WILLPOWER MELTDOWN SOMETIMES

A fifth-year medical student has been at the hospital for medical clerkship for three weeks. She will stay in a month. She is going to be a doctor after passing the national examination next year. I have to give her a grade on this clerkship. Just before rounds she said, “ do you submit my grade report to the college? I am smart to the extent that I participated in an observership program in the department of hepato-biliary-pancreatic surgery in England for two weeks last year. They spoke very slowly as they knew I didn’t understand English. I would like you to submit a good grade.”

It was very interesting. She has good communication skills. I will give her the best ever score.

A man in his early thirties passed away from a subarachnoid hemorrhage.

Three weeks ago, he presented to the hospital with a severe headache. A head CT revealed such a typical subarachnoid hemorrhage that neurosurgeons suspected there should be a ruptured cerebral aneurysm. An emergent angiography, however, showed no aneurysm. He developed hydrocephalus and underwent lumbar drainage. He had headache and mild cognitive impairment, but he could eat and walk.

Ten days after the initial onset, he developed another subarachnoid hemorrhage. This time an angiography showed very small aneurysm in the superior cerebellar artery. He underwent coil embolization therapy, but he didn’t recover. A postoperative CT showed severe ischemic changes in his brain. He had lived for a week with ventilation and vasopressin infusion. These days were necessary to accept his death. For whom? His family or us?

A fifty-year-old man was hospitalized for a cerebral stroke. He presented with mild hemiparesis in his left hand. I read his chart a nurse had written; he said, “I told an attending doctor that the weakness in my left hand had worsened slightly since yesterday. The doctor just answered ‘I see.’ I suppose he isn’t interested in it.” I was shocked. I didn’t mean it. His condition is stable, but his symptoms are fluctuating. For example, if he works hard for his paralyzed hand, the next day he may feel dull. I suppose I said “I see. Your symptoms are fluctuating. I’ll observe carefully.” I should have paid more attention to how he felt when I explained. Even though the change was too slight to recognize for me, he got nervous very much. He can walk, speak, and eat independently. He can go home. But rehabilitation staffed recommended continuing his hospitalization for further training in order to work again. I don’t think he needs it.

If you don’t enjoy the present, you won’t enjoy the future. If you are living a life where you enjoy the present, you should be grateful for your circumstances. I have read the New York Times ever since a respected man told a webinar audience to read it to understand the world. The events it reports on every day are different from what I see every day. Here are no drones or agents which attack citizens. I think about what I can do, but there are no answers.

A woman in her thirties visited the outpatient clinic three years ago, complaining of left facial pain. It was trigeminal neuralgia caused by compression of the trigeminal nerve with the cerebral artery. I prescribed Tegretol. It was very effective, but she had to quit due to allergic side effects. Then, I prescribed Topamax. It was effective without side effects. Her symptoms resolved. She had not returned to the clinic. A week ago she called the clinic and said she presented with the same symptoms again and wanted to appoint. Last Monday I met her for the first time in three years. I explained the same things as three years ago. She has been living in Japan for five years. I don’t remember where she is from. It is difficult and stressful for her to get appointments because she has to talk on the phone in Japanese. After I explained, she didn’t seem to be satisfied and tell enough what she wanted to say. She wiped away tears.

A seventy-year-old man developed chronic subdural hematoma. He is a clinic doctor in the town. He had fallen down while playing with his grandchild and hit his head. I operated for him. He was in an expensive room of the hospital with so nice carpet that I hesitated to entered the room with my shoes on. When I entered the room to see him today, his daughter and son in-law were talking with him. They are very descent. The way she talked, his hair style and polite words he chose were descent. Just before I saw him, I met his wife in the hallway who was going home. Why did she leave the room alone?

I am on the bus, thinking about what I did in the hospital today. I just worked and learned. I took a nap too. Of course I saw patients. I watched a webinar about endovascular therapy for cerebral aneurysms. I read a case report a resident wrote about cerebellar infarction due to probable vertebral dissection. It was just a report, taking patience. The resident provided a dull discussion. The webinar was helpful for the procedure scheduled on Wednesday.

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.