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Member since Jun-04-08 · Last seen Nov-28-14
Good Day to All! Ma-ayong adlaw sa tanan. And my thanks to for this excellent website. Salamat Opinions:

1. World Chess Championship

The true Chess World Champions are the holders of the Traditional Title that originated with Steinitz & passed on in faithful succession to Lasker, Capablanca, Alekhine, Euwe, Botvinnik, Smyslov, Tal, Petrosian, Spassky, Fischer, Karpov, Kasparov, Kramnik, Anand, and Carlsen. The sacredness of this Title is what makes it so valuable.

And how does one become the true Chess World Champion? In general, by beating the previous Titleholder one on one in a Match! Matches are preferred over Tournaments because of the Tradition of the WC Succession & because the chance for pre-arranging a Tournament result is more likely. The only exceptions to this rule:

A. In case where the Candidates and World Champion participate in an event that all the participants agree to be a World Championship event because of extraordinary circumstances.

Thus, the 1948 World Championship Tournament was justifiable because of the death of the Title holder Alekhine.

Likewise, the 2007 WC Tournament was justifiable under the extraordinary circumstances of the Chessworld trying to heal its internal rift over the 1993 Kasparov Schism. Anand himself became the World Champion in this 2007 Tournament & not in 2000 when he won a knock-out FIDE Tournament. Caveat: Some chess fans deem the 2007 WC Tournament as illegitimate, considering that Anand became the World Champion only in 2008, when he beat the previous Titleholder Kramnik in a WC match. From this perspective Anand only became the Undisputed World Champion in 2008.

Karpov lost his Title to Kasparov in 1985, & never regained it in the 1990s events that FIDE labeled as 'world championships'. All solely FIDE Champions that emerged outside WC Traditional Succession elaborated on above, strong as they were, were not true World Champions (eg., Bogolyubov 1928, Khalifman 1999, Ponomariov 2002, Kasimdzhanov 2004, Topalov 2005).//

B. In case the previous Titleholder defaults an event that the Chessworld largely deems as a World Championship event in the Tradition of the World Championship Succession. Thus, Karpov was the true successor to Fischer who defaulted their WC Match in 1975.

2. The strongest chess events in different eras of chess history?

Because of the brain's limitations explained below, the best professional (amateurs don't matter much in top level chess) chess players of each generation beginning in the Lasker era have always played at a similar level - near the maximum allowed by human standards. Now there are larger cohorts of chess professionals post WW2 than preWW2 thanks to government state funding in the Soviet era and presently corporate funding. The result is that large preWW2 tournaments had numerous 'bunnies', relatively weak players. By the Kasparov era, super-tournaments that featured most of the top ten, and no bunnies, had became more common. However, the top 4 or 5 since Lasker's time have always been very strong.

Consequently the smaller the top-player-only tournament, the stronger it gets. For any era. If there was a double round robin tournament in 1914 featuring Lasker, Capablanca, Alekhine, and Rubinstein, and no other, it would be as strong as any present day super-tournament.

Now weed out everyone except the two strongest players in the world. What we (usually) get is the chess World Championship match.

There has been talk of elite tournaments, composed only of the strongest top masters and no weaker bunnies replacing the World Championship match in prestige, probably because of the assumption that they would be the strongest chess events possible. False assumption. The strongest chess events in chess history generally have been World Championship matches. Even the strongest masters in each generation usually do not match the world champion and challenger in chess strength. In a World Championship match, the contestant has to meet the monster champion or challenger over and over again, with no weaker master in between. Capablanca vs Lasker 1921 was just as strong a chess event as the recent Carlsen vs Anand 2013, and far stronger than Zurich 2014. (Imagine having to play 14 straight games with a computer-like errorless Capablanca at his peak.)

3. The strongest chess players in chess history?

IMO the 1919 version of Capablanca & the 1971 version of Fischer, both of whom played practically error-free chess, are it; updated in opening theory, they should beat anyone in a match.

If computers were self-aware, I have no doubt that they would unanimously choose the 1916 to 1924 Capablanca as the strongest chess player in history. And please no red herring remark that Capa played only 'simple' chess. This young Capablanca played some of the most complicated, sharp, double edged, and bizarre positions possible; and played them without making a single losing error (and by all accounts with unsurpassed quickness), something that has always befuddled my mind when I got to peruse through his games.

We have to take this question in the context of the limits of the human Anatomy and Physiology. A concrete example would be the one hundred meter dash. The human body is designed such that the limit it can run is about 9 seconds. In order for a human being to run faster, we would have to redesign the human anatomy into that of say a cheetah. One can rev up the human Anatomy and Physiology, say with steroids, but this regimen would hit an eventual Stonewall too; the same way that we could rev up human proficiency to learn openings with computer assistance.

Since the Nervous System has physiological limits (example of a limit- neuronal action potential speed don't go up much more than 100 m/s) and so limits the human chess playing ability, increasing the number human chess players, thus expanding the normal curve of players, simply creates more possibilities of players playing like a Fischer in his prime, but will not create a mental superman who plays chess at computer levels. This explains why human and computer analysis indicate that Lasker was playing on a qualitatively similar level as more recent WCs.

'Worse' in chess, any computer assistance ends once the opening is over. After a computer-assisted opening prep, every GM today has to play the game the way Lasker did a hundred years ago, relying on himself alone, with the same fundamental chess rules and chess clock. An Encyclopedic opening repertoire is not a necessity to be a top player. In fact, there are World Champions who did not do deep opening prep; they just played quiet but sound openings that got them into playable middlegames and then beat their opponents in the midlegame or endgame. Just look at Capablanca, Spassky, Karpov, and now Carlsen.

Because of subconscious adherence to the narcissistic generation syndrome, the belief that everything that is the best can only exist in the here and now, many kibitzers would not agree to the above theses. While it is true that there have been more active chess professionals and consequently larger cohorts of top chess masters on a yearly basis since WW2 thanks to Soviet state funding and present corporate funding, the very top chess masters since Lasker's time have always played at a similar level- within the limits imposed by the human brain. There is no physical law that bars a pre-WW2 chess master from playing chess as well as today's generation. The human brain has not changed in any fundamental manner in the past tens of thousands of years.

4. The greatest chess players in history?

A related question is who is the greatest chess player in history. The answer depends on the criteria one uses. Since I place great emphasis on the ability to play world class chess for the longest period of time, Lasker would be it. He was playing at peak form from 1890 age 22 (when he began a remarkable run of match victories over Bird, Mieses, Blackburne, Showalter, and culminating in his two massacres of Steinitz) until 1925 at age 57 (when he nearly won Moscow after winning new York 1924). Kasparov (high plateau from 1980 to 2005) and Karpov (high plateau from 1972 to 1996) would follow. (At their very peak though, I believe that Kasparov was stronger than Karpov, and both were stronger than Lasker; and the peak Capablanca and Fischer were stronger than any of them.)

5. Computers vs Humans, who is stronger?

Another related question is how history's top masters would fare against computers. It's obvious from Kasparov's time that computers would totally crush them all. Opening knowledge would not matter much. Computers swamp human opponents in the middle game, simply by calculating more variations more rapidly by several orders of magnitude. Peak Capablanca probably would have the best score among humans. Talk about another level of playing is fans' subjective and IMO wrong words for their favorite players, unless one talks about chess computers. Chess computers do play at a higher level.

6. On the game and chess players young and old, past and present:

The proposition that an older player would not be able to adjust to the openings and methods of a younger generation is false, as evidenced by the observation of strong masters whose careers happened to span generations beating the tar out of weaker masters of the next generations. Lasker provides a classic example; he was beating Mieses, Blackburne, and Steinitz in the 1890s, and crushing masters versed in the hyper-modern teaching of controlling the center indirectly- Reti, Bogolyubov, and Euwe in the 1920s. In more recent times, we have Victor the Terrible, who learned most of his chess in the 1940s and 1950s, whom we have seen competing successfully with the so-called computer generation even at an advanced age.

The notion that computers are more advantageous to younger players IMO is not quite right. Younger players should have more energy and stamina in studying chess openings and endgames for long hours everyday compared to older players without computers, but the use of computers would tend to make the learning process easier for every one including the older ones.

As a corollary, computers also make it easier today for very young players in their early teens to peak at a younger age than in past eras, although they tend to level off in their early 20s to their high plateau, defined by their inborn talents and determination.

In brief. computers tend to level chess learning for everyone, young and old.

This is not a rigid rule. The best games I have ever seen played by a 12-13 year old are Capablanca's; and Tal, Karpov, and Kasparov reached their high plateau in their early 20s in a computer-less era, similar to computer age Carlsen. However let it be noted that Carlsen reached his peak sidestepping intensive computer-prepped tactical openings and beating his competitors in the old fashioned way in the middlegame and endgame. These masters peaked early not because of computers by because of their immense chess talent. Perhaps normal rules do not apply to these geniuses.

Another false notion is that the nature of the middlegame today is somehow different from the middlegame in the past. The easiest way to prove the wrongness of this proposition is by observing CG's daily puzzles. Do not peek at the names of the players that played these puzzles, and don't look at the dates. Can you glean from the middlegame play and combinations in the puzzles the date they were played? You can't. You would not know if it was played in 2014, 2000, 1950, or 1900. Chess combinations don't just suddenly change their stripes just because a hundred years have passed.

Another observation is that when the best masters of the past, Lasker and Capablanca met the occasional 'modern' structures of the Sicilian Scheveningen and Dragon, KID, Modern Benoni, Benko Gambit, they played strategically perfectly, in just the way these opening structures should be played. So how did these masters play openings and the resulting middlegame structures that are deemed incomprehensible to them by some of today's dogmatically 'modern' kibitzers? The answer is that chess rules and principles have not changed. Center, rapid development, open files and diagonals, holes, weak pawns, piece activity, initiative and attack, positional sacrifices and all types of combinations were as familiar to them as to us.

Instead, it is the frequencies of a few middlegame pawn structures have changed since WW2. Not the Ruy Lopez or QGD, but obviously Sicilians and KIDs are much more common post-WW2. Since so many games nowadays begin with the Sicilian and KID, people associate these with being 'modern' (which is a rather vague undefined term IMO). But certainly Lasker and Capablanca understood the middlegame principles behind them and when they did get these positions they played them excellently, like the top masters they are.

Moreover, Keres is a smoking gun, bomb proof evidence of the fallacy of Watson's speculation that pre-WW2 masters would not be able to learn 'modern' chess, and Larsen's assertion that he would crush everyone in the 1930s. The glaring fact is that Keres is a 1930s pre-WW2 master whose career extended up to the 1970s, and he did learn (and contributed) to the newer opening variations (the most famous of which is the Keres attack which he invented in 1943). Tellingly enough Keres beat both Watson and Larsen.

7. On ratings:

Elo ratings reflect relative and not absolute chess strength.

Chessplayers are naturally arranged in populations partitioned by geopolitical regions & time periods that have infrequent contacts with one another. Within such a population, players get to play each other more frequently, thus forming a quasi-equilibrium group wherein individual ratings would tend to equilibrate quickly; but not with outside groups. With caveats & in the proper context, FIDE/Elo ratings are simply fallible descriptors & predictors of an active player's near-past & near-future performances against other rated players, & only within the same quasi-equilibrium group.

As corollaries: the best way to evaluate a player's strength is to analyze his games & not his ratings; one cannot use ratings to accurately compare the quality of play of players from the past and present, or even the same player say a decade ago and today; & care should be taken in the use of ratings as a criterion in choosing which players to seed into the upper levels of the WC cycle. All the above often entail comparisons between players from different quasi-equilibrium groups separated by space and/or time.

Regarding inflation deniers, they imply that Elo ratings reflect absolute and not relative chess strength. Professor Elo himself would condemn their view. If the top 20 players were to suffer a serious brain injury and begin playing like patzers, but play no one else for the next decade, they would more or less retain their 2700s ratings, although they would be playing terrible patzerish chess.

8. Best Qualifiers?

The credible, fair, tried & tested Zonals - Interzonals - Candidates (with known strong players directly seeded into the Interzonals & Candidates; & here ratings may be used with caveats) over the random World Cup and the elitist Grand Prix. If possible long Candidate matches and 16 to 24 game World Championship matches. However, with the passing of the state-funded chess era of Soviet times, I begin to doubt if the strict money guzzling qualification process above can be re-installed.

9. The 1993 Chess Rift and Kramnik:

Regarding the Rift in the chessworld after Kasparov split in 1993, I believe that Kramnik has done more than any other individual in helping heal it by concrete actions - agreeing to a WC Match with Topalov in 2006 & not walking out when he could have done so with the support of most of the world's top GMs after getting accused of cheating; & agreeing to Defend his Title in a WC Tournament in 2007, the first time a living Titleholder has agreed to do so in chess history. My eternal gratitude to him.

10. Finances of a would-be Challenger:

Regarding all kinds of problems chessplayers outside of Europe & the USA face in their quest for the Title, Capablanca & Anand have proven it's possible for a non-European non-USA chessplayer to be World Champion; but apparently only if you have the chess talent of a Capablanca or Anand! For others, I guess they would have to try to get monetary support & good seconds somewhere to have some hope for a Title shot.

11. Ducking a World Championship re-match:

Alekhine vs. Capablanca - Not definitively resolved. If pushed, I would tend to favor Capablanca given that pre-WW 2, there was no definitive cycle to choose the Challenger &, after all is said and done, it was the Champion who set the conditions & who chose his Challenger. AAA could & should have chosen Capa; & there was ample time, more than a decade, to do so before WW2. On the other hand, Capa's pride may have caused him to behave arrogantly & thus offend AAA. The issue is very much debatable. //

Kramnik vs. Kasparov - For me, it's resolved. Kudos to Kramnik for trying his best to install a decent Qualifying Event. Kasparov for his reasons clearly did not want to go through the Qualifying Event that he himself had pledged before losing his Title; & did not even seem serious in playing the solely FIDE champions. Why? I can only speculate that Kasparov would rather retire than risk a loss in a Qualifier or a match to either a FIDE champion or to Kramnik. If he regained his Title, he would be the greatest Champion in history, but there was risk involved. If he retired, he would still be the greatest Champion in history, but there would be no risk involved. Kasparov chose the latter & no one should blame him for that decision; & more so don't blame Kramnik!

12. Predictions for Hypothetical World Championship Matches:

Lasker vs. Pillsbury, Rubinstein, Maroczy - Lasker wins 2, loses 1 match //

Lasker vs. Capablanca (inexperienced) 1914 - Lasker close win //

Capablanca (not overconfident & not having TIAs) 1929 to 1937 vs. Alekhine or any other master - Capa win //

Alekhine (sober & prepared) vs. Capablanca (w/ severe HPN & numerous past strokes), Botvinnik, Keres, Fine, Reshevsky, Flohr 1939 - Alekhine win //

Alekhine (alcoholic, ill, & depressed) vs. Botvinnik 1946 - Botvinnik win //

Fischer (inactive for 3 years) vs. Karpov 1975 - Karpov win//

Kasparov vs. Shirov 2000 - Kasparov win. (But GKK should still have given it to Shirov. And don't blame Kramnik. Had Kramnik declined, GKK would have chosen another; & Shirov would still be frustrated.)


I have opened a <'multi-experimental' forum> below. Its nature is that of several secret social and psychological experiments, whose objectives and parameters, and the rules that follow, are strictly defined and which I may or may not reveal. Readers of this forum might be able to deduce some of these rules. Accordingly messages shall be retained or removed with or without explanation, even those from my dear friends here in CG, although I am making it clear here that absolutely no offense is intended to any one in this experiment. I may or may not respond to certain questions and messages, also according to the rules. To my friends: Please bear with me in this matter. There can be a certain amount of disinformation and propaganda in the messages that are retained.

The title of this <'multi-experimental' forum> is:

Biased Journal of a Fourth World Brain Operator

Some abbreviations

CiH = the public City Hospital

PrvH = Private Hospital. There are three main ones. So PrvH 1, PrvH 2, PrvH 3.

ProvH = the public Provincial Hospital

SOL = Space Occupying Lesion

SQ = Subcutaneous tissue layer of the skin or scalp

CVA = Cerebrovascular accident = stroke

EDH = Epidural Hematoma, blood above the dura mater, the outer covering of the brain, and beneath the skull.

SDH = Subdural Hematoma, blood beneath the dura mater.

ASDH = Acute Subdural Hematoma, SDH incurred recently, usually less than a week

CSDH = Chronic Subdural Hematoma, SDH that is more than two weeks old

HCP = Hydrocephalus, too much CSF in the brain's ventricular system

CSF = Cerebrospinal Fluid

CNS = Central Nervous System

CAB = Continuous ambubagging

ETT = Endotracheal tube (for airway purposes)

NGT = Nasogastric tube (for feeding purposes)

NOD = Nurse on duty

The Oracle = personification of the CT (computed tomography) scan.

Magic mirror = the computer monitor where one can see CT scan images.

Witching Hour Admissions or Referrals = 12 midnight to 5am

MF = Motorcycle Fall

Craniectomy = neurosurgical procedure that involves removing a portion of the skull

Tracheostomy = a surgical procedure to create an opening through the neck into the trachea (windpipe)

INTUBATE: To put a tube in, commonly used to refer to the insertion of a breathing tube into the trachea for mechanical ventilation

EXTUBATION: the removal of a tube especially from the larynx after intubation—called also detubation.

Uneventful day = Most likely still a busy day, making daily rounds in the hospitals, following up post-op patients, seeing patients in the OPD, answering referrals, admitting all kinds of patients in the hospitals; nevertheless a day in which nothing interesting has caught my attention.

>> Click here to see visayanbraindoctor's game collections. Full Member

   visayanbraindoctor has kibitzed 6833 times to chessgames   [more...]
   Nov-26-14 Paul Keres
visayanbraindoctor: <Petrosianic: <I believe were just unlucky.> Unlucky in the sense of unlucky in their games, or unlucky in the fact that somebody a little better was always around?> A little bit of both in case of Keres. More of the latter for Kochnoi. In the mid to late ...
   Nov-26-14 visayanbraindoctor chessforum (replies)
visayanbraindoctor: <SugarDom: How's 61m?> Still alive.
   Nov-25-14 Anand - Carlsen World Championship (2013) (replies)
visayanbraindoctor: This World Championship match may turn out to be a defining moment in a long reign of a dominant champion. Magnus Carlsen. There isn't any younger player who seems to play chess at his level. There are similarities between the conditions today and in 1975. Young toothpick
   Nov-25-14 Keres vs Bogoljubov, 1943 (replies)
visayanbraindoctor: if this is the first Keres attack in chess history, then it is quite appropriate that it was played by Keres himself and ended in a Keresian smash attack. Decades later, Karpov specialized in it, although he usually played it in his patented positional squeeze manner. Old
   Nov-24-14 Alexander Alekhine
visayanbraindoctor: It would be great if CG puts up a page for the Prague 1943 tournament. It was Alekhine's last moderately strong tournament (meaning there were strong masters there along with assorted bunnies typical of pre-WW2 tournaments), and tellingly enough, he nearly wiped out the ...
   Nov-23-14 Jose Raul Capablanca (replies)
visayanbraindoctor: <Benzol> Thanks for the correction. <Sally Simpson, maxi> Thank you also. A very fascinating celestial conversation.
   Nov-23-14 Carlsen-Anand World Championship (2014) (replies)
visayanbraindoctor: Why to b4 when he had Rb3, safely maintaining the pressure, maintaining the open file, keeping his activated rook, invading the third rank? The rook was more powerful than the White bishop. I thought that was the reason why he opened the b-file. Anand looks like he is ...
   Nov-20-14 Carlsen vs Anand, 2014 (replies)
visayanbraindoctor: <sfm: It looks so hopeless for black after 31.Rh5. He is bound to lose his e-pawn. Material will be equal, but what a difference in pawn structure> I was watching this game unfold. At 28. Ng3 I chalked it up as a Carlsen win. In his usual manner, Carlsen was zooming
   Nov-15-14 twinlark chessforum (replies)
   Nov-15-14 Carlsen vs Anand, 2014 (replies)
visayanbraindoctor: Anand looks as if he is in the process of collapsing. Expect Carlsen to win.
(replies) indicates a reply to the comment.

Kibitzer's Corner
< Earlier Kibitzing  · PAGE 29 OF 29 ·  Later Kibitzing>
Premium Chessgames Member
  visayanbraindoctor: 29 October 2014. Entry 1.

<23 October 2014. Entry 3. In between the two craniectomies, I did an emergency tracheostomy on 53M in PrH1 ER. He had suffered a sudden loss of consciousness and the Oracle showed a right temporal intracerebral hemorrhage, probably secondary to a ruptured Middle Cerebral Artery bifurcation aneurysm. 53M was comatose (GCS 7), had a dilated right pupil, and had aspirated. I failed in trying to intubate him in the ER as he had a deeply located glottis (the hole into our windpipe or trachea), typical of obese heavily built patients, and I ended up doing an emergency tracheostomy on him under LA in the ER. I do not expect him to survive.>

53M died.

Premium Chessgames Member
  visayanbraindoctor: <SugarDom: The time indicate she was going to school.>

It's pretty common for kids to be brought to school by their relatives on motorcycles; unfortunately they never wear helmets. In motorcycle crash cases where there is a child, it's the child that is most often injured.

<GreenLantern: These pages are filled with fascinating insights into the lives - and sometimes deaths.>

A high mortality week. All of them are dying of pulmonary complications. I had to do a lot of tracheostomies because these patients have severely aspirated. These patients usually improve immediately post tracheostomy but begin to to deteriorate badly 3 days after, when an inevitable aspiration pneumonia sets in.

Oct-30-14  SugarDom: The high mortality rate is not the doctor's fault.

Public hospitals with too many patients and overworked nurses can't simply monitor these critical patients effectively.

I believe in first-world hospitals the casualty rate will be significantly lower. Am i right, doc?

Oct-30-14  SugarDom: Also the fact that many of the patients cannot be operated on right away due to lack of money lessen the survival chances...
Premium Chessgames Member
  visayanbraindoctor: <SugarDom: I believe in first-world hospitals the casualty rate will be significantly lower. Am i right, doc?>

I believe so. There is a higher nurse to patient ratio and compliance to medications and is much better.

Premium Chessgames Member
  visayanbraindoctor: 31 October 2014. Entry 1. I replaced the right temporo-fronto-parietal and left frontal bones of 25M, a MF victim, which I had removed a year ago while evacuating a subdural hematoma. The family has just recently saved enough money to buy OR needs.

Entry 2. I debrided and repaired a left occipital scalp avulsion of 66F. She was on a PUV that got hit by a 10 wheeler truck. I had postponed the operation for three days. She had lost much blood and I had a blood transfusion done first. Simultaneously I was trying to control her blood sugar which had shot up to nearly 600 mg%. I managed to lower it to below 300 when I began to give IV insulin every 4 hours. In the public CiH, I also have to take care of these medical problems on top of operating on them.

Entry 3. Two near midnight referrals in PrH2, both MF victims. The first, a Mr. X, came in brain dead. His brains was spilling out of a large left frontal open fracture. I showed it to the Resident on Duty and the Nurses on Duty so they would know how injured brain looks like. (I don't want to sound morbid but it looks like light gray butter that's being squeezed out of the skull.) The second, 47M, arrived with zero vital signs as I was having Mr. X ambubagged. I pronounced 47M DOA.

Nov-03-14  SugarDom:

What's your opinion, doc?

Premium Chessgames Member
  visayanbraindoctor: <SugarDom> He probably has neurological deficits making him partially disabled. He won't be able to race again.
Premium Chessgames Member
  visayanbraindoctor: 1 November 2014. Entry 1. All Saints' Day, and once again the streets are full of people visiting the resting places of their relatives. Police have redirected traffic away from the cemeteries.
Premium Chessgames Member
  visayanbraindoctor: 6 November 2014. Entry 1. <31 October 2014. Entry 2. I debrided and repaired a left occipital scalp avulsion of 66F. She was on a PUV that got hit by a 10 wheeler truck. I had postponed the operation for three days. She had lost much blood and I had a blood transfusion done first. Simultaneously I was trying to control her blood sugar which had shot up to nearly 600 mg%. I managed to lower it to below 300 when I began to give IV insulin every 4 hours. In the public CiH, I also have to take care of these medical problems on top of operating on them.> I finally got her hyperglycemia under control with repeated IV insulin doses, bringing it down to below 250. 66F did not fully wake up though. A repeat CT scan showed a progressive accumulation of subdural hygroma on top of her left cerebral hemisphere. This morning I did a small craniectomy on her in order to remove it. Post-op she woke up.

Entry 2. Right after 66F, I replaced the left fronto-temporo-parietal and right frontal bones of 29M, a MF victim. I did the craniectomies on him a year and a half ago in order to remove a huge ASDH and to decompress the swollen brain. I had also done a tracheostomy on him as he was severely aspirated. He is lucky to be alive, talking and walking.

Entry 3. In the afternoon, I replaced the left temporo-fronto-parietal bone of 51M in PrH1. He was herniating from a massive left temporal hemorrhagic stroke 8 months ago. There was no time to do a CT angiogram then (the Neurologist referred him while he was going down and I immediately rushed him into the oR which can be done in a private hospital quite rapidly), but when I opened him up, I found a relatively firm blood clot around the area of the latter segments of his middle cerebral artery. I packed it with absorbable hemostatic gelatinous sponge. He survived the operation and even became ambulatory, although he remained dysphasic (something frequently seen with left sided strokes and severe brain injuries). Post-op CT angiogram was negative for AVM or aneurysm. I am not quite sure what bled. I had signed it out as a 'burned out' AVM.

Premium Chessgames Member
  visayanbraindoctor: 8 November 2014. Entry 1. <22 October 2014. Entry 1. I did an emergency tracheostomy on 79F in the afternoon. She came in after her family found her unconscious on the floor of their house. The Oracle just shows old frontal cerebral infarcts. I suspect she has incurred another infarct, but the diagnostic problem with new infarcts is that they often don’t show up on the CT scan, especially if they are small lacunar infarcts (3cm or less). 79F had aspirated, and so I did an emergency tracheostomy on her in the ER under LA. I told her son and daughter that prognosis of aspiration pneumonia in the elderly is poor to hopeless.>

Strangely enough, 79F woke up and has survived so far. Her family has run out of funds. They decided to go 'home against advise'. Off the record I advised them to buy a suction machine in order to properly suction her tracheostomy site and turn her side to side every 2 hours as she had already developed a sacral bedsore.

Entry 2.

<23 October 2014. Entry 1. I did a craniectomy on 13F in PrH1 during witching hour. She was on a PUV that turned turtle in a neighboring province. When she arrived around midnight her left pupil was already dilated. I immediately intubated her in the ER. By the time she was brought to the OR, her right pupil had also dilated. In a great rush, I opened up her left temporal bone, and removed a huge acute subdural hematoma from a burst left temporal lobe. Then I proceeded to do a right frontal craniectomy, cortisectomy, and evacuation of a right frontal lobe contusion-hematoma. Post-op her pupils began to react again and had shrunk to 3mm. I regard 4mm and bigger as dilated. I do not know if she will survive or not...

13F developed a massive bifrontal-left temporal cerebral infarct, when those contused parts of her brain died. She is now brain dead.>

I was careless and wrong, but in this case I got a pleasant surprise. When I closely examined her three days later, I found out she was withdrawing to pain and that her dilated pupils had contracted. Her massive bifrontal-left temporal cerebral infarct would leave her hemiparetic on her right side and dysphasic, but being young, she would have reasonable chances of surviving. Unfortunately her family had ran out of money, and today they decided to transfer to a public hospital in their province that had acquired a ventilator. Hopefully the doctors there would be able to wean her off and cure her pneumonia. Then, according to my wishful thinking, she should be able to sit up, ride in wheelchairs, maybe even walk with the help of a cane.

Nov-09-14  SugarDom: <I was careless and wrong>

But how?

Premium Chessgames Member
  Annie K.: I assume Doc refers to his pronouncing her brain dead prematurely, as it turned out. Although sounds like it's been a tough month, so the pessimism is understandable. Glad to hear she made it, anyway. :)
Premium Chessgames Member
  visayanbraindoctor: That's right. I actually just thought she was about to be brain dead. For me to place in the chart that a patient is brain dead, I have to do a more detailed examination; not only check her pupils (CN 2 and 3), but also her corneal reflex (CN 5 and 7), gag reflex (CN 9 and 10), spontaneous respiration (medullary function). I hope the doctors in her province do a good job treating her pneumonia.
Premium Chessgames Member
  visayanbraindoctor: 10 November 2014. Entry 1. I returned the right temporal-parietal and left frontal-temporal-parietal bones of MF victim 23F, a pretty long operation (for me that is) that lasted nearly 2 hours because I was essentially opening up opposite sides of her head. She had an epidural hematoma on her rigth and an acute subdural hematoma on her left during the previous operation, both of which had to be taken out.

Entry 2. I did an emergency tracheostomy on 68F right after finishing with 23F. 68F is a case of a hemorrhagic stroke on the right basal ganglia (60% of hypertensive brain hemorrhages occur in the basal ganglia), but it's small enough that it does not require an evacuation. However, typical of such cases in the elderly, 68F has become bedridden and developed pneumonia. The family did not want a tracheostomy done, so at first I tried to intubate her in CiH ICU. I failed; she had a deeply located glottis and swollen tonsils which made it impossible for me to visualize the epiglottic opening. I told the family that I had to do a tracheostomy in order to secure an airway and save her from literally drowning from pulmonary secretions. 68F is now on the pneumonia-sepsis roller coaster ride, unfortunately probably the last ride of her life.

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  visayanbraindoctor: 20 November 2014. Entry 1. It's been a pretty peaceful week for me. No operations for a long time. There were some referrals who died, but there was nothing much I could do about them as they were already either nearly brain dead or suffered other severe injuries. Two of those who died were shot by known assailants. (In other words, murdered.) In these cases I just hate it if I get a subpoena; a court call wastes much of my day especially if the court is located in another city in my region. Lawyers always confirm in court that victims indeed died of their gunshot wounds; and the usual manner that this is done is by calling a doctor to testify that it is so.
Nov-20-14  SugarDom: What if you have an scheduled operation or an emergency operation during the court hearings?
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  visayanbraindoctor: <SugarDom: What if you have an scheduled operation or an emergency operation during the court hearings?>

The operation or emergency takes priority. Later I just send the judge a letter that I was operating.

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  visayanbraindoctor: 23 November 2014. Entry 1. In the morning I did an emergency tracheostomy on 19M, another motorcycle fall victim, when his ETT clogged up. Although the CT scan showed no sign of significant increased inttracranial pressure (intact para mesencephalic cisterns, uneffaced sulci and fissures), he had a midbrain hemorrhage. These patients often arrive comatose, decorticate posturing in 19M's case. I had to intubate him yesterday in CiH ward as he was also typically severely aspirated. I asked his parents and weeping younger sister not to look. Seeing a tube being shoved down into a loved one's windpipe can get pretty traumatic for relatives to watch.

His temperature was 40 in the OR. My anesthesiologist inserted an NGT (nasogastric tube), and it drained out 'coffee-ground' material- meaning blood from the stomach. This is from the stress gastritis that commonly accompanies severe brain injuries, and is usually a bad prognosticating factor. 19M was already in sepsis secondary to aspiration pneumonia.

Entry 2.

After 19M was transed-out to the ward, I did bifrontal craniectomies on 61M, a pedestrian who got hit by a motorcycle a week ago. He incurred significant bihemisphere subdural hygromas. This is CSF fluid that accumulates in the subdural space due to a traumatic tear in the underlying arachnoid layer. A ball valve mechanism prevents the fluid from returning into the subarachnoid space, from where it is normally absorbed. 61M has remained drowsy to stuporous since then, and I finally decided it would help if the pressure effects from his subdural hygromas were alleviated.

I began the craniectomies simultaneously with an Orthopedic Surgeon. He was operating on 61M's left shin, which had incurred an open tibia-fibula fracture. Such simultaneous operations can be done in this case because the leg is located far from the head. I would usually not consent to a simultaneous operation on an arm because it would interferes with my operating field. The Ortho did an external pinning procedure. By doing two operations at the same time, we save on Anesthetic gas, which often runs out in the public CiH.

While I was writing down the OR technique, the ward NOD called up to say that 19M's BP was dropping precipitously. I left my anesthesiologist and the Ortho surgeon in the OR, still operating on 61M, and assessed 19M. He was in septic shock. I ordered for dopamine in order to elevate his BP, but I had to tell his father that his oldest son was about to die. His father cried, so I told him we had a clear conscience, since we had done everything that needed to be done, and it was his time. 19M died later in the afternoon.

Nov-23-14  LarsenBentYou: Do you have an account on Figure1?
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  visayanbraindoctor: <LarsenBentYou: Do you have an account on Figure1?>

No. This journal is just an experiment. I try to keep the stories here true to life, although I can't possibly tell all of them.

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  visayanbraindoctor: 24 November 2014. Entry 1. In the late afternoon. I did a craniectomy and evacuation of a left hemisphere acute subdural hematoma on 72M, a MF victim. This septuagenarian has a history of drinking and riding motorcycles, and this time it nearly did him in.

He came in yesterday in PrH1 ER drowsy, but his operation was delayed because the family could not pay the required hospital cash advance. This is a common practice among private hospitals, in order to protect their business interests. Perhaps 90% of families easily go bankrupt over private hospital expenses for critically ill relatives; and once that happens they may end up racking debts up to several hundreds of thousand of pesos, which they can never pay to the hospital. A private hospital would quickly go bankrupt. It's why I have to transfer most patients to the public hospital for brain operations. There is even more delay of course. Who is to blame? No one specifically, since it's the whole societal system that creates massive poverty in peripheral areas that is the root cause. Unfortunately changing fundamental societal structures means going into politics, a genre dirtier than an operating field on which a fly from a trash can has landed in.

In any case, 72M was already stuporous when I got him inside the OR. After removing the ASDH on the left, I was also planning to remove a subdural hygroma on the right hemisphere through a Burr hole. It turned out that he was a bleeder, quite common for chronic drinkers. So I did not proceed with the second operation. I am planning to repeat the CT scan on an OPD basis, if he survives, in order to see what would become of the hygroma. Managing the elderly is always difficult because they tend to die of complications.

Nov-25-14  SugarDom: How's 61m?
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  visayanbraindoctor: <SugarDom: How's 61m?> Still alive.
Nov-27-14  SugarDom: Well that's a surprise, considering he's got multiple injuries not just brain injury.
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