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June 9 - June 9, 2019
Three months later I learned that Ruby’s primary care doctor, who must have had Periclean powers of persuasion, succeeded in convincing him to have the surgery—finally! Unbeknownst to me, he ended up at another hospital, where the operation almost wrecked him. It happens, even with the best surgeons. The definitive cure for an anterior cerebral aneurysm is an extremely delicate procedure. It involves the placing of a clip that looks like a miniature distorted clothespin on the neck of the aneurysm. The trick of it lies in choosing the right clip, choosing the right place to put it, getting
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Yet ultimately, as far as the hospital is concerned, the patient is always right because personal autonomy trumps probabilistic outcomes. You have to respect their wishes as human beings, we are told. But if you ask me whether the customer is always right, I would say, “Not at all.” The patient is so very often dead wrong, and very much so when it comes to his own brain.
“Exactly! The trick to medicine is to have it be an active experience, not to be a passive observer. Get in there fully with your senses, and then you’ll be a great clinician.
One of the residents on the team, name of Kravitz, was a bit of an amateur magician and also a talented pickpocket, undoubtedly the product of a misspent youth. Tricking people means knowing and controlling what’s on their minds.
How am I supposed to concentrate on that? I can’t find my wallet!” Kravitz calmly stood up and said, “Here’s your wallet. Now you know what that farmer feels like. He’s got a demented wife at home roaming the farm half-dressed.
There’s one big vein in the medial ankle, and if you can find it and slip your finger under it, it will fill with blood and you can stick whatever you want into it. Just as Tony said, “You’re never going to find it down there,” I found it, put my finger under it, incised it, and slipped a feeding tube into it—a quarter-inch pediatric feeding tube for infusing large volumes of fluid for shock and trauma. Once the line was in, the nurses started furiously squeezing the IV bags to flood the body with fluid and get her blood pressure up. We grabbed some neosynephrine and piggybacked it onto the
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she became comatose.
it was an instance of the blind men and the elephant,
a trivial and almost axiomatic thing.
There are more diseases of the muscle, just the muscle, which is a tiny sliver of neurology, than there are all diseases of the lungs. There are more diseases of the spinal cord than there are of all diseases of the heart. There are more diseases of the white matter, not the whole brain, but just the white matter, than there are of all the rheumatologic and joint diseases. Neurology has more diseases and more complexity and more need for exquisite clinical analysis than any other branch of medicine. Take one little piece of neurology: there is more to it than in the totality of any other
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breaking through the cloud cover, leaving behind the shaky confidence and self-doubt
In neurology, it takes four, five, sometimes seven years to make that transition, and once you make it, once you hit your cruising altitude, those below you in the fog might think you are performing diagnostic miracles. It is important to point out to them that you are not.
To become a good clinical neurologist, you have to be intensely interested by what the brain does, how it works, how it breaks down.
Raymond Adams would walk into a patient’s room thinking, What am I going to learn now? Because of that, he was able to synthesize hundreds and hundreds of cases, recall their essential features, and put them into diagnostic categories.
It reminded me of a ridiculous joke I’d heard on The Sopranos: “What are the chances that someone named Lou Gehrig would die of Lou Gehrig’s disease?”
“I simply can’t breathe a lot of the time,” she said. “I feel as if I’m going to choke and then die. I’m so worried when I’m alone.” “Are things getting stuck in your throat or chest, or are you just feeling as if you can’t get enough air?” “Yes, that’s it. I can’t get enough air. I never feel as if I can expand my chest enough.” “Which comes first, feeling anxious or the trouble breathing?” “They come together. I can’t tell which is which, but I do think that I’m going to die.”
she had a disproportionate degree of anxiety about the current state of her illness, a level of fear pegged to the endgame rather than what was happening at the time.
The fasciculating muscles begin to atrophy. The ability to swallow is soon compromised. The disease is most certainly fatal if left to run its course. Yet it leaves the brain and the sensory system intact. The patient can feel everything and move almost nothing,
Her husband’s only question was: “It won’t be done by a student, will it?” “It will be done by a surgical resident under the supervision of a staff member, and that will be fine.” “So, someone who has barely done it before?” “Not exactly,” I said, with intentional ambiguity. The procedure is routine enough that it rarely requires a senior surgeon.
Air hunger is one of the most uncomfortable symptoms known to man or woman.
“You do understand that on the ventilator she could be kept alive almost indefinitely, she could see the kids grow, and her mind would be good?” “Yes, but she’s stuck on not wanting to be a burden to us.”
movement of her eyes from one letter to the next, she spelled out: “N . . . O . . . I . . . A . . . M . . . N . . . O . . . T . . . D . . . E . . . P . . . R . . . E . . . S . . . D”
You can tell when someone is about to die. Their vessels constrict as blood pressure starts to fall, and the kneecaps get a little bluish.
‘I ate at his house and his wife was the world’s worst cook, and I said, ‘Now I know why you say your prayers after you eat.’”
the very picture of placidity and competence.
She is a handsome woman,
equanimity
Most people throw in the towel.
fortuitous
“Have you met other ALS patients through the fund-raising?”
George and I also sit on the board of an organization called Prize4Life. It’s an organization that seeks to increase discovery in the field of ALS by funding prizes for people doing innovative and impactful research.
irrevocable.
ambivalence.
the bigger picture of where you are in your life,
Are you a little bummed out that I would be part of this?”
“You can’t make gold out of lead,” he said to me, “and I’ve been trying for twenty-five years.
Sisyphean,
she has a whiteboard in her kitchen. The board for today has a bulleted list that includes pills, meals, money, workout clothes, a timetable, directions, reminders, emergency contact numbers, and a few motivational phrases: Happiness is a decision. What other people think of me is not my business.
three men who frequented the neighborhood,
would have fallen every step if he had not been supported by his stick.
Then one morning in the fall of 1968, after having performed over six thousand of these procedures, as many as six per day, Dr. Cooper walked into his clinic and announced that all such surgeries would stop, effective immediately. The reason was the arrival of a nonsurgical alternative: the drug called L-dopa, the secret ingredient of Sinemet.
Sinemet is in many ways a wonder drug. Its origins go back to 1967, when a Harvard-trained physician named George Cotzias found that administration of the chemical L-dopa in carefully timed doses relieved most Parkinson symptoms. L-dopa, or levodopa, crosses the blood-brain barrier and is converted into dopamine, the neurotransmitter whose curtailed production is a signature feature of Parkinson’s. Over the next decade, a series of hybrid drugs that combined L-dopa with a targeted delivery agent hit the market. One of these was Sinemet.
That’s the downside of Sinemet: the trade-off between tremor and un-seemly dyskinesias. The drug provides an inverted arc of an effect: a big shot of L-dopa knocks out the symptoms, affording a twenty-minute window of fluidity and fluency. If too much is taken, the dose will overshoot the mark, producing the wild gesticulations and head twists. When the L-dopa begins to wear off, the descent is even quicker: a rapid reentry into a state of torpor marked by a frozen affect, the opposite of Michael’s on-screen persona.
major neurosurgeons in Sweden, where the field was quite advanced.
It can cause a rapidly progressive weakness, and the disease is right in my wheelhouse:
Harry was the equivalent of me in another profession: hardworking, committed, active, with a wide circle of friends. At some point the similarities ended.
By the dictates of the scientific method, we are obliged to seek evidence to disprove our assumptions rather than verify them. If you have a theory, you are not supposed to fixate only on the evidence supporting it. Admittedly, you will rarely see Sherlock do this on Masterpiece Mystery! The Holmesian thrill lies in instantly seizing on the right explanation from the barest facts. What Holmes should be doing, and what Dr. Watson usually suggests, is exploring other possible explanations. Instead of assuming that he’s always right, Watson might say, “Just this once, consider the possibility
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Deductive reasoning, as opposed to inductive reasoning, is what detectives and diagnosticians should be doing. Deduction works from general facts toward specific conclusions. If the “facts” really are facts, the conclusions have to be true. But induction—a quicker and much more practical method of reasoning that everyone uses every day—can lead to errors. That’s because an inductive process infers a conclusion, but doesn’t prove it.
In practice, neither Sherlock Holmes nor I have the luxury of time to indulge in the true deductive method, and when the clock is ticking we have to rely on intuition. But sometimes intuition can let you down.
“Well then let’s have a look, because if the nerve roots are enhancing, that’s got to be GBS, and we could maybe put this to bed.”
