Book Review: Another Day in the Frontal Lobe

By Katrina Firlik.

Neurosurgeons are quirky people. I’ve yet to meet one who’s “normal”; mind you, my observation-count of this rare species is still only three, so perhaps my sample-size is just too small. In her book ‘Another Day in the Frontal Lobe’ Katrina Firlik describes the habitat, behaviours, and temperament of the neurosurgeon. Here are some of the findings (corroborated with my personal experience):

• Quirk 1: Neurosurgeons are your superior. It doesn’t matter who you are, or what you do, brain surgery tops everything. I suppose that’s the attitude that naturally comes after 11 years of speciality training in an isolated culture. Firlik notes the stereotype, confirms its accuracy, and then exemplifies it with an out-right haughty tone throughout her book.

• Quirk 2: Neurosurgeons do only a few things very well. You’d think that the neurosurgeon would be the ultimate expert on function of that mysterious organ, the brain. They’re not. In fact, neurosurgeons handle only a small subset of brain disease. This includes trauma, tumours, and seizures. Comprehensive brain/mind function is left to be studied by the psychiatrists, psychologists, and neurologists, with each one contributing a unique piece. In fact, most neurosurgeons spend most of their time operating on the spine (that’s where the most money is to be made).

• Quirk 3: Neurosurgeons are mechanics. Brain surgery is not, well, brain surgery! If there’s too much fluid in the brain causing a build-up of pressure, you drain some to restore normal pressure. If there’s a tumour compressing on brain structures, you remove it to decompress the brain. Obviously I’m vastly simplifying, but most neurosurgical work is founded upon basic mechanical principles.

• Quirk 4: Neurosurgeons are emotionally tough. This is a necessary attribute. Chances are, that once you’re willing to let someone cut into  your brain, things are looking pretty bad. The outcomes of neurosurgical patients are usually not happy stories.

You may accuse me of speciality profiling; of drawing on superficial stereotypes. I protest that, in medicine, the stereotypes are usually objectively true. Each speciality has a unique personality of doctor associated with it. And it makes sense. When you train for many years with a small, isolated, community day-in, and day-out, you tend to form an identifiable culture. When medical students choose their future directions, a large factor is often the culture with whom they get-along the best.

Unexpected Meeting

So it’s September, and I find myself back in Kingston poised on the brink of another year. Today we welcomed to Queen’s the class of 2013. It was their very first day of medical school – an experience that I still remember clearly for myself. And as the first-years were making memories, … for completely different reasons, I was also having a day that I will never forget:

After a casual lunch with my mentor-ship group, I dropped into the anatomy lab for what I thought would be a brief administrative meeting with the tutors to sort out the upcoming term schedule. I was completely unprepared for what happened next. “You know that you’re prosecting today, right?” No. I did not. Neither did any of my fellow tutors. Yipes… well, I guess we can still make a try of it.

So in the space of a few minutes I went from meeting green frosh, to meeting my (literally greenish) cadaver who I will be prosecting this year for the anatomy lab. (We use the term ‘prosecting’ as a more respectful word than ‘dissecting’ when preparing human bodies.) We were nervous; the room was so quiet that I could hear my scalpel blade go through as I made the first cut.

It strikes me after being so physically invasive to his body, that I know very little about him – only what his body itself can tell me, such as that at some point in his life he had open-heart surgery. His face, hands, and feet will be shrouded for the next few weeks until those anatomical regions are being studied.

From my cadaver, I will learn much about medicine and anatomy. I look forward to the review of gross anatomy, and to practising with the surgical tools. Today included use of a bone saw – a brutish instrument that makes a shocking roar of noise, and will leave you sweating. I also look forward to teaching the first-years their material using the samples that we prosect.

Leaving the lab four hours later than I had expected to, I must say I was grateful for the experience. Unexpected yes, but perhaps that’s exactly the way it needed to be to push me off into the deep end.

An Intimate Privilege

After observing for a day with the General Surgery service, I’m struck by what a trusted privilege the surgeon is given to enter within the body of a patient. Cutting through the protective layer of skin that separates the ‘us’ from the ‘outside’, the surgeon enters the most intimate recesses of a person – the cavities and tissues of their body. Such intrusion; such vulnerability. Yet every day, patients entrust surgeons with this privilege, literally bearing their inner biological lives on the table.

What an intimate privilege to enter within a body, and I’m so immensely grateful to have briefly had the opportunity today. Shadowing a general surgeon, I was allowed to witness a superficial parotidectomy (removal of the superficial lobe of the parotid gland), a lumpectomy (breast-lump removal), and  a lumpectomy with axillary dissection (removal of lymph nodes from the armpit). Those last two cases were for women with confirmed breast cancer. My role was, of course, exclusively to watch the procedures, but they did ask me to retract here and there, or cut stitches. I think they wanted me to feel included!

Surgical dissection can be exquisitely precise, and particularly for the parotidectomy it was important for the surgeons to identify numerous nerves and arteries as they slowly worked around the resection. Damage to any of these nerves could have resulted in paralysis of the patient’s facial muscles – a horribly debilitating and life-changing complication. Once a nerve was located, the surgeon would electrically stimulate it to observe for an effect. For example, if he stimulated a nerve to the orbicularis occuli muscle, the patient’s eye would squint.

Practising medicine is surely a privilege – to have the invested trust of patients for their lives and well-being. But the intimate privilege granted to physically enter within the body is greater yet.

Observership: Orthopaedic Clinic

I participated in some incredible observserhips (observership = shadowing a doctor) last week, which I’ve yet to blog about! Here’s the first of a few reports.

On Tuesday I was permitted to spend the day in an Orthopaedic Clinic. The types of patients seen here include post-operative follow-ups (e.g. knee or hip replacement), people wanting to know whether they would benefit from an orthopaedic surgery, and referrals from Family Doctors for orthopaedic problems which they are unsure about.

The doctor running the clinic was great about encouraging my participation. He frequently let me assess the patients (sometimes alone!), and we spent a great deal of time reviewing x-rays for positive findings.

An orthopaedic clinic has a neat set-up. They have their own x-ray unit at the end of the hall, and physiotherapists and occupational therapists working on-site.  There was also a fracture clinic on the same floor, but I didn’t observe any of the operations there.

There are some great things about orthopaedic practice:

• For most patients, you can have a tremendously positive influence on their health! I found the clinic to be a generally happy place, as most follow-ups were delighted with the results of their surgeries. It was remarkable to hear an older man describe how two days after his hip replacement he was experiencing less pain than ever before, and shortly thereafter had regained his mobility and could resume activities he had stopped before the surgery because of his arthritis.
• You get to read x-rays! In most specialities, official x-ray reports are made by radiologists. In orthopaedics, the surgeons are equally (if not more) qualified to read x-rays and are generally better at picking up musculoskeletal abnormalities on the image. If you like x-ray reading, this is a great plus!
• Almost all orthopaedic surgery is elective. Choosing whether to have your ankle bones fused, or your knee replaced, must necessarily be a balance between the benefits and risks of the surgery. It’s ultimately up to the patient to decide whether the pain and disability they are experiencing is sufficient to warrant the risks of surgery. In many cases, people will decide that it isn’t. There are often many lifestyle alternatives to surgery: reducing body weight can significantly reduce arthritic pain. 
• To quote our fearless Orthopaedics instructor: “It’s not rocket science!” In this speciality, first principles and a good physical exam go a long way to discovering the diagnosis.
• Lots of patients, and always increasing. As people live longer and our Canadian population is aging, the prevalence of osteoarthritis and other orthopaedic diseases is increasing. The amount of OR time dedicated to orthopaedics has only been increasing.

Here’s some not-so great things about orthopaedic practice (in my limited opinion):

• Short patient visits. As a specialist, you don’t truly get to know your patients and are often concerned with little more than their specific orthopaedic complaint. There is little time afforded to the person behind the arthritic knee. 
• Long, hard, gruelling residency. But then, that’s true of most surgical specialities.

Plastic Surgery

The Queen’s Surgical Interest Group had an interesting presentation on plastic surgery today.

I feel like plastics is a speciality that many people misinterpret; it consists of much more than elective cosmetic surgery. I learned from the guest plastic surgeon, that plastics could be described as surgical wound management. Plastic surgeons work with large, messy wounds that may have been caused by burns, or trauma. Other surgeons will also call on plastics for help in repairing wounds that they have created themselves  after removal of a large tumour. The plastic surgeons then use their specialized skills to manage the wound, possibly using grafts or flaps. They aim to preserve both function and cosmetics.

Sounds cool, eh? Of course, there are only about 22 residency positions available in all of Canada, so it is a very competitive speciality to get into.

Random picture of facial skin grafting:

Supra-Condylar Humeral Fracture

Here’s a taste for the fascinating things we’ve been learning in MSK!

Have a look at this x-ray. Try to determine which part of the body you are looking at, and which bone is broken:

Well, the answer was in the title of this post , but you may not have known what it meant. This x-ray shows a supra-condylar humeral fracture, or in other words a break to the arm bone, just above the elbow. They are common in children who have fallen on an outstretched arm.

Note a few features of this x-ray:

• It’s unclear from the x-ray alone whether the skin has been broken. The fragment of humerus displaced anteriorly (upwards) appears as if it may have protruded the skin, making this an “open” fracture.
• The elbow joint itself may still be intact – the distal capitulum and trochlea (end parts!) of the humerus are still aligned with the radius and ulna below
• The deformity would certainly be apparent on physical exam! Look at the contours of the arm – seeing an arm with this deformity would suggest a supra-condylar humeral fracture, even before an x-ray is taken.

Since this fracture was actually closed (not open), it was fixed by “closed reduction” and percutaneous pinning. Essentially that would involve traction (pulling on the arm), applying a force on the distal fragment to re-align the pieces, and then flexing the elbow to maintain alignment. Of course this would be done under anaesthetic! The reduction and alignment is then held in place with pins applied through the skin:

Phase IIA: Musculoskeletal Block

Almost a whole week of Phase IIA is already past, before I have even had the chance to blog about it!

Yes, it’s rather exciting – we’ve begun a new phase! Up until now in Phase I, we were learning the basic fundamental sciences relevant to medicine. Now in Phase II, we’ll be starting a block-by-block review of the body’s organ systems and their associated diseases. 

The very first block of Phase II is the musculoskeletal system (MSK). MSK refers to all of the bones, muscles, ligaments, and tendons of the body that form a skeleton of support for softer organs, and generate movement.

For the first aspect of MSK, we’ve been learning from the orthopaedic surgeons (bone doctors) about traumatic injuries to muscle or bone. That includes fractures, sprains, ligament tears etc. MSK pathologies are broadly divided into traumatic vs. chronic conditions. Later in the block, we’ll delve into the chronic diseases of muscle and bone such as osteoarthritis and rheumatoid arthritis.

OR Oddities

OR’s are strange places ! Here are a few things that I discovered on my recent General Surgery observership that took me by surprise:

• It doesn’t take very long to scrub-in. In fact when you live just three minutes’ walk from the hospital like I do, it’s entirely possible to go from relaxing on your couch in jeans and a sweater one minute to scrubbed-in within the sterile field of an OR just fifteen minutes later. You can come back out again even faster!
• The majority of your scrubs don’t stay sterile – it’s really just your hands and forearms, hence why surgeons are so careful to hold their hands out in front of them where they won’t touch any other part of your body.
• As a member of the surgical team, you may not see the patient’s face until after the surgery (assuming it’s not a facial surgery!). The surgical nurses and anaesthetists arrive long before the surgeons to prepare the patient. Once prepared, the patient’s face is normally hidden behind a protective shield.
• Scrubs have a very inconveniently placed hole in the fabric just below the waistline, on the side of the hip. The result is that you can always see whatever kind of underwear anyone is wearing. The team will even discuss it openly: “Oh, you wore your pink ones today!”
• There are CD-players in the OR. How appropriate it is to have Van Morrison’s “Into the Mystic” playing as the surgeon makes the first incision into the abdomen. One anaesthetist claimed that upbeat music was positively correlated with problem-free surgeries, while anything too slow could lead to complications.
• It’s not all technical language that’s used by the team. There can be a lot of “Grab that thingy there and take the guk off it.” 
• People take a long time to wake up from anaesthetic. Consciousness dawns on them slowly, and they don’t remember most of the waking-up process. So the anaesthetists are pretty much free to say anything they want that might help speed things up, and they can be a tad harsh about it!

Observership: General Surgery

Have I told you about the observership program? It’s one of the greatest strengths of Queen’s medicine, and it basically involves contacting a doctor in the community and requesting to shadow him/her at work. The idea is for junior medical students to gain experiences that will inspire their learning, guide their thoughts about speciality choices, and give them ideas for what to do with their clinical clerkships in senior years. Hopefully I’ll be doing a number of these observerships, and I’ll do my best to keep track of them here! Not only would I love to tell you about them, but I’d like a storage spot for my thoughts. Then when it comes time to make difficult speciality decisions, I’ll be able to review my first impressions.

Yesterday and today I had the incredible opportunity of doing an observership in General Surgery. I’m still a little flabbergasted that they let me do it! The surgeon who took me on was amazing – he was so willing to teach and he put up with all of my questions, which must have sounded pretty stupid to him.

On Friday night I was in for a laparoscopic appendectomy. In case you’ve never heard of laparoscopic surgery, it consists of making a very small incision in the abdomen and inserting a laparoscope to view the inside of the peritoneal cavity. The surgery is then performed using the scope’s feed on a TV-screen for guidance, and by passing tools through other equally-small incisions. I’ll be posting more about laparoscopy soon! 

This morning I was in for a colostomy, which is a procedure to connect the large bowel to the abdominal wall. Essentially an opening (a stoma) is created from the gut to the outside of the body so that faeces pass out into a collection bag instead of through the rest of the colon. This procedure was done “open”, as compared to laparoscopically, so I was able to compare the two! This afternoon I was in for a cholecystectomy, which is removal of the gallbladder.

All three surgeries were amazing!! The two today were especially interesting because I was allowed to scrub in to the sterile field, and even to lend a hand once or twice to retract or cut a stitch. The OR was somewhat surreal, and there were a lot of surprises. Once again, I’ll play a horrible trick and save those surprises for an upcoming post because I want to use this one to concentrate on reviewing the observership.

General surgery has a lot going for it. It involves a lot of different procedures in a lot of different areas of the body. In short, there’s a lot of variety – also, in the patients that you treat. A general surgeon’s patients can range from young and otherwise healthy people who need an appendix out, to those who are critically ill. Often general surgeons head-up trauma cases because multiple organ systems are affected. Additionally, general surgery is versatile. Even smaller towns need surgeons so it’s a very portable speciality.

As a speciality, it’s also not very likely to become irrelevant any time soon. That may seem to be given, but it’s not unheard of for newly discovered technologies to suddenly put medical specialities out of business. The best example may turn out to be the marked decrease in jobs for cardiothoracic surgery after advancements in interventional cardiology. 

Personally, I felt that one of the best aspects of general surgery (actually this applies to all surgical specialities) seemed to be the emphasis on teamwork. The OR team that I observed were so well-tuned with each-other, and they were having a great time together. 

Of course, getting into general surgery means going through a particularly difficult residency. The residents that I spoke to today were intentional to point out that the general surgery residents always work the most of everyone in the OR. Plus, being on call can make for a difficult lifestyle. The surgeon who I was observing commented that “if you want a 9-to-5, this is far from it”.  That’s particularly true if you practice in a small town where you might be the only surgeon around.

More details about the OR visit forthcoming, and hopefully more reports from observerships!

So, You Want to be a Surgeon?

I found this resource published by the American College of Surgeons. If any of my readers, like me, are wondering about surgery, then click the image above to read through this guide. It’s targeted towards clerks, but even as an almost med. student I found it useful. 

First it outlines some of the traits that make a good surgeon. These include a love for anatomy, comfort with three-dimensional imagery, a willingness to work long hours, and team leadership ability. Surgeons are the ones that want to physically “get in there” and “fix it”. It also dispels the myths that surgeons need unusual dexterity – surgeons are trained, not born – or that they must sacrifice their personal lives for the job.

Especially useful was the explanation of surgical specialties. There are explicit descriptions of what kind of patients each speciality deals with, what training is required for each specialty, and testimonies from current practitioners about what a career is like in that discipline. 

On a personal note, this resource reinforced my desire to explore general surgery as an option for my residency. General surgeons perform a broad variety of procedures, and have the benefit of taking on diverse cases. They also get management for operations that involve multiple body-systems, like major trauma victims. In smaller communities, often a general surgeon is the only surgeon around, and hence serves an immensely valuable role.