03/5/15

Saving King

Saving King

Click the image to go to the Amazon Kindle page to purchase this work.

A seminal work on a moment that changed the world. Stunning.

The Rev. Dr. King was shot at 6:01 pm on April 4th, 1968. He was pronounced dead 64 minutes later, after a struggle that included an emergent tracheostomy and open heart massage. In Saving King, McDaniels dramatically recreates these events in graphic detail, providing an almost minute by minute account of the first responders at the scene, followed by the action as it appears to have taken place in the emergency room. This account is based on a close reading of eyewitness reports, King’s autopsy, and the 1978 House Select Committee on Assassinations’ investigation into the MLK assassination.

Saving King is a clever work of creative nonfiction which not only dramatizes the action in heartbreaking detail, it showcases the US trauma system at work in 1968—and in 2013. One of the most interesting portions of the monograph (which runs about 8,000 words and is an intense read by any measure) comes near the end, when McDaniels goes the extra mile and shows how such a grievous injury might be handled today.

In fact, one of the things Saving King does so well is to inform the lay public about the US trauma system. In this regard it is informative and educational without seeming to be. It reads more like a novella than a monograph, and very definitely has a story to tell.

The story opens with King on the balcony of the Lorraine Motel one minute before he is shot, and doesn’t end until he is pronounced dead 65 minutes later. Along the way, we watch as the first responders (a modern term) are overwhelmed by the bleeding and essentially just scoop and run. It is a tense 15-20 minutes later before King’s airway is finally established via an emergent tracheostomy—and his breathing finally restored to something reasonable. We learn too about the incredible coincidence that led to a delay in calling an ambulance—it turns out King wasn’t the only fatal casualty that day.

The author is himself an accomplished writer, and more than qualified to write such an authoritative work. Edison McDaniels is a board certified neurosurgeon with an extensive surgical experience, including more than a little bit of trauma. He is the author of several novels, including the acclaimed Not One Among Them Whole: A Novel of Gettysburg, which  has been described as a magnificently harrowing trip into the bloody horrors of the Battle of Gettysburg. It’s about surgery in a time when every wound was potentially fatal and every operation was a minor miracle, according to the author himself.

McDaniels’ strength in writing, which comes across loud and clear in Saving King, is his unusual ability to make the intricacies of medicine and surgery understandable to the masses. This is at least in part owing to his unique combination as an experienced surgeon, a talented writer, and a passion for both. And, in his case at least, the parts sum to more than the whole. Indeed, Taylor Polites, author of The Rebel Wife, has called him “An amazingly talented writer…”

05/14/14

Because We Are Not Animals

BECAUSE WE ARE NOT ANIMALS

by Edison McDaniels II, MD

This was published in the Opinions Section of Navy Times, April 2002.

My name is Edison McDaniels and I am a neurosurgeon on active duty with the United States Navy.  Recently, I was ordered to Guantanamo Bay Naval Hospital in order to do urgent surgery on one of the detainees from the war in Afghanistan.  The man had been rendered paraplegic by an abscess in his spine.  Since returning, indeed even as I was packing to leave for Cuba, I have repeatedly been asked why we should provide medical care to these people.

The answer, of course, is because we are not animals.

Winston Churchill once said:  “Prisoner-of-war, you are in the power of your enemy.  You must obey his orders, go where he tells you, stay where you are bid, await his pleasure, possess your soul and patience.”

Of course, it is not my place to debate whether or not these men are prisoners of war.  However, it certainly seems that they are wartime detainees, and, as such, the significant implications of Churchill’s statement must apply.  In times of captivity, the onus is upon the captors to see to the well being of their captives.

So what, you ask?

Consider the horrific consequences of not doing so.  Actually, you need only to look at history for examples too numerous to count.  Read, for example, the following account of captive life at Belle Isle during the Civil War, from a young union soldier named Charles Fosdick captured at Chickamauga:

“When we first went on the island, our rations consisted of a piece of cornbread…a little bit of bacon, and a cup of pea soup. With multitudes of weevils or black bugs which would rise to the top to the thickness of an inch, at first we would take a spoon or paddle and fish out those insects.  But later on, we became so famished for food that we would break our bread into the soup and devour it, bugs and all… The pea or bug soup was set out in wooden buckets which made it very convenient for a herd of dogs, the favorites of the officers and men on duty, to go and eat and drink as their appetites suggested. This was done before our eyes…  Finally one day, one of these dogs chanced to come within the prison limits and no sooner in, than it was seized and killed.  It was then dressed to cut up and cook and furnished a pleasant repast for several hungry men.  After this occurrence, and once a taste of fresh meat, the boys contrived all manner of projects to decoy an unwary dog to cross…  And they were so persistent in their efforts, that in a short time there was not a live dog left on Belle Isle.”

Not vivid enough?  Try this morbid account of life at Andersonville prison in 1864 from inmate Charlie Mosher:

“July 31st.  I have been very sick for the past week with a dysentery.  So sick that it did not seem as if I could hold together any longer.  This is the worst sickness I have had, and there are thousands who are as bad and worse than I have been.  It is awful.  Men are lying all around in the hot sun, face up with their mouths wide.  The fleas, lice, and maggots are holding high carnival in here.  Human nature is made of good stuff or it could not stand the strain.”

Or consider the following:  On 9 April 1942, 10,000 Americans and 62,000 Filipinos were captured at the surrender of Bataan.  The ensuing march to Camp O’Donnell, Luzon, Philippines, between 12 April and 24 April 1942 resulted in the deaths of at least 10,000 (and possibly as many as 18,000) of them.  The well known atrocities that occurred during the march included the failure to provide even the most basic human needs, including food and water.  And the dying didn’t end when the march did.  In the first forty days of Camp O’Donnell, an additional 1,500 Americans and 25,000 Filipinos died as a result of malnutrition.

In the Revolutionary War, at least 11,000 American prisoners died on a single British prison ship, the HMS Jersey.

During the Civil War, 25,956 Confederates and 31,000 Union soldiers died in captivity.

Of 43,648 Americans known to have been held as POWs by the Japanese in WWII, 12,953 of them died.

These are hellish numbers, and though they may seem to refute the statement made above, “because we are not animals,” they certainly do not justify letting a man die in his own excrement.

One of the detainees, waking from an operation to remove a blind eye, told his translator that he was surprised to be alive.  He thought he was being executed as he went to sleep.

What separates Americans from those that would do us harm, is not the belief that we are any better, but rather a certain knowledge that all people are better, that all people have not just some intrinsic worth, but the same intrinsic worth.  The central core value of the great mechanism that is American society, the crowning glory of the American way of life, is tolerance for race, for gender, and for religious belief–even when that belief is far a field from most western values.  It is only when that belief crosses the line that separates man from animal that one can justify forceable intervention.

Though their acts may mark them as animals, we know better and must behave accordingly, because we are not animals.

We (the American people) have provided the detainees with food and water, shelter, lodging, and basic medical care.  Nothing more and nothing less.  In a reasonable and just society, it falls to those appointed over us to determine the ultimate fate of these wretched and troubled souls.

 This was published in the Opinions Section of Navy Times, April 2002.

04/19/13

A Game of Shadows 3

Shadows

A GAME OF SHADOWS, 3/3
by Edison McDaniels, MD

Beginning in the mid 1970’s, when the first CT scans became available, the ease and ability with which neurosurgeons could localize anatomic lesions within the skull skyrocketed. The initial CT era, which spanned about 15 years, saw the development of higher resolution imaging as well as faster machines. An entire head CT in 1990 took about 10-12 minutes or even longer. Today, about 20 seconds. This means very few patients have a serious enough injury to bypass CT and go straight to surgery. If they can be stabilized at all, a stop in CT will generally increase their chance of survival by allowing detailed imaging of not just the brain, but the chest, abdomen, pelvis, and other injuries as well. In fact, such imaging in trauma not only allows the recognition of injuries requiring surgery, it also allows the recognition of injuries suitable for nonoperative observation—injuries that would have been operated in the past but, under close observation and supervision, are not operated today.

That 15 years also saw the development of contrast agents of various sorts. These contrast solutions, you might think of them as dyes, make tumors which would otherwise be invisible on CT or MRI visible. Many tumors have the same density as the surrounding brain and are only rendered truly visible by this contrast solution. A large tumor will give itself away by the distortion it causes to the surrounding structures whether or not it is itself visible, but such distortion may not be apparent post-op. In such a case, regrowth of the tumor can be checked for with contrast solutions. This has had a tremendous effect on modern day neuroimaging and neurosurgery.

E MCD 004

MRI of a large brain tumor sitting between the frontal lobes. It is only visible because the patient has been given a contrast agent, otherwise it would appear quite similar to normal brain—though distortions in that normal brain would still announce its presence to the informed eye. This tumor is almost certainly benign (not cancer).

By the way, the difference between CT and plain x-ray is that CT does have a 3D aspect to it, which allows very fine discernment of tissue density. What looks like a solid structure on plain x-ray, the heart for instance, actually can be seen as a multichambered muscular organ on CT. In a practical sense, this means a radiologist can tell the difference between normal gas inside the small intestine, and abnormal gas within the wall of the small intestine, as might be present if the small intestine has been damaged by tumor, infection, or trauma. This means the surgeon can operate early rather than waiting for the patient to develop signs of peritonitis—life threatening infection—first.

In fact, the ability to discern the fine details of anatomy is so good on CT and MRI, that some medical schools are now foregoing real human cadavers and teaching anatomy virtually, using programs composed of thousands of pictures (CT and/or MRI slices) of the human body.

MRI has come into its own since about 1995. MRI is extraordinarily sensitive in terms of anatomic detail. One can see very fine vessels, perhaps just 2-3 mm in diameter, on MRI. Very small tumors, too small even to be operated upon, are also visible. In fact, sometimes we find things which aren’t tumors at all but incidental curiosities. These are things we would only have found at autopsy in the past. As a neurosurgeon, I see several patients a month with such findings. We generally don’t operate on these incidental findings.

ICHVeryLarge

CT of a large, life-threatening hemorrhage (the white stuff). It’s on the right side of the brain. This patient is almost certainly comatose. Without an emergent craniotomy, he or she will not survive. With surgery, his or her long term outcome might be surprisingly good if operated in time. In neurosurgery, Time is Brain. Time is life. This is one of the first lessons a neurosurgeon in training learns.

Sometimes the incidental findings seen on MRI are important. A small lesion shows up in the frontal lobe, perhaps too small to cause symptoms just yet. Is it a tumor? Or just a curiosity? Sometimes we can’t know. Such cases have to be individualized. Occasionally surgery is recommended to biopsy the lesion or remove it entirely. More often a wait and see approach is taken, wherein the imaging is repeated in a few months looking for growth or some other change.

Up until recently, most all imaging has been anatomic. Today that is changing. More and more, functional MRI is coming to the forefront. fMRI actually observes and measures physiology—neuronal activity and connectivity. This is useful to avoid damage to elegant areas of the brain during tumor surgery, or to identify the focus of seizure activity. Or, in the case of post-surgical recovery or after a stroke, to assess neural plasticity. Much of this is still experimental and only available at tertiary centers, but stay tuned. It has been called Neurosurgery 2.0.

By the way, functional imaging of the human brain has another promising use. It is now possible to see nonorganic disease—psychiatric disorders—in action. This technology is in its infancy, but imagine being able to visualize how a human thinks in an objective fashion. Schizophrenia may show activity is one particular area, mania in another. One can imagine scanning a patient to check on the efficacy of a particular treatment or medication. Taking it still further, might it be possible to ferret out a murderer in this fashion, or maybe even a future murderer?

In other words, be careful what you think—big brother just might be watching…

Edison McDaniels, MD, is a board certified neurosurgeon practicing in the American South. Follow him on twitter @surgeonwriter and read his fiction on Amazon in both paperback and kindle. 

04/17/13

A Game of Shadows 2

 

Shadows

A GAME OF SHADOWS, 2/3
by Edison McDaniels, MD

Dandy ultimately discovered that replacing the CSF with air, called pneumoencephalography, did a tolerable job of visualizing the ventricles and any tumor either in the ventricles or large enough to distort the ventricles (hence, most of the tumors discovered this way were quite large). Unfortunately for the patient, pneumoencephalography was a difficult and dangerous test to perform. The brain normally floats in the CSF. Removing most of the CSF for this procedure was no easy feat, and was extremely painful with severe headaches lasting days to weeks afterwards. Not to mention the nausea that accompanied the test. As if these things were not enough, once the air was injected every attempt was made to get it to flow into just about every nook and cranny within the skull. To accomplish this, the patient was placed on sort of tilt-a-whirl chair that spun them every which way—including upside-down. Imagine having the worst headache of your life, being utterly nauseous, probably vomiting, and then being flipped upside-down—repeatedly. Think about that next time you’re having a bad day.

For about 50 years or so, this, cerebral angiography, and plain xray were the only games in town. Today, pneumoencephalography is relegated to the pages of history. There is no real indication for it in this modern era of CT and MRI.

ICA-Angiogram

A cerebral angiogram. The black squiggles are the arteries of the brain, viewed as if looking at the side of the head. The carotid artery is the largest squiggle, coming up from the bottom of the image and branching like a tree.

Cerebral angiography was invented a few years after Dandy’s development of pneumoencephalography, in 1927, by a physician named Egas Moniz. Moniz was looking for a way to visualize the vessels inside the head. He finally settled on a solution containing heavy metals which are dense and easily visible on x-ray (though toxic to the kidneys in large doses). When injected into the arteries of the head and x-rayed, the arteries (and the veins as well) of the brain—the cerebral vasculature—are completely visualized.

This turns out to be useful both directly and indirectly. Directly because one can visualize aneurysms and other vascular malformations of great importance. Indirectly, and here we go back to the shadows again, because of what we can’t see. One of the most important past uses of cerebral angiography, as it is called, was to identify the presence or absence of epidural and subdural hematomas following trauma. This was done by reading the shadows, that is, the shift in the normal position of the blood vessels. If an acute epidural or subdural hematoma was present, it would push the normal vessels away from the side with the hemorrhage. That is, the presence of the hemorrhage would be implied by the lack of any vessels where they should normally exist.

The scenario went something like this: Little Joey gets hit by a car and is rushed to the ER. Finding him to be unconscious, but lacking any other clinical localizing signs to discern whether or not a blood clot was pushing on the brain (after all, he could just have a concussion, or worse, diffuse brain injury which does not respond to or require brain surgery), Little Joey would be rushed over to the radiology room where a neurosurgeon (not a radiologist in those days) would inject the solution of heavy metals directly into Little Joey’s carotid artery in the neck. A few quick x-rays of Little Joey’s head would be taken, and voila, the shadows would show the presence or absence of hematoma.

Or something like that.

SDHacuteShift

An acute subdural hematoma. The hemorrhage is the irregular white pattern on the right side of the image (which, do to the arbitrarily agreed upon conventions of imaging is the LEFT side of the patient’s head). A hemorrhage such as this pushes everything out of its normal place, including the vessels seen on an angiogram.

If Little Joey also had other injuries, he might just as well be whisked off to surgery for an operation on his belly or chest or whatever. Then the neurosurgeon would be left to his own devices in the operating room without any imaging to guide him. This often meant drilling a series of holes at strategic points around the head, sort of like drilling for oil. Problem was, you always got oil. The trick was to determine when you had a normal amount of oil or too much. And of course this was on top of the confusion of whatever other surgery was being conducted on Little Joey as well…

Thank God those days are largely behind us.

Oh, and that Moniz fella? In 1949 he won the Nobel Prize in Medicine for the development of his other great (uh, not so great?) contribution to medicine, the prefrontal lobotomy. Today, of course, lobotomies are rarely—if ever—indicated. But for a brief period in the late 1940s and 1950s, in the era before psychoactive medications, they were all the rage for treating psychiatric disorders. Of course, lobotomy does not treat psychiatric disease, it simply disconnects the emotional, thinking part of the brain—the part that contains little things like personality & makes you you—from everything else. Jack Nicholson’s character Randle Patrick McMurphy in Ken Kesey’s One Flew Over The Cuckoo’s Nest was lobotomized at the end of that great movie, and for once Hollywood got it right. The horrifically vacant, the lights are on but nobody’s home expression on Nicholson’s face when McMurphy returns from surgery was not an exaggeration. Not one of the Nobel committee’s more stellar moments.

As big a bust as lobotomy has proven to be however, cerebral angiography—which lead to the use of angiography throughout the body—has proven to be one of the greatest developments of modern medicine. None of the endovascular interventions for brain aneurysms, aortic aneurysms, heart disease, etc., would be possible without Moniz’s invention. In fact, it is no exaggeration to say much of modern medicine would not be possible without angiography. It saves hundreds of thousands of lives every year. That probably was Nobel worthy.

Edison McDaniels, MD, is a board certified neurosurgeon practicing in the American South. Follow him on twitter @surgeonwriter and read his fiction on Amazon in both paperback and kindle. 

Click here for the final installment. Next time: MRI & CT take over.