Monday, August 06, 2012

A prisoner on parole

They say that the artist fears the blank canvas, the writer the blank page, and the musician the blank score. Infinite possibilities to create. Infinite possibilities to fail. Previous success, instead of serving as fuel to creation, may be the very paralytic that retards our thoughts and slows our hands. For a year I laid my blog to rest for fear that my life, indescribably more trite than it once was on the front lines of medicine, on the battlefield of emotion, life, death, sadness, bitterness, and an endless list of what would be hyperboles in our day to day but egregious depreciations of the experience of an R2, would not be worth writing about. But over the past year I've continued to learn and continued to see. Despite not being on the forefront of the battle against death and suffering, we've been called back as reserves from time to time enough to boast our share of scars.

One night while on call at the county hospital I was paged regarding a young female with a gunshot wound (GSW) to the head. I had seen my fair share of GSW patients. They had always been fairly easy to triage: either the bullet was just superficially involved requiring only debridement and cosmetic repair of the skin and bone, or the damage was so extensive that you could declare them dead on arrival. Should be a quick consult, I thought. I quickly pulled up the CT scan to see what I was dealing with, and thought, "Oh god. This can't be right." I rushed down to the ER and found my patient, a Korean woman in her mid 40s. She was intubated, and in restraints, both good signs in that her airway was protected and that she was able to move around enough to warrant physical confinement. I grabbed some gloves and went to the head of the bed to where a towel was covering the left side of her face, and lifted it with such apprehension, bystanders must have thought a bomb under this white barrier. And there was. The impact of seeing half of the left side of her brain hanging out of the defect where her skull had been blown off sent me reeling. The brain, when not fixed in formaldehyde as you traditionally see after autopsies (and in TV shows and movies), has the consistency of soft tofu, and would collapse on itself should it be held in real life outside of its home in cerebrospinal fluid. A mess of oozing vessels and tofu-like grey matter fungated from within, entangling itself into her dampened hair. There's no way she's still alive, I thought. But, pupils: reactive, cough/gag: present, motor: localizing... bilaterally?? (With her left hemisphere hanging out of her head, she shouldn't have been able to move the right side of her body. Localization is being able to localize a painful stimulus, and is a good neurologic finding, and did not match her CT scan or physical exam findings - ie brain hanging out). She was losing blood fast from the venous sinus bleeding, and the loss of viscosity in the blood that was pooling on the floor made it clear that she was getting more fluids than much needed red blood cells. We took her to the OR once we realized that resuscitation without concomitant attempts at stopping the bleeding would be futile. I shaved what I could of the hair, trying to avoid the interweaved chunks and bits of brain. We prepped, draped, and cut open the scalp to discover a mess of fragmented bone and bullets. Shotgun to the head, the paramedics had said. Shot by her husband, who then turned the gun and killed himself, successfully I might add. The bleeding was too difficult to control, and despite countless units of blood products she exsanguinated on the table. We called time of death and started to close. What? It wasn't enough for you to kill her, but you had to make her suffer? It was even more difficult to shake the tragedy of this case because she was Korean. I made sure to call my parents the next day to let them know I loved them.

My last 24 hour in house call of residency was like a final exam. An alcoholic man showed up in the emergency room with a subdural hematoma that had gradually accumulated and expanded over the past 2 weeks. These bleeds are oftentimes monitored with close observation if the patient is neurologically intact so a less invasive procedure can be done to wash out the blood once it's broken down to the consistency of water, rather than making a large bony opening to evacuate the clotted blood. His had continued to expand  so he came to the ER. I took his history, reviewed the CT findings with him, and told him we would take care of this now as the hematoma had enlarged to a point where he couldn't walk properly, he was getting sleepier, and his voice and swallowing were impaired. A routine surgery, a neurologically stable patient. Things would be all right, he would do just fine, I told him. While discussing the risks of the surgery, stroke and death were mentioned, but I scoffed that in his case ... in his case it would be extremely unlikely. The surgery went beautifully, the postoperative CT looked pristine. I got him back to the ICU still intubated as he had not fully woken up, but then noticed that his lips were twitching. I checked his pupils, the right was dilated, but reactive. He was seizing. 2mg ativan, and get 2 more ready. Bolus him 1g of dilantin STAT. The subdural drain that we had left in there per routine had stopped flowing. I raised it to see if there was any backflow... there was, at 30cm H2O (this means that the pressure in this head had exceeded 30cm H2O, normal is 0-20. When intracranial pressure gets too high, the patient starts to stroke, and herniate [brain tissue starts to compress other vital brain tissue and you can go into a coma and die]). Versed, mannitol, lasix, 3% normal saline. This guy needs a ventriculostomy. I shaved the left side of his head and prepped, draped and drilled into the side we hadn't operated on. I placed one of the fastest ventriculostomies in my life and was relieved and dismayed when I saw CSF shoot out with the first pass of the catheter. ICPs in the 30s. His ICPs were temporarily controlled, but soon became refractory to the medications and drainage of fluid (you can drain CSF in order to relieve pressure inside the head, but only so much. After like 50ccs you basically drain it dry, and need for it to regenerate). I threw everything I could at him, and watched with despair as his blood pressure dipped down from all the sedation we were giving to reduce his ICP, which still refused to fall within normal range. Start levo (levophed). Increase the versed. Bolus him another liter of NS. Now people, come on. In the 3 years of residency to date my voice had never betrayed any fear or anxiety that I had within, but something about having done every aspect of this patient's care, from history and physical to operating to post operative management... he was MY patient. I told him he would be just fine. My voice bled with urgency as I continued to call for more medications and fluids. This isn't working. Call pharmacy, we need to bolus this guy with pentobarb now (pentobarbital - for chemically induced comas to greatly decrease brain metabolism and reduce ICP). We got his ICPs controlled, his seizures stopped, and his blood pressure stabilized but I felt like I had aged a year in one night. He never recovered and 3 weeks later the family decided to withdraw care. Despite doing everything by the book, I wondered if there was anything I could have done differently, faster, more efficiently. It's interesting how with great surgical skill and medical management a doctor is praised for saving a life. When things go poorly despite doing everything right, we're told "there's nothing more you could have done". Isn't there? Being good isn't good enough anymore. I need to become supernatural.

No longer responsible for taking in house call has allowed me to catch up on life, relationships, and most importantly of all, sleep. I've started having dreams again. Dreams were a luxury I didn't know were absent from my life until they appeared again one night. When you're sleep deprived, your body spends more time in deep sleep (restorative sleep), rather than spending energy on REM sleep (where dreams occur).

I'm starting to forget what it's like to be a neurosurgical resident. I spend most of my days in front of a computer now doing MRI analysis and writing papers and grants. Like a prisoner who finally gets parole after half a lifetime of gen pop life, I'd forgotten what it was like to be able to eat when I want, go to the restroom when I want, and have weekends where I can run errands and sleep in because there aren't 50 patients waiting for me in the hospital. Life has found new meaning, but at the same time I feel like I've lost more than I've found. I itch to hold the drill and scalpel again, to admire an excellent tumor resection or beautiful skin closure. Now just a fish out of water I gasp and wait till I'm allowed to have my purpose again.

1 comment:

Anonymous said...

beautiful, Won.

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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.