Moral Obfuscation

I said below in the Cat Scratch Fever post that I would return to the act of moral 'obfuscation' when a patient didn't have a complicated, Zebra-like diagnosis but rather a common one.

Obfuscation isn't the right word. More like moral ambiguity. As famously defined in the movie Girl, Interrupted, ambivalence means being pulled in two directions. This happens more with dramatic cases and sick patients than with routine visits.

As medical students we're all pulled in two directions when people are really sick. On the one hand, I feel bad for them and hope they are well. On the other hand, which is not exactly the opposite direction, I am often excited with dramatic cases because I get to do something exciting. Then I feel bad. Then I realize that this curiosity leads to learning which benefits patients. Then I feel bad again.

It's the ambiguity of feeling you are in the right place at the right time and have a purpose in life, and that time and place is not a happy place. At least for others.

Merlin Deficiency

Neurofibromatosis has two types; medical students are taught to think of it whenever they see cafe au lait spots, literally 'coffee with milk' according to those crazy French people who, as Steve Martin says, 'have a different word for everything'.

A couple interesting things. We associate these with all sorts of syndromes in children, but it turns out that something like 1% of caucasians and up to 27% of african-americans have 1 to 2 spots (as found and presented well by a classmate). Like unequal pupils, most of the time this doesn't mean disease.

Still, neurofibromatosis sydnromes are associated; these people deal with a variety of tumor types that grow out of Schwann cells, normally responsible for covering peripheral nerves in myelin, a sort of insulation that speeds transmission and makes life possible. Depending on the type these can be on the skin or, commonly, in the eye or ear.

But the real reason to post is that the alternative name for the gene in type 2 is 'merlin'. As in, the wizard. So, it's correct to say that the little girl receiving chemo down the hall right now for a resistant optic glioma has a shortage of magic in her life; specifically, a shortage of tall, long-bearded wizardry.

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.