Ninenteen

On New Year’s Day I had a phonecall for a patient who had a seizure and had to be transferred from the ward to the intensive care unit; another call for a patient who had a haematoma in the right side of his brain and became gradually unconscious; and a call for a patient with a spinal lesion who felt that her leg suddenly started to feel dead. No, I was not even on call. But I do want to know if any of my patient develop new problems. Sure, there is an on-call neurosurgeon but I very much prefer to know what’s happening to my patients at all times. I never switch off my mobile, expect of course when I am about to take off (at least on a couple of occasions I boarded on the plain while talking to the on-call resident under the not so happy glances of stewardess and trolley-dollies).

I was on call a few days earlier, just after Christmas day. Yes, something happened during that on call. But first lets go a few days earlier, a few days before Christmas. We took our neurosurgery trainees out for a dinner. We had a brief workshop earlier, how to put screws into spinal models, a useful technique for trainees (photo).

Some of our trainees learn how to fix the top part of the spine, when its falling apart

Some of our trainees learn how to fix the top part of the spine, when its falling apart

Then we headed to The Russell Square Hotel, pretty much next to Queen Square. We had our dinner at the “library room”, tall ceilings, glass bookcases with very old books. After we sat down the a professional man came to introduce himself, was the hotel manager, a Greek/Cypriot living for decades in London. he told me that this is London’d first organised hotel established sometime in the 1850’s, everything in the library room was from that date. Whoa! Our trainees and a few consultant colleagues wore their party hats, pulled crackers and had good time (photo and video). By the way I introduced videos in my blogs, add a bit of action twist.

Surgical masks and hats replaced by party hats!

Surgical masks and hats replaced by party hats!

The weekend after Christmas I was on call . Londoners and tourists alike were fighting for the Sales. I don’t like the sight of people rushing and elbowing each other to grab a shirt or a pair of shoes. Its a bit uncool. And I avoid as much as I can shops anyway, I prefer buying from the internet, street markets that thrived in different forms for thousands of years will become extinct like dinosaurs. Many retailers close down one after the other. Are you surprised that hmv went bankrupt? I am surprised it lasted so long. And by the way, do you understand people who buy CDs or DVDs? what are they going to do with them? Completely unnecessary, everything is online now, even the new 27 inch iMac has no optical drive, couldn’t agree more.

The on-call weekend was busy, people struck with all sort of maladies days only after they spent time with friends, family and loved ones around the Christmas dinner table. Some pulled through, will have more Christmases, will exchange gifts next year, will make new friends, have more dinners and drinks with friends, will achieve more, will see more, will experience more. But not all…

On Saturday my registrar called me about a nineteen year old girl. She had terrible headache. She was taken to the local emergency department where a brain scan showed subarachnoid haemorrhage, bleeding in the space between the brain substance and the membranes that wrap the brain. This is coming from a weak spot in a brain vessel called aneurysm, a ballon-like dilatation of the vessel lumen. Aneurysms are usually present for years before they eventually burst releasing catastrophic blood in the brain. This is the most severe form of stroke affecting young patients.

Patients with this type of haemorrhage are admitted to the neurosurgical unit where they have a blood vessel test called angiogram to identify the responsible vessel and then the weak spot is glued from the inside of the vessels without opening the head. Difficult aneurysm require a brain operation and placement of a titanium-made clip across the neck of the aneurysm to exclude the weak spot from the circulation, thereby avoiding the risk of further haemorrhage.

Upon arrival our nineteen year old patient had another scan that showed that the poor girl had a second major bleed hours after her first bleed. She was taken to the angio suite, at the basement of the hospital where the weak vessel was identified and the aneurysm was sealed off. She was then taken to the operating theatre where my registrar inserted a pressure monitor into her brain. Although her ventricles, the fluid-filled cavities of her brain were not dilated, I felt that we should insert an external catheter to drain some of this fluid to give her the best chance of recovery and instructed my registrar. As she was intubated and ventilated we could only monitor her status by direct readings of her brain pressure. Pressures around 15 mm of mercury  are generally considered normal for her age. Any higher pressure means that we need to intervene immediately. Her initial pressure recording were no more than 10-12 mmHg. so far so good.

Among numerous referrals and phone-calls my registrar called me around midnight. The young girl’s brain pressure has been up to 20s for the last quarter of an hour. Our anaesthetists in Intensive Care Unit had already tried several manoeuvres but the pressures were still high. Her pupils were still working. I asked my registrar to take her immediately to the operating theatre and remove large parts of her skull to decompress the tight brain. Preparing the patient for transfer can take time as anaesthetists need to follow a protocol. I know that even if the patient needs to be transferred only for 30 meters from the intensive care unit to theatre, this can easily take half to one hour. So I was very explicit to him “take her to theatre, now!” “I haven’t done this type of operation yet” was his reluctant reply.

We normally get very experienced trainees at Queen Square, usually at the end of their training, and can do quite complex operations. But not this time. “Okay, take her immediately to theatre, I am coming” said back. I entered the operating theatre when the young girl had just been placed on the operating table. I made a cut in the skin from in front the right ear to the left. I then removed very large parts of skull to relieve the severely compressed brain. The brain is wrapped in a tough membrane called the dura, normally you can see the brain underneath pulsating with each heart beat. Her brain was very stiff, the dura was extremely tight, not a good sign at all. We normally cut around the tough dura but if the pressure is too high this can lead to uncontrolled brain herniation. I made several slits, 10 cm long to release the pressure. The brain started to herniate under high pressure, that’s in keeping with pressures of 50s or 60s, and that’s incompatible with life. I released the brain at all areas possible, and after an hour I left my registrar close up. Twenty minutes later i had a phonecall from theatres, my register had problems closing the skin together as the brain was far too swollen. I scrubbed up again and closed the scalp.

In the morning time to talk to the parent and relatives. How can you tell the parents that their nineteen year old girl won’t live to see another Christmas, get married, become a mother and die someday from old age? You need to tell them that they will die after their child, what a horrible thing for a parent. There are so many communication skill courses these days on how to break bad news, most completely waste of time, if you ask me. I always find that in their darkest hour people appreciate three things. First, honestly, this is not time for false hope. Speak clearly, slowly, give them time to absorb the information, time to cry. Second, release their guilt, there is absolutely nothing they could have done to prevent this, the death of their loved one is not their fault. And third make them feel that their loved one has received the absolutely best care, everything that could possible be done, has been done!

One day all potential diseases will be detected at birth, we will able to tell that this baby when he is 38 years of age he will develop a brain aneurysm and we will able to change his DNA so he will never die from a burst brain aneurysm. It may sound like a sic-fi (have you seen the movie Gattaca?) but it is very tangible.

In the middle of everything we had snow in London. The Square where people sit on the grass for lunch in the warm months was all white!

In the middle of everything we had snow in London. The Square where people sit on the grass for lunch in the warm months was all white!

My senior colleague Michael Powell, one of the world’s most experience pituitary neurosurgeons, has officially retired. his friends came from all over the world to wish him the best. I am talking about real friends, not Facebook friends. Is clicking “like” on a computer screen makes you friend with someone? How about travelling from the four corners of the earth to “like” someone!

Mick is talking to friends and colleagues in the "mouth of the wolf". Ed Laws and Nicholas de Tribolet are absorbed.

Mick is talking to friends and colleagues in the “mouth of the wolf”. Ed Laws and Nicholas de Tribolet are absorbed.

On Wednesday we had dinner at Bocca Di Lupo (literally “mouth of the wolf” but also Italian expression for good luck, sort of “break a leg” equivalent). Edward Laws from Boston with Mrs Laws, Nicholas De Tribolet, editor in chief of Acta Neurochirurgica  (with Mrs Tribolet) Paolo Copabianca, a world-renowned endoscopist and many others were present. Mick is never short of words but when he stood up to say a few things (and most of famous neurosurgeons took out their phones to record Mick) short of choked up in the end and sat down. What a lovely man. The next day another dinner at the dinning hall of Haberdashers in Smithfield’s market in London. The company of Haberdashers was established in medieval era some seven centuries ago. It has now moved from haberdashery (materials related to mens clothing and accessories) to supporting education in England and Wales. The Hall was stunning (photo). I went for the vegetarian option, and I got a lovely starter with sliced celery and a spoonful of mushed potato. More tasty than I thought it would be. “What’s for main” I asked the stiff waiter. The waiter clear his throat and announced ” Hmm, that’s the main, Sir! I will call the maitre d'” No, its alright, time for me to mingle and go from table to table to have a little chat with friends and strangers, while they are finishing their desert. In conferences and functions people hang around people they know. I do exactly the opposite, I avoid people I know and talk to people I don’t know.

The dining Hall of haberdashers, lots of space and impeccable service. If you go for the vegetarian option you better eat at home first!

The dining Hall of haberdashers, lots of space and impeccable service. If you go for the vegetarian option you better eat at home first!

It was sad seeing Mick retiring. I also saw Professor Thomas, Professor of Neurosurgery at Queen Square who retired in 2007, before I started. “I now have your office” said to him smiling, (not to piss him off), he’s a lovely and gentle man. His wife was excited as she started talking about her friends in Thessaloniki and wanted to swap seats with her husband so she can talk my ear off, but luckily! I was seating in a different table. Neurosurgeons can and go, careers wax and wane, but eventually they all go, so much for the politics and power wars. I remember when Mr Adams retired in Oxford, a very powerful and tremendously respected neurosurgeons. Everybody was talking for a year that mr Adams will retire. When he retired, he was forgotten within weeks. Once a new nurse overheard the name and asked “who’s Mr …Adams?”. Poor Mr Adams, forgotten already! If you are a neurosurgeons remember Life is much bigger than neurosurgery!

My friend Kirsten is also leaving Queen Square. Kirsten was organising the neuro-oncology multidisciplinary meeting every week. She now studies psychology and is going to a job relevant to her studies. Kirsty is good fun. We had a few coffees and quick drinks (so to speak as I don’t drink coffee or alcohol) during the last 3-4 years since I’ve known her and she’s always eagerly asking me “when are you going to write about me on your blog?” “Tomorrow” is my usual reply and then she panics “no, no, let me read what you will write first”.  Kirsten always gives me… feedback on how I do in the meeting (from if I fight a lot and cause trouble for example, to her opinion on items of my wardrobe). She’s got good heart, I wish her the best! And sorry Kirsten I haven’t let you read it before its published!

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