If a single characteristic makes a good surgeon, or physician in general, I think it is meticulousness. An astute observer, who pays careful attention to the details of a patient’s symptoms, to an operation, to a diagnosis.
In June 2010, after a colossal effort to clean and organize the material — 500 of 650 jars have been restored — the brains found their final resting place behind glass cases around the perimeter of the Cushing Center, a room designed solely for them.
These chunks of brains floating in formaldehyde bring to life a dramatic chapter in American medical history. They exemplify the rise of neurosurgery and the evolution of 20th-century American medicine — from a slipshod trial-and-error trade to a prominent, highly organized profession.
These patients had operations during the early days of brain surgery, when doctors had no imaging tools to locate a tumor or proper lighting to illuminate the surgical field; when anesthesia was rudimentary and sometimes not used at all; when antibiotics did not exist to fend off potential infections. Some patients survived the procedure — more often if Dr. Cushing was by their side.
Dr. Cushing was an incredible figure. Few specialties within medicine can so articulatly draw their origins to a single, or group of figures, as neurosurgery can to Harvey Cushing. Michael Bliss’ Harvey Cushing has become a kind’ve definitive biography and well worth the read if you have any interest in the history of medicine. And a visit to the Cushing Center is probably well worth the trip.
I just wrote a lengthy piece on, essentially, why I deserve to be paid more. Despite that, I swear my head isn’t getting big.
God forbid something happens and I never attain “neurosurgeon status,” say I can’t pass my boards or something, and all of this in hindsight looks like bluster. The point is, no matter what I was aspiring to I think my arguments for the pay gap stand and have little to do with what ego I have.
Intermittent, spotty posting is no way to run a blog. It has been a month since I posted anything; probably explains my Google Analytic numbers of recent. Luckily, I return with pretty incredible news.
Most incredibly, I’m engaged to a beautiful and wonderful girl. Off the market ladies, I apologize. I don’t know how I convinced her to marry me but she’s so far above and beyond what I deserve that I can’t ever imagine coming off this high.
In addition, about a year ago this time I did an interview with a Wall Street Journal blogger during which I was meandering and only at times coherent. I excuse myself for that, I had recently learned that I did not match after participating in the National Residency Matching Program. The interview was on the process of medical students become residents and physicians in the match and, in my case, the scramble.
I’ve spent nearly nine months serving in a general surgery preliminary residency spot and going through the residency match once again. This time with much better results. I’m going to be a neurosurgeon. Sure the path forward is rough and lengthy, but I’ve cleared a major hurdle.
The Sex Appeal Isn’t That He’s A Neurosurgeon, It’s That Hair
Anyway, I’m back to posting and I hope readers will return to reading.
New Scientist profiles the Wellcome Collection’s Exquisite Bodies exhibit looking at the portrayal of human anatomy in the Victorian era. I can almost guarantee that the next time I’m in London I will be at the Wellcome Collection; looks very interesting.
Anyone who has spent any time at a major trauma center knows the nearly comical tragedy of alcohol associated motor vehicle accidents where the inebriated driver survives and the fourteen-year-old in the other car somehow doesn’t. It tugs at our sense of fairness. I have a particular interest in trauma and while going through a feed of major trauma and neurosurgical journals came across this paper from a mixed group out of Los Angeles.
Salim, Ali, Pedro Teixeira, Eric Ley, Joseph DuBose, Kenji Inaba, and Daniel Marguiles. “Serum Ethanol Levels: Predictor of Survival After Severe Traumatic Brain Injury.” Journal of Trauma 67.4 (2009): 697-703.
It’s a retrospective study from a single institution mining the SICU/trauma database from one of the nation’s larger trauma centers, LAC+USC, for severe traumatic brain injury whose EtOH level at the time of admission was documented. Severe TBI was defined as a head AIS >= 3. Their question focused on outcome differences between those with serum ethanol levels at the time of their accidents and those without; their primary outcome being in-hospital mortality.
Over a five year period they found 482 patients with head AIS >= 3 and EtOH serum levels drawn on admission. That’s from nearly 3,000 in the trauma database over the five year range the group was searching.
The question was certainly answered in the affirmative. Any EtOH on board seemed to convey an in-hospital survival benefit.
Indeed the serum EtOH level correlated with survival.
The mean serum ETOH level was significantly higher for survivors than for nonsurvivors (0.11 +/- 0.21 g/dL vs. 0.05 +/- 0.10 g/dL, p = 0.001). The serum ETOH levels
significantly correlated with the probability of survival (r = 0.21, p = 0.001), but this correlation was not strong as shown by the low r-value.
As can be imagined with that primary outcome, in hospital complication rates were pretty much lower across the board for those with positive EtOH levels on admission.
These findings aren’t shocking, merely confirmatory. Studies by Tien [1] and O’Phelan [2] and Kraus [3] and Tate [4], as cited by the authors of this paper had documented better outcomes for those who are inebriated at the time of their head injury as compared to those who aren’t. And indeed this isn’t even Dr. Salim’s only publication from this data mining effort. He is lead author of another broader retrospective study recently in the Archives of Surgery looking at the NTDB.
Salim, Ali, Eric Ley, H. Gill Cyer, Daniel Marguiles, Emily Ramicone, and Areti Tillou. “Positive Serum Ethanol Level and Mortality in Moderate to Severe Traumatic Brain Injury.” Archives of Surgery 144.9 (2009): 865-71. Print.
There are obvious limitations to this study. It is retrospective, as likely all in vivo studies of alcohol and trauma are likely to be. As well there were a limited number of TBIs presenting to LAC+USC who actually had serum EtOH levels tested. Formal serum EtOH testing of all trauma patients as a standard is becoming more and more frequent but likely wouldn’t have changed the findings of this study seeing as there weren’t major demographic discrepancies between those who had their serum EtOH drawn and those who didn’t (as the paper goes over). It was a single institution as well, but of course I feel safe in assuming that LAC+USC has a pretty heterogeneous population as might be seen elsewhere in the United States and most of the world.
These well documented results seem to be one of those sad, ironic, situations in life if I can prognosticate. Obviously these studies have limited clinical value at present, but perhaps if there’s some true protective pathophysiology in EtOH consumption before trauma then future bench top work may elucidate that and open some doors on acute measures that might be taken for those with traumatic brain injury early following injury.
Threat Level is an interesting blog published by Wired. Every once in a while they throw out an interesting piece of medical technology. They’ve got a piece up right now about how some Gamma Knife machines have a pretty significant software bug awaiting fixing which makes the emergency stop button non-functional under certain conditions.
[W]hen the couch moved out of position during a treatment at an university hospital in Cleveland last December, staffers hit the “emergency stop” button, expecting the couch to pull the patient out of the Gamma Knife, and the radiation shields at the mouth of the machine to automatically close. Instead, according to a report eventually filed with the Nuclear Regulatory Agency, nothing happened.
“Staff had to manually pull out the couch from the Gamma Knife and manually close the doors to the Gamma Knife to shield the source,” reads the report, which states that neither the patient nor the workers were harmed. “Radiation exposure to all individuals involved with the incident was minimal.”
Gamma Knife, CyberKnife, all these proprietary radiosurgery devices are pretty incredible.
I have a pretty strong clinical interest in image guided surgery, stereotaxy and, to a lesser extent, radiosurgery. Computer aided or directed surgery is going to become the norm well before my career is over, if I have a full one, and I imagine this isn’t the last we’ve heard of ‘glitches’ and ‘bugs’. A little scary, admittedly. Still you have to imagine that the risk versus reward in this situation, and most others, very much favors the patient. I’m not sure I’d forgo life saving radiosurgery over a story like this is my point.
While I was away on the interview trail a very interesting story hit the media wires. In Colorado a pediatric neurosurgeon went in to sample/remove a tumor from a young child’s brain. What he found was that the tumor contained fully formed anatomical parts. Included was a fully formed foot.
“It looked like the breech delivery of a baby, coming out of the brain,” Grabb said. “To find a perfectly formed structure (like this) is extremely unique, unusual, borderline unheard of.”
[...]
Sam’s parents, Tiffnie and Manuel Esquibel, said their son is at home now but faces monthly blood tests to check for signs of cancer or regrowth, along with physical therapy to improve the use of his neck. But they say he has mostly recovered from the Oct. 3 surgery.
“You’d never know if he didn’t have a scar there,” Tiffnie Esquibel said.
The question is how did this happen.
The Foot In Surgery
Teratomas are a type of germ cell tumor which can occur in the brain. They develop from embryological cell lines and often develop characteristic mature tissue including skin, hair, teeth. Cases have certainly been reported of even more complex structures appearing in teratomas, including eyes. Approximately one hundred cases of a situation called fetus in fetu have been reported. In such cases a born child ends up having parts of his assumed twin growing somewhere inside of him. Fetus in fetu often have even more complex structures, including what often appear as fully formed limbs and organ systems. As in this case.
I’m not sure if a case of fetus in fetu has ever been reported inside the cranium. Still, teratomas often occur there and in some people’s opinion fetus in fetu should be considered a highly rare form of teratoma. In anycase, this is an incredibly rare and interesting discovery. My thoughts are with the family but if the AP report is to be believed the kid is doing well.
In 1862 an American Egyptologist was far from the war that was engulfing America. In that year Edwin Smith bought a manuscript from an Egyptian collector in Luxor. A prolific collector of Ancient Egyptian manuscripts and finds, Smith was, apparently, never the less not the most gifted translator. He held onto the manuscript for more than forty five years, until his death in 1906 and in that time was not able to make substantial progress in translating the papyrus. At his death his daughter donated the papyrus, and other parts of her father’s collection, to the New York Historical Society.
In 1920 the Historical Society brought on the famous Egyptologist James Breasted to translate the papyrus. His completed translation was published a decade later.
What he translated was pretty fascinating
The papyrus is a medical textbook. Its clarity, conciseness and organization are remarkable for a medical treatise of the time. But perhaps even more impressive is its presentation of incredibly accurate physical examination and anatomical findings; along with rather reasonable treatment options.
It is also the first real neuroanatomical study. The document is broken up into forty eight cases and is an incomplete copy of a previous work. Of the 48 cases, 27 deal with head trauma and another 6 with spinal trauma. In presenting these cases the papyrus is the oldest surviving document to describe the sulci and gyri on the surface of the brain, the meninges, and the cerebral spinal fluid.
Breasted Translated This Hieroglyph As The Membrane Covering The Brain
Title: Instructions concerning a smash in his skull under the skin of his head.
Examination: If thou examinest a man having a smash of his skull, under the skin of his head, while there is nothing at all upon it, thou shouldst palpate his wound. Shouldst thou find that there is a swelling protruding on the out side of that smash which is in his skull, while his eye is askew because of it, on the side of him having that injury which is in his skull; (and) he walks shuffling with his sole, on the side of him having that injury which is in his skull…
Diagnosis: Thou shouldst account him one whom something entering from outside has smitten, as one who does not release the head of his shoul fork, and one who does not fall with his nails in the middle of his palm; while he discharges blood from both his nostrils (and) from both his ears, (and) he suffers with stiffness in his neck. An ailment not to be treated.
Treatment: His treatment is sitting, until he [gains color], (and) until thou knowest he has reached the decisive point….
Gloss: As for: “He walks shuffling with his sole,” he (the surgeon) is speaking about his walking with his sole dragging, so that it is not easy for him to walk, when it (the sole) is feeble and turned over, while the tips of his toes are contracted to the ball of his sole, and they (the toes) walk fumbling the ground. He (the surgeon) says: “He shuffles,” concerning it…
This appears, per many people’s interpretation, to refer to a closed skull fracture; with a pretty interesting description of some occular motor palsy and an ipsilateral lower extremity paralysis. Of the cases dealing with neurotrauma, they break down like this,
[The neurotrauma cases,] according to our present day terminology would be classified as follows: two compound linear fractures; four compound depressed fractures; four compound comminuted fractures; and one comminuted fracture without external wound. The symptoms and signs of head injury are given in considerable detail. Feeble pulse and fever are associated with hopeless injuries and deafness as well as aphasia are recognized in fractures of the temporal region.
James Breasted attributed the original treatise to Imhotep, the “Father of Medicine.” Such attribution would put the original work (of which the Edwin Smith Papyrus is clearly a transcription of) a 1000 years earlier. That would mean that these description of the brain and its coverings and the cerebrospinal fluid and all these detailed examination findings were recorded more than 5000 years ago.
