WILLPOWER MELTDOWN SOMETIMES

My wife and our high-school-aged son have been living 400 kilometers away from our family home for the past two months. During the school summer holidays, they traveled back to stay with me at home for a week. Today they left home. Right before she got into the car to return to their new place, she said, “I don’t want to go.” I was a little surprised. She was the one who had decided to move out, and she is strong and has never said such vulnerable words. When she said so, I understood how she felt, but I didn’t say anything. After they left, I cleaned up after them. I am already used to living without them.

A resident on duty called to tell me that a man in his sixties had presented with a severe headache and dysarthria and that a brain MRI had revealed a fresh infarction in the right cerebellum. I went to the hospital to see him in person. His ex-wife was already there. I didn’t know why. Did she really need to come to the hospital? The next day I went to his room and there were two girls there with his ex. The girls looked like his daughters. They had gotten divorced because they had decided never to see each other again, right? Can there really be good relationships after a divorce? I couldn’t imagine that. On Sunday, when he was discharged, he was alone. He said, “you work on Sunday? It’s tough.” He smiled so kindly that I was surprised, because he had always had an angry face in the hospital and I had never seen him smile before.

A 59-year-old man was hospitalized with a brain tumor. I felt he looked like my father. He had an oval face with vacant eyes and wore black-framed glasses, which reminded me of my father from a few decades ago. His wife bursted into tears whenever I went to his room. She had been fighting immense amount of anxiety every day since he fell ill. She said, “every day I wish this were a dream. When I come to see him, the reality overwhelms me. I hope he will live longer no matter his condition.”

She probably didn’t know how a patient with a malignant brain tumor dies. He will lose something precious piece by piece every day. Once, a young son whose father was in a vegetative state due to a stroke had asked me if his father still had his identity. This patient, too, will someday lose his memory of his wife and his identity. Even so, does she still hope for him to live longer?

I want to support her hope, rather than imposing my reality on her.

A 82 year old woman developed a subarachnoid hemorrhage. She had presented with severe headache. It was the rupture of an anterior communicating artery aneurysm. She had mild dementia and had been independent until the hemorrhage. I always think twice about whether very elderly patients need repair of a cerebral aneurysm, as they may become dependent after the surgery.

My colleague said, “the repair is indicated, since she is in her early eighties.” I found that very interesting, as I had never thought about the difference between being one’s early and late eighties. I told her family, “ she needs to undergo the repair to prevent a re-rupture. However, because she is very elderly, there is a risk she may become dependent after the surgery. The decision is controversial.” They said that they wanted her to go ahead with the surgery.

I performed endovascular coiling for her. Her arteries were tortuous from the groin to the brain, making the approach to the aneurysm challenging. The aneurysm was short and wide-necked. Although the coil packing density was slightly loose, the procedure was performed safely and was considered sufficient to prevent a re-rupture in the acute phase.

He is a junior doctor. When he began working for the hospital, he didn’t seem good at suturing yet. Everyone knows suturing is one of the most fundamental skills you must master before working as a surgeon. You may say he was not bad but his technique was different from the hospital’s standard. I thought the problem was both the method and the skill. I wondered what he had learned during residency.

He said “oh, no” when he got lost during procedures, even though the patients were under local anesthesia. I heard it a few times. How can I trust him? How can patients trust the senior doctor who allows him to perform the procedure?

I remember that when I was a junior doctor, my supervising doctor told me never to say “oh, no” in front of patients because it caused severe patient anxiety. Medical education needs teaching not only surgical techniques but also professional conduct. I was lucky enough to have a mentor who taught me both though I only focused on mastering the skills. Now as a supervising doctor I must teach the junior doctor who lacks even the most fundamental skills.

There are three key words. What is the difference between surgical technique, skill, and method? He might know the technique, but he still lacks the skill to do it safely. He needs to learn the method of proper wound management and patient safety.

My glasses kept sliding down my nose, so I went to an optical shop with my wife. I asked the staff to adjust the frames. He did a great job and they fit my face comfortably. I could focus easily and felt like my vision became clearer. I was happy with the change.

“I wear progressive lenses. It is more difficult to see a desktop monitor than a laptop screen. My right eye is stronger than my left. My eyes are getting older.” She didn’t seem very interested in my complaints even though we were growing old together.

Then we went to a ramen shop. She ate spicy ramen loaded with crushed garlic. I didn’t like it. Driving back home, there was nothing to talk about. I stared down at my phone screen while she was driving. I knew she hated it. When we got home and opened the door, our dog ran up to me. He was waiting for his dinner. He knew what he wanted. I felt like my vision became blurry again, like usual. I wanted something clear. I wanted to make something clear. After all, nothing had changed.

Late last night, I was driving home from the hospital after I admitted an 80 years old man with traumatic subarachnoid hemorrhage. Allegedly he had fallen down on his way to a neighborhood meeting. I saw a cat that had been run over in the median strip. I saw its yellow eyes and something red.

This morning, I was riding my bike to the hospital. I found a fly sitting on my knee. I tapped my thigh lightly, and it flew away.

I saw the patient in an emergency ward. He was alert, and had no headache or nausea. A follow-up CT revealed reduction of the hematoma and contusion in the right frontal lobe. He said “I am a neighborhood leader this term. I want to leave the hospital by next week to attend a handover meeting.” Retired people volunteer as neighborhood leaders. Young people work for themselves, not for the community. I treated a few neighborhood leaders. They had responsibilities for the work and felt very stressed. They loved this town.

I told my son that I had seen the cat hit by car. He said “many cats are living around there. Did you save it?” I said “it was already dead though its eyes were lighting.”

Do you know anyone who has ruined their life by gambling? I don’t know anyone. I haven’t ruined my life though I lost one hundred thousand yen on boat racing last year. The year-end jumbo lottery is advertised on TV, saying “do you want to become a billionaire?” Is spending one hundred thousand yen on it compulsive? I don’t think it is worth it.

The boat racing is organized by local governments. In the boat racing, you just have to pick a trifecta from six boats, so the odds of winning are 1 in 120. The easier the prediction, the smaller the payout. Even if you pour the money you have earned from working into it, the boat racers and the organizers will get rich, but you will just end up poorer.

About 100 boat races are held every day. From those, I select a few races where Boat No. 1 is most likely to finish first, and I choose the second and third-place finishers based on past performance. This usually results in about six different betting combinations. I buy my tickets online at 8:00 a.m. and check the results in the evening. Until then, I work hard and don’t watch the races live online or check the pre-race practice runs. I promise.

I read an article about compulsive gambling on the Mayo Clinic website. It says “gambling can stimulate the brain’s reward system much like drugs or alcohol can, leading to addiction.” I have never felt my brain being stimulated by boat racing. It also says “being highly competitive, a workaholic, impulsive, restless or easily bored may increase your risk of compulsive gambling.” I have such personality characteristics. It may be why I can’t quit.

A 75-year-old woman presented to the hospital with coma. She had been found in her home.

Noncontrast head CT demonstrated extensive subarachnoid hemorrhage, and CTA identified a ruptured aneurysm in the anterior communicating artery. It was 9 p.m.

A neurosurgeon called me. He said, “I decide to perform coil embolization. Can you come for assistance?”

The procedure started at 11 p.m. A 6-Fr Fubuki guide catheter was advanced over the wire and navigated into the left internal carotid artery. Three-dimensional rotational angiography demonstrated a saccular aneurysm measuring 4 mm right to left, 6mm anterior-posterior, and 3 mm craniocaudal. An anterior communicating artery arose from the proximal aspect of the aneurysm wall. A 3.2-Fr Guidepost intermediate catheter was advanced to the cavernous portion of the ICA. An SL 10 microcatheter was placed into the aneurysm doom through the Guidepost. It was not difficult to place, because the A1 and the aneurysm went straight. Of course he had good skills. Three coils were placed through the SL 10. The microcatheter was removed, and subsequent angiographic views demonstrated good embolization of the aneurysm with flow stasis in the aneurysm dome and preserved flow through the anterior communicating artery.

It finished at 1 a.m. I came home and went to bed at 2 a.m.

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.