WILLPOWER MELTDOWN SOMETIMES

A 97-year-old woman passed away yesterday at the hospital. She had suffered a subarachnoid hemorrhage three weeks before and had been bedridden ever since. She opened her eyes, nodded, and uttered a single word. Five days after admission, she developed hydrocephalus due to the subarachnoid hemorrhage. When I asked her granddaughter if she wanted her grandmother to undergo lumbar drainage to reduce intracranial pressure, she responded “Yes.” The lumbar drainage tube was removed the day before her death. It was determined that leaving it in any longer carried a high risk of infection.

An 81-year-old woman developed a cerebral hemorrhage in the left anterior and temporal lobe. The following day after admission, her level of consciousness and right hemiparesis worsened. I decided to perform endoscopic hematoma aspiration under local anesthesia. The hematoma was extremely hard, so partial removal was attempted. However, bleeding occurred when attempting to remove the hard portion, necessitating discontinuation. To reduce intracranial pressure, the liquefied portion was removed enough. Postoperative CT showed improvement in midline shift, but 80% of the solid hematoma remained. A colleague noted, “For removing the surface hematoma, a small craniotomy is more suitable than an endoscopic approach.” I have a different idea. I am thinking how to remove surface hematoma by endoscopy. On postoperative day 1, the symptoms such as aphasia and right-sided neglect remained but was a little better than yesterday.

I watched a rugby match. My favorite hometown team lost. They were so weak I couldn’t bring myself to watch until the no side. I know true fans should watch losing games until the end. They had a strong season last year and declared before this season started that they aimed to win the championship. It seems impossible to me. I expected too much. I learned two lessons from this match: to have the guts to keep running throughout the entire game, and to prepare for the situation where the captain leaves the match.

BOAT RACE is a nation-sanctioned form of gambling. It is not illegal and you won’t get arrested for participating. You can bet starting from as little as $1. Today, I plan to place my bets on Race 7 at Kiryu. My predictions are as follows: “Past race results are 1-34-6-25, and the current tournament results are 1-3-26-54. Boat 1 is certain to win first place. Boats 4 and 5 have poor tournament results, so they won’t place in the top three. Boats 2, 3, and 6 will likely compete for second and third place. Therefore, I’ll bet on 1-236-236.” The actual result was 1-2-3, with odds of 10 to 1. I wished Boat 6 had pushed a bit harder. It was not necessary to predict Boat 2 to finish second. I don’t think the prediction itself was bad. The odds were low, though.

And also, I plan to place my bets on Race 7 at Gamagori. My predictions are as follows: “Past race results are 1-3-45-2-6, and the current tournament results are 1-54-32-6.
Boat 1 is certain to win first place. Boats 6 has poor tournament results, so it won’t place in the top three. Boats 3, 4, and 5 will likely compete for second and third place. Boat 2 has the slowest ST. Therefore, I’ll bet on 1-345-345.” The actual result was 5-1-3, with odds over 100 to 1. I wished Boat 1 had pushed a bit harder. I don’t think the prediction itself was bad. But the result is everything. Since this race wasn’t on the final day, I didn’t have to participate. I will make it the rule.

Today’s profit is $1.

I performed a lumbo-peritoneal shunt. Actually, I only deployed a periotenial catheter. I was an assistant surgeon. A chief surgeon, neurosurgical resident, deployed a lumbar catheter. He had asked another doctor to assist, but the doctor had to provide important informed consent then, so I was asked instead.

A lumbo-peritoneal shunt improves symptoms of hydrocephalus. It is not a prophylactic surgery, such as endovascular therapy for unruptured cerebral aneurysms. If you have a cerebral aneurysm and feel anxiety for the rupture, would your symptom be resolved by treatment? I mean, is anxiety a symptom of a cerebral aneurysm? Well, it is not the case I want to talk about today.

I made a 3.5 cm left-sided transverse paraumbilical skin incision, and separated the underlying fat tissues with muscle retractors to expose the superficial fascia of the rectus abdominis muscles. I cut and pulled it up with silk threads on both sides. I separated rectus andominis muscles to expose the deep fascia. I pulled up and cut it. I exposed the thin peritoneum. I incised it carefully and saw vivid yellow greater omentum through the small window to confirm to reach the peritoneal cavity. I got relaxed as I was sure I was a right place. I inserted the catheter into the peritoneal cavity. I closed the peritoneal opening by means of a purse-string suture. The resident continued the abdominal part of the surgery as he finished the lumbar part. I watched him suturing the skin very carefully behind him, feeling it took too much time.

A woman in her late eighties presented with mild dysarthria and sensory impairment in her arm. She was rushed to the hospital by ambulance. A brain CT revealed a small amount of bleeding in her left thalamus. She had lived alone in a rural town. An orthopedic doctor on emergency duty called me to treat her, while I was at home eating supper. I don’t think it is a neurosurgeon’s job but a physician’s. But I have to obey the rule of the hospital. I went to the hospital and saw her in person. She was lying on a stretcher at the ER. I told her son that she would need to be hospitalized. He said, “she is smart and strong.” I said “ because het symptoms remain, she will not able to live alone again. She will need care.” The day after admission a brain CT revealed no enlargement of the hemorrhage. I told him that on the phone. I had done the same thing for another patient the day before. I talked with her for a while and I understood his saying “ she is smart.” But she did not look strong anymore.

A man in his early seventies was presented with mild weakness in his left leg. He didn’t have a severe headache but numbness in his right head. He came to the hospital a day after the onset of symptoms. A brain MRI revealed an infarct in the right medial frontal lobe due to occlusion of the distal anterior cerebral artery. I diagnosed him with atherosclerotic infarction and started administering aspirin, prasugrel, ozagrel, rosuvastatin and edaravone. It is important to differentiate from arterial dissection of the anterior cerebral artery which is referred to a high prevalence among Japanese patients. If the etiology is arterial dissection, antithrombotic therapy may increase the risk of cerebral hemorrhage. Unfortunately, his symptoms worsened soon after he was admitted. A nurse told me this on the phone, and I immediately ordered a brain CT as brain MRIs are not easily performed. There was no hemorrhage. I suspected expansion of the infarct. I administered argatroban too. His risk factors are current smoking and hypertension. He is single – is it important? He has not attended a clinic since leaving his job. I told his brother on the phone the fact and the risk of hemorrhage associated with antithrombotic therapy. He said, “he could move at the ER.”

A day after admission, the left-sided hemiparesis deteriorated further. He acknowledged he could not move his left leg at all, but he answered “yes” when asked to move his left arm even though actually he could not. He had said at the ER, “I want to go home as soon as possible. Do I really have to quit smoking?” He was far from home and smoke.

I feel motivated today. I’m determined to work hard. Why is that? There are many things I can’t accept. I wonder why I alone have to endure such hardship. For a while, I just didn’t care anymore. Still, I find my inner strength and positive attitude.

A husband of a patient whose condition had worsened due to rebleeding of a coiled aneurysm was at the hospital. I made eye contact and spoke to him. He said her wife’s condition remained unchanged—bedridden at a nursing home and unable to speak—but she recognized him. I had worsened the prognosis. That is a fact. If a more skilled surgeon had performed the operation and managed the postoperative care, the outcome might have been different. The question isn’t whether I did my best. The question is whether the patient was in the best possible condition. I mustn’t be complacent. I must take responsibility for the outcome. I should be able to do that. I’m not telling myself to do the impossible—I’m telling myself to get the best possible result from what I can do.

As the director of a stroke center at a rural hospital, I have always considered generating revenue to be important. One way to accomplish this is by participating in clinical trials and enrolling patients. During my three years as director, we have participated in two clinical trials. The first trial met its enrollment target, but we have only managed to enroll about half the required number for the second trial, which is ongoing. I have been the primary physician for all patients so far. The trials target patients with acute ischemic stroke who are in the early stages, have moderate symptoms, and are not undergoing surgical treatment. In reality, the number of patients fitting these criteria is small. Considering who might benefit, I question the value of targeting super-elderly patients in their 80s or 90s, so I seek younger individuals who seem likely to maintain independent living. This time, the patient was a woman in her 60s whose risk factor was poorly controlled diabetes. Due to rising medical costs, it seems that more people are unable to afford the necessary preventive medications. Even in this rural area, more people appear to be facing the problem of being unable to pay their medical bills.