Reaching Down the Rabbit Hole (28 page)

I ran into her recently at a medical conference, and she told me how, as a junior faculty member, she now has to conduct Chief’s Rounds when her department chairman is away. “Whenever the residents
present a case with fever and back pain,” she said, “I will say to them, ‘What is the one thing that will kill this patient if you miss it? What is the one thing you want to make sure it is NOT?’ They don’t know what to say because they’re supposed to be tricking me. They presented a patient with West Nile virus, and when I went off about protecting the downside, they looked at me like I had ten heads. But Harry Connaway’s autopsy changed everything for me. Ever since that autopsy, I see that ocean of pus in my dreams, and I say, ‘Don’t think about epidural abscess the way you were taught, because the way you are taught is not the way it happens. I know. I’ve seen it up close and personal.’”

The cases described in this book, with the obvious exception of the reminiscences and flashbacks, occurred within a span that covered two services on the neurology ward and two on the ICU. While each case was unique, the services themselves were representative. Right now, for example, as Elliott and I sit talking, we could go upstairs and find a comparable assortment of cases on our wards: some mundane, a few unprecedented, and at least one utterly fascinating. And they just keep coming.

Three men have been admitted, all in the same week, with remarkably similar symptoms. The first is a college student who was studying architecture abroad and began to have painful numbness in his feet and hands, with trouble walking. In the previous three weeks, his hair had begun to fall out. The second is a forty-one-year-old man who was admitted with an unusual blistering rash and confusion. He began to complain of a headache, and threw up repeatedly. The third is an Indian engineer who had two seizures at a pizza parlor, and came in very confused. All the tests were essentially normal, no one in the Emergency Department could sort it out, so they sent him upstairs to us.

As it turns out, all three men were poisoned over a period of weeks: the student purposely with rat poison containing thallium by a fellow student with strong anti-American views; the second with mercury by
his wife; and the engineer by an Ayurvedic skin cream, his chosen treatment for psoriasis, that just happened to contain arsenic. The moral of the story, I tell the residents, is that people are being poisoned by others and poisoning themselves all the time. Check for heavy metals, even in your sister.

Last Wednesday, a twenty-four-year-old plumber’s assistant came in. He said, “This is terrible, Doc. My arms have been getting weak, and now both of my hands are getting weak.” He had a dozen MRI scans at other hospitals, all of them normal. Again, nobody had a clue. They told him he might have ALS. His mother was frantic.

I did the exam, and said, “You’ve got a problem called Hirayama disease. Not seen much in the United States. Mostly in Japan. The ligament on the back of your spinal cord is buckling when you bend your neck forward, and all of your scans were done with the neck straight.”

I sent him for another MRI, and they called me from the X-ray department to say, “You’re wasting our time, it’s normal.”

I said, “Did you flex his neck?”

They said, “We don’t do that in the MRI scanner. That’s not the protocol.”

“You don’t get it,” I said. “The disease is defined that way.”

I bring the new scans up on my monitor to show Elliott. This is one of those cases where the right picture really is worth a thousand words, and the wrong picture is worth one. I show Elliott what the MRI looked like when they had him flex his neck. The ligament buckles, it bunches, it causes venous congestion, and it pinches the spinal cord. “Every time the kid leaned forward he compressed his spinal cord, and he’s a plumber. What it’s done over a year or two is damage the anterior horn cells in the cord, and caused what looks like ALS, but most definitely is not.”

There are eight million stories in the naked city, and we get our fair share of them. The narratives flow forth every morning when the team convenes in the conference room:

“Miss Staines is our seventy-four-year-old lady with COPD and
a stroke. She’s going to need a speech-and-swallow consult this morning.”

“Mrs. Henson is an eighty-eight-year-old lady with history of colorectal cancer, who also had a left MCA stroke in a setting of A fib. She had an episode last night where she was a little confused.”

“Dorothy Fitch has tingling in her toes after a GI illness, but normal reflexes. We still think she has Guillain-Barré syndrome.”

“Miss Tannenbaum, the twenty-nine-year-old lady with MS coming in with optic neuritis, blind in her right eye, she’s on p.o. steroids. We were going to talk to the outpatient MS doctor.”

“Kerry Norris, age nineteen. Complex partial seizure generalized into a tonic-clonic seizure. They gave her some Ativan and restarted her antiepileptic meds.”

“Eric Servi, thirty-eight-year-old man with congenital heart disease. He had a very strange anatomy of his heart as a child and has had many surgeries to fix it. He also had a stenotic subclavian. He came in with dizziness, and had a tiny punctate cerebellar infarct from an acute versus chronically thrombosed left vert. Wasn’t comfortable leaving so he stayed overnight.”

“Mr. Comstock is a sixty-five-year-old man with a history of squamous cell cancer under his left eye, likely an infiltrative tumor in the left orbit. He has been seen by just about everybody. No one wants to operate. We’ll need to go up the chain to the neurosurgeons.”

Welcome to the Ellis Island of nervous diseases, where the tired, the poor, the embolic, the metastatic, come through in wave after wave, and we examine them on every level, not just with scans or tests. In this brave new world, our approach has to be integrative, it has to be synthetic, it has to be elegant. It may seem messy at times, but neurology is fascinating partly because of its messiness, because it imposes order on chaos. And it is still the Queen.

“I got a call the other day during dinner,” I tell Elliott. “It was Callie, and she said, ‘I have this patient who has been in and out of
the hospital with seizures. He’s a complete wreck, unmanageable, and his tumor is end-stage and there is a ton of radiation necrosis.’ I said, ‘Sure, admit him.’ We put him on steroids, and he becomes calm, an almost serene bodhisattva.”

The fact that nothing bothers him suggests that his agitation was caused by the radiation, not the tumor. He is not at the level of hospice care. Steroids will keep him in line. He will die in a year or two if it’s radiation damage, and within months if it’s a tumor, but either way, his brain is altered enough by the disease or the radiation that he cannot have a true emotional reaction to what’s happening to him. He is in no position to appreciate on a visceral level the gravity of his condition. I could ask him, “Do helicopters eat their young?” And he would say, “Yeah, sure . . . probably . . . whatever.” I could tell him that he is going to die in a week, and he would say, ‘Oh, really! Die in a week? Okay.’”

That might sound philosophical, but it is not. It is the response of a damaged nervous system, and in his case, damage to the place that supplies him with an awareness of threats to his existence.

“He lacks insight,” I tell Elliot, “and even seems to know that he lacks insight.”

“How is that possible?” Elliott says. “How can you be aware that you don’t have insight?”

“I’ll have to get back to you on that, but apparently you can.”

People walking down the sidewalk in front of the hospital might find that question interesting in theory, but the minute they pass through the revolving door, all they care about is one thing: “Am I going to live or am I going to die? You better figure it out for me. I don’t care how you figure it out. There may be eight million stories in the naked city, but I only care about one of them. I care about my story. How’s my story going to end?”

What I would say to them is, “I hear you, I’m working for you, working to make you better now, working to help you survive, even if the news is bad.” What I would like to add is, “
and you can’t imagine
what goes into that
.” It’s not like being a butcher, a baker, or a candlestick maker. We’re trying to understand how the brain works so that we can fix it. We do the job, but we don’t dwell on high-flown philosophical implications: What is consciousness? Where is the soul?

We may be interested in such questions, but up on the ward we don’t care because every grand theory of mind and every sweeping generalization about consciousness falls apart when exposed to the cold, hard facts of a single case. Instead of theories, we need clinical truths: What’s wrong with this person’s brain? Can we get it back to normal or some semblance of normal? Can we at least get them on the right track? When we can’t, the question turns grim: How will I walk this patient and this family through this all the way to dementia or death? Because the job doesn’t end with the diagnosis.

Once a week, we make the trek up to the neuropathology lab, where the residents each take one of the eight places at the teaching microscope while the Chief of Neuropathology runs through the histology and morphology of biopsied tissue from some of our tumor cases. The stained tissue samples hold the evidence. The jury could go either way. Elliott usually gives me a meaningful look when bad news seems imminent. Then I know he is thinking of Max von Sydow in
The Seventh Seal
.

We all invent notions to reassure us and lies to protect us. Elliott calls these distancing techniques. His are largely cinematic. “We have just spoken to Death,” he sees himself telling the patient, “and Death has told us your time has come.”

Death, for Elliott, is the Chief of Neuropathology. What we hear Death say up in the lab may sound opaque to the man on the street, but not to us.

“Notice how very densely cellular the tumor is,” the Chief intones. “It displays pleomorphism of nuclei, which means nuclei of different sizes and shapes, and then mitoses, very many, and thickened blood vessels with prominent endothelial cells.”

The Chief is a refined and cultured man, descended from European
royalty, who is oblivious to the fact that Elliott has cast him in a Bergman film. He delivers his lines in a detached and didactic way. “We haven’t found necrosis, but already this meets the criteria for glioblastoma. You can see the tremendous crowding, the piling up of cells, a very serious problem. The gradation of astrocytomas is one, two, three, and four, and for four, the highest grade, it includes the presence of mitoses and cellular proliferation, which we have in this case.”

All very interesting, all very edifying and matter-of-fact, but at the other end of the hospital, Mr. Gerrity, a retired firefighter with a close-knit family, the man whose brain yielded up this specimen, awaits the verdict, and Death has delegated to us the task of breaking the news. For the Chief, it’s a wrap, his job is done. But for Mr. Gerrity, for his family, and for us, it’s Pearl Harbor, and World War II is just beginning.

I have a friend who is one of the leading trial lawyers in Boston, a specialist at handling murders, and he was very down recently because he had just lost a case. Even though it was clear to me and to him that his client actually did the crime, he felt bad because the guy was going away for life.

“I can sympathize,” I told him, “because I know what it’s like to lose one. It’s an irrevocable life sentence, and you will always wonder if you did enough.”

When I go to the ICU, I routinely encounter situations in which a slipup can deal somebody a life sentence, either being crippled or dead. During my ward service, chances to slip up might occur several times in a day, and because I have to work fast, my exposure to this kind of downside loss is enormous. I have to go without the contemplative time afforded a trial lawyer: time to scrutinize and adjudicate every detail, time to follow clearly enumerated rules of evidence, time to adjourn if necessary. Every day I might go through what my lawyer friend goes through three or four times a year, with the same kind of outcome, on a knife’s edge, and at the same level of responsibility.

What is it like to be always on the brink of your next big mistake? How do you manage as a physician in a high-stakes game in which
you are definitely going to make some people worse? All you can hope for is a very much higher proportion of people you make better. You can’t be in this business if you can’t live with the risk and the deep disappointment of bad outcomes.

How would I sell
that
to Gilbert? I wouldn’t even try to sell it to him. He is in medical school. He will figure it out. Instead, I periodically have to sell it to myself by fighting off the cynical realization that Disease (with a capital D) almost always wins, that we only occasionally win. We insist that this is not the case in order to maintain our sanity, if not our molecular structure. But that’s all right. A day at the hospital is not transformative. At best, I can walk out knowing that relief of suffering is what we’re good at, even if society needs to believe that what we’re good at is cure. It is to everyone’s benefit that society believes that. All of us—patients and doctors—cultivate the fiction that science conquers all, that it can provide the cures. How could God have created a world in which it can’t? We need to sustain our faith in science, our paradoxical belief in its divine power. We have always had to believe that, going back to pre-Hippocratic times. “I’m going to give you a potion, it will solve your problem.” That statement promises some control over mortality and destiny. That’s why what we do is as much shamanistic as medical, because society cannot relinquish that hope, the belief in the curative power of something, of medicine, of prayer, of diet, of therapy, of sheer expertise, of connecting with another human being, rather than acknowledge that the universe is like the eye of a dead fish: cold, uncaring, unreflective, unresponsive.

“Have you ever noticed,” I ask Elliott, “that during a code everybody is huddled around, everybody has a job, everybody’s engaged, and the focus is on both the patient and the electrocardiogram? But the instant it’s over, the moment they call a failed code, everybody just turns on their heels, and if you’re still there, spending a last minute with the body, you see this amazing thing, almost like a ballet. They just drop everything and walk away, and you see their backs.”