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

Sleep is Good

My grandmother suggested I tell you all about what my daily life is like, so I thought about many options available to me and I selected the "day in the life" approach. I have to start off by telling you that my children and wife are occasionally able to share a free on call weekend meal with me in the hospital, and so if you were to ask them what I do I am sure their answer would include "Doctor, surgeon, sick people, hot dogs, cutting on people, grape fanta, giving people medicine so they feel better, and french fries." The hot dogs might actually be higher up on their list, you are welcome to call and ask them yourself and I am sure they could tell you.

I am just picking a regular day, not an on call day since the on call day is not something I usually like to re-visit. Typically, I wake up around 5:20 and am out the door to drive it to the hospital around 5:35. I arrive and print off my patient lists from the computer so I know who it it I need to see that morning. I then check on the laboratory values of the patients I am going to see, and then any recent radiographic tests as well, and if the patient has a chest x-ray already back by 6am I will look at that real quick as well. I try to start "rounding" on my patients by 6:10, which involves seeing anyone who just had surgery or is new on our service before the others who are either ready to go home soon or are "rocks," and will likely be there for some time to come.

I usually start with gravity rounds, where I start on the highest floor first and work my way down to the lower floors. This is only the case if I don't have patients in the ICU or other "units" to see, and then they are seen first because they are more urgent. Going to the patient room, I take the chart from the pull-down and quickly look at any new orders (tells me what is really going on), overnight vital signs (this includes pulse, blood pressure, oxygen saturation of the blood, respiratory rate, urine output, intake and other output if the patient has drains or tubes or is vomiting or eliminating). Armed with this information, I look at the other doctor's notes if they are decipherable, and then charge into the patient's room where I spend usually less than 2-3 minutes asking incredibly pointed questions that are never to be repeated outside of the correct context. The conversation goes something like this, "Hi Mrs. Smith, sorry to wake you up again, any troubles overnight? Were you able to walk around at all yesterday? Are you eating anything, any nausea? Passing and gas or stool? How well is your pain controlled? Is there anything you need? Okay, I will see you later on, send you home, or explain the plan, etc..."
I then quickly scribble out a note that includes how long since they have been in the hospital, or how far out from their surgery or trauma they are, any other major issues being treated for and then pending tests or evaluation or upcoming studies or surgeries and other plans, or even when I think they will go home or back to the nursing care center, or whatever. I sandwich this information around a very detailed exam where I mention they were breathing, had a pulse, and their belly exam or wound inspection and status, and the character of any fluids draining out of anywhere.
This is repeated on the 7-15 patients I see every morning until around 7 or so we usually have some sort of educational meeting, where we also meet with the other members of the team and discuss all of the patients with each other and then go from there to the Operating Room where we first meet the patients if we haven't already, or else go straight to the OR suite and announce our presence to the scrub team and pull our gloves and gown so they have all of that. As we are scrubbing in with the attending, we fill him in on all of their patients and see what they want to do for each one and what the plan will be. After the cases we some times will physically "round" with the attending physician or we will go do other duties that may include but not be limited to pulling out drains, draining an abscess, pulling our or placing a chest tube, ordering special studies or reviewing studies with the radiologist and attending, seeing any new patients that have come to our service and getting them checked in to the hospital, and if we are lucky catching a quick lunch.
If we are on call, we get paged at any time for questions up on the floors, new traumas that have come in, or other questions that are inappropriately asked of us. If there is time remaining after the cases in the afternoon, we will quickly go over the list of patients with our team of residents (oh, each team has at least a chief or senior resident and an intern.... often a mid-level resident as well, and then 3-6 attending physicians, whose patients we are responsible for)and then make sure everything is tied down for the next day and tell the on call staff about anything that needs to be taken care of, results that the attending needs to be called about, drains or lines that need to be removed, changed, or placed. Hopefully it is only 5pm and we can go home, at the most it is 7pm by the time we get out and sometimes it is 4.
On call, means we do all of that and then at 5pm we are responsible for all of the surgical patients, any new surgical patient that comes into the ER, or that is already in the hospital but has become a surgical patient. This is typically very busy and means answering pages from all over the hospital for most of the night. Things seems to calm down normally around 11:30pm, which is typically the calm just before the shooting or drunken trauma comes in. You would be amazed by how many innocent people are shot by folks, especially when they always say they were just minding their own business (at 3am). Just a lot of crazy people out there, you know.
The on-call day ends at 7am, when you get to ditch the pager to the next on call resident. Hopefully you have been able to round on some patients before 7, but at times this is very difficult, especially if any traumas come in after 4am. In order to go home after being on call, you must have rounded on your patients, checked out with your team, possibly helped with 1-3 surgeries and then checked out again. We are required to be out of the hospital for 8 hours following being in the hospital for 30 hours continuously, but we never have to come back in before 6 the next morning, which is nice, since at times we may be on call again. Typically, I get four week-end days off a month, which is when I get to help Kristi out a little bit and hopefully sleep in some too.

That is about it... I think I will have to discuss some interesting cases and interactions if I get a chance next time I comment about work.

Yesterday, the weather was so perfect, and I was stalled in my research so I took the day off after the 7am education meeting and we went to the Cleveland Zoo, raked leaves in the afternoon, and played with the children. Tomorrow I start the neurosurgery service, so that will be interesting for me. I will be the only resident on the service, which will be no fun, but fun because I get to do whatever case I want to in the operating room, as there will be no competition. Just means I will have more paperwork and dictating to do... Oh, I forgot to mention that in the course of a normal day we are required to keep up with our dictations and paperwork, try to go to office hours, read topics for upcoming educational conferences, etc...

Have a great week
Dr. Meat

October 2006

Lessons in Physics

Most of us eventually "discover" the truth that we don't really have the ability to know everything about anything. There are some things we learn through experience. Some things we learn from the experiences of others. Then there is everything else that we really don't know the first thing about, and try to just make it through life without having our ignorance come up and bite us, or at least not while others are watching.
Although experience is a pretty good teacher, it's utility is not only in making one less ignorant. Confidence is what experience is really good at. Now, this is good and bad in that a little bit of knowledge is good in helping you mentally get going and helps you try new things and learn more because you think you know how to cover yourself if you get into trouble. Experience and the confidence it brings also can get you into trouble by allowing you to think you can do things or go places you really can't and shouldn't and just got away with it one or two times before is the only reason you think you can safely do it again.
This is all in reference to life, of course. Specifically, I am thinking of my lovely children, the lovely weather, and my current occupation. Just because I dug through the garbage once and nothing came of it doesn't mean I won't get it if I venture in there again. Just because it is October doesn't mean it won't snow and be nasty outside. Just because I know how to start an IV doesn't mean I can get away with starting a central line or just because I can put a scalpel on a handle doesn't mean I know the difference between nerve and tendon.
That being said, this past few weeks have been pretty good... I guess. The weather predictably unpredictable, the children have been growing up and learning new things with us, and we are getting closer to our first spring in Ohio. For the past 10 days I have been on call nearly every other or every third day, which makes for little time for much else. I am finally done and now I get to join a team at the hospital that is short a person, so I get to keep on rounding every morning, which is good for me I am sure.
Apple season is here, and Kristi took the kids to Amish country with Mrs. Sobie, a former ATI mom who is very knowledgeable about these things. So, we have lots of apples. We are still raking leaves, and watching some snow fall once and a while. Anne is getting a little bit better with her eczema, and that makes us pretty happy (now we have all 4 eye teeth coming in) for the most part. We had a wonderful time on Saturday at the mansion of the guy who was co-founder of Goodyear Tire. The children are learning more and more about animals and letters and numbers and phonics. Anne is walking like a champ, and that has helped her frustration level, which in turn helps ours. Jan and Alec now have I John 1 memorized and enjoy reciting it for those members of the treats for verses club.
We are still working on social graces, keeping our voices down in public, second and other ballet positions, recognizing the warning signs of a BM when Anne is in the tub with us, keeping the doors closed and only necessary lights on in the house, gravity, inertia, and responding to authority.
I have been able to get to know some of the other residents a bit better after being on call with some who I have not really worked with that much, which has been good. I was on call Sunday and over a patient with appendicitis that I was lining up to go to the OR one of the Emergency Residents says, "Hey, you sure missed a good sermon at church today." I, with experience, have learned a few social graces so I by-passed the "who in the heck are you" and replied, "Yeah, my wife emailed me and said Steve did a very good job explaining the Word and the place it should have in our lives."
Feel a bit more ingrained here since I have started running into nurses and residents and just this morning I chatted with a family doc at the hospital who goes to the Church we have been attending. Sure are nice people, and what impresses me is they seem genuinely interested in growing spiritually and being challenged and knowing what God says and how it should change the way they live. The kids are very much learning and growing, and talk about the Bible stories they learn each week. That is good too.
Well, that will do it. I have some "research" to attend to and must get back at it. Also, I need to get some exercise. This week we have Andy Smith coming by on his way back to Bible College from DC, we are having dinner with the Pastor's family, and multiple other appointments and engagements.
Feel free to drop us a line any time. Next month I think I have Neurosurgery, but I may be bumped back to Cardiovascular/Thoracic service as there is a shortage of intern over there.

David