Strokes, brains, and the mysterious part of medicine

Other than the occasional bad day (see last post), Neurology is really interesting. It’s the study of the brain and spinal cord. The brain has always been so mysterious to me. I was excited when we started our neuro class in 2nd year… Then disappointed when I realized the more I learned, the less I knew since it’s such a vast field. After 4 weeks of perfecting my neurological exam and seeing patients with a gamut of neurological deficits, I can say the brain is even more mysterious to me than before!

For starters, my doctor was the stroke director at the hospital, meaning she saw most of the stroke victims and was often on “stroke call”… On top of seeing patients in her private clinic. “Stroke call” is being on call when someone comes to the emergency room with stroke-like symptoms & the doctor has 10 minutes to see and evaluate them. This made for interesting, fast-paced days when we were seeing patients in the clinic & had to somehow get over to the ER in 10 minutes to evaluate a stroke victim! In her clinic, we saw migraines, seizures, and a gamut of other neuro defects.

Outside of being a super effective and likable doctor, my attending was amazing. She is doing research to have a neurological sign named after her. She was full of life advice and short one-liners that I will carry with me as I start my career. Some examples: “physicians kids are a rare breed. You have to give them good INFLUENCE, because they’re born into a world of AFFLEUNCE.” “I have no patience for rude patients. If you want to see me, you need to grow up and learn some respect.” “If you aren’t right yourself, you aren’t gonna be right as a physician. You can’t take care of other people if you don’t first care for yourself.” “Always remember the Good Lord has your best interests in mind, even if they don’t make sense to you at the time.” “Sometimes you’ve just gotta cry it out. It’s ok to be human. Show those emotions.”

Some of the coolest cases I saw: amarosis fugax, which is when there’s a blood clot in one of the arteries going to the eye. When we learned about this condition in med school, the key symptom was that patients would say it “felt like a shade was being pulled down over their eyes”. Imagine my surprise when a patient used those EXACT words to describe his symptoms! It was fascinating. I also got to see a patient with trigeminal neuralgia, a neurologic defect of one of the nerves in the face, where the slightest touch like a hair or the wind blowing would send electric, searing pain across the patient’s face. I got to see thrombectomies for stroke treatment, where they go in through your groin blood vessels & up to your brain & pull the blood clot out. It is an incredible life-saving procedure. I saw patients with encephalopathy (brain infection) due to mosquito bites & viral infections. We also got to do electromyograms, which test the time it takes for a nerve stimulus to cause a muscle to fire. If you have bad nerves (due to diabetes or another neuro disorder) the time it takes the nerve to “talk” to the muscle is longer. It is a really simple test to check for a potentially serious disease process. I got to see a heartbreaking case of a patient with Parkinsonism due to agent orange exposure years ago. I saw a woman with an abscess (bacteria accumulation) around her spinal cord, causing paralysis and sensory deficits at a certain level. My doctor even quizzed me to see if I could guess where the abscess was based on where the woman could feel my touch and where she went numb. I saw a woman as pregnant as I am who had a frontal cavernous malformation, which is a deformity In a collection of thin veins in your head. This deformity made it dangerous for her to have high blood pressure or to have a natural vaginal delivery- the increased pressure could cause the thin veins in her head to burst. I also saw a case of hemiballismus as the presenting sign of a stroke. My doctor had only seen 4 in more than 40 years of practice! Hemiballismus is where the patient has no control over an extremity and that extremity thrashes about uncontrollably. We were able to treat the patient & watched her regain control steadily. It was really interesting how these conditions that used to be deadly can now be medically managed safely!

Some touching stories I encountered…
We had a 50-something year old man who had a middle cerebral artery stroke. He developed swelling in his brain which we were luckily able to manage with medication instead of having to open his skull to accommodate the swelling. The heartbreaking part was that he was so young. His parents came to visit every day & reported that of everyone in his family, he had been the healthiest. He followed a strict low fat low salt diet. He exercised daily. He was up to date on all of his health maintenance exams. And after treating his stroke & swelling he wasn’t improving. We had to transfer him to a rehab center & hope for the best. He still couldn’t move half of his body and was unaware of where he was or what was wrong. It was awful.

Another case was a woman in her 80’s. She had recently gotten married to a childhood crush after they had both been widowed. They were adorable. She had the same stroke as the man above, but improved remarkably better than any of us had hoped. The second day we saw her, we were unsure if she could understand us because she wasn’t responding to our questions… Then her new husband walked in and said, “hi honey!” Her eyes brightened up and she gave us the biggest, most proportional smile ever (important in people who have had a stroke! No facial droop!). My doctor & I both teared up. It was so amazing to see, especially since we weren’t sure she was “all there.”

For every touching story, we had a crazy story. I understand patients who want to abuse pain pills or drugs or alcohol- but patients who come to the ER faking a stroke do not make sense to me. The drugs we give to treat are basically just blood thinners… Nothing exciting at all. But we had multiple patients whose “stroke” symptoms wouldn’t match the distribution of the brain’s vessels. For example, one lady was holding a newspaper up with 2 hands… When we walked in, she immediately dropped one arm to act like it was paralyzed. We also had a guy holding his arm to his chest as if it was paralyzed and when we distracted him by telling him to raise his leg, his arm magically regained function. My doctor said aloud during one of these exams that the patient scores a 10 on the CAF scale. The nurse wrote it down & asked us afterwards what CAF stood for… My doctor busted out laughing & said “crazy as f!” Haha!!

It was nothing short of an interesting and challenging month. I will not soon forget my incredible experiences with the patients I had the privilege to see & the physician who invested in one of my last months of medical school education!

In the words of Oliver Sacks, “If a man has lost a leg or an eye, he knows he has lost a leg or an eye; but if he has lost a self—himself—he cannot know it, because he is no longer there to know it.”

How fascinating the brain can be!

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Crying in the Bathroom

Sometimes medicine sucks. And sometimes it’s on your birthday. I was having a wonderful day, complete with fake mimosas and flowers and homemade breakfast sandwiches from my hubby. I got a free coffee from my favorite place on my way to the hospital. My phone was blowing up with well wishes and happy messages.

Then I had to see our 65 year old patient.

He came in last week with stroke like symptoms, but brain scans showed a mass. It appeared to be a Glioblastoma multiforme, aka the most deadly and swift of brain cancers. He and his family were in denial, and who could blame them? He was young and healthy and hadn’t had any symptoms prior to this. Over the weekend, he had a biopsy taken of the mass which proved our worst fears… And yesterday, he realized what his condition meant. He was sobbing as we explained the options to him, and he kept repeating “take care of my sons”. I was blinking at the ceiling trying not to cry, but when I looked at my doctor, my strong, independent, intimidating, straightforward, no-bulls**t doctor, she was crying. I immediately excused myself to go to the restroom… And proceeded to cry alone in the bathroom.

I wish as physicians people allowed us to feel. Everyone wants their physician to be perfect- able to diagnose, answer any question you might have, be the strong one in the situation while somehow remaining empathetic and sensitive, but not TOO sensitive… It’s extremely difficult to live up to the high expectations society, and honestly we ourselves, hold us to. Luckily I have some amazing family and friends that are able to lift my spirits when times get tough. I also think it’s really, really cool to be held to such a high standard and to meet or even exceed it. It’s such an amazing field to be in and it’s such a privilege to be part of peoples’ most intimate and vulnerable life moment. I honestly can’t believe I’ll be a physician in 2 short months!

*note: patient age and other identifying information has been edited to protect patient identity!

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