The phone went off at 4:45AM. I had already been laying awake in bed for 10 minutes, wrestling with the idea of getting up and starting another day. It was day 7 of my 2 week stretch without a day off, the black stretch that the R2s have to go through once every month. I already knew what the phone call was before I picked up. Someone had bled into their brain on the neurosurgery service and had to be red-lined to the OR, they needed backup for getting set up for rounds and needed me in early. I was out the door in 10 minutes and driving over to UCLA. After setting up things for morning rounds I relieved my co-resident in the OR and flew through the surgery with the attending. The senior residents were called away for rounds, leaving me as first assist on a pretty awesome case. We cut down to skin, him on his side of the incision, me on mine. Scalp up, periosteum off, drilling down to bone with bone dust flying with the blood and irrigation in minutes. By the time we opened dura the brain was so tight it started to ooze out of our incision. We cut open the rest of the dura to relieve the pressure and started sucking down over the sick looking brain. We found the blood clot quickly, and sucked it out along with the tumor that had bled. Once we had stabilized the bleeding and removed the rest of the tumor, he took off because he had to drop off something for his son. It's a great feeling to be the primary surgeon in any case, being able to go at your own pace and doing things in what you feel is the best way of the various techniques you've been taught. I finished closing the dura, plated and screwed on the bone flap, and was closing skin by the time my senior residents popped their heads to see how things were going. They cracked a few jokes, complimented my work, and left again. It was a great way to start the day.
This is our lot it seems. There's never really ever going to be a day off. Even when you're off duty, you can be called in at any time if they're short staffed. Death respects no vacation days, and for our hospital there's about 10 neurosurgery attendings and 15 residents. The residents are split up amongst 4 different hospitals, and the attendings aren't always in town. We're always on pager in case something comes up, being woken up in the middle of the night or post-call because we may know some critical piece of history or information that wasn't passed on in the rush of morning rounds or sign out. Yea. I'm tired. Vacation is coming up though. Hopefully I'll be able to get some sleep.
Monday, November 08, 2010
Saturday, November 06, 2010
Trust No Finger Butt Thine Own
The neurologic exam is a critical part of our history and physical when we're assessing a patient. Be it for documentation purposes prior to a surgery, or determining whether or not a patient even needs surgery, the patient's neurologic status and the documentation thereof is paramount in both a medical-legal and treatment paradigm way. As such, although we would like to trust our colleagues on different services regarding their neuro exam, as a neurosurgeon we really have to perform it and document it ourselves. I mean really, what do they know about 4+ versus 4- strength or the bulbocavernosus reflex? One piece of information in particular that seems to be stressed is the digital rectal exam. I'm not sure how many times you need to have had your finger up ...
Nevermind.
In any case, I was called recently to assess a patient with fecal incontinence. Per report there was no rectal tone. Getting a little bit of history made me suspicious that that wasn't entirely true. The guy was in pain, he didn't need another finger up his rear, and surely not right before dinner. But I had to be sure. And sure enough, there was tone. I really really really felt bad for the guy. When you're a patient you've got to wonder, "OK these docs REALLY got to talk to each other so they can COMMUNICATE what's going on up there." You don't get a CT scan everytime a different team wants to look at an image. They should make a portable rectal tone manometer so we'd only have to do it once and it can be objectively documented. But until then, as evidenced today, you can't trust the finger of anyone else's but your own.
Nevermind.
In any case, I was called recently to assess a patient with fecal incontinence. Per report there was no rectal tone. Getting a little bit of history made me suspicious that that wasn't entirely true. The guy was in pain, he didn't need another finger up his rear, and surely not right before dinner. But I had to be sure. And sure enough, there was tone. I really really really felt bad for the guy. When you're a patient you've got to wonder, "OK these docs REALLY got to talk to each other so they can COMMUNICATE what's going on up there." You don't get a CT scan everytime a different team wants to look at an image. They should make a portable rectal tone manometer so we'd only have to do it once and it can be objectively documented. But until then, as evidenced today, you can't trust the finger of anyone else's but your own.
Monday, November 01, 2010
One Third Done
We hit our 4 month mark today. It feels like I've been doing this job for a year. And if you calculate it, and of course we're duty hour compliant, but it turns out roughly to be 1440 hours that we've worked up to now in R2 year alone. An average 40hr a week job will work 1920 hours in a year. By the end of this month we'll have put in enough hours to bill for a year's labor, but sadly only have made $8.30 an hour. It's funny how the ACGME is all up in arms about us being sleep deprived and overworked, but never once filed complaints about us being underpaid.
That grievance being said, it's been a pretty smooth 4 months to date. Those still curious as to whether or not I'm still the "nice guy" who started this year, I would say yes. There have been times that I've wanted to tell someone they were being idiotic or yell at them for mismanaging a patient, but I'm sure I've been on the other side of mismanagement multiple times throughout my short career so far, and will be many times again in the future (hopefully only regarding non-neurosurgical issues). Everyone's only trying to do their job the best they can. But don't worry, the day I meet a doctor who shouldn't be a doctor because it's dangerous for patients, or are just blatantly negligent and irresponsible, I'll lay into them like there's no tomorrow.
One third done, 40 overnight calls completed, 73 overnight calls to go.
That grievance being said, it's been a pretty smooth 4 months to date. Those still curious as to whether or not I'm still the "nice guy" who started this year, I would say yes. There have been times that I've wanted to tell someone they were being idiotic or yell at them for mismanaging a patient, but I'm sure I've been on the other side of mismanagement multiple times throughout my short career so far, and will be many times again in the future (hopefully only regarding non-neurosurgical issues). Everyone's only trying to do their job the best they can. But don't worry, the day I meet a doctor who shouldn't be a doctor because it's dangerous for patients, or are just blatantly negligent and irresponsible, I'll lay into them like there's no tomorrow.
One third done, 40 overnight calls completed, 73 overnight calls to go.
Friday, October 29, 2010
Angel of Death
Yesterday was a day of tears on the neurosurgery service. It started out a day like any other, rounds, a list of tasks and chores to complete, fielding phone calls from patients and outside hospitals. But then in the late afternoon the service became a field of tears as I made my first stop to pull the life sustaining ventriculostomy on one of our patients. He had been in the hospital since the beginning of my R2 year, his neurologic function crumbling away with each week of cognitive and physical immobility. His wife, ever optimistic and never faltering, had an hour long conversation with the attending surgeon who while drying off her own eyes asked me to pull the catheter. When I did I saw a tear rolling down the side of the patient's face.
A newly diagnosed brain tumor in someone who had only weeks before been completely healthy. We discussed what we had found on the MRI and what steps would need to be taken to find out exactly what it is and how to treat it. The funny thing with brain masses is that you can never be 100% sure what you're looking at on a radiographic study until you have a tissue diagnosis. Most times the scans are pretty predictive, but in our field we do not treat until the microscopic pathology confirms the disease process we suspect. This one was clearly GBM, or glioblastoma multiforme the most malignant of all brain tumors. The wife pressed me for prognosis, I parried and tried to divert her question stating that we couldn't tell until we found out what it was. She persisted and asked me to give a realistic estimate based one what we knew. Worst case scenario, 6 months, but some live 5, 10, 15 years with what we think this is (less than 1% of patients). The creed of physician is "primum non nocere" or "first do no harm." Leaving the young couple embracing while the wife succumbed to a flood of tears seemed to violate the spirit of that motto somehow. The nurse said that I was such a great doctor because of my compassionate bedside manner. It didn't seem like they would remember me that way. They would remember me as the young asian guy who told them that their lives together would be cut short, that she would need to bury him, that they would actually fulfill their marriage vows of staying faithful till death do them part rather than being separated by the mundane trifles of life.
An elderly gentleman who had just celebrated another year on earth the day prior came in with a massive stroke, and would with 100% certainty end up a vegetable unable to eat, speak, or understand anything. To tell a family that their father/uncle/grandfather who had only hours before blown out candles while laughing with them would now be a shell of his former self, that his memories and cognitive abilities would never return, and that surgery was not only NOT an option, but would hasten his death... more crying.
Then I saw Mr. K. After a 2 month stay we had finally gotten him healthy enough to go to a rehabilitation facility. He left us engaging, still smiling, making jokes despite his tracheostomy. I had spent literally hours speaking to his wife over the past months telling her there was hope, that he would make it through this. But he returned to us blind from an episode of hypotension (low blood pressure), back on the ventilator, unresponsive and unaware. When I went in to examine him I didn't know what to say. It wasn't good to see him again, I wish he had made it out and lived a long life away from the hell of the ICU. But still, "it's good to see you again... sorry it couldn't have been on different terms." It seemed trite. He couldn't hear me.
And then a transfer from an outside hospital. A lady who had an aneurysm rupture in her head, now in a persistent vegetative state with little chance of recovery. The family asked me how long it would be before she woke up since it had already been 2 months. The doctors must have never told them her prognosis. You cowards. I just made 4 different families I met for the first time cry today because they deserved the truth and you couldn't man up to one that you had taken care of for 2 months? Granted you must always give hope when describing prognosis (unless it's pretty devastating like the stroke patient above), but unrealistic expectations just set up families for a greater let down when they realize the reality of the situation. We would talk later, and our team would be responsible for cleaning up the mess of hopes the outside physicians had scattered before them.
Yea, yesterday kinda sucked.
A newly diagnosed brain tumor in someone who had only weeks before been completely healthy. We discussed what we had found on the MRI and what steps would need to be taken to find out exactly what it is and how to treat it. The funny thing with brain masses is that you can never be 100% sure what you're looking at on a radiographic study until you have a tissue diagnosis. Most times the scans are pretty predictive, but in our field we do not treat until the microscopic pathology confirms the disease process we suspect. This one was clearly GBM, or glioblastoma multiforme the most malignant of all brain tumors. The wife pressed me for prognosis, I parried and tried to divert her question stating that we couldn't tell until we found out what it was. She persisted and asked me to give a realistic estimate based one what we knew. Worst case scenario, 6 months, but some live 5, 10, 15 years with what we think this is (less than 1% of patients). The creed of physician is "primum non nocere" or "first do no harm." Leaving the young couple embracing while the wife succumbed to a flood of tears seemed to violate the spirit of that motto somehow. The nurse said that I was such a great doctor because of my compassionate bedside manner. It didn't seem like they would remember me that way. They would remember me as the young asian guy who told them that their lives together would be cut short, that she would need to bury him, that they would actually fulfill their marriage vows of staying faithful till death do them part rather than being separated by the mundane trifles of life.
An elderly gentleman who had just celebrated another year on earth the day prior came in with a massive stroke, and would with 100% certainty end up a vegetable unable to eat, speak, or understand anything. To tell a family that their father/uncle/grandfather who had only hours before blown out candles while laughing with them would now be a shell of his former self, that his memories and cognitive abilities would never return, and that surgery was not only NOT an option, but would hasten his death... more crying.
Then I saw Mr. K. After a 2 month stay we had finally gotten him healthy enough to go to a rehabilitation facility. He left us engaging, still smiling, making jokes despite his tracheostomy. I had spent literally hours speaking to his wife over the past months telling her there was hope, that he would make it through this. But he returned to us blind from an episode of hypotension (low blood pressure), back on the ventilator, unresponsive and unaware. When I went in to examine him I didn't know what to say. It wasn't good to see him again, I wish he had made it out and lived a long life away from the hell of the ICU. But still, "it's good to see you again... sorry it couldn't have been on different terms." It seemed trite. He couldn't hear me.
And then a transfer from an outside hospital. A lady who had an aneurysm rupture in her head, now in a persistent vegetative state with little chance of recovery. The family asked me how long it would be before she woke up since it had already been 2 months. The doctors must have never told them her prognosis. You cowards. I just made 4 different families I met for the first time cry today because they deserved the truth and you couldn't man up to one that you had taken care of for 2 months? Granted you must always give hope when describing prognosis (unless it's pretty devastating like the stroke patient above), but unrealistic expectations just set up families for a greater let down when they realize the reality of the situation. We would talk later, and our team would be responsible for cleaning up the mess of hopes the outside physicians had scattered before them.
Yea, yesterday kinda sucked.
Wednesday, October 27, 2010
Sometimes human
There was a lot of traffic today.
Driving home in the middle of rush hour, isolated in the mechanical barrier that us Angelinos prefer to the stench, hustle and bustle of shared air and space (ie public transportation), my frantic speeding of thoughts slowed to the idle crawl of the cars around me. Losing interest in the repetitive pop tunes on the radio I turned to my phone to check the traffic, and then from there started calling family members I had long since talked to.
It began with my sister-in-law. We talked about their kid and how she was starting to show a preference to my brother, crying to be held by him and played with when he was around, but busily looking for toys and other things to amuse herself when she was in the room. My dad was on a service call so he didn't have his usual enthusiasm in his voice, and to be frank, just inexplicably sounded tired. He's turning 60 in a couple of weeks... reminding us both that he was getting old. My mother was her usual bubbly enthusiastic fountain of encouragement, proud of her doctor son, apologizing that she couldn't do anything to help despite knowing how hard and tiring residency must be. Then later that day dinner with some friends I hadn't seen in some time. Burgers, drinks, nostalgic bickering and teasing. Too many reminders of the life that is on hold this year.
There are always moments when physicians, in my opinion surgeons especially, have to stop being human. Stop feeling, stop needing, stop wanting. Put aside Maslow's hierarchy of needs to finish that 10 hour surgery, take call again for the 3rd time in one week, push the envelope and admit that 8th patient that night because they need medical attention just as much as the first. Illness recognizes not the fatigue of the physician, but will capitalize on it when sleep deprivation causes laziness, sloppiness, or inattentiveness. To err is human, they say. But in our profession to err is murder. So we're asked to be more than human, isolating hunger, fatigue, and emotions, burying them until we scrub out of the OR or leave the hospital. But then we see our friends, hear the voices of our loved ones, and are reminded that we're still human too.
Driving home in the middle of rush hour, isolated in the mechanical barrier that us Angelinos prefer to the stench, hustle and bustle of shared air and space (ie public transportation), my frantic speeding of thoughts slowed to the idle crawl of the cars around me. Losing interest in the repetitive pop tunes on the radio I turned to my phone to check the traffic, and then from there started calling family members I had long since talked to.
It began with my sister-in-law. We talked about their kid and how she was starting to show a preference to my brother, crying to be held by him and played with when he was around, but busily looking for toys and other things to amuse herself when she was in the room. My dad was on a service call so he didn't have his usual enthusiasm in his voice, and to be frank, just inexplicably sounded tired. He's turning 60 in a couple of weeks... reminding us both that he was getting old. My mother was her usual bubbly enthusiastic fountain of encouragement, proud of her doctor son, apologizing that she couldn't do anything to help despite knowing how hard and tiring residency must be. Then later that day dinner with some friends I hadn't seen in some time. Burgers, drinks, nostalgic bickering and teasing. Too many reminders of the life that is on hold this year.
There are always moments when physicians, in my opinion surgeons especially, have to stop being human. Stop feeling, stop needing, stop wanting. Put aside Maslow's hierarchy of needs to finish that 10 hour surgery, take call again for the 3rd time in one week, push the envelope and admit that 8th patient that night because they need medical attention just as much as the first. Illness recognizes not the fatigue of the physician, but will capitalize on it when sleep deprivation causes laziness, sloppiness, or inattentiveness. To err is human, they say. But in our profession to err is murder. So we're asked to be more than human, isolating hunger, fatigue, and emotions, burying them until we scrub out of the OR or leave the hospital. But then we see our friends, hear the voices of our loved ones, and are reminded that we're still human too.
Tuesday, October 26, 2010
I cried because I had no shoes...
... until I met a man who had no feet.
Working in a hospital in the middle of Los Angeles with Westwood around, Beverly Hills around the corner, and Hollywood a few miles away is like swimming in a balsamic vinaigrette. With the occasional night of extravagance and superficiality it's quite jarring to come back to a place where your business is the basics of the human condition. We advance diets so that people may eat, ambulate them so they may poop, and operate on them so that they may live. I won't lie, but the dichotomy is somewhat refreshing. I'm not sure if I could handle a residency where the outside world was as bleak or dark as the everyday occurrences of the hospital I worked in.
Yesterday while walking the halls I heard a clicking like the sound of horseshoes but on a smaller, two limbed beast of some sort. Tap shoes? No... the clicks were in unison. I then saw a man with no legs basically vaulting himself forward while holding what looked like metal handles - ] [ - one in each hand, onto his remaining stump cut off just below the waist, as if his arms were crutches and his waist his only good leg. I was in a hurry, and sheepishly had to pass him as I sped on by. "Excuse me," I whispered as I overtook him. I mean really, what do you say in that kind of situation? Interestingly, I saw him the next morning in the room of a patient who was also plegic below the waist. I really lack the ability right now to articulate why I'm bringing this up... but questions this raises: Birds of a feather or just featherless birds? Situations in life or life situation that bind us? Do you feel guilty about your 50 pairs of shoes now?
Working in a hospital in the middle of Los Angeles with Westwood around, Beverly Hills around the corner, and Hollywood a few miles away is like swimming in a balsamic vinaigrette. With the occasional night of extravagance and superficiality it's quite jarring to come back to a place where your business is the basics of the human condition. We advance diets so that people may eat, ambulate them so they may poop, and operate on them so that they may live. I won't lie, but the dichotomy is somewhat refreshing. I'm not sure if I could handle a residency where the outside world was as bleak or dark as the everyday occurrences of the hospital I worked in.
Yesterday while walking the halls I heard a clicking like the sound of horseshoes but on a smaller, two limbed beast of some sort. Tap shoes? No... the clicks were in unison. I then saw a man with no legs basically vaulting himself forward while holding what looked like metal handles - ] [ - one in each hand, onto his remaining stump cut off just below the waist, as if his arms were crutches and his waist his only good leg. I was in a hurry, and sheepishly had to pass him as I sped on by. "Excuse me," I whispered as I overtook him. I mean really, what do you say in that kind of situation? Interestingly, I saw him the next morning in the room of a patient who was also plegic below the waist. I really lack the ability right now to articulate why I'm bringing this up... but questions this raises: Birds of a feather or just featherless birds? Situations in life or life situation that bind us? Do you feel guilty about your 50 pairs of shoes now?
Sunday, October 24, 2010
Blindness
"GSW to head. Please come to OR 4." [GSW = gunshot wound]
There aren't very many times that we run in the hospital. Luckily so, as our Dansko clogs in the best of conditions aren't capable of staying on past a moderate jog. I was about to check on our recent post-op patients before heading down to grab a bite to eat when this page came in. The last GSW patient I had was essentially brain dead by the time I arrived, but they were operating on this one so maybe this patient had a chance.
I jogged to the elevator and pressed the button for 2, thinking that this would be faster than 4 flights of stairs. A bunch of pediatric nurses got on at 5 and took the elevator down to 3. Internally I shouted. But how could they know I was rushing over to someone that was likely dead or dying. We were in the same elevator going down, and they were potentially slowing down an urgent medical evaluation and life saving intervention. I wonder if they would have still been laughing about their workplace intrigue if they had known this.
I was there in 2 minutes, but the patient was already intubated and sedated. Great, I'll just have to go with the cranial nerve exam. There were at least 20 people in the OR, hanging blood products, setting up IVs, charting everything as the maddening chaos of the operative theater unfolded. I maneuvered my way to the head of the bed so I could at least examine her eyes, as in addition to being the proverbial windows to the soul, pupils are the best indicators for impending or completed herniation from mass lesions such as bleeding in the brain. Pupils are... oh jeez. The patient's left eye was extricated from the orbit and the right one had ruptured, sequelae from the blast damage of the bullet that was imbedded in the left temple. No CT scan, no exam. I could only wait for the trauma team to finish what they were doing so we could get a STAT CT to see what we were dealing with. The CT showed that, tragically, there wasn't much brain damage. She would survive this. The bone of the eye sockets were shattered beyond recognition, and likely beyond salvage as well. We lightened the sedation to get an exam... and I'm sure awakened her to a hellish nightmare.
Where am I? Why is it so dark? Why does my chest hurt so much. I can't breath. I can't... I can't move my arms. Why am I tied down? My eyes. Oh my God my eyes. I can't see. I can't see! Somebody tell me what's going on! Somebody, anybody. Where is he? Why did he... what did I do? Why, God, oh why? I can't see anything... I ... CAN'T... SEE...
She tries to scream, but is muffled as the ventilator pushes air back into her lungs, forcing life back into her.
There aren't very many times that we run in the hospital. Luckily so, as our Dansko clogs in the best of conditions aren't capable of staying on past a moderate jog. I was about to check on our recent post-op patients before heading down to grab a bite to eat when this page came in. The last GSW patient I had was essentially brain dead by the time I arrived, but they were operating on this one so maybe this patient had a chance.
I jogged to the elevator and pressed the button for 2, thinking that this would be faster than 4 flights of stairs. A bunch of pediatric nurses got on at 5 and took the elevator down to 3. Internally I shouted. But how could they know I was rushing over to someone that was likely dead or dying. We were in the same elevator going down, and they were potentially slowing down an urgent medical evaluation and life saving intervention. I wonder if they would have still been laughing about their workplace intrigue if they had known this.
I was there in 2 minutes, but the patient was already intubated and sedated. Great, I'll just have to go with the cranial nerve exam. There were at least 20 people in the OR, hanging blood products, setting up IVs, charting everything as the maddening chaos of the operative theater unfolded. I maneuvered my way to the head of the bed so I could at least examine her eyes, as in addition to being the proverbial windows to the soul, pupils are the best indicators for impending or completed herniation from mass lesions such as bleeding in the brain. Pupils are... oh jeez. The patient's left eye was extricated from the orbit and the right one had ruptured, sequelae from the blast damage of the bullet that was imbedded in the left temple. No CT scan, no exam. I could only wait for the trauma team to finish what they were doing so we could get a STAT CT to see what we were dealing with. The CT showed that, tragically, there wasn't much brain damage. She would survive this. The bone of the eye sockets were shattered beyond recognition, and likely beyond salvage as well. We lightened the sedation to get an exam... and I'm sure awakened her to a hellish nightmare.
Where am I? Why is it so dark? Why does my chest hurt so much. I can't breath. I can't... I can't move my arms. Why am I tied down? My eyes. Oh my God my eyes. I can't see. I can't see! Somebody tell me what's going on! Somebody, anybody. Where is he? Why did he... what did I do? Why, God, oh why? I can't see anything... I ... CAN'T... SEE...
She tries to scream, but is muffled as the ventilator pushes air back into her lungs, forcing life back into her.
Monday, October 18, 2010
Random Thoughts
There are a lot of random thoughts that become seemingly normal to the neurosurgery resident that people not in the field might find interesting, amusing, or down right appalling. I thought I'd share some of them.
1. I really should quit and find a better paying job.
2. I stumbled upon a familiar name on an operating room slip in the OR lounge. It was for a baby who we pronounced basically dead with very little chance at survival following her intracranial hemorrhage. The slip was for the harvesting of her pancreas... I don't know but after not hearing about her status for about a week it was kind of eerie for it to come back at me out of nowhere like that.
3. We routinely operate on people and have to leave the bone off so that their brain has room to swell. They go around and have to live while wearing a helmet. I thought of that when I saw my snowboarding helmet in my closet while getting dressed for work this morning. Yes, a patient without half his skull snowboarding.
4. Doctors really do make the worst patients. Especially the ones who think that by being an orthopedic surgeon or internal medicine doctor that they have the faintest idea how to manage the problems that bring them on our service. This isn't frickin Burger King, you can't have it your way.
5. If I ever get diagnosed with a brain tumor, and I'm no longer able to talk or care for myself... please hire a hitman and have me killed. Seriously. Seeing these patients that have been on our service for as long as I've been an R2, slowly wasting away, a former shell of what they used to be... being tortured by the misguided "love" of their family members who think that by holding on so tight to the memory of what once was is honoring their life when in reality it's only prolonging their journey through the valley of death. It really kills me.
6. Do robots have feelings? What about talking ones? (if you don't know, don't ask).
7. Why am I so awesome? God I suck. (simultaneously).
8. Post call sleeping is tricky. You sleep to your hearts content, and then you can't sleep at night, and you're tired the next day instead the day after call. But if you don't sleep enough, you lose that half day of freedom to your mild delirium.
9. I never thought I'd ever have to shave this many heads. All that practice cutting hair during college paid off.
10. I'm hungry.
1. I really should quit and find a better paying job.
2. I stumbled upon a familiar name on an operating room slip in the OR lounge. It was for a baby who we pronounced basically dead with very little chance at survival following her intracranial hemorrhage. The slip was for the harvesting of her pancreas... I don't know but after not hearing about her status for about a week it was kind of eerie for it to come back at me out of nowhere like that.
3. We routinely operate on people and have to leave the bone off so that their brain has room to swell. They go around and have to live while wearing a helmet. I thought of that when I saw my snowboarding helmet in my closet while getting dressed for work this morning. Yes, a patient without half his skull snowboarding.
4. Doctors really do make the worst patients. Especially the ones who think that by being an orthopedic surgeon or internal medicine doctor that they have the faintest idea how to manage the problems that bring them on our service. This isn't frickin Burger King, you can't have it your way.
5. If I ever get diagnosed with a brain tumor, and I'm no longer able to talk or care for myself... please hire a hitman and have me killed. Seriously. Seeing these patients that have been on our service for as long as I've been an R2, slowly wasting away, a former shell of what they used to be... being tortured by the misguided "love" of their family members who think that by holding on so tight to the memory of what once was is honoring their life when in reality it's only prolonging their journey through the valley of death. It really kills me.
6. Do robots have feelings? What about talking ones? (if you don't know, don't ask).
7. Why am I so awesome? God I suck. (simultaneously).
8. Post call sleeping is tricky. You sleep to your hearts content, and then you can't sleep at night, and you're tired the next day instead the day after call. But if you don't sleep enough, you lose that half day of freedom to your mild delirium.
9. I never thought I'd ever have to shave this many heads. All that practice cutting hair during college paid off.
10. I'm hungry.
Saturday, October 16, 2010
Neurosurgery Badass
After I placed an emergent ventriculostomy in one of my patients and had him slowly wake up over the next day or two, the brother came up to me all excited, thanking me for saving his brother's life. It was a little embarrassing to get that much praise for doing my job in the middle of the busy ICU, but it felt nice nonetheless. The funny part was that another patient's husband came up to me after seeing this spectacle and commented, "See, you're such a badass." Haha.
One of my friend's used to ask if I was going into neurosurgery because it was such a "badass" field/thing to do. I think a comment I heard in passing the other day to the effect that "it's not the same world anymore where doctors hold a place at the top of the social ladder" describes my sentiments best. People don't go into neurosurgery to be "badasses." If I wanted that kind of a title I would have went into investment banking and dated a escort named Vivian or something, owned my own plane, brought crates of food/supplies to the survivors of natural disasters and stuff like that. Working 100+ hours a week, being able to see my family only once or twice a year, and being constantly fatigued to a point where 12 hours of sleep will only restore me enough to realize how tired I am isn't exactly the most glamorous life. But I guess behind all the smoke and mirrors the idea of violating and salvaging the sanctuary of the human mind is appealing.
Being chained into the hospital though does have its advantages. I feel a heightened sense of awareness of the outside world, and appreciate things I never really enjoyed before. These are the best moments of the past couple weeks.
- Playing poker with the guys on a boat by candle light, cooking some dogs on the grill while we chatted the night away.
- Leaving the hospital after operating all day, cookie in hand, taking the long route to my car so I could take in the fresh smell of rain that scented the setting sun.
Life is a gift, and so long as we are not bound by the shackles of death anything is possible. My friend sent me this link about a great man I once had the opportunity to work with. His story reminds me that there's still so much to do, and still so much more to be greatful for. He reminds me that making the impossible a reality is truly a worthwhile goal to strive for.
http://www.hopkinsmedicine.org/hmn/W07/feature1.cfm
One of my friend's used to ask if I was going into neurosurgery because it was such a "badass" field/thing to do. I think a comment I heard in passing the other day to the effect that "it's not the same world anymore where doctors hold a place at the top of the social ladder" describes my sentiments best. People don't go into neurosurgery to be "badasses." If I wanted that kind of a title I would have went into investment banking and dated a escort named Vivian or something, owned my own plane, brought crates of food/supplies to the survivors of natural disasters and stuff like that. Working 100+ hours a week, being able to see my family only once or twice a year, and being constantly fatigued to a point where 12 hours of sleep will only restore me enough to realize how tired I am isn't exactly the most glamorous life. But I guess behind all the smoke and mirrors the idea of violating and salvaging the sanctuary of the human mind is appealing.
Being chained into the hospital though does have its advantages. I feel a heightened sense of awareness of the outside world, and appreciate things I never really enjoyed before. These are the best moments of the past couple weeks.
- Playing poker with the guys on a boat by candle light, cooking some dogs on the grill while we chatted the night away.
- Leaving the hospital after operating all day, cookie in hand, taking the long route to my car so I could take in the fresh smell of rain that scented the setting sun.
Life is a gift, and so long as we are not bound by the shackles of death anything is possible. My friend sent me this link about a great man I once had the opportunity to work with. His story reminds me that there's still so much to do, and still so much more to be greatful for. He reminds me that making the impossible a reality is truly a worthwhile goal to strive for.
http://www.hopkinsmedicine.org/hmn/W07/feature1.cfm
Sunday, October 10, 2010
Neurosurgery Poker
Despite my efforts to be a great upstanding doctor/physician/surgeon or even human being for that matter, the people that really know me will tell you that one of my greatest vices is my love for poker. It was more of an addiction during medical school when the paucity of required classes and countless hours dedicated to studying/research but otherwise unaccounted for would lend itself to me making a trek to the casino to play a few hands of cards. OK so it wasn't a few hands, as there were definitely nights when my buddies and I would leave as the sun was coming up. Still, I thought of it as training for my future in neurosurgery. If I could focus and stay awake for that many hours in one place, I was obviously training myself for the long surgeries and nights on call. I never imagined it could work the other way around.
There were parts of poker that had always appealed to me, relying on the ability to read the intentions and emotions of others to make your next move, being able to guard and secure your own feelings to control the stage of the game, knowing which battles were worth fighting and which retreat was actually winning, and then being rewarded for your mastery of these skills. Poker was an extension of the finer emotional gauntlets of life, and life just another extension of texas hold'em.
In neurosurgery, or maybe it's just residency in general, I've found that it's oftentimes a very similar hand of cards. Having to tell patients that their prognosis is still uncertain, that there might be hope, despite your short but sufficient experience telling you that they only have months to live. Delivery with confidence, cool, and reassurance is key so they do not despair or abandon any further tests that are needed for future treatments that may not ultimately affect their life expectancy. One has to be agreeable despite the occasional cockamamy plan of the attending surgeon, and then convincingly convey to the patient that this is the best course of action despite one's own beliefs (oftentimes in line with the resident team). Moreover, one must perceive the emotional status and intent of nurses as well as the patients to know if there's a firetrap on the horizon and how to best appease their wishes. Fighting with either of these parties is like fighting with the dealer, and will only get you expelled from the table, and usually with no winnings. I do not wish to suggest that neurosurgeons are deceiving swindlers that manipulate and scheme. Quite the contrary, I feel that our role is to create hope where there is none (in the face of certain death, wouldn't you want that chance at life?), maintain tranquility in a place where stress and suffering occasionally unearths the worst in people, and promote faith in the doctors that are treating them (despite idiosyncracies and ideological differences).
Or, it may just all be BS and I had a great night at cards this weekend despite my residency training. Who knows...
There were parts of poker that had always appealed to me, relying on the ability to read the intentions and emotions of others to make your next move, being able to guard and secure your own feelings to control the stage of the game, knowing which battles were worth fighting and which retreat was actually winning, and then being rewarded for your mastery of these skills. Poker was an extension of the finer emotional gauntlets of life, and life just another extension of texas hold'em.
In neurosurgery, or maybe it's just residency in general, I've found that it's oftentimes a very similar hand of cards. Having to tell patients that their prognosis is still uncertain, that there might be hope, despite your short but sufficient experience telling you that they only have months to live. Delivery with confidence, cool, and reassurance is key so they do not despair or abandon any further tests that are needed for future treatments that may not ultimately affect their life expectancy. One has to be agreeable despite the occasional cockamamy plan of the attending surgeon, and then convincingly convey to the patient that this is the best course of action despite one's own beliefs (oftentimes in line with the resident team). Moreover, one must perceive the emotional status and intent of nurses as well as the patients to know if there's a firetrap on the horizon and how to best appease their wishes. Fighting with either of these parties is like fighting with the dealer, and will only get you expelled from the table, and usually with no winnings. I do not wish to suggest that neurosurgeons are deceiving swindlers that manipulate and scheme. Quite the contrary, I feel that our role is to create hope where there is none (in the face of certain death, wouldn't you want that chance at life?), maintain tranquility in a place where stress and suffering occasionally unearths the worst in people, and promote faith in the doctors that are treating them (despite idiosyncracies and ideological differences).
Or, it may just all be BS and I had a great night at cards this weekend despite my residency training. Who knows...
Tuesday, October 05, 2010
Let the music play
With people starting to come up to me at work telling me that they enjoy reading my blog, there's now this immense pressure to deliver that has become somewhat suffocating. Ideally, I'd like to discuss something interesting, insightful, or moving with each of my blog posts, but let's face it, sometimes there's just nothing to say. Or sometimes, screaming out into the ethos of the internet is just a form of personal catharsis with no edification to the reader... for which I apologize.
For example, the other night on call I had the most frustrating consult from the emergency department to date. It was a kid with a VP shunt that came in with nausea and vomiting. She ended up having an ear infection. Imaging of the brain revealed that the shunt was working just fine. But the ER attending felt it necessary to have neurosurgery consult and do a full evaluation on her, despite a known etiology for her nausea and vomiting (shunt failure can cause this too, but usually it's accompanied by radiographic evidence of failure on CT).
ER Resident: Can you please see this patient?
Me: What's the reason for consultation?
ER: She has a shunt...
Me: It's working just fine.
ER: She has a shunt... and nausea and vomiting.
Me: Are you kidding me? The CT shows that it's working, her ventricles are smaller. She has left ear pain, and nausea/vomiting from otitis media.
ER: I know, I know. I'm really sorry, but my attending wants neurosurgery to consult.
Me: She's feeling better. She actually wants to go home right now.
ER: He still wants you to consult...
Me: And what am I supposed to say in this consultation?
ER: That the shunt is working...?
Me: ...
GAH! Luckily the resident was nice and understanding of the unfortunate situation she was putting me in. It was my 8th consult that night, and there was a gentleman in the next bed over in the ER with a subdural hematoma that needed draining. You've got to be kidding me. I was reminded that we're not allowed to refuse consults. True, but I can make your lives miserable by not seeing the patient and having her sit in your ER until I'm done with all my other work.
I saw the patient promptly anyway. I didn't want her to suffer for the ... management decisions of this attending.
Today, post call I tried once again to do some reading for research. I just can't. The constant sleep deprivation and disturbed circadian rhythm has left me rather anhedonic, and possibly bordering a point of depression. Coming home to a quiet room and submersing myself in good music seems to help though. I tried hanging out with some friends this weekend to escape the lull of monotony and death/dying... but it just left me more tired the next day at work. Maybe I just need to get a bigger TV...
For example, the other night on call I had the most frustrating consult from the emergency department to date. It was a kid with a VP shunt that came in with nausea and vomiting. She ended up having an ear infection. Imaging of the brain revealed that the shunt was working just fine. But the ER attending felt it necessary to have neurosurgery consult and do a full evaluation on her, despite a known etiology for her nausea and vomiting (shunt failure can cause this too, but usually it's accompanied by radiographic evidence of failure on CT).
ER Resident: Can you please see this patient?
Me: What's the reason for consultation?
ER: She has a shunt...
Me: It's working just fine.
ER: She has a shunt... and nausea and vomiting.
Me: Are you kidding me? The CT shows that it's working, her ventricles are smaller. She has left ear pain, and nausea/vomiting from otitis media.
ER: I know, I know. I'm really sorry, but my attending wants neurosurgery to consult.
Me: She's feeling better. She actually wants to go home right now.
ER: He still wants you to consult...
Me: And what am I supposed to say in this consultation?
ER: That the shunt is working...?
Me: ...
GAH! Luckily the resident was nice and understanding of the unfortunate situation she was putting me in. It was my 8th consult that night, and there was a gentleman in the next bed over in the ER with a subdural hematoma that needed draining. You've got to be kidding me. I was reminded that we're not allowed to refuse consults. True, but I can make your lives miserable by not seeing the patient and having her sit in your ER until I'm done with all my other work.
I saw the patient promptly anyway. I didn't want her to suffer for the ... management decisions of this attending.
Today, post call I tried once again to do some reading for research. I just can't. The constant sleep deprivation and disturbed circadian rhythm has left me rather anhedonic, and possibly bordering a point of depression. Coming home to a quiet room and submersing myself in good music seems to help though. I tried hanging out with some friends this weekend to escape the lull of monotony and death/dying... but it just left me more tired the next day at work. Maybe I just need to get a bigger TV...
Thursday, September 30, 2010
Helpless Human
There's an old joke that goes: What's the difference between a neurosurgeon and God? ... God doesn't think he's a neurosurgeon.
There are definitely the fair share of ego-maniacs within the field of neurosurgery. Many self-entitled based on the hardships in training and countless hours spent to reach their goal. There are the rare few however that are deserving of praise such as "hands of God" capable of performing exquisitely challenging surgeries that are both life saving and function preserving. What people oftentimes don't understand is that some lesions that are deemed "inoperable" by one neurosurgeon, may just be a matter of inexperience or lack of technical ability that cannot be admitted. But sometimes, some situations are beyond even the most gifted surgeons, and we are reminded of the adage that once God lays his hands on your patient, you should take yours away.
My last night on call was terribly draining, not on a physical level per se, but more on an emotional one as I watched multiple patients slip away into the night, far removed from the grasp of the medical care we could offer them.
We red-lined a patient with a multiple year history of end stage liver disease to evacuate a spontaneous brain hemorrhage he experienced for want of clotting products that his liver could no longer produce. His emergent surgery was striking to me for two reasons. One, it was an epic uphill battle after we removed a good part of the blood clot from his bulging blood clot swollen brain. Trying to get him to stop bleeding despite all the clotting factors we were dumping into his blood stream felt akin to trying to stop a dripping sponge with a box of matches. Two, his brain was yellow. It was probably one of the weirdest things I've seen this year. During certain stages of liver failure the body fails to breakdown and reabsorb bilirubin, so it floods the bloodstream and stains everything yellow. First it's the conjunctivae of your eyes, the underside of your tongue, your skin... and I guess your brain as well. The brain is usually a glistening grey mass (hence grey matter) with a beautiful architecture of blood vessels overlaying the surface. This appeared like a big golden egg, and in the setting of swelling from the underlying hematoma, seemed like it was a golden chicken about to hatch from a less yellow, but equally aberrantly tinted skull. After the initial amusement and childlike curiosity ensued a feeling of helplessness that pervaded through the morning, the night, and into the next day. Given his disease he would not stop bleeding. We did the best we could, and saved him from immediate death from herniation (when parts of your brain go and compress other critical areas given an intracranial mass). But he continued to bleed. I watched as his scans worsened, as his exams worsened, and with each radiographic or clinical deterioration presented the case to the team and attending. There was nothing we could do. Surgery would only make things worse. Even if he survived this incident he would likely end up a vegetable, and if he woke up, would not be able to talk or use the right side of his body. He was beyond what we as neurosurgeons, what we as human beings, could do. We were in the operating suite of a higher power, and we had no place there.
On a less religious and more uplifting level... I operated on a 9 day old baby today! She had a congenital condition that required her to have a permanent CSF shunt from her ventricles to elsewhere in her body. I had done enough of these on other patients by now that the attending let me do the case as he assisted and guided me through the parts I was still rusty on. It went perfectly, and the baby woke up smiling without crying (maybe she was still high on anesthesia). She'll be able to grow up to be a fully functional person later on because of what we did.
So for today, I guess we're even.
There are definitely the fair share of ego-maniacs within the field of neurosurgery. Many self-entitled based on the hardships in training and countless hours spent to reach their goal. There are the rare few however that are deserving of praise such as "hands of God" capable of performing exquisitely challenging surgeries that are both life saving and function preserving. What people oftentimes don't understand is that some lesions that are deemed "inoperable" by one neurosurgeon, may just be a matter of inexperience or lack of technical ability that cannot be admitted. But sometimes, some situations are beyond even the most gifted surgeons, and we are reminded of the adage that once God lays his hands on your patient, you should take yours away.
My last night on call was terribly draining, not on a physical level per se, but more on an emotional one as I watched multiple patients slip away into the night, far removed from the grasp of the medical care we could offer them.
We red-lined a patient with a multiple year history of end stage liver disease to evacuate a spontaneous brain hemorrhage he experienced for want of clotting products that his liver could no longer produce. His emergent surgery was striking to me for two reasons. One, it was an epic uphill battle after we removed a good part of the blood clot from his bulging blood clot swollen brain. Trying to get him to stop bleeding despite all the clotting factors we were dumping into his blood stream felt akin to trying to stop a dripping sponge with a box of matches. Two, his brain was yellow. It was probably one of the weirdest things I've seen this year. During certain stages of liver failure the body fails to breakdown and reabsorb bilirubin, so it floods the bloodstream and stains everything yellow. First it's the conjunctivae of your eyes, the underside of your tongue, your skin... and I guess your brain as well. The brain is usually a glistening grey mass (hence grey matter) with a beautiful architecture of blood vessels overlaying the surface. This appeared like a big golden egg, and in the setting of swelling from the underlying hematoma, seemed like it was a golden chicken about to hatch from a less yellow, but equally aberrantly tinted skull. After the initial amusement and childlike curiosity ensued a feeling of helplessness that pervaded through the morning, the night, and into the next day. Given his disease he would not stop bleeding. We did the best we could, and saved him from immediate death from herniation (when parts of your brain go and compress other critical areas given an intracranial mass). But he continued to bleed. I watched as his scans worsened, as his exams worsened, and with each radiographic or clinical deterioration presented the case to the team and attending. There was nothing we could do. Surgery would only make things worse. Even if he survived this incident he would likely end up a vegetable, and if he woke up, would not be able to talk or use the right side of his body. He was beyond what we as neurosurgeons, what we as human beings, could do. We were in the operating suite of a higher power, and we had no place there.
On a less religious and more uplifting level... I operated on a 9 day old baby today! She had a congenital condition that required her to have a permanent CSF shunt from her ventricles to elsewhere in her body. I had done enough of these on other patients by now that the attending let me do the case as he assisted and guided me through the parts I was still rusty on. It went perfectly, and the baby woke up smiling without crying (maybe she was still high on anesthesia). She'll be able to grow up to be a fully functional person later on because of what we did.
So for today, I guess we're even.
Sunday, September 26, 2010
In Sickness and In Health
Real men don't cry.
But knocking on Heaven's gates these men become more father, husband, and lover than man, a transformation that unearths a channel of tears that had long run dry. The news that a loved one is dying, that their wife has newly diagnosed cancer, that their child may never regain the ability to speak or walk again... crushing news that could squeeze the last drops from a grape long turned raisin. I don't know about you guys, but to me there's nothing more heart rending than strength in the midst of tears. The slow flushing of skin and dewing of eyes in the spouse that listens as you tell him his wife may not have much time. The sight of parents buckling down to their knees in muffled sobs at the bedside of their 12 year old child, who smilingly tells them to be strong, that everything will be all right.
I was especially moved by the interaction of a couple I met recently on call. She came in with new onset seizures, and workup revealed what appeared to be metastatic disease to her brain. We knew from the CT scan that it was serious, and that she was likely facing a diagnosis of cancer of some sort. But after a day of multiple seizures, and a pending diagnosis of possible death, the only question she had for me was if there was any way we could get her husband a beer. It's been a long day, she said. I was touched, and smiling said I wasn't sure we could drink alcohol in the hospital. He excused her, apologized and thanked me for my help. As he turned to grab her hand to check to see if she was really processing all of this she smiled back at him, and he knew she did. As I left the room she continued, "More importantly, what's for dinner?" He wiped his eyes and laughed.
He asked me not to break the results of the pending MRI scan unless he could be there to support her while it was given. He stayed all night by her bedside in a small, awkward seat that seemed it was designed for midgets and petite Asian women. When the news breaking was pushed back, he simply apologized for the morning breath he would have, and said he'd wait a few more hours. In sickness and in health, he had promised to protect her. Would we make these vows if we knew it would mean to hold their hand when they are told they are going to die? This man was the kind of man who would have sworn them all the sooner, all the more solemnly, so he could be there for her during this moment.
Many of us spend our whole lives looking for something special. A soulmate perhaps, that other half that completes us? Or maybe just someone to laugh at our terrible jokes or keep us warm at night. I don't think I know what love is, not really, not completely anyway. But, I think I'd want to marry the girl that despite all adversity and hardship of her own, would turn to a doctor and ask if he could get her husband a beer.
But knocking on Heaven's gates these men become more father, husband, and lover than man, a transformation that unearths a channel of tears that had long run dry. The news that a loved one is dying, that their wife has newly diagnosed cancer, that their child may never regain the ability to speak or walk again... crushing news that could squeeze the last drops from a grape long turned raisin. I don't know about you guys, but to me there's nothing more heart rending than strength in the midst of tears. The slow flushing of skin and dewing of eyes in the spouse that listens as you tell him his wife may not have much time. The sight of parents buckling down to their knees in muffled sobs at the bedside of their 12 year old child, who smilingly tells them to be strong, that everything will be all right.
I was especially moved by the interaction of a couple I met recently on call. She came in with new onset seizures, and workup revealed what appeared to be metastatic disease to her brain. We knew from the CT scan that it was serious, and that she was likely facing a diagnosis of cancer of some sort. But after a day of multiple seizures, and a pending diagnosis of possible death, the only question she had for me was if there was any way we could get her husband a beer. It's been a long day, she said. I was touched, and smiling said I wasn't sure we could drink alcohol in the hospital. He excused her, apologized and thanked me for my help. As he turned to grab her hand to check to see if she was really processing all of this she smiled back at him, and he knew she did. As I left the room she continued, "More importantly, what's for dinner?" He wiped his eyes and laughed.
He asked me not to break the results of the pending MRI scan unless he could be there to support her while it was given. He stayed all night by her bedside in a small, awkward seat that seemed it was designed for midgets and petite Asian women. When the news breaking was pushed back, he simply apologized for the morning breath he would have, and said he'd wait a few more hours. In sickness and in health, he had promised to protect her. Would we make these vows if we knew it would mean to hold their hand when they are told they are going to die? This man was the kind of man who would have sworn them all the sooner, all the more solemnly, so he could be there for her during this moment.
Many of us spend our whole lives looking for something special. A soulmate perhaps, that other half that completes us? Or maybe just someone to laugh at our terrible jokes or keep us warm at night. I don't think I know what love is, not really, not completely anyway. But, I think I'd want to marry the girl that despite all adversity and hardship of her own, would turn to a doctor and ask if he could get her husband a beer.
Friday, September 24, 2010
No light in this tunnel
12 weeks of R2 year done.
Pretty emotionally drained.
Can't even find the inspiration or desire to write in complete paragraphs...
Supposed to work on research today, but instead I took two naps.
It's hard to stay motivated when the only thing in the immediate future is another 24 hour shift at the hospital.
Pretty emotionally drained.
Can't even find the inspiration or desire to write in complete paragraphs...
Supposed to work on research today, but instead I took two naps.
It's hard to stay motivated when the only thing in the immediate future is another 24 hour shift at the hospital.
Tuesday, September 21, 2010
Think you can handle it?
Every time a resident steps into the operating room he is tested. Whether it be how punctual he is, the way he positions the patient, the way he handles the scalpel, or the way he controls the suction as he pulls away diseased brain. Initially the attending does most of the case, and occasionally has his resident do a couple small things. Suck here. Tie this down. Cut this vessel. At one point or another the attending surgeon decides that the resident has proven himself, and lets him do more and more. Soon it becomes, "OK I'll do this side, you take care of that side." Before you know it, you're closing up dura without scrutiny, dissecting down paraspinal muscles without supervision, and closing up shop while the attending takes off for the day. I've only been left in the room to close up a couple times during residency, and usually just the superficial skin, but today the attending just threw in a couple stitches in the galea and said, "OK Won, you got this?" ... "Uh, yes sir." ... "OK good, thanks for your help." And he was gone.
Awesome.
It's really no big deal closing up scalp, and most residents probably wouldn't get very excited about it. But to have an attending leave the room while you operate, in this case close galea and skin, means they trust you to do a good unsupervised job at finishing the case and making sure the patient makes it to recovery without complication. Small accomplishment, but at least I'm heading in the right direction.
Awesome.
It's really no big deal closing up scalp, and most residents probably wouldn't get very excited about it. But to have an attending leave the room while you operate, in this case close galea and skin, means they trust you to do a good unsupervised job at finishing the case and making sure the patient makes it to recovery without complication. Small accomplishment, but at least I'm heading in the right direction.
Friday, September 17, 2010
Overpowering Fatigue...
As of today I had gone 20 days without a day off. It doesn't seem too bad at first, but when you're trying to get your couple hours of sleep in before morning rounds, and the night is fractured by repeated pages, the fatigue overwhelms you. You look at the pager "patient neuro exam changed" and you ask yourself, "Can I get another 10 minutes of sleep before calling? Maybe 15 minutes before I go and check in on them?" Clearly judgment is impaired, and after 30 seconds of bickering between the ever dwindling sane portion of your brain, the drowsiness clears and you remember that for every 10 of these concerning pages, one or two may be real. It only takes one or two out of ten, or even a hundred, to motivate you to get out of bed and check on the patient. Only one or two pages, but one or two lives possibly in danger nonetheless. They may be bleeding into their brain, or maybe having seizures unbeknownst to the nurse or lay observers. The fear of what may happen if this concern is warranted gets the residents tired, overworked, and unnaturally fatigued body to move at the even feebler cadence of his brain. Yes we do our due diligence. But it's scary that, even for a second, we think not to.
Tomorrow's my day off!!! Friends and good food on the horizon. Something to remind me that I'm still human. To remind me what life we're trying to preserve, prolong, and save.
Tomorrow's my day off!!! Friends and good food on the horizon. Something to remind me that I'm still human. To remind me what life we're trying to preserve, prolong, and save.
Tuesday, September 14, 2010
(almost) flawless victory
Maybe it's a product of being on service for two and a half weeks without a day off, with back to back calls, but everything seemed to come together last night. After struggling with a bedside subdural drain last week (a bedside procedure where you drill a hole into the skull to pass a catheter and evacuate old blood that's been accumulating) I jumped on the opportunity to do the one on Mr. S yesterday. Surgical residency, at least for me, has been an experience of constant self appraisal and validation. Failures can only be redeemed even greater successes in the future. So for my own self esteem and standing within the resident team this procedure was critical to say the least. Oh, and yes of course, we wanted to help the patient.
Despite being fairly elderly, Mr. S required enough sedation to kill a small animal. But eventually he was docile enough to allow me to make a small incision on his scalp and drill down into his skull. I passed the catheter without any difficulty and drew back. Money. The old blood, now degraded into the consistency of CSF, flowed freely. After draining an adequate of fluid to relieve the brain of pressure, we sent him down to the CT scanner. Money again. Awesome placement. Then he came back up and I went to check in on him. There's frank blood in the drain. Poop.
#(*&#$%(*&$
Recomposed.
Another CT scan. Not much blood in the brain. No evidence of acute bleeders. Looks like it's coming from the scalp. I placed a fatty pressure dressing over the incision site and within a few minutes the blood stopped flowing from the drain. I win.
I got a couple hours of sleep before I awoke to a "Critical patient xxxx, subarachnoid hemorrhage." There are few things to get you out of bed in the morning faster than pages like that: coyote ugly, a full bladder, being late for morning rounds, and 'patient is herniating' are amongst the others. I can only imagine what the husband was thinking when I rushed into the room, hair all flat and disheveled from a restless night of inconstant pages, morning breath still lingering, and the look of a person who'd been in the hospital 60 of the past 72 hours. I had glimpsed at the scan on my way into the room and knew the patient needed a ventriculostomy immediately (a catheter placed into the fluid cavities of the brain to drain CSF and blood and monitor intracranial pressures). It's always interesting being the one to raise the level of urgency in a hospital situation. The nurses caught on to the immediacy in my voice as I asked for platelets, ddAVP, a ventriculostomy tray and catheter, and antibiotics STAT. Super STAT guys. Within a few minutes an empty room with a patient and husband became bustling with nurses hanging meds, eager medical students lingering in the background, and me giving this poor woman a terrible hair cut (we shave half the head to place the ventriculostomy).
It was 4:50 when I got down to the ED, 5AM by the time I was shaving hair. But rounds would start in 30 minutes. Luckily my co-resident had come in early that morning. I sent him off to print notes while I got the rest of the meds running and ventriculostomy set up. By the time things were ready for incision he was back. I told him I needed to set up for rounds, gave a quick one-liner "77 year old female, Fisher IV, Hunt Hess III, subarachnoid hemorrhage likely secondary to A-comm aneurysm rupture, pupils reactive, localizing right upper, withdrawing bilateral lowers, needs EVD." He responds "Done. Go take care of rounds."
They told us in the beginning that we three R2s are one person. We each need to know what the other knows regarding the service, and we pick up wherever one person leaves off. That way we can be in 3 places at once, and never lose the seamless control over our service of 30-50 patients.
I made it in time to load images, organize notes, and present for rounds. The lady in the ED got her life stabilizing ventriculostomy, which was in by the time we saw her after film rounds, and she went straight to angio for embolization of her aneurysm (which was successful). Another life saved. No huge screw ups or set backs. Not a bad night.
Despite being fairly elderly, Mr. S required enough sedation to kill a small animal. But eventually he was docile enough to allow me to make a small incision on his scalp and drill down into his skull. I passed the catheter without any difficulty and drew back. Money. The old blood, now degraded into the consistency of CSF, flowed freely. After draining an adequate of fluid to relieve the brain of pressure, we sent him down to the CT scanner. Money again. Awesome placement. Then he came back up and I went to check in on him. There's frank blood in the drain. Poop.
#(*&#$%(*&$
Recomposed.
Another CT scan. Not much blood in the brain. No evidence of acute bleeders. Looks like it's coming from the scalp. I placed a fatty pressure dressing over the incision site and within a few minutes the blood stopped flowing from the drain. I win.
I got a couple hours of sleep before I awoke to a "Critical patient xxxx, subarachnoid hemorrhage." There are few things to get you out of bed in the morning faster than pages like that: coyote ugly, a full bladder, being late for morning rounds, and 'patient is herniating' are amongst the others. I can only imagine what the husband was thinking when I rushed into the room, hair all flat and disheveled from a restless night of inconstant pages, morning breath still lingering, and the look of a person who'd been in the hospital 60 of the past 72 hours. I had glimpsed at the scan on my way into the room and knew the patient needed a ventriculostomy immediately (a catheter placed into the fluid cavities of the brain to drain CSF and blood and monitor intracranial pressures). It's always interesting being the one to raise the level of urgency in a hospital situation. The nurses caught on to the immediacy in my voice as I asked for platelets, ddAVP, a ventriculostomy tray and catheter, and antibiotics STAT. Super STAT guys. Within a few minutes an empty room with a patient and husband became bustling with nurses hanging meds, eager medical students lingering in the background, and me giving this poor woman a terrible hair cut (we shave half the head to place the ventriculostomy).
It was 4:50 when I got down to the ED, 5AM by the time I was shaving hair. But rounds would start in 30 minutes. Luckily my co-resident had come in early that morning. I sent him off to print notes while I got the rest of the meds running and ventriculostomy set up. By the time things were ready for incision he was back. I told him I needed to set up for rounds, gave a quick one-liner "77 year old female, Fisher IV, Hunt Hess III, subarachnoid hemorrhage likely secondary to A-comm aneurysm rupture, pupils reactive, localizing right upper, withdrawing bilateral lowers, needs EVD." He responds "Done. Go take care of rounds."
They told us in the beginning that we three R2s are one person. We each need to know what the other knows regarding the service, and we pick up wherever one person leaves off. That way we can be in 3 places at once, and never lose the seamless control over our service of 30-50 patients.
I made it in time to load images, organize notes, and present for rounds. The lady in the ED got her life stabilizing ventriculostomy, which was in by the time we saw her after film rounds, and she went straight to angio for embolization of her aneurysm (which was successful). Another life saved. No huge screw ups or set backs. Not a bad night.
Wednesday, September 08, 2010
Mommy's Little Girl
Three mothers, three daughters. Each pair with their own neurosurgical misery.
One born with very little brain. No treatment mom says... unsure if there's anything left to save.
One born with blood in normal brain, and mom embraces the easy fix we can offer her to save her baby's life.
One born with normal brain, but hidden within, a tumor whose treatment wherewith causes her neurologic decline to mental retardation. Her mother fights and fights and ask for the improbable, hoping for the impossible.
Some decisions are easier than others it would seem. Some make more fiscal and pragmatic sense than others. But the ones such as the last that require operation after operation to save what little function is left leave me conflicted. One of our neurosurgical attendings mentioned that he once knew a neurosurgeon from the old Soviet block who stated that issues such as these shouldn't be an issue, for it would be cheaper to make another baby than to try and save what little was left of the one you were treating. I'm no communist, but there's a lot of truth to what he said. We performed a 23 hour operation on the 3rd child, involving 3 different surgical teams, tens of thousands of dollars of surgical equipment, hundreds of thousands of dollars of OR time, and thousands of dollars of postoperative care. And ultimately the treatment failed. Had it worked, it would only prevent further neurologic decline, but not restore function that had been lost. She would not be able to speak, she would not be able to care for herself. She would never go become a productive member of society and would likely have to be cared for for the rest of her life. Economically speaking she would be one of the hundreds of thousands of dependents within the US today, who require more in medical costs per year than the average wage earning American would usually make.
I don't believe that we as human beings have no right to judge the value of another life. And in a sense we are socially obligated as physicians to do what we can to improve the human condition and relieve suffering. But say we took those hundreds of thousands of dollars spent on one flickering flame and used it to feed, shelter, and educate hundreds of smoldering coals of a rural village in Tanzania. That money could have been used to provide retroviral medications for an entire town inflicted with HIV. It's enough to feed a rural community in a third world country ridden with belly bloated, fly invested children for an entire year. But instead for intellectual curiosity and an inability to refuse treatment with the slightest chance of improvement, the best and brightest flushed hundreds of thousands into the medical debt of America to give one soul a chance. So that she may continue lifting up her arms, as her fingers no longer move, a hundred children went without food and water last night. So that she may still get up to a chair, 50 men will succumb to HIV/AIDs for want of medication today. So that she can smile for a few more years, 20 women will die during childbirth for lack of sanitary delivery facilities tomorrow. How can we judge the worth of her smile? We argue that even if we didn't treat her, our monies would not reach those in need. But maybe that's the problem. The avenues do not exist, and if they do exist aren't readily available for us to use. Millions around the world are without food, water, shelter, medication, education, and possibly summed up - without hope, while we operate on the rare and esoteric. It doesn't take a neurosurgeon to realize there needs to be change. But I feel it'll take more than a doctor to figure out how.
One born with very little brain. No treatment mom says... unsure if there's anything left to save.
One born with blood in normal brain, and mom embraces the easy fix we can offer her to save her baby's life.
One born with normal brain, but hidden within, a tumor whose treatment wherewith causes her neurologic decline to mental retardation. Her mother fights and fights and ask for the improbable, hoping for the impossible.
Some decisions are easier than others it would seem. Some make more fiscal and pragmatic sense than others. But the ones such as the last that require operation after operation to save what little function is left leave me conflicted. One of our neurosurgical attendings mentioned that he once knew a neurosurgeon from the old Soviet block who stated that issues such as these shouldn't be an issue, for it would be cheaper to make another baby than to try and save what little was left of the one you were treating. I'm no communist, but there's a lot of truth to what he said. We performed a 23 hour operation on the 3rd child, involving 3 different surgical teams, tens of thousands of dollars of surgical equipment, hundreds of thousands of dollars of OR time, and thousands of dollars of postoperative care. And ultimately the treatment failed. Had it worked, it would only prevent further neurologic decline, but not restore function that had been lost. She would not be able to speak, she would not be able to care for herself. She would never go become a productive member of society and would likely have to be cared for for the rest of her life. Economically speaking she would be one of the hundreds of thousands of dependents within the US today, who require more in medical costs per year than the average wage earning American would usually make.
I don't believe that we as human beings have no right to judge the value of another life. And in a sense we are socially obligated as physicians to do what we can to improve the human condition and relieve suffering. But say we took those hundreds of thousands of dollars spent on one flickering flame and used it to feed, shelter, and educate hundreds of smoldering coals of a rural village in Tanzania. That money could have been used to provide retroviral medications for an entire town inflicted with HIV. It's enough to feed a rural community in a third world country ridden with belly bloated, fly invested children for an entire year. But instead for intellectual curiosity and an inability to refuse treatment with the slightest chance of improvement, the best and brightest flushed hundreds of thousands into the medical debt of America to give one soul a chance. So that she may continue lifting up her arms, as her fingers no longer move, a hundred children went without food and water last night. So that she may still get up to a chair, 50 men will succumb to HIV/AIDs for want of medication today. So that she can smile for a few more years, 20 women will die during childbirth for lack of sanitary delivery facilities tomorrow. How can we judge the worth of her smile? We argue that even if we didn't treat her, our monies would not reach those in need. But maybe that's the problem. The avenues do not exist, and if they do exist aren't readily available for us to use. Millions around the world are without food, water, shelter, medication, education, and possibly summed up - without hope, while we operate on the rare and esoteric. It doesn't take a neurosurgeon to realize there needs to be change. But I feel it'll take more than a doctor to figure out how.
Monday, September 06, 2010
As the wheel of time turns
Facebook is a the modern day equivalent of Christmas cards and high school reunions balled into an instantaneous and all encompassing flood of reminders of all the things your friends are doing, accomplishing, and living... all the things that you as a neurosurgery resident aren't doing. I was browsing the updates section the other day, and saw that two of my friends got married to their respective significant others, another two got engaged, two others were having babies, another was roaming Thailand, and another just had the best sandwiches ever on a weekend getaway to the bay area.
Dude.
I'm not looking to engaged or married, or have any kids anytime soon. But man, I'd love to have a really good sandwich every now and then, and one not from the hospital cafeteria. I spend my 3 days off every month catching up on laundry and maintenance chores, craigslist shopping for a new couch, and reading for work. After all that, finding the energy to get that sandwich is pretty hard to come by. Dating someone would potentially help the situation, as someone on a normal work/sleep schedule is usually more motivated to push the obtunded significant other outside the door to get fresh air (and a sandwich). But there are obvious problems with dating someone as a neurosurgeon, especially a neurosurgery resident.
Why women shouldn't date neurosurgeons:
1. Our divorce rate is 200%. Yes, 200%. I think our department average is 150%, but rumor has it that neurosurgeons get divorced at least twice during their lives. Sure there's the initial glamor in the idea of dating/marrying "a neurosurgeon," but the long hours, missed baseball games, and never returned phone calls get old after a while. That and sharing a bed with someone whose pager goes off at least a couple times during the night when not on call, and anywhere from 0-25 times while on call... think about it.
2. Some start running their lives like they run the operating room. There are neurosurgeons that get so accustomed to being the commander and chief that they begin expecting others in the everyday world to attend to their every needs. While in the OR we have instruments handed to us by just asking, and we don't even look as it's being handed in order to not lose our orientation / focus in the operating field. Imagine how long it would fly if we just held out our hand and said "Salt. Pepper. Napkin." during breakfast without even looking up to acknowledge the giver. A drastic exaggeration of course, but I'm sure the subtleties bleed through somehow.
The list goes on, and just writing about it makes me sick with myself, or my future self rather, and thus I'll stop prematurely. But somewhere down that list is the fact that after work or call, they just won't have the energy to go out and find that awesome sandwich.
Dude.
I'm not looking to engaged or married, or have any kids anytime soon. But man, I'd love to have a really good sandwich every now and then, and one not from the hospital cafeteria. I spend my 3 days off every month catching up on laundry and maintenance chores, craigslist shopping for a new couch, and reading for work. After all that, finding the energy to get that sandwich is pretty hard to come by. Dating someone would potentially help the situation, as someone on a normal work/sleep schedule is usually more motivated to push the obtunded significant other outside the door to get fresh air (and a sandwich). But there are obvious problems with dating someone as a neurosurgeon, especially a neurosurgery resident.
Why women shouldn't date neurosurgeons:
1. Our divorce rate is 200%. Yes, 200%. I think our department average is 150%, but rumor has it that neurosurgeons get divorced at least twice during their lives. Sure there's the initial glamor in the idea of dating/marrying "a neurosurgeon," but the long hours, missed baseball games, and never returned phone calls get old after a while. That and sharing a bed with someone whose pager goes off at least a couple times during the night when not on call, and anywhere from 0-25 times while on call... think about it.
2. Some start running their lives like they run the operating room. There are neurosurgeons that get so accustomed to being the commander and chief that they begin expecting others in the everyday world to attend to their every needs. While in the OR we have instruments handed to us by just asking, and we don't even look as it's being handed in order to not lose our orientation / focus in the operating field. Imagine how long it would fly if we just held out our hand and said "Salt. Pepper. Napkin." during breakfast without even looking up to acknowledge the giver. A drastic exaggeration of course, but I'm sure the subtleties bleed through somehow.
The list goes on, and just writing about it makes me sick with myself, or my future self rather, and thus I'll stop prematurely. But somewhere down that list is the fact that after work or call, they just won't have the energy to go out and find that awesome sandwich.
Friday, September 03, 2010
A brief lapse in blogging consciousness...
I haven't really been updating my blog recently if you haven't noticed. Part of the reason is that much of the calls and post call days have started to blur together without anything novel or interesting to add. I'm getting used to the job to a point where I'm not scared or clueless or scared clueless when I assess a patient in the ED anymore. I'm starting to be able to give advice to other services during consultations with more confidence without needing to ask my senior resident about every single detail (although I still confirm my recommendations with them before finalizing my note). Two months have passed, ten more to go...
Today I had a pretty good day in the OR. Only weeks before I was fumbling with my knot tying while working with dura, afraid that if I tied too tightly I would tear it, too loosely there'd be a CSF leak when I closed this layer of brain covering. For some reason today the experience and practice caught up to me and I was able to work pretty proficiently without any problems. They say you can teach a monkey how to operate... I'm glad to see I'm catching up to the monkey.
Despite knowing how to work up and treat the majority of patients that come our way, there'll always be things that the neurosurgery team will disagree with the ICU team on regarding patient care. This will inevitably lead to arguments, and finger pointing at the R2s who obviously should know better. When you're working 100+ hours a week, with your vacations spent with the expectation that you'll be reading and publishing academic papers, the beatings seem a little much. But they say that if you're looking for a pat on the back for a job well done, you shouldn't be in neurosurgery. You're digging around in someone's brain for crying out loud. There's no room for error, laziness, or complacency. So the beatings will continue until morale improves. And we understand why. Kinda.
Today I had a pretty good day in the OR. Only weeks before I was fumbling with my knot tying while working with dura, afraid that if I tied too tightly I would tear it, too loosely there'd be a CSF leak when I closed this layer of brain covering. For some reason today the experience and practice caught up to me and I was able to work pretty proficiently without any problems. They say you can teach a monkey how to operate... I'm glad to see I'm catching up to the monkey.
Despite knowing how to work up and treat the majority of patients that come our way, there'll always be things that the neurosurgery team will disagree with the ICU team on regarding patient care. This will inevitably lead to arguments, and finger pointing at the R2s who obviously should know better. When you're working 100+ hours a week, with your vacations spent with the expectation that you'll be reading and publishing academic papers, the beatings seem a little much. But they say that if you're looking for a pat on the back for a job well done, you shouldn't be in neurosurgery. You're digging around in someone's brain for crying out loud. There's no room for error, laziness, or complacency. So the beatings will continue until morale improves. And we understand why. Kinda.
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