Tuesday, November 29, 2005

Neurosurgery for dummies

During internship, I had a one month rotation on the neurosurgery service. Neurosurgery had a one night in four call schedule with no general surgery duties, so we all looked forward to this rotation. The ward was abysmal, but the neurosurgery ICU nurses had the best reputation in the county hospital. These nurses knew more about neurosurgery than I would ever know, and they rarely let me forget it. If you think this engendered a constant struggle for dominance, think again. Only a fool of an intern would go up against one of them, and he wouldn't survive. The neurosurgery residents had learned to trust them. They certainly didn't trust us. Neurosurgery is a different world than the rest of medicine. Your patient was discharged today? Huzzah! And you say he left on his own two feet? I'll buy you a drink. During my time at County, one of the superstars of neurosurgery became part of the faculty: Takanori Fukushima, a guy who seemed to have dozens of instruments named after him. At Grand Rounds one morning, he showed us slide after slide of his success stories, post-op patients in what he called the banzai position: arms raised high, standing on one leg. The clear implication was that these patients not only walked out of the hospital, they skipped. But most of our ICU patients did not leave skipping. Many left via the second floor morgue. I saw more death on my one-month-long neurosurgery rotation than I did throughout the rest of internship. (That's why any patient who could walk away -- regardless of mental status -- was considered a resounding success.) Like any young doc, I had a lot of romantic notions about the brain and the cowboys who worked on it. These guys (sorry, ladies -- back in '90, USC didn't have a single female resident in the program, to the best of my recollection) had superhero-like status in my eyes. That would change. One day, I scrubbed in on a trauma case with Jeff, my second year resident. "Motor vehicle accident, skull fracture, subdural hematoma," Jeff told me, which was all I needed to know -- that and the patient's Glasgow Coma Scale score, which was looooow. I held retractors as Jeff opened up a scalp flap. Then he cut away a window of cranium so that he could evacuate the hematoma. Jeff's chief resident was giving a presentation to the attending physician that afternoon, so Jeff was flying solo. It was, in fact, his first solo craniotomy, and he was nervous as a caged cat. Almost immediately after he cleared away the blood clot, he ran into problems. The patient's brain began to swell, bulging well past the bony window. No matter what he tried, he couldn't fit the plate of bone back over the craniotomy. He had the circulating nurse page his chief resident -- normally a nice guy, especially for a neurosurgeon, but oh boy was he pissed at being interrupted mid-presentation. The nurse held the phone to Jeff's ear and Jeff explained the situation. He returned to the table looking a bit gray. I asked, "What did he say?" "He said to cut stuff away until I could get it closed." Stuff? "He wants you to cut off part of this guy's brain?" "Yeah. He said it's probably dead brain anyway." Jeff did as he was told, slicing off gray matter like slabs of sweetbreads until the brain would fit back in place. The patient survived surgery, but I don't recall if he ever recovered from his coma. I've looked at neurosurgery, and neurosurgeons, differently ever since. Nothing personal guys, but . . . Stuff? As we say in the ear, nose, and throat biz, you don't have to be a rocket scientist to be a brain surgeon. D.


Anonymous Candy said...

I have you to thank for my biggest "WHAT IN THE EVERLOVING FUCK" moment for the day, possibly the month.

Cut away stuff? Until the bone fit again? Because he was in a PRESENTATION?

I'm not sure that there are enough capital letters to express my incredulousness.

11/29/2005 11:59:00 AM  
Blogger mm said...

I'm with Candy. Tell buddy to keep his paws off me and my stuff if I ever end up in his surgery.

BTW, I'm a little hurt, Doug. I bared my soul about some earlier boyfriends as a direct result of your post yesterday, and you haven't even read it.

11/29/2005 02:33:00 PM  
Blogger Demented M said...

Whoa. That blows my mind--no need to cut stuff.

Sorta makes me think of the paramedics who deal with head trauma, people missing half their skull, still mobile and completely unaware they are dying. The paramedics aren't going to tell them either.


11/29/2005 04:09:00 PM  
Blogger Douglas Hoffman said...

Maureen, I'm on my way.

As for cutting stuff away: if you guys ever saw Jeff, you'd beg for his paws to be on you. The guy modeled suits in his spare time.

Anyway . . . as I understand it, this was the appropriate action, since there really is nothing else to be done (all the medical things we do to reduce brain swelling had already been done) -- but I had the same gut reaction as you folks did.

11/29/2005 05:49:00 PM  
Anonymous fiveandfour said...

Eeek, that's more than a little frightening. And a bit illuminating, too, after my mom's experience with brain surgery some year's back. Pray God no one ever has an urge to cut my stuff...

11/29/2005 09:21:00 PM  
Blogger Anduin said...

Brain surgery is the creepiest of surgeries to me. I think it's because there are no nerves in the brain so you don't feel pain, but the surgeon can touch an area of the brain and stimulate a reaction in the patient. At least that's my understanding of it. Creepy Frankenstein stuff.

11/29/2005 10:21:00 PM  
Blogger Rae said...

That is an awesome story, Doug. I love it. This confirms my belief that EVERY job is done by simple humans, no more. No job is as glamorous or magical when you see how it is done from the inside. I have always stunned people with my stories of animal training.

11/30/2005 06:52:00 AM  
Blogger Douglas Hoffman said...

Rae, there's nothing simple about cleaning ear wax. After high school, I needed an additional 16 years of education to learn how to clean wax, pick boogers, and stop nose bleeds. Nothing simple at all ;o)

11/30/2005 07:53:00 AM  
Anonymous Sonia said...

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