Shaka and Surgeons

I have read (though it may not be true) that Zulu fighting regiments killed their own wounded if they were no longer able to keep up with the relentless pace held by the impi. And relentless it was. Zulu regiments would cover 100 miles over three days of campaigning, with a large battle thrown in there somewhere. The point here though, is not military history. The point is, anyone who doubts this capacity to turn on one's own, those who have fought and endured beside you, has never sat in the surgery intern's call room in a large hospital while the occupants discoursed on their brethern.

It is often true in surgery programs than not everyone makes it. Many programs accept more interns than they intend to graduate, realizing that not everyone can hack it. This used to be institutionalized, with the programs stating up front that they would not allow all the interns to progress, turning the already stressful intern year into a competition between, say, eight hapless souls for five spots. Thankfully, this is now illegal, but still, surgery programs do not have a 100% graduation rate.

As the interns warmed to their subject, they became very specific, pointing out the faults or strengths they saw in their classmates who had dropped out, or even in the residents and staff ahead of them. Most of the faults were unsurprising, and it was fascinating to see how willing how willing these doctors were to forgive almost any fault in someone decisive and thick-skinned. Dr. Neversmile, for instance, came up and was "pretty damn talented" or "gotta respect him." Even my former chief resident, aptly decribed by one of the interns as having his "default set to hating people" was not castigated further, because he is a "solid surgeon." But one of their classmates who dropped out was described in language that was ridiculously over the top. I've never met the individual, so I can't speak to the truth of the calumnies, but as soon as they all agreed that this person was "not decisive" and "thin skinned" anything was fair game. (full disclosure, the single vulgar word used for "thin skinned" was one I am not real comfortable typing out.)

The strongest language denouncing another resident I heard in my residency of choice was "weak." Medicine is a very intellectual specialty, so there is a lot more emphasis on thinking than on action, but more essentially medicine docs are not as "cool" as surgeons. Now medical school isn't exactly a random sampling of spectators at TRL, but there are always people everyone wants to be around, people everyone else wants to be like, people for whom an easy atmosphere of hip collegiality comes naturally. The kind of guys who can do those complicated handshakes without thinking about them, or looking awkward. At least, so it appears. And most of these people seem to wind up as surgeons.

Medicine is like high school, and you've got all the groups. Surgeons: the cool kids. Ortho: the football team. Nephrologists: the chess club. Neurologists: the Dungeons and Dragons kids. Ob/Gyn: the stuck up cheerleaders.
- a surgery resident


So it makes sense, to my mind, anyway, that the qualities praised in internists are different than those praised in surgeons. And it also makes sense that those who don't quite fit in, who are a bit more self-conscious, don't last long in this environment.

Though I've managed to get along with the residents here, sharing musical tastes and movie quotes, it has been an effort. And I'll be glad to move on. Tomorrow is my last full day here, and I won't be sad. Despite the stories, and the atmosphere I've attempted to convey, I haven't learned a great deal. At least about neurology.

The Weepies - Say I am You

It's been a while since I've written a music review, largely because I've been too busy either having fun on vacation or working 14 hour days to listen to much music. But after getting out of the hospital early yesterday, I celebrated by going to Borders and picking this album up, on the recommendation of several friends over the past few months.

I must say I am impressed. These guys (guy and gal, rather) toured with the Indigo Girls last year, and it's easy to see why. Largely acoustic, with tight harmonies. The guitar work, notably on "The World Spins Madly On" is very Indigo Girls in style. However, my limited exposure to the Indigo Girls gives me the impression that they are a lot more sad than the Weepies. Here we're mostly hearing stories about love, requited and not, but even the sad songs aren't devastatingly so. The music makes you feel that, despite the hurt, there is light around the next bend. Contrast, for example, the Indigo Girls' "Closer to Fine" which despite the driving chords and thrilling harmony is shattering philosophically.

Though the Weepies may not be saying anything new, you have to love the way they say it. The chorus from "I've Gotta Have You" has been stuck in my head all day, even when listening to the rest of the album. "No amount of coffee/No amount of cryin'/No amount of whiskey/No amount of wine/Nothing else will do/I've gotta have you." The rest of the album continues in this vein, clever lyrics, pleasant harmonies. Song you feel along with.

Recommended.

Oops

Q. How do you hide a $100 dollar bill from a surgeon?
A. Put it in a book with no pictures.

Q. How do you hide a $100 dollar bill from an internist?
A. Put it under a dressing.

It's meant as a joke, of course, but there's a bit of truth to it still. And I'm ashamed to say, I lived out the second half of it today. Last night I did a post operative check on a patient who had spine surgery. And I'm getting into the swing of neurosurgery, so I check his reflexes, muscular strength, etc, which is all they really care about usually.

Except this patient was a bit different. Because of some special conditions with his surgery, he had a drain sewn into the wound, one which was important to check. So this morning, on rounds, my chief asked "how much did the drain put out?" My only answer could be "I don't know, but I'll check." So the intern and I dropped a few notches in the estimation of our team. The problem is, we hadn't known to look for a drain, because there had been no mention of it in the operative note. Not an excuse, but it showed how mistakes get propagated up the chain. Fortunately, the patient was fine.

So, this afternoon I was asked to do another pre-op check. And to ward off any reminding corrections, I said "sure, I'll do it. And this time, I'm stripping the patient naked before I write the note."

This guy didn't have a drain. But I won't make that mistake again.

I hope.

This is Neurosurgery

I walked into an operating room shortly after 8am this morning, to a case which was already in progress. And when I left the hospital, thirteen and one half hours after arriving, only after the insistent "seriously Nathan, you'll have plenty of long hours later, go home and get some sleep" from my resident, the case was still in progress.

This patient, Mrs. Walker, has an acoustic neuroma, an overgrowth of the protective layer of Schwann cells around her eighth cranial nerve. The nervous system is much like any electrical system, and it needs insulation. So, just as the average copper wire has a coating of plastic around it, our nerves have coatings, made of fat. And around the eighth cranial nerve, CN VIII, the vestibulocochlear nerve, this coating is made of cells called Schwann cells.

Mrs. Walker's Schwann cells have been growing more than they need to for a long time. And as they have grown, since CN VIII is inside the skull, they have run out of room and started to squeeze the nerve, and the rest of the brain. Obviously, this is not good. It also happens to be the job of neurosurgeons to fix.

The initial portion of the case involved starting anesthesia and then laying the patient on her stomach, with her head tilted to one side. Then, through an incision behind the ear, a section of the skull was removed. Then, in one of the best demonstrations I've yet seen of the delicacy and absolutely steady hands necessary to be this kind of surgeon, a microscope was moved into position and the cerebellum was gently retracted out of the way about a centimeter or two. Through the space created, the chief resident and a staff neurosurgeon began gently separating the tumor from its surrounding arteries, nerves, and bone. Though it takes only a paragraph to describe, by this point it was 1PM. The tumor was carefully resected from its surroundings, preserving the nerve running right down its middle.

Then things got complicated. Another surgical team, from otolaryngology, came in to ensure there was no tumor involved with the facial nerve, and to do so, they needed to shift the position of the retractors holding things open. And as they did that, some of the petrosal veins tore. These are tiny, tiny vessels that run from the superior surface of the cerebellum to the superior petrosal sinus. That sinus is labelled at about the 7 o'clock position in the image to the right. There are two problems right away with this. One, veins do not clot off as easily as arteries, so while you bleed faster from an artery, the body will do its best to stop that bleeding. Not so the veins. (at least to some extent) The second is that, with the incision where it was, these veins are behind the edge of the petrous temporal bone from where we were looking. Imagine using tweezers in a hole 3 inches deep, looking through a microscope to see the nerves you are dissecting, and suddenly, a minor emergency occurs around a blind turn at the end of that hole, forcing you to work quickly and accurately on microscopic vessels you can't see around that turn. The next approximately nine hours were consumed with attempting to fix that bleeding. The bleeding was eventually stopped by clotting it with Gelfoam. Then it was time to put everything back, close the incision, and head home. The surgeons were there in the OR until 11PM.

It was thrilling in a way, to see most of this operation and the deliberate haste with which the surgeons worked. At the same time, I realized that, despite how late they were working, all of these guys would be back in the hospital at 5am the next day to start all over again. I could never do this job. I don't mind long hours once in a while, and I defintely signed up to do medicine knowing I would work more hours for less monetary compensation than almost any other educated profession, but I'd like to have a life, someday. And I think, to have a life outside the hospital and be a neurosurgeon, you need to redefine "life."

And now, a moment of Zen

I was going to say, "shamelessly lifted from someplace I can't remember," but there's the email address for you. Send the guy some kudos.

An obstetrical memory

I don't know when I first recognized it, but I like jargon, the peculiar set of words that grow up to shroud or nourish a particular field. Hence, in college, I would laugh along with the engineers' obscure cracks about heat transfer, and the hackers making obscure puns on the distinctions between grep and grok, peppering their conversation with quotes from the immortal tomes of Douglas Adams, all the while meandering towards my own degree in an unrelated field.

Perhaps this explains why I find blogs about the humor in child raising funny, though I have no children of my own. (Not likely to soon either, but that's another story, boiling down to "got to find the girl." I digress.) I also found this article in Slate hilarious and intriguing, despite only ever having been on the other side of it. I'd like to think the hilarity is just the author's style, but the intrigue is in the point of view I didn't get in my time on OB/Gyn.

He discusses the doctor-doctor interaction, handing off the patient who is his wife with this wonderful passage:"Tabitha's doctor collected information from the doctor on call, in the way doctors do. They spoke for maybe two minutes, in English as intelligible as their handwriting."

And then, in a paragraph I like because it reflects a lot of my own feelings on medicine:

Tabitha's doctor is maybe the least likely obstetrician in Berkeley, Calif. He doesn't believe, for example, in the sanctity of his patients' whims. He has no time for superstition; he is unapologetic about his belief in the power of modern science; he believes that the best way to endure childbirth is not out in the woods surrounded by hooting midwives but in a hospital bed, numb from the waist down. He is, in short, my kind of guy.

As a resident of mine on my obstetrics rotation put it, "there's nothing wonderful about 'natural childbirth.' People died in natural childbirth, that's why there are doctors." I do know more than a few people who are fans of natural childbirth, but while (being bound for internal medicine) I'm a little more understanding of the sometimes inscrutable whims of patients, this is one I don't think I endorse. Life is painful enough sometimes.

The passage I quoted above reminded me of a patient I saw on my obstetrics rotation, who is the reason I don't like doulas. She was pregnant with twins, and had a history of several prior births that had not gone well. Her children had all been born drastically prematurely, and as a result suffered from a variety of congenital ailments. Because of her history, she had a cerclage placed, though when I first saw her, she had finally reached term, and had that particular apparatus taken out. Here is where it got complicated. She had been discussing her situation with a doula, and this non-medically trained individual convinced her it would be a good idea to give birth at home, despite her history of tragic pregnancies, and the fact that she was carrying twins. And to complicate the matter further, the final ultrasound I saw her get showed the twin closest to the cervix was smaller, and the second was breech.

When a woman gives birth to twins of different sizes, the order in which they come out has a powerful influence on the ease of the birth. If the larger twin comes out first, the second delivery is relatively easy, as the cervix and canal have stretched already. If the smaller one comes out first, the second will involve more laboring, and chances for things to go wrong, such as prolapse of the umbilical cord with concomitant asphyxiation of the newborn. This patient was set up for failure.

The next weeks were tense, as every night the patient's story was related, "just in case" she changed her mind, or showed up on the ER door with a kid halfway out of her and in extremis. And about a week and a half later, she did show up, doula in tow.

She had tried to give birth at home, and finally her screaming had gotten to be too much for everyone involved, who dragged her onto the labor and delivery deck at about 2am, probably waking the entire population of the hospital. As I went into the triage room, I was genuinely concerned someone was dying, because of all the noise. My resident was right behind me and it took a total of about 2 seconds to decide to take her to the OR.

We did manage, in the OR, to start an epidural, and then we tried to deliver the kids vaginally while waiting for the staff doc. He arrived minutes later, and began to prep for a C-section, just in case. Through the whole delivery, I heard absolutely the most foul language imaginable coming from the doula and her charge, our patient. Evidently the epidural didn't have time to kick in before the kids were coming. It was positively distracting, and my resident reflected later that it was a pity the first word the kids heard was a vulgar reference to their conception. The second child had to be delivered with forceps, and that wasn't pretty either.

The whole team came out of the delivery pretty exhausted. The doula had disappeared. My attending turned slowly to me and intoned "well I hope you've learned why natural childbirth is overrated."

Oh I have. I most definitely have.

5 things you don't know about me

I've been tagged by Zwerver with this "5 things you don't know about me" thing, and I'll admit, it is tough. The reason for this is that, being a bit of a private person, I usually reveal on this blog just about everything I'm comfortable with telling the world. And I've been trying recently to keep more closely to the subject of medicine. However, I'll attempt to foster the congenial spirit of the blogging community and come up with five things. Hey, it's my day off, and the apartment is almost clean. To help, I'll assume the target "you" is someone like Zwerver, whom I've never met.

1) The greatest struggle I face in maintaining an attitude of Christian charity is when I'm behind the wheel of a car. Seriously people, drive like you mean it.
2) I never said a "bad word" and meant it until I took physical chemistry from the one devout Christian professor I ever had.
3) I'm excited about finishing medical school in large part because it will be the only difficult thing I've stuck with long enough to accomplish.
4) I want to build a ship in a bottle.
5) I took five years to return a book once. I had to FedEx it nearly two thousand miles. Sorry, Steve.

Role reversal

In 119 days, I will be Dr. Nathan. At that point, I'll have to start teaching med students and passing on what little knowledge I already have. As Dr. Lest said a few days ago, if we don't teach those behind us, there will be no doctors eventually.

So today I had an opportunity to warm up to this, and I may have learned more than he did. There's a third year med student on my team, and today I delegated two patients from my load to him, to examine and write notes on. And being a third year, he did some pretty bad exams, and wrote some pretty bad notes. Here's where I made my mistake. As the next guy up the chain, it really is my responsibilty to make sure his work is as good as I can make it before I pass it up the chain. But I didn't. I let his notes get passed on to the intern without correction. And later, when the third year was off doing something else, the intern started telling me what he thought of his notes.

In a scientific profession, a great deal of your collegue's opinion of you is formed by your writing, and muddy reasoning doesn't win you friends. Not here anyway. And once you get off on that track, any quirk or slip becomes fodder to form a progressively worse opinion. So after the notes fiasco, I'm afraid my third year has a long uphill fight to get a good grade. The plan, according to my intern, is to "ream some sense into him. The way you learn is by getting chewed out, so you don't make the same mistake twice. If that guy doesn't hate me by the end of this rotation, I haven't done my job."

See you run into this type of person a lot in medicine, at least (and especially) in surgery residencies. They aren't bad people, per se, they just have a very hostile attitude and a firm belief in the wisdom of imparting wisdom through beatings. I'm not one of them, but I should have seen that coming.

But on the other hand there is some wisdom to what he said. By this point, he should be able to write a good note. And in residency, you have to be able to put up with a lot of drudgery and thankless work to take care of patients. Though it is often minutiae, the minutiae matter in medicine. Even the easy going guys know this. Another, much more chill intern, when discussing his plans for teaching next year when he is a resident, said "really, your interns should be terrified of you for six months. Otherwise they won't be conscientious enough."

I guess in the long term, the most important thing is that the med student/intern/resident takes care of their patients without hurting them. But I think a close second goal is preserving peace between us all. The universe is a big enough enemy most days in the hospital, without creating more.

I think I'm a tolerable teacher, but now I have a twofold motivation to be better. One, making good doctors out of those behind me, and two, equipping them them to avoid the pain of getting chewed out by others with more punitive styles.

So, third year, let me show you how to write a note...

Coffee Thoughts

The morning cup of coffee has an exhiliration about it which the cheering influence of the afternoon or evening cup of tea cannot be expected to reproduce.
- Oliver Wendell Holmes, Sr.

Wise words from a physician gone before.

Faking It

Neurology grand rounds today discussed a patient who is experiencing pseudoseizures. In other words, he's faking epilepsy. But it was absolutely the most informative and interesting learning I've done yet on this rotation.

This patient has obviously done some reading on epilepsy, as he starts out his pseudoseizures correctly, but as he progresses he makes mistakes. He was being monitored in his room with a video EEG, which, as the name suggests, films the patient while recording his brain's electrical activity. This is later reviewed, either by his physician, or a roomful of them, like this morning.

When I first watched the video, I thought I was seeing a real seizure, but as the discussion continued, and the tape was rewound and watched over and over, the points in question came out. This patient attempted to simulate decorticate posturing, but he probably read a definition like the one I linked to there, which doesn't say how the arms are twisted. He was supinating his forearms, while pronation is more common. Also, he made thrusting motions with his extensor spinae muscles, rather than the usual fixedly rigid posturing. Ten or fifteen other tiny details were discussed and analyzed. He was moving rhythmicaaly when he shouldn't be, and was fixed when he shouldn't be. The EEG didn't match epilepsy either, and displayed only motor activity. There were no rhythmic cycles in it, and some leads showed almost no activity.

So the staff started asking the residents questions about management. The funniest proposition was from a first year who said he would announce in a loud voice "if this doesn't stop, we're going to have to use rectal diazepam." After the laughter died down, he was gently reproved to use more compassionate techniques. Several different ideas were discussed, and I found it thrilling, in a way, to sit down in a room full of super intelligent people and discuss, essentially, ways to trip up someone who is lying to you, without letting them know you know he is lying.

The staff concluded with a remarkable set of points. First, he said, we have to remember that this patient does indeed have a disease, it's just not epilepsy. And second, we can't let on that we think the patient is faking it, because it won't help his behavior. On the contrary, he'll just try harder to convince us. And in the end, our goal is not to flaunt our intelligence over this poor guy, it's to help him get better and go home.

Time to consult psychiatry.

Peds Neurosurgery

Roughly a month ago, a boy named Jay was born with a prosencephalic defect. (I couldn't get a straight answer from the neurosurgeons, one telling me it was something between prosencephaly and holoprosencephaly, and another that it was sort of like holoprosecephaly. I could try and figure it out, but I'm lazy, and I have to study more neurology. Anyway, to return.) After an insult to his development very early in gestation, his brain stopped developing in the way it is expected to, and began to force his brain outside the confines of his skull, so that, at term, his CT scan looked something like the picture to the right.

Enter Dr. Lest. Aside from being one of the nicest people I've ever met, and remarkably personable and witty, he specializes in pediatric neurosurgery. He combines the personality of a pediatrician with the skills of a surgeon. Enheartening to watch. Exempli gratia, today he was speaking with Jay's family, and one of them expressed surprise that, except for the defect, he looked and acted like a normal newborn. The good doctor's reply: "I know, he's cute as a button, isn't he?"

So today was this child's surgery. If you look at that CT scan from the first paragraph, you can see that the brain is quite thin along the top of the skull. With Jay, the thin part protruded much farther from the skull, and there was actually no bone over the defect. It was essentially a fontanelle about 4cm across. So the plan was to remove some of the skin, drain the excess fluid off the child's brain, and reconstruct the skull to allow more normal development.

The surgery took 5 hours. First the chief resident and Dr. Lest removed a strip of skin over the hole, then they incised the dura over the area, sparking a tiny fountain of CSF for a few seconds. Then they peeled back the dura and looked inside. There, inside a living, breathing body, was visible both right and left thalamus, all the way forward to the optic chiasm. This was only possible because Jay doesn't have a corpus callosum and then, of course, the hole here in the middle of his brain is a bit larger than it should be.


Seeing this ranks as one of the few near-mystical experiences I've had in med school. All of them have involved this closeness to life, this first hand knowledge of these beautiful structures, these elegant machines we struggle to understand, which keep our biological lives in motion. The first was nearly three years ago, in neuroanatomy lab, when I removed and then held in my hand the brain from my cadaver for the first time. Chilling and inspiring and sad and exalting and humiliating all at once. I felt a bit like a stage Hamlet pondering Yorick's skull, only I was wearing scrubs, and I reeked of formaldehyde. I guess satori is independent of the scent of carcinogenic preservatives.

Back in Jay's surgery, several pictures were taken, as this is a "once in a career surgery, for some" in Dr. Lest's words. I certainly won't see it again. Then he and the chief were able to close the hole and reconstruct the bones to partway cover it, and start the kid on the road to recovery.

I was curious, as was the family, what this kid's chances for recovery are. And apparently, no one knows. Only time will tell. But Dr. Lest has "several dozen" former patients who've had this procedure done who are now doing just fine in school, apppropriate to their grade level. And the only way you can tell is, in his words, that they wear glasses. Anything is possible. There's a card taped to Jay's warmer that says "God is with you." Certainly, this is true, and therein lies his greatest hope.

First picture from enotes
Second two from Gray's Anatomy (not the weird medical-ish soap opera, the real one)

Holistic thinking

I've been wanting to write a more substantive comment on the recent discussion ranging from here to ibid's and S. Lee's blog and back on neuroscience. Unfortunately, every time I try to string something coherent together, I am unable to express what I'm thinking. I keep returning to what one of the commenters said on ibid's post, "neuroscience is the frosting on the cake...analyze while you eat." Which, at first reading, was unsatisfactory. I thought the poster was ignoring the the issue at hand. But when I thought about it some more, I realized that's precisely the point. It is easy, I think, to become so wrapped up in details that the picture fades. As with a Magic Eye poster, you have to step back, and use the right filter, and suddenly the picture makes sense. Reality, similarly, is best appreciated holistically, and though the details are important, they are not the picture. To use another poster-metaphor, it is possible to make a photo mosaic of almost anything, using smaller, more detailed, but incomplete versions of the whole.

Returning from the world of metaphor, though the details are important to understanding, what is more important is the reality of which they are a small part. Even though the details, in this case neuroscience, may seem to give contradictory information, I am confident that the balance of reality will prevail, and that over a long enough time course, the scientists will find themselves saying, with Eliot:

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.

Every piece of the whole, eventually, leads us to a greater understanding of it. Einstein's famous theory may have changed the way we understand the orbit of Mercury, but it does not change the singular experience of watching that beautiful planet arrive over a ridge line just before the sunrise. Bernoulli's famous principle may have allowed us to fly, but it does not alter the wonder with which we watch a flock of geese winging south.

Though on the balance, I dislike the man, Walt Whitman reached a similar conclusion, and summarized it better than I can, when he wrote the following:

When I heard the learn’d astronomer;
When the proofs, the figures, were ranged in columns before me;
When I was shown the charts and the diagrams, to add, divide, and measure them;
When I, sitting, heard the astronomer, where he lectured with much applause in the lecture-room,
How soon, unaccountable, I became tired and sick;
Till rising and gliding out, I wander’d off by myself,
In the mystical moist night-air, and from time to time,
Look’d up in perfect silence at the stars.

We can do little less. I may know progressively more about the way my patients think, and the fact that they are crying before a procedure may tell me their amygdala is working overtime, but it doesn't change the reality that they are scared, and it doesn't change my responsibility to hold their hand and talk them through it. The reality of our perceptions is where each of us must live, and as a Christian, I must interpret that reality through the lens of Christ, who asks each of us to act as if we had free will, whether or not we truly do. He asks each of us to have compassion, whether or not that can be reduced to a set of electrochemical principles. Doing less, on the basis of conjecture, would be irresponsible and wrong. And those are two things for which we cannot write an equation. We must simply know their reality.

Evening Rounds

It will come as no news to anyone who reads this blog that there are differences between surgeons and physicians. (Ha, low blow already, obviously I've picked a side) Anyway, that difference was made starkly apparent this evening on rounds.

Rounds, for anyone who doesn't know, is what docs call our going around as a treatment team to call on each patient we are taking care of. On a medicine service, this usually involves going into the patient's room, saying hi, chatting a bit, doing a quick (for medicine) exam and discussing findings and options, usually about fifteen minutes per patient if we are moving lighting (again, for medicine) speed.

Today I witnessed absolutely the quickest patient rounds I've ever seen. We saw the first patient, who is about to be transferred out of the SICU, and the chief resident literally looked in the door, pointed, and said in an earnest and friendly voice: "you okay pal?" Recieving an affirmative answer, we went to the next room.

As a future internist, I was a bit surprised. I mean, the guy is getting better, but he's still in the ICU. But, like I said, there's a difference between our styles of thinking.

A lot of it, I guess, is in the nature of the problems we face. For a surgeon, the patient's big problems are behind them once they get out of the OR. (And heck, if a neurosurgery patient is aware and talking, things are going fantastically well.) For an internist, they are probably only beginning. And while I respect the surgeon's drive and intensity, I possess more of the thoroughness and patience of an internist. Residency choice confirmation #203.

And as a short commentary on yesterday's post, two things. (I love numbered lists. For some reason, I think that fits with the topic at hand...) One, you know you're tired when you put the honey for your tea on the coaster, rather than in the cup. But two, with warm food and a job that is fun, lack of sleep fades in significance.

But I'm still headed to bed.

What time is it?

My alarm went off at 4am today. This was intentional. It is also insane. I just returned home, a little more than 17 hours later. I'm trying to wrap my mind around the idea that this will be my life for the next year, at least. I'm also quite thankful I didn't select surgery, where this would be my life for the forseeable future.

Only three and one half weeks of neurosurgery left.

Neurosurgery begins

Today I spent most of my time in clinic, usually regarded as a painful experience by most surgeons. It's easy to see why, as one of the staff docs saw thirty patients between 730 and noon. But thankfully, I have an out from some of the craziness. One, the surgeons know I'm likely to slow them down with some of the patients, so I'm not expected to see follow-ups or patients I'm not going to learn from. And two, I signed up earlier this year to teach the first year students about medical interviewing, which will take me away from this madhouse at least one afternoon a week.

Still, there is a charm all its own to this clinic. The surgeons themselves are much more laid back than might be expected from the reputation of neurosurgery. One of the senior staff members has a wonderful sense of humor as well. Today, I was presenting a patient to him, who had come in solely to get Dr. Lest's opinion on another doctor's advice. When, as part of my presentation, I mentioned that this patient "respects your opinion, in his words" Dr. Lest shot back "that's the narcotics talking." When, later in the day, he was describing a procedure he will be performing shortly, he said "Not a big deal. I'll just make an sagittal incision, expose the cerebellum and occipital lobe, and do the resection around the tentorium. It's not brain surgery." He smiled and paused. "No, wait..."

And I got the word that, this being a surgical service, I am welcome to wear scrubs, even in clinic. Wonderful.

Notes on another day in hospital

First, a bit of advice. If you are going to be pretentious and cool, and order your meal in the cafeteria in Spanish from Julio (who is a really nice guy speaking perfect English), you are absolutely not allowed to complain that he got your order wrong. I already could tell your Spanish isn't the greatest, you had to ask one of the words you used, your accent is worse than mine and I've been told by Spanish speakers that I sound like a Russian when I try to speak their language. (And channelling Trotsky is definitely passe. Even Christopher Hitchens is backing away from it now.) Anyway, complaining about your order after your own linguistic debacle is not classy, and it holds up the line. Plus, friend, this is a hospital. Probably a fourth of the docs in here can not only order in Spanish, they can discourse on G-protein signalling in it. You aren't impressing anybody.

Ok, that was uncharitable. Sorry.

Second, ahhhhhhhhhhhhhhhhh. I know I am probably deeply disturbed for feeling and saying this, but it was so refreshing to walk back into a hospital. Though I don't want to become a hospital junkie, I can see the appeal. And three weeks of vacation seems overlong for some reason. Work is good, and I like it.

No patients yet, as it was orientation time, but I'm sure they will start coming tomorrow.

Thinking about neuroscience

Everybody's
talking
about
it.

To set the stage for those of my readers who do not read the blogs of the commenters here, I'll explain that of the four above links, the first two are blogs discussing the second two, which are articles. The essential question is, what are the implications for faith of neuroscience, which to hear Tom Wolfe tell it (third article), is rapidly approaching a point at which everything can be proved to be determined by our genes.

I want to write something on the topic, but S. Lee has gone and provoked a whole round of new musings, so that wil have to wait. I recommend checking out what he has to say, meanwhile.

Internship? I must be dreaming?!

So I can tell I'm starting to worry about internship. Last night, I had a dream in which I reenacted a conversation I've had about 50 times over the holiday break, which usually begins with Distant Family Member X saying something like "So, what exactly is internal medicine?"

My stock answer is "if you're over 18, not pregnant, and don't need surgery, you come to me." Which isn't exactly true, but it is close, and of course every correct medical answer begins with "it depends." (Thank you Dr. Harvard)

Anyway, so, I'm having this dream, and all of a sudden, the random person I'm talking to about my chosen field starts getting hives, falls over, and codes. (I swear I'm not making this up.) And I look around, see someone else, and yell at them to bring the code cart as I start CPR. (Code cart? I don't remember this conversation being in a hospital.) And then I start trying, in my dream, to remember doses of epinephrine and atropine. I woke myself up after getting frustrated trying to start an IV, and not being able to find my ACLS handbook. In my sleep.

Maybe this is a good thing. More likely it is a sign of things to come, and that's not entirely pleasant. I know in college I thought it was a positive sign when I started dreaming in Russian, but now I'm not so sure.

Flashback: General Surgery

I started this blog after I had finished my general surgery rotation, so for the two fold purpose of preserving another story, and providing entertainment whilst waiting for my next rotation to start, I offer: my first day on general surgery.

I knew I was probably in trouble on this rotation. The middle four weeks of my surgery experience were to be spent on a general surgery team, the non-laproscopic surgical oncology one. Later on, the one shining light of a resident in the whole malignant program would call our team the "kings of maximally invasive surgery" but that was still waiting. But I knew I was in trouble because I had been at a large hospital staff meeting at which some awards had been given out, and the surgeon who was to be my chief had gotten one of the big ones. He never smiled, through the whole process. What kind of a guy is lauded in front of most of his peers and never smiles? A surgeon, I guess. I counted myself lucky that I had four weeks of surgery already, and knew the basics of scrubbing in and such.

Day one of general surgery then, worried me. When I came in the first day, I knew we had two thyroidectomies scheduled, because I had checked the schedule before leaving the previous day. (I wasn't usually that OCD on surgery. That showed my nervousness) And I was a little relieved that my best friend from my class was on the same team. As we came in to the scrubstation, Dr. Neversmile looked at us, asked our names, and said to my classmate "You. You're the med student on this case." Then he told the chief resident to page him when the patient was ready, and left the OR. During that first surgery, I became more and more concerned. Surgeons (and some other docs) like to "pimp" medical students, by asking them harder and harder questions about the surgery they are performing (if they are nice) or whatever comes into their head (if they are mean), usually with the intent of belittling the medical student. Supposedly, pimping is meant to be educational, but usually it just scares the med student into reading in his off time. Anyway, Dr. Neversmile was asking some ridiculously difficult questions, and my classmate was not doing well. Once or twice, when he didn't merely shrug and ask another question, he would look over at me and ask the question my friend had missed. Both of us came out of that surgery shaken. I was more worried because I had to bear the brunt of the questions for round two.

The second surgery began much like the first, technique-wise. In a thyroid surgery, the medical student stands at the head of the patient, reaching around the head on both sides to hold retractors to expose the gland. It is difficult to see anything unless you lean partways over the patient's head, and this gets dangerously close to invading the surgeon's space. My classmate had been told repeatedly to move his head back, which demand would invariably be followed by a completely unfair question like "which artery is this?" And "I can't see it" is not an acceptable answer. So the good doctor started his incision, and as he was placing the retractors, took the time to look at me and ask "who was Charles Martel?"

At this point, I was nervous enough not to think that this question might have anything to do with surgery. Having had more than a little history in my education, I quickly answered "he was Charlemagne's grandfather, steward of the royal house of France, and commander of the army that held the Muslim invaders back at Tours in, I think, 723 AD."

Dr. Neversmile, who had looked back at his work, stopped. Looking up at me, he said "do you know what that was?"

"No sir."

"That, Nathan, was an afflatus. Do you know what an afflatus is?"

"No sir."

"It is a flash of divine communication of knowledge, as if the person was breathed upon by an angel. Do you know any angels?"

"No sir."

"Anyway, that was brilliant, but not the answer I wanted. Charles Martel was actually a sea captain who was the first person to have his thyroid removed, and who died because his parathyroids were removed as well. Here, let me show you something..."

And that was it. From that point on, Dr. Neversmile was nice to me, in his own way. He still made me hold a retractor on a liver case for 4 solid hours, he still asked ridiculously difficult questions, and he still never smiled, but he actually taught me from that point on, and when we did thyroid cases, he let me peer over the patient's head and see what was going on. I actually came out of the rotation having learned something besides the fact that I never wanted to see the inside of an OR again. Thank God for that afflatus.

*As a side note, I was actually wrong about the date of Martel's victory. It was in 732 AD. It didn't seem to matter. Also, the picture of Martel the sea captain is from American Journal of Surgical Pathology. 20(9):1123-1144, September 1996.

Happy New Year

Nothing much to say, but I did get to see some snow, finally. Of course, I had to fly three fourths of the way across the country to do it, but you do what you have to do, right?

On the work front, I'm busy reading my Neurology Primer and a few other books I've picked up in the desperate attempt to not look like an idiot over the next four weeks. I know next to nothing about neurology. It truly is a black box, as far as I'm concerned, despite having a good friend who is getting his Ph.D. in the subject.

But nevertheless, it is important, and learning important things is ostensibly why I'm in medical school. 137 days to go...