Friday, April 18, 2008

A good way to end the week

I'm officially finished with night float. No more nocturnal rotations, ever. My diurnal rhythms will henceforth be afforded the respect they deserve.

As an added bonus, in the past couple of days I've received acceptances from a couple of literary journals: an online flash fiction journal called HeavyGlow, and a print journal called Bellevue Literary Review. I've been trying for a couple of years now to break into BLR, so that's a great feeling. Two acceptances in one week, after nearly a year-long drought! Crazy.

Now, I sleep.

Saturday, April 12, 2008

The thrill of victory and the agony of defeat

Sometimes in neurosurgery the greatest technical triumphs coincide with the greatest patient care defeats. That is, often those tasks that require the most manual dexterity or technical proficiency only present themselves because your patient is in a dire situation. I can provide an example from a recent call night. We had a patient come in with a severe subarachnoid hemorrhage. Here's a CT scan:

That whitish stuff towards the center of the picture (worse on the right, which, in the backwards world of radiological imaging, refers to the patient's left) is hemorrhage that's not supposed to be there. The astute interpreter of head CT scans will also note significant cerebral edema, with effacement of the basal cisterns. That is to say that the cisternal spaces around the brainstem, in which cerebrospinal fluid normally circulates freely in a healthy brain, have been compacted by the pressure in the cranium. Not surprisingly, this patient was what we would term moribund; on the five point grading scale of severity of subarachnoid hemorrhage, he was a five. When he arrived in the emergency department he showed practically no sign of neurological function.

However, this patient happened to be quite young--so young, in fact, that we wanted to give him every possible chance at recovery. In this case that included administering a medication, Mannitol, to reduce the intracranial pressure (ICP), as well as hyperventilating him (which also reduces ICP). The next option to entertain for treating high ICP is to drain off some cerebrospinal fluid from the ventricles of the brain. Here's another scan:

This is an image of the patient's brain at the level of the foramen of Monroe. Those two little darker slits towards the center/front of the scan are the lateral ventricles where they come together and drain into the third ventricle through the foramen of Monroe. When we place a ventriculostomy catheter, which is a rubber drain that we slide into the brain for the purposes of draining off spinal fluid, we try to put our catheter in one of the lateral ventricles with the tip right at the forament of Monroe. Normally we do this in patients with hydrocephalus, who have scans that look more like this, with very large ventricles...

...which clearly provide a much easier target than I could shoot for with my patient. Under normal circumstances if we have to put a ventricular catheter in someone with ventricles that small, we use special computer-assisted image guidance to ensure that we can place the catheter appropriately.

My point here is that a ventriculostomy in this particular patient was to be no small task. In fact, it would be the sort of thing that a neurosurgery junior resident could brag about.

So here I am, it's 2:00 am, and I'm dealing with this extraordinarily sick patient who needs a catheter slid into his infinitesimal ventricles. So I run up to the neuro ICU, gather my supplies, and set up for a ventriculostomy. I talk to the family, and explain to their stunned and barely comprehending faces that their loved one is in exceptionally critical condition, and that this procedure, though unlikely to help, is the only thing we can offer that might make any difference to his neurologic outcome (this sort of glum prognostication is par for the course in neurosurgery).

After the family agrees to proceed, I hurry back into the patient's room, which has now collected a handful of interested onlookers. Usually we perform these procedures in our neuro ICU, where the placement of a ventriculostomy hardly garners a shrug, but in the ED its novelty usually attracts an audience of several techs, nurses, and residents.

I act fast, because I know that every second matters for this patient's already poor prognosis. I shave the scalp, mark out my landmarks on the skull, and tape the head to the bed to keep it still. Then I prep the skin and ready my supplies. After placing sterile drapes over the area, my first move is to confirm my landmarks (this is of utmost importance when the ventricles are small), and then slice a 2 cm opening in the scalp. The most nauseating move--for the onlookers, that is, the uninitiated--comes next, which is using a hand-held drill to (quite indelicately) drill a hold through the skull. After puncturing through the inner margin of skull you need to clean up all the errant bone chips, at which time the only thing separating you from the brain is a thick lining of connective tissue called the dura mater. This I puncture open, and now all that's left before I can relax is the passage of my rubber catheter into the slit-like ventricles six centimeters deep.

Any time I advance a catheter into the brain and pull out the stylet, I expect to hit paydirt with the first shot. I have to have that expectation--after all, this is somebody's brain. But sometimes you pull out the stylet and nothing comes out, and you drop the catheter down below the level of the ear to help the fluid flow out and still nothing comes, and you feel this sense of visceral free-fall as if you've just crested the top of a roller coaster and your gut knows you're sinking before your brain does. I hate that feeling. It's guilt and fear and shame and regret all rolled into one. So then you have the pull the catheter back out and reassess everything--your landmarks on the skull, your angle of approach, the size and position of the patient's ventricles--everything. Because you have to get it right the next time.

In this case, it took me a couple of passes to find this patient's very small ventricles. But I found them. Spinal fluid shot out of the catheter tip, with an opening pressure of 45 cm of water (measured according to the height of a fluid column). That's three times the upper limit of normal, and this despite the mannitol and the hyperventilation. That is, as we say in the business, bad.

But I nailed it. Not with the first pass, but I managed to pass a rubber catheter blindly into someone's head and hit a target about the size of a poker chip turned on its side. I should have felt proud. I should have bragged about how I managed to place an impossible ventriculostomy under less-than-perfect circumstances in the middle of the night. I should have printed out the patient's next head CT scan and run proudly around the department with it.

Except the patient didn't survive to have a second head CT scan. The ventriculostomy didn't help. So instead of a victory celebration, I had to explain to the family that their loved one continued, despite our best efforts, to have no sign of neurologic function.

Technical victory. But defeat in every way that matters.

Let the light shine in

Conversation just had:

Wife: "What are you doing?"

Me: "Writing a blog post."

Wife. "Oh. I think I need to open a window in here or something. Something to remind us that we're part of the world."

Me: "What makes you think we're part of the world?"

Friday, April 11, 2008


3:55 am. Getting killed. Just grabbed a razor and some cream from supply room and shaved the beard. Back to work.

Thursday, April 10, 2008

Call nights and superstition

I'm on night float again, meaning I show up in the evening and man the call pager until the troops arrive again the following morning. A night on night float can range from eerily quiet--prompting such incredulous behavior as paging oneself to ensure that the call pager still works--to frantic, with no end to the work and seemingly every patient trying to die off on your watch. One would think that there would be such a thing as an average night, and that we woudl have roughly a normal distribution of nights ranging from quiet to scarily busy. However, it seems more as though, rather than normal, the true distribution is bimodal. You either get killed or you float by. Of course that's an oversimplification, but the fact of the matter is that you never know what a call night has in store for you, and whether you'll walk out the next morning smiling at the brilliant sunshine or just hoping it will illuminate the path to the nearest trashcan in which you can deposit your pager--and your career--post-haste.

In part, I think this unpredictibility contributes to the learned helplessness that comes to characterize the junior resident in neurosurgery, but that's a topic that I'll address some other time.

For now, I just wanted to mention that superstition has a stronghold among neurosurgery residents. And when I use the term, "neurosurgery residents," I mean me. For instance, my face itches. Badly. Why? Because I haven't shaved since last Saturday night. I haven't shaved because I've had good nights all week long--a rarity, and in fact a statistical singularity--and therefore the reptilian part of my brain concludes that the unifying thread for each of these benign nights, my growing facial hair, must be the reason why. So, of course, I can't shave. Far better to scratch my neck, uncomfortably contort my face every couple of minutes so that other residents diagnose me with Tourette syndrome, draw the ire of my chairman (who thinks that every resident should be clean-cut), and suffer the ignominy of walking around with my sorry translucent excuse of a beard. ("Hey Ian, is that dirt on your face?") I only have one more night this week, and my facial hair can get me through.

Of course, I've now just completely jinxed myself. Tonight I'll probably have about twelve consults and three ventriculostomies.

One of my attendings, though, once posited an interesting hypothesis. He said that perhaps the future--in this case, a call night--is comprised of a finite number of realities (future quanta, if you will), and that each of these possible realities already exists in different dimensions of what might ultimately constitute the future. However, the Heisenberg uncertainty principle, or something akin to it, applies to these future quanta just as it does to the momentum of an electron: that is to say that by observing one of these future quanta--by predicting it or calling it to mind--we alter it, and from the standpoint of its potentiality for a future outcome, render it infinitely less likely to occur. For this reason, then, it behooves the neurosurgery resident to enter into each call night predicting every imaginable catastrophe, for in so doing he/she removes each one from the realm of possibility. It's an interesting idea. I'm tempted to try it before tonight's shift, by delineating all of the ways the night could go terribly wrong. Surely then things will all be well.


Nah. I think I'll just grow the translucent beard for another day.

Tuesday, April 08, 2008


I think I'd like to revive this blog--a little bit of the old Internet Lazarus effect. Although, really, this blog has perhaps seen more visitors in the last several months than it did in the preceding year or so, simply by virtue of Google searches about Kapali.

Every time I write his name, see a picture of him, or even have a vague passing thought about Kapali, I can hear his laugh--throaty, baritone, and unencumbered, the way you'd think that God would laugh.

I want everyone to know about what happened to him, and how. The facts of his death--the mechanism--befuddle people. Nobody can seem to fathom how a simple punch to the face can kill somebody. Ever since grade school we've been conditioned to believe that a punch results in a bruise, some lost recess time, and in the worst case, for adults, perhaps some legal repercussions that lead to onerous court visits and exhorbitant attorney fees. But very few of us can understand how a punch can claim the life of a healthy man in his mid-twenties.

What if we did understand it? What if every man and woman who came of age in America knew that being punched in the face can cause debilitating neurologic injury? What if, before squaring off to argue with another guy in a bar, a man would think, "Well, I'd better be willing to die if I really want to get into it with him"? How would that degree of knowledge saturation change things?

It's a recognized phenomenon in neurosurgery that head trauma can lead to instant death. Many years ago a neurosurgeon by the name of Genarelli researched head trauma in dogs, and found that a certain percentage of them instantly succumbed upon a cranial insult. The mechanism is presumed to be a sudden autonomic discharge, as if your body heaves all of its adrenaline into the bloodstream at once, and it overcomes the cardiorespiratory system. There's even a term for it: "commotio cerebri," similar to the term commotio cordis that refers to sudden stoppage of the heart from an impact to the chest (a phenomenon that has claimed the lives of many football and baseball players).

Though we know about it in neurosurgery, it doesn't receive much attention. Most of the time the victims plow their cars into walls at high speed and such, so we don't think much of the outcome. However, in a few instances, a simple punch in a simple fist fight is the insult that ends a life. Somehow, in this country, this fact remains a well-kept secret.

In Queensland, Australia, that's not the case. They have a state-sponsored campaign entitled "One Punch Can Kill," because they recognize the risk posed by fighting among the region's youth. So motivated individuals are making an effort to spread the word, to ensure that twenty-somethings don't blithely wander into bars and think that a physical altercation might be, at best, a way to test their manhood, and at worst, a way to get bruised up. In Queensland they want their youths to know that they can die from fighting.

I want the same thing in this country. I want everyone who sets foot on a playground or on a sports field or in a bar to know that they can die if they fight.

In Fight Club-- for some time one of my favorite movies, and indeed a favorite among many a soul-searching young male--Tyler Durden says, "How much can you know about yourself if you've never been in a fight?" I think that question resonates with some young folks in America. But I want them to realize that you might as well ask, "How much can you know about yourself if you've never drunk a liter of antifreeze?" Or, "How much can you know about yourself if you've never fallen off a 7th floor balcony?"

A single punch can kill. Kapali taught us that. If we can spread this knowledge, and if, as a result, just one person who would have died from a punch instead chooses to walk away, Kapali will not have died in vain.

Now I just need to figure out how to educate the entire country.