The Brain Drain

So, I am on the Neurosurgery service this month, and one of my responsibilities is learning how to place ventriculostomies.  They look like this...

As I mentioned in my prior post, they serve to help monitor the pressure inside of the skull, and can be used as a means of releasing pressure if it starts to get too high.


You basically find your landmarks, put some anesthesia into the skin, drill a hole, hit the right spot, slide the tube in, connect it to the monitor, and then sew everything in place.  Before you get too freaked out, remember that the patients we are putting these into are the victims of head trauma.  So far I have helped put in four. 


Last night I put in one under CT guidance.  That's where we get a CAT scan, put the tube in part way, get a CAT scan, adjust, and repeat until we have it in the right position.  At one point I was leaning against the machine, standing on one foot, drilling the hole while my attending leaned against my shoulder to make sure I was heading in the right direction.


Again, while I can't talk about specifics, these are a few of the patients we are currently monitoring:


 - gun shot wound to head
 - hit while riding bicycle
 - roll-over car accident, not wearing their seatbelt
 - intoxicated and fell off moving vehicle
 - assaulted and hit on head
 - not wearing helmet and flipped over front of bicycle


It's just been a week, but it's turning out to be a great learning experience so far!

Under the Pale Moon Light...

So, this month, I am on-call with one of our neurosurgeons.  Since I am going to a place with no neurosurgery back-up, I thought I would take the initiative and find out what I would need to know to be able to manage any patient that came into the E.D. that would need to be stabilized before transporting them several hours away to a University facility.  Plus I get to spend some time in the O.R.and learn other procedures so that is a bonus as well.

Last night I was awoken from my sleep and drove to the hospital in the middle of the night under a full moon for this....

Let me explain... this is a CAT scan of someone's skull.  The shiny thing at the bottom of the screen is what is left of the bullet that struck this person's head.  In the upper left, you can see the hole the bullet made, and the small white pieces that are scattered just to the right of the hole are pieces of bone that entered the brain when the bullet came through.  We spent the first part of the surgery clearing out the clot that had formed.  We spent the next part of the surgery clearing out many of those pieces of bone.  We spent the final part of the surgery getting "the heck out of Dodge" as the patient was bleeding profusely and needed to be stabilized in the Trauma ICU.

When we arrived in the TICU, we put in an ICP monitor at the bedside.  This will measure the pressure inside of the skull (IntraCranial Pressure - ICP).  High pressure is bad because there's a certain pressure above which the brain doesn't get any blood flow.

I'll post photos as I can during the next month... hopefully there will be some happy endings as well to talk about.

Back to the Future

From my Central Line posting:

I think the first and most lasting memory we all have of medical school is cadaver lab.  That is where we met our first patient and started to learn about disease processes.  It’s where a lot of us experienced death up close for the first time and began our lifelong pursuit of staving it off for as long as possible.  We shared the experience with our classmates – bonding us together as future physicians.  So many friendships (and a few romances) were made over that cadaver.

I remember the nervousness as we decided who would make the first cut.  We started our dissection on the upper extremities, and that first incision to expose the flexor muscles of the arm seemed so impossible.  Who were we to cut into another person?  Shaking scalpel aside, we made our way through.

Today I was faculty at my final cadaver lab of my residency teaching the junior residents advanced procedures such as venous cutdowns and thoracotomies.  There was no hesitation in their hands as we identified landmarks and dissected out veins.  Everyone reached for the scalpel in anticipation of making the thoractomy incision.  Eager hands reached in to find and cross-clamp the aorta.  No nervousness here.  Everyone was eager to cut and learn.

As I count down the final several weeks of my residency and look to my future as an Emergency Medicine attending, I find myself thinking back more and more on my training.  Days like today take me back to where I started;  scared, unsure, wondering if I would be able to pick up that scalpel.  Now I can see where those first tentative days have led me to.  And, I thank all of those patients who gave of themselves along the way so that I could continue the promise I made to that first patient so many years ago…  ”Rage, rage against the dying of the light…”

We Got Your Back--board

There's two ways to come into the E.D. at the County:  one is passing by the waiting room, and the other is coming up the back stairs and passing the hallway where the backboards are stacked.  Either way, I can get an idea of what's waiting for me inside the E.D.

Most of the time when we take someone off the backboard, they've been placed on it as a precaution following a fall or a traffic collision.  Sometimes there's blood on the boards.  Sometimes worse.

They all get brought here... to the back hallway.  Here they wait for Environmental Services to give them a good wipe down.  There's actually a separate stack for clean versus dirty.  The clean ones get picked up eventually by their respective EMS agencies so there is a constant ebb and flow to the stack.

Still, in general, it's a good indicator of how a day is going, or how the day has been.  Lots of boards means lots of traumas, and they slow the whole E.D. down, hold up resources, overwhelm the staff.

I make a conscious decision on most days - front entry and pass the waiting room to see what's coming;  back hallway and backboards to see what's been... it helps to prepare me for the shift ahead.

Theme Night

Talk to anyone working in the Emergency Department, and inevitably it seems that some days there's a theme running through the department.  Last night was "I Broke My Face" night.

36 year old who fell headfirst off of a balcony down to a sandy bottom below.  They thought they had a small scratch on their eyebrow.  They came to the emergency department because their eye swelled up and looked like a beet was growing out of their eye socket.  CT scan showed they broke their face.  They were  admitted for having pneumocephalus - "air in the skull."

20 year old who fell headfirst over the handlebars while biking with a friend.  Seems their front tire struck their friend's back tire.  No helmet.  Landed right on their face.  CT scan showed they broke their face.  The eye socket is made up of 4 walls.  They broke three of the four.  They got to go home with antibiotics and a follow-up with the facial trauma service.

25 year old that got mugged.  They were punched in the face and came in with a swollen cheek.  CT scan showed a broken cheek bone, otherwise known as the zygomatic arch.  Because it was broken in multiple places and pushed in, they most likely will need surgery.  I left that one at the end of my shift, so I will find out what happened to them when I go back.

40 year old that was drunk and crashed their car.  Since they weren't wearing their seat belt, the windshield stopped them from flying out of their car.  However, they broke the windshield with their face.  They broke their face in about 10 different places.  The facial trauma service was going to look at that one when I left.

I worked all Fourth of July weekend and kept expecting it to be a "Drunk and Disorderly" theme weekend, but surprisingly it wasn't.  However, the Trauma season is in full swing, so the hits will, literally, keep on coming.

Playing Doctor

 For those of you that followed me from the time I was writing on "Do They Have Squirrels in Buffalo?" you might remember that I left Minnesota to move to Buffalo and start an Emergency Medicine residency.  My first post about working in the Emergency Department included my saying, "I know eventually I'll stop feeling like a medical student and start feeling like a doctor again."  That was on September 12th, 2007.


Since I have to give my residency program a full 36 months, I will be in Buffalo until September.  All of my colleagues are gone and most will be working their "real job" starting this month.  So, I am working as the senior-most resident in the E.D. along with the new 3rd years.


It's been kind of interesting, and I've taken a bit of ribbing, especially from the attendings.  Today, my nickname was "pre-ttending."  I sometimes feel like I am.  While my third year started along with my colleagues, and I actually have done my 12 months of being senior resident, I think you really need to be on your own to make that final leap from resident to attending.


What I do notice is that I seem to go on auto-pilot a lot of the time.  I remember a case where a patient coded and the attending asked what I wanted to do next.  I froze.  Now, I run codes without thinking.  I guess that's where the training has come in.  Come in with chest pain, get chest x-ray, EKG, cardiac enzymes, MONA, etc.  Come in with abdominal pain, IV fluids and anti-emetics then plus/minus on the CAT scan.


While I still falter a little on the esoteric nuances of EKG's and multiple sclerosis, I think I am doing pretty good for the most part.  Another three months and I will be close to perfect... at least I hope so... for my patient's sake.