In the dust of humility

It's surprising how many people there are, that even when the lives of their loved ones are in the hands of their doctors will still put on airs of entitlement and superiority. Oftentimes these are the so called "VIPs" that pass through our clinical service. "Very important person," as some might say. Does this mean their lives are more important, their conditions more critical, or their outcomes more significant than any other patient on the list? No, of course not. But their pocketbooks may be heavier, and their clout more weighty, than the poor Latino family one room over who are putting everything they have, including shreds of their dignity, into a homemade contribution box by the bedside of their comatose son to help pay for his ICU stay (saddest thing I've seen this week).

The irony is that these VIPs oftentimes receive the most questionable care. A battery of unnecessary tests are ordered to exclude the rare and as we call them "zebras" on the differential diagnosis, to leave no stone unturned amidst a landslide of unlikely boulders. These are the patients that ask that the attendings do the procedures that would normally go to the residents such as placing central venous catheters or ventriculostomies, procedures that some of attendings may not have performed in months if not years. I've seen the chair of liver transplantation doing a neuro exam and commenting on a patient's neurologic status, a rehab neurologist directing surgical management and diagnostic imaging. Seriously guys. You don't see us going over and telling you how to transplant a heart, stay away from my brains and spinal cords.

I met the humblest of patients the other night on call. She was homeless, disheveled, and unkempt with her dust worn clothes and uncanny amount of facial hair. She had a piece of surgical metal that had been eroding through her scalp for months, but for which she paid no mind as vanity was long discarded on her road. But her friends had freaked out enough to persuade her to come to the ER, so she did. She was cooperative, unassuming, and grateful despite the wait and knowing nothing would be realistically done over the weekend. She was the kind of patient you wished your so called VIPs would be like. But then I discovered she had lice and the wistful appeal of the homeless dissipated. We still took good care of her.

Moment of Weakness

Five months through, and it feels like I've been doing this job for a lifetime.

I've forgotten what it's like to live a normal life. But vague remembrances of a life forgotten in the sleepy yesteryear of time still linger, and it is for them my unconscious yearns.

Somewhere along hour 8 of 12 in the operating room today I sighed. I wished that I could wake up with sunlight outside, or if not that see daylight as I left work every once in a while. Today I left the hospital again in darkness. I wished that I could go home and actually cook the food I want to eat, instead of hurriedly grabbing a bite at the hospital before and after my shift. I wished that I actually had time to talk to my friends and family more than I did the OR front desk or the patients on our service. I wished that I could sleep so that I didn't spend every waking moment wondering when I could get back to bed. We come home to empty rooms and empty tables, dark corridors and cold floors. Life gets better after this year they say. But for now it's dark, and I've long forgotten the light of the sun.

You can't hide your kid from cancer

It's amusing to witness the various types of parenting styles that exist in the world. One of my previous calls I admitted two patients that particularly stood out in my mind. One was a college freshman who likely had meningitis. His symptoms weren't that bad, but the mom was so concerned that she actually wanted to follow him into the scanner to make sure he was ok. What if he has a contrast allergy, she asked. What are you going to do if he does? I responded. But I suppose it's better than the likely more common alternative of parents that just don't care.

Another patient that was admitted that night was a little over 30, but had lived with her father her entire life. He did everything for her, and treated her like his little baby girl even then. The innocent smile on her face and the way she timidly laughed at herself when her history and physical exam revealed how forgetful she was on account of her underlying pathology reinforced how beautifully unscathed her spirit was from the ugliness of the world. In addition to this man who did everything for her, she had her boyfriend, soon to be fiance who everything else. Don't tell her the gravity of the situation, he pleaded, she's never had to deal with anything hard before in her life, she won't be able to handle the truth. I often hear those words in the hospital, more often on the pediatric service, but sometimes with the elderly or dependent as well. They won't be able to handle the truth, they way. Maybe, or maybe it's you who can't handle how they'll respond to the truth. Is it really protecting the patient or is it protecting the family from the tears and heartache that will ensue. But I digress.

The patient ultimately was informed of her diagnosis. Brain cancer. No, we don't know what kind. No, it doesn't look like your typical malignant type, but we can't be sure until we have a tissue diagnosis. Yes, she'll need surgery. Yes she may have neurologic deficits including paralysis and loss of language, but we make sure that doesn't happen by careful preoperative planning. I consented her and her family, and told them it would be fine, that she would be fine. The day of her surgery was my day off, so I wasn't there during the operation. A little part of me died when I went to examine her the next morning and saw the frustration and fury from her eyes. The operation went well, but postoperatively she could not speak. Given the nature of the surgery and post op scans it was likely only transient in nature, which we explained to her, her comprehension still intact. She didn't believe me, or if she did, the overwhelming helplessness at being unable to speak when only 24 hours previously her only symptoms were headaches and vomiting, drowned out any reason we tried to feed her. She glared at me, and I'm sure she was yelling inside - you told me it was going to be ok, how the hell is THIS ok?

We were confident she would regain more of her communicative ability, but obviously it looked worse to the family than it really was. I'm not sure what exactly ensued, or what the boyfriend was thinking, but the night after the operation he decided that he would propose. She gave a thumbs up. Now, the cynics may argue that he did this to get the easy 'yes', after all, all she could really communicate was a thumbs up, and inappropriately for both yes and no at that. Other more chauvinistic types may argue that he just landed the gold mine, the woman he wanted to marry, but now unable to yell at him to do the dishes or take his feet off the table. But I'd like to think that this was again one of those small slivers of goodness that still remains in this downtrodden world. No thinking, no calculation, only knowing that she may be dying, that he wanted to spend the rest of his life with her, and that he wanted the rest of his life to start as soon as possible.

She's doing better, speaking more, and will likely leave the hospital on her own two feet, with many more years added to her life, and an upcoming wedding to plan.

Level Up! (continued)

There are days during residency whether by fault of your own or indiscriminate criticism by an attending you'll feel like an incompetent failure. Sure, when you leave the hospital you're "the neurosurgeon," but how often does that actually happen? For the most part, day in day out we're with other neurosurgeons, and at this stage in the game are the moss that grows on the log that the frog sits on. This particular day I was pulled into a senior level case because we were once again short residents to staff the complex cases for the day. Maybe he was just frustrated to have a junior resident, but for whatever reason I just couldn't make him happy that day. I left the 8 hour case feeling like I didn't know anything, that my operating technique was primate-like, and that I should really work harder to learn everything there was to know about neurosurgery this year to avoid such moments of smallness again. Unreasonable goals set to appease the bruised self-esteem, squelching the fear that such a feeling will recur because you have a plan, which seems feasible in your sleep deprived emotionally battered state.

I stuck around for the red line that was about to go because it was my operative day after all. This attending guided me through the beginning half of the case and let me make the skin incision, cut down the muscle, drill off the bone flap, cut the dura, and buzz the brain and make the first cortical incision. I never actually had a chance to do the last couple of steps, so this experience was huge for me. Suddenly I was more than just a burdensome junior resident, but the primary surgeon on a complex vascular surgery. Shortly after my chief resident cut in and took over, but even getting there was more than I could have asked for.

The challenge of being a resident learning how to operate is that the only real time we have to practice or refine our skills are in the OR itself. But the attendings don't know what we've done to date, or how much experience we've had with one tool or the other. Each time I'm in the OR it seems I get a little more experience with a new tool, a new skill set. So we learn, but consequently always seem like we're just beginning. That day I frequented 3 new surgical instruments, a new tool set to add to my armament of operative techniques. I left the hospital a little after midnight with only hours before I had to come in to take my overnight call, but it didn't matter, I felt awesome.

Level Up!

Just spent about 18 hours in the OR today operating.

I got lucky again and got to do some really senior level cases. Got to slice and dice normal brain and everything.

I need to wake up in 4 hours to start call.

Must sleep.

Starting up again

Sorry for the blogging hiatus. I was on vacation last week, and spent the time away from the computer and hospital.

There's an interesting phenomenon that occurs when R2s take that week of vacation. Being plucked from the gears of the neurosurgery team for servicing and repairs, we go from the finely tuned, well oiled machine of 3 residents to a piece meal collection of pinch hitters as our seniors cover for us and take call. Suffice it to say there aren't any great disasters, but one does miss the familiar team work that has become as second nature as the beating of our hearts or breaths we unconsciously take.

The most jarring sensation of disconnect is felt, however, when it's time to return from vacation. Rested, revitalized, and ready to take on another stretch of never ending 30hour shifts, you feel like the refurbished part being thrown back into the gears of the service. You're slow at first, the freshly applied oil still cold compared to the racing fever of the neurosurgery machine. You miss scans, have to think about the landmarks on a ventriculostomy, and forget that you can't just sleep when you're tired. But just as only a few days prior you realized all you knew was neurosurgery, that the happenings of daily living were somewhat overwhelming in their lack of structure and intensity, you find you're back at home.

Call yesterday felt like another house of falling cards. I started the day with a red-line, a hemicraniectomy for a stroke patient (procedure where you take off half the patient's skull to give their dying/dead brain room to swell following cell death). I love to operate, but operating when you're on call is painful. Every minute you're in the OR you know the work is piling up around you. The consults still come, attendings still call. It was only a 3 hour case, but by the time I was done I was three hours, 2 consults, and 25 tasks behind. But still, it felt different. Despite the 5 admissions, acute intracranial hemorrhage causing herniation (no bueno), and two bedside procedures, there was never really any moment of panic or helplessness. Tired, yes; overwhelmed, no.

It was when I was placing bilateral subdural hematoma drains at bedside that it really felt like I was making progress. If you recall, my first bedside subdural hematoma drain was a disaster. An hour of futzing around with not much success, and having to call in my senior to help me out with an audience of nursing students watching me flail. Boo. This time, I placed both drains, one on either side of the head, within 30 minutes. The CT showed awesome placement. It almost made up for the 4 CT scans I forgot to show on radiology rounds... gah.

Feeling more like a surgeon

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.

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.

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.

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.

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.

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?

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.

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.

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

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...

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...

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.

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.

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.