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...

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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.