At the Bedside

In the midst of the world’s battle with the COVID-19 virus, I sit with one of my patients who is engaged in a different, and equally enormous inner battle, every cell in her body fighting to fend off an unrelenting attack from cancer. 

She has been through so much. Chemo. Pain. Revision surgery after revision surgery. She lays in her hospital bed, gazing at the ceiling, reminiscing, recalling: 

My patient and her horse on the beach in California, circa 1970 (published with permission).

An hourglass. 

Botched parts in a play resurrected with impromptu humor. 

San Pedro, California in the late 1950s, “We all danced with the Slovenians until the wee hours of the morning. It was the melting pot of Los Angeles.”

She started her acting career when she was 6 years old, singing on the stage of Dana Junior High. 

Richard Carpatino was her first love. “Then he spit on me at school, and I knew no matter how my heart felt, I could no longer be in love with him.”

She sang in a girl’s folk band. She got kicked out of the band because the other girls said she wasn’t good enough. 

She joined a band called The Traditions and “they were very old school. One night, the leader of the band called me and told me he had too much heroine in his system. We found him on the toilet, then his brother and I threw him in the bathtub. We ended up burying him. He was such a nice guy.”

Her mom made her promise that when she became a certain age, she would do a beauty contest.  “The night before the contest, they had us write something that we would read the next day on the stage. When I got up there, I said, “Howdy!” and everyone started laughing. I knew I had them right there. When it was all said and done, I accidentally won.”

My patient’s Ms. San Pedro headshot, circa 1970 (published with permission).

Donning her “Ms. San Pedro” ribbon and a red, white and blue jumper with heels, she broke the ground at the opening of the Vincent Thomas Bridge from San Pedro to Long Beach. 

Before today, I knew none of this about her. She’d always been one of my favorite patients, breaking out into spontaneous song in her exam room, but I only knew her as a hairless fighter, hunched over on her cane, hobbling in and out with an empty threat here and questionable compliment there, a wealth of spirit always apparent. 

When we care for our patients, we see them in a state that does not represent the full richness of their souls, the wealth of their spirits, the depths of their life accomplishments. They are frail, weak, in pain, delirious. In the age of COVID-19, without family by their sides, we healthcare workers serve as their only witnesses. And there is so much we are unable to know about these human beings we care for. But I would posit, if we slow down, even just a little, we can feel tiny pieces of these histories emanating from our patient’s bodies, like flashes of parts from a 100,000-piece puzzle. 

Is there a better way to honor our patients as they near their final days? 

As I Purell my hands and get ready to leave the hospital room, my patient yells out,

“I once took my bike to the top of the hill behind my parents’ apartment, stood on the seat and rode all the way down, standing, only holding the handlebars!” 

In these ever-trying times, may we each do our best to wave our patients’ handlebar moments high. 

Wishing everyone safety and health,

Girl Neurosurgeon

Limbic Coloring

Image result for the limbic system
 The human brain, with the structures of the limbic system colorized. Arthur Toga / UCLA / Getty Images, via thought.co.

Emotions are pigments that color our lives. They also directly and substantially contribute to our experience of physical pain, something we treat often in neurosurgery. A painful stimulus in our periphery travels and synapses in the dorsal column of our spinal cord. The signal is then passed along and ultimately travels to and through the periaqueductal gray matter before synapsing in the thalamus. From the thalamus, the signal travels to and through our anterior cingulate gyrus, insula, amygdala and medial temporal lobe prior to reaching it’s final conscious state in our frontal and parietal cortices. It is important to differentiate the actual signal of the pain from what we do with that signal in our brain. Our limbic system can amplify or quiet incoming pain signals. Negative emotions amplify pain signals, positive emotions quiet them. In order to thrive in any circumstance, including chronic pain, tapping into positive emotions and memories can be medicine in and of itself. Conversely, living in fear, helplessness and hopelessness are literally toxic to our wellbeing.

How can we tap into positive emotional states?

First, we can remember them. Think about your favorite thing to do as a kid. Who was your favorite family member or friend growing up? How did they make you feel? Can you remember a time when you couldn’t stop laughing? Where were you? Who were you with? Did you feel light afterwards?

Second, we can practice them. Start with doing things that have previously made you feel good, and then expand from there. Notice how you feel in different environments and with different people, and put yourself in the environments with people who help you feel your best. Practice actions that make you feel content, at peace, and happy. Make a daily gratitude list.

Finally, we can plan them. Set aside time to plan for something you love, something you know will make you happy, and get to work making it happen.

What Is It?

Case contributed by Dr Ahmed Abdrabou.

This is a T2 MRI L spine demonstrating a sacral myelomeningocele. Meningoceles are congenital cystic dilations of the meninges that herniate through posterior column defects. They are due to a failure of disjunction in which a midline cutaneous defect forms over the neural placode during embryological development, connecting neuroectoderm with ectoderm. Myelomeningoceles involve herniation of neural tissue in addition to herniation of the meninges. 90% of patients presenting with myelomeningoceles also have hydrocephalus. Chiari II malformations, trisomy 18, trisomy 13, diastematomyelia, syringomyelia, arachnoid cysts and tethered spinal cord are also commonly associated. Myelomeningoceles should be repaired immediately after birth to reduce life-threatening risks of infection and meningitis.

What Is It?

Case by Dr Hidayatullah Hamidi and Dr Mai-Lan Ho et al.

This is a T1 MRI brain demonstrating porencephaly, or encephalomalacia resulting in a cyst in the cerebral hemisphere. Porencephaly typically results from ischemic insults to a fetal or neonatal brain. Lined with gliotic white matter, the cysts often develop adjacent to the sylvian fissures or central sulci. Patients with porencephaly often present with cognitive delay, congenital hemiplegia, chronic spasticity and/or epilepsy.

About Silcenced Superheroes

I can’t help but look at this photo of myself in the OR, now many years ago, and think about how the face mask reminds me of a muzzle. The New Oxford American Dictionary defines “muzzle (v.) to prevent (a person or group) from expressing their opinions freely”. Surgical residency is full of this. The important thing is to keep your reflections and ideas tight to your chest. At the end of the day, everyone has to show their cards.

Check out Dr. Nisha Mehta’s reflections on being a woman physician in the 20 teens.

“Guilt is useless. Determination is important” – on being a physician with little kids.

Just as pregnant women are at increased risk of domestic violence, breast feeding healthcare workers are at increased risk of losing their jobs.

Do not despair, my friends. Change is on the horizon. Approaching faster than we think.

What Is It?

Case courtesy of A. Prof Frank Gaillard.

This is an example of arachnoiditis, or adherence of the lumbar nerve roots to the thecal sac. There are two primary etiologies of spinal arachnoiditis: infection and inflammation. Some patients have a history of spinal meningitis, others a history of prior spine surgery, intrathecal drug delivery or intrathecal hemorrhage. Patients can experience leg pain, sensory changes or motor weakness. When assessing for arachnoiditis, look for I) clumping or distortion of the lumbar nerve roots, 2) nerve roots adherent to the thecal sac resulting in an “empty thecal sac sign”, 3) nerve roots and thecal sac clumped together centrally within the spinal canal. Presently, there is no good treatment for arachnoiditis. Intrathecal drug pumps may help with pain.

What Is It?

Case courtesy of Dr. Alexandra Stanislavsky

This is a coronal CT demonstrating a left occipital condyle fracture. Condyle fractures usually occur from high energy, non-penetrating trauma to the head and neck. Of patients presenting with an occipital condyle fracture, approximately 63% will have other neurological deficits, usually involving CNs IX, X, and XI. There are three types of condyle fractures according to the Anderson Montesano Classification: Type I) minimal fragment displacement, Type II) associated with other basilar skull fractures, Type III) avulsion fracture with displacement of fragments.

Neurosurgery + Motherhood

 

  

I was a neurosurgeon before I was a mother. People often ask me which is harder, and I always reply, “For sure, motherhood.” I’ve found that this is a hard answer for many to hear.

It is my and my husband’s wish that we raise children in this world who, value the work that women do, respect ALL human beings regardless of sex, color, religion or education, and break loose from the chains of 20th century oppression (Photo credit: S. Malkhassian).

The Milky Way Mind: Ending gender bias in medicine, leadership and the workplace

By Whitney James, MD – Girl Neurosurgeon

“What we have found consistently, is that when we present women and men with exactly the same credentials, qualifications and backgrounds, for a job that is traditionally male, held by men in our culture, thought to require male attributes, we consistently find that the woman is seen as more incompetent than the man.”

– Madeline Heilman, PhD, Department of Psychology, NYU

A couple of weeks ago, I was honored to be the keynote speaker at Kaiser Permanente’s Women in Medicine Symposium in San Diego, California. Some of my key messages:

  • Presently, fewer than 1/5 of our elected leaders are women.
  • Fewer than 1/20 of Fortune 500 CEOs are women.
  • In 1966, only 6% of medical student graduates where women. In 2016, 46% of medical school graduates were women.
  • Yet still, in 2018, only 1 in 5 full professors of medicine is a woman.
  • Only 15% of Department Chairs in medicine are women.
  • Only 3% of Chairs of Departments of Surgery are women.

Women in traditionally male fields, such as medicine, often find themselves in a catch 22. Either they are perceived as “too nice”, which comes across as “weak” and “incompetent”. Or, they are perceived as competent, but “unlikeable”, “untrustworthy”, “not a team player”. Sometimes, the perception can oscillate back and forth between “weak” and “unlikeable” many times during the course of a work day. Shankar Vedantam has an entire Hidden Brain episode devoted to this very topic, and definitely worth a listen.

One of my key messages in my talk was that nothing is going to change without the support, backing and motivation of the majority group, in this case men. In any situation of discrimination, the discriminator must be the one to question their own perceptions and subconscious biases, recognize them, and be committed to opening their minds to alternate possibilities. It should not be on the shoulders of the discriminated to change their behavior so as to conform to the majority group.

Ending gender bias in medicine, leadership and the work place can’t just be on the women aiming for the corner office.

It has to be on all of us.