The iris is ignored. Unless there is an iridectomy, and irregularity, ophthalmology goes right past the iris after checking for sufficient anterior chamber depth. But I think it's gorgeous. These pictures on the web discuss the beauty of their subjects, but they miss the patent fact that the iris is a thing of beauty in ninety year old veterans, too.

Look at that thing. The texture is wonderful. Irises like Saharan sand-dunes, like kelp in the Pacific. And when you look at it, it moves, contracts, bunches up and then relaxes. Sure, lens, retina, fovea, hemorrhages, optic nerve, blah, blah, blah. But let's not forget the beauty inherent in our patients in or mad rush for pathology.

Wear Your Seatbelts

A classmate recently had a roll-over accident and sent out a mass e-mail reminding people to wear their seatbelts with pictures of his car.

I prefer to remember a couple of patients. It would start with a funny feeling, and then the pager would go off; a text page. Level 1, 24-yo unbelted ejected driver high-speed MVA, GCS 3. Then some vitals, unstable. His arrival is busy, scrubs, x-ray lead, and gowns blur around him, while I remember his head, bright red from across the room. His scalp is bleeding. His nose is bleeding. His ears are bleeding. He bleeds around his intubation. The blood pools in the antihelical fossa of his ear as it drains out of the canal. Blood, blood, blood. We take a stapler to the scalp, which is the trauma way of treating a minor injury. One can only imagine what his brain looks like. I clean the blood from his nose for a while, then stop. There are bigger problems.

Or, in rehab, another young man, recovering from an unbelted ejection from his car. He had been on his way home from picking up his brother upon return from Iraq. It's not hard to imagine, and indeed forgive, the idea of stopping for a few beers. Now, months after his injury, he can't speak, walk, or remember three objects you tell him to remember for more than five minutes.

So yes, wear your seatbelt. Put your children in their car seats. All the king's horses, all the king's men.


Can't Escape the Psych

'I don't know. I can't localize his lesion; he's had three episodes of left-sided weakness, he says it came on suddenly followed by headache, and he had pins and needles on both sides. So, if we were to go with one lesion, motor only, let's say, that could be his right internal capsule...but to have three episodes that resolve completely and last for days?'

Dr. S strokes his beard, says a non-commital 'yes', which means, 'I'm thinking of how to tell you what I think', and says, 'I don't think he's had a stroke. At this point, I'm hesitant to call it conversion disorder...there's always a kernel of truth to these. And, just because this isn't, quote-unquote, real, doesn't mean he can't have a real stroke'.

'What about the one-sided migraines that affect 0.00005% of the population?'

'Well, it doesn't fit the onset...and before you really go and lay your nickel down and say, 'I think it's migraine', we would need to rule everything else out...'

Conversion. As in conversion from the brain to the body, crossing the border, if there is one. Conversion disorder occurs most in young women with other psychiatric diagnoses. As in, 27-yo female w/hx of OCD presents with acute onset of bilateral pins and needles in hands along with right-handed weakness, worse in her fingers than wrist. Oh, BTW, she just had a huge fight with her boyfriend and he's moving out. There's no explanation for her neurological complaint. None. You can't put it anywhere in the CNS. So the patient 'converts' their emotional stress into a syndrome that fits their own idea of illness, and makes it real. The opposite of self-help.

Or, factitious disorder. The patient fakes it, but in order to take on the role of the patient, be cared about, get tests, perhaps in an attempt to compensate for some loneliness curled around their heart. We look at their hearts, often, with sound waves, with dye. We don't see the loneliness.

At extremes, people may contaminate their own surgical wounds, give themselves thyroid hormone. An historical precursor was named after a German baron, Munchausen, who told amazing tall tales upon returning from a war with the Turks.

That's him. But the idea that these patients are making up their lesions is somewhat more sinister than his tall tales of riding on a cannonball, or pulling himself out of quicksand by his beard. I've blogged about one before, the patient below who would put her head in the pillow to drop her O2 saturation. Perhaps not faking, but on a spectrum from the professional patient to Munchausen's.

Or, most distasteful, described in my lifetime, Munchausen's by proxy, in which a parent, usually a mother, makes their child sick deliberately in order to receive care for themselves. Perhaps I won't say any more about that.

These people are included with malingering in some articles, people who are faking pain, for example, in order to obtain narcotics. But I don't see them in the same spectrum. Imagine being so lonely that the attention of a stress test relieves some need; that the clustering of your family in a tiny room, with the gentle beeps of IV monitors to guide you, starts to feel more familiar and comfortable than home, or what passes for it. That seems worse than wanting narcs bad enough to complain about abdominal pain, a lot.

My world tilts a bit more towards the bizarre; or, more likely, I see a bit more of what's real. I still can't let go if the idea that he has the migraines that cause paralysis, and that's he's in that 0.00005%.

Anisocoria and PFO

25% of us walk around with a hole in our heart. When we're little, the foramen ovale allows blood flow from right to left without having to go through the lungs, which don't work right. But in up to 1 in 4 of us, it doesn't close, and we're never the wiser.

20% of us walk around with unequal pupils, anisocoria, which is a finding on neuro exam.

Just something to think about. Not all that looks broken, is.


Trach, PEG, SNF

"So, someone like this, who is already on the borderline of having her husband take care of her at home, with a major cerebrovascular incident, it's unlikely she'll be back...it looks like she's headed for", count them off on fingers, "trach, PEG, and SNF".

As in a tracheostomy, because she can't breathe, a PEG tube, which allows us to dump food directly into her stomach, and a SNF, or skilled nursing facility, which some used to call nursing homes.

She can blink, but can't tell her right from her left. She easily coughs with the whole-body-but-silent cough of necrotizing pneumonia on a ventilator; the sound doesn't come out, but all the lines on the ventilator go crazy. When she came in she couldn't even move; she was in a seizure that wouldn't let her move that lasted forever and a day. Status epilepticus.

She has infarct upon infarct upon infarct in her brain, three, layered, all of which could result in her waxing and waning weakness on one side; one way it is described is as an anamnestic respose, literally an 'unforgetting' that the brain engages in when put under stress. Old strokes become new again.

I keep wondering where mercy lies. The triad, the trach PEG SNF triad, an epithet, a plan, an epitath--would I want to be kept alive? Are these still people who can live meaningful lives? The same question comes up again and again for the 30-yo in an earlier post, off ventilator, on ventilator. He's strong, responsive, too. He can open his eyes sometimes, squeeze fingers, communicate. He was trached and PEGed today also.

The choice to withdraw care is somewhat like the choice to have an abortion. People who haven't stood in that circumstance can't know what it's like, and that includes me. If it were my parent, or aunt, or uncle, or spouse, I might want to keep them alive as long as humanely possible and longer. If it were me, I might be more cognitively aware than I thought. Would I feel trapped and ready to go, or would I cherish every flicker of light I could see through the skylight of the intensive care unit?

I guess we'll have to wait and see. My only advice from three weeks of seeing people vanish into their own bodies is that judgement on any decision about end of life care is not something to be taken lightly. Someday, we all might be trached, and PEGed, and SNFed.