Size matters

We have two people in this week who have major cranial defects. These are doctor-created cranial defects, and thus are better than the alternative. The alternative is having your cranium infected with nasty bugs or having your brain swell to the point that it squooshes up against the inside of your skull and dies.

When I say "major", I mean major. As in half of the top of your head is gone.

Bone flaps out bother me. The small ones I can handle without any problem, but the big ones still give me pause. There's just something about talking to someone who's perfectly rational and normal and happy but whose head slopes away into nothingness just west of midline that squicks me out.

I never realized until I started seeing this on a regular basis how much space there is between your brain and your skull. I always thought that the brain was packed in there, nice and neat, like a suitcase packed by someone more talented and patient than I. For the most part, that's true--there's not so much space there that you could swing a cat. But the difference between perception of "not a lot of space" and the reality is huge.

The reason having half your head gone is disturbing on an aesthetic level is that most of the stuff that shapes our skulls is on the outside of the bone. Think about the top of your head for a minute: you think of hair and bone, right? You've forgotten about all the muscles in your scalp, all the tendons and ligaments that connect this to that, all the padding that goes on top of your brain-case. If you take that away, you end up with somebody who looks fine in profile (from one side, anyhow) and who looks like a scooped-out melon from the front.

Plus, you can see the pulse of the brain through the skin. Yes, the brain pulses. It doesn't just sit there in your skull humming popular songs to itself; it has arteries and great big ol' veins that feed and drain it. Cut a hole in the skull to take a look at the brain and the whole thing is pulsing quietly away. I'm sure that sometimes it's humming popular songs in time to the pulse, but I can't hear them from the outside. Take the protective bone away, though, and the whole shooting match becomes quite clear: this lump of cholesterol and nerves is jammin' away inside your skull.

Speaking of major defects

We have one orthopedic surgeon who's quite fond of narcotics. For his patients, that is, not personally. The people he operates on get a scheduled list of huge doses of things like OxyContin and Lortab. This makes them, since they're usually older and not equipped to handle drugs like that, prone to going nuts.

I had one of his patients yesterday. The previous day she'd been fine, if a little focused on her bowels. Yesterday, though, she was confused and impulsive, trying to get out of bed and wander down the hallway. After a number of phone calls and various tests, we discovered that she didn't have a pulmonary embolism, didn't have blood clots in her brain, and was probably suffering from narcotic overload.

Which is a comforting thought--stop the narcotics, and eventually you'll stop the problem--but meanwhile, I had to keep running hither and yon to keep her from hurting herself.

With confused patients I can usually take anything in stride. This woman yesterday, though, had me longing for a drug I could abuse. For some strange reason, she frustrated me no end. I was at the point of losing my temper with her, though what was happening wasn't her fault at all.

That makes you feel bad. I don't expect to like every patient I have simply because they're sick, but I still feel bad when one of them makes me want to scream.

Plus, there's the worry that they won't ever get better. Most of 'em do, of course, but you still wonder.

Tomorrow I start a three-day run. Monday, Tuesday, Wednesday is generally the hardest thirty-six hour stretch at work, given that we have surgeries galore on those days. I am not looking forward to this at all. I do, however, have four days off in a row just after this run, so I can look forward to *that* instead.