Ponder This: The difference between a neurotic and a psychotic is that, while a psychotic thinks that 2 + 2 = 5, a neurotic knows the answer is 4, but it worries him.

That's Me

His CT scan looks worse than this one. And it's on the other side. The 'hypodense' areas on scan are dead or dying brain, the fluid build-up from a massive stroke.

Down the middle you can see the ventricles on the left side of the image, which is the right side of the head. Not only are his ventricles effaced on one side as here, but the midline is being pushed into the other side of his skull--or, at least, it was, until the neurosurgeons took the skull off. That's the treatment of choice. Brain swelling from a massive stroke, young, 'juicy' brain (said with a straight face, it's not derogatory), and a young guy has 80 plus-percent mortality with medical treatment alone, cut to between 47 and 53 percent with the removal of the skull piece.

His family has camped out in the elevator lobby between two units; there are constantly ten to fifteen people there, men women and children, with air mattresses, portable DVD players.

On day 4 after surgery, a repeat CT is, unfortunately, even worse; in addition to the right-sided lesion, there are new, bilateral, occipital lesions. He's now likely blind; the area at the back of the skull processes vision.

The walls are plastered with pictures of the patient and his wife, who is seven months pregnant, on an ATV, dressed up at their wedding. Their three year-old daughter with straw-colored hair, who, when I first see the patient, is standing next to the bed, looking up at the parade of coats; she can't even see her dad from the floor, the bed is too high.

He had a headache. He went to the chiropractor. His headache got worse. Then he lost consciousness. That's it. Done.

Should he come back? His vitals have leveled off, temp is stable, BP is controllable, ICP (the pressures in his head) are low, which is a good indication that the swelling is down. But his brain is jelly. Or, at least, half of it. Paralysis, loss of sensation, slurred speech, blindness. Neglect. Not of his children; of half of his reality. Since it's in the half of his brain that's likely non-dominant for language, he won't be able to put his world together. If you show him his left arm, he won't know that it's his own arm. But he won't be able to move it anyway. Does that mean they cancel out?

There's a steel of spirit needed to even enter the room that becomes second-nature to clinicians for defensive reasons. If you allowed these cases to get all the way into your head right away, you'd just cry in the broad, antiseptic hallway and then leave for the day, desperate to return to fresh air, movement, life. Within that context there is a feeling of helplessness, a knowledge that we've built to acquire that tells us how long the road to recovery will be, and how incomplete his return will be. He has truly put one foot in the grave, and I'm not sure if he can come back.

The family wants him back. Of course. But do they want him back? I don't know, I've never been the caretaker for a massive stroke victim. The question is worth asking. Death is not always the worst option, is it?

Every morning, we go in and push on the beds of his fingernails to see if he withdraws to pain, pull open his eyelids and shine lights in, rock his head back and forth gently to check for eye movement, try and decide if his periodic writhing movements are purposeful or stereotyped and primitive. Primitive because they come from a part of the brain that predates the concept of history. That breathes for us, sets heart beat, controls the myriad of daily control tasks, provides basal input into the motor system so we don't have to coordinate the thousands of muscle motor units involved in every single action.

He's me. Thirty. Kids. Healthy. He wasn't being risky, wasn't skydiving, wasn't drinking. Just got a headache.

The leading cause of death I have to worry about is still trauma, and yet I manage to ride my bike to work every day. But sometimes patients get to me not just because they are suffering, sick, and beautiful, but because it's so easy to put myself in their shoes--or, more accurately, in their compression stockings and compression devices, balloons that inflate rhythmically from the bottom up around each leg to ward off clots.

Grief wells up like air underwater which I cannot breathe.


Free Little Bird

One last psych post.

HL sat up in bed when we talked to her with glasses on, a tiny whisp of a woman, reading. The muscles in her neck were prominent, and her collarbones were more visible than normal as they joined the sternum, prominent above the collar of a baggy grey sweatshirt.

There's a Lisa Loeb song for kids that came into my head as soon as I saw her.

I'm as free a little bird as I can be...Gonna build my nest in a big oak tree, where no one can never bother me...

She had tried to end it all. Why? Well...her husband, who she had married only a year or two ago, had said he wanted a divorce for no reason and was apparently having an affair, but they were still living together, and he apparently changed his mind daily as to whether he wanted to actually finalize the divorce or not. They slept in seperate beds. She had a long history of sexual abuse. She had a history of anorexia nervosa; and she had OCD. She counted. She would look up and count to distract herself from troubles. She was a recovering alcoholic, and had fallen off the wagon. Hard.

I suppose I would too.

Normal conversation for B6/5, actually. But the most interesting part came when we talked about her drinking. She had started a new job and not told anyone she had an alcohol use 'issue', then gone out one night and, well...she said one drink led to another and to another.

"Did you have a feeling associated with this relapse?"

"Freedom", she said, clearly, after thinking for a fraction, and pushed her glasses back into place with a tremulous hand. And, despite my feeling about alcoholism and what it does to people and families, I thought to myself, go on, build that nest. Better you climb into the oak tree where no one can bother you than go back to a house where your nutso hubby emotionally tortures you with the daily possibility of divorce. And this for a person who by temperment and disorder has a need to control her reality to a degree that natural drives are the enemy to be kept at bay by castle walls of restrictive behavior and rituals. Imagine that. And for that relapse, that evening, she felt free. It almost killed her.

I'm struck at how strong and fragile we are at the same time. Not least of all this one, who, despite it all, was an executuive for marketing at a major national brand. Free as she can be, drinking deep red wine, one tall glass after the other.


The Onion must have known it was my last day.

Or they wouldn't have printed this awesome meth article,

Which is both hilarious and sadly accurate. Enjoy, while I enjoy a brewski having finished a month in the bin with the looneys, who I will miss and who I hope will continue to improve through thoroughly effective psychotherapeutic and pharmaceutical intervention.

Talk at ya soon, A



Through the central square of the hospital, three walked, in clean, short, white coats. Their newness was a beacon; the shining, spotless coats, clean-shaven faces (just so happened they were all guys).

The only people who have spotless white coats in the hospital are the new medical students and the attendings. The attendings have spotless coats because someone washes and irons them for them in some mysterious way I'm sure I won't find out until the day after the end of residency. But you can tell, given the creases in the sleeves that every attending has, they don't all get up themselves and iron their coats at four in the morning. If that were the case, some of them would be bound to skip it.

And the new medical students, their coat is probably still fresh from the ceremony that starts medical school. They don't have the ripped pockets from stuffing them full of extra books in a vain attempt to ward off ignorance. Or, for that matter, stuffing lunch into them, or even a drink. I saw one experienced resident fit a full cup of water with no lid on it into his pocket to pass through the ICU, then take it out again on the other side. Only one of the reasons he was a mentor.

No coffee spilled from late nights, no staining chlorhexadine scrub from washing hands after going to see a patient with C. diff (actually, soap and water is probably good enough, but tell me that my first week of medicine). No gunk from the chest tube removed a bit too briskly.

What's amazing is how close I still am to those spotless students. We acclimate quickly, and after only a semester I and all my colleagues have strong, strong opinions on diagnosis, treatment, current issues. We aren't always right, but increasingly, we are. And to think, six short months ago, I felt as though I hadn't a clue. Don't get me wrong, I'm still not competent, but getting there.

The coat must also be some metaphor for training. It's no coincidence that it's spotless only at beginning and end. The training drags you through the mud of humanity and your own self for years to re-forge you on the other side. And we ask for it.

So those new students inspire feelings of relief that I'm finally learning the 'real' stuff of medicine, 'living the dream', and not just watching it on PowerPoint. But their spotlessness reminds me how far I have to go, how I'm still deep in it. And, truth be told, the clean coat of the attending is a different clean; a clean of someone who has learned to live in the midst of medicine. A clean I'm not ready for yet. For now, I'll stick to the proud, battered coat I have, with the ripped sleeve, torn pockets from overstuffing and running into corners rushing to finish my scutwork before rounds, and stains from Lord knows what. Until I earn the longer coat.