Sins of the Mind

I saw this movie on TV when it was released, in 1997. One of those utterly forgettable made-for-television-films. However, two years ago there was a case which brought this movie back to mind. A young woman, with a large aneurysm, very difficult to treat. The aneurysm had ruptured twice, and it seemed likely it was going to bleed again. Every time a brain aneurysm bleeds, there is a 50% chance of instant death. So something had to be done. She underwent three operations, the aneurysm was approached from both sides, and finally it was successfully clipped. Unfortunately, the procedure resulted in damage to both of her temporal lobes.

As a result, the young lady started behaving oddly during rounds. She started exhibiting uninhibited sexual behavior, speaking in a suggestive and seductive manner, as well as touching and grabbing male doctors. I started dreading the morning rounds because it was always an awkard situation. How to respond? Getting angry or reprimanding her was useless, because she did not consciously think she was doing anything wrong. Nonchalance was the only way to deal with it, and that seemed to work reasonably well.

She was suffering from Kluver-Bucy syndrome, a condition caused by bilateral (both sides) temporal lobe injury. She was eventually discharged from our unit and transferred to another hospital for rehabilitation, but to this day I don't know how she recovered. It would be interesting to know whether she was finally discharged and returned to normal life, and whether the hypersexuality persisted, and how she manages with it. Now that I think about it, I'll try to find out, and if I do, I'll let you know.

Cheers,
Stuart

 

Kids

Continuing on the topic of internet, check this out. For more information, read this article.


No surgery today, but a big presentation tomorrow, and you know how it is, haven't even started working on it yet. Must be a universal law: Presentations cannot be prepared until the night before..

Cheers,
Stuart

Revolution, finally

An off topic entry in my electronic diary, but I've noticed recently that the internet is finally changing for the better. I've been using the internet since 1990 or so, and although I'm only semi-literate when it comes to computers, I've kept myself somewhat up-to-date on what's going on.

Some years back the WWW started going downhill big time. At first, when Google appeared it was a great thing - but these days, the first 20 or so results are not what you need but commercial sites that exploit the way google works.

Now this: blogs. The world wide web is exploding, and it's becoming again what it was originally intended to be: A web of freely flowing information, where everyone has an equal opportunity to publish. The result? Blessed anarchy. The commercial powers are losing the game. People are linked to people, individuals are expressing themselves, and finding each other. And what creativity, so much talent!

And the search engines? Google is still great for finding the most relevant sites, if you know which keywords to use and which ones to avoid. But Google is not up-to-date. Many blogs (even Blogger blogs) are not found by google at all! And niche sites with few references to them are hard to find. Yahoo search is much better for bypassing the google-optimized commercial sites, and also for finding new stuff, recently published blogs, etc. Then there's Technorati of course, a great search tool for bloggers and their readers.

Having said that, Google scores big time with a new innovation again. I just got a gmail account, thanks to Dan. My first impression: this is how e-mail should be. I hope it will become available to everyone soon.

The commercial powers are looking to dominate the blogosphere, for sure. But I have a feeling we are making history now. The world of information is changing, and bloggers are the pioneers.

I know that all of this is probably yesterday's news to any hard-core bloggers out there, and that the whole phenomenon has already been analyzed to death by greater minds, probably sprouted a few Ph.D. dissertations, too, but I felt like writing this down anyway.

P.S. Thanks to New Links for the Technorati icons.

Breaking the Taboo

I'm feeling pretty good today, so for a change I reward what possible readers this blog might have with a post they won't have to cringe at..

Most people (including most neurologists) think of the brain as untouchable. We neurosurgeons don't claim to comprehend the inner workings of the brain (here's where you turn to the neurologists and psychiatrists) -- but we are manual workers, and for us the brain is accessible. We know that the brain is modular. We know that we can touch the brain, even remove parts of it, and we have a pretty good idea what it will mean to the patient. By modular I mean that the brain is not some complex neural network where everything is interconnected and nothing can be touched without damaging the whole network. For instance, if I remove someone's occipital lobe, I know that the person will suffer from partial loss of vision, but otherwise he will be the same as before. If I remove a cancerous tumor from the motor region representing the left hand, I know that there is a risk of paralysis of the left hand, but that's it - the person will be the same otherwise. I know that I can remove a part of the frontal lobe without any noticeable changes in the individual's personality or physical performance. This is what makes brain surgery possible. We know what will happen to the patient if some part of the brain is damaged, and we know what will not happen. And with modern techniques, such as microsurgery, we can access any part of the brain causing minimal or no damage.

Certain regions of the brain are especially important to daily living. We call these the "eloquent" brain areas. These include the speech, motor, and visual areas. If there is even the slightest damage to eloquent brain tissue, the results can be disastrous to the quality of life of the individual. We think twice before operating in these areas. Other regions of the brain are more redundant. Take the anterior (front) part of the temporal lobe, for instance. Removing nearly the entire temporal lobe on one side will cause no harm to the patient. Not even a skilled neuropsychologist can detect any changes after a succesful temporal lobe removal.

The ancient motto of the medical profession is "Primum non nocere", which means: First, do no harm. This is the ultimate test for the neurosurgeon: Often we need to do harm in order to heal. We must decide whether the benefits are greater than the harm done. There are great risks involved in brain surgery, and the difference between success and disaster is literally microscopic.

Inevitably, great failures happen. The most difficult part of being a neurosurgeon is learning to live with one's failures. When a disastrous complication occurs, and they do, the burden is great. The patient was in my hands, and whatever happened was the direct consequence of my actions, and the responsibility is mine alone. The way I've learned to live with it is by the realization that all of medicine is about probabilities, not about absolutes. There is always a certain inherent element of failure and misjudgment, which can never be eliminated.

 

Assorted Objects in the Brain

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Originally uploaded by Ressler.

Never mess with a golfer who's had a subpar day. This unfortunate fellow has had a 9-iron introduced to his brain.

People tend to be imaginative when it comes to dealing injury and death. One of my patients presented with a crossbow arrow shot through the eye. By a jealous boyfriend, what else is new. Another one was unexpectedly hit with a large axe in the back of the head, by an unknown person, just randomly. We did operate and he lived through the first week but the damage was too great in the end. Another one refused to offer a cigarette to a stranger and was rewarded 15 minutes later by a baseball bat in the head. The attacker had walked into a store and stolen the bat, then returned to deal punishment.

That cheer you up? If not, here's a wonderful story. There was a man who according to our hospital records attempted suicide 18 times. He wasn't very good at it. On his 12th or so attempt, he was hospitalized and admitted to a ward, which is located on the 12th floor. Like a true pro he immediately saw the unique opportunity and jumped out of the window, only to have his leg caught in the balcony railing right below. The leg was badly mangled and he spent another couple of months recovering from extensive surgery. Then, a couple of years later, someone pointed out that he hadn't been admitted recently. To this day there has been no sign of him so he must have finally succeeded.

Okay, I promise I'll try and post something more uplifting soon....

 

Knife in the Brain

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Originally uploaded by Ressler.

The image here is from the internet. I'm not posting scans of my own patients - even without the identification removed it might violate their rights somehow. Anyway - I've seen a case almost like this one, but my patient had a knife through the eye. Her boyfriend had pushed a very large bread knife into her head while she was sleeping. All the way up to the handle. She was brought into the ER with a knife handle protruding from her eye. We took her in the operating room and did a craniotomy, i.e. opened the skull, pulled the brain aside a bit, and retracted the knife while making sure that the blade didn't damage any blood vessels or the sensitive cranial nerves such as the optic nerve. The operation was a success, and she recovered very well.

A colleague of mine had to go to court to testify. He came back extremely pissed at the defense attorneys demanding to know whether my colleague could say for 100% sure that the man hadn't had second thoughts while pushing the knife and eased on the pressure feeling remorse, which they felt he had done and therefore the court should show lenience. Load of crap if you ask me.

We doctors are generally reluctant to go to court to testify, because the lawyers seem to ask trick questions all the time and it seems they exist in some other reality compared to that which we see in our line of work.

 

Dead or Alive? part II

A handy reminder that your days are numbered: Deathclock

For instructions on how NOT to kill yourself with a shotgun, look here.

A couple of anecdotes that you may or may not find amusing:

When a doctor is on call, he is from time to time required to go to the ward to determine death. A med school buddy of mine was doing just this in the middle of the night, when the patient suddenly sat up and demanded to know what the hell was going on. The good doctor had walked into the wrong room. It's also a good idea to double check that you've got the right patient file when you write down the time of death. There's nothing quite as embarrassing as discharging an officially dead person who's feeling just fine.

You may encounter surprising technical difficulties: Another classmate from med school was on call in a rural hospital, and was paged to go down to the morgue to determine death and to do a cursory forensic examination. They'd already placed the corpse in the refrigeration unit. You know the type, with the end-opening drawers. Well, he pulled out the container, which was located at shoulder-height, and, as it happened, the body was that of a very obese woman, and what do you know, the body rolled off the tray and fell on the floor. As an intern, he was too embarrassed to call for help, so he spent a good part of the night wrestling the ample cadaver back onto the tray.

My own morgue-at-night story is rather less amusing (it would be, wouldn't it). I was on call, years ago, in a small hospital up north. It was September. I remember that, because it was moose hunting season, and that's integral to this story. Word came that a woman had been shot. She went straight downstairs (that's where the morgue was), D.O.A., or should I say S.T.H.O.A. (Shot To Hell On Arrival). I unzipped the black body bag and, oddly enough, the smell of strawberry yogurt was the first thing I noticed. Pretty soon after that I noticed that there was a gaping hole in the woman's chest. There was a yogurty substance splattered all over, amidst the blood. She had a neat hole in the back. The next thing I noticed was that she was one of our nurses. According to her husband (whom I saw right afterwards), he'd been cleaning his rifle when suddenly it discharged and the round hit his wife who'd been baking in the kitchen. No mention of yogurt. I didn't buy his story. He said he was a skilled marksman (so it seemed) and had killed four moose that day (and one wife, I didn't add). He had alcohol in his blood. The police took him for questioning, and he was later tried for manslaughter. He walked.

This case will stay with me for the rest of my life, because I like to eat yogurt. Smell is a powerful reminder.
 

Dead or alive?

The boundaries that divide Life from Death are at best shadowy and vague.
Edgar Allan Poe: Premature Burial (1844)

According to this article, a hundred billion people have been born. Out of those, about a hundred billion have died. We the living are here but for a fleeting moment, mere links in the great chain of human existence.

I'm still in a morbid mood. So this is going to be another one of my more-or-less existential posts.

One of my patients joined the Air Force last night. Good for her, given the circumstances. She was in her eighties, paralyzed and couldn't talk. She was barely conscious, with no hope of recovery. Another one is silently waiting for death. He won the Jackpot this year: metastasized pancreatic cancer plus a massive stroke. I've been giving him as much morphine as the nurses can carry. Finally this morning he seemed free of pain. I was happy about it. The morphine will expedite his vacating the runway, but he's had the clearance from Heavenly Air Traffic Control for some time now anyway.

Ever wondered how you can tell for sure whether someone is dead or alive? It's not always easy, you know. If the head is separated from the body, it's a pretty straightforward diagnosis. Sometimes it can be tricky though, and for laymen I imagine it might not always be obvious. Generally, the dead do not breathe, they do not have a pulse, and they don't react to anything at all. If you find someone who fulfills these criteria, chances are they've cashed in their chips. Should you start CPR, then? If you see a person collapsing and then find out that they don't breathe or have a pulse, go for it. But if you find your 90-year-old grandmother in said state, you'd be wasting your time. If you notice signs of rigor mortis, meaning the body is rigid, they've been dead for several hours and beyond the reach of any Earthly medicine.

Speaking of the Beyond, there is something called the "Lazarus phenomenon". That's when CPR (resuscitation) is deemed unsuccesful and therefore ceased, and after a while the patient gets spontaneous circulation and starts breathing. It's very rare, but it happens. When a patient is brain dead and moves spontaneously (due to spinal cord reflexes), that's called a Lazarus sign. We see that sometimes in the neuro ICU. Another tricky situation is hypothermia. There's a medical adage, "nobody is dead until they're warm and dead". Which is to say, severely hypothermic patients may recover after surprisingly long periods of apparent death, once warmed up. So maybe Mr. Poe was right.

I've seen many deaths. It doesn't bother me much anymore. We doctors builds a huge defensive psychological wall around ourselves, and the most terrible things can bounce off our psyche like rubber balls. It has its disadvantages, though. Sometimes we may appear "cynical" when we really are not, it's just a mechanism of preserving our own mental health. Someone's death or suffering still affects those caring for them, and sometimes the defensive bubble is filled from the inside, and when it overflows, I sit down and write a new morbid post in my blog.

Death can be a good thing, like for the patients that I mentioned above. Sometimes though, it's terrible. The death of a child is always hard to take, and accidental deaths involving several family members are the worst. The Tsunami, of course, was the ultimate random death-dealer. I treated some of the victims, and talked to their close ones. Was not fun at all.

Things happen so randomly. An orderly gets squeezed to death by a trash can in the elevator, a child drowns in knee-deep water, a youngster gets killed by snow falling from a roof. Never know what's gonna happen, and to whom it's gonna happen. I call it the Great Fly-Swatter of God.

Right now I'm acutely aware of my own mortality (writing this post sure didn't help). When will I kick the bucket, buy the farm, throw in the towel? These euphemisms bring to mind my personal favorite, translated from another language, "throw the spoon in the corner". It's absurd. Just like life and death.

So it goes.
 

Deadeye Dick

A man walked into the ER. Complaint: Headache. Nil else of note. Well, you walk in through this door, you're gonna get scanned. Here's a surprise finding: a bullet in the brain. A large one, too. This one requires a closer look. Measurements: 7.62 mm x 39 mm. I've done my military service, and I know what THAT means. Time to interview the fellow a bit. Yes, by the way, I was shot in the head in Somalia a few years back. It seems there had been some kind of riot, and this man had been doing some shopping in the marketplace when he was suddenly hit by a round. The entry point was at the very top of his skull, and the CT scan showed that the bullet was located in a fluid compartment in the back of the brain, sharp end pointing straight downwards. A shot in the air amidst the riot, the gravitational parabola, a chance in a million, and this guy gets it straight in the head. Other than dropping his bananas, he had seemed fine. No brain could survive a direct encounter with the business end of an AK-47 assault rifle, but this particular round had taken the high road. I'm secretly a geek, and I get fascinated by stuff like this. So I made some calculations. Based on the conservation of energy principle, a bullet like this shot straight up would climb to 24,500 m (80,000 ft), and come back down at the original muzzle velocity, 700 m/s (2300 f.p.s.). But that's not true because air resistance slows it down both ways. It seems the Army geeks have been puzzled enough by this and conducted some experiments, and found out that the actual downward velocity of a similar bullet would be about 90 m/s (300 f.p.s.). It seems that's enough to pierce the skull, but the energy is low enough to make survival possible.

Headshots are nasty. Often there's just a neat little hole on the outside, but on the inside, it's a mess. We see quite a bit of them here. Some murders, some of them execution-like, but mostly self-inflicted, with a .22 caliber pistol. The problem with the .22 is that the energy is low, and the victims often survive initially, and as a result are operated on and spend days or weeks in the intensive care unit. Eventually most of them die (which is generally the intended outcome when one chooses to shoot himself in the head), but some survive to find their lives even more miserable than before. Sometimes it seems kind of futile to desperately try to save them, since they didn't want to live anyway. I wonder if anyone has ever sued their doctor for saving their lives after a suicide attempt? Wouldn't be surprised, really. Damned if you do, darned if you don't, right?

Shotgun is a more drastic weapon of choice for relieving oneself of earthly worries. Done correctly, it's a sure way to go. But carelessly performed, all you get is a terrible mess. Let me explain. Now, if you put the shotgun muzzle in your mouth, point the weapon horizontally, straight back, NOT upward, and squeeze the trigger, you're all set for a permanent vacation. But based on what I've seen, here's how NOT to do it: tilt your head back, press the muzzle against the underside of your chin, then squeeze the trigger. Bad idea! You'll blow off your face, but you'll live. After extensive plastic surgery, you'll go home looking real ugly, and possibly blind. It's embarrassing, really.

To end this rather grim post on a positive note, I remember a young lady who was shot in the head, point-blank range, by her jealous husband, and had a severe injury but survived, was heroically operated on several times, recovered, and visited us, wearing a nice dress, and while she had a mild paralysis, she seemed like an interesting and attractive woman, which means that the best part of her brain was saved.
 

The Drugs Don't Work

Discharge! Today's victory. The dentist with the headache. She is gone. Doctor Pain was on his way up in the elevator, but I made sure the patient went down the stairs. She has a strong jaw, and frowns constantly. The jaw muscles are strong because she has bruxism - she grinds and clenches her teeth. The frown is from the migraines. She is repeatedly admitted because of her headaches. Nothing works for it, we've tried every trick in the book. She is a Pain Patient. They are never happy. They are always in pain. "Now the drugs don't work, they just make you worse, you know I'll see your face again". She'll be back, but she looked fine in the morning. I don't think she had any headache this morning, but she frowned anyway, and I hate that. I wish she would just stop frowning. I wrote her a prescription, said "you want some rest. I'm glad you came to see me to get this off your chest. Come back and see me later, *ping*, next patient, please, send in another victim of industrial disease!"
 

Doctors

Every night I lie awake
And every day I lie abed
And hear the doctors, Pain and Death,
Confering at my head.

They speak in scientific tones,
Professional and low—
One argues for a speedy cure,
The other, sure and slow.

To one so humble as myself
It should be matter for some pride
To have such noted fellows here,
Conferring at my side.

Sara Teasdale (1884-1933)