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.


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.



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.


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.


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.