds go home on Christmas

Being on call for neurosurgery Christmas Eve kinda sucks. The night of anticipation and eventual culmination is something to be excited about usually, but when you're getting hammer paged by the ER and the slew of patients that have become paranoid with their recent surplus of time to ruminate about their surgeries, it just kinda sucks. So, I went down the street and bought a Santa Claus hat and the rest of the night was pretty awesome.

Not really, but, when you get to walk into a patient's room and say "Hello, I'm Dr. Kim, the neurosurgeon on call," and have them look at you, and then the santa hat, and then back at you... it's almost worth the consult.

The magic of the holidays for the on call resident is not in the gifts or the fact that there are no elective surgeries (only emergencies), but rather in the simple fact that everyone wants to go home. I had a man come into the ER with a subdural hematoma. Granted it had been stable for 24 hours now on repeat CT scans, but he had been taking aspirin, had a low platelet count, and coagulation problems to boot. We would normally admit this guy, give him blood products, hook him up to EEG and watch him for an additional 24 hours. But hey, it's Christmas. We sent him home. (It was still sound from a medical-legal standpoint, but I won't get into the details). Our service stays light, rounds stay quick, and it feels like we're on vacation despite having to stay in the hospital.

Amusingly, the Santa hat seemed to almost become an extension of the white coat. Not only did my patients have to listen to me regarding their neurologic status and health, but I was telling them to have a Merry Christmas. Yes doctor, we'll be sure to take the antiepileptics. Yes doctor, CT scan before the next clinic appointment. Yes Dr. Kim, we'll have a good Christmas. I guess it was nice getting a few smiles despite me telling them they had a brain bleed. At one point I got a little carried away and tried telling a confused/disoriented patient that she was at the North Pole... it's ok though, beats thinking you're in a hospital.

Merry Christmas everyone.

Wednesday, December 22, 2010

So last season...

I was never really a big Christmas guy. The notion that we needed dedicated days of the year to spread good will towards men and be generous to others, to me, has always been a sad commentary of our times. The capitalistic movement to buy affection with apparel, joy through jewelry and love through laundry lists of wants and needs seemed very backwards, and to a lower-middle class kid somewhat unjust that he wasn't able to truly show others he cared. Still, it was fun sometimes, and the past few years I had really gotten into the gift giving and present contemplating. But nothing sucks the excitement of Christmas out of you faster than q3 call and being in house on Christmas Eve.

I'm post call right now, and spent the better part of the afternoon shopping for the neurosurgery mentors/attendings that have helped me throughout the years. The very idea of looking for presents for my brothers and parents exhausted me, and in my guilt I told them not to send me anything so we could exchange gifts next year when I actually had something to give. Walking around the ant colony like mall 3 days before Christmas was even more depressing. Having worn scrubs for the good part of the last 18 months I didn't notice that my clothes were slowly going out of fashion. I looked like the November 2008 college collection in the midst of Christmas LA 2011. But even so, just thinking about trying on new outfits sounded overwhelmingly tedious, having been up now for about 34 hours (there was a one hour nap in there somewhere). So there I was, shopping to continue my political relationships in neurosurgery and thank the neurosurgeons of years past, family neglected, self discounted and shamefully out of style. Neurosurgery stole Christmas this year.

Sunday, December 19, 2010

...

Fell asleep while talking again today post call.

Forced to get up to study for operative case tomorrow.

Really really tired.

Thursday, December 16, 2010

And the rain falls...

One of the more difficult tasks in being a resident on the front lines is managing the expectations of patients and their families in the face of death and debility. Just when you think you have a grasp on how patients should do... how they're expected to do... life still manages to upset the odds. Granted you always mention the caveats, as we often throw in the cliche that we don't have a magic crystal ball that can tell us the future. But even so, we minimize the unlikely, and in the eyes of a patient or family member who can only hear one answer, inadvertently tell them that they'll either going to live or die.

I had a patient come in after falling and hitting his head the other day on call. He was pretty old, but all things considered looked like he would walk out of the hospital in one piece. His CT showed diffuse subarachnoid blood around his left temporal lobe, but it wasn't causing any mass effect or obvious compression of the neural tissue. From what I had seen before, the prognosis for this amount of blood wasn't bad. I reassured the family, encouraged them that the first couple days were the most important in determining outcome, but that he was looking good now. No, they didn't have to call in the whole family from across the states. No, they didn't have to have his grand-daughter take the first flight in to be there. He went from talking and following commands to not talking and being extremely agitated. He's just sun-downing, I thought, (disorientation that elderly people may experience when in an unfamiliar place at night while experiencing any physical illness), he'll pull through this. I left post call confident he'd be ok.

The next day I was in the OR till 7PM, but he was still listed as being in the ICU so I didn't bother to check in on him. But the following morning on rounds I noticed that we had skipped him. I asked later what had happened, only to find out that the family had chosen to place him on comfort care, and with a little morphine to ease his pain he slipped quietly into the night.

I was furious.

Murderers, I thought. He was doing well. Why did they have to withdraw care? He was going to make it. I TOLD them he was going to make it. But apparently he didn't do too well the ensuing hours after I had left. I had fought so hard to get him through that night. Seeing my efforts undone by my own unrealistic expectations, by the decisions of family members behind the scenes... I can see why people in this line of work can become cold. How many times does your hopeful encouragement need be proven wrong before it becomes empty words and pleasantries to prevent despair rather than inspire hope? People die. And they'll continue to every day in our ICU. But we need to believe we're making a difference in their outcome. We need to believe that all our fancy intracranial pressure monitoring, lactate pyruvate ratios, transcranial dopplers and jugular venous bulb recordings are leading them towards recovery. Don't get me wrong, we definitely see our fair share of miracles. But in spite of our pontificating and intellectualizing, some people improve while others don't. Some recover from the cold lifeless barbiturate comas on life support while others suddenly pass from the world of the living. We fight against the closing curtain with all our might, but in the end, people die, the sun grows cold and the rain still falls.

Friday, December 10, 2010

The world is my bed

Sleep used to be like water, a refreshing break from the toil of daily life, a quencher of thirst from the dry monotony of our days. Now it's become the air I breathe, wherewith at every opportunity that arises I take a breath, fearful that the next moment I may find myself under the flood of consults and chores, unable to breathe.

We began the year able to go home post call and sleep for only a few hours, then feel fully refreshed and able to spend the rest of the day making up for lost time. Now I come home, barely making the 10 minute drive without dozing off at the wheel, and at times pass out for five minutes while parked in my parking spot before I can find the energy to climb the single flight of stairs to my apartment. The cumulative fatigue of the 50ish 30 hour shifts in addition to our 12-18 hour operative days is has begun to take its toll. I've always been notorious for falling asleep during class, but now I'm falling asleep during signout, while I'm talking. Today I shut my eyes for a moment in the OR lounge while my colleague was on the phone, only to wake surrounded by anesthesiologists and no one from neurosurgery to be found. It's been a while, but so far this year I've fallen asleep standing up during our floor rounds, and as scary as it is, there have been a few times I've fallen asleep while standing in the OR (don't worry, nothing happened).

People might read this account and say that's exactly why we need to enforce stricter duty hour regulations, that the new 16 hour shifts being implemented by the institute of medicine is appropriate and necessary to prevent physician fatigue. I've always found it funny that the institute of medicine, and not the college of surgeons is trying to force feed these work hour limitations on the world of medicine and surgery. We train during residency to work under these conditions of fatigue and sleep deprivation because that's how the world is. Some of our surgeries can last longer than 24 hours (I've been on service for one that went 32 hours). There are redlines and emergencies that come in at all hours of the night, and care not for how much we've slept or how long we've been working. By taking away the grueling training of residency by limiting the number of hours we work each week (they propose something ridiculous like 60), we'd have to extend the neurosurgical residency by about 4 years I would imagine (it's already 7). Not only that, you can't "sign out" a surgery to another surgeon like you would a service of patients. The nuances of all the steps that ensue, the opening, the microvascular dissection, the surgical decisions regarding positioning and anatomy exposure, would take the near length of actual OR time to sufficiently pass on. Surgeons become surgeons because they can tolerate this brutal lifestyle. You make surgery shift work, and soon we'll find surgeons that need their nap times after a 12 hour shift. How do you tell a patient's family, sorry, the surgeon has to take a nap, we'll just keep the skull open until he gets back in five hours.

Enough ranting.

Oh wait, one more rant. Someone was in my parking spot when I came home post call today. The person that gets in between me and my bed after a call night beware. Thoughts of keying, kicking, smashing windows, and the sort passed my mind. I tried to have it towed, but ultimately just parked elsewhere and called the landlord to have him deal with it. I guess I'm a pacifist after all.

Saturday, December 04, 2010

In the dust of humility

It's surprising how many people there are, that even when the lives of their loved ones are in the hands of their doctors will still put on airs of entitlement and superiority. Oftentimes these are the so called "VIPs" that pass through our clinical service. "Very important person," as some might say. Does this mean their lives are more important, their conditions more critical, or their outcomes more significant than any other patient on the list? No, of course not. But their pocketbooks may be heavier, and their clout more weighty, than the poor Latino family one room over who are putting everything they have, including shreds of their dignity, into a homemade contribution box by the bedside of their comatose son to help pay for his ICU stay (saddest thing I've seen this week).

The irony is that these VIPs oftentimes receive the most questionable care. A battery of unnecessary tests are ordered to exclude the rare and as we call them "zebras" on the differential diagnosis, to leave no stone unturned amidst a landslide of unlikely boulders. These are the patients that ask that the attendings do the procedures that would normally go to the residents such as placing central venous catheters or ventriculostomies, procedures that some of attendings may not have performed in months if not years. I've seen the chair of liver transplantation doing a neuro exam and commenting on a patient's neurologic status, a rehab neurologist directing surgical management and diagnostic imaging. Seriously guys. You don't see us going over and telling you how to transplant a heart, stay away from my brains and spinal cords.

I met the humblest of patients the other night on call. She was homeless, disheveled, and unkempt with her dust worn clothes and uncanny amount of facial hair. She had a piece of surgical metal that had been eroding through her scalp for months, but for which she paid no mind as vanity was long discarded on her road. But her friends had freaked out enough to persuade her to come to the ER, so she did. She was cooperative, unassuming, and grateful despite the wait and knowing nothing would be realistically done over the weekend. She was the kind of patient you wished your so called VIPs would be like. But then I discovered she had lice and the wistful appeal of the homeless dissipated. We still took good care of her.

Thursday, December 02, 2010

Moment of Weakness

Five months through, and it feels like I've been doing this job for a lifetime.

I've forgotten what it's like to live a normal life. But vague remembrances of a life forgotten in the sleepy yesteryear of time still linger, and it is for them my unconscious yearns.

Somewhere along hour 8 of 12 in the operating room today I sighed. I wished that I could wake up with sunlight outside, or if not that see daylight as I left work every once in a while. Today I left the hospital again in darkness. I wished that I could go home and actually cook the food I want to eat, instead of hurriedly grabbing a bite at the hospital before and after my shift. I wished that I actually had time to talk to my friends and family more than I did the OR front desk or the patients on our service. I wished that I could sleep so that I didn't spend every waking moment wondering when I could get back to bed. We come home to empty rooms and empty tables, dark corridors and cold floors. Life gets better after this year they say. But for now it's dark, and I've long forgotten the light of the sun.

Wednesday, December 01, 2010

You can't hide your kid from cancer

It's amusing to witness the various types of parenting styles that exist in the world. One of my previous calls I admitted two patients that particularly stood out in my mind. One was a college freshman who likely had meningitis. His symptoms weren't that bad, but the mom was so concerned that she actually wanted to follow him into the scanner to make sure he was ok. What if he has a contrast allergy, she asked. What are you going to do if he does? I responded. But I suppose it's better than the likely more common alternative of parents that just don't care.

Another patient that was admitted that night was a little over 30, but had lived with her father her entire life. He did everything for her, and treated her like his little baby girl even then. The innocent smile on her face and the way she timidly laughed at herself when her history and physical exam revealed how forgetful she was on account of her underlying pathology reinforced how beautifully unscathed her spirit was from the ugliness of the world. In addition to this man who did everything for her, she had her boyfriend, soon to be fiance who everything else. Don't tell her the gravity of the situation, he pleaded, she's never had to deal with anything hard before in her life, she won't be able to handle the truth. I often hear those words in the hospital, more often on the pediatric service, but sometimes with the elderly or dependent as well. They won't be able to handle the truth, they way. Maybe, or maybe it's you who can't handle how they'll respond to the truth. Is it really protecting the patient or is it protecting the family from the tears and heartache that will ensue. But I digress.

The patient ultimately was informed of her diagnosis. Brain cancer. No, we don't know what kind. No, it doesn't look like your typical malignant type, but we can't be sure until we have a tissue diagnosis. Yes, she'll need surgery. Yes she may have neurologic deficits including paralysis and loss of language, but we make sure that doesn't happen by careful preoperative planning. I consented her and her family, and told them it would be fine, that she would be fine. The day of her surgery was my day off, so I wasn't there during the operation. A little part of me died when I went to examine her the next morning and saw the frustration and fury from her eyes. The operation went well, but postoperatively she could not speak. Given the nature of the surgery and post op scans it was likely only transient in nature, which we explained to her, her comprehension still intact. She didn't believe me, or if she did, the overwhelming helplessness at being unable to speak when only 24 hours previously her only symptoms were headaches and vomiting, drowned out any reason we tried to feed her. She glared at me, and I'm sure she was yelling inside - you told me it was going to be ok, how the hell is THIS ok?

We were confident she would regain more of her communicative ability, but obviously it looked worse to the family than it really was. I'm not sure what exactly ensued, or what the boyfriend was thinking, but the night after the operation he decided that he would propose. She gave a thumbs up. Now, the cynics may argue that he did this to get the easy 'yes', after all, all she could really communicate was a thumbs up, and inappropriately for both yes and no at that. Other more chauvinistic types may argue that he just landed the gold mine, the woman he wanted to marry, but now unable to yell at him to do the dishes or take his feet off the table. But I'd like to think that this was again one of those small slivers of goodness that still remains in this downtrodden world. No thinking, no calculation, only knowing that she may be dying, that he wanted to spend the rest of his life with her, and that he wanted the rest of his life to start as soon as possible.

She's doing better, speaking more, and will likely leave the hospital on her own two feet, with many more years added to her life, and an upcoming wedding to plan.

Friday, November 26, 2010

Level Up! (continued)

There are days during residency whether by fault of your own or indiscriminate criticism by an attending you'll feel like an incompetent failure. Sure, when you leave the hospital you're "the neurosurgeon," but how often does that actually happen? For the most part, day in day out we're with other neurosurgeons, and at this stage in the game are the moss that grows on the log that the frog sits on. This particular day I was pulled into a senior level case because we were once again short residents to staff the complex cases for the day. Maybe he was just frustrated to have a junior resident, but for whatever reason I just couldn't make him happy that day. I left the 8 hour case feeling like I didn't know anything, that my operating technique was primate-like, and that I should really work harder to learn everything there was to know about neurosurgery this year to avoid such moments of smallness again. Unreasonable goals set to appease the bruised self-esteem, squelching the fear that such a feeling will recur because you have a plan, which seems feasible in your sleep deprived emotionally battered state.

I stuck around for the red line that was about to go because it was my operative day after all. This attending guided me through the beginning half of the case and let me make the skin incision, cut down the muscle, drill off the bone flap, cut the dura, and buzz the brain and make the first cortical incision. I never actually had a chance to do the last couple of steps, so this experience was huge for me. Suddenly I was more than just a burdensome junior resident, but the primary surgeon on a complex vascular surgery. Shortly after my chief resident cut in and took over, but even getting there was more than I could have asked for.

The challenge of being a resident learning how to operate is that the only real time we have to practice or refine our skills are in the OR itself. But the attendings don't know what we've done to date, or how much experience we've had with one tool or the other. Each time I'm in the OR it seems I get a little more experience with a new tool, a new skill set. So we learn, but consequently always seem like we're just beginning. That day I frequented 3 new surgical instruments, a new tool set to add to my armament of operative techniques. I left the hospital a little after midnight with only hours before I had to come in to take my overnight call, but it didn't matter, I felt awesome.

Wednesday, November 24, 2010

Level Up!

Just spent about 18 hours in the OR today operating.

I got lucky again and got to do some really senior level cases. Got to slice and dice normal brain and everything.

I need to wake up in 4 hours to start call.

Must sleep.

Monday, November 22, 2010

Starting up again

Sorry for the blogging hiatus. I was on vacation last week, and spent the time away from the computer and hospital.

There's an interesting phenomenon that occurs when R2s take that week of vacation. Being plucked from the gears of the neurosurgery team for servicing and repairs, we go from the finely tuned, well oiled machine of 3 residents to a piece meal collection of pinch hitters as our seniors cover for us and take call. Suffice it to say there aren't any great disasters, but one does miss the familiar team work that has become as second nature as the beating of our hearts or breaths we unconsciously take.

The most jarring sensation of disconnect is felt, however, when it's time to return from vacation. Rested, revitalized, and ready to take on another stretch of never ending 30hour shifts, you feel like the refurbished part being thrown back into the gears of the service. You're slow at first, the freshly applied oil still cold compared to the racing fever of the neurosurgery machine. You miss scans, have to think about the landmarks on a ventriculostomy, and forget that you can't just sleep when you're tired. But just as only a few days prior you realized all you knew was neurosurgery, that the happenings of daily living were somewhat overwhelming in their lack of structure and intensity, you find you're back at home.

Call yesterday felt like another house of falling cards. I started the day with a red-line, a hemicraniectomy for a stroke patient (procedure where you take off half the patient's skull to give their dying/dead brain room to swell following cell death). I love to operate, but operating when you're on call is painful. Every minute you're in the OR you know the work is piling up around you. The consults still come, attendings still call. It was only a 3 hour case, but by the time I was done I was three hours, 2 consults, and 25 tasks behind. But still, it felt different. Despite the 5 admissions, acute intracranial hemorrhage causing herniation (no bueno), and two bedside procedures, there was never really any moment of panic or helplessness. Tired, yes; overwhelmed, no.

It was when I was placing bilateral subdural hematoma drains at bedside that it really felt like I was making progress. If you recall, my first bedside subdural hematoma drain was a disaster. An hour of futzing around with not much success, and having to call in my senior to help me out with an audience of nursing students watching me flail. Boo. This time, I placed both drains, one on either side of the head, within 30 minutes. The CT showed awesome placement. It almost made up for the 4 CT scans I forgot to show on radiology rounds... gah.

Monday, November 08, 2010

Feeling more like a surgeon

The phone went off at 4:45AM. I had already been laying awake in bed for 10 minutes, wrestling with the idea of getting up and starting another day. It was day 7 of my 2 week stretch without a day off, the black stretch that the R2s have to go through once every month. I already knew what the phone call was before I picked up. Someone had bled into their brain on the neurosurgery service and had to be red-lined to the OR, they needed backup for getting set up for rounds and needed me in early. I was out the door in 10 minutes and driving over to UCLA. After setting up things for morning rounds I relieved my co-resident in the OR and flew through the surgery with the attending. The senior residents were called away for rounds, leaving me as first assist on a pretty awesome case. We cut down to skin, him on his side of the incision, me on mine. Scalp up, periosteum off, drilling down to bone with bone dust flying with the blood and irrigation in minutes. By the time we opened dura the brain was so tight it started to ooze out of our incision. We cut open the rest of the dura to relieve the pressure and started sucking down over the sick looking brain. We found the blood clot quickly, and sucked it out along with the tumor that had bled. Once we had stabilized the bleeding and removed the rest of the tumor, he took off because he had to drop off something for his son. It's a great feeling to be the primary surgeon in any case, being able to go at your own pace and doing things in what you feel is the best way of the various techniques you've been taught. I finished closing the dura, plated and screwed on the bone flap, and was closing skin by the time my senior residents popped their heads to see how things were going. They cracked a few jokes, complimented my work, and left again. It was a great way to start the day.

This is our lot it seems. There's never really ever going to be a day off. Even when you're off duty, you can be called in at any time if they're short staffed. Death respects no vacation days, and for our hospital there's about 10 neurosurgery attendings and 15 residents. The residents are split up amongst 4 different hospitals, and the attendings aren't always in town. We're always on pager in case something comes up, being woken up in the middle of the night or post-call because we may know some critical piece of history or information that wasn't passed on in the rush of morning rounds or sign out. Yea. I'm tired. Vacation is coming up though. Hopefully I'll be able to get some sleep.

Saturday, November 06, 2010

Trust No Finger Butt Thine Own

The neurologic exam is a critical part of our history and physical when we're assessing a patient. Be it for documentation purposes prior to a surgery, or determining whether or not a patient even needs surgery, the patient's neurologic status and the documentation thereof is paramount in both a medical-legal and treatment paradigm way. As such, although we would like to trust our colleagues on different services regarding their neuro exam, as a neurosurgeon we really have to perform it and document it ourselves. I mean really, what do they know about 4+ versus 4- strength or the bulbocavernosus reflex? One piece of information in particular that seems to be stressed is the digital rectal exam. I'm not sure how many times you need to have had your finger up ...

Nevermind.

In any case, I was called recently to assess a patient with fecal incontinence. Per report there was no rectal tone. Getting a little bit of history made me suspicious that that wasn't entirely true. The guy was in pain, he didn't need another finger up his rear, and surely not right before dinner. But I had to be sure. And sure enough, there was tone. I really really really felt bad for the guy. When you're a patient you've got to wonder, "OK these docs REALLY got to talk to each other so they can COMMUNICATE what's going on up there." You don't get a CT scan everytime a different team wants to look at an image. They should make a portable rectal tone manometer so we'd only have to do it once and it can be objectively documented. But until then, as evidenced today, you can't trust the finger of anyone else's but your own.

Monday, November 01, 2010

One Third Done

We hit our 4 month mark today. It feels like I've been doing this job for a year. And if you calculate it, and of course we're duty hour compliant, but it turns out roughly to be 1440 hours that we've worked up to now in R2 year alone. An average 40hr a week job will work 1920 hours in a year. By the end of this month we'll have put in enough hours to bill for a year's labor, but sadly only have made $8.30 an hour. It's funny how the ACGME is all up in arms about us being sleep deprived and overworked, but never once filed complaints about us being underpaid.

That grievance being said, it's been a pretty smooth 4 months to date. Those still curious as to whether or not I'm still the "nice guy" who started this year, I would say yes. There have been times that I've wanted to tell someone they were being idiotic or yell at them for mismanaging a patient, but I'm sure I've been on the other side of mismanagement multiple times throughout my short career so far, and will be many times again in the future (hopefully only regarding non-neurosurgical issues). Everyone's only trying to do their job the best they can. But don't worry, the day I meet a doctor who shouldn't be a doctor because it's dangerous for patients, or are just blatantly negligent and irresponsible, I'll lay into them like there's no tomorrow.

One third done, 40 overnight calls completed, 73 overnight calls to go.

Friday, October 29, 2010

Angel of Death

Yesterday was a day of tears on the neurosurgery service. It started out a day like any other, rounds, a list of tasks and chores to complete, fielding phone calls from patients and outside hospitals. But then in the late afternoon the service became a field of tears as I made my first stop to pull the life sustaining ventriculostomy on one of our patients. He had been in the hospital since the beginning of my R2 year, his neurologic function crumbling away with each week of cognitive and physical immobility. His wife, ever optimistic and never faltering, had an hour long conversation with the attending surgeon who while drying off her own eyes asked me to pull the catheter. When I did I saw a tear rolling down the side of the patient's face.

A newly diagnosed brain tumor in someone who had only weeks before been completely healthy. We discussed what we had found on the MRI and what steps would need to be taken to find out exactly what it is and how to treat it. The funny thing with brain masses is that you can never be 100% sure what you're looking at on a radiographic study until you have a tissue diagnosis. Most times the scans are pretty predictive, but in our field we do not treat until the microscopic pathology confirms the disease process we suspect. This one was clearly GBM, or glioblastoma multiforme the most malignant of all brain tumors. The wife pressed me for prognosis, I parried and tried to divert her question stating that we couldn't tell until we found out what it was. She persisted and asked me to give a realistic estimate based one what we knew. Worst case scenario, 6 months, but some live 5, 10, 15 years with what we think this is (less than 1% of patients). The creed of physician is "primum non nocere" or "first do no harm." Leaving the young couple embracing while the wife succumbed to a flood of tears seemed to violate the spirit of that motto somehow. The nurse said that I was such a great doctor because of my compassionate bedside manner. It didn't seem like they would remember me that way. They would remember me as the young asian guy who told them that their lives together would be cut short, that she would need to bury him, that they would actually fulfill their marriage vows of staying faithful till death do them part rather than being separated by the mundane trifles of life.

An elderly gentleman who had just celebrated another year on earth the day prior came in with a massive stroke, and would with 100% certainty end up a vegetable unable to eat, speak, or understand anything. To tell a family that their father/uncle/grandfather who had only hours before blown out candles while laughing with them would now be a shell of his former self, that his memories and cognitive abilities would never return, and that surgery was not only NOT an option, but would hasten his death... more crying.

Then I saw Mr. K. After a 2 month stay we had finally gotten him healthy enough to go to a rehabilitation facility. He left us engaging, still smiling, making jokes despite his tracheostomy. I had spent literally hours speaking to his wife over the past months telling her there was hope, that he would make it through this. But he returned to us blind from an episode of hypotension (low blood pressure), back on the ventilator, unresponsive and unaware. When I went in to examine him I didn't know what to say. It wasn't good to see him again, I wish he had made it out and lived a long life away from the hell of the ICU. But still, "it's good to see you again... sorry it couldn't have been on different terms." It seemed trite. He couldn't hear me.

And then a transfer from an outside hospital. A lady who had an aneurysm rupture in her head, now in a persistent vegetative state with little chance of recovery. The family asked me how long it would be before she woke up since it had already been 2 months. The doctors must have never told them her prognosis. You cowards. I just made 4 different families I met for the first time cry today because they deserved the truth and you couldn't man up to one that you had taken care of for 2 months? Granted you must always give hope when describing prognosis (unless it's pretty devastating like the stroke patient above), but unrealistic expectations just set up families for a greater let down when they realize the reality of the situation. We would talk later, and our team would be responsible for cleaning up the mess of hopes the outside physicians had scattered before them.

Yea, yesterday kinda sucked.

Wednesday, October 27, 2010

Sometimes human

There was a lot of traffic today.

Driving home in the middle of rush hour, isolated in the mechanical barrier that us Angelinos prefer to the stench, hustle and bustle of shared air and space (ie public transportation), my frantic speeding of thoughts slowed to the idle crawl of the cars around me. Losing interest in the repetitive pop tunes on the radio I turned to my phone to check the traffic, and then from there started calling family members I had long since talked to.

It began with my sister-in-law. We talked about their kid and how she was starting to show a preference to my brother, crying to be held by him and played with when he was around, but busily looking for toys and other things to amuse herself when she was in the room. My dad was on a service call so he didn't have his usual enthusiasm in his voice, and to be frank, just inexplicably sounded tired. He's turning 60 in a couple of weeks... reminding us both that he was getting old. My mother was her usual bubbly enthusiastic fountain of encouragement, proud of her doctor son, apologizing that she couldn't do anything to help despite knowing how hard and tiring residency must be. Then later that day dinner with some friends I hadn't seen in some time. Burgers, drinks, nostalgic bickering and teasing. Too many reminders of the life that is on hold this year.

There are always moments when physicians, in my opinion surgeons especially, have to stop being human. Stop feeling, stop needing, stop wanting. Put aside Maslow's hierarchy of needs to finish that 10 hour surgery, take call again for the 3rd time in one week, push the envelope and admit that 8th patient that night because they need medical attention just as much as the first. Illness recognizes not the fatigue of the physician, but will capitalize on it when sleep deprivation causes laziness, sloppiness, or inattentiveness. To err is human, they say. But in our profession to err is murder. So we're asked to be more than human, isolating hunger, fatigue, and emotions, burying them until we scrub out of the OR or leave the hospital. But then we see our friends, hear the voices of our loved ones, and are reminded that we're still human too.

Tuesday, October 26, 2010

I cried because I had no shoes...

... until I met a man who had no feet.

Working in a hospital in the middle of Los Angeles with Westwood around, Beverly Hills around the corner, and Hollywood a few miles away is like swimming in a balsamic vinaigrette. With the occasional night of extravagance and superficiality it's quite jarring to come back to a place where your business is the basics of the human condition. We advance diets so that people may eat, ambulate them so they may poop, and operate on them so that they may live. I won't lie, but the dichotomy is somewhat refreshing. I'm not sure if I could handle a residency where the outside world was as bleak or dark as the everyday occurrences of the hospital I worked in.

Yesterday while walking the halls I heard a clicking like the sound of horseshoes but on a smaller, two limbed beast of some sort. Tap shoes? No... the clicks were in unison. I then saw a man with no legs basically vaulting himself forward while holding what looked like metal handles - ] [ - one in each hand, onto his remaining stump cut off just below the waist, as if his arms were crutches and his waist his only good leg. I was in a hurry, and sheepishly had to pass him as I sped on by. "Excuse me," I whispered as I overtook him. I mean really, what do you say in that kind of situation? Interestingly, I saw him the next morning in the room of a patient who was also plegic below the waist. I really lack the ability right now to articulate why I'm bringing this up... but questions this raises: Birds of a feather or just featherless birds? Situations in life or life situation that bind us? Do you feel guilty about your 50 pairs of shoes now?

Sunday, October 24, 2010

Blindness

"GSW to head. Please come to OR 4." [GSW = gunshot wound]

There aren't very many times that we run in the hospital. Luckily so, as our Dansko clogs in the best of conditions aren't capable of staying on past a moderate jog. I was about to check on our recent post-op patients before heading down to grab a bite to eat when this page came in. The last GSW patient I had was essentially brain dead by the time I arrived, but they were operating on this one so maybe this patient had a chance.

I jogged to the elevator and pressed the button for 2, thinking that this would be faster than 4 flights of stairs. A bunch of pediatric nurses got on at 5 and took the elevator down to 3. Internally I shouted. But how could they know I was rushing over to someone that was likely dead or dying. We were in the same elevator going down, and they were potentially slowing down an urgent medical evaluation and life saving intervention. I wonder if they would have still been laughing about their workplace intrigue if they had known this.

I was there in 2 minutes, but the patient was already intubated and sedated. Great, I'll just have to go with the cranial nerve exam. There were at least 20 people in the OR, hanging blood products, setting up IVs, charting everything as the maddening chaos of the operative theater unfolded. I maneuvered my way to the head of the bed so I could at least examine her eyes, as in addition to being the proverbial windows to the soul, pupils are the best indicators for impending or completed herniation from mass lesions such as bleeding in the brain. Pupils are... oh jeez. The patient's left eye was extricated from the orbit and the right one had ruptured, sequelae from the blast damage of the bullet that was imbedded in the left temple. No CT scan, no exam. I could only wait for the trauma team to finish what they were doing so we could get a STAT CT to see what we were dealing with. The CT showed that, tragically, there wasn't much brain damage. She would survive this. The bone of the eye sockets were shattered beyond recognition, and likely beyond salvage as well. We lightened the sedation to get an exam... and I'm sure awakened her to a hellish nightmare.

Where am I? Why is it so dark? Why does my chest hurt so much. I can't breath. I can't... I can't move my arms. Why am I tied down? My eyes. Oh my God my eyes. I can't see. I can't see! Somebody tell me what's going on! Somebody, anybody. Where is he? Why did he... what did I do? Why, God, oh why? I can't see anything... I ... CAN'T... SEE...

She tries to scream, but is muffled as the ventilator pushes air back into her lungs, forcing life back into her.

Monday, October 18, 2010

Random Thoughts

There are a lot of random thoughts that become seemingly normal to the neurosurgery resident that people not in the field might find interesting, amusing, or down right appalling. I thought I'd share some of them.

1. I really should quit and find a better paying job.

2. I stumbled upon a familiar name on an operating room slip in the OR lounge. It was for a baby who we pronounced basically dead with very little chance at survival following her intracranial hemorrhage. The slip was for the harvesting of her pancreas... I don't know but after not hearing about her status for about a week it was kind of eerie for it to come back at me out of nowhere like that.

3. We routinely operate on people and have to leave the bone off so that their brain has room to swell. They go around and have to live while wearing a helmet. I thought of that when I saw my snowboarding helmet in my closet while getting dressed for work this morning. Yes, a patient without half his skull snowboarding.

4. Doctors really do make the worst patients. Especially the ones who think that by being an orthopedic surgeon or internal medicine doctor that they have the faintest idea how to manage the problems that bring them on our service. This isn't frickin Burger King, you can't have it your way.

5. If I ever get diagnosed with a brain tumor, and I'm no longer able to talk or care for myself... please hire a hitman and have me killed. Seriously. Seeing these patients that have been on our service for as long as I've been an R2, slowly wasting away, a former shell of what they used to be... being tortured by the misguided "love" of their family members who think that by holding on so tight to the memory of what once was is honoring their life when in reality it's only prolonging their journey through the valley of death. It really kills me.

6. Do robots have feelings? What about talking ones? (if you don't know, don't ask).

7. Why am I so awesome? God I suck. (simultaneously).

8. Post call sleeping is tricky. You sleep to your hearts content, and then you can't sleep at night, and you're tired the next day instead the day after call. But if you don't sleep enough, you lose that half day of freedom to your mild delirium.

9. I never thought I'd ever have to shave this many heads. All that practice cutting hair during college paid off.

10. I'm hungry.

Saturday, October 16, 2010

Neurosurgery Badass

After I placed an emergent ventriculostomy in one of my patients and had him slowly wake up over the next day or two, the brother came up to me all excited, thanking me for saving his brother's life. It was a little embarrassing to get that much praise for doing my job in the middle of the busy ICU, but it felt nice nonetheless. The funny part was that another patient's husband came up to me after seeing this spectacle and commented, "See, you're such a badass." Haha.

One of my friend's used to ask if I was going into neurosurgery because it was such a "badass" field/thing to do. I think a comment I heard in passing the other day to the effect that "it's not the same world anymore where doctors hold a place at the top of the social ladder" describes my sentiments best. People don't go into neurosurgery to be "badasses." If I wanted that kind of a title I would have went into investment banking and dated a escort named Vivian or something, owned my own plane, brought crates of food/supplies to the survivors of natural disasters and stuff like that. Working 100+ hours a week, being able to see my family only once or twice a year, and being constantly fatigued to a point where 12 hours of sleep will only restore me enough to realize how tired I am isn't exactly the most glamorous life. But I guess behind all the smoke and mirrors the idea of violating and salvaging the sanctuary of the human mind is appealing.

Being chained into the hospital though does have its advantages. I feel a heightened sense of awareness of the outside world, and appreciate things I never really enjoyed before. These are the best moments of the past couple weeks.

- Playing poker with the guys on a boat by candle light, cooking some dogs on the grill while we chatted the night away.

- Leaving the hospital after operating all day, cookie in hand, taking the long route to my car so I could take in the fresh smell of rain that scented the setting sun.

Life is a gift, and so long as we are not bound by the shackles of death anything is possible. My friend sent me this link about a great man I once had the opportunity to work with. His story reminds me that there's still so much to do, and still so much more to be greatful for. He reminds me that making the impossible a reality is truly a worthwhile goal to strive for.

http://www.hopkinsmedicine.org/hmn/W07/feature1.cfm

Sunday, October 10, 2010

Neurosurgery Poker

Despite my efforts to be a great upstanding doctor/physician/surgeon or even human being for that matter, the people that really know me will tell you that one of my greatest vices is my love for poker. It was more of an addiction during medical school when the paucity of required classes and countless hours dedicated to studying/research but otherwise unaccounted for would lend itself to me making a trek to the casino to play a few hands of cards. OK so it wasn't a few hands, as there were definitely nights when my buddies and I would leave as the sun was coming up. Still, I thought of it as training for my future in neurosurgery. If I could focus and stay awake for that many hours in one place, I was obviously training myself for the long surgeries and nights on call. I never imagined it could work the other way around.

There were parts of poker that had always appealed to me, relying on the ability to read the intentions and emotions of others to make your next move, being able to guard and secure your own feelings to control the stage of the game, knowing which battles were worth fighting and which retreat was actually winning, and then being rewarded for your mastery of these skills. Poker was an extension of the finer emotional gauntlets of life, and life just another extension of texas hold'em.

In neurosurgery, or maybe it's just residency in general, I've found that it's oftentimes a very similar hand of cards. Having to tell patients that their prognosis is still uncertain, that there might be hope, despite your short but sufficient experience telling you that they only have months to live. Delivery with confidence, cool, and reassurance is key so they do not despair or abandon any further tests that are needed for future treatments that may not ultimately affect their life expectancy. One has to be agreeable despite the occasional cockamamy plan of the attending surgeon, and then convincingly convey to the patient that this is the best course of action despite one's own beliefs (oftentimes in line with the resident team). Moreover, one must perceive the emotional status and intent of nurses as well as the patients to know if there's a firetrap on the horizon and how to best appease their wishes. Fighting with either of these parties is like fighting with the dealer, and will only get you expelled from the table, and usually with no winnings. I do not wish to suggest that neurosurgeons are deceiving swindlers that manipulate and scheme. Quite the contrary, I feel that our role is to create hope where there is none (in the face of certain death, wouldn't you want that chance at life?), maintain tranquility in a place where stress and suffering occasionally unearths the worst in people, and promote faith in the doctors that are treating them (despite idiosyncracies and ideological differences).

Or, it may just all be BS and I had a great night at cards this weekend despite my residency training. Who knows...

Tuesday, October 05, 2010

Let the music play

With people starting to come up to me at work telling me that they enjoy reading my blog, there's now this immense pressure to deliver that has become somewhat suffocating. Ideally, I'd like to discuss something interesting, insightful, or moving with each of my blog posts, but let's face it, sometimes there's just nothing to say. Or sometimes, screaming out into the ethos of the internet is just a form of personal catharsis with no edification to the reader... for which I apologize.

For example, the other night on call I had the most frustrating consult from the emergency department to date. It was a kid with a VP shunt that came in with nausea and vomiting. She ended up having an ear infection. Imaging of the brain revealed that the shunt was working just fine. But the ER attending felt it necessary to have neurosurgery consult and do a full evaluation on her, despite a known etiology for her nausea and vomiting (shunt failure can cause this too, but usually it's accompanied by radiographic evidence of failure on CT).

ER Resident: Can you please see this patient?
Me: What's the reason for consultation?
ER: She has a shunt...
Me: It's working just fine.
ER: She has a shunt... and nausea and vomiting.
Me: Are you kidding me? The CT shows that it's working, her ventricles are smaller. She has left ear pain, and nausea/vomiting from otitis media.
ER: I know, I know. I'm really sorry, but my attending wants neurosurgery to consult.
Me: She's feeling better. She actually wants to go home right now.
ER: He still wants you to consult...
Me: And what am I supposed to say in this consultation?
ER: That the shunt is working...?
Me: ...

GAH! Luckily the resident was nice and understanding of the unfortunate situation she was putting me in. It was my 8th consult that night, and there was a gentleman in the next bed over in the ER with a subdural hematoma that needed draining. You've got to be kidding me. I was reminded that we're not allowed to refuse consults. True, but I can make your lives miserable by not seeing the patient and having her sit in your ER until I'm done with all my other work.

I saw the patient promptly anyway. I didn't want her to suffer for the ... management decisions of this attending.


Today, post call I tried once again to do some reading for research. I just can't. The constant sleep deprivation and disturbed circadian rhythm has left me rather anhedonic, and possibly bordering a point of depression. Coming home to a quiet room and submersing myself in good music seems to help though. I tried hanging out with some friends this weekend to escape the lull of monotony and death/dying... but it just left me more tired the next day at work. Maybe I just need to get a bigger TV...

Thursday, September 30, 2010

Helpless Human

There's an old joke that goes: What's the difference between a neurosurgeon and God? ... God doesn't think he's a neurosurgeon.

There are definitely the fair share of ego-maniacs within the field of neurosurgery. Many self-entitled based on the hardships in training and countless hours spent to reach their goal. There are the rare few however that are deserving of praise such as "hands of God" capable of performing exquisitely challenging surgeries that are both life saving and function preserving. What people oftentimes don't understand is that some lesions that are deemed "inoperable" by one neurosurgeon, may just be a matter of inexperience or lack of technical ability that cannot be admitted. But sometimes, some situations are beyond even the most gifted surgeons, and we are reminded of the adage that once God lays his hands on your patient, you should take yours away.

My last night on call was terribly draining, not on a physical level per se, but more on an emotional one as I watched multiple patients slip away into the night, far removed from the grasp of the medical care we could offer them.

We red-lined a patient with a multiple year history of end stage liver disease to evacuate a spontaneous brain hemorrhage he experienced for want of clotting products that his liver could no longer produce. His emergent surgery was striking to me for two reasons. One, it was an epic uphill battle after we removed a good part of the blood clot from his bulging blood clot swollen brain. Trying to get him to stop bleeding despite all the clotting factors we were dumping into his blood stream felt akin to trying to stop a dripping sponge with a box of matches. Two, his brain was yellow. It was probably one of the weirdest things I've seen this year. During certain stages of liver failure the body fails to breakdown and reabsorb bilirubin, so it floods the bloodstream and stains everything yellow. First it's the conjunctivae of your eyes, the underside of your tongue, your skin... and I guess your brain as well. The brain is usually a glistening grey mass (hence grey matter) with a beautiful architecture of blood vessels overlaying the surface. This appeared like a big golden egg, and in the setting of swelling from the underlying hematoma, seemed like it was a golden chicken about to hatch from a less yellow, but equally aberrantly tinted skull. After the initial amusement and childlike curiosity ensued a feeling of helplessness that pervaded through the morning, the night, and into the next day. Given his disease he would not stop bleeding. We did the best we could, and saved him from immediate death from herniation (when parts of your brain go and compress other critical areas given an intracranial mass). But he continued to bleed. I watched as his scans worsened, as his exams worsened, and with each radiographic or clinical deterioration presented the case to the team and attending. There was nothing we could do. Surgery would only make things worse. Even if he survived this incident he would likely end up a vegetable, and if he woke up, would not be able to talk or use the right side of his body. He was beyond what we as neurosurgeons, what we as human beings, could do. We were in the operating suite of a higher power, and we had no place there.

On a less religious and more uplifting level... I operated on a 9 day old baby today! She had a congenital condition that required her to have a permanent CSF shunt from her ventricles to elsewhere in her body. I had done enough of these on other patients by now that the attending let me do the case as he assisted and guided me through the parts I was still rusty on. It went perfectly, and the baby woke up smiling without crying (maybe she was still high on anesthesia). She'll be able to grow up to be a fully functional person later on because of what we did.

So for today, I guess we're even.

Sunday, September 26, 2010

In Sickness and In Health

Real men don't cry.

But knocking on Heaven's gates these men become more father, husband, and lover than man, a transformation that unearths a channel of tears that had long run dry. The news that a loved one is dying, that their wife has newly diagnosed cancer, that their child may never regain the ability to speak or walk again... crushing news that could squeeze the last drops from a grape long turned raisin. I don't know about you guys, but to me there's nothing more heart rending than strength in the midst of tears. The slow flushing of skin and dewing of eyes in the spouse that listens as you tell him his wife may not have much time. The sight of parents buckling down to their knees in muffled sobs at the bedside of their 12 year old child, who smilingly tells them to be strong, that everything will be all right.

I was especially moved by the interaction of a couple I met recently on call. She came in with new onset seizures, and workup revealed what appeared to be metastatic disease to her brain. We knew from the CT scan that it was serious, and that she was likely facing a diagnosis of cancer of some sort. But after a day of multiple seizures, and a pending diagnosis of possible death, the only question she had for me was if there was any way we could get her husband a beer. It's been a long day, she said. I was touched, and smiling said I wasn't sure we could drink alcohol in the hospital. He excused her, apologized and thanked me for my help. As he turned to grab her hand to check to see if she was really processing all of this she smiled back at him, and he knew she did. As I left the room she continued, "More importantly, what's for dinner?" He wiped his eyes and laughed.

He asked me not to break the results of the pending MRI scan unless he could be there to support her while it was given. He stayed all night by her bedside in a small, awkward seat that seemed it was designed for midgets and petite Asian women. When the news breaking was pushed back, he simply apologized for the morning breath he would have, and said he'd wait a few more hours. In sickness and in health, he had promised to protect her. Would we make these vows if we knew it would mean to hold their hand when they are told they are going to die? This man was the kind of man who would have sworn them all the sooner, all the more solemnly, so he could be there for her during this moment.

Many of us spend our whole lives looking for something special. A soulmate perhaps, that other half that completes us? Or maybe just someone to laugh at our terrible jokes or keep us warm at night. I don't think I know what love is, not really, not completely anyway. But, I think I'd want to marry the girl that despite all adversity and hardship of her own, would turn to a doctor and ask if he could get her husband a beer.

Friday, September 24, 2010

No light in this tunnel

12 weeks of R2 year done.

Pretty emotionally drained.

Can't even find the inspiration or desire to write in complete paragraphs...

Supposed to work on research today, but instead I took two naps.

It's hard to stay motivated when the only thing in the immediate future is another 24 hour shift at the hospital.

Tuesday, September 21, 2010

Think you can handle it?

Every time a resident steps into the operating room he is tested. Whether it be how punctual he is, the way he positions the patient, the way he handles the scalpel, or the way he controls the suction as he pulls away diseased brain. Initially the attending does most of the case, and occasionally has his resident do a couple small things. Suck here. Tie this down. Cut this vessel. At one point or another the attending surgeon decides that the resident has proven himself, and lets him do more and more. Soon it becomes, "OK I'll do this side, you take care of that side." Before you know it, you're closing up dura without scrutiny, dissecting down paraspinal muscles without supervision, and closing up shop while the attending takes off for the day. I've only been left in the room to close up a couple times during residency, and usually just the superficial skin, but today the attending just threw in a couple stitches in the galea and said, "OK Won, you got this?" ... "Uh, yes sir." ... "OK good, thanks for your help." And he was gone.

Awesome.

It's really no big deal closing up scalp, and most residents probably wouldn't get very excited about it. But to have an attending leave the room while you operate, in this case close galea and skin, means they trust you to do a good unsupervised job at finishing the case and making sure the patient makes it to recovery without complication. Small accomplishment, but at least I'm heading in the right direction.

Friday, September 17, 2010

Overpowering Fatigue...

As of today I had gone 20 days without a day off. It doesn't seem too bad at first, but when you're trying to get your couple hours of sleep in before morning rounds, and the night is fractured by repeated pages, the fatigue overwhelms you. You look at the pager "patient neuro exam changed" and you ask yourself, "Can I get another 10 minutes of sleep before calling? Maybe 15 minutes before I go and check in on them?" Clearly judgment is impaired, and after 30 seconds of bickering between the ever dwindling sane portion of your brain, the drowsiness clears and you remember that for every 10 of these concerning pages, one or two may be real. It only takes one or two out of ten, or even a hundred, to motivate you to get out of bed and check on the patient. Only one or two pages, but one or two lives possibly in danger nonetheless. They may be bleeding into their brain, or maybe having seizures unbeknownst to the nurse or lay observers. The fear of what may happen if this concern is warranted gets the residents tired, overworked, and unnaturally fatigued body to move at the even feebler cadence of his brain. Yes we do our due diligence. But it's scary that, even for a second, we think not to.

Tomorrow's my day off!!! Friends and good food on the horizon. Something to remind me that I'm still human. To remind me what life we're trying to preserve, prolong, and save.

Tuesday, September 14, 2010

(almost) flawless victory

Maybe it's a product of being on service for two and a half weeks without a day off, with back to back calls, but everything seemed to come together last night. After struggling with a bedside subdural drain last week (a bedside procedure where you drill a hole into the skull to pass a catheter and evacuate old blood that's been accumulating) I jumped on the opportunity to do the one on Mr. S yesterday. Surgical residency, at least for me, has been an experience of constant self appraisal and validation. Failures can only be redeemed even greater successes in the future. So for my own self esteem and standing within the resident team this procedure was critical to say the least. Oh, and yes of course, we wanted to help the patient.

Despite being fairly elderly, Mr. S required enough sedation to kill a small animal. But eventually he was docile enough to allow me to make a small incision on his scalp and drill down into his skull. I passed the catheter without any difficulty and drew back. Money. The old blood, now degraded into the consistency of CSF, flowed freely. After draining an adequate of fluid to relieve the brain of pressure, we sent him down to the CT scanner. Money again. Awesome placement. Then he came back up and I went to check in on him. There's frank blood in the drain. Poop.

#(*&#$%(*&$

Recomposed.

Another CT scan. Not much blood in the brain. No evidence of acute bleeders. Looks like it's coming from the scalp. I placed a fatty pressure dressing over the incision site and within a few minutes the blood stopped flowing from the drain. I win.

I got a couple hours of sleep before I awoke to a "Critical patient xxxx, subarachnoid hemorrhage." There are few things to get you out of bed in the morning faster than pages like that: coyote ugly, a full bladder, being late for morning rounds, and 'patient is herniating' are amongst the others. I can only imagine what the husband was thinking when I rushed into the room, hair all flat and disheveled from a restless night of inconstant pages, morning breath still lingering, and the look of a person who'd been in the hospital 60 of the past 72 hours. I had glimpsed at the scan on my way into the room and knew the patient needed a ventriculostomy immediately (a catheter placed into the fluid cavities of the brain to drain CSF and blood and monitor intracranial pressures). It's always interesting being the one to raise the level of urgency in a hospital situation. The nurses caught on to the immediacy in my voice as I asked for platelets, ddAVP, a ventriculostomy tray and catheter, and antibiotics STAT. Super STAT guys. Within a few minutes an empty room with a patient and husband became bustling with nurses hanging meds, eager medical students lingering in the background, and me giving this poor woman a terrible hair cut (we shave half the head to place the ventriculostomy).

It was 4:50 when I got down to the ED, 5AM by the time I was shaving hair. But rounds would start in 30 minutes. Luckily my co-resident had come in early that morning. I sent him off to print notes while I got the rest of the meds running and ventriculostomy set up. By the time things were ready for incision he was back. I told him I needed to set up for rounds, gave a quick one-liner "77 year old female, Fisher IV, Hunt Hess III, subarachnoid hemorrhage likely secondary to A-comm aneurysm rupture, pupils reactive, localizing right upper, withdrawing bilateral lowers, needs EVD." He responds "Done. Go take care of rounds."

They told us in the beginning that we three R2s are one person. We each need to know what the other knows regarding the service, and we pick up wherever one person leaves off. That way we can be in 3 places at once, and never lose the seamless control over our service of 30-50 patients.

I made it in time to load images, organize notes, and present for rounds. The lady in the ED got her life stabilizing ventriculostomy, which was in by the time we saw her after film rounds, and she went straight to angio for embolization of her aneurysm (which was successful). Another life saved. No huge screw ups or set backs. Not a bad night.

Wednesday, September 08, 2010

Mommy's Little Girl

Three mothers, three daughters. Each pair with their own neurosurgical misery.

One born with very little brain. No treatment mom says... unsure if there's anything left to save.
One born with blood in normal brain, and mom embraces the easy fix we can offer her to save her baby's life.
One born with normal brain, but hidden within, a tumor whose treatment wherewith causes her neurologic decline to mental retardation. Her mother fights and fights and ask for the improbable, hoping for the impossible.

Some decisions are easier than others it would seem. Some make more fiscal and pragmatic sense than others. But the ones such as the last that require operation after operation to save what little function is left leave me conflicted. One of our neurosurgical attendings mentioned that he once knew a neurosurgeon from the old Soviet block who stated that issues such as these shouldn't be an issue, for it would be cheaper to make another baby than to try and save what little was left of the one you were treating. I'm no communist, but there's a lot of truth to what he said. We performed a 23 hour operation on the 3rd child, involving 3 different surgical teams, tens of thousands of dollars of surgical equipment, hundreds of thousands of dollars of OR time, and thousands of dollars of postoperative care. And ultimately the treatment failed. Had it worked, it would only prevent further neurologic decline, but not restore function that had been lost. She would not be able to speak, she would not be able to care for herself. She would never go become a productive member of society and would likely have to be cared for for the rest of her life. Economically speaking she would be one of the hundreds of thousands of dependents within the US today, who require more in medical costs per year than the average wage earning American would usually make.

I don't believe that we as human beings have no right to judge the value of another life. And in a sense we are socially obligated as physicians to do what we can to improve the human condition and relieve suffering. But say we took those hundreds of thousands of dollars spent on one flickering flame and used it to feed, shelter, and educate hundreds of smoldering coals of a rural village in Tanzania. That money could have been used to provide retroviral medications for an entire town inflicted with HIV. It's enough to feed a rural community in a third world country ridden with belly bloated, fly invested children for an entire year. But instead for intellectual curiosity and an inability to refuse treatment with the slightest chance of improvement, the best and brightest flushed hundreds of thousands into the medical debt of America to give one soul a chance. So that she may continue lifting up her arms, as her fingers no longer move, a hundred children went without food and water last night. So that she may still get up to a chair, 50 men will succumb to HIV/AIDs for want of medication today. So that she can smile for a few more years, 20 women will die during childbirth for lack of sanitary delivery facilities tomorrow. How can we judge the worth of her smile? We argue that even if we didn't treat her, our monies would not reach those in need. But maybe that's the problem. The avenues do not exist, and if they do exist aren't readily available for us to use. Millions around the world are without food, water, shelter, medication, education, and possibly summed up - without hope, while we operate on the rare and esoteric. It doesn't take a neurosurgeon to realize there needs to be change. But I feel it'll take more than a doctor to figure out how.

Monday, September 06, 2010

As the wheel of time turns

Facebook is a the modern day equivalent of Christmas cards and high school reunions balled into an instantaneous and all encompassing flood of reminders of all the things your friends are doing, accomplishing, and living... all the things that you as a neurosurgery resident aren't doing. I was browsing the updates section the other day, and saw that two of my friends got married to their respective significant others, another two got engaged, two others were having babies, another was roaming Thailand, and another just had the best sandwiches ever on a weekend getaway to the bay area.

Dude.

I'm not looking to engaged or married, or have any kids anytime soon. But man, I'd love to have a really good sandwich every now and then, and one not from the hospital cafeteria. I spend my 3 days off every month catching up on laundry and maintenance chores, craigslist shopping for a new couch, and reading for work. After all that, finding the energy to get that sandwich is pretty hard to come by. Dating someone would potentially help the situation, as someone on a normal work/sleep schedule is usually more motivated to push the obtunded significant other outside the door to get fresh air (and a sandwich). But there are obvious problems with dating someone as a neurosurgeon, especially a neurosurgery resident.

Why women shouldn't date neurosurgeons:
1. Our divorce rate is 200%. Yes, 200%. I think our department average is 150%, but rumor has it that neurosurgeons get divorced at least twice during their lives. Sure there's the initial glamor in the idea of dating/marrying "a neurosurgeon," but the long hours, missed baseball games, and never returned phone calls get old after a while. That and sharing a bed with someone whose pager goes off at least a couple times during the night when not on call, and anywhere from 0-25 times while on call... think about it.

2. Some start running their lives like they run the operating room. There are neurosurgeons that get so accustomed to being the commander and chief that they begin expecting others in the everyday world to attend to their every needs. While in the OR we have instruments handed to us by just asking, and we don't even look as it's being handed in order to not lose our orientation / focus in the operating field. Imagine how long it would fly if we just held out our hand and said "Salt. Pepper. Napkin." during breakfast without even looking up to acknowledge the giver. A drastic exaggeration of course, but I'm sure the subtleties bleed through somehow.

The list goes on, and just writing about it makes me sick with myself, or my future self rather, and thus I'll stop prematurely. But somewhere down that list is the fact that after work or call, they just won't have the energy to go out and find that awesome sandwich.

Friday, September 03, 2010

A brief lapse in blogging consciousness...

I haven't really been updating my blog recently if you haven't noticed. Part of the reason is that much of the calls and post call days have started to blur together without anything novel or interesting to add. I'm getting used to the job to a point where I'm not scared or clueless or scared clueless when I assess a patient in the ED anymore. I'm starting to be able to give advice to other services during consultations with more confidence without needing to ask my senior resident about every single detail (although I still confirm my recommendations with them before finalizing my note). Two months have passed, ten more to go...

Today I had a pretty good day in the OR. Only weeks before I was fumbling with my knot tying while working with dura, afraid that if I tied too tightly I would tear it, too loosely there'd be a CSF leak when I closed this layer of brain covering. For some reason today the experience and practice caught up to me and I was able to work pretty proficiently without any problems. They say you can teach a monkey how to operate... I'm glad to see I'm catching up to the monkey.

Despite knowing how to work up and treat the majority of patients that come our way, there'll always be things that the neurosurgery team will disagree with the ICU team on regarding patient care. This will inevitably lead to arguments, and finger pointing at the R2s who obviously should know better. When you're working 100+ hours a week, with your vacations spent with the expectation that you'll be reading and publishing academic papers, the beatings seem a little much. But they say that if you're looking for a pat on the back for a job well done, you shouldn't be in neurosurgery. You're digging around in someone's brain for crying out loud. There's no room for error, laziness, or complacency. So the beatings will continue until morale improves. And we understand why. Kinda.

Monday, August 09, 2010

Love Sonnet Number 27

She was 14 years old when she decided she would find love. But time in his age old stinginess did not afford her such happiness until she was 50. It was then she met him. He was quite the charmer: quiet in his knowing understanding, firm in his resolute compassion, and yet helplessly weak under her unraveling brown eyes. They spoke of movies, detailed places previously long forgotten in the recesses of their minds, and fabricated fantasies of all the countries they would need to experience before they passed from this ephemeral dream. He had loved before, and even married. But time had been cruel to him too, and had taken his previous her, early on. Something about too many abnormal cells, he said.

Time didn't think her enough.

She waited half a century to find love, but only half a year to find out she too would have to leave this man behind. They thought they had removed all of the cancer, but nausea and vomiting lead to an MRI ... an MRI lead to a neurosurgeon ... and the neurosurgeon lead to a diagnosis. Metastatic disease he said. They would have to operate. Brain surgery, she thought. She only had months to live, weeks if she didn't have the surgery. But she couldn't tell him. How could she? Be it despair or questions of personal damnation, how could she say he would have to bury her as well?

Love is strong, she thought. Love is kind, she sighed. Love does not despair, she wept.

Tuesday, August 03, 2010

Defeated...


Sometimes you feel like you need this pill (which I think really describes all the symptoms of R2 year). Today was one of those days.


I've been told multiple times throughout my time in neurosurgery that if you haven't seriously thought about quitting, I'm talking about having an alternate career plan lined up paper work in hand, that you're not actually in neurosurgery residency. Well, it's just one of those days...

Thursday, July 29, 2010

First big screw up

If you're in the health profession long enough, there will be a time when you realize you could have killed someone, and sometimes there will be a time when you actually do. Luckily, yesterday wasn't a day of the latter, but being one of the former it really shook me up. The infuriating thing was that it wasn't due to operative inexperience, medical ignorance, or even straight up stupidity. It was due to the fact that no one ever really explains all the things you're responsible for doing as a junior resident on neurosurgery. A patient came in and had a head bleed, but the neuro ICU attending accepted the patient, the neurocritical care fellow knew about the patient, and I reviewed the patient's scan and clinical exam findings with him and thus felt the case was staffed. How was I to know that he never even bothered to look at the films, and if he did that he didn't realize that the patient had to go to the OR for emergent surgery. No one ever explained to me that every patient that comes to the ICU attending must also be staffed with a neurosurgery attending. You'd think the ICU attending would tell us what was up and what to do... but no.

The patient had fell earlier that morning and had a cerebellar bleed on CT from an outside hospital. She was awake and talking with no real neurologic deficits, so none of the warning bells went off in my head. The patient was staffed with an attending, seemingly neurologically intact despite her head bleed - nothing to worry about, the ICU team will take care of her in the morning. When my seniors came in the next morning and saw the scans they were a bit upset to say the least. She should have gone to the OR as soon as she hit the floor. I had failed to see that the bleed in cerebellum had began effacing the outflow track of the CSF in her brain, causing ventricles to swell. She was pretty old so I thought maybe she just had atrophy of the brain making her ventricles look big. If I had known we needed to staff all the patients with our team, not just the accepting physician, this would have been caught immediately. We ended up red-lining her (rushing her as an emergent surgery within the hour). She ended up doing just fine... but the obvious alternate scenario still plagues me. What if she had come in earlier and herniated while we waited for the team in the morning? It was only an hour difference, but in neurosurgery even minutes can be the difference between a full recovery and permanent neurologic deficit or death. I got lucky.

They say that good clinical judgment comes with experience, and that experience comes from bad clinical judgment. Lesson learned, no one died... I really got lucky.

Thursday, July 22, 2010

Only Cry in the Elevator

Some family members of the patients on the neurosurgical ward are truly amazing. One patient's wife in particular really touched me while I was on call last night. When you speak to Mrs. Z, she always seems so cheerful, almost to a point of idiocy and unawareness. But she's always so grateful, so attentive, and so seemingly aware of the treatment plan and the status of her husband that you're inclined to think she's not a complete idiot. However, last night as I was about to make my midnight rounds in the ICU I thought I saw her leaving the unit to go home for the night. I wasn't sure if we had consented her for her husband's procedure on Friday (he's delerious and thus can't sign for himself), so I approached her to find out. She was waiting for the elevator. "Mrs. Z?" I asked, wondering if I had the right person. She turned around and upon recognizing me quickly wiped the tears from her eyes, abruptly cutting off the flood of sadness she held back the whole day while smiling, laughing, and encouraging by her husband's side. "It's been a long day," she said, smiling again behind her flushed and still tear-damp face. "It's been a long month for you," I thought to myself.

The family members of the comatose patient's almost have it easier. They don't have to pretend to be strong, hopeful, or happy to boost the morale or spirits of their loved ones. But the patient's that still seem to understand what's going on, are aware enough to know that they are sick, if they're lucky, or dying, if they're like many patients on our service... those family members wear the smokescreen of love in the forms of smiles and undying optimism so their loved ones won't succumb to despair in addition to their devastating illness.

Tuesday, July 20, 2010

Beautiful Brain

The brain is a beautiful organ. If you haven't had a chance to see a freshly opened skull (in a controlled operative setting, craniotomy by hatchet doesn't count), you really need to before you die. To see the brain pulsating with each heart beat, glistening in CSF with the blood vessels coursing its surface is truly one of the most beautiful things I've seen while alive.

Today I assisted in a temporal lobectomy. The indication for this surgery is usually medically intractable seizures. Oftentimes the temporal lobe, whether it be due to structural abnormalities or aberrant neuronal synapses, is the source of seizures that are poorly responsive to medications. So... when something is causing problems, surgeons take it out. In order to perform the lobectomy, however, you have to make a fairly decent sized bone window to approach the lobe and take it out. Consequently, you get to see a lot of brain. After making an approximately 30cm upside down question mark shaped incision, drilling down the bone and cutting out a roughly 10cm diameter flap of bone, we cut open the dura and voila, there she was, glistening in all her glory. Cheezy yes, but you really gotta see it to believe how beautiful it is. I'm an adrenaline junky and aesthetic... it's moments like these that make the 110 hour work weeks and 30 hour work shifts worth it... barely... but yea, worth it.

Friday, July 16, 2010

Quiet Night

I'm happy to report I enjoyed my first quiet night on call. Only one code trauma where neurosurgery was involved, and it turned out to be some drunk that had way too much booze. Only one consult that ended up being non-operative. No one acutely crumping in the ED or the unit (ICU). I thought my pager was broken. I actually got 2ish hours of sleep. Man, if I can get one of these nights every other call or something this year might not be too bad.

Now that I'm operating every other day or so, residency has taken on a whole new level of complexity. Attendings are starting to expect me to position, prep, and drape the patient before they get into the room now. Figuring out how to position the head in relation to the anesthesia peeps, the endotracheal (breathing) tube, whether or not they need a frame to hold their head or if we're just operating with it placed on a foam doughnut... all these considerations aren't things I've actively thought about before, nor took note of how disparate it is between one surgeon from another. I need to start writing these things down...

Today I evacuated an epidural hematoma on a 6 year old kid. Epidural hematomas are blood collections that form between the dura (protective covering of the brain - it's skin essentially) and the skull. I drilled down with a tiny acorn (named for its shape) drill until the blood started gushing out. By this time due to the decomposition of the hemaglobin into hemosiderin, it had taken on a green vomit-like color. As the old blood pulsed out with the kids heartbeat, it appeared something akin to the skull vomiting in tiny spurts through an equally tiny mouth. We enlarged the bony opening by drilling a piece off and washed out the blood until the irrigation was clear. I put the bone flap back on with a titanium plate and screws, stitched up the scalp and called it a day. Nice and simple. Not a bad way to end a not-too bad call.

Tuesday, July 13, 2010

House of falling cards

Every morning by 5:30AM (sometimes 5:15 when we have early morning meetings) the R2 that was on call the previous night has to show all the CTs/MRIs that were performed the previous day. By 5:30AM the R2 needs to have an updated copy of the patient list and the rounding notes for the day printed out, collated and stapled in the order we see patients throughout the hospital. By 5:30AM, all the post op checks, CSF collections, dressing removals, ED consults, transcranial doppler results, and acute patient management need to have been done. With a list of probably 50 things to do at any given time throughout the night, with more coming in in the way of pages and calls to the phone, it feels something akin to frantically trying to stack a pile of falling cards into an organized house before we present the overnight events to the team in the morning. Only after signing out the virtual pager to the next R2 on call does one feel that he's making ground in eliminating the number of tasks he needs to perform.

I still feel like I'm flailing. There's still too much to learn. They say it'll come with time, but our attendings expect perfection now. The unreasonable expectations motivate me in a sick way. It's an impossible task, an insurmountable puzzle... I love a good challenge.

To my readers: I apologize for my writing style. According to an online analysis (http://iwl.me/), my style has deteriorated from that of Margaret Atwood and Edgar Alan Poe to that of Stephen King and Dan Brown over the years. Ugh. I'll try to do better.

Wednesday, July 07, 2010

When our hands are bound, we reach for God

Being in a profession where life and death are the biggest questions regarding patient prognosis in the minds of family members has its self-reflective moments of existentialism and spirituality. My Sunday School teaching impressed upon me that be it arrogance or the natural course of knowing, the more man believed he knew, the further from God he would stray. The natural curiosity of man fills the unknown with an omniscient, omnipresent, omnipotent being to satisfy the equation of the incomprehensible and organize the chaos of the universe in a black box known as deity. It doesn't change in the hospital, and seems more pronounced when the inexplicable tragedies of life meet good people. You ask around the emergency department, they'll tell you it's always the good ones that suffer, while the gang bangers and alcoholics escape bullets and 5 car pile ups with nothing more than flesh wounds and a government paid hospital bill.

Godot or no, sometimes it just doesn't make sense. I'm still scratching my head over a tiny baby girl that acutely decompensated in the emergency department. She was doing marginally, more fussy, sleepy, but moving around and crying appropriately. Next thing you know, she's seizing, being rushed to the OR to revise her VP shunt (ventriculoperitoneal shunt). Now she's comatose, not waking up, slowly deteriorating and no one knows why. Nothing kills me worse than seeing a grown man cry. But seeing a new father repeatedly kissing his daughter, asking her to wake up, telling his wife that he can taste the tears on her face... no one ever told us when we entered this life that some lots would involve becoming vessels of infinite tragedy.

The mysterious ways of God? Or maybe just the nonpartisan chaos of reality. Somewhere, far from here, a wealthy man just boarded his yacht off the Amalfi Coast in Italy to spend the day with his beautiful wife and children. Here at UCLA, we're discussing the withdrawal of care of a 3 month old that experienced little but surgeries and hospitalizations throughout her short tour on earth. There they are admiring religion as an aspect of history, canonized in the cathedrals of time. Here we are praying against all odds for a modern miracle, reaching for God now that death has bound our hands.

Sunday, July 04, 2010

First Call

Technically no, officially yes. Another busy night: 9 consults, one red line.

Admittedly, it's fun being able to be the go to person regarding all matters neurosurgery within a large hospital in the middle of the night. Run down and see the trauma, run back up to the ICU and tell a family their family member's prognosis has drastically changed based on a recent study we'd obtained, and then rush a patient to the OR for emergent surgery since she seized in the ED. The expectations of the emergency department are somewhat unreasonable, as they 3 ED residents calling you about different neurosurgical patients, all pressuring you to see theirs so they can send them home or admit them. Hey guys, simma down.

The work feels meaningful and frankly a lot of fun. But seriously, the nurse that was paging me at home at 5PM when I was post-call to clarify a stool softener order... three times... yea, not cool man.

Lesson learned: Don't trust a CT to tell you about mass lesions, get an MRI.

Friday, July 02, 2010

Day 2

Second day operating. They say that every time you go to the OR you learn something new, no matter how small or trivial the case you're doing may be. Well at least in the beginning it's very true. I had never seen a burr hole made using a nice, who knew the pediatric skull of a 3 month old would be thin enough to carve through with a scalpel. Every OR case is like a puzzle, or a gauntlet of human coordination and ingenuity... even doing the small cases it's pretty awesome.

I'm on call tomorrow, and I'm already tired.

Thursday, July 01, 2010

Day 1

So far so good. No one has died, I haven't committed any egregious errors in management, and my co-residents and I don't hate each other. It's pretty great being able to go to the OR without the dread of knowing that as you're there the floor work is piling up on you. I was "operative" today, so I was able to do my two cases and let the other guys take care of the floor and ICU. Pretty awesome.

Wednesday, June 30, 2010

A Journey of a Thousand Miles...

usually starts with a flat tire and a broken fan belt.

Well it's official. We just had our orientation for our R2 year of neurosurgery. Amongst all the other info we received today, we got our business cards, loupes (those fancy OR glasses with telescopes in the lenses), call schedule, team assignments, and a whole lot of "good luck, you're going to need it."

This year was the reason for which this blog was created. It's purportedly the hardest year of residency we could ever imagine. Listening to the instructions from our attendings in regards to the "back up" we'll have during our first few weeks on call made it sound like we were preparing for war or some great natural disaster. The way the more experienced nurses are heading off to vacation and how the attending surgeons have ceased operating silently reaffirms the huge white elephant in the room: new interns, new R2s - don't get sick, because all around the US during the month of July in academic institutions people die. It's a well known fact that everyone gets promoted during this time. The residents that only months earlier were marching to the beat of a seasoned chief resident now are asked to call their own cadence. The residents who only days before, separated by a week of debauchery and drunkeness, were mindless work horses known as interns, are now expected to make clinical decisions and perform surgery - albeit under close supervision. And the medical students who only weeks before were still strictly book learned and green, are now scrambling around the hospital with their heads cut off like chickens, but still trusted and referred to as "doctor." Yea, now's not the time to be ill.

That being said, if you do find yourself in the hospital at this time, be assured that everyone is hypervigilant. Everyone's work will be checked, rechecked, and checked once more over as no one exactly trusts anyone to do their job completely right. They say that Christmas is a bad time to be in the hospital as that's when residents get overconfident and too big for their britches, making decisions they can't support or correct when things go wrong. So that elective surgery you were thinking about? Yea, I'd shoot for sometime in October.

But I digress. Back to neurosurgery. 337 days, 48 weeks, 116 overnight calls, 200 operative cases, and one soul to preserve throughout the whole ordeal. It's exciting, but let's face it, it's scary. Although all medicine/surgery has its risks, neurosurgery is one of those fields where if you get lazy, sloppy, or lose focus for even a second, someone could die. Perhaps a little melodramatic, but unfortunately true. But hey, it keeps things interesting.

Tuesday, June 22, 2010

Tripped at the finish line

Two days left in intern year, post call, and I start getting fevers and chills in the cafeteria. No biggie, probably just a flu or whatever. I get home and then ensues the worst 24 hours of my life. Fevers, chills, rigors, nausea, vomiting, intolerance of oral intake more than 10cc. I seriously thought death was upon me, but if it wasn't I seriously wished it would come.

That being said it was a pretty disappointing way to end intern year. My senior residents tell me about how they get through residency without a single sick day, and I land one right at the finish line before my first year. I feel pretty weak, but honestly, I think projectile vomiting is where I draw the line.

Still, last day of intern year coming up. Hurrah hurrah!

Friday, June 18, 2010

always remember, and never forget

I used to be a fairly sentimental guy. I'd listen to the slow jams, be able to turn any spoken word into prose, and mentated little phrases and speeches on friendship, love, loyalty, etc... I was a humanist in some sense, an anthrope if you will. But the more I isolated myself in my books and labs, the more I lost touch with people, obviously. But I guess the thing that bothers me upon reflection is that it doesn't really bother me at all. Well at least until today. I forgot my best friend's birthday, second year running. Last year it was because I was in the middle of intern year orientation, and the days were a frenzy of new people and information. This year I'm actually an intern, and being on call running around the hospital isn't the most conducive setting to allow for reflection on the people in your life. Not that she's an all star best friend either (yes you know what I'm talking about), having forgotten my birthday as well last year. Though I'm convinced she just pretended to to make me feel better about forgetting hers... she would be that kind of friend if she were smart enough to remember things, but she's pretty dumb actually, so more likely than not she just forgot (:

With sleep deprivation comes memory consolidation problems. I don't remember much of anything anymore. If it's not on my patient list sheet with my boxes of tasks to do, labs to follow up on, radiology studies to get reads on, patients to discharge, notes to write, orders to order... if it's not there, I don't "remember". This piece of paper is my brain, it's the only thing with information worth keeping throughout the day. My life utterly reduced to check boxes of people I do not know, nor will ever meet again once they leave this place. And yet there's no check box for calling my best friend on her birthday. I wonder if being a great doctor means you suck as a person outside the hospital? People say it can be done... but I obviously have a ways to go.

Clearly, I'm not fit for human consumption.

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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.