AANS Neurosurgeon | Volume 28, Number 4, 2019

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Me and My Big, Fat Subdural

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I’m not sure where to start, as this is a complicated and unusual story. So, I’ll start with introducing myself first. I’m a retired professor of emergency medicine at the Albany Medical College. In that capacity, I have supervised and trained residents in all specialties during their emergency department (ED) rotation. One of those residents was the man who was to become my neurosurgeon. In addition, for 20 years I was the Evidence Based Medicine (EBM) teacher for the required four-year EBM course in the medical school.

Now, the first major head injury I ever had was while moving into a new house. I slipped and hit the left parietal side of my head on the corner of a bureau. It hurt! And then, I thought, “Oh s—, this is going to give me a cerebral bleed of some sort. After all, I’ve been on Coumadin for my atrial fibrillation for three years, and although I’ve had no serious problems yet, this could be it.” I waited for the headache to arrive and when it didn’t, I promptly forgot about the whole thing. 

Jump forward six months to a surprise snow storm on Easter Sunday. I was walking into the garage and slipped on some ice. As I fell, I was conscious of being careful not to hit my head. I successfully kept my occiput from hitting the pavement by quickly jerking up my head. “Wow,” I thought. “It looks like I dodged the bullet, again.”
 
The Patient Experience
When I awoke in the middle of the night with a headache, I was worried. But, I took a few Tylenol and tried to go back to sleep. Getting no relief, I asked my wife to drive me to the ED. There, I learned that I actually had two subdural hematomas, an old one in the left parietal region, most likely where I hit my head six-months earlier, and a new one along the falx. After three days of observation in the hospital, I felt fine. My falcine subdural was resorbing and my neurosurgeon let me go home with several regularly scheduled follow-up CT scans to watch everything go away. I thought that I had dodged the surgery bullet and was pleased with the efficient, kind and overall excellent care that I received. I felt that I was being treated as a VIP patient. It all worked out so well and seamlessly.
 
One month later, while coming home from one of these routine repeated serial CT scans, I got a frantic call from my department chair. She told me to get to the ED right away because my right fronto-parietal subdural had enlarged and I now had more than one centimeter of midline shift. I didn’t feel bad, and my only symptom was that I had no appetite that day. I had no headache, nausea, vomiting or focal neurological signs. However, being a good patient, I followed her instructions and a few hours later my neurosurgeon was wheeling me to the operating room (OR) for drainage of my subdural. The episode scared my wife, who was only slightly relieved by the sight of my surgeon personally wheeling me in the stretcher to the OR.

As a patient, I lost all track of time, which really didn’t bother me much. I spent a week in the hospital with the first three days in the Neuro ICU. I have only a few, somewhat faint, memories of the experience. The most memorable experience was in the ED when I developed severe abdominal pain after being given intravenous Vitamin K to counteract my INR of 3.3. Then, the day after my surgery, I apparently was unable to urinate fast enough for the nurses’ desire, and a Foley catheter was inserted. My ICU stay was actually pretty boring, and I was much happier on the floor where I could have regular visitors.  

All in all, I was treated very well (more like an evidence-based VIP) and felt that the staff was helping me to be as comfortable as possible. The phenazopyridine that I got for the residual burning after removal of the catheter was a real blessing and it was given without any questions asked. I was thankful for the frequent morphine (or whatever it was) for my pain, which receded quickly. After all, I’m just grateful that I was able to walk out of the hospital without any significant neurological deficit.

Using the Patient Experience to Enhance Medical Education  
As best I can tell, I’ve made a complete recovery. There are a few holes in my head to remind me of the whole ordeal. My wife won’t let me go out in the snow without my “shoe grippers,” but, otherwise my life is pretty much normal. I worked in the ED for eight years after my surgery and continued to teach medical students how to critically evaluate studies, make sound probabilistic decisions about diagnosis and how the health-care system works.

I was treated as something of a VIP, as my physicians had all been my students (medical and residents). I got a very warm feeling that they had all turned out so well, and that, in some part, it was due to my teaching. I can honestly say that I got excellent care from the nursing staff too. After all, I had a week to enjoy the amenities of our hospital, and my pain and other issues were very well controlled, making my stay as pleasant as possible. Okay — so there were some drugs involved — but I never had to beg or cajole to get treated. And yes, the first shower was a real blessing.

Since my surgery, I’ve used my experience to enhance my teaching. As an educator of medical students and residents, I now use my own head to teach that first part of the physical examination. This is where the students tentatively put their hands on a patient’s head looking for any abnormalities. I can see that they are not pressing very hard, so I now ask them to feel my head and see if there are any abnormalities. After they say, “No, it feels fine,” I tell them that they must press harder and to try again. Yes, they then feel the holes in my head, and now know how hard to press on the patient in order to find all of the physical examination findings of consequence.

Although this experience has not changed my view of medical education, I do have some suggestions for our trainees. First, it would be a good idea for every medical student to spend some time in the patient’s shoes at least once during training. This has been tried in the past 30 years in some schools, but should be more common. Since we are using many more simulated patient interactions, medical students could be simulated patients or shadow a hospitalized patient. At least with standardized patients, the student can get feedback on their communications with patients and families. 

Guiding Patients Through Unfamiliar Waters
My neurological exam is pretty normal, with only a bit of a problem with tandem gait. The biggest problem seems to be balance on an uneven surface, and I can no longer bowl because I am not sure where my feet are located when it’s time to let go of the ball. Too soon, and it goes into the gutter; too late and the ball pulls me half way down the alley. So, I figure that it must have affected my “bowling center.”

For anyone who becomes a neurosurgical patient, the experience can be quite daunting. My wife likes to remind me that I almost died. She is right! As a medical professional, with knowledge of the intricate anatomy of the nervous system and experience with the devastating consequences of neurologic injury, undergoing a neurosurgical procedure was very unsettling. Not only must all physicians, neurosurgeons included, possess the clinical and technical skills necessary for success, but they must also have the interpersonal skills to help guide their patients through unfamiliar waters. Although, I intellectually knew what was happening and what needed to be done, emotionally, I was clueless and unprepared. My prior personal relationship with my neurosurgeon helped to ease my concerns, as his warm, calm and confident demeanor was a comforting force for my wife and I.

I was fortunate for the wonderful care I received, and my excellent recovery. Because many of my health-care providers (including my neurosurgeon and some of his resident staff) had been my trainees, my passion for medical education was galvanized by my experience. Not only was I left with the physical imprint of my operation to aid the teaching in my future clinical diagnosis courses, but I now had the framework of what it meant to be a patient who had placed full trust in my doctors during a life-threatening illness, and was ultimately rewarded with a very satisfactory outcome.

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