Divergence
DIVERGENCE
Ever since I had set my mind on becoming an expedition medic, I had barely looked back on my decision. For years on end, my life was all about surgery – specifically neurosurgery.
I mean, come on, is there anything cooler than the human brain? Nothing is quite as fascinating. My rotations in neurology and neurosurgery as a junior doctor only seemed to confirm that. There was nothing I was surer of – I was born to be a neurosurgeon. I was born to be McDreamy’s prodigé (never mind the newly qualified neurosurgeon who has Derek Shepherd’s exact same hair, similarly devilishly handsome looks, and a more muscular frame).
Then I took a year off, travelled all around, and realised I didn’t want to spend the majority of my life cooped up in the dungeons of a hospital. I wanted more out of life – I wanted way more. Suddenly, all my surgical aspirations ebbed away as I set off on this new journey.
As much as I love surgery, every single day I spent in ED only seemed to confirm I had made the right choice. And for that, there were many reasons. First off, I’d be giving up seventy-hour work weeks. Then the thirty-hour on-call shifts which would sometimes be way longer. Carrying around the damned pager that never stops friggin’ ringing. Arguing with ward staff who only do the bare minimum. Dealing with the arrogance and god complexes of the higher-ups. Running ragged from one ward to another. Holding a retractor for hours on end. And let’s not forget the lack of respect and autonomy junior trainees seem to have. Suddenly, it felt as if I had been crazy to consider spending my life like that in the first place.
And so, day after day, I was only reassured that I had made the right choice. Emergency medicine trumped surgery on most aspects, and the idea of becoming an ED doctor was one I quickly got on board with.
Incoming Trauma!
That said, I can’t say I didn’t look back at what I had given up at all. Flash forward to one fateful day where I was forced to come face-to-face with the decision I had made a few months previously. I was told to stay on standby for an incoming trauma. It was a 49-year-old man who had fallen off a sulky and been trampled by a horse.
He arrived already fully sedated and intubated. Turns out, the second he hit his head on the ground, he started vomiting uncontrollably and then began to mumble incoherently. Not a good sign – a very obvious sign of raised intracranial pressure (ICP), likely from an intracranial bleed of some sort. In an effort to do damage control, the pre-hospital team intubated him – to protect the airway and help control ICP.
As gruelling as such a scene might be, these are the scenarios I actually look forward to (see: “Candy but with blood” scene from Grey’s Anatomy). The second he came into the resus bay, I quickly busied myself, following the team leader’s instructions. I put in an intravenous cannula and sent labs, then started mannitol (an osmotic diuretic used to reduce ICP), followed by an arterial line for continuous haemodynamic monitoring.
Neurosurgery and Emergency Medicine Collide
As the lead doctor performed a FAST scan (Focused Assessment with Sonography for Trauma) and called the anaesthetist to manage ventilation and sedation, I arranged a CT polytrauma-scan and contacted neurosurgery to give them a heads-up about a possible intervention.
My ex-mentor Christa was the on-call neurosurgeon. Skipping the usual pleasantries given the circumstances, we discussed the case – it took me right back to the days I had spent in the neurosurgical ward with her, absorbing everything I could. Back then, it had felt as if I were The Chosen One. The one destined for this path. Now I stood in ED speaking to her not as a trainee, but as a colleague.
The CT confirmed our suspicions – and then some. He had an epidural haematoma, a subdural haematoma, and a subarachnoid haemorrhage. The radiologist also noted an orbital fracture, something that felt almost incidental compared to what was happening intracranially. His skull was more blood than brain at that point.
As we transferred him back to ED, the neurosurgeon had arrived. She made a brief assessment and spoke to his relatives, explaining that any intervention would be a Hail Mary and that the likely outcome remained poor. They would, however, proceed with an emergency craniectomy – essentially removing part of the skull to allow the brain to expand and reduce pressure. One by one, the family came in, all sobbing – incredulous at seeing this stallion of a man reduced to a body held together by tubes and wires.
As a neurosurgical FY, I had experienced my fair share of such moments. Neurosurgery, by far, is one of the most emotionally brutal specialties – no one and nothing can convince me otherwise, especially in trauma cases. By the end of my rotation, I had learned to appreciate that we do what we do to give people the best possible fighting chance. That is privilege.
It felt good to be reminded of these things – all the lessons that had been hammered into me by that same neurosurgeon over countless hours in ward rounds and theatre. Although I wasn’t her trainee anymore, the lessons still applied, especially here. And, as I watched her reassure the relatives while remaining firm about the high-risk procedure and poor prognosis, I couldn’t help but feel proud to have trained under her. I was just so damn lucky.
We ensured everything was ready for transfer. The cardiac monitor was on, vitals being recorded. The endotracheal tube was secure and oxygenation stable. Defibrillator pads were in place in case he crashed. Drugs, ALS trolley, the lot. It would be me, the lead doctor, the anaesthetist, and a couple of nurses escorting him to theatre.
Bittersweet Endings & Beginnings
There is nothing quite as dramatic in ED as transferring a patient to theatre, especially one heading for emergency surgery. The way people look at you as you push a blood-covered patient through corridors is something else.
The transfer was uneventful. We got him to theatre without issue. As the doors opened, I was met with a scene I knew so well – the green-tiled, brightly lit, antiseptic-smelling operating theatre where everyone moved like clockwork. Orderlies preparing the table, scrub nurses laying out equipment, the neurosurgeon adjusting lights and headrest. I couldn’t help but join in. After all, I had spent months learning this world. Then the patient’s blood pressure began to spike and his heart rate dropped – a sign of impending coning and herniation. I alerted the neurosurgeon, and the team moved quickly to begin surgery. The lead doctor gestured for me to come to his side.
Stepping back from the surgical table felt momentous. It was me walking away from a career I had once imagined for myself for years. And just like that, our job was done. We had stabilised him and delivered him to definitive care. The rest was in the hands of neurosurgery and the theatre team. I, on the other hand, was no longer needed.
As I stepped away, I couldn’t say I wasn’t emotionally overwhelmed. It felt like stepping out of a life I had once wanted to live. Not regret. Not remorse. Just something quieter. Bittersweet. I knew it would be hard, and in a way I was glad it happened early in my training. It gave me closure. I had spent a long time trying not to think about the fact that I would never hold a scalpel to someone’s brain. And I was okay with it. That’s how I made my peace with it.