Neurology Week 2

Monday, October 1, 2007
This week I’m working in the clinics. Clinics are kind of a painfully boring process, because we don’t actually DO anything. Instead, we just watch the doctors do stuff. It wouldn’t be such a big deal except at this point in my education, I feel like I’ve been “watching” forever and really relish the opportunity to take some action. Oh well.

This morning I am in the neuromuscular clinic. It’s not very busy. Our first patient is a lady with fasciculoscapulohumoral dystrophy. Try saying that 20 times quickly. It’s interesting because, if I had just seen her out on the street walking around, I don’t think I would have noticed that there was anything wrong with her. I would have just thought that she didn’t move her arms very much when she walked. She’s actually in pretty good health. So it’s a quick visit.

Our next patient is a very pretty 24 year old girl named A.S. A.S. is coming in because she has felt weak all over… for 7 years… ??? Her symptoms are really weird. And I think both the jr and sr doctor that are involved in her case think that she’s nuts. I get the feeling from listening to them talk that they often think that their patients are nuts. We do a full exam and then decide to do something called electromyelography (EMG). An EMG is where they attach all of these electrodes to different parts of your body, and then measure how well your muscles respond to your nerves getting stimulated. It’s kind of unpleasant. But the worst part is, they also stick needles into the muscle as well. She tolerates it well… and everything comes back negative. It’s a really weird situation. She’s really pretty… she seems really nice… she seems genuinely worried about her health… and yet… there is something about her that’s just not right… and you really do get the sense that she might be a little nuts… I try to keep my distance from her, because there’s one thing you learn very quickly when you’re a male medical student… Pretty female patient + kind of nuts = BIG TROUBLE.

But on my way out to lunch, I run into her everywhere! Yipes.

In the afternoon, I’m with my Chief Resident, which is very cool, because I really enjoy working with him. We have a really interesting case that comes in. It’s a Mr. B.W. He comes in after going to a bunch of doctors somewhere south of Richmond. He apparently was at home over the summer and had a seizure that no one else saw. But after that, he started having this weird series of tremors. We do all of these neurological tests… and the thing is… it’s pretty obvious that he’s faking… okay… maybe faking isn’t quite the right word for it… but it’s obvious that his tremor is probably caused by a psychological cause. This isn’t unusual. It’s something called conversion disorder. Sometimes, when you’re dealing with a psychological or emotional stress that’s too intense to handle, your body turns it into physical symptom.

In Mr. B.W.’s case, I spend some time talking to him and his wife… and I am able to piece it all together. It turns out… in the spring, their 9 year old daughter passed away. She was mentally delayed with cerebral palsy, which means she had a lot of developmental issues and a lot of medical issues. Taking care of a child with complicated health is an all-consuming job. When the child dies… it leaves a huge void that is really difficult to fill. Suddenly, the parents find themselves having to relate to each other with all of this time suddenly emptied from their normal routine. It is a huge stressor. Many couples do not make it through this and end up getting divorced. In the case of Mr. B.W. and his wife… his body turned this stress into a visible physical disability that brought him and his wife back together. She worked with him in a very obvious maternal way. She took care of his every need. She helped feed him. She helped bathe him. But his symptoms… if you wrote down the symptoms that he felt he was having… you would read about and think… “Textbook case of Parkinson’s Disease.” The only problem is… when you test his reflexes… when you test his tremors… they are very clearly “controllable.” That is to say… you can do things to make them go away… in a way that is physically impossible with an actual neurological condition. So why would this guy’s subconscious pick Parkinson’s Disease of all things? After talking to him… I found out that his grandfather had Parkinson’s. And he used to take his grandfather to the doctor all of the time.

I felt like a rockstar for figuring this out. Seriously. I can’t remember the last time I had so much satisfaction in deciphering what was going on with someone. When I present the situation to my Chief, he is ridiculously impressed. He pats me on the arm and says, “very nice, man… very nice.” But the problem is… how do we help him? He’s not deliberately faking this… And you can’t very well say to him… “Dude… it’s all in your head.” I was at a complete loss. When we presented to the attending, he was skeptical of our diagnosis until he actually went in and physically examined him. At the end of the physical exam, he sat down with Mr. and Mrs. B.W. and said, “Well, I’ve seen a lot of different movement disorders in my life… and this doesn’t fit any patterns that I have seen… I can tell you with 100% certainty that you do NOT have Parkinson’s. I should tell you, that there are many psychological conditions that can cause these kinds of physical symptoms.” As he said this, I was thinking to myself… that’s about as smooth a way to discuss this as I could possibly imagine. However… this did not go over well. This did not go over well at all. There was some serious frustration and anger coming from the couple. And in my head… I couldn’t figure out how else this situation could or should have been handled. In the end, our attending offers them some tests that can maybe be more definitive and I think that was a smart idea. Offering them the option to look at objective data to rule certain things out is probably the best thing to do.

Thursday, October 4, 2007
Tuesday and Wednesday were gigantic wastes of time. We didn’t really see many patients, and the ones we did see were basically there for follow-up appts. Most of the time we were there, we had to listen to this Dr. talk on and on and on about stuff that none of us cared about. Like his dream car… like how much school cost when he was a student… the guy had the worst case of diarrhea of the mouth I have ever encountered. And it DROVE ME CRAZY.

Today, I am in boredom hell. We are in something called EMG clinic. Like I said before, EMG stands for Electromyelography. It’s a really boring procedure, where they zap a series of nerves to see how well your nerves are working. It’s painfully boring to watch. Imagine watching someone press a button that causes squiggly lines to form on a computer screen. Imagine them doing this like 100 times for an hour. Yes. Very boring.

We sit through a couple of these when we get a gentleman named Mr. C.W. come in. I look at his chart and I realize that he has the exact same birthday as my dad. He is here to get his nerves checked, because he has a type of cancer called Multiple Myeloma. It’s a cancer of a type of white blood cell that often occurs in older adults. It’s pretty easy to treat if it’s caught early enough. Treatment is with a drug called Thalidomide. Thalidomide is a drug that was once used to help pregnant women with morning sickness… until they discovered that it created HORRIBLE birth defects in babies. It often caused children to be born with less than fully grown in arms and/or legs. It stopped being used at all for a while, but now is used to treat leprosy and multiple myeloma. The only problem… it can cause permanent nerve damage.

So we get ready to run the EMG on Mr. C.W. who has been on Thalidomide for his Multiple Myeloma… except he needs help getting his shirt off because he can’t move his fingers anymore. As I do so, I tell him that he has the same birthday as my Dad. He asks me, “Same year and everything?” When I tell him, yes, he replies, “They made them good back then.” I laugh and I say, “Yes, sir… not soft like they do, now.” He gets a good laugh out of this. Then we do the EMG. And it’s awful. He has significant nerve damage. And it’s permanent… even if he never took another dose of thalidomide again.

I help Mr. C.W. get his shirt back on. As he walks out, he says, “Tell your Dad I said hello.” I thank him. And as I see him walk out to get his wife so that they can hear the news together, I am grateful that my Dad is healthy.

Neurology sucks.

Friday, October 5, 2007
It’s my last day of clinic.

The morning is boring and uneventful. In the afternoon, I have Resident Clinic. I am with a Resident that I have already figured out is pretty awful. I go in to see a Ms. L.L. who had previously had seizures and was taken to the hospital. The Neurology service had figured out that she had probably had a seizure because she was in severe liver failure, but we’re following up on things with her in clinic.

When I go in to see her, she is this really nice old lady who is there with her adult daughter. I talk to her about her seizure and then talk to her about her liver failure. It turns out this nice, sweet old lady used to do drugs. She shared a needle with someone and ended up getting Hepatitis C. With her Hepatitis C, she developed cirrhosis of the liver, which is basically where the liver gets so scarred up that it causes liver failure. This ended up turning into liver cancer. She is now trying to get on the Transplant list. It’s a really amazing interview and the physical exam goes smoothly.

Then I go to talk to the Resident. He bounces from room to phone to room to phone. It takes him an hour after I left the room to go back in with me. Once we get in the room, he talks to her for about 10 minutes, when his pager goes off. Then he does the most amazing thing. He picks up the phone in the room and returns the page. He sits down and he talks on the phone… for 25 minutes. I looked at my watch and kept track of the time. 25 freakin’ minutes. I couldn’t believe it. The crazy thing is… it was very clearly NOT that important. He spent about 2 minutes talking about important stuff… and then started going off on a series of other VERY UNIMPORTANT tangents. The mother and daughter are staring at the ground… very obviously uncomfortable… very obviously unhappy. I AM FURIOUS. How could he do this to her? I start trying to figure out what the heck I should do. Do I leave in disgust? Do I stay? I hate this more than anything I have ever had to deal with. Finally… I take out a sheet of paper. I write on the paper, “I’m sorry for him,” and hand it to the daughter. She smiles and writes down, “It’s not your fault… but thank you.” He finally gets off the phone… and he does a quick exam… and then he leaves… the daughter shows the note to Ms. L.L…. and Ms. L.L. touches my hand and says thank you.

This is the one thing I had always worried about coming into 3^rd year. I knew that I would run into situations where I was going to have a better rapport with my patients then my supervisor. What I didn’t anticipate was running into a situation where my supervisor was going to be so blatantly unprofessional in front of me.

Being on Neurology is so much easier in many ways than Surgery ever was. But there's a lot about it that sucks in a major way. I'll be glad when it's done.