Friday morning I was planning to spend some time with my parents. They had
arrived at the airport late the night before so I thought to catch up over breakfast.
I was on call on Friday (that is Christmas eve, as well as Christmas day and
Boxing day!) but I was a bit relaxed as Keenan, the on call resident on Friday was
quite experienced. He had passed his qualifying exams and was heading to become
a consultant. He could handle pretty much everything, what could possibly be
referred that he would require for me to rush to the hospital?
Within the noise from the showering water I heard the xylophone ringtone of
my iPhone. I had developed like a sixth sense to hear my mobile under all conditions, even
during driving with blustering music or walking in the middle of very busy
London neighbourhoods. I also know when it is from the hospital, that is my
seventh sense by the way. More about the rest of my extra senses in future blogs.
Keenan started presenting an urgent referral, in a polished, professional way, in a
strict chronological order. This is a skill trainees develop over the years; no
TV-like drama, no panic, just the facts, complete and starting from the
beginning. How old the patients was, what he was doing before he became unwell,
what are his neurological responses and what was the findings on the CT scan.
As you treat more and more patients you realise that diseases of the brain follow
a pattern, based on the age of the patient, the gender, the time of the day,
and the beginning of the story. With every sentence that comes out of the mouth
of a resident, your mind frantically and automatically searches its database
for similar patterns and matches thousands of possible diagnoses in a split of
a second. For example if the resident starts talking “an 80 year old woman
presented with recurrent falls…) you think instantly: “chronic subdural
haematoma”, before the keen resident finishes his sentence.
So my resident started talking “a 27-year old man with a GCS of 4 (that is
very deep state of coma)” (i am thinking acute extradural haematoma, and
thinking at the same time, Keenan is experienced enough to handle that, I
don’t have to rush) “and CT showing an intracerbral haematoma” (i am
now thinking a bit more tricky but my resident can still handle it) “and
blood in the Sylvian fissure” (i am now thinking aneurysm, my resident
needs my help) “and possible evidence of an AVM” (i am now
thinking, I got to run). All these raced through my mind before Keenan
had finished his first sentence.
I was in the hospital about half an hour before the ambulance arrived and looked
at the scans. A very large, 10 cm blood clot was sitting deep in the dominant
left hemisphere, between the temporal, posterior frontal and parietal lobes,
that is a potential damage to what controls at least movement and feeling in
the right hand side of the body, speech, and memory. At the depths of the blood clot, a vascular malformation, a bunch of abnormally dilated veins was the culprit of the
catastrophic bleed. This malformation, or AVM as it is formally called, was possibly there since the birth of my young patient, like a ticking bomb waiting silentelly for twenty seven years to go off this Christmas eve.
I had a clear plan before the patient arrived, I had asked Stephan, a world-class
neuroradiologist (was so lucky he was on call with me!) to block off the
abnormal veins with a special type of glue stopping further haemorrhage. That
was less risky than removing a very deeply seated malformation through an
operation. I would then go in to remove the blood clot by doing a craniotomy.
When my patient arrived he was intubated with his organs supported. Around his
trolley in intensive care unit about ten health care professional were
instantly gathered; paramedics, anaesthetists and nurses from the referring hospital and
anaesthetists and nurses on our side, taking a handover, replacing arterial lines,
taking new specimens for labs and cross-matching blood, taking notes. I looked
at his pupils; both were fixed and dilated, a very bad sign that the patient
has already started slipping away with irreversible brain damage. A second team
with radiologists and anaesthetists were waiting in the basement for embolization.
A third team with my theatre nurses were waiting in theatres of the first floor
preparing the equipment I asked them to have ready. About thirty people with all the skills and expertise they accumulated over the years were ready to start a battle on a Christmas eve, for a young man who, strictly speaking, was clinically dead.
I spoke to my neuroradiologist, Stephan said he needed about half an hour to
block off the malformation, I looked again to my patient with fixed pupils. My anaesthetists were waiting to take my patient to neuroradiology. I had no time! Change of
plan! I decided to take my patient straight away to operating theatre, remove
some of the clot, then embolize the malformation and return back to theatre to
complete the clot removal. I removed a bone flap that gave me access to the
affected part of the brain. Upon making a very small cut in the surface of the brain,clotted blood was expelled under extremely high pressure. It was bleeding a lot! I removed some more blood clot. In a few minutes the brain started pulsating with each heartbeat, a rather good sigh as opposed to a stiff, lifeless brain. I stopped the haemorrhage, put temporarily the bone flap back and prepared the patient for a trip to angiogram suite for embolization. When I removed the drapes and I looked at his eyes, his left pupil had come down in size, the first step was successful.
The embolization was tricky, took an hour and a half, longer than expected but was successful. The patient came back the theatre for the 2nd stage of his operation. Under the operating microscope I removed all visible blood clot and started searching for pockets of blood hidden in the brain. That specific area of the brain was extremely sensitive,
or eloquent, as neuroanatomists have historically called it. Any damage would cause
irreversible loss of speech or movement, although the blood clot had already
caused tremendous damage. I secured under the operating microscope all small
areas of haemorrhage. I looked around through every possible corner to make
sure that there was no bleeding vessels or residual clot. My resident put the
bone flap and stitched the scalp. We removed the drapes and looked again at my
patient’s eyes, both pupils were now small, and reacting to light. What a
So often in neurosurgery we take decisions in unusual cases, patients who present in ways that books do not describe, dilemmas we were never taught or seen during our training, yet, our decisions have to be sound. If I waited for my patient to be embolised first, he would not be alive now. If I have gone to remove the vascular malformation from the depths of his brain, he would have lost too much blood. In an emergency like this you
have to decide there and then, and trust your gut feeling, the total sum of all
your experiences you had, the cases you’ve seen and treated, opinions you’ve
heard and articles you’ve read, all small and big details that emerge into your
conscious mind at that critical moment and suddenly becomes clear, “this is
what I should do!”.
Neurophysiologists tell us that the basal ganglia are not just involved in generation of movements, but used to store memories millions of years ago before language was developed. Our ancestors could remember a good or bad experience but they could not express it, they could only groan. Language was non-existing. It took millions of years for man to be able to express all depths and colours of the human thought, as it appeared in the finest form in the poems of Homer and the philosophy of Plato. We now know that basal ganglia are involved in the emotional component of memory. I believe that this is what we call a “gut feeling”. There is a reason why we think a certain decision is
good or bad, we just don’t know why because we can’t express it verbally.
Trusting your gut feelings can be tremendous in difficult cases (in neurosurgery and in life!).
All this had finished by lunch time on Friday. The three days continued with similar pace and non-stop emergencies: An elderly man who came partially was paralysed after one of his thoracic vertebra crashed as it had been affected by what appeared to be a form of cancer; we had to clear the pressure and stabilise his spine with strong titanium screws.
Another man assaulted and part of his skull was driven into his brain
substance. Other people with blood clots in the surface or the depths of the
brain, tumours in the brain or the spine, injuries and traumas…
While all this was happening, in less than a mile from Queen Square, in the room 90 of the British Museum (http://www.britishmuseum.org) masterpieces
on paper were on display (photo). Picasso, Matisse, Magritte, Mehretu among
others, made their drawings as temporary templates before moved forever on
canvas. One of the drawings (photo) led to “Les Demoiselles d’Avignon” when Picasso shocked the world of art sometime in 1907. About a mile further down, Oxford Street was buzzing with shoppers and the usual endless waves of tourists (photo). People were buying gifts for their loved ones, enjoying life, rightly oblivious that any misfortune may move suddenly their lives upside down.
Yes I know it’s nearly end of February and you’re planning your summer holidays (may I suggest the fabulous Greek islands, …no, I don’t get a commission!). Yes I know a blog is supposed to be a contemporary diary. But I prefer the emotional dust from all grave emergencies to settle down, I prefer to soften the memory of deep despair I see on the
faces of relatives when I tell them that their son, their mother, their husband
or wife may never make it. But I do love the memory of hope on their faces, the
memory of trust and confidence, the memory of comfort that they are not alone in this.
And I do love the memory of their faces when, against all odds, their loved
ones come back to them. But I can’t share their happiness for too long, my phone
is going off again, I don’t have to look the number, my seventh sense tells me it’s from the
hospital, my next case will start soon…