October 1^st, 2007

I can only say with no exaggeration that I finally saw the height of lunacy in Ward 4, the terminal ward for patients who do not respond to sustained drug treatment, are homeless and have nowhere to do, show recurrent relapses,etc. Interestingly, the main entrance to the entire facility has a sign that says "you are entering a family-friendly facility" -- hardly the case, unless you count passing drugs among visiting family members as such.

After waiting for an hour or so staring at the felon mug-shot wall, the security officers finally managed to explain to me (after discussion amongst themselves) that the call button would track my location even if I were to take off running through the complex, but I should nonetheless test the button since they've had problems in the past (my preceptor K attests to this) of not finding a person. Apparently, the time to rescue is also dependent on the distance between you and the security office on the ground floor of the main building. K is a five-foot Korean with the stature of a frail teenager; how he manages to persist in the wards despite being knocked senseless by a manic patient a few years ago is beyond me.

The patients fall into two varieties: those who insist on speaking with you all the time and those who avoid you and everyone else, all the time. The situation makes for a great merry-go-around, where K and I would pursue one mute, depressed patient down the hallway, only to be pursued by a talkative bipolar patient behind us. Incidentally, the said patient also thinks that we're under German law, and that no Jew is to come here. Insert other screaming patients that cut in front of your path periodically, and there you have it. I can't say that I particularly like the stench of unwashed people, but I very much admire the short Korean.

October 15^th, 2007

In his claustrophobic office today, K started me with a 20min lecture on schizophrenia, bipolar disorder, and drugs to treat each before starting the rounds. Using an extremely even tone, so different from the resounding screams and hysterical laughs in the background, he tells me "these patients aren't getting out" as though in afterthought.

I started the interviews with an innocuous 84 yr male who by all criteria looked your average absent-minded, slightly foul-smelling geriatric patient. It turns out that he served in WWII in Normandy, and so is characteristically full of war stories with occasional interruptions on how poorly the country is run. Mild memory lapse, slight delusions, has two daughters, spent time in Riker's island...er wait..

Evidently, he committed first degree murder in a mall shooting spree after returning from the front; was found guilty of weapon possession a few years later; was found guilty of assault at the age of 81 in which he, having been released from 25+ years in jail, repeatedly hit a neighbor on the head with a metal pole while under the delusion that she was responsible for his dwindling bank account. He looked so harmless!

And all throughout the interview, K and I heard footsteps pacing manically outside the interview room -- the sort where the shoe and part of the trousers drag on the floor -- that shuttled back and forth past the hour. I am most impressed with compulsive patients.
me: "So, what do you want to do once you get out of here?"
pt: "I want to be a psychologist!"

October 22^nd, 2007

Psychologist: M.G. is experiencing delusions in which she believes everyone is trying to poison her through any means possible. She adamantly refuses to take oral anti-psychotic medications and so receives intramuscular injections three times a day.

Me: That sounds incredibly painful; have you tried simply blending the drugs in her food and so have her take it that way?
Psychologist: (pause).. that would reinforce her delusions, now _wouldn't_ it?
Me:. But wouldn't that make her _sane_, if her suspicions turned out to be true?

November 5^th, 2007

Having been on Ward 4 three times in the past, I've learned not to appear too surprised upon seeing the Chronically Manic Pacer and the Perennial Screamer roam the halls, but this time the man lying prostrate on the floor seemed a bit too strange...

[The script has been carefully calculated to require a cast of two
geriatric patients, one intern, and a piano player]

<<>>
ME: " Sir, why are you on the floor, blocking the hallways? "
WC: " Because the Voices tell me that I'm an invalid, and so I can't get up. "

<<>>
ME: " So how have you been since I saw you last? "
JG: " Well I haven't been sleeping well, They tell me to do things at
2am, 3am, telling me to do things ... "
ME: " What sorts of people have been talking to you? "
JG: " My admirers of course, and my daughter sometimes, but she's been
very quiet lately... she's a cripple you see ... a cripple buried in
the grave. She doesn't come to visit me very often. But I tell you,
my daughter still talks to me using her Wills...she and a few other
people can get inside your head and make you do things and see
things... "
ME: " What exactly does she say when she makes contact? "
JG: " She tells me that she's uncomfortable because her foot is tied
to something, something like _chains_ that tie her down to the grave,
and I told her that it's God's punishment for her leading such a
_wild_ life, and that I pray for God to release her. "
ME: " Do you think it's fair punishment?"
JG: " O I think it's not too bad, I didn't hear anything from her so
she must not be in so much pain."
ME: " Tell me more about the 'Wills', what do they do? "
JG: ..mutters " What's that? Her? " " They're telling me
not to say too much to you "


<<>>

ME: "Sir, I thought you were paralyzed from the waist down, how is it
that you're walking about, trying to push past the guard door?
WC: "Who told you I'm paralyzed? Are you _crazy_?"

November 20^th, 2007

-- "But I was under the impression that most people failed at suicides
for lack of will and dedication"
-- [heh] [heh] "There's an inherent bias there: those who live to
_talk_ about these incidents did not proceed onward."

Ward 5 is the inpatient adult male ward that I did not find too palatable after the third address of "Miss miss, will you find me a girlfriend" from Mr. Raspy Voice. And Chronic Pacer Jr. was entertaining in that he muttered rap music as he cycled through the corridors in a manner very similar to that of his geriatric counterpart, but it was clear upon following him for ten minutes or so that his left-right turns were interestingly stochastic in nature instead of the usual right-turn only routine.

Decidedly sad for sure, but not nearly as so compared to Dr. S himself (the attending) whose office is a poorly converted bathroom. I walked into what looked like a 1960s-era dingy WC with a minimalist sink, shower stall, tampon dispenser, and tiled seating area -- ordinary to
be sure, if it weren't for the fact that his desk was lodged between the shower and the door, that one of his guest seats was in the shower stall _itself_, and that his coat hanged on the wall hook over the toilet seat. Nevertheless, I was quite impressed with his impassive nature when confronted with loud bangs on the door coming from a middle-aged patient with severe obsessive compulsive disorder. "Surely you don't want to interview _him_, Lilly"

In contending with his obsession and paranoia, the patient verbally lists numbers, dates, and historical events in a triumphant display of cognitive computational power that effectively silenced me for a good five minutes. But as often is the case with these patients, he invariably cannot not hold a conversation for longer than a few seconds. He is also under the delusion that his depraved rapist father (now deceased) regularly makes ghostly visits to him during the night, clearly agitating him to the point where he is very unintelligible in speech and flailing in motion. His medication levels are well above FDA-approved standards, but evidently to little avail, since he later stopped answering my questions altogether and took to counting his money feverishly instead.

December 5^th, 2007

Holidays are particularly terrible in the wards this time of the year -- the familiarity of the season tends to trigger a resurfacing of memories associated with their previous lives, which in turn agitate them to the point where many needed fast-acting, intramuscular injections. I recall one lady who stood at the office door chanting "I just want to go home, to go home, I JUST WANT to go HOME, HOME, home..." for a good five minutes, which rendered me unable to respond.

I am reminded of Thomas Mann's <> that describes a sanatorium in the Swiss Alps in which patients with all sorts of disease remain during the course of their recovery. The shortest unit of time there is measured in months, because the established daily routine and the associated tasks fill up the time, leaving them with little opportunity to consider that which they are missing. Mann does a much better rendering: "He would sit there propped up against his pillows, and gaze out into the quickly falling dusk -- today's dusk, which was hardly distinguishable from yesterdays. The day, chopped into little pieces by all these synthetic diversions, had in fact crumbled in his hands, and turned to dust -- and he would notice it
now, either in cheerful amazement or, at worst, with a little pensiveness..." Quite beautiful.

December 11^th, 2007

Here is an interesting case of graphomania. Aside from the usual hubbub of chatting with the schizophrenic and bipolar denizens, I met a newly admitted patient I call Grace who presented with a strange compulsive writing disorder -- the sort that would have made any WHO bureaucrat proud -- as part of a larger spectrum of paranoid and delusional disorders. Curiously, she writes daily memos to K, the two social workers, and the nursing staff withnospacesbetweenherwords in which she details anything that comes to mind, opening with the line "I entered an alternate universe where my comments were treated as those spoken from a mentally ill person, not to be taken seriously." Compared to the uncontrolled babbling of the mentally retarded patient sitting next to her, Grace is unusually, and sadly, very intelligent.

3:45pm Grace refused to talk to me, and positioned herself on a writing table in the far end of the common room with her back everyone else, and proceeded to stare into her lap.
3:50pm Grace still stared.
3:55pm I looked at the empty report in my hands and realized that she alone stood in the way between me and the exit.
3:56pm Tried one more time to get her to speak to me by devising the following plan: I did my best impression of a super-secret high school note-pass by slipping her my scribble: "Hi, my name is Lilly, what's yours?"
....
4:05pm Grace apparently worked as an executive assistant in Insignia, which explained why all her memos strictly followed the standard format of From: To: Date: and RE: headings. Since her admission in April to Bronx State proper, she has filled eight volumes of writing, the first six of which she plans to publish on the internet. She also showed me her current entry titled "A Harlem Real Estate Story", intended to draw attention to the crippling real estate price rise in the area and the general state of affairs of the NYC housing market. Sometime around 4:30pm, I left.

January 7^th, 2008

"No, I didn't hear any voices these past few days because they were on holiday."

Ward 4 had a change of clientele since I was last there three weeks ago, but Graphomaniac still remained right where I left her -- by the desk in the far side of the room, hunched over the desk in deep thought with her back to a room full of generally quarrelsome patients. Thanks to state mandates to reduce mental health costs, the criteria for discharge have become progressively lenient so that even the Graphomaniac, with her paranoia and compulsion, can be released into group housings or nursing homes, but curiously she refused to leave. By her logic, she does not want to be discharged until she's proven not crazy...

It's not quite a simple matter of writing "You're Completely Mentally Well", since upon discharge the attending still takes full responsibility should something grave happen to Graphomaniac, and hence cannot conscientiously do so given her current spectrum of problems. But perhaps it would suffice to receive something that resembles an official report (she is a careful reader of all memos, after all), with the fine print "VOID" in pale blue, size 6 font. Perhaps nothing quite so insidious.

January 21^st, 2008

I met my first indisputable case of a Capgras Syndrome patient who I will call Astronaut. As a paranoid schizophrenic with grandiose delusions, she tells me that she has earned 44 Ph.D.s (don't we all) in psychology, sociology, communications, literature, and other disciplines during her 60 years of life. And somewhere between that and having a family, she also started a side-career as a nurse so that "the idea of helping others would spread like cancer".

And after having just stored away all her diplomas, she has been tapped by NASA to do a reconnaissance of space using Astronaut's expert intelligence in human knowledge, to which she replied with a resounding "yes" and has been servicing her spaceship every since. While in outer space, Astronaut tries to inject herself into what she calls Earth Mother, a primordial reservoir of material for populating New Planet Earth -- an entity apart from our world, undetectable by any conventional instruments. In her mind, New Planet Earth is consecrated as an utopia of sorts without the clutter of our earthly troubles.

I asked her what she does while alone in space. And she replied "I am there to study the effects of silence."

I don't know enough about psychology to offer anything beyond this conclusion: that having compensated her real-life inadequacies through delusional constructions to a degree that alienates her from the supposedly less capable earthly beings, she has in essence severed the avenues by which she derives meaning and use for all she knows. Knowledge in utter isolation accomplishes much less than what it is capable in collectivity. She returned to her seat after the
interview, and sat alone in silence.

February 3^rd, 2008

The premiere example that moralists like to use to illustrate the problem of choice is the Seven Eleven nightshift clerk at risk of robbery. Imagine that you, as the clerk, have keys to the safe and are held at gunpoint by a robber who demands that you open it. You have the choice of either opening the safe, in which case the robber may spare you but you lose the money, or of not opening the safe, in which case the robber may shoot you and then open it himself anyway. Compare this set of grim outcomes to a scenario where the clerk does not have access to the safe, and therefore is not presented with the decision to open it. Word may not get around to the robber cohort immediately, but in the long run they will come to learn, through the robber networks, that Seven Eleven clerks do not have keys to the safe and therefore are poor targets for quick cash. As a result, clerks without access are safer.

Once a choice is presented, one is no longer in the position to remain neutral, even though one's actions may not appear to have changed. In the first scenario, the clerk who was merely scanning items and standing nowhere near the safe before the robber appeared (call it state A) is obligated to make a choice between going about as he was at gunpoint (state B) or opening the safe (state C). In contrast, the clerk without access remains at state A because, for the purpose of
example, the incidence of robbery has fallen off appreciably. The first clerk may maximize his utility by choosing B and rejecting C, or choosing C and rejecting B, but he will never match the level of wellbeing at A, even though A and B superficially involve the same action – going about as they were.

For this reason, patients often do not want to be presented with a decision, especially for elective or experimental interventions. Contrary to all the indicators on rising health care consumerism and patient autonomy, most people subliminally find choice unsettling. When confronted with a decision of, say, using radiation therapy as post-operative care for breast cancer surgery, the patient invariably moves from state A (not having to make any decisions) to either do nothing, or undergo radiation. In doing nothing, the patient bears the weight of responsibility in knowing that a relapse will be a consequence of her poor judgment; in agreeing to therapy, she likewise is to blame should side effects perchance make her condition worse off. No one is claiming that radiation therapy is detrimental in its own right at all tines, but the uncertainty is sufficient to trigger anxiety and, therefore, reluctance in making the choice.

When doctors say "take this slip with you to radiology" instead of "let's explore radiation as a possible measure," he is sparing the patient the responsibility of making the decision because, from the perspective of the patient, any negative consequence that arises from the course of action can be attributed to someone else. Experiencing a relapse of breast cancer after following the doctor's orders to do nothing can be traumatizing, but the other scenario – suffering a relapse after having consciously decided yourself to not undergo radiation – can be even worse.

It is perfectly understandable for patients to occasionally partake in this outsourcing of responsibility, but there is danger in a persistent exercise of this habit because they may become crippled in their decision-making ability as rational individuals. Nowhere is the extreme of this problem more visible than in the psych wards, where patients completely forfeit responsibility of their well-being to the attending physician. The greater visibility of mental illnesses in modern times, in particular those associated with chronic depression, may have arisen out of this abdication of responsibility that, in the long run, takes away from the patient their own ability to persist in times of trouble. In an alternative setting where Prozac did not infiltrate the drug cabinets of America with such ease, perhaps those suffering from depression would have looked within themselves for a solution and gambled to take on the possible consequences, rather than
to a bottle of pill. And perhaps in the course of doing so, they would have regained the dignity that was lost in disease, and avoided succumbing to the cascade of ever-increasing drug dosages and pill varieties.

February 12^th, 2008

I had decided to switch to the adolescent psychiatric wards in the remainder of my time there, and felt such a reprieve from my usual selection of schizophrenics and bipolar patients. Apart from the more uplifting architectural design -- the children's wards are newly constructed and smelled wonderfully of antiseptics -- there was a prevailing notion that these children will not remain forever in the wards.

That is not to say, however, that they're not deeply troubled. My first patient has been hospitalized for a year after having been brought in on account that she, a physically and sexually abused seven year old, tried to suffocate her brother and injure him with a knife. I had thought it would be difficult to distinguish between a normal girl -- one who speaks of imaginary friends who join for tea -- and a girl who has hallucinations, or between normal hyperactive boys and those manically so, but the difference is startling after only two minutes of speaking to my patient. As though commenting on the color of her hair ribbons, she said "I had my hammer and I wanted to kill my brother."

My second patient, a 17 yr old male, suffered from extreme paranoia to the point where he would chain his front door to the post, block his bedroom door with furniture, placing various weapons around the house, etc. all to protect himself against what he thought were house intruders bent to kill him. He even took the trouble of planting soap bars across the entrance of the front door so that the killers would skid and fall splayed across the floor. "It's like that scene in Home Alone," he said, "I felt just like that little kid, but much worse." His paranoia is under control at 500mg of Clozapine, an acute anti-psychotic, but not at 450mg. Nevertheless, he's due for release into an adult rehab center so that he may begin to lead a more normal life.

February 15^th, 2008

When conducting a mental status exam it is standard practice to begin with a patient's orientation to time and place, which serves as a tremendously informative indicator on the severity of illness, and directs a subsequent series of questions on mood, affect, and thought processes. So in response to my asking "what year do you think it is", something is clearly amiss if a patient blurts out 1950 or 3050 AD. But others are off by two years, possibly five, or perhaps even ten -- in such situations, I wonder whether one should attribute the disorientation to mental illness, or to a tenuous hold on the passage of time that can afflict even normal individuals if they were subjected to the daily routine of the institutionalized.

It is apparent that patients on Ward 4 keep time differently; they each cycle according to a particular unit of time. For instance, a conspicuous elderly man with a frontal lobe lobotomy paces the entire expanse of hallways -- taking the appropriate turns here and there -- that brings him back to the start within ten minutes, after which he begins the cycle anew. Grace, a bipolar patient with a writing compulsion, has written daily memos unfailingly since her arrival, incrementing her volumes at a steady pace of a few pages each day. Ms. Green, a paranoid schizophrenic, measures the passage of time in units of weeks in anticipation of our weekly interviews. Still others are aware of the changing seasons that add yet another year to their stay. But what's common to all patients is the repetition: their own constructed cycles, combined with the external regimen of meals, medications, and social activities, distract them from the monotony that would otherwise painfully prolong their stay.

It is said that monotony dilates a moment and, at the same time, compresses the years until they seem nothing at all for lack of substance. Many of the institutionalized have created a repetitive
"doing" in defense against this monotony, but to what degree of success? Although busy on the order of days, time measured in years still manages to escape them without notice because nothing of novelty has happened. To say that "I walked 500 complete rounds on the Ward 4 hallways on January 10th, 1998" or "I wrote a memo on February 1st, 2007" does not distinguish those particular experiences from any of the identical others. The years blend as a result, and many lose track of their passage.

I am reminded of Thomas Mann's words: "Emptiness and monotony may stretch a moment ...but they can likewise abbreviate and dissolve large, indeed, the largest units of time. Conversely, rich and interesting events are capable of filling time, until hours, even days, are shortened and speed past on wings; whereas on a larger scale, interest lends the passage of time breadth, solidity, and weight, so that the years rich in events pass much more slowly than do paltry, bare, featherweight years that are blown before the wind..." The instinctual defense against monotony has, for some patients, shortened their days, but offers no solution for the years that are gone.

March 10^th, 2008

I once met a schizophrenic patient whose only remarkable symptom was hearing a calming voice that said 'Everything's going to be okay.' -- Cimino.

I and a few other first years were sitting in a conference room, recounting stories that we've accumulated after making rounds in the psych wards this term. One girl mentioned an otherwise normal patient who hears voices from family members who he, as a single male, has never had. The protocol to treat auditory hallucinations is no different from that for any other schizophrenic, but in this case I wonder if it's ethical to eliminate the voices with drugs when the voices are a comfort to the patient and pose no threat to others.

The issue involves how we decide what is beneficial for patients in a specialty that is prone to, and historically infamous for, encroaching upon patient rights under the guise of caring for those who are supposedly unable to make independent judgments. I am reminded of my own patient, one who thinks she's a 30-something red-head when she's in fact close to 90, who is always boisterously happy on the ward for having entertained herself with grandiose plans for the future, and I wonder whether we shouldn't ease her off medication and simply marvel at the resilience of the human mind to be happy under such grim circumstances. Her symptoms can be categorized under "grandiose delusions," but perhaps just as easily under "rigor and life in old age".

---
In the five months that I've been on Ward 4, no patient recovered to a degree where he or she could be discharged based on sound psychiatric evaluations. Of the few that nonetheless left under administrative pressure to reduce patient count, one died and the whereabouts of another is unknown.

March 16^th, 2008

At the conclusion of the last interview with my boisterously happy schizophrenic patient, she said to me in an uncharacteristically reflective tone: "I've certainly become more aware of you." It seemed as though she was momentarily pulled back from her set of grandiose delusions – that she is a red-headed 30 year-old when she is in fact 90; that she routinely communicates with her daughter who is chained inside a grave for lack of restraint in childhood; that the risen form of her daughter will take her home, at which point she will begin a writing career; that she receives billions of dollars every day; and, perhaps most incredulous of all, that she will one day be a psychiatrist.

I considered whether her anti-psychotic drugs were appropriately given to rid her symptoms when she appears to be so happy in entertaining ideas that remove her from the grim reality of a state institution. After all, her symptoms can be categorized under "delusion," but perhaps just as easily under "creativity" borne from resilience of a human mind able to create a world apart from that in which we live – a dreamworld of sorts in an exercise of solipsism to defend the mind against darker thoughts. If so, are we justified in obliterating these dreamworlds merely because they do not correspond to our collective definition of reality? And why do we feel the urge to include her in our world?

This is the classic philosophical debate between the Modernists, most notably Descartes and Bacon, and the Ancients like Socrates and Plato, over the question of origin of an individual's world. Descartes asserts that all originated from the conception of Self, that the Self exists apart from, and is unbounded by, the circumstances which gave rise to the individual. The mind is its own place; it can create infinity out of thin air by mere thinking, and this thinking in turn defines existence. The Ancients, on the other hand, do not entertain this notion of creating something out of nothing because the Greek world is bounded. To them, man is limited by his history and
environment because there is danger in the capricious excess that forms the basis of so many Greek allegories. Under this framework, my patient is living the Cartesian dream whereas the rest of us remain on the bounded world.

April 24^th, 2008

Somewhat weary of flagrantly psychotic patients, and eager to see those still with problems in their head, I started rounds on the neurology wards with a feisty attending half my size.

The first patient had a bulbar lesion in the pons which affected his limbic system in such a way that the slightest mention of anything remotely related to emotion will trigger massive, hysteric sobbing episodes. So in response to my question "where do you work?", he erupted in a fitful cry. To "how is your daughter doing," the same reaction, even though his daughter is doing just fine. This is a type of neurological diagnosis that does not require extensive testing
beyond speaking to the patient. That, or I have such an effect on him as a conversation partner.

The second patient was a morbidly obese woman who presented with falling episodes despite her extensive (20+ drug) regimen. Upon her request to decrease the amount of medication, the attending curiously discovered that three of them were psychiatric drugs for which there were no indications. That is, there was no cause for prescription. I would like to think the better of her referring doctor in that the patient's symptoms were in remission because of her being on the drugs, not that drugs were wantonly prescribed by a drug-happy primary care physician.

I thought we would do very little for the catatonic third patient, but was surprised to learn that even still, there are neurological exams to be performed. To gauge responsiveness, one could use a feather to tickle the nostrils, for which you hope to see an arm swat, or one could opt for a nipple twist, which I immediately decided I would never, ever do.

Another attending then gave me a tutorial on how to read EEGs that measure brainwave activity, and I gave him an impression of how little I knew by asking if the various flatlines in all the head-leads were due to detectors falling off the patient's head. Regrettably no – the flatlines were in fact a brief suppression of neurological activity immediately preceding an epilepsy episode, which is characterized by large peaks and dips darting up and down the page as though they're roller-coaster rides. I always appreciate an exercise in humility

June 15^th, 2008

Apart from learning how to read EEGs and working on the clinical research project that provides the opportunity to do so in the first place (NB indentured servitude), I did manage to see a few patients in the neurology outpatient clinic who looked shockingly normal to me. This is reason for concern -- perhaps starting in the psych wards has desensitized me towards patients who seem utterly normal when they, in fact, genuinely require medical attention.

I saw an otherwise unremarkable woman with a pituitary adenoma who underwent a gamma knife surgery -- a highly precise, non-invasive neurosurgery technique able to target lesions at the intersection of ~200 gamma beams. It requires only an overnight hospital stay and avoids the usual problems of opening someone's cranium. All was well until she later crashed her car and developed petit-mal seizures -- the sort where one would remain unresponsive to external stimuli for seconds or even minutes, often with no recollection of the episode after recovery.

Her husband noted, not without alarm, that she would pause mid-chew during dinner, remain in her spell for twenty seconds or so, and reemerge as though the time did not elapse. I wonder if she notices clock hands that inexplicably jump on occasion, or kitchen-top timers that skip entire blocks of time (often seen in TV cooking programs). I also wonder if her kids make use of
the wonderful opportunity to take the last meatball without her notice.

Ten seconds at the dinner table is fairly innocuous, but ten seconds on the road can mean not noticing the highway exit, the red traffic light, the tree, etc. This is good reason to bar epilepsy patients from driving. I can't say that the patient left with a more definitive treatment plan, but at the very least, she was amused by the series of neurological exams that asked her to do everything short of a chicken dance.

June 20^th, 2008

After a week on the neuro consultation, I speculate that it is often the people who carry the most instruments who have the least obligation to perform invasive procedures, perhaps out of a subliminal desire to compensate. That is, neurologists are often seen carrying around a sizable black bag containing reflex hammers, probes, tuning forks, pins, etc., when none of these instruments -- if properly used -- should gain access to the brain.

The attending, an old-school epilepsy specialist who believes in the wonders of physical exam more so than in sophisticated imaging, reached for his instruments and performed a peripheral nerve exam on an elderly, frail man suspected of a stroke. It may have been an ordinary procedure, but it hilariously resembled a beating; either for want of bedside manners or for having been trained prior to the focus on patient relations, the attending used a bit more force than what was needed. Hence, it is no surprise that the frail patient would look somewhat uneasy whenever the attending and the entire group of students -- each eager to practice his own exam -- entered the room. If I were the patient, I would choose to fake cough and be turfed elsewhere rather than to withstand med student abuse tactics, of which there are many.

I picked up one such gem when we examined a Bell's palsy patient (one with cranial nerve VII paralysis) suspected of damage to his stapedius muscle in the ear. In assessing whether CN VII innervation is still intact, one would normally expose the patient to loud noise and rate the response, be it a big wince from an affected patient or a smaller wince from a normal individual. But instead, the attending asked the patient to put on the stethoscope, and held a high frequency tuning fork on the other end so that the patient, and he alone, heard a loud screech. I'll have to nod sympathetically, perhaps almost tragically, if he points to my stethoscope and says "that's tough work, Doc."

Of course, not all patients are cooperative. We were asked to examine a patient on chemotherapy who is hospitalized for associated renal failure, CN VII lesion, and acquired vancomycin resistant infection. I noticed that she was cosmetically-conscious, and did not wear an eye patch even though her right cornea was becoming progressively worse for lack of blinking - a reflex innervated by CN VII. Understandably, she is generally upset at the medical establishment for having seemingly precipitated all her problems, but became much more so when she saw all seven of us, in gloves and gown, crowd into her room. She looked at me through her riveting, unblinking eyes and said "no, no, no more of this, I can't handle more of _her_ today", evidently mistakening me for her radiation oncologist who is also Asian. I suppose we all look alike under scrub and gown.

June 30^th, 2008

Some patients with intractable epilepsy qualify for surgical removal of certain areas of the brain from which epileptic discharges are thought to arise. They first undergo what is known as the Wada test to assess variability in neuronal circuitry. This procedure, designed to map certain cerebral functions to the left or right cerebral hemisphere, is a crude but indispensable method of determining whether the resection will help the patient or produce the next Terri Schiavo.

I tagged along with the neurological team and arrived at the procedure room where a handful of very tall Germans, dressed in full-length radiation vests, already began snaking a catheter towards the cerebral vasculature with extremely precise hand-guided movements. The radio filled the room with a quintessentially classical selection that seemed to orchestrate the exquisite motion of the spinning magnets, the fine rotation of imaging equipments, and the controlled movements of the vested Germans, who must have compulsively muttered "precision precision precision" in their thick German accent.

The catheter is advanced from the femoral artery in the thigh to the left or right internal carotid artery to deliver a dose of sodium amobarbital, commonly known as truth serum, to numb one cerebral hemisphere at a time. This effectively mimics surgical removal of that half so that neurologists can gauge whether the remaining hemisphere has sufficient control of speech and memory for everyday function. The truth serum, of course, also renders the patient unable to lie for a few seconds -- a precious chance to ask about things like drug compliance.

This particular patient presented an unusual complication in that her persistent trigeminal artery (embryological defect) would have carried the barbiturate not only to the cerebral hemispheres, but also to her brainstem, which would have stopped her breathing. Luckily the Germans were able to advance the catheter sufficiently downstream to avoid the hazard, but it was a bit unsettling to hear the attending's wonder at who's going to intubate the patient should they fail.

With the patient running on half a brain, the neurologist then asked the her to recall a series of objects -- rubber duckies, bright pens, wristwatches, test tubes, etc. -- all of which he removed from his larger black bag. Aside from memory, he also tested language, or as much as he was able given her left hemisphere-driven hysteria. The Wada results produced partial mapping of memory and language to both hemispheres -- a complication that resulted from hypoxic injury in her early years. The lack of oxygen to certain areas of the brain most likely triggered a neuron network reorganization in her childhood that preserved cerebral integrity, but one which now poses a challenge to the neurosurgeons who are planning to operate on her.

If luck would have it, she will emerge with a constellation of interesting personalities. I'm waiting to see if Ted Kennedy (D-Massachusetts) will become a fire-breathing Republican with his left temporal lobe, the source of his glioma, removed – Joe.

July 9^th, 2008

Even after having stood over the chief neurosurgeon's shoulder for 4+ hours, and having peered longingly at the only stool in the OR on which the said surgeon is sitting, never, for want of stolen relief, drape yourself against the wall without first checking to see whether the Code Blue button is mounted behind you. (On the other hand, that would have been a wonderful way of introducing myself to the rest of the surgical team. "Just kidding on that Code Blue, heh heh")

Don't touch anything, don't press anything, don't step on anything (egos in particular).

Simply nod appreciatively when the team decides to fix the patient's skull inside the abdomen to temporarily relieve high intracranial pressure without compromising nutrient supply to the skull. Laugh politely when the fellow remarks that the patient won't ever lose his skull that way, and perhaps even suggest that the patient avoid dangerous maneuvers that would damage the thin flap of skin covering his brain.

August 20^th, 2008

To pick up where I left off, I was following a neurosurgeon who was to perform a temporal lobectomy to treat a patient's intractable epilepsy. The operation took place in a new OR with at least five plasma screens fitted into a typical high school classroom, simultaneously showing MRIs, catheter imagings, EEG readouts, and potentially news channels too.

The neurosurgeon herself looks rather unassuming in person and in surgeon garb, but has the interesting habit of nimbly carving her burritos with knife and fork. Her assistant, a technician responsible for recording real-time EEGs, has an equally odd habit of reading a rather outrageous selection of books like <> in the OR. This apparent culture of cutting struck me as very fitting for the specialty.

I arrived after they had already begun removing parts of the temporal lobe, working nimbly around the small square of exposed brain matter as though it's just ordinary tissue. Except it's not. The retracting, pinching, squeezing, and cutting all inevitably disturb what we conceive as memory and personality of a person, or at least the portion of which that can be confined to any physical location within the brain. So in trying to get to a deeply-buried lesion, the neurosurgeon may need to artificially move memories of childhood summers until they are against the feeling of intense hate for the Lisp programming language, pushing the two together until they finally
flop back to their respective places once the resection is complete.

Ordinarily, the nervous system is wired to respond rather aggressively to physical insults of this magnitude with intense pain -- this is true anywhere in the body except in the brain, where we have no sensory innervation. As I see it, the brain doesn't need to experience pain partly because all is lost if the cranium were already penetrated. Or, the Grand Architect himself intentionally simplified the design because it is absurd that we should temper with it in the first place. I leave that to the thinker.

September 29^th, 2008

"I'm not your friend; I'm your doctor" -- ER resident, in reply to the "my friend, my friend" colloquialism from an inebriated patient.

Weary of studying neurology, I put on a white coat, flung a stethoscope around my neck for legitimacy, and walked into the ER as though I belonged. Within 5 seconds of stepping into the trauma room, I joined the group of nurses and residents as they wheeled in a teenage girl with head trauma, and within 15 seconds, I was peering into privileged anatomical regions to check for other signs of assault. The nurse asked "would you like some morphine?" but was in fact already injecting it as though the patient has very little to say under the circumstances. The ER chief peeked in and was gone, ultrasound came in and left, the EKGs wheeled in and out, and, in a matter of minutes, the entire buzz of activity let up, migrated, and descended upon a second patient. They say ER is for people with short attention spans.

I then side-stepped to a case of scalp laceration following a fall, and shifted towards a very deliberate (but at times faux-stressed) second year resident as he proceeded to prepare a 50mL syringe for irrigating the wound. The standard procedure to treat scalp lacerations involves antiseptics and stitching, but the patient declined stitches and was very adverse to antibiotic treatment, largely because the resident aimed the high-pressure syringe directly onto the open wound, which caused torrents of pink blood to wash down his face and neck. The patient nearly cried legal action after two cycles, at which point the resident wrapped his head with gauze. He looked like a giant Q-tip.

I looked around the various examination pods and saw your standard fare of gun-shot victims, motor vehicle victims, homeless looking for overnight shelter, and others who listlessly stared ahead -- all were waiting for attention from the handful of residents on call. Most people weren't too terribly conversational, but admittedly I too would be so after hours of wait. Someone really ought to overhaul ER wait time.

October 5^th, 2008

The jolly old neighborhood partied again, and I saw the aftermath when, predictably, the stretchers came in drones around 3am: "Give me some pain killahzzzz!" croaked a 29 year old male with multiple bat hits to the head and a gunshot wound to the right leg. Contrary to the usual readiness in administering morphine, the attending this time withheld the drug for a sensory and motor examination that started at the head ("Does it hurt here?" "Of course it does!") to his flank and to his perineal region where the heaviest resident checked for rectal tone by inserting his finger. The patient immediately said with great emphasis, in a tone completely different from his earlier complaints of malaise: "I. don't. like. that.", and fell silent as we then dutifully injected the morphine. We covered him and wheeled him to CT, after which I never saw him again.

I then saw a petit guy with a large gash to his forehead who muttered "6289, 6289..", and who had in his possession a notebook filled with gang vocabulary and its translation -- it looked like a fifth grade vocabulary list with one column of words like "double deuce", "jac se", and a second in plain English. It's a Rosetta stone of sorts.

- "What hit you?"
- "6289"
- "What hit you?"
- "a 6289!"
- "What's that in English?"
- "a AnJ bottle" (NB 60oz. whiskey)
- (aside to me) "See? Sometimes you just have to ask"

You'd think that low-ranking gangsters would pick up slang terms on the job, and not that they would have to study for it. The resident tried to turf him to internal medicine on account of his being too drunk, but unfortunately the gash was his ticket to stay. They wheeled him to CT too and I never saw him again.