Unforgotten

“The unconscious never forgets.” Sigmund Freud recognized that the mind can draw relevant recollections into awareness instantaneously under times of stress. In other words, the human brain can bring forth long forgotten memories when confronted with crucial life events. How remarkable that stunning circumstances can trigger memories of related experiences that occurred decades ago!

Focused on my work, the investigation of health and disease through imaging, I was suddenly forced to accept my frailty and to reexamine my future. After a potentially fatal accident I remembered experiences long past that influenced my obtaining the life-saving interventions. Not only have I remembered forgotten experiences, but also I have pondered what future actions will form indelible memories for me and for others. Let me recollect my confrontation with death and the memories that influenced my actions to obtain the desperately needed interventions.

           I’ve got to run to the farewell party in the outpatient center before going to the clinic to take care of my patient whose scan is scheduled to begin at 3:15 pm. The party began at noon; it is shortly after 1 pm, so I can spend a few minutes to say goodbye to my dear colleague.

           On the last step, my mind elsewhere, I sense myself pitching forward, losing my balance. I arch my back to pull my body upright, to no avail. To protect myself from a fall on the pavement, instinct reaches my left arm forward. Nevertheless, I hit my left cheek on the pavement by the sundial. I get up. Colleagues behind me ask, “Are you okay?” I say, “Yes,” while I continue to walk to the outpatient center. My left cheek, left shoulder, left knee, and hands are sore. I do not have a headache. On the way to the outpatient center, I see my manager who tells me to go to the restroom to rinse the blood from my face with cold water and then go to conduct the scan at 3:15.

           I feel shaken, but okay. “I am a strong man,” I tell myself. I can complete the scan as scheduled at 3:15. My abrasions will heal in time.

           In the outpatient center before joining the ongoing party, I enter the restroom and lock myself in. I am shocked to see blood flowing from an abrasion on my left cheek. I look acutely ill.

           More than a decade ago I fell on the pavement outside the hospital while running to catch a shuttle bus home. The loose heel on my right shoe caught on the pavement. My left eyebrow hit the pavement. A coworker helped me up. At that point I intended to continue running to the bus to proceed to go home directly. She said, “You need to go to the emergency department.” I did reluctantly, fearing that I would wait there several hours.

           In the emergency department I told the nurse that I had not seen my injury. She told me to look at myself in the mirror on the wall. There was a bleeding laceration of three or so inches on the left eyebrow extending to the skin above the eyebrow. I remembered then that unless facial lacerations receive immediate treatment by plastic surgeons, disfiguring scars are likely to result. I told the emergency physician that I would like to see a plastic surgeon in the emergency department for the initial therapy regardless of the wait. He came quickly to repair the wound in layers. First, he sewed together the underlying tissues. Second, he sewed together the skin separation above that foundation. He then gave me an appointment to see the attending facial plastic surgical attending a week later. I needed no further intervention for the scar on my eyebrow, and you wouldn’t notice it now. Once in a blue moon I feel burning when wind blows across it.

           I worry now, again, that the abrasion on my left cheek may result in a nasty scar. My left knee is sore but my pants aren’t torn, so I assume that there is no abrasion, until I pull up my pants leg to find the left knee oozing blood and the soft tissue on the inner surface of knee swollen to the size of a grapefruit. The abrasion on knee will heal eventually. Will the knee be damaged? I have abrasions on both hands. My left shoulder is sore from reaching out to break the fall. I need to see the patient for the 3:15 scan. I may need to monitor him for a couple of hours or more after the scan begins. If I wait until 5 or later to go to the emergency department, then the staff will not consider this an emergency so I might then wait for several hours to be seen.

           I walk past the conference room with the ongoing party to my office. My manager tells me to go to the clinical center for the scan because the dose and the patient are ready. When a co-worker sees me, she says, “You look awful. Our administrator says that employees must go to the emergency department immediately when this happens.” You’re right; I need to go to the emergency department right now. I tell my manager that I want to go to the emergency department. He then says that he will accompany me there. He insists that we first go to the scan center to check on the situation there. In the center the research coordinator for the 3:15 scan says that I look awful, and the physician there agrees to continue for the 3:15 scan while I go to the emergency department.

           I tell the emergency physician that I am worried about my abrasions and possible fractures and that I desire plastic surgical consultation for my facial abrasion. In addition to the facial and left knee abrasions, there are abrasions on both hands and a purplish discoloration on the left shoulder. I go to radiology for x-rays of both hands, my left knee, and my left shoulder and for a facial CT.

           As soon as I return to the waiting room after the facial CT, the attendant calls me to go to CT. I tell him that I already had my CT. He checks to verify that in fact another CT is ordered. He brings a wheelchair. I tell him that I can walk fine. He insists that I ride in the wheelchair. I am puzzled. How come am I undergoing another CT?

           After the second CT I am placed in a room around 5 pm. The emergency physician explains that although I have no fractures, the facial CT suggested a subdural hematoma. A CT of the brain was needed to evaluate that possibility.

           My supervisor sends a message to my pager, “How R U?” I respond, “R O subdural.”

           The emergency physician then explains that I do have a right frontal subdural hematoma. She informs me that she has called neurosurgery to evaluate me.

           My supervisor arrives. I begin to have a frontal headache. I feel good, unusually happy. I want to see a plastic surgeon to treat my facial abrasion. My supervisor tells me that I have impaired judgment due to my right frontal lesion. I ask him to act in my behalf.

The neurosurgery resident arrives. After interviewing and examining me, she tells me, “If you go home to rest for a couple of days, you’ll be fine. I just need to contact my attending for his approval to discharge you.” That report is promising; I can go home.

The attending neurosurgeon is anxious. He displays the CT of my brain on the monitor to view with me and my supervisor. There is a right frontal subdural hematoma with a diameter of 1.5 cm. The midline has shifted 1.5 cm. “The CT does not lie. This is a significant bleed,” he tells us. “People with this presentation may deteriorate rapidly. If you go home, I have to say it’s against medical advice. I want you to stay in the hospital for surgery or for observation. I would prefer to take you to the operating room right away.” The attending and my supervisor leave the room. When they return, my supervisor urges me to agree to undergo surgery. The neurosurgeon gives me a consent form to sign. The risks include “seizures, infection, stroke, and death.” Additionally he tells me that he will remove a flap of bone over my right temporal region. If there is brain swelling, then he will not replace the bone flap until days later when the brain swelling subsides. He wants me to agree to surgery right now.

           When I was twelve, our family physician noted a curvature of my spine. He referred me to a new local neurosurgeon who agreed to evaluate me in the emergency room of a nearby hospital. Since this was on a weekday and my father was at work, my mother alone accompanied me. The neurosurgeon said that he could place a rod in my spine. I was afraid. My mother told him that she would discuss his recommendation with my father. When we departed the hospital, she told me, “He is very eager to operate on you.” We recognized that there are serious risks of surgery. She contacted our prior family physician who had retired; she recommended conservative orthopedic surgeons. These orthopedic surgeons, a father and his son, recommended physical therapy. They followed me annually without operating on me. Since then I have met people with curvatures of the spine who underwent placement of rods in the spine. They have had limited range of motion because of the restriction of the rigid structure in the spine. Some have eventually had the rod removed to alleviate problems resulting from the rod. I am glad that I never had a rod placed by that young neurosurgeon.

           My attending neurosurgeon is a young man who is also eager to operate on me. I have never seen him before now. I do not know his qualifications. Do I trust his judgment? Is he acting 100% in my interest? However, I recognize that I may die unless I undergo the recommended procedure. Although I ponder the alternatives, I eventually agree to undergo the surgery recommended by the neurosurgeon and my supervisor. I call my sister to leave a message to ask her to act in my behalf with our family and with my condominium. I realize that I may not wake up after the procedure. This may be the last time that I am alive. The neurosurgeon orders my transport to the operating room immediately. Since hospital transport is not immediately available, the neurosurgery resident herself wheels me to the operating room. 

           Outside the operating room the anesthesiologist asks me to sign another consent form. I am on the operating table at 7 pm, within six hours of my injury. The anesthesiologist places a mask on my face telling me to take five deep breaths. I remember taking the fourth breath.

           The clock reads, “10:15.” I am alive! I feel the pain of the bone and the skin of the operative site on the right temporal region. I have three intravenous lines and an arterial line. Leads on my torso and extremities are connected to the cardiac monitor. I can move my arms and legs. I have survived the procedure, and am resolved to recover fully, following precisely the recommendations of my treatment team, so that I am able to regain my previous excellent health. My neurosurgeon tells me that a cortical artery was actively bleeding when he examined the surface of my brain. If he had not halted the bleeding, then there would been continued bleeding within my skull. I know that uncontrolled hemorrhage within the closed container of the skull leads to death. I am alive only because he recognized my problem and corrected it. I thank him for saving my life.

. . . .

The memory of my prior facial laceration fully resolved by immediate plastic surgery in the emergency department led to my going again to the emergency department immediately after my injury. My vanity saved my life. If I had waited until I completed the scheduled scan around 5 pm, the diagnosis and treatment of my arterial bleeding within my skull would have been delayed several hours. I likely would have passed away due to the increasing accumulation of blood compressing my brain. I am alive today with full recovery because of the accurate and prompt diagnosis and treatment in the emergency and neurosurgical departments. On the other hand, I hesitated to accept the neurosurgical recommendation for immediate surgery because I remembered the wisdom of refusing the neurosurgical recommendation for an operation as a child. Finally I trusted the advice of my supervisor to undergo the surgery immediately. We hark back to previous decision points in our lives, only partially relevant to the present crisis, as we struggle to make a crucial decision under pressure.