Tuesday, July 17, 2018

Epidural and subdural hematoma

After a 5 PM–1 AM shift at the ED a few weeks later, I saw a guy punch a girl and knock her straight to the ground, literally right in front of me. I attempted to gently help the girl to her feet. As I lifted her hand from the ground, everything went black. I had absolutely no recollection of what occurred after I lifted her hand. My friends told me afterward that the assailant's accomplice seized me by the shoulders and slammed my body backward and onto the concrete; my head smashed the ground like a watermelon.

I have a vague memory of going to bed but felt normal upon waking. I had a mild headache, but I was able to eat breakfast, smile, and felt surprisingly well. "Dude, we thought you were dead for a minute last night," my friends said over and over in different ways. We laughed together. Everything felt normal until around 4 PM, 16 hours after my head hit the concrete. My headache worsened, I became nauseated, and began to vomit as the world started spinning. I grabbed onto my friend, who noticed I was walking erratically, and asked him to take me to the ED. Fortunately, it was the same ED I worked at. The triage nurse knew me and sensed that something was off. I was taken in immediately.

My vitals were stable. My mental state was not. I told them my story like I was fine and survived it without injury. But I was obviously affected and slurring my speech. The doctor noticed this right away. From what I've been told—my memory of that day is still severely limited—a doctor who was familiar with me walked into the room and heard me speak. He wasted no time and wheeled my bed out of the room and personally pulled me into the CT scan. What did the scan show? 

It's just as you suspected, future doctor: a large brain bleed. An epidural hematoma and a subdural hematoma, plus a subarachnoid hemorrhage with a temporal bone fracture with, fortunately, minimal midline shift. I had experienced what you learn about regarding an epidural hematoma in medical school: the "lucid interval." My neurosurgeon told me that I was less than 2 hours away from a coma or death. He performed an emergency craniotomy and excavated the buildup of blood from the torn middle meningeal artery. The official surgical document stated, "We opened up the cranium and the middle meningeal artery was shooting profusely." The blood was drained to relieve pressure on my brain. I awoke in the neuro ICU with a shunt in my head, wondering what my life would become. 

'You Will Not Make It in Medical School'

The next few days weren't easy. I remember that I couldn't stand up on day 2 and needed the help of two nurses. Not being able to do anything on my own for the first 3 days following surgery was discouraging. But I knew that if I gave up right then and there and didn't go through therapy without giving it my all, I would never be the same. By day 5, I was walking up and down the stairs with only minimal assistance. I eventually passed all of the neurologic exams. On day 6, I was discharged. I had multiple medical appointments following this injury. Most of these appointments went exceptionally well, and the physicians encouraged me to continue pursuing my dream.

I canceled the rest of my interviews. I was stuck at home with terrible headaches. Going through that with physical therapy, occupational therapy, and speech therapy was just too much to continue. I committed to Lincoln Memorial University-DeBusk College of Osteopathic Medicine (LMU-DCOM) at this time because I knew, even amidst the agonizing headaches, dizziness, and routine struggles, that I could complete medical school.

All of this testing and work aimed at ensuring that I remained the same person continued for several months. In May 2014, approximately 3 months before starting medical school, I felt that I was back to normal. I had an appointment scheduled with a neuropsychologist who was to clear me to resume normal activities. This man, with a PhD and MD in neuropsychology, didn't try to sugarcoat anything. He told me quite directly: "You will not make it in medical school. You're too slow at recalling objects, and your short-term memory is poor. You have trouble with spatial organization as well." As I left his office, I told this doctor that I was grateful for his time and appreciated his assessment. I then told him that I'd send him a copy of my diploma when I graduated from med school. And on to medical school I went.

No Time to Feel Sorry for Myself

I was diagnosed with a major neurocognitive disorder secondary to traumatic brain injury, with a contusion to the left temporal lobe region, superimposed on attention-deficit disorder and posttraumatic stress disorder. Regardless, I was ready to give this whole "becoming a doctor thing" a shot. There was no time to feel sorry for myself. I was beyond excited to start my lifelong goal of becoming a physician.

A doctor recommended that the "use of compensatory strategies or accommodations will be needed to level the playing field." Being the previous A student that I was, I surely did not think I needed any of these accommodations. Actually, I didn't even consider any of this doctor's recommendations. I wanted to go through med school just like everyone else. I'll admit that anatomy lab practicals were a pure struggle, histology images were nearly impossible to recall, and microbiology was no fun. I was definitely more fatigued than I had been previously while learning. The headaches at times were so unbearable that I couldn't get out of bed. Hell, I was already a hypochondriac before my injury, and sometimes I even freaked myself out by telling myself that my brain was re-bleeding. You can imagine how this year was for my parents, living 1000 miles away...

Then again, what med student doesn't get fatigued and have headaches? What med student, absorbing all of this new detail about diseases, doesn't think he has all of them? "My stomach hurts... Oh man, I must have appendicitis." I didn't think I was any different from my colleagues. I passed all required courses the first year. I was not an A student, but I did not fail a single course. 

Second year was a little more bearable. I had slightly fewer headaches and the mental fatigue was mildly improving. The first 2 years were so densely packed with information that by April of my second year, I was mentally drained. There was still the beast at the end: Step 1. We were given April and May off, except for osteopathic classes, to study, and had to take the exam by June 10. I wasn't sure how to study for this and tried what seemed like 100 different resources. Looking back, I should have taken longer breaks, studied over a longer period of time, and overall been healthier.

Don't Lose Hope

As a third-year on my first internal medicine rotation, I stumbled upon a service called OnlineMedEd. I needed a source that was not just notecards and not just reading a book, which had, among other things, gotten me in trouble during Step 1. I watched one of their free videos, on coronary artery disease, and was immediately impressed by the presentation of the information and how they made it seem so simple. I proceeded to watch all of the cardiology videos and knew that this was the source for me.

OnlineMedEd's PACE method, along with the available content, was exactly what I needed to excel during my third year, as I learned the hard way the year before that overworking and cramming was not healthy for my bruised brain. I would read the notes, watch the videos, do associated clinical cases and questions, and use notecards to reinforce what I learned. I'm being honest in saying that the USMLE felt like an attending quizzing: "Hyperkalemic patient with EKG changes; first drug to give?" Of course, this is easy to answer after you've heard this question on every in-hospital rotation in your third and fourth year. COMLEX was only slightly different, because the questions (in my opinion) were more convoluted and I barely studied the OMM portion.

I know that this is all subjective, so here is the objective information. My results:

COMLEX Level 2: 622 (+176 from level 1)

USMLE Step 2: 258 (+48 from step 1)

Residency placement at my #1 choice

This story was not meant to make you think that I'm some crazy miracle. It was meant to tell you something real: I had a gun to my head, traumatic brain injury, countless sleepless nights, throbbing headaches, and debilitating neurofatigue, topped off by a dismal Step 1 score. I still made it.

If you only remember one thing from this, I'd like you to remember this: Life is going to continually test your strength and commitment to your goals, but it is solely up to you how you will react and respond. Your obstacles don't have anywhere near the strength that you do. We have the amazing inherent ability to control our thoughts and actions. You don't always get a second chance to redo the day before. But, when you wake up, it is a new day for you to win or lose. Don't lose hope!


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