AANS Neurosurgeon – Neurosurgery Cold Case Post-Mortem Identification

This is a fascinating interesection of science, art, forensics and neurosurgery.  You have got to click on this link and read this fabulous piece!
AANS Neurosurgeon – Neurosurgery Cold Case Post-Mortem Identification

AANS Neurosurgeon – The CSNS: Serving a Vital Function for all Neurosurgeons

AANS Neurosurgeon – The CSNS: Serving a Vital Function for all Neurosurgeons

EMC2

No, I have not forgotten the = sign in my EMC2

• is an emerging syndrome that will soon reach epidemic proportions, 
• will be the AIDS of the 2010-30 decades,
• may consume massive health care dollars.

I suspect many of the physicians out there have encountered this syndrome but may not have fully recognized what they were seeing.  further, this new medical challenge may prove even more daunting on every level than treating early AIDS patients.  Medical school education is completely unprepared and have little ability to make the rapid adaptations that would be required to meet this new public health need.

EMC2= Elderly (with) Multiple Chronic Conditions

I can give you many examples from just the last few weeks and I suspect my medicine colleagues could rattle off dozens.   Recently, I was asked to consult on an 85 year old who slipped on some concrete stairs and suffered a skull fracture and small subdural hematoma (blood clot between the skull and brain).  He was lucky and had no real brain injury but he remained in the hospital for over a week because:

1. He developed an arrhythmia that led to extensive medical testing
2. He experienced extreme difficulty urinating and as a result, suffered a bladder infection
3. His degenerative lower back problems greatly inhibited his early mobilization and led to high concerns about the risk of acquiring a blood clot in his leg.

Part of this frustrating syndrome is the social component that almost always accompanies the medical condition.  In this patient, he was the caregiver for his wife who suffered with advanced Alzheimer's dementia.  Not a visit went by when our conversation didn't stray to his concerns about his wife-was his neighbor caring for her properly?  Did she understand why he wasn't there to prepare her meals, help her wash and dress?  Would he be able to return to providing her care when he was released from the hospital?

One of my colleagues estimated that within 2 years, one of every three patient would meet the criteria for EMC2.  Coordinating their care, balancing their social and medical needs, making decisions about complex multi-pharmacy interactions and conflicting health needs (what is good for the heart may be bad for the brain, what is good for arthritis may be toxic to the aging liver/kidney).  Sure, geriatrics has emerged as a specialty but there is remarkably little known about how to best manage these patients, few hospitals have geriatric hospitalists (there are precious few geriatric specialists and even fewer that serve as more than nursing home guardians), and many specialists refuse to defer to a geriatric doctor in managing the many medical concerns of a given patient.

I never like to raise an issue without presenting some constructive suggestions.  The first step is clearly acknowledging the problem and bringing together innovative thinkers across the spectrum of medicine and medical education to develop a rapid response to this raging epidemic.  I promise a future posting to outline some more specific areas that will need to be addressed and some initial steps I hope the medical community will consider.

I think Einstein would approve.

There are only two ways to live your life.  One is as though nothing is a miracle.  The other is though everything is a miracle.

The Economy and Healthcare

Much is said about the economy these days-is it rebounding?  Is unemployment down? Who is responsible for the massive debt? How can we save Medicare?  Into this setting, a little reality slips in to my office on a frequent basis.  Today I saw a middle aged man who has a significant lumbar (lower) spine problem.  He has a ruptured (herniated) disc with nerve compression causing severe pain, numbness and weakness.  Together we have tried many treatments to heal this problem which have given him temporary relief but the symptoms soon return, usually worse than before.  The time has come when he should seriously consider surgical intervention BUT he can't.  Here is his story.
This hard working man has spent the last 18 months out of work, made redundant in the heat of the recession.  Just two months ago he finally landed a great, competitive job which he loves (and his evaluations have been outstanding to date) and is finally beginning to right his personal economic boat.  Taking the necessary time off of work, he feels, would jeopardize his job-there are 30 or more talented individuals who would gladly snap his position up.  Bad timing all around.
I find it really difficult at times like these to remain a dispassionate neurosurgeon.  This man is suffering great pain and disability.  He has taken no time off of work and even refuses most medicines because he wants to perform well every minute at work.  Firing him because of having surgery would be wrong and probably illegal but as a large company, I suspect they could find some way to handle that.  Being ill is hard enough, having those issues compounded by fear and financial insecurity has to aggravate the problem considerably.  Of course, I understand that the company needs him at work-that is why they hired him-and what good alternative do they have?
No one plans to have a medical problem and this many has done all the right "health" things (not overweight, exercises, goes to the doctor regularly, etc.) but nature can get in the way.  I am glad that I help many patients in my practice because when faced with this patient, I felt largely helpless.  I just hope the time I took to talk with him, reassure him, adjust his medications to try and get some relief will help in some small way.

Call From ER

Sunday morning the call came from the service-the Emergency Room is looking for you. OK, so I was on my way out to walk the dogs along the Hudson River on a glorious late spring morning but...I was hoping it would be quick and painless.
"Emergency Room," she answered.
"Hi.  This is Dr. Benzil, I am returning the call to Dr. W."  I replied.
"Is HE available?" she volleyed back.
PAUSE-I wasn't sure what she meant so...
"This is Dr. Benzil, Is Dr. W. available?"  I tried a different tactic.
Still she seemed confused, "I will get her to the phone when HE picks up."
Finally I understood. "I am Dr. Benzil, a she not a he."
I imagined some light bulb turning on, "Oh, I will get Dr. W."

It is June 2011.  I have worked at this hospital and this ER for more than 7 years and do more cases there than any other neurosurgeon and yet, the deep seated notion of doctors (particularly neurosurgeons) as male clearly lives on.  Sigh, perhaps in the next decade...

The Passing

Gill Scott Heron

I learned early Saturday morning

And I wept

His music and words

Had touched my soul

Had lifted me up

Many late nights and

Early mornings

When much younger

I had a first date

And he sang to the room

But it seemed like he sang

Just to us

And we stayed on

For a second show

That date soon became

My lifelong mate

And still you would 

Croon and remind us

Of what was right

And how to live,

Think, and challenge

I am so thankful

You made such music

That I saw you

Not once or twice

But many times

And that I will always have

Your songs in my life

Your revolution is over

The world's will never be

But I hope you have

Found a little slice of

Peace and happiness

You so deserve

For all you have done for others.

Gil Scott Heron Dies May 27, 2911
(For more information see-Washington Post, NPR, CBS News, Chicago Tribune)

Blogging Again

Returning Home
Leslie K. Price

It has been nearly a month since I last blogged and for the month prior to that, had found myself with less time to devote to this pursuit than I would like.  In the ebb and flow of life-between the challenges of work, family, and personal needs-somethings rise up and others fall to the back by necessity.  Once the pause happened, I felt that I would only return when I felt I could potentially return to regular entries.  I am hopeful that I now can.  How did I feel when I wasn't immersed in the blogosphere?  I missed the outlet for the "connections" I made while seeing patients and carried on my day to day clinical practice.  I dearly missed writing and the reward that comes from completing a creative endeavor.  I felt I had set aside some good friends, even though these are friends I know only from their writing and their "profiles".  On some levels, I felt unburdened of the "deadlines" I had set for myself for writing and I realized (AGAIN) that the blog is for me-an outlet, a connection- and not an obligation!
So I return.  Hopefully stronger than before, with renewed vigor and interest.  I hope you are still out there reading...

Homecoming-Parenting Again

Zanzibar!

October 14, 2011 my son departed for the African continent.  More than 6 months later, he will soon return and my life will be changed, in ways I cannot yet predict.  Like many young adults, my son needed time to figure out where he wanted to take his life.  Together, we opted for time volunteering in Africa as a way for him to "get away" while giving back something.  His first 3 months were spent building civic projects in the hills of Eastern Ghana.  I know only a little of his time there but he lived with no electricity or running water in a place that was equatorial hot.  He met volunteers from all over the world and seemed to have his eyes opened to many things about himself, being American, and regarding world politics.  It seems work was easy as the Ghanaians are soooo friendly but not sooo hard working. He then traveled east to Tanzania where he lived in finer accommodations but had to struggle to teach English and math to students in an orphanage.  Again he met many people and gained insight into how hard teaching is, the impact of a tourist economy, and the beauty of Mt. Kilimanjaro.  Of course, it wasn't all hard work and no play-he did treat himself to a short but impressive (his experience) safari and a week on the spectacular beaches of Zanzibar-a place of which most of us can only dream.
His path home took him through England where he traveled to see family, family-friends, fellow volunteers from Africa and to pay tribute to his deceased grandparents.  During his time there, I know he has been scrubbed clean and obtained some fresh clothes-slowly shedding the layers of Africa from his ski, hair and cloth.  But I suspect even when he stands back on American soil, that Africa will not leave his system so easily.  How this experience will change him, our (and others) relationship, and his dreams and future plans, will only emerge slowly over time.  I will do what I can to support his re-entry but I too have learned things during his time away-I know I can never return to how we co-existed in past years, that I need not completely sacrifice my health and happiness to accommodate an "angry young man".  I know that being a good parent (mother) means more than opening a wallet, preparing a meal, lending the car, or greasing the way.  It is also letting go, allowing them to fall, forcing them to confront, refusing to lower standards, and holding your head high.  Parenting-the hardest work I have ever done and ever expect to do.
Wish me luck!

And Finally Spring

Madison Square Park
May 1, 2011
(Taken by author)

Spring has been slow in coming to NY but last weekend, we had the spectacular combination of warm (but not hot) and sunny to highlight the fast ripening beauty of spring all over NY.  As we approached Madison Square Park, these candy-colored tulips just leapt into our visual pathways and exploded upon retina and occipital lobes.  Finally, the days of black and white are over for the next 6 months.  My garden will soon blossom chives while the hellebores, bleeding hearts, and azaleas brilliant color swatches to the garden canvas.
Sunday was also a special day on an entirely different level-I quietly celebrated my 23rd anniversary with the man who has brought such joy and love to my life. Here's looking at you-for at least another 32!!!

Fingernails and Insurance

She came into my office with the usual complaints-neck and arm pain, back and leg pain.  All started after the car accident more than 10 years ago.  As the story unfolded I took my notes but my attention was drawn to her fingernails.  What struck me was how perfect they looked-luciously long, groomed, and painted.  These were obviously well tended nails-the kind that take an hour to create-with the latest technology for fillers/lengtheners and the like.  I have sat next to women in various nail salons who were receiving such nails and was struck by both the time and cost associated with this-not to mention the frequency of required treatments to maintain.  For some reason, on this patient, these perfect nails struck me in an unpleasant way.
This was a woman who otherwise seemed to care little for herself.  She was sloppily dressed and not only overweight but clearly out of shape and unhealthy.  When she removed her shoes during the examination, her socks were more gray than their original white.  In addition, her history as she related included numerous times when she opted not to have insurance because she didn't want to pay her "portion" or when she opted out of recommended care because she couldn't afford the required co-payments.
Fast forward, and before me sat a woman now with a chronic pain syndrome-out of work for more than 6  years as a result and thus statistically unlikely to EVER return to gainful employment.
And yet her fingernails were perfect...
Hard as I try, I can't put myself in this woman's shoes.  I can't say for sure that she made poor choices about her limited funds.  It may be that the only thing she does for a "treat" just for herself is her nails.  Perhaps even this was a first-a special occasion and not something done regularly.  Undoubtedly there are many possibilities that perhaps I can't even imagine.
I just know I was struck by the dichotomy-the willingness to devote significant amounts of resources to her hands while neglecting a whole spectrum of healthy living activities, some of which require little or no money at all.  It did raise the question in my mind about the balance between societal and personal responsibility, especially when it comes to health and utilization of those precious resources.  In the coming years, perhaps these questions will be an increasing component of the discussions about health care insurance, Medicare, and reform.

Black and White and Yellow

It is like they took a black and white photo

And someone had just one paintbrush

And began to touch it all up with

The color yellow.

As I drive along the road

My eye is invariably drawn

To these audacious highlights

Signaling spring.

The wind still howls on many days

The rain can lash cold against the face

But nights draw longer inexorably

Seasons change.

Why yellow in all that is touched?

Whether sun-stroked bush

Or multitudinous erupting bulbs

April's color.

Yellow, breathing life back into

The slumbering world of black and white

Assaults the eyes and senses

Brings a smile.

Just Two

Brilliant purple they stand alone

Two welcome beacons of

Warmth, light and color

That will soon infuse the day

Saffron threads peek out

From beneath regal robes

Huddled close to ground

Beneath still barren trunk

Oh, how just two

Can raise my smile

Cause heart to swell

Lift shackles of winter.

The Apple Doesn't Fall...

As a woman neurosurgeon, I wear the simultaneous hats of surgeon, mother and wife (along with chef, businessperson, volunteer, leader...) so I am thrilled to announce that my daughter has started her own blog called College Kitchen.  Even if you are well beyond college, she has a great insight into cooking healthy, fast and inexpensive meals-just what every college kids needs but also what so many of us that juggle hectic lives need too.
It will be very interesting for me to watch her evolution as a blogger.  I have already shared with her the few "tricks" I have learned during my time in the blogosphere but more importantly, I have shared with her how my own blogging has transformed the way I think about each day and each encounter.  I wonder if it will have the same impact for her.  Perhaps her blog will catapult her to fame and fortune-like Julia (and Julia), maybe it will help others learn how easy it is to prepare fast but healthy food, perchance she may gain insight into a new part of herself or her future...all I know as  mother is that I am so proud of her, and specifically tickled that she now also has a blogspot address.

A Blogger Reunion

Nearly a year ago, my mother and I traveled to Poland on a roots trip and after we returned, I decided to write about our adventures (Poland-Germany Travelogue).  This blog event has had some remarkable ripples I would like to share-the power of the Blogosphere.
Several months after our trip, my mother's first cousin read the blog before he made his own trip back to Poland and was able to use our experience to help his own.  In fact, he was able to dig deep enough to identify the exact house where my great-grandfather lived and worked (and where my grandfather was born!).  He then sent us my mother photographs of this house which my mother forwarded to me.  I know this all sounds complicated but the end result is that this cousin lives very near to me and we have made plans to meet each other to exchange Poland stories! So around the globe and blogosphere to meet my second cousin!
My blog was also read by a woman who created the site on JewishGen about Smigrod and Dukla.  She has asked that she be able to link my travelogue to this website-which I gladly agreed to.  But then a few days later, she wrote and asked about an inquiry she had about a family that sounded much like mine.  While this is another fairly convoluted tale, the result was that I have made contact with one of my first cousins, who I have not seen since my grandmother died more than a decade ago.  I have now seen photos of his two lovely children and we have chatted about a number of topics.
Perhaps a generation ago, families were closer and there was more regular contact between distant cousins, I can't say, but I do know that this wild and wacky electronic world has brought me in contact with family in a whole new way.  I am sure others have similar stories.

What are we Scared of?

Listen carefully-I have an important secret to reveal (we as physicians often hold our medical wizardly very close to the chest so this may be a rare opportunity).  One inescapable fact of life is that ultimately we all die.  It is the final outcome for us and for all our patients.  Of course, neither I nor other physicians need be fatalistic-there is much we can do to help our patients live long, happy and healthy lives BUT we do always have to keep this basic tenet in mind.  It is as basic a medical principle as those of circulation, respiration, and digestion which most second graders have mastered.
So why have we, as Americans in 2010-2011 decided there is some crazy taboo about discussing end of life issues with our patients?  During the recent Health Reform Debate, this topic became politicized as "death panels" (bipartisan debunked by PolitiFact).  Then just last week, the subject was again stirred up by inflammatory headlines such as The Hill's:

Medicare chief: Keep gov't out of end-of-life care planning

By Jason Millman - 02/09/11 12:55 PM ET

I can honestly say that in my many years as a neurosurgeon, I have done more good for my patients through such end of life discussions that I have done with my scalpel. That doesn't mean I have spent my career rationing or withholding care, it doesn't mean I have easily given up on difficult cases, and it certainly doesn't mean I have been lazy (done well, these types of discussions are more time consuming and difficult that alternatives). But it does mean I am honest and realistic, I am willing to broach challenging subjects with my patients and their loved ones, and I have learned to carefully use words such as futile. In doing so, I know that I have helped these people begin the challenging process of grieving in a way that will help them emerge on the other side whole. In doing so, I have gained invaluable inner riches that provide me sustenance.

It is rare that someone feels it is a "right time to die" and no wants to be cheated (for themselves or their loved ones) of a treatment that could allow them to live for a day/week/year/decade. However, I also believe that no one wants to be kept ignorant of critical health decisions or to suffer needlessly because hopeless treatments are administered. On one level, the politicians got it right-we need to take politics out of death-but that doesn't mean we can ignore reality.

Birthday Mom

Once a year, I have a week in which I celebrate the birth of both of my children.  They had the same due date, just one year apart and ultimately just a year and four days separate my oldest and youngest.  So when the last week of February nears, I am taken back to those challenging days-the end of pregnancy when the anticipation and anxiety of childbirth (especially the first time) are nearly overwhelming.  I worked full-time up until the very end with both and I think that actually helped distract me but it also meant I was utterly exhausted.
Fast forward 21 years and I am relaxing on Amtrak traveling from New York to Washington, DC-a far cry from the 13 plus hours of labor.  Wand then on Saturday a lovely jaunt to the Phillips Collection in Dupont Circle on and then a special dinner at Citronelle.  I think every parent-daughter relationship has its good and bad moments-right now we are all in a nice place and the time shared was a joyous celebration for all.
Somewhat in contrast, my son turned 20 on the day we left DC.  He is currently on a volunteer project in Tanzania, after 3 months of work in Ghana, and we were not able to reach him in any way around the time of his birthday. Mail takes 3-4 weeks to arrive (and succeeds only about 75% of the time), his nearest internet cafe seems on-line about half the time when he gets there (infrequently), and he lost his phone...Finally a week letter, we did make contact and were able to extend him a "virtual" hug.
For me, it is always a week of introspection, thinking about the early years of my marriage, the decision to have kids, the financial struggles intrinsic to most young families, and the many, many challenges of raising children simultaneous with building a career in neurosurgery.  Despite the challenges, I have found both to be extremely rewarding.  I look forward to many years of reaping the rewards of both of these essential parts of my life.
Happy Birthday Dina and Daniel!
Love,
Mom

Age Before Beauty

There was shocking and disturbing news at the recent American Stroke Association conference-strokes rates have risen dramatically between 1994-5 and 2006-7 but only in the younger populations!  While there are many explanations for the data (51% rise in 15-34 year old males, for example) but certainly in part, this is related to the obesity crisis coming home to haunt.  Strokes are sad because:

1. Even with early warning signs and advanced medical therapeutics, strokes remain devastating in terms of quality of life-they less often kill than maim
2. Stroke rates can be dramatically impacted by lifestyle decisions-obesity, smoking, sedentary lifestyle, etc.

This study should serve as the shot across the bow-we can no longer ignore the dangerous health trends in this country-a FAST FOOD NATION is doomed to egregious health outcomes, stroke being a prime example.  Each one of us has to commit to trying to live healthier lives and help others to do so as well,

I have long been an exercise enthusiast and have been proud of my locavore/healthy cooking style.  Nonetheless, like many 50-somethings, found my weight had crept to dangerous levels.  I have made further adjustments and am proud to say, have dropped 25 pounds over the last 6 months.  But then I decided to take an even greater step and try to turn my new awareness to greater purpose.  I have set a challenge in both of my offices related to sustainable weight loss.  I decided that as a physician I have to both walk the walk AND talk the talk.  I hope everyone will try and think of at least one thing you can do in your own life or for those you love to help reverse these dangerous trends.

All my Lovin'

To all my family and dear friends,

While Hallmark and Hershey's have tried to drag Valentine's Day over the edge (I won't even mention Victoria's Secret), I still think of today as a day to smile and give thanks for all those I love.  Today, I send out special love to one dear friend in particular-Glenda, this is for you.

Forgive me, I should have called sooner

There is no excuse, no rational cause

You were on my mind, I sensed you in need

And I always tell others-now, do it now!

I wish you were nearer, I would be of more use

I would love to bring you soup

Rub your back, brush your hair

Or just sit by quietly at your side

There are no words I know I can say

You have paid your dues twice and again and again

You deserve better after all you have given others

Just know we are here, will do all we can

Be proud of all you have done and will do

One has grown tall and will make you so overjoyed

Another has stood by your side, with love you share

And countless who have gazed at your historical visions

For me, I can say you no better friend there is

From days long ago in the lab to right now

We have shared our hopes, fears and struggles

I am honored to call you dear friend.

Exciting Progress

This week there was exciting news published in the New England Journal of Medicine about the potential benefits of intrauterine surgery on a fetus with spina bifida (see also Spina Bifida Association).  In the past, similar approaches have resulted in unacceptable risks to the mother and complications of the pregnancy.  With advances in technology and technique, these risks have been limited and in fact no additional risk to the mothers were found.  Dramatic positive results included (full text at NEJM link above):

• The first primary outcome, fetal or neonatal death or the need for a cerebrospinal fluid shunt by the age of 12 months, occurred in 68% of infants in the prenatal-surgery group and in 98% in the postnatal-surgery group (relative risk, 0.70; 97.7% confidence interval [CI], 0.58 to 0.84; P<0.001) 
• The second primary outcome — a score derived from the Bayley Mental Development Index and the difference between the functional and the anatomical level of the lesion at 30 months — was significantly better in the prenatal-surgery group than in the postnatal-surgery group (P=0.007). 
• In post hoc analyses, infants in the prenatal-surgery group were more likely to have a level of function that was two or more levels better than expected according to the anatomical level (32% vs. 12%, P=0.005) and less likely to have a level of function that was two or more levels worse than the expected level (13% vs. 28%, P=0.03) than were infants in the postnatal-surgery group. 

The New York Times hailed the research as opening the door to the great potential for fetal surgery.  Many days I have happy to be a neurosurgeon, some days I feel GREAT to be a neurosurgeon.  Reading the results of this study, as someone who has spent many hours with these patients and their families, I am thrilled!

The Social History

A  49 year old woman came to my office last week with 5 years of debilitating headaches.  Her neurological evaluation included an MRI which  revealed a pineal region cyst.  After several years getting interval MRIs focusing on this benign cyst until she took her care into her hands and sought the opinion of a neurosurgeon.  I looked through her extensive catalogue of MRIs and could confidently reassure her that this cyst was not a worry and not the source of her headaches.  She was relieved but asked the expected question, "Then what is causing my headaches?"  I think I know but before I answer let me divert for a moment...
Pain-in its many forms and expressions-is probably the greatest challenge for physicians.  You can't see it or touch it, there are no tests that reliably predict it or measure it (there are scales that are used but they remain completely subjective), and it is always a "symptom" rather than a diagnosis (think appendicitis as diagnosis/right lower abdominal pain as symptom OR brain tumor as diagnosis/headaches as symptom).  Despite all this, pain is always real-one might complain more than another or let it interfere with life more but anyone who comes to my office complaining of pain IS REALLY experiencing pain.  Because pain is the end product expression of many factors and modulations-both physical and psychological.  And to date, science has failed us miserably in understanding the real mechanics of pain.  Sure I could enumerate molecular knowledge about receptors, agonists, antagonists, signal transduction and the like but in the end, it wouldn't get any of us closer to understanding how and why patients suffer, how stress can bring on a headache or aggravate back pain, or how a wedding can temporarily halt longstanding cancer pain (as just a few examples of a myriad of pain enigmas).

Early in my career, I learned an invaluable lesson from an enormously gifted and talented plastic surgeon (who I count as both friend and mentor), Dr. Jane Petro.  We were jointly running a peripheral nerve clinic and had to evaluate a patient with RSD (Reflex Sympathetic Dystrophy as it was known then, now referred to as Complex Regional Pain Syndrone-CRPS).  After the patient left, she engaged the team in a discussion of a striking paper that demonstrated the very high correlation of RSD with abuse (both child and spousal abuse) (References below).  The clear implication was that our life events clearly impact our response to injury and disease in ways that remain unknown to us.  But while we may not understand the mechanism, it is evident that all health care providers have to more closely attend to understanding the lives of our patients in order to administer to their medical needs.
Which brings me to the Social History-probably the most under-rated component of a patient's history (beyond the perfunctory smoking, alcohol, and drug history).  Despite the pressures and my role as a sub-specialist, I always ask a few questions about home, employment and background.  At the least, I know a few things about my patient and it helps me view them as people (fathers, sisters, colleagues, etc.).  And sometimes the information turns out to be critical for successful outcomes or interventions.  For example, I recently performed a spinal fusion on a woman who was clearly in a threatening marriage and based on that information, I made sure she went to rehab post-op, even though she was likely medically well enough to go directly home.
So how does this all relate to my headache patient? Well, by just asking one simple question, she revealed a recent divorce after several years of a nasty separation.  Clearly, her headaches were temporally related to the onset of marital strife.   Trust me, this woman truly suffers from terrible headaches-they are real and life-altering, neither imagined nor exaggerated.  How? I don't know. Why headaches and not some other complaint? I don't know.  What is the best intervention now for this woman? I don't know.
But I do know, taking the Social History remains a critical component of understanding and providing the best care to our patients.

References:
Abuse-related injury and symptoms of posttraumatic stress disorder as mechanisms of chronic pain in survivors of intimate partner violence. - Wuest J - Pain Med - 01-MAY-2009; 10(4): 739-47

Prevalence of interpersonal abuse in primary care patients prescribed opioids for chronic pain. - Balousek S - J Gen Intern Med - 01-SEP-2007; 22(9): 1268-73

Sexual and physical abuse in women with fibromyalgia syndrome: a test of the trauma hypothesis. - Ciccone DS - Clin J Pain - 01-SEP-2005; 21(5): 378-86

Psychologic factors in the development of complex regional pain syndrome: history, myth, and evidence. - Feliu MH -Clin J Pain - 01-MAR-2010; 26(3): 258-63

Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st ed.; CHAPTER 82 - Domestic Violence

Katz: Comprehensive Gynecology, 5th ed.; Chapter 10 - Rape, Incest, and Domestic Violence

Sport Related Head Injury

This has got to hurt!

Super Bowl is just days away and I am as big a fan an ANYONE (see my blog sidebar for evidence!) but I do admit that as a neurosurgeon, I find it increasingly difficult to watch the players heads bounce off the ground with resultant concussions or worse.  I recently presented an educational radio program for my community that I thought I would share.  No cool pictures-just me talking!

Aaron Rodgers "New" helmut (after several concussions)

Quagmire: To Laugh or Cry

Jacob wrestling the angel (from which he acquired back pain)

During the last two years I have treated a young woman who personifies my perception of the challenges of America (and our health care system).  She has limited educational and economical opportunities, landed in a threatening marriage, was injured in a car accident, and is overweight and unhealthy, now with severe pain and a resultant narcotic dependence (doctor prescribed).  Her MRI scans demonstrated significant disc herniations in both her neck and back with severe nerve compression, etc.

Ancient treatment for back pain

Despite all the factors mitigating against success, I offered her surgery hoping it might help lift her up and allow her to move forward with her still young life (she was just 29).  I was thrilled at her post-op visit after her second surgery to see a better dressed, slimmer, and much more animated woman greeting me.  She had thrown out her abusive husband, returned to work part time and lost 15 pounds.  Her progress was outstanding and encouraging.
Fast forward 12 months-she is back and the sight she cuts is not nice.  Now her skin is gray and droopy-an obvious reflection of poor nutrition, her weight has rebounded plus some, her narcotic use is higher than ever, and her back pain has returned. And then she relates a particularly distressing tale, motivated, I think, by her own guilt.
After her second surgery, her insurance company sent my professional fees to her (this is a local practice when the doctor does not work within the insurance network) a check of several thousands of dollars for this complex spine procedure.  She tells me she deposited the check in her bank with plans (when it cleared) to write me a check to cover her fiduciary responsibility.  However, because of unrelated financial problems, the money was "seized" or "frozen" by some creditor and taken to pay off some other debt she owed.
I admit, I am gravely disappointed-nothing worked the way it should.  This woman has potential that I fear she will never realize.  I have performed surgery that I have not received compensation for because of the perverse insurance system we live under. A quagmire and a failure-I feel a part but also feel helpless as an individual in a complex system. I fear that until we address the totality of these types of issues, our health care system will continue to groan and fail for many similar individuals.

Edgar Tafel and Me

Edgar Tafel 1912-2011

I learned this week of the death of Edgar Tafel-a noted architect and also Frank Lloyd Wright (FLW) Fellow and Historian.  I am connected to Edgar because I live in the first house he ever designed and built (after he left the FLW Fellowship).  After we moved in to this unique and special home, we contacted Edgar who graciously came to visit us-beginning a friendship of many years.  Over a rainy-day lunch, he regaled us with talk of building this home for his parents, architectural history, stories of FLW, and his own personal history of loves, careers, and more.  Later, we had him return to deliver an aspiring lecture at our library on FLW followed by a reception in our backyard.  We also had the privilege of visiting him in his townhouse in NYC on several occasions.  Quite by chance, when we bought a small apartment in NYC, it was less than two blocks from his home, to which he had returned full-time.  I last saw him just a few weeks ago-stopping in on a whim while walking my dog.  Last week, I again passed his door with on a canine walk and realized he had died-I can't tell you how but I did.  I returned to my apartment and furiously "googled" him without finding any news.  But just days later, the obituaries appeared.  He was 98! He had lived long and large-seeing so much of modern architecture, art and music-all things he loved dearly.  While he is not a household name, his impact on how homes, places of worship, and college campuses are built will long outlive him.  His gracious and generous endowment to Cornell University will also assure his remarkable legacy.  Tonight I will say Kadish for Edgar Tafel.

The Albert House

First Presby Church NYC (Village)

Patient Wisdom

Sometimes my patients utter wisdom that I feel blessed to share with others.  Here is a recent representation from just one day in the office:

• As to my children, I don't worry about the first 10 years (of their lives), it is the second 10 I lose sleep over.
• Parental wisdom comes in waves.  At first children think their parents the wisest humans in the world.  Then there comes a time when they know absolutely nothing.  This may last for 10 years or more.  Then the next generation arrives and suddenly the parents regain their rightful place as all knowing and wonderful.
• You may have been taking care of these types of patients for years but I have been dealing with my mother for more than 40-I think I know her well.
• If you ask the wrong question, you may get an answer you don't need nor want.
• I realize there is a price to pay for everything.
• I can only ask that you do your best and that you are honest.  No one is perfect.

Everyday, my patients share themselves with me.  I am eternally honored by their trust and the wisdom they share with me-it has enriched my life.

Health Insurance News

California seems determined to lead the country in health insurance reform.  This week, they announced emergency measures that would require that health insurance companies spend at least 80% of their premium dollars on direct patient care.  While this same provision is part of the recent health reform bill, somehow these headline stories really struck a note with me and crystalized some key thoughts about our current health crisis.
First, we no longer pay for health insurance-we pay for a health care policy.  Insurance is something you pay a smallish amount of money to pay for something that you hope will never happen.  Health insurance used to e something like that-we paid to cover the big things that might arise while we paid "cash" for everyday health care needs.
Second, as a result of number one, individuals are no longer connected to health care costs and thus have no role in stabilizing costs.  Sure, rises in premiums are hard felt but they are no longer directly connected to how individuals use their policies.  Once they have paid, they have little or no incentive to limit their use of services.
Third, having free market health policies (not real insurance) puts us all in a horrible conundrum-if it is free market, then why should their be any constraints on how much profit these companies make, how much their CEO's earn, or what services they choose to cover? But no one really feels like it should be the free market like cars or restaurants or supermarkets...because it is our and our loved ones health and we need to know there is some control, somewhere...
So in the end I find it somewhat like a Rubik's Cube puzzle-once you know how to solve it, then it is easy but until then, it seems unfathomable.

• Why should even 20% of our premium dollars go to administering the delivery of health care-I can't speak for others but what I do pay in premiums, I want invested right back in taking care of patients-not administrators who work to find every way they can to not pay doctors or hospitals or negotiate with the same in good faith.  
• Why should non-physicians get significant say in what services, surgeries, x-rays get approved?
• Why should consumers be able to demand tests, care, interventions that have no indication just because they have paid for a commercial product?
• When will partisan bickering be put aside to allow for real discussions about what ails our failing health care system?

Journey Back Poland (Germany)-Final Berlin

Berlin Wall Remnants

Berlin was ultimately the perfect place to conclude our Mother-daughter "Roots" journey for a variety of reasons.  In planning the trip, it was natural to end in a city with an international airport and Berlin was also where my grandmother and grandfather last lived in Europe before fleeing to Haifa and then on to New York.  Berlin also offered a broader view of the history of Germany/Eastern Europe/the Jews than the smaller cities and villages where we had spent most of our time. Finally, Berlin today most definitely is looking forward and this energy, enthusiasm and optimism was the perfect balm to the grief and sadness that inevitably suffused much of our looking back and connecting with our personal and ethnic history.
After driving through primarily remote regions, our approach to Berlin served as an abrupt return to the 21st century with congested, interlacing roads with the requisite confusing signs-at least when keeping up with the pace of the Autobahn.  We found our hotel, perfectly located within walking distance of nearly all the important East Berlin sites with several convenient transportation hubs available to allow more expansive exploration.  My first great surprise was learning the hotel would arrange to have my rental car returned-that I would not have to negotiate the Friday evening rush hour traffic in central Berlin after all.  With my new found freedom,  I had time to set off to stretch my legs and explore our immediate neighborhood.  Mom rested and we made arrangements to enjoy a nearby Turkish restaurant for dinner.

Alexanderplatz

The next morning we took the U-bahn to Alexanderplatz-the meeting point for our guided tour on Jewish life in Berlin.  As much as I like exploring on my own, the right guide can really unveil the heart and soul of a city and that's just what happened. We saw smaller and larger memorials to the Holocaust and to the small but meaningful efforts at resistance-hearing stories little known of bravery but also of brutality.

In the heart of the old Jewish quarter, we also saw the Hackescher Hofe which have largely been rebuilt (gentrified) since the fall of the Wall and may be one of the ultimate representations of the rebirth of what was once a bleak East Berlin.  The tour culminated at the New Synagogue-a spectacular building completely renovated to serve as tribute to the once thriving Jewish community of Berlin.

New Synagogue

Hackescher Hofe

We said goodbye to our guide, hopped on another U-Bahn and headed to (Charlottenburg), the center of my grandparent's life during their married years.  The lovely Platz (square) was ringed with inviting cafes-just what we needed.  Then we set off up Knesebeckstrasse in search of my grandfather's store.  We easily found the first address and were lucky to get inside the lovely iron doors to look around.  It was an amazing feeling to think of my grandparents selling furs right on this spot to support the family.  We then wandered on to the second address.  This one was less obvious, especially as we had one photography of my Grandpa Henry standing in front of the store so we were trying to match not only the address but the door frame.  In the end, we linked them all and felt this confirmed when we walked around the corner and found a fire station-Mom immediately recalled her brothers talking about this.  We had been to their places of birth and to places where they were raised but somehow, this felt so much more tangible-like I could reach back through time and touch the lives of my ancestors.

Knesebeckstrasse

Knesebeckstrasse

We had paid our respects to our family and now we paid homage to history.  Though we were both exhausted-physically and emotionally-we headed to Checkpoint Charlie then wandered back along the remnants of the Berlin Wall.  While little remains of the physical structure-art, poetry and historical placards remind all of another challenging time in German history.  I deposited Mom at the hotel and with just a little time left, walked up to Berlin's monument to Jewish martyrs.  An entire large city block has been given over to this memorial which is both simple and moving.  I love the fact that tourists and Berliner's alike perch on the stark stone blocks to rest and remember-with signs of a rebuilt Berlin bursting forth in all directions.  I concluded by foot wearing day walking to, through and around the Brandenburg Gate.

Berlin's Memorial to Jewish Martyrs

Now, Mom and I could share a final meal together and celebrate all that is Scharf, Benzil, and Kranzer.  After donning our best attire, we headed to one of Berlin's restaurant stars: Rutz.  There we luxuriated over a spectacular 5 course meals accompanied by the best of German wines.  Certainly a fitting end to a very special adventure.

Naomi at our final meal at Rutz