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.

~ 

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.

The Wind Riders

We are back on campus this week so the only crazy medical stories are the ones my other 45 or so classmates and I share with one another. But, I was inspired recently by the birth of spring around me. There is nowhere quite like the Pacific Northwest in springtime. It is a wild, and reckless springtime. I think us humans feel a bit wild and reckless ourselves as we bloom right along with the world around us. This one is for LJ. 

I notice them now
arriving, listless in the nights,
scattering in the mornings, bending
on the wind, getting caught up
in the window screens, their small
orange bodies a tangle
of movement,
there are hundreds.

Where is the mother of all of these children?
Awakening from her own winter? Where she
filled the cracks in the floorboards
with her own slender legs?

Her babies will grow, through the heat and rain of summer,
through to fall, where they will collapse
greedily, into our shared space.
They’ll appear in troves,
as big as coins, shocking in their glory,
so delicate and quick.

The dawn will bring a fortress weaved of the backyard,
between hydrangea and pine, between
an old wooden ladder and
a favorite chair. And I will stand still
and silent each day
navigating the best path.

This year, I decide to grow with them,
exsanguinate life from the night, elicit a lucid, quaking
calm from the day. Knowing each moment a marker
in a short span of time. After all,
we share a growth cycle,
the wind riders and I,
even as I watch them now,
bending, individual
glistening
whispering drops

of sunlight.

The Ten Thousandth Hour

A very good friend of mine once told me: “If you don’t know where to start, just start where you are.”

And so I’m going to start with my ride home from another day of practicing neurosurgery. Today was a 13-hour day, in a string of 10+ hour days, and the day’s end found me walking through downtown Seattle at 9pm with a grin. I gathered quite a few stares with my attire: cowboy(girl) boots, aqua scrubs, and an outdoor coat from REI. It was as if all of the fractured parts of a personality—my personality—were finally coming together. The animal lover, the outdoor adventurer, and the medical nerd.

I’ve spent time thinking about how someone gets good at something, like really good. I’ve heard that it takes upwards of 10,000 hours to sufficiently retain a unique and demanding skill and declare oneself somewhat of an “expert” at it. I’ve heard that a Buddhist monk will spend 10,000 hours in silent meditation before he or she feels they can adequately meditate. I’ve thought about that kind of discipline and whether or not I would find something I could–-or would want to—dedicate that much of my own precious life to. 

That was years ago. Now, I know I could spend years perfecting lightweight backpacking, long distance running, mountain viewing, meditating, writing, philosophizing. But…nothing has seemed to satisfy my interest, curiosity, and instill such a unique personal challenge quite like medicine.  

That same friend who told me to start where I am also told me to quit while I’m ahead. With another long day of surgery tomorrow and my last few days of this rotation drawing near, I’m going to heed that advice.

Only 9,999 hours to go...

Brain Verse

There are a few things I never thought I would see in this lifetime. 

For example, I don't expect to see conjoined twins, a 9-foot tall person, or a human being live to be 130 years old. But, up until very recently, there were two other things I never thought I would see: The first was a heart beating calmly and strongly inside a man's chest. But that is old news now, as that happened during my first clerkship in general surgery. Second, I never thought I would see a brain. I  mean, a clear and clean brain, still inside of someone's head, and prepped for examination. 

But, just this past week, I saw not one, not two, but three patients prepped in such a manner. With nearly ten professionals--nurses, doctors, PAs, anesthesiologists--standing around the room in great expectation. Three brains! Two of them undergoing a treatment for Parkinson's Disease called DBS, or Deep Brain Stimulation. 

I first heard of DBS through Michael J. Fox. Many of us know him as the famous actor who developed early Parkinson's Disease (PD) and subsequently began a foundation dedicated to treatment, education, advice and research for further treatments for PD. 

I'm going to go on a bit of a tangent about DBS because there is yet a third thing I never thought I'd see in this lifetime. In fact, it's not even something I ever "heard" of. And that is something I'm going to call brain verse. 

To begin with, DBS works for those with PD and dystonia--dystonia depicts movement disorders, in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures. DBS has also recently been used for obsessive compulsive disorder and it is currently being researched for use in those with Tourettes Syndrome, depression and even obesity. For Parkinson's, DBS works by inserting a micro-electrode, as thin as a hair, into a part of the brain called the subthalamic nucleus (STN). When this electrode is stimulated, it essentially confuses all the neurons in the STN and for those with Parkinson's, that means the relief of the majority of their symptoms, which may include dystonia, tremor, bradykinesia (slow movement), inability to talk, shuffling gait and cognitive decline, and possible psychosis due to the medications used to treat PD. 

Before surgery is done the brain is mapped--using MRI and CT scans of the head--to pinpoint exact measurements in the brain so that the electrode can be inserted, a half a millimeter at a time, until it reaches its target--in the STN. As the microelectrode is inserted, slowly, by a neurologist, this electrode records brain cell activity. What I learned from my first DBS procedure, is that different parts of the brain actually sound, well, different. Different parts have different neuronal activity and the neurons fire quicker or slower, depending on where they are in the brain. A set of speakers in the surgical suite pick up this activity, and, through them, we can hear the brain verse. The neurons of the thalamus, for example, kind of sound like an idling tractor. The entire surgical team listens to the speakers waiting for the distinctive sound of the target area, the STN. The STN, I heard, is much quieter in amplitude, but the neurons here are almost continually firing. The STN sounds like a purring kitten, with hiccups. 

Whats even stranger, is that the patient is awake--and hopefully calm and cooperative--through this mapping. And their head is placed in an archaic looking cage so that they aren't able to move, which is, of course, a good thing. 

A patient undergoing DBS placement. 

Once the electrode is in place, the neurologist turns it on, and tests it on the patient in the operating room. We all watch to see if the tremor goes away, which is why the patient must be awake. 

The first time I met a patient with PD she had a tremor so bad I could not shake her hand and she was unable to walk into the exam room. During her surgery, when the electrode was placed and stimulated, I watched her ten-year old tremor disappear. Just like that. It was as if a light switch had been thrown. I stuck my head under the surgical drape settling down over her forehead, grabbed her hand in a firm handshake, and smiled. I couldn't help it. 

I can't wait to see her walk into the office next week. 

My neurosurgical rotation is, surprisingly, already halfway done. In the past two weeks I have seen things I never thought possible. I've been present for difficult conversations about new onset Alzheimers disease, scrubbed in on multiple surgeries, helped heal chronic back pain, held many hands, shook my head a few times right along with the patients, tried to convince several neurosurgeons to hire me, worked with a world-renowned neurologist, meditated with a patient, and pretty much ran the gamut of human emotion. Needless to say, neurosurgery is captivating on all levels and I can't wait to see what the next two weeks will bring.  

Oh, and next time I need to tell you about the man with the fused backbone...

Eleven Roses

(for John)

The 12th one was left 

in the middle of the street,

by an old man waving a cane

warding off his caregivers, frail gown

snapping in the wind 

flesh,  

the color 

of a bruise.

At the hospital, after the police left,

his family never came,

his hearing aids never worked,

run out
of batteries,
his memory
never failing

to remind him

that none of this
was fair.

After two weeks 

of staring, listless, nothing
ness

someone had the heart 

to bring him batteries.

Now 

his hearing aids worked
he could tell his story

the right way

call his daughter, his only daughter

and say

"fuck you"

and begin

behaving

just well enough

for just long enough 

to go back.

The roses all wilted by now. 

Goodbye, New Friend

This is a brief ode to internal medicine, because I will miss you immensely. 

I'll miss walking the halls at 7am like I know what I'm doing. I'll miss making a sick patient laugh to the point where they good naturedly tell me to stop it because it is making their belly literally hurt. I'll miss being a friendly and familiar face for people who have no friends or family in the area. And I'll definitely miss listening to a 92 year old woman with dementia tell me she wants to go home, to her parents (who surely can't still be alive but I'm not going to tell her that), because her mom "makes the best meat loaf." 

What I won't miss is the number of times it seems that I said, either out loud or under my breath, "that sucks," or "this sucks." Because the reality is, if I am in internal medicine and I see you that means you are very sick. And most of the patient's ailments or circumstances or issues with lack of insurance or follow up care, well, it just simply sucks. It really sucks to think of so many patients I've seen in the last month that, once they are discharged, have nothing. Nowhere. No one. I won't miss reaching the first Friday of my rotation, one week down, and breaking down with sadness for them all. 

But I did learn one important thing which I guess is perhaps the most important thing: I loved it. I loved the chaos, the calm, the frantic running around, the camaraderie with the nurses, social workers, docs, the chaplain. I loved how the spiritual and social and psychological part of how we heal was recognized and acknowledged time and time again.

Best of all, I realized I could do this. 

They Call it Takotsubo

The 77 year old man found his way into the emergency room, it seemed, almost by accident. He appeared dazed, shaken, dyspneic (short of breath), was feeling nauseas, had recently vomited, and was now clutching at his chest in apparent distress. Several of the nurses knew him only as Mr. Zims. He occasioned this small town ED frequently after the death of his wife several weeks earlier. 

By all measures and algorithms, it appeared that Mr. Zims was having an acute myocardial infarction, or MI (heart attack). But that's not what was happening. In fact Mr. Zims had very few of the traditional cardiac risk factors for a heart attack. He didn't have hypertension, hyperlipidemia (high cholesterol) or diabetes. He wasn't a smoker and he didn't have a family history for cardiovascular disease. But what he did have was something far more ominous. And something that we have all experienced more than once in our lives. What Mr. Zims had, and what the diagnostic and imaging tests would confirm, was that for all intents and purposes, he was suffering from...a broken heart. 

"Broken Heart Syndrome" or Takotsubo cardiomyopathy, was first described in Japan in 1990. Takotsubo mimics acute coronary syndrome. Just like Mr. Zims, patients often present with chest pain. Their EKG's show abnormalities suggestive of MI including ST-segment elevation. These patients also have elevated cardiac enzymes. All of these findings are consistent with an MI. But, the thing is, they are not having a heart attack. 

The Japanese word Takotsubo translates to "octopus pot", because this is the shape the heart takes on when it is in this stressed state. The apex (or bottom of the heart) balloons out when the ventricles contract. But, surprisingly, there is NO significant coronary artery stenosis. Although the exact etiology is still unknown, the syndrome appears to be triggered by a significant emotional or physical stressor. For Mr. Zims, this stressor undoubtedly was the recent loss of his wife. The prognosis in Takotsubo cardiomyopathy is excellent, nearly 95% of patients experience complete recovery within 4-8 weeks. 

Octopus Pot 

I write about this "Broken Heart Syndrome" mostly because I am completely mesmerized by the fact that such a thing exists; that we can, in fact, die of a broken heart. How poetic. How horrifying. How sad. How, in some mystical way, touchingly beautiful. Mr. Zims will be okay, I am sure of that. Figuring out what was wrong with him was the first step towards his recovery. At least his physical recovery. His grief may last the rest of his days. 

In medicine, and especially in training, we all have our "bucket lists" of medical conundrums we wish to see. Learning about Takotsubo was a good fortune, mostly because I will now have it on my differential diagnosis in the future. Mr. Zims will help me help others. But there are other things, other medical phenomena that one may only read about. These are the "zebras" that we learn about. Phenomena so rare one doesn't usually think of them first when a patient arrives with a unique clinical presentation. In my PA program, witnessing a "pheochromocytoma" would be nothing short of an act of god. And not that I wish misfortune or ill will on another human being, but there are other things I hope to see. And I'm sure even more that I hope not to. 

Either way, take care of your hearts, all. They really can break. I know that now.