Best birthday present, ever.

The past few months through the retrospectoscope have been like looking through fog frosted glass while backing up an SUV. My research year was coming to a close, and as I said goodbye to the normal 9-5 work day and life without a pager, I began to have little tastes of things to come. Our residency is scheduled in such a way that we start to cover the compatriot ahead of us when he goes on vacation. Not enough to just see the sword of Damocles looming from above, you're allowed to cut your tongue on its cold steel for one week at a time while still but a servant in the king's court.

Many things were vaguely reminiscent of the life I had somewhat forgotten in the eddies of sleep deprived memories. Working long hours, operating without food or water for half days at a time. But the home call was definitely something new. When you're a junior resident, you sign out and leave your work at the hospital. When you're a senior, you're constantly on pager. No more hitting the bars after a long work day with your buddies to recount war stories from the days prior. No more weekend getaways with your significant other to escape the monotony of blood and brain that permeates every part of your life. No sir. Senior resident equals 24 hours each week where they can't touch you, but aside from that all consults seen by the in-house juniors go through you, and you need to be available at all times to operate on a minutes notice. That adds up to 12 days in 90 when sleep was protected and uninterrupted. Or 78 in 90, when there was a good chance you were the neurosurgical undead.

That said, for the first time you were the neurosurgeon. You ran the service. You decided who to operate on. You determined who could be saved, and who was beyond saving. There's a saying in neurosurgery that once God lays his hands on your patient, you take yours away. Well, I was never really the most reverent one.

She just turned 82. A spritely one they said. A bedside drainage procedure had failed, so we counseled the family and decided to evacuate the hematoma in the operating room. The surgery went well, and through a moderately sized craniotomy we were able to evacuate the majority of the blood that had caused her to get weaker and drowsy. I was at my friend's place after work for about 20 minutes when I got a call that she had blown a pupil. CT scan showed a large rebleed into the surgical cavity. She was doing so well, and it had just happened. Most people would have said to let her go at this point, but she wasn't going to die tonight, not on my watch, and sure as hell not on her birthday. I sped down the 405 and made it to the hospital in record time to see the patient being moved onto the OR table. I tore down her head dressing and positioned her accordingly after I had called my senior and attending and got everyone to start the case. Give her mannitol, keep her CO2s low, guys this a real red line, let's move, NOW. I was making skin incision and extending the craniotomy within minutes and was able to visualize the bleeders. My chief joined me shortly to help, the attending much later. He grumbled, annoyed that he had to come in in the middle of the night to what seemed like a futile situation. The size of the hematoma, her age, all strikes against her. But he didn't account for our genuine desire to make sure she would live.

I saw her in clinic 3 months later and she looked fantastic. She had a little bit of a rocky hospital course, but was now walking, talking and laughing like the spritely young thing the family told us she was. It was worth everything. I had been working for 3 days with only 6 hours of sleep (total) and was literally falling asleep while running clinic when I heard she was there for her follow-up. Seeing her like that gave me an energy that coffee could not provide, a sense of joy that achievement could not afford. This is why we do what we do. And why when we do, we do it damn well.

Please be happy

Happiness wasn’t so distant, actually. Just a little beyond our fingertips, like grasping mist through a half remembered dream. It wasn’t complicated or endlessly multidimensional like misery, it was quite simple really. It was that moment right before waking, where the angels of slumber gently glide their fingers over your skin as you float within the warm clouds of your bed. It was the beginning of a smile, while the emotion is still raw and isn’t judged, or quantified, or remorsed, but just is. But though simple, happiness was never easy. When our lives are so deeply rooted in those that would love and leave us. When our notion of self worth is a reflection of how others that would belittle and despise us would view our selves. When we live in a world where beauty is skin deep and heroism is celebrated briefly but tragedy consumes us for years. You’re right, happiness isn’t easy. But happiness was always a choice. It’s a choice to acknowledge what you do have, instead of dwelling on what you don’t. It’s a choice to wake up to the freshly created existence of the new day that has never been lived before and be determined to live. And it’s a choice to fill your life with those you love, and those who love you… those that bring you up and those that inspire you. It’s a choice to spend a quiet night finding yourself, and a not so quiet one finding yourself in others. Happiness is a choice because you choose happiness. It’s hard to think that such a choice exists when there are only so many letters in our day to day alphabet soup. But there are 7 billion people in this world, 196 countries to travel to, a few hundred trillion synapses in your brain, and a lifetime ahead of you. If you find yourself in unhappiness, read the unread book, sing the unsung song, take the road less traveled and find yourself in a foreign place where misery has not laid its familiar webs. And somewhere in the cold drink on a summer’s night or the stifled laugh between friends in a quiet hall you’ll find it, because you chose to.

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.

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.

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.

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.

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.

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.

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.

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...

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.

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...

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...

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.

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.

...

Fell asleep while talking again today post call.

Forced to get up to study for operative case tomorrow.

Really really tired.

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.

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.

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.