Sunday, August 9, 2009

Rumbal Dlains

Tuesday, 4th August

It sounds trivial, but the most physically excruciating thing I’ve had to learn is how to stand for several hours at a time, without any sitting breaks. When you are scrubbed in to a 5+hour operation, your arms must be flexed and held at the level of your thorax at all times, and you’re not allowed to sit down, because chairs are not sterile. The pain sets in gradually, first stabbing the feet, and then gnawing its way through nerve fibres, settling finally at the junction between the hips and back: the sacroiliac joints. This is the point at which waves upon waves of pain fibres meet, and you find yourself bending your knees just to redistribute some of the perpetual aching, until chairs look like paradise. This said, it takes a just short while to get used to. After the first 2 or 3 days, I was fine: my muscles had bulked up the task.

The number of hours that residents are required work in this country is ludicrous, bordering on medically dangerous. For a neurosurgical resident, the hours are insane. A typical day would roll as follows:

5am - arrive at the hospital to round on patients and write up the progress notes.
7am – multidisplinary meeting to discuss all patients, with neurologists, Intensivists and critical care nurses.
7:30am – operating list starts.
8pm – operating list finishes (if your own list finishes before this, you have to scrub in and help in other attedings’ lists).
8:30pm –evening ward round, checking on the patients
10pm –Home

The same cycle continues day after day, with junior residents working at least one weekend shift (day or night). In between operations, the residents must also help the anaesthetists with post-op care of patients i.e. transporting the patient to PACU (post-anaesthesia care unit) and writing up all post-operative notes. Any floor work to be done on neurosurgical patients e.g lumbar punctures, central lines, is also their responsibility and each resident has a bleep that goes off hundreds of times per day. It’s absolutely crazy, but they learn very fast and get good practical experience.

One of the senior residents on our team is a Japanese lady who is 5’0’’ and so thin that she is almost 2-dimensional, yet her strength seem to outweigh that of the other residents (all 6’0''+ men) combined. Almost machine-like in her efficiency, she rapidly constructs the complex network of metal bars that are required to hold the patient’s head in position during operations, and screws them in together so tightly that none of the male residents can unscrew them afterwards. Wasting very little time on small talk, she writes discharge notes and reviews patients’ CT scans whilst eating lunch in the call box, and stops only briefly to tell me and Geoff, the other medical student on the team, that there is a “anoolsm crapping” in room 15. I must look utterly gormless as it takes me a couple of minutes to decipher that the procedure she is referring to is, in fact, an aneurysm clipping. It then dawns on me that one of our other patients isn’t having a “rumbal dlain” (a procedure I had never heard of) but a “lumbar drain”, which is entirely understandable. I felt somewhat terrible for misunderstanding her and looking thoroughly confused, but I’m on the ball now, and am an expert in converting r’s to l’s and vice versa.

Nocturnal Adventures

Saturday, 1st August

I have become a creature of the night. Stairs creak as I skulk around at 5am, trying not to wake up the rest of the household. Wolfing down my cereal, I gaze outside at evanescent shades of darkness, and realise that I have not seen sunlight in 4 days. I hurriedly assemble a cheese and tomato sandwich, cut it in half and wrap it in some foil: this will be my sustenance over the gruelling day ahead. Throwing my rucksack over one shoulder, I walk out of the house and begin my trek towards the Emory shuttle bus-stop. Within moments of stepping outside, I am greeted by Atlanta’s all-consuming humidity: as the ink-blue sky begins to dilute, the crickets chirp at my feet and a thin film of condensation envelopes itself around me.

It’s still not quite daylight when I reach Emory University Hospital at 06:20, though the sun will soon rise, its baking rays marching mercilessly towards their noon-time crescendo.

Inside, the air-conditioned hospital is a picture of luxury: the lobby is marble-floored, and decked with gold-framed portraits of important-looking men from the 19th century. Fine leather sofas fill the spacious flooring, and stand underneath impossibly large chandeliers. Copies of the “Atlanta” magazine are scattered on all table tops as the cover features Dr Daniel Barrow, Emory’s vascular neurosurgeon, named as “Atlanta’s top doctor”.

It’s my 4th day, and I finally know where I’m going – hopefully I’ll only get lost once.
My uniform consists of Emory scrubs, a short white coat (denoting medical student status) and trainers. I have purposefully left behind the stethoscope: apparently it’s very “non-neurosurgical”. To the patients and other staff, I look every part the Emory medical student in Neurosurgery. Yet I still feel foreign and somewhat out of my depth: what am I doing in a huge place like this, making decisions for patients and consorting with some of the world’s most famous neurosurgeons? It’s like a bizarre dream intermingled with fear of the unknown.

Luckily, I don’t get lost and successfully make my way to the residents’ on-call room in the Neuro-ICU, my base for the next few weeks. Here, I receive a very American greeting as I am high-fived by Nitin, the junior resident on night-call: “Yo dude, how’s it hanging?” he enquires. “Erm…good thanks” I mumble through a series of poorly-stifled yawns. With the other junior residents, I grab coffee and then we head to the conference room for the morning sign-out. This is a multidisciplinary meeting with Neurologists, Intensivists and other critical care staff, during which the status of each neurosurgical patient is reviewed, and decisions made as to their care. Nitin updates everyone on the new overnight admissions, and we finish with the morning ward round in the ICU. This meeting can often take a while, as Emory is a phenomenally large Neurosurgical unit catering for patients within a 200-mile radius. This often means that we get critically ill patients from far-flung areas of Georgia, and sometimes even from other states.

The operating list starts promptly at 07:30, and I am supposed to scrub in to every procedure, helping the residents with their work. Often, residents will do the bulk of the procedure i.e. opening and closing, with the attending coming in only for the difficult and dangerous part which requires enormous technical expertise. So far, it has been a fascinating experience, as I have observed and helped with craniotomies (i.e. drilling burr holes through the skull and removing a flap of bone) and craniectomies. I have rapidly had to learn how to perform surgical throws and ties, as there are absolutely key to the art of suturing. It is incredible to watch the surgeons deftly manipulating thin pieces of thread through their fingers, which move at dizzying speed: every move requires a high degree of focus and accuracy.

After the bone is drilled through and a piece removed, the underlying brain covering, the dura mater, is exposed. This is a delicate lining which covers the brain and spinal cord, themselves bathed in cerebrospinal fluid. The resident cuts a flap through the dura, and stitches this to the skull, in order to ensure that blood doesn’t collect between the bone and dura (extradural haematoma). Now, the brain tissue itself meets our eyes, its intricate network of blood vessels, grooves and folds glistening under the brutal surgical lights. Only attendings have the required expertise to navigate safely through this dense highway of neurones, and the residents greet them with a respectful “sir” as they stride into the OR, like knights on horseback. I watch the rest of the operation on a television screen, as the attendings are performing microsurgery to remove tumours, or clip blood vessels.

First Day

Saturday, 25th July.

Woke up at about 7am, had a shower and helped myself to breakfast in the enormous expanse that constitutes a kitchen in this house. For the first time, I met the Mike and Anna’s 8 month old baby, a girl named Kiran (also known as “picklehead”). The kid is very cute and has officially gained my approval, as she stopped crying once I picked her up from her chair. That’s all it takes.

Had a drive through the suburbs with Mike and Picklehead, admiring the greenery, open roads and plethora of restaurants. Public transport here is laughable, and it seems that driving is the new walking, even if you want to visit your next-door neighbour (who, admittedly, probably lives 2 miles down the road).

Met up with some friends of the landlords in the evening (Leslie and Mark), who took it upon themselves to decide that I absolutely must experience eating in an American Diner. Being resigned to the fact that I probably already have atherosclerosis, I accepted that this would be no bad thing: I’ll trade some of my arteries for the most cultural thing America can offer: a grill-bar called “three dollar burger”. Unsurprisingly, the food was delicious: I had a veggie pesto burger, with an obscene number of “fries” liberally scattered around the plate, and a small coke, which was about the size of my forearm. There was an incredible view of the sunset, with melting orange dipping into the purple hue of night. I sat contented, listening as Leslie recounted, with much aplomb, a hilarious tale of her friend who carried a dead dog in a suitcase through the metro (don’t ask how she got herself into this situation), and then had the suitcase stolen! I can only imagine the thief’s disappointment and utter confusion…

Sunday, July 26, 2009

Flight etc

Friday, 24th July 2009

Typically, it started pouring down with rain the moment I boarded the aircraft at Heathrow. After I was “randomly” chosen for a “random” inspection of my carry-on luggage (complete with suspicious glances and frisking from airport personnel), I was just about ready to don my headphones, grit my teeth and fly away. But of course, the plane was delayed by an hour and a half because of England’s glorious weather.

In my very fitted, almost made-to-measure cattle class seat, I was surrounded in every direction by orange-hooded, orange-capped and devoutly Christian spiritual volunteers from Tennessee. It was thus nigh impossible to read without timely interruptions of “Gyood Lorrrd, we ain’t got no hot dowgs in heeere” or “Johnny, why don’t ya sit down read yur bi-a- ble like a gyood boy?” I stared straight ahead at my non-functioning TV screen in apoplectic silence, letting their Southern drawl infiltrate my ears and permeate the substance of my brain. The woman to my right was clutching her bible for dear life, and I wondered why. Surely nobody else would want to steal it: they all had bibles of their own. This particular one was entitled “the daily bible… nothing you’ve ever read before”. For once, the irony didn’t escape me.

My quarters were closing in on me, as the child in front had just discovered the “lean back” button for his seat. With my nose practically touching the TV screen, and for palpable lack of anything else to do, I decided to try and suddenly fall asleep. This plan met with spectacular failure as soon as the Tennessee titan to my left started poking my shoulder and asking to be let out, in the first of what would be twenty trips to the toilet.

Eventually, the plane took off and I discovered that I was never going to be able to sleep, as Mrs Daily Bible started laughing raucously at her TV screen, watching “17 again” and the Titan next to me kept shouting across aisles to his “buddy” seven rows ahead of us. Brilliant.

Watched a couple of TV shows and, in sheer desperation, a movie called “He’s just not that into you”, which was entirely predictable and mostly awful. Spent the rest of the flight reading Midnight’s Children by Salman Rushdie and drinking Sprite, whilst glancing up now and again at the moving map. I marvelled at the bizarre route through Greenland that my plane was taking to avoid the Atlantic jet stream.

Touched down in Atlanta at about 18:30 local time, but didn’t get past immigration control until 19:15. This was due, in part, to the intense scrutiny with which I was studied by the US Border control officer. “What is the purpose of your visit to the United States?” she asked, looking fiercely quizzical with least 100 kg of might tucked (or not) behind folded arms. I gulped, stared calmly back and gave her my letter from Emory, saying that I was here on a medical elective. Thankfully, she dropped her stapler at this point, and spent about 5 minutes trying to pick it up. By the time she returned, she just looked thoroughly exasperated, stamped my passport and waved me away. So that was that.

After the usual 37 minute wait in baggage claim, I was forced to once again surrender my suitcase to the mystical realms of carousel travel. Why the Americans want to re-scan a suitcase that has just come out of an aeroplane escapes me. Somehow, I managed to re-unite myself with my suitcase about 5 miles at the other end of the airport, and took the train to Avondale. The in-train entertainment consisted of spontaneous outbursts of angry rap and breakdancing from some very talented teenagers, which was a lot better than any of the in-flight entertainment.

The lady I’m staying with picked me up from the train station, whence she drove to her very beautiful house. I stayed up for a while, chatting to her and her husband, and met their friends, a young couple from MIT who have just moved into the area. They were all incredibly friendly and welcoming, despite my permanently glazed-over expression, borne of extreme tiredness.

After an hour or so, I excused myself and went to bed, utterly exhausted. One day down, and 65 to go!