The B Sides

Wheeling a stretcher down a narrow hospital hallway at nearly full speed can be a harrowing, exciting, and somewhat terrifying experience.

Especially for the patient on the stretcher.

The OR (operating room) suites--all 20 of them--are eerily quiet on my last weekend in neurosurgery. Those of us on call cool our heels not hoping (hoping?) for an "emergency" surgery. These are the ones, as a student, you somewhat cut your teeth on. Because they can happen at anytime, at all hours of the night, and the learning opportunity is enormous. The last major surgery I took part in during my neurosurgery rotation happened to be an "emergency" surgery, and I was on call.

The only post-operative recovery room on a Saturday at one of Seattle's largest hospitals is the "B room", so we maneuver the large unwieldy stretcher to "The B Side," which is what I've come to call it. Like so many names in medicine it sounds like a band name, The B Sides.

For "brain surgery" it was, for all intents and purposes, an easy operation. A month prior, I would have thought that no brain surgery is "easy". The patient arrived in the emergency room on Friday night, I did her intake and exam myself. She was feeling fine other than a complaint of "the worst headache of my life." As students, these exact words cause our ears to prick up. Could it be, I wondered? Nah...

After a CT scan was done, my suspicions were correct. It was eerily obvious from the image we acquired of the patient's brain that a healthy amount of new and old blood was occupying nearly the entire left side of her head. The patient had fallen a few weeks before, hit her head, and suffered a subdural hematoma, a brain bleed. Blood was continuing to bleed into her skull and as this blood built up she finally began to have symptoms, like her horrible headache.

A subdural hematoma can be handled in a pretty straightforward procedure where the surgeon puts in a few "burr holes" (yup, just like a drill) that then allows the stagnant blood from the bleed to drain. It's, literally, a quick in an out procedure, and from the few I've helped with, the surgeon is all wrapped up in less than an hour.

Of course, not everything always goes as planned. A patient, for example, may have a difficult time waking up from anesthesia, he or she may have some brain lability as the tissues expands back into the space that was taken up by the blood. If the bleed happens on the left side of the noggin the left side of the brain then "bounces back" after the blood is removed and this person may wake up with "aphasia" or a problem finding words. If the bleed happens on the right, they may wake up with some motor or movement abnormalities. Much of this is to be expected. Much of this should go away. But, oh, the moments when the human body surprises me is precisely why I have come to adore and also bow down to the enigma of all that is flesh and bone.

Human bodies often do exactly as you would expect. People come out of anesthesia just fine. They get hurt and they heal. There are band aids for cuts, aspirin for fevers, and burr holes for brain bleeds. But sometime the body does exactly the opposite. And you are left with a mystery, a moment of uncertainty and concern, a test of everything you have ever learned, an opportunity to see how fast one can do extensive medical research online to find a next step, a solution, a new potion. There are the moments when the body does, quite literally, fail to follow through. And that is what happened with my patient that day.

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Tonight I begin my 4 week rotation in the Emergency Department, or ER, of a large hospital in the PNW--in fact its the busiest ER in all of Washington State. I hear the place is as big as "a football field", has over 100 beds, and I am nervous. I have classically been the most vasovagal person I know--in other words, I'm a fainter. Years ago, the sight of blood would surely do it, but as recently as a year ago, simple stories of bleeding would quicken my heart rate, turn my hands sweaty and put that nauseous feeling in the back of my throat. Watching someone suture up a laceration put me in a tailspin where I had to sit down. In fact, even the thought of suturing! But, my surgery rotations changed all that, or did they? 

Surgery is elaborately deliberate. There is a system to surgery. A protocol. There is a sterile field and patient preparation and draping and deliberation before the inside of a human body is exposed. There is a chance to get to know a patient before they end up on the table. The privilege of knowing and appreciating a personality. In neurosurgery especially, this was often more critical than the operation itself. Does the patient have more motor deficit after surgery? Does their personality seem altered? Are they acting "funny" and do we need to be concerned? After all, its a brain we are talking about. For the patient mentioned above, the one with the subdural hematoma, knowing the patient's history and personality beforehand likely saved valuable time when it was noted that the patient was not recovering from the operation as expected. It was painfully obvious to anyone who had met this patient that they were not the same person when they came out of surgery, and wouldn't be for nearly a day. 

~

I've worked as a graveyard shift and swing shift supervisor in the largest non-profit detox and substance abuse center in Denver, CO. I've been in the middle of extreme chaos. I know I can handle many things going on at once. I know I can verbally de-escalate men much larger and much angrier than I'll ever see and women in the throes of hysterics (and large, angry women and men in the throes of hysterics!) I know exactly how much I can do before I know I can't do anymore. I know my limits. I know it's true: that full moons, Friday nights, and sometimes early Monday mornings (after a long weekend) are often the busiest in a crisis center like a detox, or an emergency department. And I've  had more than a handful of experiences already in several ER's during my rotations that I know I'm in for some fun, some fright, a few firsts, and perhaps, most importantly, some personal growth. I think my preceptor is going to be a big part of that. He already told me he won't allow me to work every day (something I've often tried to do) and that I'm only to work 4 days a week. His words: You will work hard and it will be challenging. But a big part of learning medicine is learning how to take care of your self and your loved ones. He'll probably never know how timely that advice could arrive.

Photograph courtesy of Stephen Hatch: http://www.StephenHatchPhotography.com

Will I be able to handle the surprises? Will I faint? Only time will tell...

Wishing a lovely Wednesday afternoon to you all. If you get injured, please come see me in the ER. I'll do my darnedest to help you and when I run out of ideas I'll go find someone else. Because of my experience working in detox, I now follow the moons. We are currently in the first quarter of a new moon cycle. Perfect for beginnings. Tonight the moon is waxing crescent heading towards a full moon on the 24th, which by the way, is a Friday. Full moon Friday?

Don't worry, I already asked to work it.