Newsletter Editor   Jonathan Friedman, MD Assistant Editors   Henry Aryan, MD   Aaron Cohen-Gadol, MD   James Liu, MD   Michael Oh, MD   Brian Snyder, MD   G. Edward Vates, MD, PhD Officers   Lawrence Chin, MD   Brian Subach, MD   Jonathan Friedman, MD

Chairman's Message
Lawrence Chin, MD

Book Reviews
    Hemostasis and Fleece-Bound Sealing in Neurosurgery
    Edward S. Ahn, MD and Lawrence S. Chin, MD
    Operative Exposures in Peripheral Nerve Surgery
    Patricia B. Quebada, MD

AANS Annual Meeting Highlights for Young Neurosurgeons
    Real world course
    Top Gun: Neurosurgery Challenge
    YNC Sponsored Silent Auction

Young Neurosurgeons Making a Difference Abroad
Henry E. Aryan, MD

Young Neurosurgeons Committee Update
Edward R. Smith, MD

DuraSeal® Dural Sealant - A Valuable Tool to Achieve Watertight Dural Closure
of Sutured Dura
Peter Nakaji, MD

Why Recruit Medical Students into Neurosurgery?
Isaac Yang, MD and Henry E. Aryan MD

Interview between Robert Spinner, MD and David Kline, MD on the Effects of Hurricane Katrina
Robert Spinner, MD

Chairman's Message
Lawrence Chin, MD

A common question that I have been asked by many residents and young neurosurgeons is: "How can I get involved in the American Association of Neurological Surgeons?" Often the perception is the American Association of Neurological Surgeons (AANS) is a powerful, mysterious organization that is run by the elite of neurosurgery when, in reality, the AANS is a service organization that works for all neurosurgeons and their patients through the dedication of its volunteers.

If you look at the list of past AANS presidents, you will see a remarkably heterogeneous group of academicians (not all of whom are chairmen) and private practitioners. The AANS is governed by a Board of Directors (15 members) composed of six elected officers (President, President-elect, Vice-President, Treasurer, Secretary, and Past President), five Directors-at-Large, and four Regional Directors. The Regional Directors are nominated by state delegates through the Council of State Neurosurgical Societies (CSNS), but all Directors-at-Large are elected by the voting membership of the AANS. The CSNS plays a vital role in organized neurosurgery and is an inclusive grass-roots organization interested in socio-economic issues. Every state has a neurosurgical society that is looking for smart, young volunteers. In addition, residents can be elected and serve as voting members. Play your cards right and you might be the next Regional Director to the AANS.

In addition to the Board of Directors, there are ex-officio members of the board. This group is composed primarily of the different chairs of the joint sections of the AANS/CNS (Cerebrovascular, Spine, Tumor, Trauma, Pain, Stereotactic, Pediatric, and History) and the chair of the Young Neurosurgeons Committee. Another way to get involved is through one of the joint sections. Get to know people in your specialty and go to their section meetings. Nearly every section has a newsletter that is looking for content, and writing articles is an easy way to demonstrate your interest in neurosurgery and the AANS.

Then there is the Young Neurosurgeons Committee (YNC) which is probably the best way for young neurosurgeons to establish a presence in the AANS. Our meetings are held on Monday evenings at 5:30 pm during the AANS and Congress of Neurological Surgeons (CNS) annual meetings. Although there is a voting membership of the committee that is formally elected, anyone with an interest may attend the meeting and we are always looking for volunteers. Through the YNC, young neurosurgeons can be placed on virtually every AANS committee as a liaison. Furthermore, having the chair of the YNC present at Board meetings ensures that our voices are heard. A list of the former chairs of the YNC indicates the success of our group: Roberto Heros, MD, Emily Friedman, MD, Paul Camarata, MD, Ian McCutcheon, MD, Karin Muraszko, MD, David Jimenez, MD, FACS, Gregory Thompson Jr., MD, John Golfinos, MD, and Mark McLaughlin, MD. Included in the list is a Past President of the AANS (Dr. Heros), former Board member (Dr. McLaughlin), and several active AANS committee members. In addition, several are department chairs: Dr. Heros (University of Miami), Dr. Muraszko (University of Michigan), Dr. Jimenez (University Texas-San Antonio), and in May, I’ll be taking over at Boston University.

The AANS thrives on the diversity and strength of its constituents. As young neurosurgeons, we must take advantage of our strength and enthusiasm to further our specialty. The benefits will be felt by our patients and future generations of neurosurgeons.

The YNS Committee leadership will always be open and responsive to suggestions from any young (or less young) neurosurgeon. Please email me, Brian Subach (vice-chair), Jon Friedman (secretary), or Chris Phillips (staff liaison) with your ideas, and I look forward to seeing you in Boston.

Book Reviews

Hemostasis and Fleece-Bound Sealing in Neurosurgery. Christian W. Matula and Christina N. Steiger. Stuttgart: Thieme, 2005, 94 pp, illus. Price: $59.95

Hemostasis and Fleece-Bound Sealing in Neurosurgery is a book replete with color photographs that illustrate the authors’ experience with fleece-bound sealing to address the neurosurgical challenges of hemostasis and dural sealing. The product used is TachoSil, a tissue glue-coated collagen sponge introduced in 1992 by Nycomed (formerly Hormon-Chemie, Munich, Germany) in Austria. The collagen carrier is composed of horse tendon type I collagen and the adhesive is composed of human fibrinogen and thrombin. The authors describe that the product’s advantage as a tissue sealant are 1) the tamponade effect achieved by pressure applied on the wound from the collagen sheet, 2) the lack of preparation time, and 3) the ease of handling. The indications for application are hemostasis for oozing out of brain parenchyma and tumor resection areas, dural reconstruction, and in special situations such as reinforcement of sutures or fixation of implants.

The goal of the book is "to present the authors’ many years of experience in the form of an atlas or guide to fleece-bound sealing in neurosurgery." There is an intentional emphasis on intraoperative pictures with the minimum text required to describe important points. The authors disclose that they have no financial or proprietary interest in the product.

The book is divided into five parts. Part 1, "Introduction," provides a history of tissue sealing and hemostasis, including the introduction of fibrin glue and the collagen sponge. Part 2, "General Remarks," is a detailed description of the product, TachoSil, with its mode of action and indications in neurosurgery. Part 3, "Special Remarks," is the main focus of this book where color photographs from 25 cranial cases and four spinal cases illustrate the usages of this product. Special emphasis is placed upon "the sandwich technique," where there is a three-layer construct of dural closure with an inner intradural TachoSil layer, a middle autologous dural replacement, and an extradural TachoSil layer. There are useful schematic drawings that illustrate the cranial and spinal applications. The intra-operative photos could perhaps be improved with arrowheads or labels that correspond to the figure legends to assist in reader orientation. There also may be some excessive photographs that do not directly pertain to the dural closure or hemostasis portions of the operation. Part 4, "Results," summarizes the authors’ extensive experience with the described techniques with regard to range of application, complications, and postmortem findings. The book is concluded with a concise Part 5, "Summary and Conclusion."

This book achieves its goal of serving as a guide for the use of fleece-bound sealing in neurosurgery. The book would be useful as a guide to any neurosurgeon who is interested in using TachoSil to address the challenges of hemostasis and dural sealing which have always plagued this field of surgery.
Edward S. Ahn, MD and Lawrence S. Chin, MD

Operative Exposures in Peripheral Nerve Surgery

Operative Exposures in Peripheral Nerve Surgery. Allen H. Maniker. Stuttgart: Thieme, 2005, 152 pp, illus. Price: $129.00

Operative Exposures in Peripheral Nerve Surgery by Allen Maniker is a 139 page reference outfitted with concise text and illustrated with clear color photographs of meticulous cadaveric dissections of the major peripheral nerves. The publisher contends that this is the first book that guides surgeons through the operative exposures of the major peripheral nerves using actual dissections. The book is organized by upper and lower extremity sections and details the brachial plexus, suprascapular nerve, axillary nerve, median and interosseous nerve, ulnar nerve, and the spinal accessory nerves in the upper extremity. For the lower extremity, the book details the lumbar plexus, femoral nerve, lateral femoral cutaneous nerve, ilioinguinal nerve, genitofemoral nerve, sciatic, peroneal, tibial, sural, and plantar nerves.

This is a worthwhile book for both the novice and experienced peripheral nerve surgeon. Each chapter begins with effective and concise reviews of the nerve anatomy and the relevant surrounding vascular, soft tissue, and bony anatomy. This is then followed by a discussion of positioning and surgical exposures — pertinent issues relevant to a successful operation that typically goes uncovered in regular anatomy texts. The author highlights invaluable surgical pearls at appropriate moments to ensure surgical accuracy and success. For example, the book details the appearance of the waveform of the carbon dioxide monitor if the phrenic nerve is stimulated by direct low voltage — a simple intra-operative test to ensure accuracy. Identification of the phrenic nerves leads to proper exposure of the C5 root.

This book details operative anatomy in a step-by-step fashion with spectacular photographs of cadaveric dissections. This helps allow a clearer understanding of fascial planes, fat pads, and the complexities of soft tissue that often times an artist’s illustration cannot depict. The book does not go over diagnosis of peripheral nerve disease, nor does it cover postoperative care, but it achieves its intention of covering operative exposures very well.

Overall this is a phenomenal text from which neurosurgeons, plastic surgeons, orthopedic surgeons, and any other type of subspecialty willing to undertake peripheral nerve surgery would benefit. The text typically sells at a very reasonable price which makes this text attainable by large academic institutions as well as by residents.
Patricia B. Quebada, MD

Top Gun: Neurosurgery Challenge

At the AANS 2006 Annual Meeting, the Young Neurosurgeons Committee will present, for the first time, a series of challenges for residents and fellows at their booth in the main exhibit hall.

The three day competition will include a tremor analysis, a computer-simulated ventriculostomy station, and another station to be determined. Residents and Fellows will receive scores for their competency and the top score will receive a cash prize. More details will be provided prior to the meeting.

Resident and Young Neurosurgeon Activities at 2006 Annual Meeting
For additional details on all activities specific to residents and young neurosurgeons, please see: www.aans.org/young_neurosurgeons/Young Neurosurgeons AM program06.pdf

Completing the many years of clinical training to become a neurosurgeon is no easy task. For some, the ongoing responsibility of lab and research endeavors makes nonclinical time that much more precious. Little time is left for family and friends, let alone for hobbies and outside interests. However, for those who can make the time, charity work in and outside the United States can make a difference in the lives of many, and be tremendously rewarding for all the parties involved.

During my training, I have been fortunate to be involved in such work abroad. What started as an idea has evolved into an annual trip, founded and organized primarily by a fellow resident at University of California – San Diego, Rahul Jandial, MD, and with the assistance of Variety Children’s Lifeline, an international children’s charity group. International Neurosurgical Children’s Association (INCA) was founded in 2002 with the goal to provide surgical and nonsurgical care to children with neurological disorders in South America. The most recent trips were to Hospital General Maria Auxiliadora (HGMA) in Lima, Peru in conjunction with Michael L. Levy, MD, PhD, FACS, chief of Pediatric Neurosurgery at Children’s Hospital San Diego.

HGMA is a 600-bed facility designed to provide care for the indigent population of Lima (Image 1). Governed by the Peruvian Ministry of Health, HGMA is situated in one of the poorest neighborhoods in the outskirts of Lima (Image 2). The facility is staffed with four general neurosurgeons, all of whom trained in South America. Equipment and supplies are sparse and the surgeons make do with what they have (Image 3).

In a typical five-day trip, and with ample planning, the INCA team is able to perform 15-20 surgical procedures (Image 4). The most recent trip involved three neurosurgeons (two of whom are residents) and an anesthesiologist. Each trip involves donating neurosurgical equipment and teaching the local neurosurgeons how to use it. Performing surgery on 15-20 patients a year does little to impact a community, but donating badly needed equipment and teaching local neurosurgeons how to use it can have a profound impact. Equipment is often donated from local instrument companies and the rest is purchased based upon need from our budget, which is derived from charitable contributions. Recent equipment donations/purchases included an operating microscope, neuro-endoscopy equipment, and a high-speed pneumatic drill.

The trips also allow an opportunity to review interesting cases and to see how similar things are done elsewhere (Images 5-7). More importantly, however, individual lives can be drastically improved or saved, and nothing is more satisfying for a surgeon (Images 8-10). After years of arduous training, experiences like this can remind us of why we chose a career in medicine.

Images

Image 1: Hospital General Maria Auxiliadora (HGMA) is a 600-bed facility designed to provide care for the indigent population of Lima, Peru. Image 2: View outside the window of HGMA at one of Lima’s poorest neighborhoods. Image 3: Makeshift light box to review films. Patients pay to have CT scans performed at another facility. Image 4: OR schedule for a typical 5-day trip. Image 5: Michael L. Levy, MD, PhD reviewing films with Victor Benllocpiquer, MD, Chief of Neurosurgery at HGMA. Image 6: Newborn child with and encephalocele being positioned for surgery. Image 7: Hydrocephalic 1-year old with severe craniofacial deformities and failure of palpebral fissure splitting. Image 8: Henry E. Aryan, MD with his patients post-op. Image 9: Rahul Jandial, MD examining a patient on the pediatric ward. Image 10: Hanging outside the OR doors, this photo reflects the mission of HGMA and the culture under which medicine is practiced

Young Neurosurgeons Committee Update
Edward R. Smith, MD

The Young Neurosurgeons Committee (YNC) is a group of residents and practicing neurosurgeons in the early stages of their careers that aims to serve as the primary representative body for young neurosurgeons within the structure of organized neurosurgery. In addition to compiling somewhat lame attempts at witty restaurant reviews highlighting cheap eats in the Boston area (see my last submission to this newsletter…), the YNC actually has a series of more important objectives.

The purpose of this article is to highlight a number of the goals of the YNC, with a particular emphasis on one of the major fundraising efforts of the group, the AANS Silent Auction. At best, it is our hope that readers of this article will be inspired to contribute to the mission of the YNC, through volunteering their time, willingness to participate on the committee or through donation of items to the silent auction. At the very least, the newsletter editor is hoping that there is someone out there with better writing skills that will volunteer his or her efforts to replace a certain pediatric neurosurgical restaurant review writer...

Soon!

The YNC aims to encourage the early involvement of young neurosurgeons in all activities of the AANS. This is done through open invitations (such as the one implicit —I suppose now explicit - in this article) to contact current members of the YNC in order to find out more specific ways to participate. Involvement ranges from selecting particular projects of importance to a given individual to taking advantage of benefits and opportunities offered by the AANS/YNC to volunteering to become a member of the committee.

Many of the potential benefits of involvement in the YNC are obvious. Current areas of effort include streamlining certification for accreditation, increasing sources of funding for research and improving services designed to target the needs of younger neurosurgeons (coding courses, information on starting a new practice and medical liability/reimbursement issues, among others).

These efforts require frequent and clear communication between many different groups. Each of the joint sections of the AANS/CNS (Cerebrovascular, Spine, Tumor, Trauma, Pain, Stereotactic, Pediatric, and History), the state and regional neurosurgical societies and other national organizations (such as the American Medical Association and the American College of Surgeons) need representation. In addition to the tangible results produced by these liaisons, there are the intangible benefits of increased efficiency, closer collaboration between specialties and the development of leadership skills, all of which serve both the individual involved and the profession as a whole. Ultimately, this type of representation, collaboration and involvement will produce leaders in these fields — a stated goal of the YNC.

Lastly, the YNC aims to actively recruit and promote the participation of young neurosurgeons in the annual scientific programs at the national meetings, as well as supporting the Neurosurgery Research and Education Foundation (NREF).The NREF provides grants to residents and faculty in the early stages of their careers. Given that many of the recipients of the grants from this group come from within the ranks of the demographic represented by the YNC, there has been a major commitment by the YNC to support this cause.

The primary means by which the YNC supports the NREF is through money raised in the AANS Silent Auction. This auction, held annually at the national meeting, has been increasingly successful, most recently under the stewardship of Edward Vates, MD, PhD at the University of Rochester, in conjunction with Terri Bruce at the AANS. Over the years, it has benefited from the attention of dedicated committee members and last year over $23,000 was raised.

Since I don’t have any new restaurants to pitch, I will end this update with two requests. First, as a member of the Silent Auction Committee, I would ask that anyone who has the means to make a donation (or who has incriminating photos of those with the means to make a donation), please do so. It’s easy, it’s for the good of your colleagues (maybe even yourself…) and, most importantly, it will help our profession. Regarding what might be acceptable as donated items, I submit a quote from our illustrious Silent Auction Chair; "Wine, tickets to shows or sporting events, historical books, Cushingalia, spiffy electronics, cash, cars, houses, boats, gold bullion...all are acceptable, and also tax deductible!"

It doesn’t get much clearer than that.

The form for donation can be found on the AANS website at http://www.aans.org/research/neurosurgery/nref_y.asp. Although the deadline for the 2006 auction is coming up soon, donations can be made at any time, and anything not received in time for the 2006 Auction can be used in the 2007 Silent Auction. Every donation helps. If you don’t have anything to donate, you can also bid on the items that were donated and help the NREF raise funds that way.

The second request I would make is to ask all residents and young attending neurosurgeons who can to get involved in the YNC. The committee exists for our benefit and your involvement will help both the profession as a whole and you as an individual. Information about how to get involved can be obtained by contacting members of the YNC at http://www.aans.org/young_neurosurgeons/.

If nothing else, your participation could cut down on the number of things that I write, which could only improve the quality of this newsletter.

DuraSeal® Dural Sealant - A Valuable Tool to Achieve Watertight Dural Closure
of Sutured Dura
Peter Nakaji, MD

A cerebral spinal fluid (CSF) leak, especially coming on the heels of a long and difficult craniotomy, is truly a nuisance.

CSF leak rates range from three to thirty-five percent depending on craniotomy location. More than a nuisance, CSF leakage can lead to wound infection, meningitis, pseudomeningocele and other potentially dangerous complications that prolong hospital stay, add to patient discomfort, and increase morbidity.

Fibrin glues have been used to augment dural closure but have unknown efficacy and are not Food and Drug Administration (FDA) approved for cranial applications. Since its release last year, I have routinely used DuraSeal Dural Sealant (Confluent Surgical, Inc.), the first and only FDA-approved cranial dural sealant.

The DuraSeal System is composed of two solutions, a water-soluble amine and a polyethylene glycol (PEG) that, when mixed together polymerize to form a hydrogel in two to three seconds. The hydrogel forms an adherent watertight seal that is strong enough to withstand normal ranges of intracranial pressure. The hydrogel has a blue colorant that acts as visual aid for sealant coverage and thickness and disappears in six hours. In four – six weeks, after the dura has healed, the hydrogel liquefies back to the PEG molecules and are absorbed and cleared through the kidneys. Because DuraSeal is completely synthetic, the risk of viral transmission is eliminated.

A major plus of DuraSeal is that it works fast – it adheres to the dura within seconds of application. The blue color allows the surgeon to see where it has been applied and allows the surgeon to limit the thickness of the application to one – two millimeters (mm). It can be removed if need be, but is surprisingly adherent compared to fibrin glue. Nursing staff acceptance has been high because DuraSeal only takes two minutes to prepare.

DuraSeal is supported by rigorous efficacy data. In two clinical studies the safety and performance of DuraSeal were evaluated in a total of 158 patients that underwent cranial surgery, and who demonstrated an intraoperative CSF leak either spontaneously or upon Valsalva maneuver at 20 cmH20 after standard dural repair. In all 158 patients treated, the dural sealant demonstrated a 98.7 percent intraoperative and a 97.5 percent postoperative success rate in holding a watertight seal. There were no device-related adverse events.

Clinical experience with DuraSeal has shown that the following application techniques optimize performance of DuraSeal as a sealant:

• For secure tissue adherence, remove all blood clots and fluids from the application site, and rinse and dry the field as best as possible. Patting with a dry gauze sponge is usually sufficient.
• DuraSeal is not a space filler like Gelfoam. It absorbs by liquefying, not by tissue in-growth or fragmentation. Only apply a maximum of one – two mm of sealant over the suture lines – it is usually all that is needed. It is better to discard a few milliliters of hydrogel than to apply too much.
• DuraSeal is not a dural substitute for large gaps. Application to gaps over three mm can lead to subdural sealant migration. Bridge larger gaps with a dural substitute and seal over it.
• Make sure there is a margin on native dura upon which DuraSeal can adhere.
• Spray forcefully (rather than drip) the sealant for even coverage. As opposed to when applying fibrin sealant, DuraSeal should be sprayed with gusto.

Following these techniques, the surgeon will find that DuraSeal Sealant provides a safe, effective watertight seal to sutured dural repair, and as a result can decrease the time and effort spent managing CSF leaks.

Why Recruit Medical Students into Neurosurgery?
Isaac Yang, MD and Henry E Aryan, MD

The recruitment of medical students into a neurosurgery residency is one of the most important academic tasks accomplished by neurosurgery residencies. Attracting the best of the best is important to maintaining the high level of skill, dedication, and commitment required to carry on the legacy of neurological surgery. Although it may not be acknowledged formally, this recruitment is the lifeblood of any residency program and to the entire specialty. As the training and composition of medical students change, it is imperative that neurosurgery residency programs also advance our recruitment to encourage medical students to enter our specialty.

Despite recent resident work hour changes and greater emphasis on lifestyle among graduating medical students, neurological surgery will still be uniquely defined as attracting only the most motivated, enthusiastic, and hard working medical students. The dedication, commitment, and hard work that define our specialty must be emphasized to future medical students considering a career in neurosurgery. This legacy of devotion, responsibility, and enthusiasm was initiated by Harvey Cushing who once said, "Nothing great or new can be done without enthusiasm. Enthusiasm is the fly-wheel which carries your saw through the knots in the log." These standards of character, ability, morals, a deep sense of personal responsibility and enthusiasm for hard work are still required for becoming a neurosurgery resident today as it was in Cushing’s day.

Medical school curriculums are changing and neurological surgery programs and residents must more actively recruit medical students who truly demonstrate characteristics as being the best of the best. Many medical students do not have sufficient neurosurgery exposure to faculty and residents in order to be inspired by the challenge and passion of neurosurgery. At many institutions, only subinterns gain significant exposure to the art and science of neurosurgery. With the increasing interest in more lifestyle specialties, many of these potential applicants will never have had the pleasure of seeing a pulsating brain, experiencing the satisfaction in treating a patient’s movement/pain/seizure disorder, or the fulfillment of restoring function by removing a herniated disc. These initial exposures could be a turning point to inspiring outstanding medical students to pursue the rigorous residency of neurosurgery. Furthermore, the earlier these experiences occur, the more profound effect they can have to inspire the next generation of neurosurgeons. Because many junior level medical students are not exposed to these experiences, neurosurgery programs should encourage their respective medical schools to incorporate neurosurgery into their curriculum. Not only will this improve their neuro-anatomy education, but also give students a chance to be inspired to pursue a career in neurosurgery. Because there are a limited number of neurosurgery residents and faculty compared to most other specialties, each program must do more than other specialties to actively promote their program and expose more medical students to the field of neurosurgery. Giving student lectures, having them observe in the OR, and involving students in research are ample opportunities to increase medical student exposure. It is also important to have current and well-designed Web sites that can inform and further expose interested medical students to the field of neurosurgery.

Because residents are often more accessible to medical students, recruitment is an even greater responsibility for the residents. We need to be role models that reflect these core values of our neurosurgical specialty and be approachable to students in order to expose them to the field. Conversely, residents may be able to spend increased time observing prospective candidates for neurosurgical residency. Furthermore, it is important to maintain our camaraderie and tight community as a neurosurgical specialty. Despite our competitive field, we must maintain healthy rivalry among programs based on respectful competition and cooperation. Poor attitudes reflected about different programs do not reflect only on institutions, but negatively on the entire specialty as a whole. Our own sense of civil alliance will only further inspire outstanding medical students to pursue membership in our neurosurgical society.

Although the San Francisco Match reports increasing numbers of applicants into neurosurgery with rising board scores and qualifications, neurological surgery programs and residents cannot become complacent. Medical students are the only pool from which our residents are selected, and the importance of attracting the best of the best from this pool cannot be overstated. If we become stagnated in our level of recruitment, we will be overshadowed by other competitive residencies with more attractive lifestyle issues merely because the best of the best did not have the opportunity to be exposed and inspired by the challenge and passion of neurosurgery.

Interview between Robert Spinner, MD and David Kline, MD on the Effects of Hurricane Katrina
Robert Spinner, MD

S: Describe the circumstances and environment when the hurricane struck.
What were you doing?

As you can imagine, Katrina has affected us greatly, both professionally and personally. David Kline, MD

K: I was part of what is called the Code Gray Team involving a faculty member and several house officers. I could see the big storm outside swirling around and a lot of rain coming in the windows. Very soon my room got wet. I moved out to the hallway and it was apparent that house officers and residents already had to move their gear out of their rooms.
It was evident that by about 6:30 a.m. there was no electricity, because all the lights had gone out in the hallway. We could hear water coming down the elevator shafts, so we knew the elevators weren’t usable. We went downstairs from the 14th floor and rounded up our patients in the surgical ICU on the 12th floor. We went from there to our own ICU and step-down units on the seventh floor, and then to the medical ICU on the sixth floor. Of course, since there was no electricity, nurses and nurses’ aids, and in some cases, the janitorial staff, were already bagging our ventilator patients. I should mention that on Sunday night, which was the night before the storm, we had admitted to our service a patient with a closed-head injury who I think was GCS 10 and that patient was scanned. There were some small early contusions but no shifts or clots. By that morning, the patient had a GCS of 12. We had no way to re-scan the patient because all of the electricity was out in the building. By then, there was water around the hospital and it was getting deeper and deeper. The connection to the medical school was chained shut and looking through the window, I could see that the security personnel from the medical school were no longer there. I did not realize at the time that I would not be able to get back there – at least not for six or seven weeks.

The greatest challenge we faced were the temperatures in the upper 90s and the high humidity. We had a number of patients who were unconscious or semi-comatose, and fevers became the big problem. It was hard to cool the patients. We had to show the personnel how to massage and rub the patients to vasodilate their peripheral vessels. Once people learned how to do that, things were a bit better. The fans were a godsend. By late afternoon some battery-powered respirators that work off walled oxygen (which I’d never seen before) had been located and we got about five of those. At about the same time, some generators had been located across the street in the warehouse and had been boated through the water, to the emergency room ramp. Then crews of men had to wrestle these generators, which were quite heavy, up the stairs. The stairwells and inner halls were pitch-dark even though it was the middle of the day, because there were no lights or windows.

The major problem that was evident even by the afternoon and the first day was lack of communication. We could phone around in the hospital the morning of the first day, but not after that. Those lines were lost and the beepers that the house officers carried no longer worked because they had to go through a central system that required electricity. We located some phones by the second day, that strangely enough, we could call out on but apparently people were trying to call in, and you couldn’t. We could not call out on any line that required a 504, which is our area code in New Orleans. In other words, I could call San Francisco, but I couldn’t call my wife because she had a cell phone with a 504 number. She had evacuated to across the lake where we have property. It turned out, unknown to me at the time, that she eventually went on to Houston.

We would try to get information about what was happening. There was no television, but someone had a battery-operated radio and what we heard over the radio was not good. The flooding by the second day was high. We could see people wading through the water about waist-deep; sometimes there were areas up to mid-chest around the hospital. Some of those people seemed to be heading towards the Superdome where we understood a lot of people had been evacuated to, but then a lot of people were heading away from there as well. It was a little uncertain as to why that was.

A very poignant situation arose when a patient with metastatic melanoma died that second night, so then we had to find a place to put him. We finally wound up putting him in a stairwell that wasn’t used much. Subsequently, other patients in the hospital who passed away were placed in the same spot because the morgue was in the basement, which eventually became flooded.

S: When and where did you evacuate?
K: The residents had tried to evacuate me by other means several times. I didn’t feel right about that. They loaded me onto a flatbed truck which was being used to drive out through the water. They were National Guard trucks or at least commandeered by them. There were two National Guardsmen in each truck with automatic rifles or machine guns of some sort, because people from other buildings had been taking shots at some of these trucks that had gone out from the emergency ramp earlier. You had to lay down flat on the flatbed of the truck with the patients – you know I wound up lying next to or sort of on top of a very elderly, large woman who was somewhat demented and kept on trying to pull out her IV and her Foley. That’s how we drove through the water. We were told that a heliport was being put together on the roof of that garage so we’d be evacuated from there. That turned out to be partially true. I reached there around 11:30 a.m. or so Thursday morning, but did not or was not able to be evacuated from the garage until 1:30 a.m. the following morning. There were several hundred Charity Hospital patients there and we were trying to give them care or maintain their care, I guess, would be a better way to put it. The circumstances were even worse than at Charity because we didn’t have as much equipment. They had stock piled some medicines there, but not all medicines, water, power drinks, power bars and peanuts, tubing, IVs and that type of thing, oral airways, but not with the ability to intubate. They had a generator there, so we could run a few respirators off that. Eventually, later that day, we lost that because the generator was moved up to the roof to provide light for incoming helicopters. To make a long story short, we evacuated some of our patients I think, late that afternoon, but only maybe a dozen. Some of my patients, one in particular, deteriorated very badly and he developed a lot of secretions. We lost him when we lost the generator and the ability to respirate.

They asked for volunteers to go out on the small chopper which was going to take people to some unknown location. They were certain though, that the three doctors and one nurse who were going to go with would either be brought back to the garage or brought to the Superdome. We had heard a lot about the Superdome. The Superdome was not a good place to be. By then they also had people down at the Convention Center and we heard that was very bad. There were no volunteers for that. I didn’t volunteer either, but then my patient grew worse and there was a child who needed care. As a group, we decided to re-volunteer. There was an ER doctor, myself, and the oral surgeon, and a nurse or perhaps two nurses. I went out on a small chopper with my patient who had a spinal cord abscess whom we had operated on the week before Katrina, who had become septic and developed pulmonary problems. The ER doctor carried a little 6-year-old boy and the oral surgeon loaded an elderly emphazematous pulmonary patient. Off we went and where we went, turned out to be the airport, Louis Armstrong Airport, which they were using as a staging area for nursing home patients and some hospital patients. I think we were with some of the earliest, sicker hospital patients to reach there on Friday morning, I guess about 2:00 a.m. Then we had to go through two triage systems there. We were lucky with that.

Some other interesting events occurred that would require more detail to describe concerning the FEMA system. Our major problem was we didn’t have Social Security numbers for our patients – and FEMA does everything by Social Security number – but despite that, we were able to talk our way through primary and secondary triage. And the litters of some of our patients were then streamed out on where you board planes – you know where you go to the final stage to wait for your plane at the gate – concourses for Delta and Continental. There were hundreds of litters lined up there. Eventually FEMA and the National Guard loaded us onto an Army Medivac plane, which was huge, and took 31 of the litters, some walking wounded; also some families or family members of some patients were able to come, as well as some nursing home patients.

The plane started out going to Kansas City, which wasn’t very good because I had no idea how I’d get back from there. It then got rerouted to Charleston by the time we were loaded up. By the time we took off, it was Dallas/Ft Worth. By then I knew my wife and stepson were in Houston because one of our residents had managed to work a system out where she would text message, and although the cell phones wouldn’t accept dialed numbers, they would accept text messages. So my wife actually was able to call in from Houston. You couldn’t call in from New Orleans, but from Houston she could. So I got to talk to her the third day and I was able to talk to my daughter in California and have her get in touch with Albert Gore and he and his people orchestrated several planes to come and help evacuate from the airport. At any rate, mid-flight, one of the crewman came and said “Doc, didn’t you say you wanted to get to Houston?” And I said “Yes.” Then he said, “We’re going to Houston.” We’d had another flight change, and that was the first time in five days that I really felt great. I was almost euphoric at that point. That all worked out, so when we landed, FEMA personnel were there, and they had 20 or more ambulances waiting. They asked for the name of the patients and they had a board with numbers. They’d call out a number and a gurney would come from one of these ambulances. The patient would get loaded aboard and off they would go. We really didn’t find out where they went. I mean, that was very hard to find out even when you went in. It was Nassau Airport that we got evacuated to – the place in which spy planes go out and planes are housed that teach people about the effects of gravity – they had an antigravity simulator plane there. So we got debriefed and a psychiatrist saw us and talked to us for about half an hour to make sure we weren’t going to go crazy. We could change out of our scrubs and they had other scrub-like things there. We also had good bathroom facilities, but no showers. Then they had some social service people that helped us locate someone to come pick us up, if you were in good enough condition for that. So the psychiatrist and social worker were able to track down my wife and then she drove there. They had snack food there, but it was much like it was at Charity. They had coffee, but it was Texas coffee, it wasn’t New Orleans coffee! I guess I got out and back to civilization by about 6:30 or 7:00 a.m on Saturday morning. That was that.

S: So now let me just ask you a few other things. How has the storm affected you personally and professionally now that you’re back at home?
K: Well, of course, my home was flooded and the place we owned across the lake had a tornado go through it so it received severe damage. Professionally, Charity Hospital was closed and it’s doubtful that it’s going to reopen and that was an important part of our training program. Ochsner stayed open and that was important for our training program. We have two residents there and Ochsner now is busier than it was pre-Katrina, so that is good. Touro and Children’s, which were two other places where residents trained, have come back up. Touro is about at half of what it was before, although neurosurgically, it’s probably closer to 80 percent of what it was before. Children’s is almost totally back and so that is good, but we’ve lost our public service which was important because that’s where residents started and finished. They spent their chief year there and they had a large amount of responsibility at least by American standards for patient care and surgical procedures. We’ve tried to reconstruct that service at our Earl K. Long Hospital in Baton Rouge. It’s a smaller hospital, the number of cases is fewer, and the facility is smaller. That’s been slow. They’ve never had neurosurgery there before, but today we are doing a giant subfrontal olfactory groove meningioma, so we have gotten to that point.

We’ve lost some residents so we’re short-handed. We’re utilizing our PGY-1 now, here at Earl K. Long, to help out. We have matched with a PGY-1 who is currently in that year and so he’ll be able to start neurosurgery in July, and we are scrambling at this time for a match for 2007.

As you can imagine, Katrina has affected us greatly, both professionally and personally.

S: What do you foresee in the future for Neurosurgery in New Orleans?
K: Well, personally, I think there should be one program combined; an LSU/Tulane program in New Orleans. I think more of the training part of neurosurgery will be privatized or more private-oriented than it was pre-Katrina. But I think we have fairly good assurances from our administration – our Dean and Chancellor that University Hospital is going to come back up. I think that’s certainly going to take a year or so. So we will eventually have public service there. A trauma service is being started at Elmwood, which is a hospital owned by Tenet, and sold to Ochsner a few years back. Ochsner, through Tenet, is only permitted to run specialized services there, but they’ve agreed to let the state lease that for trauma. Of course, we see a fair amount of trauma at Ochsner, which usually saw some, but not a whole lot. We see some trauma at Touro, and of course also at Children’s. A lot of the trauma is being cared for now at Ochsner, West Jefferson, and East Jefferson. West Jefferson stayed up, being on the West Bank that didn’t get flooded, and East Jefferson is in an area that had less flooding, so it came back up a month or two ago. I think there will be some public care at Elmwood, hopefully by this spring or summer and at University Hospital when that comes back up. But for now, a lot of public work is up in Baton Rouge. LSU also has public institutions at Lafayette, Lake Charles, Bogalusa, Homa – but they’re not places where there is neurosurgery. We hope to reconstruct – and are trying to reconstruct – and will reconstruct neurosurgery for LSU. Whether it will encompass or partner with Tulane is uncertain at this point. I think our main base now is Ochsner and there are other bases at Children’s Hospital and at Earl K. Long. The medical school plans to move back. Some of the medical school basic science areas are already back in laboratory buildings on the campus, but more need to return. The intent of the administration is to have the clinical return to New Orleans, but I think there will be a stronger Baton Rouge connection for a long time.