I'm Sorry, Man

The picture here is from the first page of Beowulf--not the CGI version that was produced with Angelina Jolie but the oldest surviving piece of English literature. It's a testament to how important words are, and for how long we've struggled as people to get our meaning across.

Imagine, then, not being able to find your words. Imagine speaking in truncated sentences, stopping in the middle, fumbling. This is a finding called non-fluent aphasia. Sudden onset of speech difficulty is often listed as 'slurred speech' in stroke education, but that is actually dysarthria and comes from loss of control of the muscles of the mouth and tongue to some extent. Aphasia is a stroke that somehow involves the higher cortical functions of language, and patients literally cannot find the words they need.

A gentleman came in with this last week. It had first happened in Mexico, on vacation, and then resolved somewhat; it had returned four hours before arrival and it was his only presenting symptom. Histories like this make me sad. It was no doubt what he had. There was an upside--he had very few deficits. But imagine not being able to find words anymore.

Imagine being mute not from some physical ailment but from literally not being able to get to that word or phrase that is dying to come out. It happens to all of us (ironically, for me the other day when I was trying to remember the word 'dysarthria')--but this is different. He stopped in the middle of almost every sentence, and he made grammatical mistakes normally heard in an ESL class.

His main question? When can I go back to work? He worked in business, had meetings all day. Not soon, dude. Not soon.

The Laying On of Hands

Today at conference we ended up going around the table and swapping stories like geezers comparing fish. Here, in no particular order, are some of my favorites.

Elderly, gaunt gentleman with a giant sternal scar from a CABG comes in with nausea, vomiting, and a mass pushing up like a grapefruit just below the lower edge of his sternum. I walked in and started to ask questions, nonchalantly examining his abdomen at the same time. He was going along while I noticed a large hernia, probably at the base of his old CABG incision, and gently applied steady pressure for twenty or thirty seconds. Pop! In it went, and his lump was gone. "Cured", I said. He stayed for a couple hours for observation and went home. Priceless.

An elderly granny, cute like only old people are cute, took her morning beta-blocker and promptly 'bradied down' into the thirties, starting to get loopy as her heart rate dropped. We came over to see her, and my intern, having just pimped me on the antidote to beta-blockers--glucagon--proceeded to fix her with one dose. Way, way cooler than atropine. From an intern. Big shoes to fill, big shoes.

One man, having a full-on, strength-sapping, one-sided-weakness-causing, speech-slurring, tragic stroke, sneezed. And was cured. No joke.

Scruffy, unshaven construction worker comes from the bar, not for trauma, or a fist laceration from someone else's tooth, or alcohol poisoning, but for supraventicular tachycardia, narrow peaks of anxiety ticking along regular as clockwork at about 160 or 180 sitting in bed. Joe, the attending from Chicago who's seen everything and works nights as if he's of the undead, walks in, nonchalantly. We prepare the adenosine, get a line. Joe says, head cocked to the side, "try something for me...bear down like you're going to the bathroom." So the scruffy guy valsalvas hard, and beep...beep...right down to about 75 or 80, normal sinus rhythm. He sticks there, too. Beautiful. About 1 in 4 SVT rhythms will break with a valsalva maneuver. Free, easy, all-natural, organic medicine.

Here's to the fun cases.

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.