Neurosurgeon Thanksgiving

Giving Thanks is such a good thing. Anything that gets your focus off of yourself is a good thing, and I am hard pressed to think of anything to thank myself for. Being in the line of work that I am gives me much more to be thankful for than most, I think. During my month of Neurosurgery I have been able to meet many grateful and many devastated people.

Two weeks ago a woman in her mid 50's came in to us because we operate on the brain and she had a problem where the remedy matched our job description. It sure is nice to not need an advertising budget as all of your work comes to you. She had been complaining of worsening headaches and some mood changes. She went into the emergency department at her local hospital, fortunately for her because everyone who follows her example gets a CT of their head, and they immediately sent her to us.

I examined her and noticed she had a very flat affect. This is doctor speak for lack of emotion or expression. Her husband added that she had lost nearly all motivation for doing much of anything over the past bit, and was concerned her scan was related. The nurse and I looked at the scan and decided she needed surgery. She got an MRI because the surgeons need the MRI to better show the limits of the tumor that had entirely replaced her Right Frontal lobe... In essence she had a golf ball sized tumor in the front of her brain that was squeezing the living daylights out of it. Fortunately for her, there is not too much that goes on there that will let you know something is wrong. There is no motor or sensation control there, or even speech or anything, so you won't have much more than headaches and problems thinking and feeling (sort of like a functional lobotomy, really)emotion.

When we opened up her scalp and drilled out a wallet-sized chunk of skull so we could access the tumor we were impressed again with the size of the lesion. It was a dark grey mushy mass of tissue inside the ivory white brain tissue, and it took us quite some time to dissect it carefully away from the healthy normal brain tissue, especially since these tumors are so vascular (which means they bleed whenever you touch them). We did finally get her tumor out and filled up the hole with saline so her brain wouldn't collapse back into the hole. We carefully sewed back the layers covering the brain and then I got to screw the flap of skull back on and we closed her scalp.

To my amazement she was only a little nauseated when she woke up. Then when I saw her in the ICU the next morning, she actually smiled! Wow, she hadn't done that for some time. By the third day after her operation she was joking, planning out her holiday preparations and was trying to make up for lost time in the energy department. I am not sure if her husband will be thanking us or not since she lost her energy gradually so he could get used to it, but now she had it all back over the space of 3 days, which has to be quite the shock.

Makes me especially grateful for what I have and how blessed I am. Also makes me feel very safe and secure to know that I have a personal relationship with God, and that He is so steadfast and dependable. Living is so unpredictable in itself, with seemingly random tragedy and elation waiting for each of us around the corner. I sure do not depend on my body for satisfaction or function tomorrow. I can either be cynical and sour about not being able to know that I too won't end up under the lights with my brain exposed, or else I can just accept that uncertainty and take solace in the odds and put my confidence and trust and life in the hands of the Creator and see what it is He would like my body to be doing during the time it is here.

Another guy we took some brain tumor from won't be so blessed. He is pretty devastated and upset given the fact that his tumors, unlike the lady above, are not primary brain tumors but they are metastases from lung cancer that has not yet been located. He has a 10 or less percent 5-year survival and he is very much into his body. He did smoke for years and years until he had a heart attack. He then started working out with the same enthusiasm he used to smoke with, ate all natural stuff and paid close attention to his body. What he gets from that is metastatic brain cancer that will buy him radiation and chemotherapy and a very low chance of making it more than 2 or 3 years from now. Unfortunately he worshiped his body, so he is devastated about it.

I have been thinking about him some lately, and hope I get to see him again sometime as the time he spent in the hospital was very busy for us... I never got a chance to talk with him about God more than just passing one-line comments to ascertain his openness to the subject, which seemed to indicate he was as he has no family and only a few friends around here. I will keep praying he will come to know God in a way that allows him to place his life in His hands (as if it is not already, you know?).

Well, that is what I have been dealing with the past week or so, along with many other patients as well. My stretch of being on call has come to a close so I get to enjoy Thanksgiving at home with the family and even get this weekend off, except I have to go in tomorrow because we are opening up a few more brains and spines.

We hope you all have a good Thanksgiving and have ability to be thankful for the blessings you have undeservedly been given.

David

Give the surgeon a break

Well, I have had some interesting cases this past week, and thought I would share them with you all.
I have been on the Neurosurgery service this past week. This means that I deal a bit more with the sad cases. I guess it is something like oncology or neurology where there are devastating conditions, many times the prognosis is bleak, and people don't do so well. This all makes for patients who don't give you much backtalk, families who are upset, and attending neurosurgeons who are impatient, have a good sense of humur, and fly off the handle at the most "trivial" details. I say "trivial" because to me it doesn't seem all that important whether or not the patient has this or that done or medication taken. After working on their service for the past week I realize they deal with such intense situations and stressful situations that they need a place to vent or they will go nuts. Better they vent when not in the middle of someone's brain or spinal cord surgery, in my opinion.
One interesting thing I have learned about surgery and surgeons in particular is that they get a bad rap for being mean, harsh, unkind, insensitive, etc... I realize this is true very often, but hardly ever unprovoked, and hardly ever is it personal. In surgery, each patient can potentially die at any time. You live each moment of each day doing all you can to try to anticipate problems, complications, errors, and mistakes so the patient has the best chance of making it out of the hospital at least as well as they came in as. Against you there is a tremendous amount of opposition. First, you have the patient himself. Now, patients vary with the way they come in. The trauma patients are nearly always intoxicated out of their minds, foul smelling as if they are all having a competition to see who can make the most of us pass out or at least wrinkle our noses the most, and in great humor as we attempt to care for them by jabbing their arms with needles, poking and proding the extend of all injuries, and inserting large tubes in small orifices under the guise of "this is necessary for your care." Now, this is all true, the necessary part of course, but usually these patients work so hard as law abiding citizens during normal business hours, that they need to blow off steam and go to church around 2:30 am, which is when they are innocently walking home minding their business or driving to church when some idiot is driving through a green light.
Oh, sarcasm and being calloused is one of the requirements to pass the surgery boards, I am told. Anyway, I say all of this to give you the backdrop for the very rare trauma patient who is one of the rest of us. Usually these are either victims of the other trauma patients who are intoxicated and operating motor vehicles, or else they come in during normal business hours. Just yesterday, I was post call, which means I was up all night dealing with the drunken idiots who were out running into parking lot lamp-posts after a few drinks to calm their nerves. I was preparing to go home and was just holding the pager for the intern who was on call as he was in the operating room and I wasn't. Of course, as soon as I attempted to leave a trauma was called in. Now, traumas at 10:30 am on a nice sunny warm day make me think differently then the ones on cold nights after payday.
Anyhow, I was covering my partner on this trauma yesterday morning and the guy was nice. He didn't smell like a dumpster behind the liquor store, and had not a single tattoo on his body. Unfortunately for him he had fallen victim to bloody gravity. Fell from a scaffold and was paralized from the nipples down, also started loosing feeling and strength in his hands and arms as we were examining him. He never swore at us as we were poking and proding and inserting... probably because he was paralized. I have this theory, and it seems validated over and over. The nicest people get the most devastating diseases and injuries. The drunks total their vehicles, ride their motorcycles drunk at 1am and come out with scrapes and bruises and a few free meals. The honest law-abiding citizens who really do go to church end up falling off the stepstool helping the blind widow get some powdered milk off the shelf. They usually end up either paralized from the eyebrows down, or a vegetable on a ventilator from bleeding in their brain... Or they have no injury at all, but when they had the pan-man-scan to look for internal injuries they find the honest citizen has metastatic cancer all over and only has a few more weeks to live.
The other case that came in yesterday was a nice lady of 69 who was having trouble walking and had passed out a few times. She had a CT to look for bleeding and they found a mass in the lower part of her brain. I was working this evening with the neurosurgeon on her brain and we got to see the tumor and took it out to find it could be some form or lymphoma. Well, she was pretty upset when she found out we wanted to remove it because we thought it was a tumor. Thing was she had a son who died at age 42 after 7 years fighting off a brain tumor. Seems like I have it pretty good for being such a nice guy... Well, at least I thought I was, but since I haven't had any really bad disease or tragic injury I figured maybe I was meaner than I thought. Maybe it will be in my favor that I have ordered enemas on all of the medical patients just before I go on vacation. Not really, but it makes one wonder if karma wouldn't bother you so much if you used bigger needles than necessary, no lubricant for catheters, and three fingers for rectal exams.
To get back to the enemies of the surgeon. First, there are the patients who try to die without telling anyone or letting you know but are constantly disguised and hidden among the patients who are constantly crying wolf and feigning all sorts of serious diseases and complications. Next, the nursing staff calls you for anything and everything besides the important things, forgets to check the pulse and blood pressure of the only patients who really need it checked, and don't record the urine output of the patients who develop kidney failure because they need more fluid that you had ordered but they forgot to administer because the patient has been without an IV for some time now but they forgot to call you so they could start a new one, or they tried one but you were busy with all of the tylenol and benadryl orders for people who can't sleep. Finally, there are the families who figure you have nothing better to do than keep them informed on any change in their loved one's condition, and want an explanation. This wouldn't be any problem except that you have 28 people on your list to see and take care of, the operating room is calling you for the next case, the three nursing units are calling you for orders, the ICU needs transfer orders for one patient and central lines changed in two others, your chief resident needs you to check with the radiologist on some scans and you haven't had breakfast or lunch and need to use the little boy's room before surgery before you have an accident. If you just knew which patient that has shortness of breath had the clot in their lung, medicine wouldn't be so difficult.
I am starting to understand why many surgeons get so worked up about things. I have learned that you can't trust anyone, assume anything, and always keep your bladder as empty as possible. One other thing. Most surgeons can blow up in your face if you mess up like Mt. St. Helens. Most surgeons completely forget the matter and are your pal 5 min later. So far I have been chewed out about 7 or 8 times, but I never felt like the surgeon was unconcerned for my education and have always felt like they truly want me to be a great doctor and surgeon. Funny how if you get that feeling from someone you will take just about any tirade or attack and feel bad but not humiliated. I keep coming back to the fact that I am only responsible to God for my actions and responses. That sure helps.

Well, I have to run along to bed since I am on call tomorrow and have to be there early since I am rounding with the Chair of surgery on a bunch of patients I have never met so it will take me a bit.

David

November 06