I got out late today only because I was in the OR for a couple of hours this morning. Not that I got to do anything, but they let me scrub and were friendly enough. This is one rotation where I have absolutely no desire to touch anything. I’m too scared of the nerves.

I also got to do my first ever central line. It took several tries, but eventually went in successfully, and no punctured lungs. The patient was actually very dramatic, and occupied whatever part of the day wasn’t spent in the OR. He presented to the ER complaining of an unbearable headache for several days, fainting several times, constant dizziness, frequent nausea and vomiting, and visual changes. CT showed subarachnoid hemorrhage, and he was sent for an angiogram.

Then we got paged that he had “had an episode of asystole.” Calculated to give us tachycardia. When we got to radiology, he was awake and talking, but his vital signs were classic for Cushing’s triad: hypertension and bradycardia (the third feature being either altered mental status or elevated ICP, depending on which one you can measure). So the resident put a drain in his ventricle, right there in angio. It was a quite circus, trying to be ready for a code, and do a couple of complicated procedures, using supplies available in radiology, and frequently breaking down and sending urgent messages for help to the ER or ICU to get another piece of equipment. Neurosurgery involves so many specialized materials.

When it came to drilling a hole in his skull and running needles through his scalp, the patient’s stoicism, which had kept him out of the hospital for nearly a week, rather broke down, and he fiercely accused us of breaking our promise that the only thing going to happen in the lab would be a simple angiogram. By this time, however, he was losing his orientation, and we soon had to give up discussing the matter with him, and proceed to simple wrestling, in the knowledge that it would be better to save his life, and talk about consents and assault and battery and risks/benefits later on.

This patient was amazing to me because (after four years of medical school and two months of internship) this is one of the few times that I have seen a patient with a classic disease, lifethreatening, deteriorating in front of our eyes. Somehow the hospital starts to feel safe, as though things are under control there; but with this patient, even though we knew what was happening, that didn’t stop his mental status from disintegrating within hours.

In other news, I have my first patient with whom I feel there are serious ethical issues involved in the plan of care. Hopefully I can talk about it later. I hate what’s happening, but since the attending is angry, too, and can’t do anything, there doesn’t seem to be anything I can add.

The schedule remains pretty long, but I’m resigned to it now. Surgeons are supposed to be in the hospital at all hours and never leave a job unfinished; but neurosurgeons have us beat hands down as far as work ethic and hours go,¬†and we know it. The only goal now is not to shame my service; for this one month, I’ll keep up with the neurosurgeons. (Not to mention being the only woman in sight for the first time in a while – another reason not slack off.)

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