Thursday, June 30, 2011

The End

It was the best of times, it was the worst of times. It was a time of tribulations, a time of sorrow. It was a time that weathered our thinning heartstrings, leaving in the wake of untimely deaths and undue suffering, men that were some reason stronger. In every man there is a point of inflection in the tapestry of his life where the threads of youth intertwine to form the cords of manhood. Through baptism by sleep deprivation, hopeless situations, academic intensity and emotional intimidation we became something more than what we were a year ago.

116 overnight calls done.

Through repetition and remembering, our hands that once trembled while accessing the brain have found steadiness. Where once we hoped against hope with the families of loved ones for miracles, we now hold out our hands to catch their crumbling dreams. We do not cry, no, we never did; but now we no longer think of tears. As the number of patients we've touched, saved, and buried grow, our energies are diverted to our ability to save rather than our capacity to empathize. But we have known sorrow, though the chords that move us have changed. Death has become our companion, so we no longer fear him. But abandonment, seen in the brain tumor patient admitted for medical issues, silently choking on his own saliva in the corners of the medical ward; or the wife that leaves unable to handle the despair that comes with a diagnosis of a terminal illness... the consolidation of loneliness in an already lonely profession, in an already lonely world, chills us.

We recognize there is still much to be learned, and still many sleepless nights to be had. But in this year of hazing we hope that we were broken down beyond the imperfections of our upbringing and built into something better. Only time will tell.

And now, we play.

Tuesday, May 24, 2011

The Perfect Game

There's been no shortage of perfect games in the world of baseball over the past few years it seems. But to experience a call night with no consults, no traumas involving neurosurgical needs, and no ER admissions is something akin to the holy grail of a neurosurgery resident's call night at a level one trauma center in the middle of one of the largest cities in the United States. But the gods were kind last night, and for my 101st call as an R2 I had a no hitter. Going into any call you pray that it'll be a light day. With the post operative checks, the 15 patients in the ICU, and the 20 some odd patients on the floor any given call can potentially be a busy one without the steady flow of consults from other services or the emergency department. As a lot of what we do as physicians is innately pattern recognition, my co-residents and I have become increasingly superstitious about our rituals and routines that we perform to ensure a quiet call night. Initially when I started I noted that whenever I brought my book bag to get some reading done, I would be hammered by incessant calls from the ED and direct admissions from clinic. Suffice it to say my book bag has not experienced much use in the past few months. Granted, it's a little healthier and far less harmful than one of my co-residents who believes that the number of chocolate muffins consumed will be inversely proportional to the number of consults he'll get while on call (true story). I don't see them to be correlated to how busy his calls are at all... but now he's addicted and can't stop eating them.

101 calls done people. Only 12 more overnight calls for this academic year. Don't get me wrong, we'll still be doing in house call as a 3rd year, but it'll be more along the lines of 3 times a month instead of every third night.

Wednesday, May 18, 2011

My Chemical Romance

14 calls left.

I don't remember a time when I wasn't a junior neurosurgery resident. Maybe it's because we've worked enough in 10 months to bill for two years; or maybe because we've been awake long enough to have lived two lives. My dreamless nights suffocate under the fatigue of the day, and lacking any visions apart from this reality, my consciousness holds only the threads of this endless toil. As reality blurs into what should be dreams, whilst we sleep still standing and read pages half asleep, intracranial pressure management and surgical techniques overtake every moment of our lives, forcing us to relive our jobs many times over. The compounded whittling of endless nights have shaved us down to emotional cadavers, as our weary minds stumble behind our weathered bodies. At 1AM when the 20th hour of my work day strikes, my judgment fails me as my body cries out for just a moments rest. Oftentimes it's then that I realize I haven't eaten since morning, though my stomach has become accustomed to the constant neglect and abuse of on-call binging. As I'm ready to despair, and let the post op patients go unattended and the nurses pages unanswered for a quick nap, I pull myself together long enough to grab two Full Throttles from the downstairs night cafe. Unashamed of my growing emotional dependence on caffeine I knock one back, and receive the energy to last through my post op checks and the rest of the night's check list of tasks. The other I drink during rounds to keep me awake long enough to sign out my patients and stumble to the downstairs call rooms where I bury myself within the darkness of basement level quarters. By the time I wake and determine it's safe enough to drive home, I've been in the hospital for 36 hours. This year needs to end.

Monday, April 25, 2011

Dead on Arrival

One day during your surgical residency you'll realize that you've come to a point where you yourself can actually save a life. Be it through your split-second diagnostic reasoning that diagnoses an aortic dissection or your expedience in rushing a patient to the OR to evacuate an intracranial hemorrhage. With this power, however, comes the bitter fruit of knowledge that makes you cognizant of when a life could be saved, but wasn't.

He wasn't even 20. But the death of his friend the day before was too much for him to handle. While drinking the sadness of life with the spirits of liquor he suddenly found himself falling, to be reawaken to the piercing pain of reality as the spikes ran through his legs. He lay there, dangling from a fence, the blood in his head squeezing consciousness from him as the twinkling of lights from anoxic brain damage painted the last mobile of stars he would see in this world.

He was unresponsive when the paramedics found him. His left pupil was fixed and dilated when we moved him from the gurney to the recovery suite table. He has a left sided hemorrhage, probably a subdural, I thought to myself. He needs a CT scan and an emergent hematoma evacuation, I continued. He's young, his brain isn't too compliant, he may have herniated already, but we need to give him a shot.

My patience quickly smoldered into helpless rage as I watched them place bilateral chest tubes, multiple central lines and IVs, and turn him to check for spinal injury. Guys, let's get him to CT now. But not knowing how serious his pneumothoraces were, or how indicated the chest tubes were, I couldn't argue with the ABCs (airway breathing circulation) of trauma. Honestly though, it should be airway, brain and CT for someone with a blown pupil. The CT scan confirmed the subdural hematoma, and we rushed him to the OR. As I sawed off the bone and cut open the dura, blood clot shot out of the operative field and I knew the brain underneath was probably already dying from ischemia. The brain continued to rise up like muffin tops in an oven, and as the cortex herniated through our bony window the attending surgeon told us it was futile. Close the skin, he said. There's no hope, he finished. My senior resident and I looked at each other. Maybe we could open more bone, maybe there's more medical management we could do to help reduce the intracranial edema. But we knew as well as he that it was too late. He had probably already stroked his whole dominant hemisphere and even if we did decompress him adequately would remain a vegetable for the rest of his life. He didn't want to live anyway, what right did we have to save him? Still, we could have. To save life, and even return it to those that throw it away, that is a surgeon's power, his duty even, if you will. As I closed his skin, pushing down the brain that still tried to escape out of the boy's scalp, each stitch I wondered how we could have gotten there faster, how if a matter of seconds could have made a difference.

Only earlier we were consulted on a 7 year old boy who's spinal cord was internally severed from a motor vehicle accident. The injury is incompatible with life, I told the peds ICU team. The boy's father had killed himself the year before. His mother had killed him by driving under the influence. She posted bail and made it to his bedside in time to tell me that she thought she saw tears coming from his eyes sometimes. Yes, I thought, wouldn't you cry too if your mother's stupidity resulted in your death?

There will always be lives we cannot save. And sometimes even harder is realizing that by the time they reach you, there is no life to be saved. But for the rare instances where seconds mean another smile, another laugh, another breath of fresh air, we work tirelessly to improve, to be ready, so that when we scrub out of the OR we can look at their families with relief, not regret, and be met with tears of joy, rather than the wails of despair.

Breath of Fresh Air

In the worst of times the breath of our friends becomes the air we breathe.

I finally got my vacation. Thank you so much for the awesome times guys.

After the 48 hours of insanity in Las Vegas I flew out to a neurosurgery conference as I submitted some of my research, which was accepted for a digital poster. Small beans in the grand scheme of things, but not too shabby for someone who barely has time to do his laundry.

The conference was relaxing in it's sleepy schedule with optional conferences and lack of mandatory engagements, but overwhelming in the vastness of knowledge and neurosurgical greatness that I found myself surrounded by. It was nice to see what others in the community were doing, and inspiring to think that one day when the dark days end I too would be able to engage in such life changing, cutting edge work.

But after 7 days of awesomeness I returned to the grind.

Thanks guys for posting on my blog, it means a lot to know that people in the electronic ether find the things I say interesting from time to time.

Sunday, March 27, 2011

Anhedonic

Last call I was placing an emergent ventriculostomy into somebody with a tangerine sized hemorrhage in their brain when a transfer from an outside hospital rolled in that needed to be red-lined to the OR for subdural hematoma evacuation. Even that barely got my pulse up.

It all feels the same now. Nothing seems to excite me anymore. The only things I feel are tired or very tired. I need another vacation.

Sunday, March 20, 2011

Pain within the walls

Every patient that walks through our doors has walked a path of sorrows. The winding roads that have left scars within their skins and tears within the tapestries of their hearts start to harden into the walls they build around them. Our own fatigue simmers and smolders, forging the iron cast appearances of disinterest and coldness. Limiting transference, maintaining professionalism, they would say.

They build their walls one hospital trip at a time. "Your child is very ill" the foundation, "he may require surgery" the mortar, "he may have a brain tumor" the moat. With each surgery, each clinic visit, each MRI scan that shows possible progression of the disease they lay the bricks of their walls ever taller, ever stronger. Avoiding the compassionate, and oftentimes pitying looks of their neighbors and friends, as the constant reminder is too much to bear, has become cause to their construction. We're doing ok, they want to believe, to prove.

All the while the brutal work hours, unappetizing hospital food, empty chairs and empty tables sing the chorus of our misery. The job is painful, but our fatigue and sorrow must be left at the door. So we build our own walls to hide our souls. Inundated by neurosurgery, thoughts of quitting are commonplace. We ask ourselves if this is really what we want to do for the rest of our lives. The fatigue erodes the passion within, but our walls remain tall. We cannot show them weakness, they need us to be strong.

However, sitting there in their hospital beds, dawning hospital gowns with their backs open to the sterile air and their hearts open, thirsting for empathy, their defenses crumble. They lament the pain they've experienced, lash out with the frustration their roads have been littered with. We cannot comprehend their pain, as our dilapidated minds fail for want of reprieve and compassion themselves. We build our walls ever higher for fear that their weakness may overtake us, and in our ivory towers shiver in our own misunderstanding.

Tuesday, March 08, 2011

Reawakening

The primitive man did not fail to paint murals or script sonnets for want of creativity or ingenuity, but rather for want of shelter, sustenance and sleep. I often refer to Maslow's hierarchy of needs to explain, if not justify, my laziness in pursuing literature, art, music, love, etc., which dictates that only after man has the most basic of needs such as food, water and a roof over his head is he able to, or even arguably capable of, pursuing the more finer aspects of human living. Well in a brief moment of reprieve I was able to sleep, and finding myself rested, discover that I still have thoughts independent of the ones that are forced upon me.

The past weeks have been interesting. Notable moments include driving a Ferrari California at midnight while on call; openly reprimanding an intern for his failure to perform his duty adequately; and feeling my soul die as the year continued to draw on without end.

We're more than two-thirds of the way done now. Having worked nearly 3000 hours, with more than 75 overnight calls, the hospital has become more home to me than the apartment I live in. At night I still fumble for the light switches when I get up for work in my one bedroom apartment. In the hospital I can get from the cafeteria to the ICU without looking up once. People I don't know and likely have never met are greeting me by name, knowing that I'm basically a white coated version of Tom Hanks from that terrible movie Terminal (yes I do keep a tooth brush in the hospital). And inadvertently, I've become very accustomed to my job. So much so that it's starting to frustrate me when others can't do their own. One often forgets that other people actually have lives outside the hospital, that their existence consists of more than ventricular drains and craniotomies. But they've been there for years, shouldn't they know how to do all this? Although outwardly still patient, internally I've become less tolerant of laziness and more critical of incompetence. What used to be a list of tasks to me has become a list of individual patients, each with a system of problems that need to be addressed. Instead of simply trying to keep people alive, the small nuances come to mind so we can maximize patient recovery. With my mind set on perfection, the idle, green minds of the new recruits who still lack the experience and big picture as I did only 6 months ago perturb me when they leave tasks unfinished so they can check out of the hospital an hour or two early. Likely the small stones they left unturned won't change anything in the long run, but they lack the spirit needed to help our patients overcome their improbable diseases.

Too much soap boxing.

The chronic sleep deprivation has destroyed my hippocampus and I no longer have any ability to form long term memories. I dated this girl for a bit (I forget her name) but do recall that she was constantly mad at me because I couldn't remember her favorite fruit, her favorite color, her birthday... her name... So demanding. I could tell you the post-op days, medication lists and neurologic exam on any one of the 40 patients on our service... but ask me if you like pineapples or not and yea... fail.

Every morning I wake up wondering if I still want to do this. I don't think about quitting, but do spend a good deal of time creating interesting ways in which I could get myself fired. I'm open to suggestions...

Tuesday, January 18, 2011

Things we forget...

I just came back from a week of vacation. Feeling refreshed, and yet tired knowing that I have to take call my first day back. Our census hit an all time high while I was away. You feel a little bad about leaving your fellow residents with that, but bad in the same way as the guy who wins the lottery does about his new found wealth.

I haven't blogged in a while because everything seems the same now. The emergencies are still emergent, but have taken on a repetitive lull that make them not so worthy of writing home about. Writing about my hardships falls on my eyes like whining, and my moments of accomplishment feel like bragging rather than self discovery. I'm halfway done... and for some reason feel strangely lost.

My friend reminded me to look at the moon today as it was especially beautiful. For that reason I looked at the night sky twice, instead of once or not at all. The moon had moved, as it always has, as it always does, but in a way that I had long forgotten. I am a neurosurgery resident. I can tell you how oxygen is delivered by which blood vessel to the internal capsule of the brain, but if you had asked me yesterday if the moon moved across the night sky, I would have had to think about it, and might have answered 'no'.

I'm losing touch with reality.

Friday, January 07, 2011

Permacall

We're down an R2. In order to be as compliant to duty hours as possible my coresident and I are doing day and night shifts. Oh it's painful. Being stuck with call during the day for 7 days in a row is a world of hurt I didn't think could irk me so. I'm tired. I'm losing patience. It's not the hours, but just having to deal with new consults and admitting patients every day becomes draining in an inexplicable way. I can see the advantage of always being in house though. I have a better grasp on the service than I ever did before, and know more about the patients and their families than I do about my own.

I really need a vacation...

Followers

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.