Lately, I have become inordinately excited about the prospect of pursuing the very new field of Endovascular Surgical Neuroradiology (aka Interventional Neurology) as a potential career pathway. A few weeks ago, my major three interests were Pulmonary-Critical Care, Interventional Cardiology, and most recently, Neurology. This new field seems to encompass several of my medical interests, all of which I might feel sad to abandon if I had to choose one over another. But now I wonder: how deep does this new interest of mine find its roots?
I believe that the various fields in medicine often attract people with similar interests and personalities (that extend beyond basic stereotypes). I have worked with doctors in a few fields so far that have impressed upon me particular styles and characteristics. For example, my fiancée loves mystery novels and puzzles (e.g. Sudoku, crossword puzzles, Bejeweled, etc.): I think this detective and puzzler archetype fits in nicely with Neurology in which the physician both methodically and insightfully unravels the mysteries of the injured or dysfunctional brain. In Cardiology, I find the doctors are much like cowboys: there’s an aggressiveness and pervasive confidence (especially given the many successes in the field), and in the Catheter Lab, it’s possible for a single doctor (with the help of a scrub nurse or other assistant) to save a person’s life (unlike in many surgeries, where the effort is much more team-based). Psychiatry has presented a variety of personality types and working styles to me, but the common theme I have found is the storyteller core: at the center of their interests, these doctors are interested in the elaborate life stories of their patients, and they often relate to others through telling their own life stories. Lastly, Infectious Disease physicians are the true biologists willing to confront the intrusion of nature into our lives: while other doctors might find fascination in disease marking the body’s failure to function properly, these ID doctors find a world of wonder in the numerous, rapidly-adapting microorganisms that wage war upon our bodies.
I have not been sure how my prior interests could connect with my future pursuits: in other words, I have not known how to draw strength and energy from the things that have interested me all throughout my life thus far. I don’t necessarily see myself at this time as the detective or the cowboy. What sort of things have I really liked and enjoyed that might reflect a core, underlying mode of operation?
Video games. I have always liked playing video games, despite my father’s constant insistence that I would fail out of school at the rate I played them. In particular, there is one long series of games that I have always enjoyed that I feel serves as an amusing, if not fairly accurate, allegory of why I am suddenly so passionate about this new field of medicine: The Legend of Zelda.
For those unfamiliar with the classic Nintendo-console series, each installment features the Hero’s Journey of a young, ordinary man with an extraordinary task and destiny (to save his homeland from evil and ruin). The series follows his journey as he fights his way through a variety of dungeons and fortresses, usually solving environmental puzzles and picking up new tools and allies along the way as he tries to reach his objective. To my surprise, the adventure parallels that interventional path to treatment of vascular diseases and highlights some of my core personal interests that can be applied to medicine!
Step 1: You have been summoned by the Great Deku Tree!
One of the biggest obstacles to the treatment of stroke is the time it takes for its victims to realize that they are suffering from one. Time is brain (much like “Time is muscle,” the slogan of cardiologists treating heart attacks), and there always exists the problem that something must be done before it’s too late! At this time, the main FDA-approved treatment is the intravenous use of tPA or tissue plasminogen activator in ischemic strokes (the vast majority of strokes), an enzyme that breaks up clots but must be used within three hours of the start of symptoms. After that point, tPA can actually increase the potential hemorrhagic conversion of an ischemic stroke, changing the nature of the disease from a vessel occlusive disease (i.e. nutrient/oxygen-started brain) to a bleeding disease (i.e. bleeding into the brain tissue and causing direct damage and mass effects). New interventional treatments (discussed below) can extend the treatment window to 6-8 hours or more. Nonetheless, time is of the essence!
It is important that family members and friends recognize common symptoms of stroke because patients are often in denial of the severity or implications of their symptoms. You can save the life of a loved one this way!
Step 2: Go, Epona, go! We have no time to lose!
It breaks my heart, but I understand why many (poor) people avoid calling the ambulance: the bills can be very expensive! ($1000+) However, if there’s one instance when it is absolutely necessary to get an ambulance ride as opposed to calling a friend or family member or driving oneself to the ED, it is with a suspected stroke (even more so than with heart attacks, in my opinion, since a heart can be augmented or replaced unlike the brain). Furthermore, calling an ambulance gives the medical team advanced notice that you or a loved one might be having a stroke, thus speeding up the arrival of treatment and avoiding the necessity for triage upon arrival in the ED. Stroke Team Activation! (At this time, if I were an Interventional Neurologist and was at home, I would get paged and would be rushing to the hospital. If I were at the hospital, I would be getting the CT scan, tPA in the ICU, and Catheter Lab ready for possible treatment.) Every minute counts.
Step 3: You have received the Map!
One of the first things that needs to be determined upon arrival is the nature of the stroke: is it an occlusive (ischemic) stroke or a bleeding (hemorrhagic) stroke? 80-85% of strokes are ischemic, and those are the ones that can be treated with tPA and interventional techniques. Hemorrhagic strokes are treated differently, but if you give these patients tPA, the damage gets even worse since you are giving a medication that breaks up clots (that would otherwise stop the bleeding)! So, noncontrast head CT, stat!
If the patient arrived within three hours of the onset of an ischemic stroke, we can treat with tPA in the Intensive Care Unit (stroke patients require specialized care in the first 24-72 hours that differs from most patients, such as keeping the bed flat, aggressive temperature control < 99°F, tight control of blood glucose, maintaining “permissive hypertension,” etc.), open up the blockage, and minimize any damage. However, what happens if the patient arrives after the three hour deadline? Then we have to assess whether an interventional procedure is possible and indicated. Where is the occlusion? Let’s take a look!
Angiography allows interventional neurologists to determine where a blood vessel is occluded by a clot, thus setting the goal for an interventional procedure. The angiogram provides a “map” to the occluded vessel, and the interventionalist can maneuver a microcatheter through the blood vessels to either deliver tPA directly into the clot (to minimize hemorrhagic conversion or damage elsewhere) or use a mechanical device to break up or pull out the clot. Is the patient aware of the procedural risks and the consequences with and without interventional treatment? Does the patient consent? Yes? Let’s go!
Step 4: Over, sideways, and under
My favorite games usually involve environmental puzzles: given the tools you have, you need to figure out a way to get from point A to point B, often requiring some maneuvering and finesse. To me, this embodies the practice of interventional techniques: you have to thread a thin wire through the blood vessels of the body, around twists and turns, beyond bifurcations (forks in the road), and into the areas of occlusion or damage. This is not always a straightforward process, and this is where skilled hands are an asset! I have been complimented various times throughout my life (including by physicians) about my hand skill and motor coordination, but I have little interest in Surgery as a potential career path and lifestyle. Nonetheless, I would like to use my hands to help heal and treat those suffering from disease, and interventional procedures may offer me this chance.
Step 5: The Final Boss
Upon arriving at the site of injury, the moment of truth presents itself: will I succeed in breaking and removing the clot without complication and collateral damage? How can I best accomplish this goal in this situation?
So far, the options of intra-arterial thrombolysis (with tPA), mechanical clot thrombolysis, and clot retrieval. All of them constitute precision strikes on the culprit clot.
Step 6: Success!
The clot has been removed, and the vessel has been revascularized! The patient can be sent back to the ICU for post-treatment care. During my time with the Stroke service, I had the chance to witness the marked difference in outcome between a patients who received tPA in time and those who were not able to be treated due to their arrival after the three hour deadline. Many people survive strokes without treatment, but it is not just a matter of life and death: it is also a matter of disability and quality of life after the stroke, as many people are permanently disabled (physically and/or mentally) by strokes, the leading cause of long-term disability worldwide. Interventional techniques offer hope of extending the treatment window and reducing the overall mortality and morbidity from the disease.
Nonetheless, the medical care does not end there. Patient education and secondary prevention of stroke is essential to prevent the ordeal from occurring again. Or ideally, we can prevent the strokes from ever happening in the first place with primary prevention and care!
This has been a light-hearted approach to exploring how my past interests reflect core objectives that I can achieve in my future career and engrained principles and character traits that I would like to draw upon to make each day a worthwhile adventure. Perhaps for the first time, I am thinking less about the professional experience in each field based on current standards and practices and more about what things can be in the future.
And to the future of medicine and those I hope to save, I will bring:
The resolve to protect without hesitation,
the strength to endure in the face of everlasting darkness