Another head bleed

Last night was my first time taking R2 call for neurosurgery, and incidentally one of the busiest nights for neurosurgery in a while. It's nice to hear the ER attendings muse "I've been here for 17 years, and I don't think I've ever seen neurosurgery get hit this hard."

Fan-frickin-tastic.

It starts with morning rounds at 0515. Head CTs and MRIs from the night before, followed by rounding on the service's 35 patients (we're light right now). ICU rounds, battling it out with the neurocritical care team regarding what we think is the best care for the patient. Then a casual breakfast in the otherwise chaotic day at 0700, followed by phone calls to the attending neurosurgeons giving them updates on their patients. This is probably the most stressful part of the day. You never know what they're going to ask you about their patients, making it seemingly impossible to have the right information ready for them. Lots of "uh..." "one second sir...".

And then it starts. A young girl with leukemia who bleeds into her brain. A devastating hemorrhage that's left her unresponsive and intubated. But we can give her a chance. Set up the OR, consult pediatric hematology, hang blood products to correct her platelets of 25 and crit of 12. Oh yea, and who has a white count in the 300s? Honestly. While the blood products are running and hemapharesis going to correct her leucocytosis I steal off to grab a bite to eat. It's lunch at 1400, not too bad. I sit down to a nice piece of salmon and corn bread, yum. Phone rings.

Me: "Yes Dr. xxxx? Products are running and hemapharesis going. Well I don't believe we can do that in the OR. No I'm not completely sure. Yes sir."
Dr. X: "Your patient is dying, go go go!"

I got one bite of my salmon, and in trying to save my soda for the road, watched it explode on the cafeteria floor. It would have been more tragic had I known the next time I'd get a chance to eat would be 0330 the next day.

Push blood products. Deliberate best course of action. Coordinate OR time with hemapharesis. Rush patient to the OR. Pager rings: code trauma. Another CT scan, another head bleed. As the first case finishes up we wheel the next one through. 4 consults pending in the ED. Head bleed, head bleed, head fracture with head bleed, new brain mass... Phone calls from transfer centers asking to send patients with ventriculoperitoneal (VP) shunt malfunctions. Another consult: 90 year old Chinese male with ... head bleed. Hey, does anyone speak Chinese???

32 hours, two back to back red-lines, 11 consults, 0 sleep. I signed up for this? Stupid stupid stupid...

No more Mr. Nice Guy

I'm not sure about other programs, but they say your R2 year (second year of residency) of UCLA neurosurgery changes you. The neurology residents currently have bets going to see if I'll "stay nice" after the next year is over. The junior residents put their money on the persistence of good nature, saying I'll stay the same despite calamity and circumstance... but the senior residents know better. They've seen the lot of residents that come in smiling, charming, joking in common camaraderie, turn sour as the Q3 call (30 hour call every third night) and hail storms of consults (just last week the neurosurgery R2 got 7 consults in one hour) pulverize the softness of human civility and forge, out of necessity, the machine-like unfeeling neurosurgery junior. As if a surgical residency wasn't hard enough, now I have to be cognizant of staying humane while going through it? I don't promise anything, but I hope to write in this blog daily as this experience unfolds, so that if in 400 days the warm, young hearted boyish charm (^^) in my words degrades into the binary outputs of the terminator they expect me to become... somewhere, somehow, the slow transformation from man to machine will be documented and understood, and I'll be vindicated.

I'm getting temporarily promoted to R2 this Thursday and taking in house call. We'll see how it goes.

Inspiration Remembered

During one of my neurosurgery away rotations I was honored to have worked with Dr. Alfredo Quinones. This man has the energy of a hamster on speed and the perseverance of a monkey trying to open a plastic banana. Of particular interest, is the tale when he hopped over the United States-Mexican border to illegally escape into the land of honey and opportunity. He was caught the first time and sent back; hardly enough to stop this man. He attempted again, obtained an education, trained in neurosurgery at UCSF, and now is an attending neurosurgeon at the prestigious Johns Hopkins University (I believe he's legalized now, so don't call the INS). One of the few things I'd taken away from the rotation at JHU, aside from a trip to the ER after being plowed by a 2003 Yukon (crazy Baltimorans), was him sitting me down and telling me that in order to succeed in life, one needs to surround himself with brilliant people. Reminiscent of an old Spanish adage 'digame con quien tu andes, y yo te digo quien tu eres' (tell me who you walk with, and i'll tell you who you are), I've found these words to be increasingly more true.

Saving the World:
A good part of the medical community I believe, or would like to believe, for at least a few seconds in their life had dreams of saving the world: eliminating poverty, achieving world peace, delivering chicken nuggets to everyone on Wednesdays. Small people, big aspirations. But the world teaches us that when we grow up, we are no longer children, and we put off our childish thinking and infantile delusions. There is no world they say, only isolated islands of capitalism, communism, and forsaken third world-ers somewhere at the bottom of the ladder. The hooing and hawing of politics and international policy drain the drive of the inspired, entangling them in logistics and law until they hang themselves in their vain efforts to break free of the system. But then there are others that in their Neo-like genius realize that the system can be bent, and even broken. There is no spoon.

I once believed that such people were truly rarities, the ones that you never meet, but only read of in books and epitaphs. But I recently met someone that really gave my matrix a run for its money. She wasn't born into royalty like Princess Diana, or birthed from the fires of political unrest like Gandhi. Nor was she a nun like Mother Teresa or a rock star like Bono. But in her own small ways, she was affecting change in rural countries, improving the lives of others in our own, and dreaming of ways to take these things to bigger scales in the future. As you know, I'm rarely one that gives compliments or openly admires people; but I was was thoroughly stricken with her life attitude, and probably came off as a blathering groupie. Not so much because she could change the world, but that she was doing so now. I always thought I'd have to grow up, be in a position of power to bring such change, but no, she was doing it now, yesterday, before she even graduated college. So yes, she deserved such praise.

Changing the world, one life at a time:
Then there are others who've devoted their lives to the pursuit of saving individual lives. We in the United Sates are in an age of science and technology where we can spend hundreds of thousands of dollars with the most sophisticated methods to save, and maybe not even save but prolong, the life of one person. Meanwhile the people of Malawi are dying by the tens of thousands for want of $1 a day supply of medication. I do not mean to excuse the latter egregious crime of our modern world, but mention the dichotomy to highlight how privileged we really are. We've come so far from the days where the lack of food, clean drinking water, or simple medical remedies would decimate towns in one untoward year. Now we focus on curing the ailments of those who've lived too long - osteoporosis, dementia, cancer, and other conditions where our exhausted topoisomerases give in to the calling graves below. Of these, perhaps one of the most specialized, smallest niche occupying, is the neurosurgeon. One in particular that inspires me is a friend of mine. His tireless pursuit to become the best, to eliminate the world's need for people like himself by curing the disease he treats, and inspiring the generations below to follow his lead - he definitely gives me something to work towards and aspire to be.

So the moments of inspiration are definitely there. They're in the people that happen to walk a path different from the ones laden with the mundane and trite technicalities of the world. They're in the roads that they forge, the roads less traveled as Frost said, and it makes all the difference. As the world saver said, it's about creating value from nothing; these friends are artists of humanity, in their ability to bridge people and create cures that did not exist before. They say the artist fears the blank canvas, and I'll admit to such fear. Fear that the brush strokes of my next 20 years will culminate in the scribblings of a six year old rather than the Monet I had envisioned. But to allow such fear to blind us would only hide the paths of change that my two friends walk. So thus I take the first strokes, and hope that their steps will guide the rest.

Moments of Inspiration

The monotony of intern year is not without its moments. Moments of reflection, moments of fatigue. Moments that take your breath and others that give you life. But the monotony of intern year is usually without these moments in its monotony. The shrill alarm that ends the peace found in the passing near death state we so learn to love, reminding us that we are to rejoin the world of the living, the suffering - the not dead. Early morning rounds. Moments of "crap, I forgot..." and others of "Yea, I'm smart, I know." But even self complimenting gets old. Orders, orders, orders. Follow up this, follow up that. "Patient's family is in the room." "But he said he'll go down for the study if you give him IV dilaudid."Day in. Day out. And nights in between. But these moments, oh these rare moments, when one sees the glimmer of life in the sea of repetition and death.

What were they...

I don't remember...

And the incessant pages go on. The late night admissions leave shards in the once tranquil tapestry of thoughts. And we forget the rare moments as the not so rare, the constant, the incessant, the flooding of uninspiring feculence flushes us back into waking realism.

Maybe they weren't so great.

Waste: A 15 year old boy, so much life ahead. Dead now. Found face down in a splay of syringes. Thirty-four weeks I carried him. He cried after his first shot; so different now with his pin cushion arms. Such a damn waste of life. His life must mean something. A liver. Two kidneys. Three meters of small bowel. Three lives saved out of tragedy.

Ironic Medicine

I was told today that I must be a good doctor because I looked so tired.

I can't help but feel sometimes that my choice of profession is somewhat sick. The countless hours spent in the hospital is a stark reminder of how precious life is, how every ephemeral moment should be treasured. And yet it seems that the ones that are living the lessons I'm learning are the ones that haven't learnt said lessons at all. And me who keeps learning the lessons they're living, will keep learning and not living so that they may live instead.

A moment of today, all of my yesterdays, for one more tomorrow.

consumed

And in hate he was consumed,
until there was nothing beyond nothing,
of why he was.
Void of everything,
in the infinite shades of a man's heart,
infinite, only as time would make him,
cold, only as time would leave him.

The making of a coffee table

As with all great stories, this one begins with one of the cardinal sins of man. Though I fear to disappoint, and rest assured I bear with my own disappointment that this story does not detail one of the racier vices of lust or grand theft, this tale sparks its birth from the green seeds of envy. But not just any envy, dear readers, no. It was envy of a 30” Toshiba flat screen HDTV with a 5.1 channel digital surround sound Boss speaker set and an XBOX 360. He obtained these items in a shopping spiral to adorn the barren void of our common room, but in doing so inadvertently mocked my nascent sense of electronic gadget ego found in countless college aged Korean men. When I moved out into my own apartment, I decided, no, I pledged that I would have an entertainment system to rival that which I had seen.

The pride of the Korean male coursing through my body fueled my search for the ultimate TV. However, it also fed my necessity to find the best possible deal on this new addition to my life… and thus my search on craigslist began. After weeks of searching and emailing I found the TV I wanted. It was a 30” Sony HDTV WEGA, editors choice in 2004 for best picture quality and bang for its buck. Beautiful. I met with Dave, who later revealed himself to be a CEO for a porn industry in North Hollywood, traded cash for the goods, and made my way home. A part of me died (a few hundred dollars of me to be exact) when I found that the TV didn’t work. Now, before you berate me for being an idiot (trust me I know), let me assure you that I did everything I could to remedy this tragedy. I tried getting it fixed, I tried taking the case to court, and I tried beating it senseless in hopes that things would start working again (the latter of the three after the form two courses of action were taken). Long story short, busted TV, Won very sad.

The TV thus sat, and many of you have seen what a lovely side table it has made over the months. My backpacks and jackets had grown fond of being carelessly thrown upon the electronic shell of what was a masterful tantalizing piece of audio video heaven. However, the bulky corpse, I found was too much for my apartment to accommodate, and thus began the making of a coffee table.

The project was simple, the front glass plate would make an excellent table top. Take out the tube, take the front plate, chuck the rest. No problem.

Unscrew, unscrew…

The front plate is actually a part of the picture tube…

Big problem.

Hatchet.

Problem solved.

I then ensued to smash away the glass from the posterior aspect of the picture tube (for those who can’t visualize what it looked like previous to my Last of the Mohicans’s moment, see figure 1). Shards of glass flew everywhere, but despite the adrenaline and terror, I threw my faith to my Rubbermaid dish gloves and make-shift surgical mask of toilet paper and continued. Actually the mask only came after I realized that I was pulverizing the glass and aerosolizing it… probably the 3^rd scariest thing I’ve done in my life. I taped up the bottom ends of the cut surface to don the guise of safety, and the top was complete. Too low for a coffee table, though. Hey, the frame has circular holes in it. HEY, the ikea lamp poles fit PERFECTLY into them. After much research online, I found that the lamp poles would be fit by a 19/6 – 18 TPI bolt… yea. Good thing Home Depot has everything.

Final product~

And they said it couldn’t be done…

holding breaths

Every moment we are alive, we are living. A trite statement of rhetoric, perhaps, but one whose simplicity it took me 24 years to understand. A being of goal oriented thinking, I spent my entire life wondering when I would finally be able to live, as if years of education and training were merely preparation for a future of luxury, of contentment, of "life". Fool. As if the future - which with its counterpart, past, do not exist, as one is merely an idea of events yet to happen, while the other is the scent of events that already were - were something special. As if these delusions of grandeur could really be more incredible than the oxygen that flows through my blood, giving life with each breath; more great than the calm morning wind that caresses the core of my being as I walk tranquil streets. A phantom of things to come, the potential of things that are not, more real or wonderful than the simple majesty of things that are? Impossible. Yet just as difficult to see. Those that hold their breath, waiting for tomorrow, not pausing to inhale the fragrance of roses, will die waiting, as tomorrow never comes. The tragedy of life is not that we must die, but that we wait to live.

Trauma Surgery Rounds at Harbor

I shadowed the trauma team at Harbor UCLA hospital today.

There was a man who was brought in naked, just the way he was when he jumped (or maybe fell) off the third story balcony of his home, blue pills scattered all over the place. He had multiple fractures throughout his body: left humerus, right pubic symphisis, transverse spinous processes. He had slit his wrist somehow before he left his loft, yet despite all this was amazingly still alive. His perineal bleeding led to his scrotum swelling up to the size of his thigh (i kid you not); I wonder if he thought he was more of a man for this. He crashed while waiting for the interventional radiologists, who were the only lazy bastards in the hospital that couldn't be found - 20 minutes of this man's life added to their already inflated paychecks. A thoracotomy was performed, and the trauma surgeon manually pumped John Doe's heart with the accuracy of any good SA node. I watched Doe's left lung inflate and deflate, inflate and deflate, into the open air of the OR. He flatlines. No good. No pulse. Intrathoracic defibrillators. Still nothing. Ok, wait. A heartbeat. Radiologists continued looking for the ruptured vessels to stop the incessant bleeding. Need more blood. The blood bank says they're running out. Tell them to call the Red Cross. More blood. More plasma. They drip the life of others into him as it drips back out as his own onto the OR floor. He flatlines. Time of death, 21:55. 16 units of blood, 12 units of plasma, transferred from life saving bags to the OR floor and his scrotum. Police say he had been drinking heavily while abusing antidepressants for the past week. He didn't want to live anyway. With slit wrists, blue pills, and a third story balcony, what right did we have to try and save him?

swept away

A great mind once spoke of taking a road less traveled. The footsteps along a path of consequence, forged in the heat of passion; a passion for living, a passion for believing, a passion for dreams. I too have embarked on such a path, but feel as if I am being swept by the tides and eddies of consequence, into a depth I do not comprehend nor wish to fathom in fear of my own mortality, my own humanity, the smallness of my being that nurtures a flame of purpose, or a search thereof, within the human soul. Though this vessel is small, and powerless against these tides, I shall keep it sailing with pride as the waters of misfortune wash me to the directionless depths of mediocrity.

I am water... flow with me baby.

You are water. You're not really organic; you're

neither acidic nor basic, yet you're an acid

and a base at the same time. You're strong

willed and opinionated, but relaxed and ready

to flow. So while you often seem worthless,

without you, everything would just not work.

People should definitely drink more of you

every day.


Which Biological Molecule Are You?
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Hand of God

Howl, lonely wind!
Howl in forlorn melody.

Ubiquitous wind; they call for you.
Your invisible, thankless hand,
With purpose, unanchorable; name ungiven.
Resonance of desperate prayers.

Blow, empty wind.
That lonely hearts may breathe,
lonely breaths,
and fallen leaves may find fallen limbs.

Soothe, loving wind.
Kiss dry the eyes you've stung.
Deal hope, with death you've given.
Promise spring, in autumn's eulogy.

Bastard wind, torment me not!
Let silent cries, be silent still.
May fallen leaves, adorn this path,
of tattered love, and broken will.

The thoughts of an unexpressful mind...

"Each one of us is alone in the world. He is shut in a tower of brass, and can communicate with his fellows only by signs, and the signs have no common value, so that their sense is vague and uncertain. We seek pitifully to convey to others the treasures of our heart, but they have not the power to accept them, and so we go lonely, side by side but not together, unable to know our fellows and unknown by them. We are like people living in a country whose language they know so little that, with all manner of beautiful and profound things to say, they are condemned to the banalities of the conversation manual. Their brain is seething with ideas, and they can only tell you that the umbrella of the gardener's aunt is in the house."

--W. Somerset Maugham, The Moon and Sixpence


I must say that I disagree with this statement. Not so much in the obvious truth in the limit of our human tongue, but rather in the lamenting of the nature of man and language. There is deficiency in all things: physical energy is lost wastefully to friction and heat; seeds are produced in masses of thousands so that one may have the chance to live. It is clear that words in their banality degrade meaning and emotion into the very simple signals that this writer speaks of. However the deficiency in our expression is what makes good expression truly great. As the diamond in the rough is prized for its worth, while the diamond in the diamond field is but another diamond, the degradation of our every expression into the mundane whisperings of everyday life ensure that our truest moments are left as opportunities for theatric excellence. Our broken hearts are expressed in tears and writhing mouths, void of any words, but laced with human expression. Our smiles are recognized in every language, dialect, and nation... death and grief just as consoled and understood. The handicap of our tongues to express the majesty of our minds make the poems that move tears from dry eyes, music that move hearts from closed walls, and speeches that move men and women to their feet in inspired unity, truly works of art, a testament to the human spirit despite the shackles of our physical beings and restraints of our simple tongues.

A world where thought was shared in complete and utter understanding would be a more banal world than this. The value of human thought is not in question, but rather the ability to share these thoughts. In a world where all is shared, and nothing expressed, all thoughts would be equal, all ideas understood, and they would all meld and mend into a potpourri of human feeling, no one being more distinct or precious than the others, no one more moving or melancholy than the next. All thoughts would be shared, each one understood, on account of this perfect communication. Why express yourself through poetry, art, music, or deeds, when the feelings of your mind and the intentions of your heart are already known? A world without the need to overcome the barriers of human expression would be a world without the need to be human. Our language limits mankind from ever reaching one another, and inadvertently sears the desire to forever long for one another in consequence. Let our barriers remain, so that we may forever fight to overcome them, and in doing so, live out our humanity.

Pediatric ICU

On Thursday morning I shadowed one of my instructors who works in the peds cardiac ICU. It was amazing. One of the patients was a 14 day old baby who had his chest cut open with only a thin film of plastic draping the hole in his thoracic cavity to prevent infection. Lemme tell ya, watching a baby's heart beat from an opened chest is friggin nuts.

I luv bein a med student.

I was used today...

Vishal asked me for my cell # today... he subsequently mentioned that he felt better now that he had an even number of entries in his cell phone. So used. He said I should write a blog entry about it. So here it is. But I've exhausted the excitement, drama, and altogether overwhelming emotion of the incident in my first few lines, so I shall bring a close to that saga of my life.

Chapter 2: Vengeance is Mine
I looked up your cell # on the med roster Vishal and added you. You're #143. You may have the peace of mind knowing that you have an even number of entries in your phone, but let it haunt you, let it hound you, let this sword of Damocles plague your every waking moment and the lulls within your dreams because you know that somewhere, somehow, you're an odd entry in someone's phone.

Glasses

Sometimes the glass is half full.
Sometimes the glass is half empty.
And sometimes, there just aint no frickin glass.

Ode to a Med Student...

Never let them see you bleed.
When you're wounded
tell them it's ketchup.
But not your ketchup
no, that would show weakness.
Someone else spilt it.
Obviously.

Never let them see you cry.
When they look,
ask if they think it strange
that it's raining,
under a cloudless sky.
Ludicrous.

In weakness, show strength.
In strength, show weakness.
Sun Tzu thought so.
Sun Tzu taught so.
This art of war begs a dialectic champion.

Misery loves company.
Our education binds us,
intertwines our minds behind us.
My weakness will become yours,
and yours will become mine.
Hiding our tears from ourselves,
averting our eyes from wounds not there,
and in unified solitude,
conquer that which might have been,
and that which tomorrow may be.

Is it possible?

Today was another amazing day.

Another day, another chapter closes, another verse begins...

Today was my first day of medical school. Like whoa. The people are amazing, the faculty are incredibly nice, and the curriculum looks like it'll keep me entertained far better than I was during undergrad. The day started off well. I woke up at the ungodly hour of 7 to shower... after which I moseyed on down to the shuttle stop so I could take the bus to avoid the strenuous 15 minute walk to campus. Introductions were haphazard as I sifted through the milieu of people, making my way to the all so important pastry table. Muffins, fruit, whatever; they had good orange juice and that's all that matters. My love for this orange juice did not go unrequitted, as it soon found its way to my backpack and pants (it doesn't waste any time this juice), embracing me with its glory. What a way to start the day eh?

The rest of the morning went rather quickly. We listened to deans talk about how great UCLA was (duh), and some more interesting statistics regarding matriculation and whatnot. UCLA undergrad sends the most to UCLA med (about 30 students), followed closely behind by Berkeley (woo hoo... we're so awesome haha). Another interesting factoid (this will give you all the more reason to come here zohair...) there's about a 3:2 girl to guy ratio here. With only 160 students in your class, the potential for drama is just way to high if you ask me though. But, different strokes for different folks eh?

We met in groups to do some learning. Then watched this amazing cultural awareness presentation put on by professional performers. Then we went to Chili's to chill (I'm so punny).

Anyway. It's awesome. When I'm working 80 hour weeks with 32 hour shifts during clinicals, I'll look back and think on the good old days... Here's to another 4 years.

whispers in the night..

the problem with staying awake when you're not supposed to is that often times the paths of your conscious mind begin to blur. the lucid becomes mirky, the crystals now limestone. maybe i'm getting nostalgic. maybe now that i'm at the edge of the world, ready to embark on something that matters i'm getting cold feet. the human lust for opposites permeates our condition as people. it drives me crazy. we never know what we have until it's gone. we don't know it has begun until it's over. all is fair in love and war. comfort breed contempt and children. actually that last one had nothing to do with this topic but it's an interesting quote.

i believe i'm at an all time low on endogenous intoxicant. those beautiful opiates, endorphins, and neuropeptides that remove us from the reality of our days. namely they are: chemical fluctuations in an evolutionary mechanism to pass on our genes, the depression of our reticular activation system and downmodulation of the thalamocortical tract, and ethanol ... simply put: love, sleep, and alcohol.

not being someone that drinks, i'm short outta luck when it comes to inebriation i'm afraid. being a poor med student i can't afford the luxury of love. and being someone with bigger aspirations than he can swallow, sleep is a distant dream as well.

one of my friends was playing all her depressing music cause she's been kinda in a rut. i told her it wasn't healthy at first, but sitting here bored outta my mind i realize how beautiful it is to twist your own soul in bittersweet anguish in the memories and feelings of other heart trodden beings . not only do they feel the pain you feel, but they've colored and adorned themselves with shades of their own. it is this ensemble of misery that cries out to us, pleading us, be a part of my melancholy... in our unified tears we are strong, alone are wet eyes are pitiable.