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Reaching Down The Rabbit Hole
Extraordinary Journeys Into The Human Brain
Allan Ropper and Brian Burrell
"What they hope, what they expect, what they deserve, is that we take the time to listen, because the act of listening is therapeutic in itself. When we do it right we learn details that make us better doctors for the next patient."
Neurology is the last place in medicine where your personal synthetic intellectual effort is value added, and despite all the gee-whiz gadgets, for when the tests don't tell you enough. Have to examine the patient and pull together all the symptoms and signs into a larger framework.
62 yo Columbian woman brought into hospital by friend who noticed she was acting strangely, after her weekly sexual tryst with a casual friend. She couldn't form new memories - kept saying felt fine and why am I here? Transient amnesia or TGA. After a while her memory returned, but with a hole, so didn't recall anything of last sexual encounter. Fortunately, she had another one scheduled for the following Thursday.
Test people who claim to be blind by waving $100 bill in front of eyes. (Eyes follow it) $1 bill doesn't work. Or move a mirror across face - again eyes will follow. One surgeon, when confronted with someone he thinks is faking, sticks a post it to his forehead saying GO FUCK YOURSELF while he's interviewing the patient.
"I'm not saying you're crazy, just that something is bothering your brain in a way that is beyond your control."
When a patient realizes he is going to die, it's not uncommon for his anger to get transferred to everything else but the disease - the food, the nurses, but especially the doctor. And when a doctor new, he can take that to heart. One old doctor listened to a young colleague complaining about having to deal with that anger, and while listening held his pen out in front of him, as if offering it. The young guy took it. "Did you want that pen?" "No, not really." "Then why did you take it?" " I thought I was supposed to." "Your patients are holding out their troubles . They are not really asking you to take them. They'll get along without your suffering. You have another job to do."
Today rarely do autopsies, so doctors don't get feedback of seeing their diagnoses confirmed or challenged. The actual visual learning makes a difference.
When first treated Michael J Fox for his Parkinsons, actor promised him a Ferrari if he could fix him up enough to keep acting career. He got one eventually, but it was from Mattell of Japan.
A boyfriend who has lost all emotion, a man who drives around a roundabout for an hour, the ice skater who keeps having life-threatening strokes – it’s just another day at the office for clinical neurologist and Harvard professor Allan Ropper.
How do you begin to understand a sick brain when your primary source of information is your patients’ brains?
This involves a combination of Sherlock Holmes-type deduction and openness to the bizarre nature of neurologic problems. The nervous system is “hard-wired” so that signs such as paralysis have a predictable location and cause in the brain but others such as confusion, hallucinations and bizarre behaviour have to be analysed in an imaginative way because the brain cannot give accurate information to the doctor.
Technology such as enhanced MRI must be a great help, but bedside manner seems vital in clinical neurology. What do you look for?
Most of the important aspects of examining a patient are subtle and sometimes intuitive. The manner in which patients relate their story, body language, shifts in posture and facial expression tell a story all their own. MRI and CT scans are only shadows and cannot determine how illness affects an individual.
A truly confused person, someone who can’t find his own mind, can be overwhelming even for professionals, you write. Why?
It is difficult to know if a confused patient has any capacity to reason. Getting control of their attention and behaviour may be a big problem. Their distorted reality and altered internal emotional experience create a disconnection between the doctor and the patient.
Many ailments once thought “psychosomatic” are now regarded as non-psychological, but can the brain still cause plenty of problems in the body?
There is an important distinction between psychosomatic and hysterical. The first was overplayed in the last century, with all manner of illness being attributed to the psychological state – for example, asthma, ulcers, migraines, all of which have a structural or chemical basis. On the other hand, the brain is able to produce stunning symptoms of loss of function including blindness, paralysis, tremor and walking trouble. These occur mostly in individuals who have had some form of serious childhood or recent adult trauma. We do not understand hysteria and no one is confident in its treatment. It is a large part of neurologic practice since the brain is the only organ that seems to cause its own problems.
Unlike how it’s shown on TV, can prolonged resuscitation actually result in brain problems?
Brain damage after resuscitation varies greatly. The cause of heart stoppage or lack of oxygen, the age of the patient, the ambient temperature and circumstances of a cardiac arrest all determine whether there will be brain damage. In recent years, it’s been demonstrated that mild cooling may improve outcome. Anything from mild mental slowness and serious memory loss to coma or brain death may result. It’s true that TV and films oversimplify the matter.
You have some interesting methods of detecting fakers and malingerers.
I talk in the book about some of the curious techniques my colleagues use to detect hysteria. We move a $100 bill in front of people who claim to be blind and they follow it. There are ways the nervous system works that can be used to demonstrate that paralysis is not real. One of these is Hoover’s sign – a hand under the heel of a patient on an examining table will detect, when the patient tries to raise the allegedly paralysed leg, whether the other leg is being pushed downwards. This kind of bracing is necessary for any movement against resistance. The word “fakers” troubles me because most people I see do not seem to be consciously producing their own problems. But there are also true malingerers who fake to get out of some responsibility or to attract attention.
You collect arcane cases. What is the strangest you have ever come across?
I suppose “strange” is in the eye of the observer. I saw a patient recently who had a parasite slowly squiggling through her brain. For me, it was bizarre to see her examination change every few days as the parasite moved around. In underdeveloped countries where this organism is well known I suppose no one would be alarmed.
How is real-life diagnosis different and similar to the likes of TV programmes such as House?
Whenever an expert in a field such as the law, science, engineering and even the arts comes across a popularised depiction of what they do, they usually cringe. The public’s fascination with medicine has led to many programmes and articles that lead me to do the same. I’ve not watched House so I can’t comment, but my kids have told me I’m far less irritable and at least as smart! I understand that my textbook, Principles of Neurology, was on the shelf behind Hugh Laurie in one episode, so at least they got that right. The problem with popular entertainment is that medicine depends on an intimate interaction between patient and physician at one moment in time and that is difficult to capture when the goal is dramatisation.
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