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Member since Jun-04-08 · Last seen Oct-25-14
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.

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 6748 times to chessgames   [more...]
   Oct-25-14 visayanbraindoctor chessforum (replies)
visayanbraindoctor: 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 ...
   Oct-24-14 twinlark chessforum
   Oct-24-14 Annie K. chessforum (replies)
visayanbraindoctor: <Thanh Phan: <Annie K.> Miss Pham during her continual hospital stay has noted as you, transfer of bodily fluids could and might influence if they contact that disease, even breath with coughing could result in the transmission,> This is alarming. Yersinia ...
   Oct-15-14 FIDE Grand Prix Baku (2014) (replies)
visayanbraindoctor: <It is safe to say that playing better moves will result in a higher elo depending on how one defines better moves.> I do agree with this if you mean it as a general statement. If one plays better, then one usually (but not all the time) will turn in better ...
   Oct-10-14 Gelfand vs Kasimdzhanov, 2014
visayanbraindoctor: This is the most interesting endgame so far in this tournament, IMO worthy of study. When Gelfand moved 39. Ke4, he made a decision to give up his king rook pawn. But the general rule in endgames is that the advantaged side should retain as many pawns as possible and the ...
   Oct-08-14 Paul Keres (replies)
visayanbraindoctor: <perfidious: <....FIDE,....floundering like an inebriated elephant....>> Amazing that this was written in 1937. Chess politics, like love, alcoholics, and elephants doesn't seem to change much.
   Oct-08-14 Fabiano Caruana (replies)
visayanbraindoctor: <Lupara: Caruana's style of play is also somewhat similar to Botvinnik's style, but a little more aggressive. Much like Botvinnik, Caruana emphasizes preparation.> I also agree. My note in Caruana vs Mamedyarov, 2014 <More and more, he reminds me of ...
   Sep-22-14 World Chess Championship Candidates (2014) (replies)
visayanbraindoctor: Compare this Candidates tournament with the original ones: Budapest Candidates (1950) 1 Bronstein ** ½½ 01 ½1 11 1½ 01 ½½ 1½ ½1 12.0/18 2 Boleslavsky ½½ ** 1½ ½½ ½½ 1½ ½½ ½1 ½1 11 12.0/18 3 Smyslov 10 0½ ** ½½ 1½ ½1 01 ½1 ½½ ½½ 10.0/18 4 Keres ½0 ½½ ½½ ** ½½ 10 1½
   Sep-22-14 Viswanathan Anand (replies)
visayanbraindoctor: <Reisswolf> You are probably right but there is still the example of Alekhine who forced a change in attitude in himself, changing his style into that of a Fischer or Carlsen to grind out wins against an unsuspecting Capablanca in the 1927 match. In that match, ...
   Sep-21-14 Keres vs Geller, 1962 (replies)
visayanbraindoctor: <Olavi> I actually read it from a kibitzer's post here in CG, I just forgot where. I understand your point that the source is unverified. So let's just say Botvinnik never uttered it. It doesn't change the gist of my core statements about Keres.
(replies) indicates a reply to the comment.

Kibitzer's Corner
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Premium Chessgames Member
  visayanbraindoctor: 12 September. Entry 1. Operated on 30F, removing a left temporal acute subdural hematoma from a burst temporal lobe. She was on a tricycle that got hit by a 10 wheeler truck. She was deteriorating, but post-op exhibited an improvement in sensorium.
Premium Chessgames Member
  visayanbraindoctor: 15 September. Entry 1. In the morning, I evacuated a huge 70cc left fronto-temporal-parietal epidural hematoma (EDH) from 29M, another MF victim who was decorticating. Post-op his left pupil was still dilated. Afterward, I informed the anxious wife and sisters that he might not make it.
Premium Chessgames Member
  visayanbraindoctor: 16 September. Entry 1. 29M woke up. His dilated left pupil has returned to normal size. Seeing that he could now follow commands, I extubated him. Another case that proves that even if a patient is posturing (decorticate or decerebrate) and anisocoric (one pupil dilated), removing an EDH might save him and return him to a functional life.
Premium Chessgames Member
  visayanbraindoctor: 17 September. Entry 1. Two witching hour admissions kept me up most of the night. Cousins 27M and 21M were riding on a motorcycle when it hit a car. As if often the case, the backrider, 21M, was more seriously injured. He was decerebrate and he died around 12 hours after I admitted him. 27M was awake but incurred a 6cm left frontal scalp avulsion. As not to waste time and his family’s money, I debrided and sutured the wound under local anesthesia in the ER.
Premium Chessgames Member
  visayanbraindoctor: 21 September. Entry 1. A 64M has too much drink, slipped and fell. He arrived in PrH2 with BP 0 and apneic. After emergency intubation, his vital signs returned. CT showed a huge 80 cc acute subdural hematoma on the right cerebral hemisphere, and a massive infarct on the right posterior cerebral artery territory (medial part of the occipital lobe and thalamus). He was anisocoric. The daughter wanted an operation. My policy is that as long as the patient is not brain dead, and the relatives insist even after being informed their patient will most likely still die and would be a living vegetable in case he survives, I operate. If I don’t some of these relatives blame me for allowing their patient to die by not doing everything possible. In this case though, the daughter changed her mind. No operation. I expect the VS to drop to zero soon.
Premium Chessgames Member
  visayanbraindoctor: 22 September. Entry 1. 64M died.
Premium Chessgames Member
  visayanbraindoctor: 24 September. Entry 1. Operated on three patients in the evening.

At PrH2, I removed the right fronto-parieto-temporal crhronic subdural hematoma of 55M, who fell off a motorcycle 5 weeks ago and was becoming progressively disoriented and hemiparetic and numb on the left. There was a thick pseudomembrane surrounding the hematoma. In these cases, I try to remove as much of the pseudomembrane as possible, carefully peeling it off. This couyld get bloody at times. In 55M, I left alone the pseudomembrane sticking to the Sylvian vessels. These are the large blood vessels on the Sylvian fissure, the boundary between the temporal (on the side of the head) and frontal lobes. He was doing fine post-op.

At CiH, I removed an acute subdural hematoma from 8M’s left cerebral hemisphere. He got hit by a van while crossing the highway. (Some parents can be so neglectful as to allow their children to play beside highways.) he woke up post-op.

Still at CiH, I next removed the right parieto-temporal epidural hematoma of 26M, another MF victim. This guy had already severely aspirated his own vomitus. Post-op we could not extubate him. He probably won’t make it.

Premium Chessgames Member
  visayanbraindoctor: 25 September. Entry 1. In the morning, I returned two pieces of 28M’s right frontal bone. He had previously been operated two years and 3 months ago. He had fallen off a tricycle when it got hit by a motorcycle (that’s a twist; it’s usually the other way around). His right frontal bone incurred a comminuted fracture through which his brains and CSF were oozing out. I did my SOP for such cases, plugging the hole with a temporalis muscles flap.

I could only save two pieces of his frontal bone then. These two pieces are what I replaced onto his frontal defect.

With three operations last night and one this morning, I have tied my previous record of four operations in less than a day.

Premium Chessgames Member
  WannaBe: Welcome back!!!
Premium Chessgames Member
  visayanbraindoctor: <WannaBe: Welcome back!!!> Thank you.
Premium Chessgames Member
  visayanbraindoctor: 28 September. Entry 1. Unusual case. 68M got punched on the face by a drunk in a neighboring province. (In PrH2 ER, I noted that his left lateral orbital rim showed abrasions and soft tissue swelling, which indicates that he got punched by a right hander.) Approximately 30 minutes, back in his house, his sensorium suddenly began deteriorating. After 30 more minutes, he was comatose. The family brought him to a nearby private hospital where he was intubated. Hoping for the best, his wife and daughter brought him to my province to see me upon recommendation of the physician in charge. When I saw him in the ER he was already brain dead. CT scan showed a huge right fronto-parietal intra cerebral hemorrhage, probably from a ruptured cerebral aneurysm. In case this goes to court, I will have to tell the judge that the patient’s stroke was probably triggered by the drunk’s punch.
Premium Chessgames Member
  visayanbraindoctor: 29 September. Entry 1. <24 September. I next removed the right parieto-temporal epidural hematoma of 26M, another MF victim. This guy had already severely aspirated his own vomitus. Post-op we could not extubate him. He probably won’t make it.> 26M has improved, now with eye opening. I extubated him.
Premium Chessgames Member
  visayanbraindoctor: 30 September. Entry 1. <28 September. Entry 1. Unusual case. 68M got punched on the face by a drunk> 68M died.
Premium Chessgames Member
  visayanbraindoctor: 1 October 2014. Entry 1. In the morning I did a right squamous temporal craniectomy on 30M, a motorcycle fall victim, in order to remove a 40 cc epidural hematoma. He was awake but complaining of headache. Although I suggested observing the patient for a week, his family did not want to take any risk and insisted I remove the EDH.

In the afternoon I replaced the two frontal bones which I had taken out of 17F’s skull 10 months ago. She was a typical young female backrider who fell off a motorcycle, and incurred a bifrontal contusion and subdural hematoma.

Immediately after 17F, I did an emergency tracheostomy on 47M, another MF victim. He had aspirated and was in severe pulmonary distress- intercostal and sternal notch retractions, and rapid labored respiration. He was also turning blue (cyanosis). The tracheostomy relieved him, and his O2 saturation (taken by pulse oximeter) went back to 99.

Premium Chessgames Member
  visayanbraindoctor: 2 October 2014. Entry 1. <24 September. Entry 1. Still at CiH, I next removed the right parieto-temporal epidural hematoma of 26M, another MF victim. This guy had already severely aspirated his own vomitus.> 26M was awake and then suddenly just stopped breathing and died according to the NODs. He also had multiple fractures of the left and right humerus bones, left elbow, right ankle, and right clavicle. Probably a pulmonary embolus.
Premium Chessgames Member
  visayanbraindoctor: 4 October 2014. 23F, whom I operated on way back on 25 August suddenly died. It was unexpected as she had regained consciousness and volitional movement. I suspect that she suddenly vomited and aspirated, although she was on NGT feeding and not DAT. It’s difficult to say considering the poor monitoring in the public CiH.
Premium Chessgames Member
  visayanbraindoctor: 11 October 2014. Entry 1. I answered a near midnight referral, 55M who fell off a motorcycle after hitting a bus. He is completely quadriplegic (paralyzed in all limbs). I localized his lesion after testing for pain- he has a complete spinal cord transection at the cervical 5 level (his lower neck). Each part of the spinal cord receives skin sensory input from specific areas of the body (dermatomes). In 55M’s case, he still feels a little pain sensation from his C5 dermatome, which is that skin area on our deltoids, but no sensation at all below it all the way to his feet. Thus I can deduce that his spinal cord at the C6 level has been functionally transected. That is the part of the spinal cord under the sixth cervical (neck) vertebra.

With his spinal cord severed in his lower neck, 55M cannot breathe properly. There are two ways by which we move our chest in order to breath. One is by our diaphragm, which is controlled by output from the C4 spinal cord in the middle of our neck; and this is still functional for 55M. The other is by our intercostal muscles, the muscles between our ribs. These muscles are innervated by the thoracic spinal cord, which is lower than our neck, and are paralyzed.

In brief, if the neck (cervical) spinal cord is severed, the rest of the thoracic, lumbar, and sacral spinal cord is also permanently gone, since they are located lower and more peripherally. Sensation from our lower body cannot reach the brain because the electrochemical impulses that mediate it has to pass our neck (cervical) spinal cord, and it can’t do that if the cervical spinal cord is cut. Likewise when our brain orders our limbs to move, the electrochemical impulses that mediate motor movement cannot reach our lower body, and we are paralyzed.

All these cervical spinal cord transection patients sooner or later die of pneumonia, since they are unable to cough out or breathe properly. In the first world setting, with a tracheostomy, suction machine, ventilator, unlimited antibiotics for the recurrent respiratory tract infections, and thousands of thousands of dollars for all the medical expenditures, they can last for a few years, a terrible life where they are conscious but can’t move their limbs at all. In my setting they usually die of pneumonia within two weeks; when pneumonia sets in the family usually can’t maintain a daily antibiotic regimen, or even afford a ventilator. I am not hopeful of 55M at all.

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  visayanbraindoctor: 14 October 2014. Entry 1. In the evening I answered a referral in PrH 2 ER, 17M, a backrider who fell off a motorcycle in a neighboring province. He was going home with a classmate from a school event. He was already anisocoric (dilated right pupil), decorticate, and had aspirated. Bad prognosis. I intubated him, and then transferred him to CiH, where I did a craniectomy and evacuation of a huge 70cc right frontal epidural hematoma. His aspiration destines him for the pneumonia sepsis roller coaster ride.

Entry 2. Earlier in the afternoon in PrH2 ER, I had admitted 91F, who her daughter said suddenly fell down the floor. Her face was swollen from the trauma. She was in CP arrest when she arrived in the ER. I happened to be around, going home from my rounds, and I had CPR done. I did not know if she had a stroke and fell down, or slipped and fell and consequently became comatose from the trauma. Here is only one sure way to solve this dilemma immediately in the ER setting, to do a CT scan. No money. After about 15 minutes I pronounced her dead. I told the family I would sign it out as a trauma case.

Entry 3. While doing rounds in the CiH charity ward shortly after seeing 91F, I saw a comatose patient (62M) in severe respiratory distress. Although he had not yet been referred to me, I intubated him to save him from immediately dying. Upon asking, I learned that he was a victim of a hit and run. It turned out that the family had no money to pay for a CT scan or even meds; and since they were not able to identify the van that hit him, they could not ask for financial aid from the owner of the vehicle. Suffering from aspiration pneumonia and comatose, and with no financial resource, prognosis is hopeless.

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  visayanbraindoctor: 16 October 2014. Entry 1. <14 October 2014. Entry 3.> 62M died.
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  visayanbraindoctor: 17 October 2014. Entry 1. <14 October 2014. Entry 1. In the evening I answered a referral in PrH 2 ER, 17M, a backrider who fell off a motorcycle in a neighboring province.> 17M died of pneumonia and sepsis.
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  visayanbraindoctor: 21 October 2014. Entry 1. Another MF victim from a neighboring province, 34M is from a northern island (of the Bicolano ethnic people) and had no immediate family members around. He was brought to PrH2 ER by co-workers who claimed he was on duty. This means that his company would pay for him (I hope). I had to do an emergency tracheostomy on him in the ER under LA because he had aspirated his own vomitus (typical of comatose head-injured or stroke patients).
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  visayanbraindoctor: 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.
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  visayanbraindoctor: 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.

Entry 2. <21 October 2014. Entry 1. Another MF victim from a neighboring province, 34M is from a northern island (of the Bicolano ethnic people) and had no immediate family members around. He was brought to PrH2 ER by co-workers who claimed he was on duty. This means that his company would pay for him (I hope). I had to do an emergency tracheostomy on him in the ER under LA> In the afternoon, I did a craniectomy on 34M’s open depressed right frontal bone, evacuating an underlying 40cc intracerebral contusion-hematoma. I also repaired the dural laceration caused by the depressed bone, through which CSF was leaking into his nose, by flapping over perisoteum and suturing it around the hole. His problem post-op would be aspiration pneumonia, but he is still young and may well survive.

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.

Oct-25-14  GreenLantern: <visayanbraindoctor: 4 October 2014. 23F, whom I operated on way back on 25 August suddenly died.>

I'm sad to hear this - I was following her case.

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  Annie K.: Doc, great to see your forum back, and thank you for filling in the interval!

Catching up with all these stories, all at once, certainly impresses both just how severe brain injuries are, how difficult it is to try to save the victims... and how great a difference you *can* make, even if much still depends on the patient's prior lifestyle/condition (alcoholism, obesity, etc.), funding for equipment and medication, and various kinds of luck. But without doctors like you, they never would have had a chance at all.

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