The Young Neurosurgeon: Lessons from My Patients

By Paul Edward Kaloostian

In the ER, the OR, and in the waiting room where the doctors deliver heart stopping news to the families of their patients, a neurosurgeon’s apprenticeship is arduous. This memoir of the day-to-day experiences of a resident in neurosurgery at one of the nation’s busiest trauma centers provides a rare window into the training of the doctors who open patients’ skulls and operate on their brains and spinal cords. Paul Kaloostian’s intimate account describes both the lifesaving feats and tragic failures that are the daily ups and downs of twenty-firstcentury neurosurgery. Kaloostian shares the lessons of humility, faith, and compassion that were often more important than the surgical expertise he acquired in the operating room.

• Language: English
• Publisher: University of New Mexico Press
• Release date: Sep 15, 2013
• ISBN: 9780826353535

Paul Edward Kaloostian

After earning his MD degree at UCLA, Paul Edward Kaloostian did a seven-year residency in neurosurgery at the University of New Mexico Hospital. He is currently a fellow at the Johns Hopkins University Medical Center, where he specializes in complex spinal surgery and spinal oncology. He has authored scientific textbooks and poetry books, as well as neurosurgical chapters and manuscripts.

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PREFACE

In medical school and residency training, just like everything else in life, each and every day is a chance to grow and to learn. We make mistakes and we attempt to learn from them. And we learn to be doctors by dealing with patients’ lives up close. We interact with patients and hear their stories. We laugh with our patients, and at times we cry with them. We have a duty to our patients and are called upon to play a vital role in their lives. Every day we aim to provide for others and to heal them. We help our patients, who have nowhere else to turn for help with their health problems. But in the meantime, throughout this long journey of education and successes and failures, we learn about ourselves. What makes us who we are? This is an important question, and as we progress through life, we learn a variety of answers.

In this book I share a few of the countless lessons I have learned from my patients. To protect the privacy and confidentiality of these patients and physician-patient relationships, I have changed the names and some circumstances in these stories. Each chapter recounts events that have shaped who I am today and who I will become. Some chapter titles are quotations from patients or colleagues who have profoundly influenced me, and who have made a positive difference in me as a doctor and as a man.

INTRODUCTION

I am a neurosurgeon. I never thought that I would say all those words in one sentence. But as far back as I can remember, I always wanted to be a neurosurgeon.

My childhood experience was a blessing. My parents, who were dedicated and highly skilled physicians, quickly not only taught us what it truly meant to be a doctor but also showed us through their actions. My siblings and I learned that this is a serious business. We are entrusted with the lives of other human beings, and these people rely on us. Thus education, dedication, integrity, and character were the highest ethical standards in our house. My parents worked long hours healing patients and teaching medical students. I know they were tired when they came home late at night, but they never showed it. In fact, they would sit down and talk about what they’d had the opportunity to do that very day when treating such sick people. Quite often, they would even allow us to shadow them while they were working, so we could see firsthand how a doctor really works. I remember feeling so proud, and as a child, I couldn’t wait to have that opportunity myself.

Education was important in our house. Being a doctor clearly involved a life of continued learning. In middle school and beyond, my siblings and I spent many summers at Harvard University, Brown University, and Stanford University (to name a few places), and we were able to take courses and interact with such accomplished people. My experience at Brown University with Dr. Bear (who taught the neuroscience course and who wrote the book for the course) really confirmed my interest in neurosurgery. What fascinated me most about neuroscience was the delicate yet intricate nature of the brain and spinal cord. I also was absolutely in love with how humans can get into the brain and spinal cord and fix problems that often alter human lives forever. Such an honor and a privilege it was to have had that opportunity to learn about the unbelievable anatomy and structure of our central nervous system, and to one day have the skills to enter these sacred areas.

As I finish my seventh year of neurosurgery residency and enter an instructorship at Johns Hopkins Hospital, I can say that this field can be so great but also very difficult. Having performed more than 2,200 cases and procedures, I have had the fortune of seeing many pathological conditions and learning from my great mentors. I have spent many hours in the hospital and have cared for many patients. I have worked very hard and have sacrificed much to better myself and my patients. But at the same time, I have experienced much loss and sadness with patients whose lives I have been blessed to enter and whose lives I unfortunately could not salvage. Thus, I needed to describe these real life experiences so that I could unveil what medicine is really about. It is not about what people see on TV. It is not about what people discuss while eating at a restaurant or chatting at parties. It is about much more. It is about human conditions and feelings that sometimes transcend what people should ever experience. This book is a glimpse into what it means to be a doctor, a neurosurgeon. Not what’s on the surface, but what is deep down in the heart, eyes, and soul of someone in those shoes day after day: a young neurosurgeon. These are the lessons I learned from my patients. I hope that you can then understand what it really means to be a doctor.

Paul Edward Kaloostian, MD

Neurosurgery

CHAPTER ONE

THE BIOPSY

Neurosurgery has a surprisingly long history. Anthropologists have identified specialized tools of varying sizes and shapes that were used centuries ago and skull bones with carefully made holes. For centuries, of course, aseptic technique was not practiced, and most surgery was probably done by trial and error. Mortality was high, but it is very clear that science and reasoning, as well as curiosity about the brain, were important parts of the process. As the field of neurosurgery has progressed, modern techniques and instruments have been created, each representing some improvement over its predecessor. That constant desire for improvement is what pushes the field forward and, most importantly, raises the quality of patient care.

Many advances have been made since the time of Harvey Cushing (1869–1939), the physician who is considered the father of modern neurosurgery. One such advance is the use of stereotactic neuronavigation, a technique used to precisely reach pathology anywhere in the brain. Recent advances in this methodology in tumor biopsy have made brain-tumor biopsies much safer for patients. The following review of the case of a patient with a brain tumor illustrates this point and provides a quick glimpse into the daily practice of neurosurgery in an academic hospital setting.

It’s a Friday morning, 5 a.m., although my eyes can’t be trusted to read the clock this early in the day. I arrive at the University of New Mexico Health Sciences Center and start rounding (going on rounds) on our patients. In the intensive care unit, one of the senior general-surgery residents asks me to see a patient his team is caring for. The resident looks at least six and a half feet tall. His entire team of medical students and junior residents is circling him. He’s wearing a long, white coat that seems much too small for him. It’s dirty. His eyes look tired. He has clearly been on call that night for the trauma service. He and I started our training at the same time, and now our conversation is shaped by unspoken mutual trust, admiration, and the desire to provide excellent patient care.

Paul, sorry to bother you. I know you’re busy. We have this patient in bed 17 in the medical ICU that we need your help with.

Mike! No problem, man. What’s going on?

In his characteristic deep, hoarse voice, he tells me about the patient. Mrs. Chávez is a fifty-four-year-old female who fell down outside her house. She tripped on a step and struck her head. She is complaining of a headache. However, when we scanned her head we found something rather interesting and unexpected. The radiologists are calling this a tumor of some sort. We would like your expert opinion.

How big is the mass? What is her exam?

She’s awake and following commands. She has a slight weakness of her right arm, but is otherwise doing well and is in good spirits, considering her predicament.

One of the medical students adds, The mass is about four by four centimeters. He adjusts his white coat, pulls out the team list, and starts writing information down. This student believes he is part of the team, a little bit awkward but trying to be helpful. When you think about it, we physicians are all a little bit awkward. I mean, you almost have to be to survive the years of training and the intensity of the daily regimen and duty that we have to our sick patients.

Thank you, I reply. We will see the patient right now.

My team and I head for the ICU. As we walk down the hall, we encounter other large teams, all rushing around the same way we are. The hallway gets noisier and noisier with the echo of multiple voices. It reminds me of recess in school with seemingly thousands of voices of different pitches filling the air and then slowly fading away. Patients’ families are sitting in the hallway, some lying down on couches, snoring away; others are lying on the floors. There is an unspoken understanding between residents and these family members, a connection that in a way allows the family members to feel completely at home in the hospital. Despite the noise, they are sleeping deeply. You can’t even see a muscle twitch in any of them. I know what long and tedious days these people experience while their loved ones lie sick in a cold, spacious hospital.

How was the night, guys? I ask the obstetrics team.

It was a quiet night. We are waiting on a few patients to go into labor any moment now, says Dave, the OB chief resident. He speaks in a monotone voice.

This man has been a good friend of mine since we were interns, seemingly in another life but really only five years ago. Dave is in his early forties. He started out as a lawyer. He practiced tax law in Miami, and needless to say, he had plenty of business. One day when we were interns, we were eating lunch together in the