A few more pictures of the temple

These were taken with Lee's digital camera. The previous photos are
actually still clips from video that I recorded with the IPOD Nano
that one of my girlfriends gave me for my birthday. The IPOD videos
are pretty cool though, as they contain ambient sounds of the
surrounding forest. If I figure out a way to upload them to the blog,
I will.

"Tiger Country"

Brain stem is the part of central nervous system that connects the cerebrum and cerebellum to the spinal cord. Its diameter is about the size of a thumb. Nerve fibers communicating between the cerebrum, cerebellum and rest of the body traverse this area. It also contains nuclei that regulate respiratory and cardiac functions. The center that keeps us awake and alert resides in the brain stem as well. Because so many vital structures are packed into such a tiny space, surgical interventions in this area are very technically challenging. Many neurosurgeons consider the brain stem as the "tiger country" because one mistake here can have devastating results.

This patient is a 65 year-old female presented with headaches, nausea and vomiting. CT, MRI and angiogram revealed a very vascular cystic lesion in the posterior fossa, which is most likely hemangioblastoma given its hypervascularity, appearance and location. This case went on for 11 hrs yesterday. It was a very tricky resection because the feeding artery of the tumor was actually hiding underneath the draining vein. The patient's blood pressure was very unstable (going from 90/50 to 160/120 in just a few seconds) during the last part of resection because the tail of the tumor was very close to the medulla. In the last photo you are actually looking into the 4th ventricle at the posterior aspect of brain stem (medulla). The patient was awake, alert and followed command this morning. This is pretty amazing since many patients with this type of surgery would be left unable to breath on their own (damage to respiratory center) or in a permanent unconscious state.

Lee
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Baiyun Mountain

On Sunday we took a trip to the edge of the city to go up Baiyun
Mountain, which literally means White Cloud Mountain. It has been an
important site in China over the centuries. We walked up it via a
roadway and stairs (shut up Kim) and took a gondola down. Anyway, the
neatest thing on the mountain was a Buddhist temple that is found
about 3/4 of the way up. I don't think the temple is very old,
however, or at least it has been recently renovated. Here are a few
pictures from the trip to the mountain.

Nick

Esophageal cancer in China

I saw two esophageal cancer surgeries last week. Both were squamous cell carcinoma (a histological description) and both were in the upper third of the esophagus, closer to the mouth. To do the surgery, the section of esophagus with the tumor is removed along with some lymph nodes. Then the doctors turn the stomach into a tube with fancy stapling and attach it to the end by the mouth.

The interesting thing is that esophageal cancer in China is flipped from that in the US. In China, most cases are squamous and in the upper or middle third. In the US, most are adenocarcinoma and in the lower third, close to the stomach (gastroesophageal junction).

A diet high in spicy food and perhaps smoking and pollution explain the Chinese esophageal cancer. The American cases are caused by obesity and overeating. Those things lead to acid reflux, which causes cellular change in the lower portion of the esophagus into cells that are more resistant to acid. Unfortunately this change (called Barretts esophagus) also predisposes to the cancer that we see in the USA.

Nick
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Elevators

This morning I failed to squeeze my way into the hospital elevator since there were like 25 people in front of me. So, I had to climb 13 flights of stairs in a shirt and tie to get to the neurosurgery floor ... Definitely not doing that again.
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Guangzhou taxis

Two points. One, they are cheap. They are priced in Yuan about the same as they are in the states in dollars. So a twenty dollar ride is 3 bucks for us - that rocks.

Two, they are extremely unsafe in my opinion. Why? For starters, the back seats don't have seatbelts. Its like they went out of their way to remove them actually b/c the belt is physically there, just the buckle is removed.

But its worse than that, because not only are there no belts, but there are solid steel barriers between the front and rear seats. These are designed to protect the driver from mugging I guess. But in any sort of accident, even one that wouldn't normally have the force to throw the unrestrained driver from the car, a person will be thrown headlong into the steel bars right in front of them and crack their skull like an eggshell falling on a tile floor.

Oh, I forgot to mention a third thing. Everyone drives aggressively, at least by my standards. Also, lanes are more of a suggestion than anything resembling a traffic law.
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Fyi

Bud diesel is considered high class in this city. So at an expensive place in the states, you know how someone will order a bottle of Patron? Here, they order 12 budweisers. No, I'm not kidding.
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a Guangzhou Artist

I was coming home from the subway today and I encountered this man who
was painting on the street. He was a double amputee and he was
painting very pretty Chinese watercolor pictures (thats what Lee
called them). He was selling them for 20 Yuan each, which is about 3
US dollars. That is relatively expensive by Guangzhou standards for
something that is relatively abundant and easy to come across.
However, from a Western perspective, I've hardly seen anything like
them and I thought they were really pretty. So it occurred to me that
they are worth much more to me than 3 dollars, so I went back
immediately to buy more.

As it turns out, the local police had booted him and his wife from
their spot near the Martyr's Park. He was walking toward me and his
wife was still behind, yelling at the police. He smiled as I passed
but I indicated to him that I wanted more. Getting his wife to stop
yelling at the police took him a bit and then she let me look at the
stack of paintings they had. I got to choose the ones I wanted, and I
bought 5 more watercolors for 100 Yuan. Additionally, he had
watercolors of people and animals that were more complex but were
selling for 50 Yuan. I offered to buy one for only 20 Yuan as that
was about all I had at that point. While the man quickly agreed
(after all I had just bought 6 of his other ones), his wife kept
insisting on 50. I finally showed her that I
only had pocket change left and the man hushed her and agreed to my 20
Yuan offer for a nice watercolor of a farmer.

Honestly, I would have bought his entire stack if I knew I could get
them all home safely. I am worried that they will bleed into each
other or that they will get damaged; Lee says they won't bleed, but
they are very fragile. I will try to find a way to protect them. At
any rate, 7 beautiful Chinese paintings for 17 US dollars, each of
them very frame worthy. In fact, if I was more of a capitalist, I
would have gotten his contact information and had him mail these
paintings to America and I would sell them for 100 dollars each and we
would both get rich. Anyway, I've attached a photo of him painting
one of the watercolors. Very impressive.

The other great thing about travel

Especially in a country where you don't know how to do anything and only a few people speak broken English: you feel like such a dumbass, all the time. I feel like they could make a Mandarin sitcom where they follow me and watch me try to order food, pay the bill, get on the subway, et cetera.

It can be a humbling experience. Its good practice perhaps for being a surgical intern in a year.
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Spine tumor case

This is an impressive case of dumbbell shaped intramedullary neurofibroma with extradural components extending into the left thoracic cavity. Amazingly this 37 year-old patient had minimal symptoms and was only diagnosed because a mass on the chest xray from a routine health screening. This patient is scheduled for OR tomorrow.

*No HIPPA violation here, all identifying info have been removed, you got a 1 in 1.3 billion chance to figure out who it is.*

Lee
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