WILLPOWER MELTDOWN SOMETIMES

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.

I cannot live in the past, nor can I live in the future. I can only live in the present. Nothing will remain for me after I die, nor can I leave anything behind. Therefore, I want to live in the present to the fullest for someone else. I will keep this firmly in mind as I live through today.

A woman in her early forties undertook a coil embolization for a ruptured cerebral aneurysm of the right internal carotid artery. I was assigned a secondary operator. The aneurysm was heart-shaped. A primary operator so skillfully shaped a microcatheter tip that it naturally entered the aneurysm while he was retracting the microcatheter. I thought things would proceed smoothly from there and I could go home early, but they did not. He chose too large size of a first coil to place it. He attempted to advance it using a balloon, but the microcatheter tip inevitably backed out from the aneurysm during the final few millimeters. He switched the first coil size smaller and shorter. As of a second coil, the same thing happened. Consequently, the neck area became sparse. Even with a balloon, oversized coils are difficult to place properly. A delta-shaped neck remained, so we added a smaller coil. However, when he was withdrawing the microcatheter, a loop of the coil was snagged and partially emerged into the parent artery. We discussed whether the coil might migrate distally. We concluded it should be fine since the coil was properly entangled within the coil mass, located in the neck rather than the parent artery. Personally, I would have packed it in a piecemeal fashion. While this might result in insufficient coiling, given the acute phase of rupture, I believe a simple, quick, and safe approach is preferable.

He has malignant brain tumor. It is gradually growing in spite of radio chemotherapy. Right hemiplegia due to the tumor made him bedridden, but he could eat and talk with his wife until a week ago.

When they were young, he annoyed her often for reasons she never tells. She has taken care of him since he presented with hemiparesis.

I told her that he would remain unconscious and asked her if resuscitative measures should be attempted when he suffered a cardiopulmonary arrest. She said “I really love him” and signed the DNAR code.

I was surprised because I had never said such a thing to someone I loved. I wondered if I had ever really loved anyone.