The Give

It often seems like each rotation has something essential about it, and that essence often echoes the themes of my life (or vice versa - this is a chicken or egg situation, of course). For example, while I was on orthopedics, every day I saw desperate patients begging for (and often promised) a solution to their pain. In my life, I seemed to be making all sorts of rather desperate hail mary gestures (there is an entry in here somewhere, I promise). Now that I am on neurology, I am watching people deal with breathtaking loss of physical functions; my life this last month has been filled with a wide range of witnessed and experienced loss of people, ideas, expectations, and places.

What amazes me is that no matter the source of the loss, the outcomes all seem to converge. It appears that loss in any form distills the world down to something very small. Like someone who has suffered a stroke, an emotional or external loss leaves one childlike. Someone coping with loss moves from moment to moment (for how can you think beyond that?) and, similar to the recovering stroke patient, even the most fundamental activities become a challenge. Eating, drinking, moving, speaking, sleeping can be so difficult that they essentially have to be relearned. Sometimes it takes all the effort and concentration one has just to breathe - and there is nothing more basic than that. And those who lose are completely dependent on those around them to hold them, feed them, remind them to breathe until those activities are relearned. Loss, then, is so transformative that it serves as a sort of rebirth (although it's a rebirth partially mocks our fantasy of wiping the slate clean).

But it's only a partial mockery of the clean slate fantasy, since the loss of something familiar (and it has to be familiar, for we cannot lose something we did not know) results in at least the hope of pursuing the aspirations and dreams that were blocked from fulfilling before. "I will do this because I was never able to do this with them around/that plan in place." It's a partial mockery because the slate is not clean - it is not simply a free space, but an actual vacuum created by the loss. In other words, what was once there defines the "clean" slate. The decisions that follow in response to loss are wholly created and shaped by the loss itself. And in stroke patients, the parameters for how they relearn walking, talking, reading, eating are set by the nature of the functions they lost.

The Take

Strokes are not subtle events. They happen with a vengence. The onset comes with little warning. The symptoms may begin quietly, but they quickly crescendo until they reach an intensity impossible to ignore. Strokes rip away functions so fundamental that they only becomes visible in their absence. They are wholly changing events. The climatological equivalent of a stroke would be a tornado - they develop unexpectedly and cause focused destruction - leaving one thing intact while destroying something else. One day your house was there - strong, sturdy, filled with many years of improvements and memories. You knew how to skip each creaking step and where to leave the faucet handle so that the water temperature was perfect. The next day, your house is gone. Strokes are similar. One day you could walk, shake hands with a stranger, smile at a child, tell your partner you love them. The next day, you can't. And just like in a tornado, where your house is destroyed and your neighbor's is fine, a stroke doesn't take away everything. Instead, it picks and choses - so your right leg may be fine, but your right arm is unusable. You may talk, but you might not understand anything. You may understand everything, but not be able to speak intelligibly. Walking might be easy, but seeing difficult.

The recovery from a stroke thrusts adult patients into the role of a child. Like a young baby, they are forced to rely on those more capable for help with daily living. And like an infant, they must (re)learn how to do things. They have to take a first step, form their first words, eat their first solid foods, read their first book. It perverts the desire to be childlike in one's approach to life - for these patients are not childlike in mind, but rather are forced to depend like a child and learn the tasks of a child with the understanding of an adult.

May you Live in Interesting Times

I'm fairly certain Neurlogy is not for me. It is, as my attending declares, a field of nerds. And while I indulge myself with the label of nerd, he is referring to a very specific brand of nerds who are meticulous in their pursuit of the diagnosis. It is not just the highly specific diagnosis that they enjoy, they also love the pattern used to acquire that diagnosis. The art of physical pursuit is exemplified in neurology. The science of futility is also exemplified by neurology. While the diagnoses are specific and intricate, it is rare that something can be done to treat the condition (prevention of progression they can do, treatments of symptoms they can sort of do, but curing the disorder - rarely achievable). Neurologists define the label "academic," (as in he practices a very academic form of medicine).

The patient interview usually involves the doctor asking some questions and the patient answering them. The doctor nods his head, the patient looks concerned. The doctor then turns to me, says about 20 words, only 15 of which I understand (only 5 of them are comprehensible to the patient, and those are: the, it, but, because, and patient). He then proceeds to nod a bit more, perhaps ask me an unanswerable question, tell an unrelated story about Chamberlain and the Battle of Gettysburg, and then say:
"Isn't this an interesting case. You know, the Chinese have a curse. . 'may you live in interesting times.' The medical equivalent of this is 'may you be an interesting patient.' Man, you never want to be interesting to medical students. Nope."

He then turns back to the patient (who is looking confused, concerned, and petrified) and says, "there's just not that much we can do for you," maybe writes a prescription for some medicine that may or may not relieve symptoms, and wishes the patient a good day.

OR, my other favorite patient interaction is by the bedside:
Imagine a patient, recovering from a very severe stroke, who can barely move the right side of her body, is confused about where she is, and can't get her words out very well.
Dr: "Wow. .you are doing much better than your MRI would lead us to believe."
P: Mmdfnek kitten throws?
Dr: Hmm. . well, really, believe you me, you are doing great. . Just great. I mean, you can move your arm on the right side. . that's just amazing. Yes, I would expect you to have some difficulty talking, but really, you are just doing awesome.
P: Mdhadfk group trial of words?
Dr: Ok, well. . we'll be back to check on you tomorrow. Have a great day. . I'm really quite impressed.

And that's about it.
In fairness to the doctors. . these are certainly exaggerated stories. There are many wonderful things that Neurologists do (seizure control, headache management, peripheral neuropathy management, MS treatment, etc - the list is endless). Their physical exam is a beautiful thing. And they do a good job of delivering (continually) bad news - they do it day in and day out, and they are better at it than most doctors.

So that's a bit of neuro. May you never have to see a neurologist.