Oksanna

Chapter five, Oksana. Oksana is five years old. She presented with hydrocephalus, that's water on the brain. 

It's an inappropriate buildup of cerebrospinal fluid, sort of a mental drowning where the brain gets soaked with fluid that can't be absorbed. You need to do some type of a bypass procedure to eliminate the buildup of fluid. So we've taken her to the operating room and she's positioned for a procedure called an endoscopic third ventriculostomy. 

That's where we go in, poke a hole in the floor of a thin membrane at the bottom of the brain that allows the fluid to leak out, percolate out and basically get reabsorbed. So it's a way of providing a bypass so the fluid can go away without leaving a piece of tubing in to drain it. Old fashioned way to do that would be to put a shunt in, put a tubing into the brain and tunnel it down into the belly. 

But with this procedure, we can actually make a hole in the floor of the brain, allow the fluid to trickle out and become reabsorbed. So we take her to the operating room and we make a small hole in a point called Coker's point, which is two and a half centimeters off the midline. And we drill a hole, we pass a little endoscope in through the brain down into the fluid pockets of the brain. 

So I pass this in, I'm looking at the screen where the area is where we're going to make this hole. And I'm with my attending, we're using a new laser to make a hole in the floor. And what it will do is it'll burn a small hole in the floor, allow us to make that hole in that passageway. 

And as I'm doing that, I'm holding this scope right in where we want to be. And we use the laser and all of a sudden my screen gets blurry. And I thought maybe this end of the tip of the endoscope has gotten blurry. 

So I'm about to pull the endoscope out and clean the tip of the endoscope. When my attending breaks in, Dr. Albright, Mark, don't move a millimeter. Look up, I'm going to clean the tip of the endoscope.

And then I look at the exit valve of the endoscope. There's bright red blood squirting out, arcing out through this hole with every beat of Oksana's heart. My God, we've poked a hole in something. 

I want to pull this scope out right away. Leland Albright says, Mark, hold it right there. So I'm holding the blood squirting out. 

Dr. Albright in the coolest calmest voice turns to anesthesia and says, anesthesia, we were having massive blood loss. We need immediate transfusion. Call the blood bank. 

We need mass transfusion protocol immediately. The anesthesiologist calls. The anesthesiologist fills the IVs with water, with saline to keep the Oksana's heart beating, to keep some blood in her body. 

We rapidly transfuse her. I'm still holding this scope immediately, exactly where it is. Dr. Albright says, Mark, hold it steady there. 

Hold it steady there. I'm not really sure why he's telling me to do this, but I'm holding it. I'm holding it. 

I'm holding it. I'm holding it. I'm holding it. 

I'm holding it. I'm holding it. I'm holding it. 

I'm holding it. I'm holding it. I'm holding it. 

I'm holding it. I'm holding it. I'm The laser had penetrated through the membrane into a major blood vessel in the brain, poked a hole there. 

We had to wait for that blood vessel to spasm. If I had pulled this scope out before the bleeding stopped, all that bleeding would have went into her brain, would have pressurized her brain, would have killed her immediately. By allowing the blood to squirt out and not damage the structures inside the head, we saved her. 

When the bleeding stopped, when that blood vessel closed off and the bleeding stopped, we were able to leave a catheter there and take her to the ICU and stabilize her. Then on another day, we went internally through the blood vessels and patched the inside of that blood vessel so it wouldn't leak again. That was an experience.

And that is an example of the fear freakout problem. When we have the fear freakout, we want to escape. We want to run, fight or flight, right? I wanted to pull that thing out.

That was the first thing I wanted to do. It would have been the worst thing possible to do. So the first instance of what you feel, the first reactant that you feel, suppress. 

Don't do it because it's almost always self-preservation rather than doing what's for the best. If I had pulled that scope out, she would have bled right into her brain tissue and would have died. Having Dr. Albright there, having him keep me steady and waiting for that bleeding to stop on its own, transfusing her with more blood that just kept going through that leak until it stopped, that was the way we treated her. 

That's cognitive dominance.