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.

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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.