fellowship · neuro

Doctor on board

I just got back from a family vacation, which was perfectly lovely. What was not lovely, was the air travel involved. Is it just me, or has air travel become increasingly unpredictable in the last 5 years or so? I’ve been taking cross country and transatlantic flights since I was a babe in arms, and I never remember significant delays, missed connections, being rerouted. Whereas looking over the last few years, I can count on one hand the number of times I’ve made it to my destination on time.

Our outbound flight, for instance, was a transatlantic jet. We were delayed five hours due to “mechanical issues,” whatever that means. When we finally got airborne, they served “dinner” immediately (at like midnight) and then turned off the lights so everyone could get to sleep.

In the middle of the flight, somewhere over the Atlantic, I was jarred awake by a loud thump/shudder. What was that? In the aisle, a fellow passenger has collapsed. Like, totally out cold. Holy shit. I’m in the window seat, my mother’s by the aisle (also awake), I climb over her and kneel down next to the woman on the floor.

“Ma’am? Are you ok? I’m a doctor, can I help you?”

She groans and struggles to her knees. I give her my hand and try to help her stand, but she cannot bear her own weight. I ask her a few more questions, she grunts and can’t answer. There’s something dark on her lower face, but I can’t see properly because all the plane lights are off. Seems totally dazed, but tries to crawl to her seat, just a couple rows ahead. Because the flight is so empty, she has the entire row of 3 to herself, so I help her back into her seat and she tries to lie down to sleep… and promptly falls off the seats again.

At this point, I’m legit worried about her cognitive status and apparent aphasia. This is not just a simple mechanical stumble-and-fall. She seems concussed. Maybe hypoglycemic. Maybe post-ictal. Stroke unlikely, as she’s young, but we’ve all been sitting for a long time with lots of opportunity for venous thrombosis, and if she’d been walking back from the bathroom where she’d Valsalva’ed….

One of the other passengers has pressed the call bell for the flight attendant, and between the two of us, we are able to lift the ill passenger back into her seat. A couple other flight attendants hover nearby, nervously. One is holding the Green Sheet, the medical assessment summary, which I’ve filled out before on other passengers for much less. By this time she’s a little more alert, says she’s fine, says she’s sleepy. I want to take her back to the galley, where there is some light, and examine her properly. The flight attendant refuses, saying “She looks ok now. Maybe she just fell asleep.” I think of Natasha Richardson but bite my tongue.

“Ok,” I say. “I’m a doctor. I’m just a couple rows behind, in that seat right there.”

The flight attendant thanks me. The Green Sheet disappears. I climb back over my mother into my seat, my eye still on the ill passenger. She sits up a little while longer, talking to the person in front of her, then lies down again.

I check on her once more later in the flight, surreptitiously, when walking to the bathroom. She’s lying Roman-style across the seats, watching a movie. She looks alert. Later, as we’re waiting to deplane, I overhear her talking to some other passengers, explaining that she’s passed out before inexplicably, she must have been tired and/or dehydrated, she feels much better now. She says she has only a hazy recollection of what happened.  There’s some dried blood along the vermilion of her lower lip; she must have split it on an armrest. But other than that, she looks quite normal.

Was I over-reacting, friends, to be thinking of life-threatening things like untreated (undiagnosed?) epilepsy or stroke or epidural hematoma? Maybe. I’m glad she did well, and that my original suspicion of concussion was likely correct. But I don’t think I was wrong to consider those more serious, if statistically less likely (but still biologically plausible) possibilities. This is how doctors generate a differential: what’s the most likely? what’s the most serious? As one of my attendings loved to say, don’t anchor on something (patient said she’s sleepy, therefore she must have fallen asleep… while walking after sitting in a relatively brightly-lit airplane bathroom) without considering evidence for and against all the other possibilities.

I’m still a little annoyed at myself that I didn’t insist on examining her properly though. I’m a neurologist. Of all the possible inflight medical emergencies, this is what I do. I’ve been consulted for far less by the ED back on terra firma. And to defer to a flight attendant, whose medical qualifications include … CPR? Why on earth did I do that, unless it was because he was in a uniform and I was in jeans?

If this ever happens again — and I hope it doesn’t, but I bet it will because I’ve been the “doctor on board” at least once a year since I was in medical school — I’m not going to back down. If someone ever had a bad outcome because I didn’t examine them properly, I really don’t know what I’d do with myself. To be honest, there’s not much I could have done, if I’d diagnosed stroke or epidural hematoma over the Atlantic. But to go against my own better medical judgment because of some perverse sense of not wanting to cause a scene…. ugh. I need to be better than that.

health policy · neuro · PGY-2 · residency

Behind

I spent the week in subspecialty clinics, which was awesome. Except for one thing: the schedulers.

Patients are usually scheduled for follow-up appointments, in 30 minute slots. Occasionally there is an initial visit, which gets an hour. So today, I got to work at 7, spent an hour reading about the 6 follow-ups on my schedule, because even though they are well known to the clinic, they are not well known to me.

My first patient was scheduled for 8, but of course did not show up until 8:15. So by the time I’d seen her, staffed her with the attending, and written her refills, it was nearly 9. (And she was the easiest on my list.) And so it went for the rest of the day, as I slipped further and further behind. I had 2 extremely complicated patients, each of whom took over an hour even before I talked to the attending. Both of them actually need psychiatric care, which I am not qualified to provide — one does not think he needs a “shrink” and the other has limited resources. But when someone tells me they are actively suicidal with access to weapons, I’m not gonna be like “Well that’s not my problem, see ya later!”

Meanwhile, some lady showed up on the wrong day (her appointment is actually later this month) and the schedulers tried to guilt me into seeing her. “Look,” I said, “I’m nearly 1.5 hours behind as it is. She can wait if she wants, but I’m going to see the people who have appointments today first, since they’ve already been waiting.” (She didn’t wait, thank god).

I deferred all my notes, which I hate doing because I worry that patients and plans will blend together. As soon as a patient walked out my door, I went to the waiting room to get another. I felt like a revolving door, and I was rushing slightly toward the end, because I had to get to the Main Hospital, 2 miles away, for a conference.

I saw my last patient, scheduled at 10:30, at almost noon. Skipped grand rounds, disappointingly, because it was on prion disease, and who doesn’t like prion disease? Drove back to the Main Hospital for conference, then had an observed H&P scheduled for 2, then holed up in an empty room for 2.5 hours to write all those notes. Luckily I had no afternoon patients.

It was like this on Wednesday afternoon, too, when they scheduled me for 5 patients between 1:30 and 4, except between a late start and a rather ponderous attending, I didn’t finish seeing people until 6. I was teaching a class that night, so I couldn’t stay to write notes; instead I came back to work at 6:30 in the morning to write them all before Thursday clinic started.

This issue doesn’t happen in the Resident only clinic, I think because the schedulers take staffing-with-attending into account; it nearly doubles the visit time because you have to catch the attending (They are usually staffing 3 or 4 residents at a time), present, and have the attending at least eyeball the patient. But I suspect this is what clinic is like in the Real World of private practice — this revolving door mentality, never feeling caught up, which is frustrating to doctor and patient alike.

(The other frustrating thing: when I left clinic at a little after 5, the support staff, including the schedulers who pushed me into this, were all long gone. As a matter of fact, when I was waiting for the attending on Wednesday, I asked one of the staff if I could bring my next patient back and then staff two together — she said no because “I’ve already cleaned all the empty rooms.” It was 3:45 and she was ready to go home.)

So folks, next time you are pissed that your doctor is running late, remember that she is just as mad as you at a totally broken system that serves no one but the administrators.

MS-4 · neuro

Waiter’s tip

Today when walking to the office, I saw a woman who was walking funny.  Didn’t quite know what was up at first, just that something was off.  So then I looked a little more closely, and saw that her right arm was held close to her side, rotated inward, stiff at the elbow, with her wrist flexed and her fingers curled in.

In other words, an Erb’s.

And then, as I was leaving clinic this afternoon, I saw a man walking with his wife, except with every step he kicked his foot out, like he was dancing a minuet. So either he had a strange gait abnormality, or my life is actually a musical. Both are valid possibilities!

(God, I love neuro.)

clinic · ethics · MS-4 · narrative medicine · neuro

I spoke too soon. Last night’s class was the best yet; the debate was really intense, and even the really quiet ones had a lot to say. See, that’s the power of a really great story — it attacks you and forces you, sometimes against your will — to pay attention. Moments like that really make me love teaching.

Today, workwise, I was down on the Eastside practice with my preceptor, and then seeing patients on my own in the residents’ clinic.  It ran the gamut. The Eastside is private, very classy with paintings on the walls, patients who have done their homework, pleasant staff. The residents’ clinic is in the old, old part of the hospital, with cinderbrick walls and tiiiiny little exam rooms — I think the one I was in used to be a closet. Not even joking.

Of course, the quality of care is no different, because these are the same doctors, with the same brains. But I can’t help but wonder how much the ambiance affects the patient’s perception of the visit. It really disturbs me, the extent of the rich/poor dichotomy here. (Fun fact: our ED is in a different building from the hospital because the donors apparently did not want the uninsured rabble being too loud for the private patients. And don’t get me started on the Fancy Rich People’s Ward.)

I suppose that in the end, it doesn’t really matter, because the doctors are the same, the medicine is the same, even the computer system is the same. How much difference can a pretty painting make, when you’re sick? Both practices have access to Really Smart People, and both function very smoothly. But as a patient, I definitely know which one I would rather go to — even if that induces a fair amount of middle-class guilt.

narrative medicine · neuro

Heureusement

In April 2009, France Alzheimer, a national organization created to “soutenir les malades et leur famille” (“support patients and their families”) released an advertisement entitled “Heureusement” (“Fortunately”). The commercial, developed by the advertising firm Saatchi & Saatchi Paris, stirred up a minor controversy in France due to its bleak and unrelenting portrayal of Alzheimer’s disease as a progressive, isolating illness.  Taken together, the ad and the response it generated demonstrate the fear that our society has at the thought of living with Alzheimer’s disease.

Continue reading “Heureusement”

books · narrative medicine · neuro

Dickens and Parkinson

I am making my way through Charles Dickens’ Little Dorrit for a class on the Victorian novel.  The Victorian novel concerns itself with society, not illness per se, so imagine, dear Reader, my surprise at coming across this:

Turning himself as slowly as he turned in his mind whatever he heard or said, he led the way up the narrow stairs. The house was very close, and had an unwholesome smell. The little staircase windows looked in at the back windows of other houses as unwholesome as itself, with poles and lines thrust out of them, on which unsightly linen hung; as if the inhabitants were angling for clothes, and had had some wretched bites not worth attending to. In the back garret–a sickly room, with a turn-up bedstead in it, so hastily and recently turned up that the blankets were boiling over, as it were, and keeping the lid open–a half-finished breakfast of coffee and toast for two persons was jumbled down anyhow on a rickety table.

There was no one there. The old man mumbling to himself, after some consideration, that Fanny had run away, went to the next room to fetch her back. The visitor, observing that she held the door on the inside, and that, when the uncle tried to open it, there was a sharp adjuration of ‘Don’t, stupid!’ and an appearance of loose stocking and flannel, concluded that the young lady was in an undress. The uncle, without appearing to come to any conclusion, shuffled in again, sat down in his chair, and began warming his hands at the fire; not that it was cold, or that he had any waking idea whether it was or not.

‘What did you think of my brother, sir?’ he asked, when he by-and- by discovered what he was doing, left off, reached over to the chimney-piece, and took his clarionet case down.

‘I was glad,’ said Arthur, very much at a loss, for his thoughts were on the brother before him; ‘to find him so well and cheerful.’

‘Ha!’ muttered the old man, ‘yes, yes, yes, yes, yes!’

Arthur wondered what he could possibly want with the clarionet case. He did not want it at all. He discovered, in due time, that it was not the little paper of snuff (which was also on the chimney-piece), put it back again, took down the snuff instead, and solaced himself with a pinch. He was as feeble, spare, and slow in his pinches as in everything else, but a certain little trickling of enjoyment of them played in the poor worn nerves about the corners of his eyes and mouth.

(Little Dorrit, ch. 9)

Frankly, that’s a better description of Parkinson’s disease than I’ve read in any neurologic textbook. James Parkinson wrote “An Essay on the Shaking Palsy” in 1817, when little Charles was still in short trousers. This annoys me, because wouldn’t be awesome if the first description of a disease comes not from the medical but from the literary world? Nevertheless, kudos to Dickens for being so observant.  (And by the way, Arthur Conan Doyle: you are a physician; surely you can do better than “brain fever” when you need to off a character.)

neuro · news · pharm

A pill for MS

First off, thanks to Chenoa, Lila, and MedZag for the kind words on the last post. It’s good to know that other people care about this stuff too.  I’ll keep you all updated in how the year goes.

Fingolimod
This is fingolimod; ain't it a beaut? (Image from Wikipedia)

In happier news, the FDA approved fingolimod in the treatment of multiple sclerosis! Up till now, MS treatment has been all intramuscular or intravenous. So this is an exciting step forward, to have an oral medication.  What’s more, a trial published in the New England Journal in February showed that fingolimod was actually superior to interferon in one-year follow-up. (PDF link; you’ll need Acrobat Reader and possibly a subscription to the NEJM.)

I had a patient with a new diagnosis of MS during my neurology sub-internship. (She had likely been living with the disease and its aftereffects for decades, but had never been diagnosed.) She was very squirrely around needles — we actually had to LP her under fluoroscopy because she couldn’t keep still.  My attending, resident, and I discussed her long-term medication plan, and I decided on weekly interferon as the best compromise between injections and relapses.  But I kind of want to track her down and say, “Look! We can do something to help you!”

Yes, yes, there may be long-term side effects.  In the trial, the high-dose of fingolimod was associated with two fatal infections, both herpesvirus.  This new treatment is not a panacea, and it may well turn out to be the new Tysabri, another highly-anticipated MS drug that led to progressive multifocal leukoencephalopathy. (I had a patient with that, too. It was ugly.)

But for now, at least, a very tentative thumbs-up to Novartis.

(Disclaimer: I don’t work for Novartis, and I don’t think I own their stock, but I’m not a medical professional yet either. This is not intended to be medical advice. Please don’t go to your neurologist and demand fingolimod; or if you do, at least have a better citation than “some med student blog on the internet.”)