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Friday, March 29, 2024
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Neurosurgery Residency – 120 hours a week

As my tour of duty as a general surgeon was drawing to a close, several important things happened. In the same week, the chief nurse in surgery and my now good friend and favorite patient–Marlene–presented in my office with masses in both breasts. The nurse assisted me with Marlene’s bilateral radical mastectomies and asked me to do hers. The base and hospital commanders, and several of her friends told her that she could go anyplace she desired to have her surgery. She told them that she had seen enough in Port Hueneme to make her decision. I did her chest surgery and a little later removed her ovaries because her cancers were aggressively metastasizing. She left California to go home in the South for her last days.

                Marlene’s husband and son were both apprehended for having sex with the base executive officer’s underage daughter. They were not criminally charged because the officer feared for the negative repercussions for his daughter, for him , for his wife, and for the navy. They were both enlisted men in the navy. Both were busted down to E-3, seaman, rank and assigned duty in Reykjavik, Iceland beginning in late November. That left Marlene alone in terms of family but fairly rich in terms of friends. She was in awful pain for her last month. I admitted her to the hospital; and then, at her request, released her to her home for hospice care. I had her on an IV drip of morphine, and she was in and out of consciousness but became reasonably comfortable. I stayed with her several nights. The last time, she asked me to give her a blessing. I am not sure if she had an idea of what, if any religion, I followed, or if I had any authority to do something like that, but I did give her a blessing—essentially that her pain would subside, and she would have peace. That came to pass. She stopped fighting the pain sometime in wee hours of that morning. I was holding her hand. I informed her friends and church members that she had died, then I went home and hugged my wife glad that she was well. Then, I cried.

                In June, 1972, my tour of duty with the Seabees concluded. The base and hospital commanders fervently implored me to stay on in the navy and to do my neurosurgery training as a naval officer because the navy was in sore need at that time and would be worse so soon. It was a win-win arrangement; so, I enthusiastically agreed. To sweeten the pot, I was promoted to commander upon re-enlisting. We loaded up and moved to Dallas, Texas for the wildest ride of our lives.

                The first day of my definitive neurosurgery residency I was on call. It was a weekend. The senior resident on call with me was to become my future partner in private practice eight years later. Our first patient from the ER had a through and through gunshot to the head—what was called a “Fearless Fosdick Wound” in those days. The exit wound had not broken through the dura and skin quite yet, and the victim had a subdural hematoma. The resident had me lean in very close to be careful and gentle.

                “After all,” he said, “we are dealing with the human brain.”

                He told me to be gentle, but to make a definitive cut in the dura, taking great care to watch the incision all the time. A massive gush of purple blood geysered out of the opening and soaked my eye and the rest of my face. The resident and the OR nurses had been waiting for several minutes with pent-up merriment to see me get punked, and they all laughed themselves silly. I waited for my laughing jag until after one of the nurses held up a mirror for my face. That weekend, we did six trauma cases. All but one died. I was alone on Labor Day weekend and set the residency record of fourteen cases of all sorts in three days and only half of them died.

                I did more than 3,000 craniotomies and twice that many backs, necks, and peripheral nerve cases during my five-year residency. Our chief got sick during my fourth year and had to take a long sabbatical. He was not available to select a new resident either of those years; so, I became the chief resident for my final two years; and I was without an attending surgeon to hold my hand. I ran into a major issue during the second to the last month of my residency. I was at the Dallas VA to see a consult—a thirty-something-year-old man with excruciating neck pain who—the nurses said, was “low-sick”. That he was. When I saw him, his posterior neck was red, hot, tender, stiff, and swollen—all cardinal indicators of a major infection. I rushed him to the radiology department and coaxed the tech to help me do a myelogram even though it was only five minutes until quitting time. The patient had a complete myelographic block and was beginning to lose strength in his legs. By the time I rushed him to the OR, his arms were getting very weak as well. He was losing consciousness. The Grim Reaper was knocking at his door.

                I rushed him into the only OR room still open and told the nurse to alert the anesthesiology resident that I was there with a patient and that we had a five-alarm emergency case. She returned and timidly told me that the resident could not come into the OR until he had seen his chief. I said some naughty things, but that did no good. I took this imminent bull by the horns and started an IV, put in a Foley catheter, and intubated him—much the same as I did regularly during my navy general surgery days. The nurses and I turned the man over prone and scrubbed and draped his neck for a cervical laminectomy. Every move was done in controlled staccato hyper speed.

                Then, the nurses balked. None of them was willing to jeopardize her job and career by ventilating the patient or trying to manage the anesthetic issues. I put down the knife, broke scrub, and walked out like a stalking bear. The resident—a young man fresh out of his internship, timid, and quavering—looked at my demonic eyes and started to cry.

                “Stop that!” I ordered. “Get in and help me before this poor man dies. It is preventable….PLEASE!”

                Fortunately for him, the chief of anesthesiology marched into the room at that moment looking infuriated. One look at his resident increased that level of fury exponentially.

                “Who do you think you are, brow-beating my resident like this, you rotten bully,” he shouted.

                His face was bright red, and he was sweating.

                He was about to say more but thought better of it when he looked the Devil Incarnate in the eye.

                “This is not over, Scumbag,” he hissed; but he and his resident moved into the OR—not quickly enough for my sense of purpose but at last, they were in the room.

                Everything was going to hell in a handbasket with the patient. The chief took over, got his blood pressure back up to normal, and put him to sleep; not with real alacrity, but the level of motion was faster than before. I did the world’s fastest cervical laminectomy, moving as fast as I possibly could and still protect the man whose life was in my hands.

                When I removed the first of four posterior cervical vertebral elements, pus exploded out of the opening in a most satisfying release of pressure. I could only hope that I was in time. I removed the rest of the posterior elements and exposed the inflamed dura. To my great relief, there was no evidence that any of the infection was under the dura and on the spinal cord itself. Otherwise, all my action, fury, and anxiety, would have been for naught. I got cultures, washed the wound with copious amounts of saline with antibiotics, and placed antibiotic installation and drainage catheters in the wound site. I closed the wound partially and packed it with antibiotic soaked gauze sponges.

                The anesthesiologist decided to wake him up fairly quickly. God smiled that night when our patient began to complain, to cough, and to move his arms and legs vigorously to get up and away from us. Suffice it, he did well. Why he got that epidural abscess remained a mystery. I was entirely willing to settle for the result without having to know the reason why.

                The chief of anesthesiology was still seething with anger. As soon as we finished our paperwork, he stomped over to where I was standing and began to berate me for being a cad. I stood up. I was taller than him by a foot, and heavier by forty pounds; and I was not in the mood.

                “I will have your job, you…you…”

                His vocabulary of invectives failed him. I just waited. I had been on call for four days straight, and I was pooped.

                Finally, he got down to his intended threats, “I will see to it that the faculty fires you, and that you are served with a letter of condemnation from the county and the state medical and legal officials. Then, you won’t be so high and mighty.”

                I spoke quietly but with unmistakable menace, “And we will meet the faculty council together, and they will get to hear us out. I am not so sure whose career will suffer the most,  but my bet is that you will regret for the rest of your life that you took me on when I dispassionately tell them how you were so bent on showing me who was king of the hill at the expense  of a man’s life.”

                He had calmed some and gave what I had to say some thought.

                “I’ll get back to you about this. You haven’t heard the last of it.”

                I was too busy to think about the two anesthesiologists any more for that week. The next Friday, the anesthesiologist sought me out to tell me personally,

                “I have thought about this. You were right about the need for haste. And you also did a remarkable job of getting the patient ready for surgery. I compliment you on how well you moved to do an operation that I would have thought would take hours. That said, I despise what you did to my resident. He is still afraid to go into an operating room. But, I am willing to let it all drop if you are.”

                I certainly did not need trouble; so, I gladly agreed. I found the resident and patched things up, and he found his reservoir of courage again and was a bit tougher in the bargain thereafter.

                Vera and the children were overjoyed that the neurosurgery residency was finally over, and I had my final papers all signed with ever “T” crossed, and every “i” dotted. We moved on to Portsmouth, Virginia to begin my career as a naval neurosurgeon.

                Was I a spherical SOB as many neurosurgeons are described? Was my zeal excessive in my pursuit of benefit for my patient? What kind of doctor do you want? Does the end justify the means?

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