neurosurgery


Yes, I know Lost is almost concluded; and here I am starting the first season. My only excuse is that I was waiting to make sure it would have a conclusion, before I got involved.

My favorite part of the show is Jack, one of the main characters, who is a surgeon. The writers seem a little confused about what kind of surgeon he is; in the first episode, he refers to having learned not to fear when dealing with a potentially catastrophic bleed during an operation on the cervical spine of a young woman. Characters who don’t like him refer to him as “the spine surgeon.” However, halfway through the season, his most serious conflict with his father, previously the chief of surgery at the same hospital Jack worked at, is revealed to be related to an incident in which his father operated while drunk on a young woman with abdominal trauma from a car accident, and Jack was forced to scrub in to help, but ultimately was unable to save the patient, due to an error his father had made. So I’m not completely sure what a spinal surgeon is doing as the pinch hitter in a trauma laparotomy; but he’s certainly very talented. Maybe he’s double boarded in general and neurosurgery. Or maybe he specializes in young female patients. . .

Apart from that, and the typical cluelessness about medical protocol (horribly incorrect CPR on multiple occasions; the OR is pitch dark; etc), this is only the second realistic TV portrayal of a doctor I’ve ever seen (the first was the murdered fiance, a cardiothoracic surgery resident,  in the first season of Damages, and he was killed off, which I didn’t appreciate). And boy is it realistic. I can completely picture a doctor, and especially a surgeon, behaving exactly the way Jack does, with a hero complex obliging him to attempt to rescue every one, no matter what kind of disaster has occurred, and with a penchant for leadership which really holds the community together, although it also antagonizes some people. Also, most of his medical activities are fairly possible; supposing a plane to actually contain all the useful implement and drugs which he finds, the wilderness medicine he practices doesn’t seem too outlandish.

But the truest part is Jack’s perpetual flashbacks to medical tragedies which haunt him, and drive him on a perpetual mission not to lose another person for whom he feels responsible. I can’t believe the writers had any idea of how true this is, since even the medical dramas, with medical advisers, don’t capture it; but without being lost an a magical island, all doctors are haunted in this way, and this is the most vivid portrayal I have ever seen.

All quiet on the transplant front again. Seems like as soon as I come near the service the operations disappear.

Which leaves time to study for the ABSITE, a good thing since the test is coming up in. . . 8 days. I got to the neurosurgery part of the review book, and had a flashback to my neurosurgery rotation.

It was far enough in to the month that I was holding the call pager by myself most days. I got called to see a lady in the ER. She’d had a headache for a few days, but that day it was much worse, and her son had finally forced her to come to the ER. Her history of severe, poorly controlled hypertension was a red flag, and the ER doctors got a CT scan. By the time it was done, and they had recognized the subarachnoid hemorrhage, her mental status was deteriorating to the point that, while still fairly alert, she could no longer answer questions coherently. I didn’t waste much time on exam, just verified that her pupils were still equal and reactive, and there were no other gross neurological deficits yet (neurosurgery physical exam is the most abrupt and pointed of any specialty), then called the resident. He concluded that her worsening symptoms were due to a still-active aneurysm, and arranged for her to be taken to radiology for an emergent cerebral angiogram and coiling of the aneurysm. I saw her off, then tried to tackle some of the other pages that had been accumulating (hypotensive post-op patient; tachypneic patient failing a vent wean; rising ICP; hyponatremia in a trauma patient).

About half an hour later I got a stat page from radiology: “Your patient just had a bradycardic arrest on the table, maybe you should come down here.” I asked the nurse to please page my resident as he was the only really useful person, and then ran down the stairs.

I arrived (with the resident soon on my heels) to find that the report was very slightly exaggerated. She hadn’t completely arrested, just become so bradycardic that there had been several 20-second pauses between heartbeats. That had improved with atropine, and she was now awake. So awake, in fact, that she was insisting on leaving AMA.

Which posed a problem, since her vital signs were a classic case of Cushing’s triad, found in impending brain stem herniation: bradycardia, hypertension, and slow respirations. Well, actually, she was breathing just fine, since she was loudly insisting that we let go of her, give her clothes back, and let her leave.

The resident announced that he needed to put in a ventriculostomy drain now – right there, in the middle of the angio suite. He started finding the supplies – some of which had to be brought down from the neuro ICU. I was left to deal with the matter of consent. The patient herself was very dramatically not consenting. By now, it was taking the efforts of two nurses to keep her lying down (which of course wasn’t doing any good for her blood pressure or her intracranial pressure, which was what we intended to relieve by placing a drain). Her son, whom we knew to be somewhere in the hospital, had disappeared: either he was trying to get a bite of lunch, or the move to the maze in the depths of the radiology department had lost him. So when the supplies were assembled, we decided to proceed with the drain as an emergent procedure – no consent required.

Despite all of us knowing quite well that the patient’s protests were further evidence of altered mental status and injury from the blood now surrounding her brain, it was no fun to perform an invasive procedure on patient who spent the entire time protesting that we were kidnapping and abusing her, and who had to be held down by several staff members. Once the drain was placed, we ended up intubating her right there as well, as her level of consciousness continued to decline.

So by the time her son caught up with us, in the neuro ICU, we had the job of explaining that his mother had gotten significantly worse, and was now on a ventilator.

It was all downhill from there. Everything that can go wrong with subarachnoids went wrong with her: her ICP stayed up despite all measures to lower it; she had surgery to remove the aneurysm, but with no improvement; she remained in persistent vasospasm, despite every single treatment in the book being tried; she developed diabetes insipidus (seen in brain injured-patients when the hypothalamus stops producing anti-diuretic hormone, needed for the kidney to concentrate urine). After two weeks in the ICU, she died. So the last her son saw of her, conscious, was in the ER; and the last time any of us had talked to her had been while we were wrestling with her in radiology.

That’s why I hate dealing with subarachnoid hemorrhages, and I could never imagine being a neurosurgeon. Within twenty minutes she went from a pleasant lady with a headache to being delirious, then intubated and critically ill; and nothing we did could help at all.

We’re revisiting the subject of restricted duty hours. As Aggravated DocSurg comments in his humor-laced sarcasm, any sane person would be happy to be working less; so I must not be sane, to be a resident arguing for longer hours. But I think the “old fogies” have a point; and we ought to listen to them before it’s too late to turn this around.

This essay by a neurosurgeon (beyond being an extraordinary demonstration of how to claim to be superhuman, without being arrogant) has applications for all surgeons. Dr. Vates argues that neurosurgeons are unique because they deal with the only non-replaceable, non-repairable part of the human body, which is true; and that they are a breed apart, and that’s true as well. But he also suggests that if you think a surgeon’s ability to perform complex or delicate operations is impaired by fatigue, the solution ought to be to get really good at the procedure, so as to have room to work with when you’re tired. He repeats the line, which ought to be a self-evident truism, but apparently doesn’t compute for the folks at ACGME, that there are no hour restrictions in private practice, and that if we’re concerned about fatigue impairing judgment, that too should be practiced first under supervision.

Apparently some idiots are seriously proposing limiting the work week even farther, to 56 or 48 hours. I object. 80hrs is barely enough now; frequent readers of my blog will have recognized that I regard this as a rule made to be broken. If they cut it down to 56, they will have to extend the length of the residencies; right now, most people are 30 by the time they finish residency, let alone non-traditional students. Lifestyle may not be an issue under that regime, but paying back debts in time to have some money saved for retirement will be.

So I highly approve of Dr. Vates’ solution: The ACS needs to take its toys and leave, ie opt out of the ACGME, and set up its own standards for residency accreditation. Of course, since ACGME recognition is a prerequisite for Medicare to pay for anything, and for board eligibility, this is the kind of thing that would have to be orchestrated with 100% participation, essentially a boycott of the ACGME by the surgical specialties. I’m looking to see where I can sign a petition to that effect. . .

Probably the person that I feel most sorry for, over the last month, is the neurosurgery intern. At my hospital, the neurosurgery intern belongs to general surgery for eleven months, and then in June, the mother ship comes for him and he gets swallowed up by the neurosurgery program (which, since it has twice as many attendings as residents, and all very busy, does indeed literally swallow up the residents). He’s doing q2 or q3 call now, and can be found in the hospital, running between the ICU and the ER, at basically any time of day or night, any day of the week. He will be doing this for at least the next year, as the junior-est of the neurosurgery residents gets worked to death by the attendings, and by the rest of the residents who regard it as their turn to stop taking q2 call. He looks about ten years older, already, than he did last July, and I think greyish-yellow comes close to describing the color of his face. Actually he’s amazingly cheerful about it, which I guess is the only practicable response.

I shouldn’t feel sorry for him, really, because he chose this, knowing what he was getting into. In fact, he claims this program is nice to its residents, compared to some others. I tell him I don’t even want to imagine the others, in that case.

For an intern, having graduated from medical school at the same time as me, he knows an amazing amount about neurosurgery. He must be truly in love with it. I, and even my senior residents, respect his opinion when we talk to him about trauma patients (which is good, because half the time he’s the only neurosurgery representative easily available). That, I’m still trying to figure out. He is so extraordinarily good that, as an intern, he can give a recommendation to the senior trauma residents, and have it followed with respect. That’s not just because he represents neurosurgery. He earns that respect, by living in the hospital, studying incessantly, having made several remarkable correct calls, and having saved more than a few lives already. I’ve caught the neurosurgery attendings actually listening attentively when he tells them about a patient, which is also a rarity, and a high mark of respect. (Usually they don’t even listen to their own residents till they’re four or five years in.)

(Oh look, there’s blood scattered all over my scrubs. I wonder where that came from. I guess that solves the question of whether to take a shower now or later.)

I keep underestimating how bad people can be. Here there was one resident who I thought was just bitter because of something that happened in the last couple months. Today he was in charge, without the chief there to protect the junior resident and me, and I found out, in much greater detail than I’d known before, how nasty he is. He messed with me and the resident for four hours before we managed to escape. All I can say is, thank God he hasn’t been in charge all month; and I don’t know how the junior residents are going to stay sane around him for the rest of the year.

You think this is an over-reaction. I thought maybe he was just accidentally pushing buttons, till he left the room for a minute, and the resident started cursing him out with every word in the book, and the nurses just nodded and said, “Yes, that’s exactly how we feel about him.” Later on, I was walking through a room, and heard some other random nurses cursing him. I’d  guess that if you have all the hospital employees who know you cursing you on a regular basis just because you’ve showed up for the weekend, there’s something seriously wrong. 

He’s horribly rude to the patients. He changes carefully arranged management plans just for the sake of showing that he’s in control. I’m actually a little scared that everyone who really knows the ICU patients has left for the day, and he’s alone with our handful of critically ill patients, who need their labs and mental status checked every two hours, and followed carefully. I’m hoping that 24 hours won’t be enough to seriously harm them before other team members get back tomorrow.

I was trying not to take him too personally. But then when we were rounding with the attending, he started telling the attending that I leave the hospital early every afternoon, and avoid doing any work. I didn’t mind too much (ok, I minded, but I didn’t say anything) when he just teased me like that privately; but for him to tell the attendings that destroys my reputation as a hard worker, which I do care about. So I said, as lightly as I could manage, and smiling, “I should sue you for slander.” He laughed, but immediately changed his tune, and admitted that I’d been carrying their pager and handling their calls.

It’s kind of scary to think of how much damage this guy has done in the past couple of years, and how he’s twisting the younger residents whenever there’s no one around to protect them. I am so glad to get out from under, and thankful that he has no equal in my own program. It’s too bad that he’s going to graduate and get a job; at least in the real world, people will be able to quit to get away from him.

I realized, not for the first time, the real difference between the medical drama shows and the actual hospital: In the dramas, the plot moves because everyone pours their feelings out publicly, and all conflicts are explored in depth, loudly and without reserve. In reality, we grow very stiff faces. It’s unprofessional to argue, whether for a nurse to make a dramatic objection to the doctor’s plan, or for the junior residents and interns to object to the seniors, or for any residents to disagree in more than a cursory way with the attendings. No matter what we think, we smile and nod on the outside. There’s been enough drama and plot development this last month to fuel several episodes of House or ER. But you’d never know that from listening during rounds, or during bedside discussions with the nurses. Most of it is never verbalized, and when it is, it happens in a back room between a few people who know each other.

Let’s just say that if this guy were in a TV show, he’s done so many bad things, and antagonized so many nice people, that you could predict his rapid demise or firing within a few episodes. Unfortunately, this isn’t a TV show, so he’ll be around a while longer.

This morning, after sitting through an amazing number of hours of lecture (which did make up for some sleep I missed last night), I was delighted to discover an epidural hematoma evacuation that had been added on. (For interns, as for med students, tracking OR cases is like a delicate exercise in military intelligence, involving keeping your antenna tuned to covert communications and cultivating sources inside the camp; the only good thing is that interns have a little better access to sources.) The chief again let me make the incision, do a lot of the drilling, some of the hemostasis after the clot had been removed, and screwing the bone back down. I cannot believe this guy. He let me do so much. Even when I was doing really ridiculous things, like holding the screwdriver wrong, or holding the forceps wrong (which I ought to know better by now), he somehow managed to correct me in an encouraging way. He would tell the scrub tech things like, “Dr. Alice will be placing the bone flap in a few minutes, when she’s done drying off these bleeders.” It sounds silly, but the plain idea of me being about to do anything as purposeful as that, and announcing it ahead of time, was fun.

Then I ended up somehow with the call pager again (with unheard of good fortune for an intern, my beepers didn’t go off while I was in the OR; this is contrary to all statistical laws, which dictate that as soon as you get near a chair, a cafeteria, a bed, a bathroom, or a scalpel, the beeper must go off). I can understand a little why the resident I’ve worked with the most seems so scatterbrained. Getting paged every two minutes, about things which are all important, and all require about 45 minutes to deal with, is rather nerve-wracking. I was trying to be organized, but my method of organization somehow ended up with me postponing till last yet another epidural hematoma in the ER, which of course I should have seen first. (The fact that the trauma team mistakenly called it in as a stable subdural may have contributed to that mistake. I suppose that would explain why the obnoxious resident acted as though general surgeons can’t tell the difference between epidurals and subdurals. Classically, and when big enough, these two are supposed to look rather different on CT. When small, it can occasionally be difficult to tell which is which.)

Yesterday one of the attendings amused himself by catching a fresh medical student and sending him off on incredibly complicated mission to coordinate a plan of care on a critically ill patient between three different surgery services. We residents watched the student set off with a look of determination, and smiled to ourselves. (We did then sort it out ourselves, explain to the attending, and fish out the student; but it was funny. And the student was setting himself up for it.) At least, it was funny yesterday. Today, another attending discovered me on the end of the call pager, made a few remarks about why he had to get stuck with the rookie in an emergency, and sent me off on a similarly hopeless mission with instructions to call back in two minutes. I think I must have looked rather like the med student. . . Serves me right for being amused. (It turned out fine.)

I stayed late for the second epidural hematoma, but a different senior was in charge, and he didn’t let me do a single thing. I had to stand there and admire his clever ways of doing things (which somehow, as far as I can see, never turn out quite as clever as he expects). I was upset with myself for expecting any better, because I know what this guy is like. Note to self: how to encourage and teach interns. I think the chief could let me do as much as he did because he knew for sure that he could handle the whole thing easily himself. It takes a lot of confidence to be able to let go and let an incompetent junior putz around for a while. I hope I get to be good enough that I can teach others that way.

This morning I placed my first (and probably last) ventriculostomy catheter. Actually I didn’t place it, the chief had to, because I confess that the internal 3-D anatomy of the skull rather escapes me, and I was unable to correctly guess the location of the lateral ventricle based on the nose and ear (draped). But I made all the holes, and sewed things in – and got my clothes completely covered in blood, also for the first time. The patient, rather to my surprise, improved dramatically.

M&M was a real firecracker session. One of my friends got rather unfairly involved in a multi-target disaster; in true stoic fashion, she actually objected to the sympathetic comments afterwards more than to the attack itself. I am not looking forward to the month next year when I’ll have to present at M&M.

Our new medical students are here. You can tell them because they’re the sharply dressed ones in the hallway trying to find scrubs so they can start looking for the OR. It feels extremely good to finally know more about where things are located than at least a few other people in the hospital. This set of students will be fun because the interns have got their feet under them and are ready to teach and be helpful, and these students are still early enough in the year that they’re seriously considering surgery. (Actually my inconquerable habit of blunt honesty leads me into warning them against surgery, but I try not to talk like that too much.)

The day ended with a bang when the ER started calling us consults every five minutes (literally) around 5pm. The one resident and I went down to see, and every time we turned around, someone else would walk up to inform us of yet another patient. The difficulty was compounded by the fact that on this evening, the ER was splitting at the seams. Usually there are a few people scattered in the hallways; but tonight, they were simply stacked along all the walls. The patients had to be giving us directions about which one of them had which complaint, and which person had left to go to CT  (it was difficult to tell when someone was gone, because the walls were so crowded, you couldn’t tell whether a space had been occupied, or was still open for someone else). The resident told me to “go see the spinal injury.” I asked him whether he meant the woman, or one of the two men. He said, “the woman.” I asked what her name was, and where he had been told she was. He waved down the hall: “Across from room 3.” There were three demented elderly ladies with cervical collars sitting along the hall across from room 3. I was very frustrated. Before I could ask which of the three we needed to see, someone else came up to announce that a helicopter was coming in with a major head injury. I am clearly not cut out to work in an ER. Actually, if the resident could have spoken coherently enough to hand a few of his consults to me, rather than turning in circles and never really delegating anything, I wouldn’t have been as frustrated. The fact that a psych patient was howling in the waiting room loud enough to be heard through the whole department, and someone else was vomiting profusely next to us did not really contribute to clear thought, or communication.

(Just in case you’re wondering, that last paragraph was not exaggerated.)

Next Page »

Follow

Get every new post delivered to your Inbox.