Posted on 07/22/2005 2:20:41 PM PDT by sionnsar
One of the biggest “red flags” of neurology is the “blown pupil”. This term refers to a pupil (the black portion in the center of the eye) that is dilated on one side. If this dilatation occurs suddenly in the context of a severe headache, this may be a sign of severely increased pressure within the brain. The brain may be in danger of being pushed through the foramen magnum (the hole through which the spinal cord joins the brain). That’s bad. All of the most vital functions of the body are controlled by the “brain stem” (the area of the brain near the foramen magnum). Pressure near the top of the brain stem just causes a “blown pupil”. If the pressure increases and actually impacts the top of the brain stem, the patient usually has not only the abnormal pupil, but is sleepy, with arms stiffly flexed at the elbows (“decorticate” posturing). If the pressure increases further, affecting the middle part of the brain stem as well, breathing stops or slows, coma is established, and the arms and legs reverse to being stiffly hyperextended (“decerebrate posturing”). If the pressure continues to increase and affects the lower part of the brainstem, breathing stops, the heart rate becomes irregular, and all tone is lost as the patient sinks into a comatose, breathless, floppy state from which he/she almost never recovers. Most people who “just” have a blown pupil recover fully. Those whose symptoms proceed to “decerebrate posturing” essentially never do. Thus, attention to such “red flags” is critical.
This tidbit of neuroanatomy was brought home to me about 20 years ago during my first year as a neurology resident. An attractive 20 year old woman was brought to the emergency room with a severe headache, and was found to have a “blown” left pupil. As I arrived she suddenly stared at me in terror and cried “Oh my God! My arm’s gone numb! Why is my arm numb!?” I barely had time to open my mouth when she suddenly stiffened, flexed first her left, then her right arm, drooled, made one or two jerking movements of both arms, then slowly arched her entire body, and then fell back, both arms hyperextended, both pupils “blown”, her entire body seizing. The whole episode took less than 10 seconds, and her CT scan showed a massive intracranial bleed from a ruptured aneurism. She never did regain consciousness, and died two days later.
Now there are some “neuroanatomy lessons” that one really, really, really does not wish to study more than once in a career. This is why I may have “overreacted” when what I’m sure my more liberal readers would call a “tempest in a teapot” erupted 2 years later. At that time, I was chief resident on the pediatric neurology and neurosurgery ward. At Johns Hopkins, chief residents are responsible for the hospital wards, and pediatric neuro was extremely busy. About half of our patients were indigent children called “resident patients” (for whom I was completely responsible) from the surrounding Baltimore inner city neighborhood. These usually were acutely ill with meningitis, hydrocephalus, intractable seizures, and all but absent parents, who rarely complained. The rest of my patients tended to be wealthy and affluent children (“private patients” for whom I shared responsibility with a neurology or neurosurgery attending physician). The latter usually were less acutely ill, but had tricky brain tumors, bizarre genetic syndromes, unusual and rare disorders, and they, and their protective, and demanding parents, were flown in from all over the world.
In general, I can proudly and truthfully say that indigent patients at Johns Hopkins receive the same high quality care that the wealthy receive. However there are occasions that matters can become strained. That month was one of them. The ward was bursting at the seams with a rash of summer encephalitis cases, to which had been added an unusual and toxic mix of “resident patients” with hydrocephalus (increased pressure due to spinal fluid that cannot drain out of the brain) and blocked shunts (mechanical devices placed in the brain to drain the fluid, which can often “back up” causing sudden spikes in brain pressure). To this was added some increased notoriety of several Hopkins neurosurgeons with a major increase in pediatric brain tumor cases. This stressed “bed access” but the biggest impact was on operating room time. Hospital beds for pediatric neurology patients can be found on other hospital floors if need be, but operating suites, let alone operating room nurses, anesthesiologists and others cannot be conjured out of thin air if a multiple neurosurgery emergencies materialize simultaneously.
This had strained the normally friendly relationships between myself and “Dr. X”, my counterpart, the chief resident of pediatric neurosurgery. It was our practice to round together twice daily on all the patients, and we always began with the sickest. These included three little kids with hydrocephalus and blocked shunts who had been on the ward with severe headaches, vomiting and obvious shunt blockage for between 1 and 3 days.
By the third day, as we looked at “D” our responses had become practically liturgical. I would begin by saying, “D” is the sickest. I’m really worried about him. With “stiff ventricle syndrome”, he can really go fast if he codes. When do you think you could revise his shunt?” His answer would always be “Shari, I’m going to really, really try to squeeze him into the schedule today. Tomorrow, at the latest, I promise. We don’t need much OR time, maybe half an hour, but we have 3 big cases (usually elective brain tumors), and it’s hard to tell how long they’ll tie the rooms up. If a room opens early, we’ll rush him right in. If he deteriorates, let me know and I can tap his shunt again, that’ll help.”
Then we would move on to the next two patients with blocked shunts and I would be told, “I’m sure we can find some time tomorrow, let me know if there’s a change in his/her condition.”
This had gone on for three days, and each day my anxiety had increased, as each day had also brought new prescheduled pediatric brain tumor cases who, though certainly in need of care, could have far more easily waited a few days than could my kids with blocked shunts, and whose complex and lengthly surgeries would surely tie up the operating rooms for several hours at a time.
This was the situation when my pager went off and the nurse told me “D” is not responding and has a “blown pupil”. I was blessed with an outstanding team, and I am proud to say that when I arrived a few minutes later, my junior resident was hyperventilating the patient on a gurney; he was already beginning to recover; and he was on his way to the operating room, the neurosurgery chief having cancelled one of the elective cases to accommodate the now critically ill child. We all held our breath until “D” was out of surgery and clearly recovering in the ICU, and then I rounded on Dr. X.
“So. When will you be able to revise the [shunts on the] other two?” I inquired (possibly not in the most “irenic” of voices).
“Uh. Yes. I do understand your point, Shari” said Dr. X. “But first we are going to need to get “S’ back on the schedule, her parents are here from Pennsylvania and her surgery was scheduled a long time ago. . .They’re pretty upset.”
“But she’s not critically ill,” I said.
“Yes, but of course “D” was the sickest. . .I think the others aren’t quite that bad.”
“And we’re not going to wait until they are.”
“Shari, Be reasonable. I don’t have any control over this. You know that. We have two big cases tomorrow, they’re coming in today, and we need to get “S” back on the schedule, somehow, you know how short of operating time we are. . .”
“Then why are you admitting elective cases?” I asked.
“I don’t have any control over that” said Dr. X. “You know that. The schedule was set weeks ago, we’re just going to have to do the best we can. . .”
I had had enough. “Pediatric neurology will not admit any more elective neurosurgical patients until such time as our emergencies go to the operating room.” I said flatly.
Dr. X stared at me. “For God’s sake, Shari; Grow up! You can’t do that. We’ll both be fired.”
Actually it truly was a “tempest in a teapot” as “progressives like to say. I officially closed the ward to new elective admissions two minutes later. Five minutes later I was in the pediatric neurology departmental chairman’s office as he took a telephone call from a prominent neurosurgical attending calling for my head, and twenty minutes after that I was cooling my heels in the outer office while my chairman discussed logistics with both the chairman of neurosurgery, and the head of the hospital, privately. When he emerged after about half an hour, he simply said “L” (the second sickest of my patients) will go to the operating room this evening, “T” has an appointment at 7am tomorrow morning, one of the elective neurosurgical patients has been rescheduled for two weeks, and the other’s parents are downstairs in Admitting, raising hell.” Relieved, I pushed off to Admitting to calm the parents in question, and to arrange for the child’s admission to the ward. By “sign out” rounds that evening, “D” and “L” were both much better, “T” was stable, the new admissions and their parents were settled in, “S” was playing Nintendo in the game room and her parents had stopped sulking about having her surgery delayed 24 hours to accomodate “D”. Dr. X and I were more in charity with one another than we had been all week.
I think that was probably the last time I heard the suggestion “Grow up” as an explanation for trying to pretend that a dreadful and unjust situation didn’t exist. At least it was until a few days ago, when I admit overreacting again. At that time, the provocation was marginal. A “progressive” deacon had posted a note on her blog linking to two notes. One note, the one she was rejoicing over simply noted the appointment of her friend as the first female priest in a formally Anglo_Catholic diocese. The other reported the inhibition of a faithful conservative rector by his bishop under a canon used for priests converting to Catholicism, because that priest had exercised his right to receive delegated pastoral oversight from an orthodox bishop, in view of his bishops perceived heresy.
Since the deacon in question is known for her swiftness in correcting injustices (however marginal) to individuals of progressive theology, I found her silence on the note she asked us to overlook, on the way to reading about her friend’s “triumph”, telling. As I said (among other less pertinent and charitable things) “None the less, the deafening silence of progressives on this matter is truly impressive. All liberals. Not just Jane. I haven’t heard a single voice noticing it, not even AKMA who is a regular reader of Titus One Nine. Can they all be blind, deaf and stupid? I don’t think so. I think better of “progressives” than that.”
Since then the majority of the (highly liberal) readers of the blog in question have largely responded in the words of “The Archer”, a first year seminarian at Seabury Western. “GROW UP”.
This bit of Episcopal “wisdom” has been echoed by multiple “progressive voices” including the deacon in question, and a progressive seminarian at Church Divinity School of the Pacific. The latter has typed literally books of cyber ink on her blog on the rights of gays and women to not feel excluded by any behavior they might wish to engage in. However, in her essay responding to me, entitled “For the Love of God Please Grow up” her major contribution appeared to be “Really, I’m a very busy gal, and I’ve learned to not inject myself into arguments just because I think that my woefully ignorant opinions are worth something.”
Would that that were true.
Pathological ecclesial busyness and ignorance is also claimed by the deacon in question “You know, today has been busy. It’s a work day for me, at a church with no internet access; and even if I had been able to get online, I likely wouldn’t have been there long. There were way too many items on the ecclesial “Honey Do” list”. There was also a more peaceful posting directed specifically at myself by a left of center parish priest, “Reverend Ref”. The latter contains some fine sentiments: “In our forgetting unity through diversity, we are all trying to become eyes so that we can make sure everyone sees things the “correct” way, whether right or left, liberal or conservative.” However the meat of that posting by Rev. Ref. again relies on claims of ignorance. “One side claimes it requested outside oversight, the other side claims they demanded it. One side claims a parish was abandoned, the other side claims there were/are extenuating circumstances that were well documented but ignored. What is known for sure is that I don’t know the specifics, so my preaching to Bp. Smith would seem out of line.”
It’s always very easy to not know anything about a subject. It is even easier to be extraordinarily busy; none of us have nothing to do. But it seems to me that what we are doing is not forgetting sentiments, such as “unity through diversity” as Rev. Ref. claims, but instead we are forgetting human beings. Sentiments can be argued over indefinately. We can talk for weeks about what an appropriate allocation of operating time might look like, and whether the educational benefits of having indigent patients managed entirely by residents, outweighs the risk of denying such patients the protection of an attending physician with more clout. We can talk for weeks about whether a bishop’s authority can be limited by a panel of advisory, or whether canons or gospels can be reinterpreted to favor novel theological interpretations.
But human beings can’t wait. While intelligent and well meaning people pondered the question of operating room resources, a poor, black six year old, with no family or private physician, was in danger of dying. While intelligent and well meaning people claim ignorance or busyness, a faithful rector with a child with special needs is about to be cut off from job, health care, and pension. And while progressives talk incessantly about reconcilliation, they do nothing about implementing this in any sort of timely fashion. Bishop Smith has already made clear that DEPO will have no place in his diocese. Thus, sentiments, (such as that of the Pacific seminarian in her addendum) where she claims “the problems facing us in the church today are too serious for such a facile solution “ are simply a cowardly excuse to wait until the problem dies. As a neurologist I can truthfully say that most “problems” will die if you only wait long enough, however having watched more than one “problem” die, I can tell you this does not leave you with any sort of good feeling about yourself, nor is it likely to result in a hospital or church one can feel proud of.
Which brings me to the title of my essay (and that of many others on this subject). What precisely does “growing up” have to do with silence when the powerless are in danger? Is that really “maturity”? Or is the motivation of progressives reflected in the second part of Dr. X’s answer? [Shut up] “You’ll get us both fired.”
Traditional Anglican ping, continued in memory of its founder Arlin Adams. I would like to note that I was mistaken about A.K.M.Adams. He does indeed believe in the liberal values of “justice for all” not simply justice for the currently favored group.
I would also like to note that Fr. Jake (while I do not agree with him) at least has the courage of his convictions.
If anybody can point to any non-AAC bishops who are not cowardly suck-ups, please point me to their letters on the subject.
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