If all goes well, the entire team makes it up to the cafeteria for a working breakfast. That’s when we receive the update from the intern regarding the floor patients. Patients who have made it to the floor are usually pretty stable and so we trust the intern to look after them. Vexing social issues tend to be more common than medical issues: Mrs. Y’s family doesn’t want to take her home and they don’t like any of the nursing homes they’ve seen; Mr. X’s wife is upset that Dr. Z hasn’t been by to speak to her in two days; Mrs. Q is still complaining of pain but her insurance won’t cover another day here. In general, we can’t focus much on these things as residents. They are too remote from the life-and-death end of the spectrum and we don’t have much time for them. They wear on us, though, like water on a stone.
At the end of breakfast, the critical discussion of the day takes place: Which residents will be assigned to which operations? This largely dictates how the rest of our day will go. Seniority rules, with chiefs granted their first choice. Many factors play into the decision: which attending is involved, how technically challenging or “fun” the operation will be, whether it’s a “fresh” case or a “redo” case, and whether the operation is routine or uncommon. One of my chiefs would display his seniority as a royal might display royalty. He would look over the schedule and announce to the rest of us, aristocratically: “Today I will be in room seven with a fresh microvascular decompression, followed by a light lunch, and I’ll finish off my day with a nice microdiscectomy.” The same chief was famous for telling us at breakfast: “If you need me, I’ll be in the pons” (a part of the brain stem).
The more junior residents came up with clever ways of enforcing fairness in their more meager choices, the leftovers. A common method was to use a special trump card that was passed between residents of the same rank, usually kept in the breast pocket of the white coat. During one year, a photocopy of our chairman’s face was taped to the card to give it an air of official sanction. The card was more often used to avoid a case that nobody wanted to do rather than to select a choice case. It was handed between residents, always with a touch of drama and ceremony.
By the time breakfast ends at seven-thirty (just in time for the OR), we have discussed every last patient. Given the natural ebb and flow of disease, trauma, and our attendings’ national meeting schedules, our neurosurgery service can consist of as few as twenty-five patients and as many as seventy. The census typically hovers around the fifties or so. Central to keeping everything organized is “the list”: a continually updated computerized roster of all the neurosurgery patients in the hospital. The list is so critical to keeping everything straight that any perturbations can cause widespread grief, and even panic, across the entire team. When the computer system is down altogether, and lists cannot be printed for morning rounds, the f-word is bounced around liberally among all the residents. Everyone is then forced to write all the names by hand, and the mood quickly sours.
One of the worst fates that can befall an individual resident is to lose the list while on call. This can ruin your night. It’s not that the computerized list is irreplaceable—it can be reprinted—it’s that the notes scribbled underneath each name serve as critical reminders of who the patients are and of the numerous tasks required of you while on call. If you lose the list, you have to try to recall who was having which scans, who needed certain labs checked, and who needed a spinal tap. Each resident knows a handful of the patients very well, but the rest are known only secondhand, from the brief presentations on rounds.
A resident can highlight the tasks on the list in many ways: putting little boxes in front of each task, lining them up in a column along the right-hand margin, using a different pen color, or circling them. It was the rare resident who had no consistent system at all, and I always worried about that resident. Critical hallmarks of a model resident are consistency and obsessive-compulsive attention to detail. A couple guys I knew, though, were a bit too obsessive, faithfully recording every last normal potassium level. I worried about them, too.
When you’re left alone in the evening with your to-do list, triage is key. You want to complete the essential tasks first, in case you end up in the OR for a few hours and can’t get to the rest of the list until early morning. Here’s what might be on a typical to-do list for one evening as a resident on call: check four scans, check three lab results, reexamine a postoperative patient and call the attending neurosurgeon with the details, do a spinal tap on one of the trauma patients with a fever, talk to an irate family member on the floor, and switch a medication dosage. As these tasks are attended to, other things pop up at random: urgent pages need to be answered and emergencies in the ER need to be seen. In between all this, you try to grab dinner.
Sometimes you can get a little sleep while on call, and sometimes not. Because I was the first and only female resident in my residency program (until the second woman was accepted a couple years later), the call room had a decidedly masculine feel. I still remember the “Tall Cool Red One” beer poster that hung on the wall, featuring a thin attractive redheaded woman in a bikini. The room was small, but there was enough wall space for two other posters, also beer posters, ones with apparently less memorable slogans. The other notable feature in the room was the dent in the wall near the phone. The phone hung just above head level on the wall next to the bottom bunk bed. The dent’s origin was easy to envision, as it appeared to be created by the slamming of the receiver end into the wall. I mentioned earlier that urgent questions about nonurgent matters can try a resident’s patience. This is especially true at three a.m. when awakened from a stolen hour of sleep.
In the morning, you begin the same routine again. The post-call morning is different, though, because it’s more difficult to stay awake and you haven’t showered (a ponytail day for me; many of the guys had crew cuts). In addition to being tired and dirty, you’re also open to critique on whatever actions you took (or didn’t take) overnight, combining a sleep-deprived irritability with a vulnerability to attack.
Arriving back home late Sunday morning following a sleepless Saturday night on call is absolutely heavenly. I would be content to sleep the day away, but my husband, Andrew, saw that as a declaration of defeat, another admission that we led highly abnormal lives. One Sunday morning, after I had spent the night covering the pediatric service and he had spent the night covering the adult service, we returned to our sun-filled town house. Neither of us had slept. I ran to the bedroom, shut the blinds, and jumped in bed. He reopened the blinds and announced that we were going to go on a hike, to enjoy the outdoors: “Don’t be lame. We have to have some kind of a life,” he implored.
I gave in but secretly promised myself that I would go to bed really early, like immediately following dinner, if not during dinner. We drove an hour away—not too smart in our condition, I admit in retrospect—to one of our favorite hiking areas alongside a whitewater river. We pulled into the parking lot, where rugged outdoorsmen were lifting kayaks off the roofs of their cars and muscular hikers were loading up their backpacks.
Andrew parked the car and I begged: “Let me just lean my seat back for a minute. I’m not quite ready to get going. Let’s relax for a second.” I could barely keep my eyes open, and Andrew gave in, leaning his seat back, too. It was nice outside. He cracked the windows. With the sun and the breeze, we both fell asleep, instantly. Several hours later, as the temperature in the car dipped with the setting sun, we woke up, put our seats back up, and headed home. We hadn’t set foot outside the car, but at least we had put on our hiking shoes and made the effort to get out of the house.
When the hospital became my home during the worst stretches of my residency, even the smallest forays out into society got me all excited. I absolutely loved going to the grocery store. Here were all sorts of people around me, not immediately worried about their health, exercising their freedom to walk up and down the aisles with no care other than what type of ice cream they wanted to buy. That was beautiful.
Being outside of the hospital did have its downsides, though. The fact that my job tended so strongly toward the serious (and often depressing) made me a little intolerant of people who voiced excessively trivial concerns. To this day, I still get mildly annoyed by people who are frazzled and tortured by the least important decisions: Pulp or no pulp? Skim or 2 percent? I feel like butting in: “Look. You’re not deciding whether or not to pull the plug. Lighten up.”
Going to a movie was a treat, but I often had trouble staying awake. When Andrew and I go to rent a movie now, he often has to remind me: “We saw that one, remember? Oh, that’s one that you slept through.” Perhaps my greatest weakness as a neurosurgery resident was that I love getting at least seven hours of sleep, and eight is perfect. I wish I could say that I was just fine with four or five, but that would be lying.
Second thoughts about the career choice tend to crop up several months into the junior year, when you realize that the routine is unremitting, you’re chronically sleep-deprived, and the highs seem a bit further apart than expected. But once you’ve made it that far, you figure you should probably just keep going, just like everyone else ahead of you is doing. When you’re still near the start of the tunnel, it is always insightful to hear from those who have already made it out. I saved an e-mail message that got tacked to a bulletin board in the residents’ office. It contained advice to the junior residents, from a recent neurosurgery resident graduate. The cynical tone is typical of the culture:
“Remember to use the Heisenberg Uncertainty Principle. Keep moving to avoid detection by the Boss. Create the Illusion of Industry. Show up at Key Events (Resident Dinners, M&M). Sit in the front row. Try to do well on the Boards because it gives you breathing room to goof off afterward. Don’t volunteer any information. Fight the temptation to offer your opinion. You will regret saying anything that can and will be used against you. Keep your mouth shut. Do not become overly familiar with Dr.
X…
Remember, you probably won’t be doing aneurysms in the community anyway. Too much work for not enough cash. You need the ancillary services available too, and most hospitals do not have interventionalists. Dr.
Y
and Dr.
Z
are the Most Powerful and should be smoothed. That’s my lecture for the day.”
Now that I have emerged from the tunnel myself, I look back on this lecture and wonder what I would add (or correct; the reference to the Heisenberg uncertainty principle may not be quite right). The advice is fairly comprehensive as it stands, but I can at least offer this additional humble, concrete pearl of wisdom: resist the temptation to eat from the hospital vending machines and the nurses’ stations on a daily basis. The stress and the erratic schedule of residency threaten to derail even the most balanced physiology. You have to work to avoid entropy, or you end up in trouble. Residents who gain weight tend to fall behind the team in the stairwells and hallways, huffing and puffing, during the mad dash through morning rounds. They can’t button up their white coats as comfortably. They break a sweat when everyone else remains cool.
Whereas some of the residents do remain principled in their eating and exercise habits (stealing away to what’s known as the “ortho library,” the weight room located in a forlorn corner of the hospital), others tend to pack on extra pounds in concert with the extra stress. Admittedly, I did slack a bit on the exercise, but I endeavored to maintain a reasonable trimness—perhaps, at least partly, inspired by the same “Tall Cool Red One” on the wall that probably should have offended me.
SEVEN
Evolution Through Blood
Two competing theories of evolution distinguish themselves by the gradations of change: gradual versus punctuated. According to the more traditional theory, evolution occurs slowly and steadily. The punctuated theory describes an uneven evolution. Based on fossil records, the notion here is that periods of relative stagnation are punctuated by more sudden and dramatic changes, propelling evolution forward at irregular intervals.
Through our training, neurosurgery residents evolve from lowly interns to fully fledged neurosurgeons. Based on my own experience, I believe this evolution is both gradual and punctuated. Although the learning curve continues unabated throughout training (and beyond), certain events push the process along at accelerated clips.
By the way, I have heard a few neurosurgeons refer to their own skill as a “gift,” as if their ability to remove a tumor were granted—fully formed—from above. This is more akin to the creationist theory and won’t be covered here. I think such skills are learned, not granted by an abstract deity.
Bleeding is a simple but pervasive theme in neurosurgery, and one that sheds light on the punctuations in our evolution. There are at least two situations I can think of that constitute informal rites of passage in the training of a neurosurgeon: removing a life-threatening blood clot by yourself and controlling profuse, active bleeding by yourself. The
by yourself
part is key. The solitary nature of these acts accelerates the evolution of self-confidence above and beyond the comparatively straightforward acquisition of manual skills. It’s one thing to act with confidence when someone is looking over your shoulder and can step in to assist (or bail you out); it’s another to remain confident when no one else is scrubbed in with you. At this point, you may be thinking, “I don’t want any trainees going through this rite of passage when
I’m
on the table!” but that’s how surgeons come of age, and it’s not as dangerous or as cavalier as it sounds. Our hands have been through all the motions before, and the necessary supervision is always around the corner.
Just to remind you, if you come to the ER of a teaching hospital in the middle of the night with a neurosurgical emergency, the resident on call will be the only one immediately available. Senior help can be called in from home, if needed. At nonteaching hospitals, there will be no resident. The staff neurosurgeon will have to be called in, which generally requires that he or she remain within about half an hour from the hospital when covering the ER (hopefully there’s no traffic). So, if you are still squeamish about the concept of the surgeon-trainee, consider the fact that this extra half hour may be unkind to a brain already under duress. I would be grateful for the omnipresent and energetic trainee.
Returning to rites of passage, I am reminded of a historic coming-of-age ritual for boys entering adulthood in certain Native American tribes: for a prescribed period of time, they had to survive alone in the wilderness, gathering whatever they could find to eat, and relying on their own skills and instincts while awaiting a vision. (Compare this to other coming-of-age rituals, like the bar mitzvah or first communion, especially when it comes to the options for filling the belly.) Although the personal evolution of a neurosurgery resident is not quite so ritualized, the punctuating events are equally compelling and memorable, and often call for a similar self-reliance.
Consider one particular night of punctuated evolution in my training. I was a junior resident, which means that it was my first fully dedicated year of neurosurgery. In our jargon, I could also say that I was a “PGY-2,” or in my second postgraduate year. (The initial year after medical school is internship. Interns rotate through a number of surgical specialties—general, orthopedic, plastic, transplant, et cetera—and are not yet exclusively neuro-centric.) I was on call overnight and it was around midnight. At this hour I was, of course, the only neurosurgical representative in this large teaching hospital. My mentors were at home sleeping, hoping not to hear from me.
The ER paged me with a level one trauma alert (the most severe). They could tell, based on the paramedics’ report called in from the ambulance, that a head injury was part of the picture. By the time I dropped whatever scut work I was doing and ran down there, the patient had arrived and the members of the trauma team were hovering like worker bees, performing their initial assessment and shouting out their findings to the nurse taking notes in the corner of the room. “Equal breath sounds!” Check. “Palpable radial pulse!” Check.
One of the first things you learn about managing trauma victims is to respect the “ABCs”: airway, breathing, circulation. The neurosurgery resident shouldn’t butt in to do a neurological assessment until the trauma team confirms breathing and a pulse. The brain is no good without blood flow or oxygen anyway, so we are willing to wait our turn at the edge of the trauma bay. Orthopedic surgeons need to wait in the hallway even longer. The brain takes precedence over broken bones.
The bummer here was that the patient had just received medication to paralyze him, moments before. He had been agitated and moving around too much, and could have been a danger to himself or others. And, it was difficult for the trauma team to assess the guy, flailing around like that. He had a breathing tube in place and the respiratory technician was at the head of the bed “bagging him.” A paralytic medication paralyzes nearly all of the muscles in the body, including the ones involved in breathing.
In these situations, the only neurological function we can check is pupillary response (the tiny muscle that controls dilation and constriction of the iris is one that still works despite a paralytic). The other reflexes are pharmacologically suppressed, so there’s really nothing else to test. I shined a penlight in his eyes and saw that both pupils constricted briskly and evenly. I added my two cents: “Pupils equal and reactive!” Good. At least he had that going for him.
We can also glean a few important facts, secondhand, by asking the paramedics what his neurological exam was like in the field. I walked out to the hallway and took one of the paramedics aside as he was packing up his equipment.
Apparently, the patient was an unrestrained driver in a motor vehicle accident and was ejected from the car. The paramedics found him on the side of the highway. Nice. If he had simply worn his seat belt, he would have been awake and telling his own story. (He wouldn’t be telling me, though, because my services probably wouldn’t have been necessary in the first place. I would have completed my menial tasks for the evening and headed off to bed, actually getting some sleep before going to the OR the following morning.) His wallet was recovered from the back pocket of his jeans. Based on his driver’s license, we knew his name and that he was eighteen years old.
The paramedic told me more. Surprisingly, although our subject was unconscious in the sense that he never opened his eyes or verbalized anything beyond a moan, he was still “localizing” at the scene: in response to a strong pinch of the chest, he would reach up and try to swat the hand away. This demonstrated that he had a good deal of higher brain functioning. He was at least sophisticated enough to feel pain, localize it, and try to stop it. These types of movements are considered purposeful. The ability to follow commands (“show us two fingers,” for example) is one step ahead of localizing. He wasn’t able to achieve that level of sophistication.
We have a standardized grading scale for head injury patients, the Glasgow Coma Scale (or GCS). The exact details aren’t necessary here, but suffice it to say that the scale has three components: eye opening, verbalization, and arm movement. We can make some rough predictions about long-term outcome based on a head injury victim’s initial score at the scene or in the ER. Based on the paramedic’s report, our patient scored a five out of six—not bad—in the last category. He was certainly not a lost cause.
Doctors often speak in a very matter-of-fact way during critical situations like this. They discuss the facts, the protocols, the procedures. An outsider might find this discourse cold and unfeeling, even bordering on cruel. After all, we’re talking about an eighteen-year-old kid here. He’s a senior in high school. He has parents, siblings, friends. He’s part of a community. He has a future. Maybe he has a girlfriend. Was she in the car, too? The emotional impact is staggering. He’s not just a collection of clinical data.
Believe me, I have these thoughts, too. In fact, I can become plagued by these thoughts. During the first few moments in the ER, though, dwelling on them is distinctly unhelpful. In fact, anything that slows us down is not only unhelpful, but possibly even harmful. The ability to act quickly could mean the difference between this eighteen-year-old going to college or heading for a nursing home. We do have feelings, but our predominant thought in the heat of the moment is: we have the ability to help this guy; what do we need to do for him? The cool clinical demeanor reflects the practicality of getting a job done; it does not reflect a lack of humanity. Later, when his bodily organs are stable, we can reflect on him as a person, at least until the next ambulance arrives.
At this point, the trauma team needed to get him to the CT scanner, just a few steps down the hall, as soon as possible. (In busy trauma centers, it is nice to have a dedicated scanner right there in the ER.) The team was a machine. He was in the scanner within about ten minutes of hitting the door. After positioning him on the scanner table, everyone scrambled into the control room to watch the images as they appeared on the monitor, one by one.
A head CT starts at the base of the brain and works its way up to the top in serial slices. The first few images looked fine: no blood on the lowest cuts. The critical cuts through the temporal lobe, though, were a different story. Freshly clotted blood on a CT scan is bright white. There was plenty of bright white on these cuts. The patient had developed a large right-sided acute subdural hematoma, a blood clot that forms between the brain and inner surface of the skull, just underneath the dura, or outer lining of the brain. In this scenario, as ongoing bleeding expands the clot, the brain is pushed aside and can knuckle into the neighboring brain stem. Once the brain stem is threatened, life is threatened. A telltale sign of this knuckling, or herniation, is dilation of the pupil on the side of the clot. The nerve that controls pupillary response (the “third nerve” or “oculomotor nerve”) runs just adjacent to the brain stem. His pupils had been fine just a few minutes prior.
I ran from the control room to the scanner. I opened his eyelids. His right pupil was now “blown”—our short way of saying fixed and dilated. It was huge and round and did not respond to light. This clot had expanded (and was expanding) before our eyes. My next thought was not really a thought but a knee jerk. “We’re going to the OR.” The “we,” though, was really just “I.” And, for the first time, I was rushing a guy to the OR by myself with absolutely no time to kill. If I waited until senior supervision arrived, this eighteen-year-old was definitely not going to college.
I was ready for this. The neurosurgeon who taught me the ropes is a nationally renowned head injury guru and had taken me through all the steps before. He warned me that if someone is dying of a subdural hematoma in the middle of the night, he doesn’t want to hear my voice on the phone. He wants to hear the voice of the OR nurse relaying the message that I’m in the OR and the patient is on the table. So that’s what he heard.
From the ER, we wheeled the patient into the elevator for a short ride up to the OR on the second floor. I killed the otherwise idle fifteen or twenty seconds in the elevator by shaving the right side of his head. We keep extra razors in the call room. One of my senior residents told me to keep one handy at all times in my white coat when I’m on call, for occasions just like this. Sometimes a razor will get passed, batonlike, in slow motion, from the resident finishing call to the resident starting call, as if in a relay.
In the OR, the anesthesia team kicked into high gear, receiving the handoff from the trauma team—another well-oiled machine. The OR nurses were flawless, too, unwrapping the instrument trays, wheeling the gas tank for the drill into place, setting out the sterile gowns and gloves. (They had done this a few times before.) I sprayed Betadine, a brown antiseptic solution, over the patient’s freshly shaven scalp and got started. Few words were exchanged: ten-blade…retractor…drill…suction.
By the time my attending walked in, the clot was just on its way out. He scrubbed in to check my work and helped me finish the case. At the end, he patted me on the back and thanked me for “saving the guy’s life.” Although the gesture and words were simple, they were enough to propel my confidence and complete a stage in my evolution. Going forward, I knew that I could remove a blood clot, rescue a brain stem, and remain calm while doing so. At that moment, I felt a little more like a real neurosurgeon, and a little less like the poseur I had worried that I was.
In retrospect, the line about “saving the guy’s life” implied individual credit where team credit was due. I was only one person in a large team that saved his life, including: the stranger who called 911 at the side of the highway, the paramedics, the trauma team, the CT technician, the anesthesiologists, and the OR nurses. Efficiency saved his life. If he had arrived in our ER an hour later, or was delayed in getting up to the OR, I would have been next to worthless.
As with many exhilarating experiences during residency, this one was tempered by the slow onslaught that followed. His recovery was prolonged. He didn’t regain full consciousness for days. We watched a steady stream of despondent relatives and friends file into and out of his ICU room. We checked labs, wrote notes, consulted other specialists, performed countless exams, and ordered follow-up scans. We worked to get him off the ventilator. We held family conferences. The questions from loved ones were thoughtful, understanding, and unremitting.