23 February 2023
P.B. Raksin MD, FAANS
Neurosurgery Lead and Director of the Neurosurgery ICU at Cook County Hospital in Chicago, IL
I was planning to use this space to advocate for a paradigm shift in guideline construction to place greater emphasis on the needs of the end user (stay tuned), but frankly, I could use a pick-me-up right about now. And that was not going to do it.
So, we turn to the ordinarily unlikely source of sunshine we call Neurosurgery Clinic, where I had the privilege of not one, but two patient encounters in a single session that served as a reminder of why we do what we do. (A few details have been changed to protect patient privacy.)
I became acquainted with the first patient last year, when he was “found down” in an alley. He arrived to Trauma resuscitation as an UNKTRA with a GCS 5. He appeared to be in his 60s. We took him emergently to the operating room to perform a craniectomy and evacuation of an acute subdural hematoma. He had been beaten so badly that his facial features were unrecognizable. The police came to fingerprint him, but he was not in the system. A few days later, one of the Trauma ICU nurses realized this patient was the subject of an emotional Facebook post by a frantic family searching for their missing relative – a beloved Chinatown chef – and facilitated a reunion. The patient had a lengthy initial hospital course and was ultimately discharged to a long-term care facility. When he returned for his cranioplasty a month or so later, he remained nonverbal and minimally interactive. Imagine our surprise when – about a year post-injury – he walked into clinic unassisted and was able to answer simple questions and follow commands! He is still in outpatient therapy and has not shown interest in cooking (blame it on the frontal encephalomalacia), but his family is grateful to have him in their midst.
The second patient was brought to the ED very recently by her granddaughter because she didn’t seem to be recognizing family members. This was a day or so after returning from her native Central American country by plane. CT head demonstrated an approximately 2.5cm mixed density subdural hematoma. The patient was awake, but confused. She had a mild hemiparesis. I am intentionally burying the lede, much as the resident did when he called just before midnight to make the case for whisking this 95-year-old woman to the operating room. I have to admit I briefly tried to find a reason not to subject a great-great grandmother to the bowling ball treatment, but alas, she allegedly had “no medical problems” aside from poor hearing and an unexplained old craniotomy flap on the contralateral side. So, I acquiesced. The next day, the same resident informed me that he had a surprise: the patient was not 95 years old. She was actually 105! Bettering many patients half her age, she was out the door – in a snowstorm – on post-operative day #2. She is back to her cognitive baseline. When I asked her age in clinic, she responded “108” and proceeded to argue with her granddaughter, who told her she was actually only 107 (the number keeps getting better). The granddaughter went on to explain that the document listing her true age was destroyed in her native country, so she had been assigned a random – more youthful – birthdate at some point. I have no reason to doubt her. The patient’s son is currently 82. You can do the math. We agreed to no further CT scans. Why mess with Mother Nature?!