Love Sonnet Number 27

She was 14 years old when she decided she would find love. But time in his age old stinginess did not afford her such happiness until she was 50. It was then she met him. He was quite the charmer: quiet in his knowing understanding, firm in his resolute compassion, and yet helplessly weak under her unraveling brown eyes. They spoke of movies, detailed places previously long forgotten in the recesses of their minds, and fabricated fantasies of all the countries they would need to experience before they passed from this ephemeral dream. He had loved before, and even married. But time had been cruel to him too, and had taken his previous her, early on. Something about too many abnormal cells, he said.

Time didn't think her enough.

She waited half a century to find love, but only half a year to find out she too would have to leave this man behind. They thought they had removed all of the cancer, but nausea and vomiting lead to an MRI ... an MRI lead to a neurosurgeon ... and the neurosurgeon lead to a diagnosis. Metastatic disease he said. They would have to operate. Brain surgery, she thought. She only had months to live, weeks if she didn't have the surgery. But she couldn't tell him. How could she? Be it despair or questions of personal damnation, how could she say he would have to bury her as well?

Love is strong, she thought. Love is kind, she sighed. Love does not despair, she wept.

Defeated...

Sometimes you feel like you need this pill (which I think really describes all the symptoms of R2 year). Today was one of those days.


I've been told multiple times throughout my time in neurosurgery that if you haven't seriously thought about quitting, I'm talking about having an alternate career plan lined up paper work in hand, that you're not actually in neurosurgery residency. Well, it's just one of those days...

First big screw up

If you're in the health profession long enough, there will be a time when you realize you could have killed someone, and sometimes there will be a time when you actually do. Luckily, yesterday wasn't a day of the latter, but being one of the former it really shook me up. The infuriating thing was that it wasn't due to operative inexperience, medical ignorance, or even straight up stupidity. It was due to the fact that no one ever really explains all the things you're responsible for doing as a junior resident on neurosurgery. A patient came in and had a head bleed, but the neuro ICU attending accepted the patient, the neurocritical care fellow knew about the patient, and I reviewed the patient's scan and clinical exam findings with him and thus felt the case was staffed. How was I to know that he never even bothered to look at the films, and if he did that he didn't realize that the patient had to go to the OR for emergent surgery. No one ever explained to me that every patient that comes to the ICU attending must also be staffed with a neurosurgery attending. You'd think the ICU attending would tell us what was up and what to do... but no.

The patient had fell earlier that morning and had a cerebellar bleed on CT from an outside hospital. She was awake and talking with no real neurologic deficits, so none of the warning bells went off in my head. The patient was staffed with an attending, seemingly neurologically intact despite her head bleed - nothing to worry about, the ICU team will take care of her in the morning. When my seniors came in the next morning and saw the scans they were a bit upset to say the least. She should have gone to the OR as soon as she hit the floor. I had failed to see that the bleed in cerebellum had began effacing the outflow track of the CSF in her brain, causing ventricles to swell. She was pretty old so I thought maybe she just had atrophy of the brain making her ventricles look big. If I had known we needed to staff all the patients with our team, not just the accepting physician, this would have been caught immediately. We ended up red-lining her (rushing her as an emergent surgery within the hour). She ended up doing just fine... but the obvious alternate scenario still plagues me. What if she had come in earlier and herniated while we waited for the team in the morning? It was only an hour difference, but in neurosurgery even minutes can be the difference between a full recovery and permanent neurologic deficit or death. I got lucky.

They say that good clinical judgment comes with experience, and that experience comes from bad clinical judgment. Lesson learned, no one died... I really got lucky.

Only Cry in the Elevator

Some family members of the patients on the neurosurgical ward are truly amazing. One patient's wife in particular really touched me while I was on call last night. When you speak to Mrs. Z, she always seems so cheerful, almost to a point of idiocy and unawareness. But she's always so grateful, so attentive, and so seemingly aware of the treatment plan and the status of her husband that you're inclined to think she's not a complete idiot. However, last night as I was about to make my midnight rounds in the ICU I thought I saw her leaving the unit to go home for the night. I wasn't sure if we had consented her for her husband's procedure on Friday (he's delerious and thus can't sign for himself), so I approached her to find out. She was waiting for the elevator. "Mrs. Z?" I asked, wondering if I had the right person. She turned around and upon recognizing me quickly wiped the tears from her eyes, abruptly cutting off the flood of sadness she held back the whole day while smiling, laughing, and encouraging by her husband's side. "It's been a long day," she said, smiling again behind her flushed and still tear-damp face. "It's been a long month for you," I thought to myself.

The family members of the comatose patient's almost have it easier. They don't have to pretend to be strong, hopeful, or happy to boost the morale or spirits of their loved ones. But the patient's that still seem to understand what's going on, are aware enough to know that they are sick, if they're lucky, or dying, if they're like many patients on our service... those family members wear the smokescreen of love in the forms of smiles and undying optimism so their loved ones won't succumb to despair in addition to their devastating illness.

Beautiful Brain

The brain is a beautiful organ. If you haven't had a chance to see a freshly opened skull (in a controlled operative setting, craniotomy by hatchet doesn't count), you really need to before you die. To see the brain pulsating with each heart beat, glistening in CSF with the blood vessels coursing its surface is truly one of the most beautiful things I've seen while alive.

Today I assisted in a temporal lobectomy. The indication for this surgery is usually medically intractable seizures. Oftentimes the temporal lobe, whether it be due to structural abnormalities or aberrant neuronal synapses, is the source of seizures that are poorly responsive to medications. So... when something is causing problems, surgeons take it out. In order to perform the lobectomy, however, you have to make a fairly decent sized bone window to approach the lobe and take it out. Consequently, you get to see a lot of brain. After making an approximately 30cm upside down question mark shaped incision, drilling down the bone and cutting out a roughly 10cm diameter flap of bone, we cut open the dura and voila, there she was, glistening in all her glory. Cheezy yes, but you really gotta see it to believe how beautiful it is. I'm an adrenaline junky and aesthetic... it's moments like these that make the 110 hour work weeks and 30 hour work shifts worth it... barely... but yea, worth it.

Quiet Night

I'm happy to report I enjoyed my first quiet night on call. Only one code trauma where neurosurgery was involved, and it turned out to be some drunk that had way too much booze. Only one consult that ended up being non-operative. No one acutely crumping in the ED or the unit (ICU). I thought my pager was broken. I actually got 2ish hours of sleep. Man, if I can get one of these nights every other call or something this year might not be too bad.

Now that I'm operating every other day or so, residency has taken on a whole new level of complexity. Attendings are starting to expect me to position, prep, and drape the patient before they get into the room now. Figuring out how to position the head in relation to the anesthesia peeps, the endotracheal (breathing) tube, whether or not they need a frame to hold their head or if we're just operating with it placed on a foam doughnut... all these considerations aren't things I've actively thought about before, nor took note of how disparate it is between one surgeon from another. I need to start writing these things down...

Today I evacuated an epidural hematoma on a 6 year old kid. Epidural hematomas are blood collections that form between the dura (protective covering of the brain - it's skin essentially) and the skull. I drilled down with a tiny acorn (named for its shape) drill until the blood started gushing out. By this time due to the decomposition of the hemaglobin into hemosiderin, it had taken on a green vomit-like color. As the old blood pulsed out with the kids heartbeat, it appeared something akin to the skull vomiting in tiny spurts through an equally tiny mouth. We enlarged the bony opening by drilling a piece off and washed out the blood until the irrigation was clear. I put the bone flap back on with a titanium plate and screws, stitched up the scalp and called it a day. Nice and simple. Not a bad way to end a not-too bad call.

House of falling cards

Every morning by 5:30AM (sometimes 5:15 when we have early morning meetings) the R2 that was on call the previous night has to show all the CTs/MRIs that were performed the previous day. By 5:30AM the R2 needs to have an updated copy of the patient list and the rounding notes for the day printed out, collated and stapled in the order we see patients throughout the hospital. By 5:30AM, all the post op checks, CSF collections, dressing removals, ED consults, transcranial doppler results, and acute patient management need to have been done. With a list of probably 50 things to do at any given time throughout the night, with more coming in in the way of pages and calls to the phone, it feels something akin to frantically trying to stack a pile of falling cards into an organized house before we present the overnight events to the team in the morning. Only after signing out the virtual pager to the next R2 on call does one feel that he's making ground in eliminating the number of tasks he needs to perform.

I still feel like I'm flailing. There's still too much to learn. They say it'll come with time, but our attendings expect perfection now. The unreasonable expectations motivate me in a sick way. It's an impossible task, an insurmountable puzzle... I love a good challenge.

To my readers: I apologize for my writing style. According to an online analysis (http://iwl.me/), my style has deteriorated from that of Margaret Atwood and Edgar Alan Poe to that of Stephen King and Dan Brown over the years. Ugh. I'll try to do better.

When our hands are bound, we reach for God

Being in a profession where life and death are the biggest questions regarding patient prognosis in the minds of family members has its self-reflective moments of existentialism and spirituality. My Sunday School teaching impressed upon me that be it arrogance or the natural course of knowing, the more man believed he knew, the further from God he would stray. The natural curiosity of man fills the unknown with an omniscient, omnipresent, omnipotent being to satisfy the equation of the incomprehensible and organize the chaos of the universe in a black box known as deity. It doesn't change in the hospital, and seems more pronounced when the inexplicable tragedies of life meet good people. You ask around the emergency department, they'll tell you it's always the good ones that suffer, while the gang bangers and alcoholics escape bullets and 5 car pile ups with nothing more than flesh wounds and a government paid hospital bill.

Godot or no, sometimes it just doesn't make sense. I'm still scratching my head over a tiny baby girl that acutely decompensated in the emergency department. She was doing marginally, more fussy, sleepy, but moving around and crying appropriately. Next thing you know, she's seizing, being rushed to the OR to revise her VP shunt (ventriculoperitoneal shunt). Now she's comatose, not waking up, slowly deteriorating and no one knows why. Nothing kills me worse than seeing a grown man cry. But seeing a new father repeatedly kissing his daughter, asking her to wake up, telling his wife that he can taste the tears on her face... no one ever told us when we entered this life that some lots would involve becoming vessels of infinite tragedy.

The mysterious ways of God? Or maybe just the nonpartisan chaos of reality. Somewhere, far from here, a wealthy man just boarded his yacht off the Amalfi Coast in Italy to spend the day with his beautiful wife and children. Here at UCLA, we're discussing the withdrawal of care of a 3 month old that experienced little but surgeries and hospitalizations throughout her short tour on earth. There they are admiring religion as an aspect of history, canonized in the cathedrals of time. Here we are praying against all odds for a modern miracle, reaching for God now that death has bound our hands.

First Call

Technically no, officially yes. Another busy night: 9 consults, one red line.

Admittedly, it's fun being able to be the go to person regarding all matters neurosurgery within a large hospital in the middle of the night. Run down and see the trauma, run back up to the ICU and tell a family their family member's prognosis has drastically changed based on a recent study we'd obtained, and then rush a patient to the OR for emergent surgery since she seized in the ED. The expectations of the emergency department are somewhat unreasonable, as they 3 ED residents calling you about different neurosurgical patients, all pressuring you to see theirs so they can send them home or admit them. Hey guys, simma down.

The work feels meaningful and frankly a lot of fun. But seriously, the nurse that was paging me at home at 5PM when I was post-call to clarify a stool softener order... three times... yea, not cool man.

Lesson learned: Don't trust a CT to tell you about mass lesions, get an MRI.

Day 2

Second day operating. They say that every time you go to the OR you learn something new, no matter how small or trivial the case you're doing may be. Well at least in the beginning it's very true. I had never seen a burr hole made using a nice, who knew the pediatric skull of a 3 month old would be thin enough to carve through with a scalpel. Every OR case is like a puzzle, or a gauntlet of human coordination and ingenuity... even doing the small cases it's pretty awesome.

I'm on call tomorrow, and I'm already tired.

Day 1

So far so good. No one has died, I haven't committed any egregious errors in management, and my co-residents and I don't hate each other. It's pretty great being able to go to the OR without the dread of knowing that as you're there the floor work is piling up on you. I was "operative" today, so I was able to do my two cases and let the other guys take care of the floor and ICU. Pretty awesome.

A Journey of a Thousand Miles...

usually starts with a flat tire and a broken fan belt.

Well it's official. We just had our orientation for our R2 year of neurosurgery. Amongst all the other info we received today, we got our business cards, loupes (those fancy OR glasses with telescopes in the lenses), call schedule, team assignments, and a whole lot of "good luck, you're going to need it."

This year was the reason for which this blog was created. It's purportedly the hardest year of residency we could ever imagine. Listening to the instructions from our attendings in regards to the "back up" we'll have during our first few weeks on call made it sound like we were preparing for war or some great natural disaster. The way the more experienced nurses are heading off to vacation and how the attending surgeons have ceased operating silently reaffirms the huge white elephant in the room: new interns, new R2s - don't get sick, because all around the US during the month of July in academic institutions people die. It's a well known fact that everyone gets promoted during this time. The residents that only months earlier were marching to the beat of a seasoned chief resident now are asked to call their own cadence. The residents who only days before, separated by a week of debauchery and drunkeness, were mindless work horses known as interns, are now expected to make clinical decisions and perform surgery - albeit under close supervision. And the medical students who only weeks before were still strictly book learned and green, are now scrambling around the hospital with their heads cut off like chickens, but still trusted and referred to as "doctor." Yea, now's not the time to be ill.

That being said, if you do find yourself in the hospital at this time, be assured that everyone is hypervigilant. Everyone's work will be checked, rechecked, and checked once more over as no one exactly trusts anyone to do their job completely right. They say that Christmas is a bad time to be in the hospital as that's when residents get overconfident and too big for their britches, making decisions they can't support or correct when things go wrong. So that elective surgery you were thinking about? Yea, I'd shoot for sometime in October.

But I digress. Back to neurosurgery. 337 days, 48 weeks, 116 overnight calls, 200 operative cases, and one soul to preserve throughout the whole ordeal. It's exciting, but let's face it, it's scary. Although all medicine/surgery has its risks, neurosurgery is one of those fields where if you get lazy, sloppy, or lose focus for even a second, someone could die. Perhaps a little melodramatic, but unfortunately true. But hey, it keeps things interesting.

Tripped at the finish line

Two days left in intern year, post call, and I start getting fevers and chills in the cafeteria. No biggie, probably just a flu or whatever. I get home and then ensues the worst 24 hours of my life. Fevers, chills, rigors, nausea, vomiting, intolerance of oral intake more than 10cc. I seriously thought death was upon me, but if it wasn't I seriously wished it would come.

That being said it was a pretty disappointing way to end intern year. My senior residents tell me about how they get through residency without a single sick day, and I land one right at the finish line before my first year. I feel pretty weak, but honestly, I think projectile vomiting is where I draw the line.

Still, last day of intern year coming up. Hurrah hurrah!

always remember, and never forget

I used to be a fairly sentimental guy. I'd listen to the slow jams, be able to turn any spoken word into prose, and mentated little phrases and speeches on friendship, love, loyalty, etc... I was a humanist in some sense, an anthrope if you will. But the more I isolated myself in my books and labs, the more I lost touch with people, obviously. But I guess the thing that bothers me upon reflection is that it doesn't really bother me at all. Well at least until today. I forgot my best friend's birthday, second year running. Last year it was because I was in the middle of intern year orientation, and the days were a frenzy of new people and information. This year I'm actually an intern, and being on call running around the hospital isn't the most conducive setting to allow for reflection on the people in your life. Not that she's an all star best friend either (yes you know what I'm talking about), having forgotten my birthday as well last year. Though I'm convinced she just pretended to to make me feel better about forgetting hers... she would be that kind of friend if she were smart enough to remember things, but she's pretty dumb actually, so more likely than not she just forgot (:

With sleep deprivation comes memory consolidation problems. I don't remember much of anything anymore. If it's not on my patient list sheet with my boxes of tasks to do, labs to follow up on, radiology studies to get reads on, patients to discharge, notes to write, orders to order... if it's not there, I don't "remember". This piece of paper is my brain, it's the only thing with information worth keeping throughout the day. My life utterly reduced to check boxes of people I do not know, nor will ever meet again once they leave this place. And yet there's no check box for calling my best friend on her birthday. I wonder if being a great doctor means you suck as a person outside the hospital? People say it can be done... but I obviously have a ways to go.

Clearly, I'm not fit for human consumption.

sleep psychosis

You know there's something wrong with your life when you're excited to get 2 hours to sleep. Well that's where I am. Sunday night, 30 minutes. Monday night, 30 minutes. Tuesday night, 2 hours... hurray.

And yet, I'm blogging... to be continued, must get some z's.

Last Supper

The neurosurgery seniors took the incoming R2s to a really nice steak dinner today at Mastro's. Although the premise was that of indoctrination and forewarning of the responsibilities of the upcoming year, my fellow R2s and I saw it for what it really was - a last supper for those on death row. Listening to my seniors talk about their experiences as the neurosurgery R2 over the past years was simultaneously comforting and disconcerting. Hearing that there's layers of back up, that they'll be there to answer every simple question in the first few months, that we essentially weren't allowed to make any management decision on our own initially... those things were of great comfort. That we'll undoubtedly fall asleep in the OR (which I've already done multiple times), screw up, upset attendings, etc. Fine, whatever. "You will kill people"... almost in jest, but with enough preceding sincerity that you know they're being truthful... that was kind of sickening.

I've heard the stories (none of these from UCLA btw): elective spine cases where one wrong slip leads to quadriplegia in an otherwise healthy gentleman; plunging into the aorta in a lumbar fusion case causing the patient to bleed out on the table; taking too much tissue in a epilepsy case that results in hemiparesis - these are the catastrophes one never thinks will happen to him, but invariably WILL happen if you're in practice long enough. In poker they say you don't always remember all your great wins, but you definitely remember the terrible losses, the bad beats, the hands that leave your pockets empty and hearts cavernous as you get up to leave the table. It's only natural for surgeons, at least the good ones, to remember the tragedies, as they're hopefully few and far between.

After being an intern in the hospital for a year, sure, I've seen people die, often in front of my own eyes. Good people, healthy people, the ones you expected to walk out of the hospital the next day. But no one's died yet because I screwed up. And to be honest I don't think I'd be able to post such a complication if it did happen. I guess that's the problem with medical writing, especially when speaking from a resident's point of view. Next year I'll probably more likely than not violate work hours, be involved in cases where devastating complications occur, and maybe even get to a point where I'm given enough responsibility to cause some of my own. But these are probably the things not written in this blog. How do we report that to the general public and expect them to understand, rather than litigiously hunt our heads? But make no mistake, for the most part in our profession, the patients that come our way would die without our intervention. Brain tumors, intracerebral aneurysms, intracranial bleeds and abscesses... these are dead men walking, their fates already written without neurosurgical intervention. But maybe this line of thinking is to justify my own existence and absolve my mistakes... we'll see.

Not so lazy Sundays...

Days off during residency are bittersweet at best. It's nice being able to sleep through till morning, awaking to the sun rather than the leftovers of the passing night. On my days off it usually takes me an additional 3 hours to get out of bed. Not because I'm fatigued to the point where 8 hours of sleep isn't enough, but more because upon awaking I remember that the only thing that awaits me is more neurosurgery reading or paper writing. We're always instructed that our days off should be the time we catch up on our anatomy, write papers for journal publication, and continue our research projects. Exercise is a good idea, not for overall general health, but more so we can develop the stamina to get us through the long operative cases.

Yesterday I woke up at 10AM, all rested from the night before, ready to take on the new day. I got up, turned on my computer, saw the list of things to do for the day, turned off my computer, threw myself back into bed and went back to sleep. I woke at 1PM. OK fine, that's enough. I was still in a post-post call daze/depression, as I personally take on a rather dampened affect when I'm fatigued, so the rest of the day wasn't too productive.

I awake today (9AM mind you, not at the time of this post) reinvigorated, ready to take on the cruel peer reviewer comments of this paper I'm revising. Seven different sets of comments, each asking different things and expecting different degrees of crazy. What happened to the good old Sundays when we could lounge and read the comics after a nice family meal? There's no rest for the weary... careers in radiology are looking pretty good right now...

Egoism makes you bleed...

GAH, what a frustrating day.

At some time during your residency you start to get more comfortable with your everyday tasks and procedures. First it's the little things such as presenting vitals and physical exams on rounds (no, medical school really doesn't prepare you for everything). Then it's smaller procedures such as drawing CSF, starting arterial lines... then before you know it you're throwing in central venous catheters and ventricular catheters (that yes, go into the brain), like it was tying your shoes. Well, admittedly I don't believe I'm quite at the point where I can do an EVD (external ventricular drain - entails drilling a hole into a patient's skull at bedside and placing a catheter, more or less blindly using anatomic landmarks, into his brain, aiming for the ventricles, in order to drain cerebrospinal fluid [CSF] in the setting of increased intracranial pressure from bleeding, tumors, etc) like I tie my shoes, but I've gotten fairly adept at it. But this isn't about the advanced techniques, but rather the simpler ones we become overconfident in.

I was setting up to place an arterial line today, and as my last few had gone swimmingly, so I told the family I'd be done in 20 minutes. "Twenty minutes?" the nurse asked. "Yes," I responded, "no problem." It wasn't really due to arrogance, but maybe there was some underlying overconfidence there. Well in any case you can probably see where this is going. The line placement was a disaster. The patient kept flexing his wrists and arm like he was arm wrestling me despite the local anesthetic, boluses of propofol, and IV morphine and versed we gave him. I even achieved arterial flow, but his clonic movements made it impossible to thread the guide wire. At this point I should have stopped, but my claim that I could do it in 20 minutes (and the goading of the timer on the wall... cursed competitiveness) drove me on. His arm started looking like a pin cushion. Just as I was about to call it quits, my patient got his vengeance and curiously the needle turned in my hand and stabbed my other hand as I was trying to put it away. Did it break skin? No I don't think so... but then there it was, the faint tint of blood with the wrong color... the color of it being on the inside of the powdered latex. GAH.

I broke scrub (got out of sterile attire) and washed my hands. You win sir, this time. We sent the routine labs for HIV, Hep C, Hep B... I'm not too anxious as his family denied him having any history of these diseases, but I'm still somewhat apprehensive. It was a hollow needle, with a large bore: the kind of needle that has a greater chance of ruining your life.

Moral of the story: don't get cocky. Arrogance leads to bloodshed... and not infrequently your own.

Another manic holiday

You have to be a little manic to be a neurosurgeon. Occasionally, we must eat delusions of grandeur for dessert and use flight of ideas as our condiments to be able to deal with the sleep deprivation and high expectations. Cinco de Mayo this year was definitely one of those times. Crazy partying down in Hermosa Beach, driving home at 3:30 in the morning and waking up in an hour and change to get to work by 5:30. Then operating all day. Man. What a rush though. I was doing out patient procedures with just the attending and he let me do most of the cases as they were pretty simple. Changing batteries on deep brain stimulator generators, localizing nerve roots using fluoroscopy for radiofrequency ablations. Awesome times. The best part of working with an attending surgeon is that if you earn their trust during the earlier parts of the operation, they'll just leave the room and let you finish up once the "critical parts" of the operation are done. It's fun being "the surgeon" in the room, sewing things up, making sure the patient wakes up, and taking him to recovery. Suffice it to say I was in dire need of some operative cases. When you're cutting and slicing up the insides of someone's skull or body, sleep is definitely a distant thought... at least for now. I'm sure one day it'll become commonplace and I'll pass out on the operating table just like I do everywhere else (I swear I have narcolepsy).

Another head bleed

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

Fan-frickin-tastic.

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

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

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

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

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

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