The Dark Side

Today was the toughest day I've ever spent in the hospital. The children were the sickest, not just of the neurology patients, but arguably in the whole hospital. Now usually, I only see patients on follow up visits; their acute events (ie, the stroke) has already occurred and been treated, or I see only the images and do not meet the patient in person. This means I have been shielded from the real crisis so far, I don't generally see the life vs death dynamic. But today, today I did.

It started in stroke conference when I saw some of the most severe image studies I think you could acquire from a still-breathing child. They were mostly infants, which means they have a high level of neuro-plasticity (adaptivity) but they are also very fragile. One child had literally 1/3 of his brain missing. He had had a hemorrhagic stroke which created a cavity in his brain; the cavity being where most of us have our right middle cerebral territory. Now the baby has a clot in his femoral artery, but they cannot anti-coagulate because of the high risk of additional bleeding in the brain. They cannot image to track the stroke because he has a pacer due to pre-mature birth related cardiac problems. Basically, the baby is falling apart and treating any one of the conditions will kill him by exacerbating another.

Next we reviewed the images of a congenital heart defect (chd) baby. These babies are extremely prone to encephalopathic (brain) disorders because their blood supply in utereo tends to be very poorly oxygenated. This child had a hypoplastic left ventricle (missing left atrium/ventricle aka a "blue baby") and now was experiencing almost daily white matter strokes. I literally lost count while we went through the images because there were so many of them. They are a post-operative complication, the operation being the placement of a BT shunt (without which the child will certainly die) and some children experience them while others do not. By the time this infant stabilized, most of the white matter was lost.

After stroke conference I attended two patient consults with my attending and the prognoses did not improve. The first patient had recovered from a stroke but was left at high risk of recurrence and with a seizure disorder. While we were evaluating her she had a seizure despite being loaded with anti-convulsents. The only drugs left in the arsenal do more harm then the seizures themselves, but the mom was hysterical. I think she thought she was watching her child die in front of her, which raises an interesting issue of how to treat the parents when you're treating the child. With the exception of status epileptus, most seizures will resolve themselves and will not cause brain injury, but the mother's ears were shut. Very little was actually accomplished and I think the mother, not the stroke, will ultimately be the problem for this patient.

The last patient of the day was by far the worst. He was not actually a stroke, but a mitochondrial disorder. If you've had biology you will recall that the mitochondria are responsible for producing cellular energy, so abnormalities can cause diffuse and severe effects. In this case, the toddler could no longer breathe without a ventilator, had lost all his language, and could not move his limbs against gravity. He couldn't swallow or hear, and was losing his sight now as well. He had seizures and was fed through a G tube (tube placed into the stomach) and his kidneys were failing. He spent June - Dec of last year in the hospital and May - July of this year as well. After the exam, the mom asked the 64 million dollar question "how long will my child live?" And then came "how much can we do?" And now began my first experience with pallative care. The answer is, the child will live to his next birthday if he doesn't get the flu. Any virus, any common bug, will kill him. Without motion or sight or verbalization, he cannot communicate pain. The question is not how much we can do for him, it's how much you want to do. What kind of life is this child living? Don't worry, children aren't like animals, we don't put them down, but we do sign DNR orders and refuse surgeries and treatments to hasten the end when prolonging it is more cruel. That's the kind of conversation we had with this toddler's mom. That was how I ended my work day. This will be part of my life as a doctor and it's harder than I thought. It's really hard.

Developmentally delayed.

A group of friends and I went to a bar last night for a few drinks and to meet one of the girl's new(ish) man. Said man was very amicable and held his own with a table full of strangers quite well (cute and in a band too, well done Ms. A).

While there I was approached by a woman in a bright red top and matching lipstick as to whether I would be willing to meet her very cute single friend? As flattering as the offer was (why me?), why couldn't the guy come up to me himself? And, by the way, I'm not actually single. Then one of the guys at my table decides the woman in the red is quite desirable (after striking out with our waitress) so would I please go talk to her? I did (she's not single either), but I was silently wondering when men regressed to high school? After all, the "I'll tell my friend who will tell her friend that I think she's cute" thing worked so well then?

Around midnight, after all the fixing up fell through, I got a text from a NY (male) friend of mine exhuberantly informing me that he was, in fact, in my city drinking right now. Could we meet up, he needed my advice? Meet up we did and he talked (or rather, bitched) through last call. He called his friends (who he ditched to see me), but they weren't answering so he was now stranded. I offered him my futon, but he would have to be out early because I had to wake up and finish an assignment and get to lab. Back at my place I pull out the futon and get him a pillow. I go to bed. He knocks on my door, he's leaving, he's found his friends. As he's saying goodbye it dawns on me (from some of the untranscribed conversation) that he thought by "futon" I meant "my bed" and by "need to leave early" I meant "we'll have exhausting sex". What's worse is that, judging by the text I got the next day, he still thinks it will happen one day (never).

Out patient clinic

This past Friday I shadowed one of the attendings for a full day of out-patient neurology clinic. Thankfully I have been attending grand rounds, neuroscience conference and stroke conference regularly so I managed to at least follow the conversations and define most of the acronyms. Unlike the aforementioned conferences though, today was a mixed bag - I saw children (recall I am in pediatrics) with mitochondrial disorders, stroke, neuropathy resulting from traumatic or premature birth and descriptive clinical disorders (ie Turrets or Cerebral Palsy). There were also patients with unknown etiologies and highly atypical presentations.

A few things really surprised me. First, there is a marked difference in the involvement and knowledge level of the parents. Some could name every date and time of a symptom and the dates of every doctor's appointment for the next year, others were a little more relaxed. At first I thought the laid-back ones didn't care or didn't understand, but then I realised the real difference was which parents had accepted their children's diagnosis and prognosis.

The only children that were dysmorphic (physically looked malformed) were the developmentally delayed babies. This may have been coincidence, but pretty much all of the toddlers through teenagers looked like everyone else you see in school (some were a little hyper).

A basic neurology exam, one that looks for deficts and clinical abnormalities, is deceptively simple. I'm actually reading a book right now called The End of Medicene (it's making me angry) in which he critisizes how simple some of the tests performed in a physical are. The thing is, tests don't need to be complicated and digital to provide the information you need. An example. Put your arms straight out in front of you, palms up, parallel to the floor. Close your eyes and vigourously shake your head no. Open your eyes. Your hands are probably still level, but someone with a single hemisphere deficit will find one hand drifted downwards. Which hand also tells us which hemisphere. Yes, we need the 4D MR perfusion imaging and other complicated, high tech tests to help us accurately diagnose and treat, but that doesn't mean a simple test is worthless or unrevealing.

My favourite patient was a young boy with a head of short fuzzy blong hair in a McNabb jersey who was hyperinsulinemic/hyperammoniec. During his exam he refused to pay attention to the attending and instead was staring at me. In the end I had to stand behind the doctor to help the boy focus. While his mom was discussing recent events the boy played catch with me and climbed up onto my lap - he's going to be a real heartbreaker when he's older.

R.I.P.

No, this is not a 9/11 post.

Someone I know, more specifically, someone I taught this summer, was killed. He was enthusiastic, capable, and young: he had his whole life ahead of him. I knew that most of the people in that program lived very different lives than I have. That to grow up poor and a minority in a city has certain temptations, certain risks, and a lower life expectancy, but this really drove the point home. So much potential, just... extinguished.

Every place I have lived has taught me something. Philadelphia is the city that is really rubbing my nose in the realities of life for those who didn't grow up near golf courses and taking piano lessons. The people I saw in the ER, the men I worked with in Veterans Upward Bound, even the composition of the neighborhood I live in... I have never seen so low a level of general education, so many guns, and such a high level of drugs, violence, anger, PTSD, alcoholism... and all so beautifully juxtaposed with the Ivy league, rich-kid haven that is UPenn.