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.

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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.