The Million Dollar Decision

The first day I started my job as an attending neurologist, one of my mentors told me the most difficult part will be balancing work and personal life. I didn't believe him. Just 1 month out of residency, I thought the challenge would be making difficult medical decisions, being able to see a large volume of sick patients without letting the stress overwhelm me, and managing complicated disease states. I thought the challenge would be doing a good job.

When I reflect back on my life, I've always been motivated to do well, and I've always worked hard. I've been successful in a lot of different areas but I have of course often dealt with rejection and failure. After residency I interviewed for 3 movement disorders fellowships and was rejected. But I've taken the same motivation and intellectual curiosity that I've applied through high school, engineering school, medical school, and residency to my first "real job" as a general neurologist. When things are challenging, I ask more experienced physicians for help, make phone calls, and review literature. Neurology is not an easy career, but I've been able to be successful because I bring knowledge, an inquisitive nature, and hard work to every patient. It's a bit cliche, but I like to approach every patient as a puzzle that needs to be solved, although often there are not answers.  My success has been recognized and I was unanimously voted in to be offered partnership in our private group after my first year. Accepting this would double my salary to at least half a million each year, maybe more.

I've been able to slowly earn the respect of many patients and physicians. But then there are the puzzles I can't solve; patients who are progressively getting weaker with no explanation, the intractable headaches of unclear origin, the rapidly progressing dementia in young patients. At times I feel powerless to change the course of events.

And of course there is the challenge of balancing work and my personal life. There are the nights where I work till 8 or 9PM. I probably average at least 60 hours a week, more like 70. The days I am not working, I am often driving to see my fiance in Columbus. I know my absence is hard on her sometimes, and she is not happy when I'm late. On our second or third date, I had planned to make a nice dinner for her, and unfortunately had a Spanish speaking clinic patient added on at 5PM which delayed me an hour. In my haste, I ordered pizza hut instead. My time is in high demand, and I know she works as hard or harder than I do. She has moved to cloudy Ohio when she would have preferred a sunny beach somewhere else some days. My parents and family also would like to see more of me.

I recently interviewed for a neurophysiology fellowship at Ohio State in Columbus, Ohio for 1 year. At the end of this training, I'll become proficient doing EMGs and better at reading EEGs.I'll have exposure to a few of the rare causes of neuromuscular disorders. It's hard to walk away from my hometown, my patients, and a very lucrative partnership offer.  If I accepted my partnership offer, my salary would increase to around $570,000. By leaving, I may be losing  approximately $800,000 in salary over 2 years although it would actually be a lot less than that accounting for taxes. However, I'd be working quite a bit less in fellowship with no weekends and no call and I'd be able to spend more time with my future wife. I've thought about this a lot.

The decision to leave is based on a decision of love for my fiance and optimism that I can be a better neurologist by doing extra training and learning more. I do not think that I'd be happier making more money since the most important things in life can't be bought, although I would like to give that money back to my family and the community. I hope to return to Cincinnati with my wife after finishing this fellowship. But I suppose I should mention the minor detail that I have not been formally offered the fellowship yet, but I expect to get it!

The Best Day of Our Lives

Maybe I've been able to help people on some level through my life, but I have never given anyone the best day of his or her life until January 23, 2016 on the day I proposed to my girlfriend.

By October of 2015, I knew she was getting a bit restless. Was this serious, or was she wasting her time? Things weren't always perfect, but I had made a conscious decision that I never wanted to lose her, and I only wanted to see her happy. We went engagement ring shopping at Tiffany's. The name itself is so respected, that I thought it would be a surefire success. Surprisingly she could not find anything that suited her. Now that we had been dating over a year, it was becoming easier to tell when she wasn't happy. At this point, I knew it was going to be a process. I wanted to do it right, and I wanted her to look back on the proposal with nothing but fondness and love.

I ate dinner with my parents soon afterward and told them I was planning on proposing. They were happy. I emailed her parents and asked for permission. They were thrilled.

She emailed me photos of rings she liked. I searched a few jewelers in the area, and eventually came across a place in Hyde Park that had something that appeared perfect to me.  It was the upper limit of what I was willing to spend, but I knew that I did not want to compromise or cut corners on the engagement ring. So I purchased a ring with a very nice oval shaped diamond. The stone was GIA certified with a D color category (perfect color) and I think maybe VSI (very small inclusions) quality level. I paid $5,900, and waited patiently 10 days for the stone to get fixed to a very nice titanium ring. It was a ring that was unique and nearly flawless. The diamond reflected the light in a way that was captivating and captured your attention and intrigue every time. I purchased the ring at the end of November just after Thanksgiving.

And then there was the waiting...

It was rare for us to have a weekend off together. The cold winter months threatened to make our commute from Cincinnati to Columbus potentially challenging. I was in India at the end of December for my cousin's wedding. I had a great time celebrating his wedding and meeting family. But at the same time I was struggling to determine how I was going to make our proposal special. I had thought about proposing in Columbus, but eventually I figured the familiarity of home in Cincinnati would work in my favor.

I watched a few episodes of How I Met Your Mother. Around the end of season 1, Ted Mosby hires a string quartet to surprise Robin in her apartment when he asks her out. Who does that?

I exchanged emails, and eventually hired a string quartet. I left them instructions to wait in my apartment at 4:30PM. I would knock on the door and they would start playing Air on the G String by Bach. She liked Taylor Swift and I like the Beatles, so I asked them to play those songs too.

Snow had hit Cincinnati on the Wednesday before the proposal. I was getting back from work around 8:30PM and was driving down a steep hill covered with a thin layer of snow. My little VW Rabbit slipped and I lost control. The car spun out and did a 180. Thankfully I was safe and no damage was done. Other cars drove around me. I breathed a sigh of relief and made it home safely. The forecast threatened for even more snow on the Friday before the proposal.

My anxiety climbed, and I spoke with her father. He wanted her to come Saturday to avoid the storm. I knew she would be upset, but on Thursday I told her to wait 1 more day. I needed more time, and I used the threat of snow as an excuse to cancel my clinic on Friday. It gave me time to buy roses, clean the apartment, and buy groceries. I purchased a nice Servatii's chocolate mousse cake in advance and had the baker write our names in icing. My parents picked it up.

I went in to work at the hospital Friday afternoon and was able to finish quickly. By Friday at 5PM, there was no snow in Cincinnati. The forecast was wrong. I called her father and asked for his permission for her to come sooner. He reluctantly consented, and she drove down Friday night. I had a nice taco dinner with red wine and dark chocolate waiting for her. She loved it.

On the day of the proposal, I asked her to wear something nice. I wore a tie which was unusual for me outside of work. She wore a white dress with a black cardigan sweater over it. We looked nice, I won't forget it. We went to lunch at the Rookwood in Mt Adams and had a nice salad and veggie burger. I managed to get a small grease stain on my tie. We still had 2 hours to burn before the 4:30PM surprise engagement. So we drove down to Newport Barnes and Noble and I read a headache book while she worked on coursework for residency. I went to the restroom and took one last look at myself in the mirror around 4PM. I was satisfied, and we drove back to my apartment. I told her I was tired and pretended like I was planning on taking a nap when we returned. My parents had let in the quartet and her parents to my apartment.

I knocked on the door to my apartment, and we were greeted by Bach Air on the G String just as planned. I brought her in and our parents came by. I picked up the ring and flowers from my bedroom which I had kept hidden. And then I got down on one knee. I opened the ring box, I think it was upside down so I flipped it. "You make me so happy, and I want to spend the rest of my lives together. Will you marry me?"

There was a minor grammatical error. I think no one noticed. I started to wish I practiced in front of a mirror. I think she said Yes. I couldn't hear her over the music, and I was so nervous I might have missed it. "I don't know what to do now." Neither did I.

I tried to slide the ring over her finger, but it got stuck at her proximal intercarpal phalangeal joint. I got nervous. Would we have to resize the ring? But she gave it a bit more gentle force and it fit perfectly. I gave her a hug and kiss. I hugged my mom and shook my dad's hand.

We all had a few drinks of water (her parents do not drink alcohol) and enjoyed the quartet's music some more. They played all of the well known pieces: Canon, Viva la Vida, and Claire de Lune. I looked over to her and she smiled. She said her heart was still beating 150 times a minute. She didn't seem like the type who would like surprises, it almost felt mean to spring this on her.

We drove back to my parents' house in West Chester where my mom had lovingly prepared a nice dinner for everyone. My sisters and her newly engaged brother and sister-in-law to be came to dinner as well. We celebrated and had a delicious meal. My brother in law who was working called to congratulate us.

My older sister drove me and her back to my apartment and congratulated me. My new fiance looked at me with wide eyes and smiled ear to ear. "You're the best!" She texted all her closest friends.

The next morning we went for a short and light workout session. We ate left over tacos and chocolate cake. She told me, "It was the best day of my life! Was it the best day of your life?"

All I had to do was say yes. "Well it's definitely in the top 5. I'd have to contemplate each of those days and compare them side by side to decide." (All I had to do was say yes). "I've had a few tasty donuts and well I've never given anyone the best day of her life before... Yes, yes it was the best day of my life."

"So the day you proposed to me wasn't as good as the time you ate a tasty donut?"
"No, it's just that I never thought about comparing the two."

Maybe it was the stress of preparing everything. The unpredictable weather, the fear of rejection, or the chance of getting pooped on by a bird or having my fly unzipped on accident led to a lot of anxiety leading up to it.

I have never given anyone the best day of her life before this. So yes, it was all worth it without a doubt. But I don't think it was the best day of our lives. I think it was the best day of our lives so far.

A One Man Army

One of the major benefits to joining a large, well established private practice neurology group is that there Is a wealth of experience surrounding me. If I have a difficult patient or tough question, there's 12 other neurologists who are just a phone call away. The grim spectre that hangs over our heads is that the mean age of our neurology department is probably around 60, and there are at least 2 neurologists who are 2 years away from retirement. If they leave, a surplus of patients will have to get redistributed, and the manageable 1 weekend per month call schedule could become a significantly less manageable 1 weekend every 3 weeks.

Dr. Z embodies the self-sufficient 1 man army. He reads EEGs, does EMGs, has botox clinic once a week, does his own blood draws, and thankfully for me, he takes weekend call at least 1 in four weekends, making my call schedule less. Of course, he has accumulated a well-deserved fortune for all his hard work. He has a daughter who followed in his foot steps and currently works as a neurologist at Northwestern.

He also has CNS lymphoma, which luckily, is in complete remission.

The first weekend I was supposed to take call, my hospital credentials got delayed. Dr. Z magnanimously stepped up and took my call that weekend, which was historically busy.

4 days later at the end of his botox clinic, he was unable to move his right arm. He convinced our MRI technician to get an MRI of his brain. Dr. Z read his own MRI, and saw a punctate area of diffusion restriction confirming a small acute ischemic stroke. He burned the image on to a CD, and drove himself to a nearby hospital with the CD in hand.

In the emergency room, a neurologist from the UC stroke team offered him IV tPA, a thrombolytic medication which can improve outcomes in acute ischemic stroke. Dr .Z declined. He was admitted to the ICU as a "precautionary measure" and because the rooms were bigger. He was evaluated by one of the neurologists in our practice the next day. At this point, he had made a good recovery and had regained almost all motor function of his right arm. About 12 hours after his admission, he signed out of the hospital against medical advice. He took one day off, and then returned to work 2 days after he was discharged from the hospital.

When he returned to work, it was slightly uncomfortable. Several of my partners and I entered his office to express our well-wishes. "I was very lucky," Dr. Z said. He explained his thought process very systematically. He figured that he needed to get an urgent MRI because it was unclear if his weakness was from his lymphoma or a stroke. He declined tPA because his stroke was small and he was optimistic he would make a good recovery on his own. He left the hospital early because he understood that the likelihood a prolonged hospitalization would find a hidden/cryptogenic cause of his stroke was low.

He is back to normal, seeing up to 20 patients a day in his busy neurology clinic, and he took weekend call again last weekend. I offered to work his Saturday (I already had plans to meet Lalitha's parents Sunday), but he declined and said he may take me up on a trade later. His call was yet again another historically busy weekend. He has decided that he will retire next year.

Dr. Z took an unconventional approach to his emergent stroke management, but he made a full recovery and you can't argue with results. I sometimes compare myself to him. My skill set is not nearly as broad. I get other people to do EMGs and blood draws that I order. I work about 10 hours a week less and probably make half as much money as he does. I have profound respect and admiration for physicians who can function as a one man army, but I acknowledge that I need help every day for virtually everything, and I'm very lucky that it is there most of the time.

When the Dust Settles

I have moved back home to Cincinnati to take a job working in a large private practice neurology group. On my first day I was greeted by a gift on my desk which included a picnic basket, picnic blanket, bottle opener, and chocolate bar. I have a medical assistant with 30 plus years of experience in neurology who works hard for me but harder for her patients. In fact, after my appointments, I tell her to order whatever labs I want, write any prescriptions, and then it magically happens and I sign off on them. I no longer spend hours each week talking to patients about medication refills, filling out DMV paperwork, or discussing normal test results, because my medical assistant does that for me. I have been welcomed with open arms into a group that is aging and needs to pass the torch to young doctors so the practice sustains in to the future. Tomorrow I take my first inpatient call week at a local private Christian hospital. I'm nervous.

I was given two pieces of advice by some of the senior neurologists in the group when I started.

1) You eat what you kill. This basically means that the more patients you see and the more patients you see, the more money you make. On the flip side, I have also been told to learn to find the right balance between work and personal life.

2) If someone asks you if you want to see a certain type of patient, the answer is always YES. Starting out, my schedule is not busy so I need to see patients to make a living. It's very early in my career so it's still too soon for me to know exactly what my subspecialty interests are in neurology. So I've been told to see everything. Down the road as I become more established, I can filter out what I do and don't want to see. If a patient calls and wants to be added on at 5PM on a Friday, the answer is YES. If one of my partners asks me to take their weekend call, the answer is YES, because you eat what you kill. At least for now.

I have been fortunate to inherit a lot of multiple sclerosis patients from my predecessor who recently retired from the group at age 72. He is currently traveling the world, but he has kindly offered to meet with me weekly for breakfast at 7AM to mentor me and give me advice.

I get asked a lot by my patients why I like to focus on MS. The truth is the need is there and it just happened to be the subset of patients I inherited when I came in to the group. There is no magical story or enthusiasm I have toward MS. However, I like to think that every patient I see becomes a reflection of myself. If I deliver good care, they tell their friends. Their friends then tell their friends. And then I enjoy a good reputation. If I deliver poor care to just one patient, it's like adding a tablespoon of egg nog to an otherwise delicious cold root beer. My reputation becomes muddied. But being a good doctor is not the same as being liked by your patients. Ideally I would like to do both. Of course expectations don't always align with reality.

I saw a young college student with migraines two weeks ago. This is something I've seen many times before. I offered her various preventative medications. Propranolol, topiramate, amitriptyline. I explained the side effects of each medication and she did not want to take them. I discussed a very safe alternative of magnesium and riboflavin, but I also discussed that it often takes months for that to work even though it is basically completely safe without dangerous side effects. She chose the magnesium and riboflavin which I told her she could purchase over the counter. 1 minute later after I walked out the door she was in tears. "I expected more from a neurologist." I asked my medical assistant to prescribe her some amitriptyline. I hope this helps...

Last week I saw a woman who had a roux-en-y gastric bypass procedure 10 months ago and had lost 80 lbs. Now she developed left foot drop (weakness in raising her left foot). I examined the patient carefully. She could barely left her left foot, and now she was subtly weak in her right foot too. I told her she had common fibular nerve damage. I told her I did not know the exact reason, but that she may improve with physical therapy. We discussed that I could offer her an extensive workup which would include EMG/Nerve conduction studies, lab work to check for autoimmune processes, and maybe even an MRI of the brain if things still remained unclear. I told her that I think it is unlikely that she had MS, ALS, or that her weakness was related to her gastric bypass.

She was worried, but preferred to avoid a timely and costly workup. She opted to try physical therapy and an ankle foot orthotic first and see if things got better. 2 days later she called to let us know things were worse. She was so weak that she couldn't move her foot to drive. We obtained many labs and one of my partners did her EMG and nerve conduction study. The EMG/NCS report was equivocal and apparently it was somewhat limited by artifact. There were no sensory or motor potentials in the lower extremities is what I heard. Some fasciculations were found which can be an ominous finding suggestive of ALS. But when I examined her, it didn't seem to fit ALS. I had localized her lesion to the common fibular nerve, but the EMG and NCS in no way supported this and was equivocal, and of course muddied the waters. This is why I try to limit ordering EMGs...

I spent about 1 hour thinking harder. Maybe she has multifocal motor neuropathy, charcot marie tooth with hereditary neuropathy with liability to pressure palsy, mononeuritis multiplex from an undiagnosed autoimmune or neoplastic condition... These were all conditions I've read about but almost never diagnosed previously.

I reviewed the literature and saw at least 7 case reports of fibular neuropathy after gastric bypass. The mechanism is unclear but it is related to rapid weight loss. I think she probably has this now in retrospect, but I told her something completely contradictory earlier...

Ultimately, I accept my limitations. I am a general neurologist, and not a neuromuscular specialist. My partner who performed the EMG is also not a neuromuscular specialist and I bet that the quality of the EMG will be better at an academic health center. It's not as simple as calling Dr. Chahin who did 3 neuromuscular fellowships at Mayo Clinic (neuromuscular disease, peripheral nerve, and myopathy) and having him do a quality EMG and benefiting from his expertise which is what I would have done in residency. I'm probably going to refer her to the University of Cincinnati, where the wait list will be at least 4 months. I may try to talk with some other neuromuscular specialists I know.

In the mean time, I have a patient who is getting weaker faster than I anticipated, and her problems are compounded by the fact that I am swimming in diagnostic uncertainty and there is a chance that the specter of ALS has reared its ugly head...

I can't defer to my attending physician anymore, because I'm the attending physician. Maybe I should have done another year of fellowship an learned how to do EMGs myself. Maybe I should have worked harder in residency. I've also been told you learn more during your first year on the job than in any other period of your life. I'll figure this all out, and when the dust settles, maybe it will all make sense some day.

Blog post ideas

Here are some topics I'd like to write about later when I get the time:

1) Sagging brain
2) Do it now (NPH and timing)

Well that's it I guess.

Anesthesia Arun

Anesthesia Arun

I'm on a flight to Bangalore via Paris. It's been awhile, maybe a year since I've got a blog entry in. Now that I have a girlfriend, Lalitha gets most of my free time, but I sincerely wouldn't want it any other way!
I reconnected with Arun Ganesh after he started anesthesiology residency at UNC. I affectionately nick-named him Anesthesia Arun. We were pretty close childhood friends in West Chester. He had 2 brothers, a big house with a finished basement, lots of toys and Nintendo games, and what seemed like an unlimited supply of energy. Every Sunday, we would often go to his house for Hindu Sunday class. In the mornings we sat through painfully boring lectures and learned Indian bhajans.

Then we would eat lunch and snacks, and run and play. That was by far the best part. His dad got a job in New York, so Anesthesia Arun left when we were about 9 years old. Our parents kept in touch. I heard that he and his brother went off to Ivy League schools. I of course, remained in Cincinnati until I finished med school and realized there wasn't much keeping me there, so it was on to Chapel Hill!

I never saw him again until we were 27. By then he was married to an ophthalmology resident at Duke. We tried to meet up for dinner, but had trouble with our busy schedules. When we passed in the hallway, we'd exchange a warm hello and continue on our way.

One evening, I asked him to hang out and have a beer. He texted me back with "In a kidney transplant, fml." Another evening I texted him to see if we could get dinner, and he responded that his wife just gave birth to a baby boy, Avi. I congratulated him. And then I paused.

We were at two very different points in life. He had a wife and kid and lived in a house in the suburbs. I had only recently started to make time to date again, lived in an apartment with steep student loans, and marriage and kids were barely even in my thought process.

On one instance, I got consulted to see a patient with altered mental status and new strokes who had coded the night before. On reading the chart, I saw that Anesthesia Arun intubated the patient the night before during the code. His work was done, it was a very linear path. I'm sure that my assessment and plan regarding that critically ill patient's altered mental status was not unique. My note probably said altered mental status is likely multifactorial from recent vascular insult. Would recommend considering infectious and metabolic causes and limit sedating medications.

And then I thought, wouldn't it be nice if I were Anesthesia Arun instead of Neurology Arun? It's got to be rewarding to successfully intubated people, place central lines, and do other procedures like epidural blood patches and occasionally place spinal cord stimulators for pain management. Not to mention, he gets to come home to a loving family in a large house, and he would surely land a lucrative job offer as anesthesiology is known to be one of the best life style careers. My dad always wanted me to do anesthesia for that reason. My career choice involved problems which rarely had a quick fix, long call hours, and needy patients who constantly request medication refills and disability forms.

Later towards the end of my residency, Anesthesia Arun and his wife Nisha kindly invited me and Lalitha to their house for lunch. Nisha had made a delicious Indian meal with mango pie for dessert. Their son Avi was adorable and just learning to walk. But Arun and Nia were tired. Anesthesia Arun was doing a pain management fellowship at Wake Forest the next year.

I told him it must be nice to do procedures all day and have virtually no outpatient responsibilities. But Anesthesia Arun told me that after doing procedures all day long you feel like a mechanic. He said that he needed a fellowship so that he'd be able to keep his skill set unique and so that he wouldn't get replaced by a nurse anesthetist. His wife took a job working part time in an ophthalmology private practice group so she could spend time with Avi.

Anesthesia Arun congratulated me for taking a position at a large private practice group in Cincinnati. He told me that I'd have no regrets because extended fellowships would just mean more years where my salary would remain small.

Well to each his own. Maybe the grass is always greener on the other side. Our paths separated and converged again briefly. I hope we meet again. As John Mayer says, "Don't stop this train. Don't for a minute change the place you're in." I know quoting John Mayer is cliché and he can be a dbag sometimes, but I like his music more than a little.

My treasure (Draft)

This story starts in early February during my last few weeks working as inpatient wards senior on the neurology service. I was in the process of trying to figure out where to work next year after I finish residency. I exchanged emails every day regarding job offers and contract negotiations, as usual I was pretty tired all of the time.

A patient was transferred from a nearby hospital in Raleigh for evaluation of neuromuscular causes of shortness of breath. She was in her late 60s, and I will refer to her as Senora Alvarez. She was from Venezuela and spoke Spanish only. She reported that over the past 8 months she had progressively worsening difficulties with breathing. She felt weak and had gradual weight loss as well. Sometimes it was difficult for her to climb stairs and swallow food. At the outside hospital, she required a tracheostomy because of constant ventilator needs. She could mouth words, but needed to write things down to communicate with us. A percutaneous gastrostomy feeding tube was placed to provide her with nutrition. The neurologists in Raleigh had difficulties agreeing on her diagnosis. Her blood tests came back positive for acetylcholine receptor antibodies suggesting that she may have myasthenia gravis. She received a round of plasma exchange, and reports that she felt better. However in spite of this, somewhere along the lines, another neurologist had told her that she has ALS and would most likely be dead in 3 months.

Because of the uncertainty of her diagnosis, she was transferred to our hospital. She was small and frail, but her face was bright and she often wore a smile. She had fasciculations (muscle twitching) of her tongue and in her thighs. She had muscle wasting as well, most noticeable in her hands. Her reflexes were brisk. She was still able to swallow, eat, and walk, but she required a breathing machine often as her carbon dioxide levels in her blood were significantly elevated. My co-residents and I had no doubts that she had ALS, but there was disagreement among the neurologists at the outside hospital where she had an EMG that was not consistent with ALS. Afterall, her bloodwork suggested that she has myasthenia gravis and she had a good response to plasma exchange.

We obtained an EMG which had findings which were not classic for ALS. So then we obtained a nerve conduction study with repetitive stimulation along with a single fiber EMG. The electromyographer reported that there was likely 2 separate processes going on such as neuromuscular junction disorder and motor neuron disease, but the findings were not specific for any unique disease process. So this only added more uncertainty as to what was going on. The patient started to develop worsening hypercarbic respiratory failure and had to be briefly transferred to the intensive care unit for further ventilator optimization. We asked another neuromuscular specialist to evaluate the patient, and thankfully he agreed that she had ALS. Finally our suspicion had been confirmed.

The family had requested that we not discuss Senora Alvarez's diagnosis with her. They cried, but remained strong. They did not want Senora Alvarez to worry, and this seemed to be in keeping with there culture. They told me that the best possible outcome at this point would be to get her out of the hospital so that she could die at home surrounded by family. I told them that this was not an option, but that I would make sure to tell her when her family was with her. I also said that I would wait until later to discuss prognosis. Later that evening, 2 of her sons and her husband came by and I told her that she has ALS and she also probably has myasthenia gravis. She asked if there was a cure, and I said no.

I purposely did not try to overwhelm her with a grim prognosis. I thought it would be best to ease her into a reality which I'm sure she already saw coming. The next day we had another family meeting to discuss prognosis and goals of care. Just prior to this meeting, her sons showed me a video on his cell phone of Senora Alvarez dancing with her grand daughter several months prior. Her nurse, 2 sons, one daughter, the interpreter, and a medical student were all present. We discussed that she had ALS, and that this is the reason why she is so short of breath. We discussed that the natural progression of this disease is for her to become slowly weaker, and that there are no treatments available to reverse this process.

I did not tell her how long she had left. If I had to guess, she probably had anywhere from 2-10 months. We discussed what she would want to do if her heart were to stop beating, and she decided that she would want CPR to bring her back if this were to happen even though it my fracture her ribs.

I offered her IV IgG immunoglobulins or a second round of plasma exchange to treat what is most likely myasthenia gravis. We decided to do a treatment of IVIG but I do not think it helped. In my heart I think the only reason I had suggested it to her is to let her know that we had not given up on her.

We discussed that over time, the expectation is that she would continue to get worse, but that she would not be alone. She had a whole team of physicians, nurses, and therapists caring for her.  I told her that she would need the ventilator to live. She would always have the ability to tell us to make her more comfortable and help her transition on to death if she did not want some of the life sustaining measures we were offering her. However, given that Senora Alvarez still had the ability to walk, eat, and communicate, it may be too early for this. She had a large family who loved her very much.  She agreed and wrote down on her paper, "Yes, they are my treasure!"

It is probably best to go gently into that good night.

About 9 days ago my grandfather passed away in Bangalore, India at the age of 86. He lived a world away from me, and unfortunately I am unable to travel to India to be a part of the funeral process; the thought of going to India and taking leave of absence from residency never even crossed my mind. My dad flew over last week to help with arrangements and will be there through Dec. 22nd. Around the same time my grandfather passed away, I was consulted by the surgical & cardiac intensive care unit teams to comment on prognosis in critically ill, comatose patients.

The first patient was an African American woman in her 60s who went into cardiac arrest during a surgical procedure to remove an adrenal mass which is thought to be cancer. She was essentially normal prior to the operation. She received norepinepherine and pressors and CPR in the operating room and had return of circulation within approximately 4 minutes. The surgery was aborted. She remained unresponsive for 2 weeks on a breathing machine. She developed renal failure and was placed on continuous dialysis. She developed hepatic failure for unclear reasons. An MRI of her brain was obtained which showed multiple small to medium sized strokes; possibly related to her low blood pressure intraoperatively, possibly embolic from her heart. During a transesophageal echocardiogram, she briefly had cardiac arrest again and CPR was started with return of circulation.  I was consulted for assistance with assessing prognosis. Her sedating medications were stopped 12 hours before I examined the patient, but she remained completely unresponsive.

My thoughts were that the prognosis was not good. She had a possible adrenal malignancy, renal failure, hepatic failure, some strokes, and was nonresponsive. Although her pupils react to light, the fact that she had no purposeful motor response or movements of her limbs after 2 weeks made me feel her likelihood of making a meaningful recovery was poor. I based this off a landmark paper entitled Predicting Outcomes in Hypoxic Ischemic Coma written by David Levy in the 1980s. Over 200 patients who were comatose after cardiac arrest were retrospectively examined, and their prognosis was charted based on their neurologic function at certain points in time. Almost none of the patients who had absent motor response to painful stimuli had a meaningful recovery.

The next day I discussed the case with my supervising attending physician. She had a very different opinion. The patient had been on high doses of sedating medications for 2 weeks and in the setting of renal & hepatic failure, her opinion was that these sedatives could linger in the system indefinitely in spite of dialysis. The strokes were not devastating and the patient had good function of her brain stem reflexes. Her opinion was that we were unable to comment on prognosis because we needed more time to see how the patient would do after the sedatives had been discontinued.

I was frustrated. I felt there was evidence in the literature that the patient should do poorly. Multiple organ systems were failing in this patient, and I felt that the family should know that the likelihood of making a meaningful recovery is low. I felt the best possible outcome would be withdrawing care and letting this patient pass. Fundamentally, I felt it is wrong to have a patient with no meaningful neurologic function use expensive ICU resources and take up an ICU bed that could go to someone who needs lifesaving interventions in a more acute setting. I shuddered to think of the family holding on to hope and have this patient remain unresponsive indefinitely for months, years, in a long term care facility where she would be getting dialysis and fed through a tube.  Although I was unhappy, I held my tongue.

The next day at the family meeting, the ICU team, surgeons, myself, and a very large African American family was there. I echoed the opinion of my attending physician that I cannot comment on prognosis at this time since the patient was getting heavy amounts of sedation and it would take longer for her to clear these medications because of her renal and hepatic impairment. However, I said that if there is no improvement in the next few days, I suspect the prognosis would be poor based on my experiences and review of the literature. I qualified this with the statement that every patient is unique and I could not make any guarantees that I knew whether this patient would get better or not.

The patient's husband was asked what would his wife want in a situation like this where she is unable to tell us herself.  He said confidently, "she would want to live." This made me sad. Perhaps if my language had been more devastating and aggressive, the decision would have been made to withdraw these invasive life prolonging methods which I felt were futile.

3 days later, I received a page from the surgical intern that the patient was improving. I re-examined the patient, and she was spontaneously opening her eyes. She was wiggling her toes on command. And that was it. She was not moving her arms or her legs otherwise. She had a tracheostomy in place but could not move her mouth or talk.  I'm not sure how I feel about this. A large part of me hopes that my initial evaluation is wrong and that this poor woman will walk out of the hospital someday. If she has managed to survive 2 codes and cheat death twice, she is fighting for her life. A smaller and more guilty part of me hopes that she suffers some debilitating blow such as septic shock or disseminated cellulitis and passes away before she gets transferred to a long term care hospital where she remains minimally responsive indefinitely.

The day before my grandfather died, I was consulted to assess for brain death and comment on prognosis in a gentleman in his 50s who underwent therapeutic hypothermia after suffering cardiac arrest.  This patient was also normal previously with his only medical comorbidity being hypertension. While at work, he developed some chest pain, and then lost consciousness. EMS performed CPR and took him to an outside hospital. The patient was intubated and connected to the breathing machine, and the code continued for about 2 hours with continuous CPR. Eventually, the pulse was regained and there was return of circulation. At some point, the decision was made to start therapeutic hypothermia to slow down his metabolic demands and theoretically improve his chances of survival. A head CT was obtained and showed diffuse edema/swelling throughout his brain along with possible downward herniation of the cerebellum through the foramen magnum with brainstem compression. The next day I was called to comment on prognosis.

I knew that the prognosis was bad. The patient was comatose, his pupils were nonreactive to light, and he had no brainstem reflexes. When patients meet criteria for brain death, then the hospital has the prerogative to withdraw life prolonging measures to end life. However, this gentleman did not meet brain death criteria because the department policy is that 72 hours have to pass after a patient is warmed from therapeutic hypothermia before a brain death evaluation can be performed.

I communicated to the family that the patient's head CT looked bad and key structures in the brain appear to be compressed. I discussed that it is hard for me to comment on prognosis since the patient was "ICED" the day before. For this reason, I could not declare him brain dead. His daughter was a nurse. She asked my many questions about the details of his medical care. I was intentionally vague. I discussed that it may be reasonable to wait the full 72 hour period to see if any recovery was made, although I was pessimistic that this would happen. His daughter seemed well educated and had a keen grasp of how things work in a hospital. His wife said she would pray for a miracle. 3 days later, the patient remained unresponsive, and the family gave permission to take him off the breathing machine and allow him to pass.

Going back in time about 8 days prior to the day after Thanksgiving, my family and I were discussing my grandfather A.N Murthy. He was around 86 years old. He lived by himself in his home in India. He owned a car which he very reluctantly agreed to stop driving just 1-2 years prior; the traffic in Bangalore is overflowing and can be unforgiving. He hired a cook who would make his food. His neighbors looked out for him. I saw him last in August. We went for a long walk with my dad near the high school I went to.  At that time, he seemed quite healthy, and I was impressed. When I said goodbye to him to go back to Chapel Hill and continue residency, he encouraged me to visit him. He told me he could feel himself grow weak, and he wished me the best of luck with my career.

The day after Thanksgiving, my family was reminiscing about my grandfather's visit. My mom expressed concerns that he may be too old to make the long trip from Bangalore to Cincinnati by himself. If he were to get seriously ill in Ohio, it would be very complicated arranging his care.

I was engulfed in the neverending work hours of residency. I told my mom that I deal with death on a regular basis. I said that people live longer these days, and in spite of living long full lives, patients and their families actually wish they could have lived longer well into their 80s, 90s, and beyond. I said that at his advanced age, things are unpredictable. My exact words were, "he may live to 100, or he may die tomorrow, both are equally possible." It was very easy for me to maintain this aloof assessment. It was clear that I would never be responsible for caring for my grandfather if he were critically ill. Unfortunately, he passed just 1 week later after I made this nonspecific prognostic declaration.

On an early December morning, he told a family member that he felt weak and ill. He was taken to a nearby hospital in Bangalore, and was intubated and connected to a breathing machine. I do not know anything else about the nature of his illness. The next day, a doctor decided that the prognosis was poor and he was extubated and let go. There was no family meeting, there was no "goals of care discussion."

I miss my grandfather very much and I feel like a part of my has been taken away that I will never get back. But I am glad that there was not a "family meeting" or "goals of care discussion." His close family was scattered many miles away throughout India and America. Making arrangements to have discussions on the phone would have been incredibly difficult to account for the different time zones. I doubt that our family could quickly and efficiently come to a decision about whether to prolong his life. My gut feeling is that if he somehow lived through whatever it was that made him sick by means of invasive life prolonging therapies, he would wish he were dead.

So why do American physicians have to ask for the permission of family members designated as health care power of attorneys to withdraw life prolonging therapies and let patients pass? Should doctors have supreme authority to withdraw life prolonging therapies? If this were the case, maybe we would become corrupt and hospitals would be where you go to die rather than where you go to get better. It's much easier to let patients go than to keep them alive indefinitely. I think Americans have an unjustifiable fear of death, and that our medical system needs to re-evaluate the way we handle end of life care. I'm glad that this topic is being discussed more and that physicians are rethinking end of life care.

The Light at the End of the Tunnel

                Yesterday I interviewed for a movement disorders fellowship at Rush University Medical Center in Chicago. 3 weeks ago, I interviewed for fellowship in UCLA. I really liked all of the faculty at Rush and I am impressed with the city of Chicago. I will rank Rush number one, and I will find out if I get the fellowship in 2 weeks.  Moving to a big city seems like the next step for me.  Chicago has great parks, culture, food, and the lake front is spectacular. The public transportation is good enough that I may not have to drive at all. And of course, I’d be a 6 hour drive from Cincinnati. (Of note, it was looking unlikely that UC would have a movement disorders fellowship opening next year so I did not formally apply).  Also, my talented girlfriend, who is a 4^th year medical student planning on going in to emergency medicine, would have plenty of options if she chooses to follow me to Chicago as there are lots of residency programs within a close proximity.

                But things in my life typically don’t go according to plan. 4 years ago I was planning on matching in to neurology in Indianapolis (just 90 minutes from Cincinnati), but I ended up in Chapel Hill. I had no close friends in North Carolina, but I learned to love the “Southern part of heaven” as my second home. The clear blue skies, the clean air, the low traffic, the beautiful UNC campus, and overall warmth and kindness of the people in Chapel Hill makes this the perfect place to live if you are 40 with 2 kids.

                My vision of moving to Chicago may be ruined by the fact that I misread my calendar and did not show up on time for my scheduled interview at Rush. Arrangements were made to postpone my interview 24hours, but that’s not the kind of first impression I wanted to make. I would imagine there are many people interviewing for just 1 spot. I know now that nothing is guaranteed.

                I have 10 months of neurology residency left.  Some days are good, but I often feel vulnerable. Some days I feel like I am being attacked by patients who make demands for narcotic medications they know I can’t give them. Some patients want paperwork and legitimate medication refills completed in a manner that is faster than I am able to finish as they do not realize I have many other work obligations.  Sometimes I feel attacked by some of my co-residents, who may seem nice on the surface but ultimately have motives to advance their careers sometimes by criticizing their peers to make themselves look good.  Other times I feel under attack from my supervising attending physicians, who often are quick to find fault in the plans I suggest or with trivial technicalities regarding the notes I write.  It can be very difficult to learn and practice neurology correctly when the people who supervise and provide your training can’t agree themselves on the appropriate way to manage neurologic diseases.

                But now I have no choice but to finish residency to the best of my ability. I am around $115,000 in debt and I have poured in thousands of hours that I have logged, and it will all be for nothing if I don’t finish now.  How is it fair that nurse practitioners and physicians assistants can do many of the same things I do and have spent less than half as much time and money on their training?  How is it right that we sometimes order screening MRIs for patients with MS which cost thousands of dollars and do not typically change the treatment course?  How is it practical that we often prescribe expensive medications like IVIG, natalizumab, and Botox which can also cost thousands of dollars but are not always indicated and can have potentially harmful side effects? Is it right to order 20 lab tests with results that are often difficult to interpret and even harder to explain to your patient when a neurologic diagnosis is unclear?  I know I’ve ordered tests that aren’t indicated and perhaps written for medications that are expensive and not helpful. Maybe it’s part of the learning process.  There have been a few stories where thousands of dollars in diagnostic testing have resulted in the diagnosis of rare and fascinating progressive neurodegenerative conditions with no treatment. However, I know that there have been a few success stories too where thousands of dollars in diagnostic tests and treatments have made the difference for my patients.

                I’m not sure if I will complete a fellowship, but I hope to finish residency as a profoundly intelligent neurologist with a firm grasp on neuroanatomy and the indications for ordering tests and medications. Also, I hope to be someone who can be smart enough to do nothing when nothing can be done rather than putting patients through thousands of dollars of diagnostic tests and treatments along with countless hours spent driving to and from the doctor’s office.  Neurology is ultimately a compromise because sometimes tests with soft indications have to be ordered either because a supervising attending physician wants it, or a patient insists on it.  Residents can become vulnerable as they are the face of patient care and are easy scapegoats when things don’t go according to plan. Also, residents are underappreciated, underpaid, and overworked. 

                In the near future I will figure out my plans after residency and the prestigious fellowship with better working hours or the high paying job in private practice may be the metaphorical “light at the end of the tunnel.”  Regardless of what is next, I think my career goals will always remain the same. One of my favorite attending cognitive neurologists tells his residents and medical students that there are three goals in medicine: 1) Deliver excellent patient care, 2) Have fun, and 3) Teach each other.  On some level I think I’ve accomplished all of these to the best of my abilities. Maybe after residency I will have more fun!

Cold hands, slowed conduction velocities and prolonged latencies

"Cold hands, warm heart." That's what we say to patients we examine who complain about our cold hands. It's essentially a meaningless phrase. Yesterday I found out my cold hands meant prolonged latencies and slowed conduction velocity of the median nerve at the wrist suggesting carpal tunnel syndrome.

I've been on the neuromucular rotation for 3.5 weeks now and I'm slowly learning how to do nerve conduction studies. These are the tests neurologists use frequently to help confirm diagnoses such as carpal tunnel syndrome, guillain barre, ALS, or various nerve entrapment syndromes from peripheral nerve compression.

After doing some studying and observation, the first patient I did a nerve conduction study on was a very nice woman who had possible tarsal tunnel syndrome. This condition involves entrapment of the tibial nerve were it runs in the ankle causing pain and weakness primarily in the first three toes and ankle. She had some trauma of her ankle many years prior and ankle surgery 3 years prior, but continued to be plagued by ankle and foot pain and weakness.

I did her nerve conduction studies with intermittent supervision from one of the techs. It was a cold winter morning in Chapel Hill so while her feet were warming up we made small talk about her life in Wilmington on the eastern coast.  She admitted she had some apprehension about the study as her physician told her the shocks from the nerve conduction study would hurt, and the needle from the EMG would be even worse. I tried to put her at ease. I did not tell her that she was the first patient I would ever do this study on, but I think she figured this out soon. I was slow in arranging the electrodes, fumbled with the wires, and mislabelled her sites in the computer. The tech very patiently corrected these errors and I completed the studies with his help. A study which should have lasted 30 minutes dragged on for about 90, but I was lucky that my patient was very easy going, had good anatomical landmarks, and enjoyed my small talk. Also the schedule was light as most people cancelled their appointments since the forecast was predicting snow.  She tolerated the shocks (or stimuli as we like to call them) very well with minimal pain. The results of the study were essentially normal in spite of her history and exam so strongly suggestive of tarsal tunnel syndrome. Her referring surgeon would now have some difficulties deciding whether to surgically release her nerve in the setting of normal nerve conduction studies. The needle EMG was an ordeal for her, but that was done by someone else as I don't have enough experience to be turning my patients into pin cushions yet...

And then in the afternoon I tried to find a med student or co-resident to be a practice patient for me to improve my skills. No one was available so I had to do the nerve conduction study on myself. This is a difficult process. You really need two hands for this study, one to apply the stimulus to the nerve, and another to press the button on the machine to give the stimulus. When I practiced on myself, my dominant right hand was occupied with the electrodes and stimulator used to do the study. I decided not to warm my ice cold hands up because I was having difficulty keeping my hand under the warmer since I only had one free hand to work the computer. The results of my right arm study were abnormal with prolonged latencies of the median nerve at the wrist and palm which is suggestive of carpal tunnel syndrome.

I showed the results to my attending since this is a requirement to move on in the rotation. If I had been more familiar with the normal values I would have thrown out the study and repeated it with warm hands. I explained that my hands were cold, but he was not sympathetic. "You have carpal tunnel syndrome Arun. These values are abnormal. Don't worry we can take you to the OR, I've done a few of these procedures before!"

I know he was just joking, but for a brief moment I was upset. I had a mental image of myself in a hospital gown with my attending standing bedside with a scalpel in his hand. I thought about how I have been fortunate to avoid significant health problems thus far through residency.  The next day I repeated the study. This time, I kept my hands under the warmer for 20 minutes. The results were normal.  So to me, cold hands means prolonged latencies, slowed conduction velocities, and occasionally false diagnoses in the EMG/NCS lab.

A difficult discharge

Somehow I have gained a reputation in residency as being the person who is "too nice." My coworkers often criticize me for accepting "soft admits" and filling the service with patients who should be discharged from the ER. Whether or not this is true, it makes me think back to February of my intern year when I discharged a difficult patient from the internal medicine service.

He was a 60 year old man whom I will refer to as Mr. Winters who had irritable bowel syndrome. He was admitted with intractable abdominal pain. The details are somewhat hazy as it has been a few years, but his workup included a CT abdomen/pelvis with and without contrast, an upper and lower GI endoscopy with biopsies, all of which were "stone cold normal."  He was having normal bowel movements and tolerating po. Our gastroenterologist essentially gave him a clean bill of health from a GI perspective.

In spite of this, poor Mr. Winters continued to have severe abdominal pain. On morning rounds the decision was made to discharge Mr. Winters as there appeared to be no dangerous medical cause for his abdominal pain. He lived at home by himself and he had expressed anxiety in leaving the hospital.

Somehow I had gained an uneasy rapport with Mr. Winters because I spent over 20 minutes of my time to listen to his history. It is unusual for residents to spend more than 5 minutes talking with patients after an initial history and physical has been taken. He told me about his time in Vietnam. He reportedly had to be admitted to a hospital there when he had intractable seizures. When he returned home, his family relationships were severely damaged. He seemed to hint that he had an extramarital affair in Vietnam, and that ended up alienating him from his wife who left him and his daughter who could not forgive him.  Again the details are hazy, but what is certain is that poor Mr. Winters had no family, lived alone, and still reported severe abdominal pain.

Later in the afternoon when I was making arrangements to discharge him, he was on the floor writhing in pain. He did not want to go home and be by himself. I called his daughter who seemed exhausted and upset with her father. Ultimately, one of his neighbors and close friends also expressed reservations to releasing Mr. Winters; but agreed to spend time with him and drive him home.  Mr. Winters was upset that I was discharging him. He still was writhing on the floor with abdominal pain. He asked me what he should take for his pain. I told him tylenol. In retrospect that response seems callous and cruel.  I didn't want to commit the cardinal sin of intern year, which is hospitalizing patients who do not meet inpatient criteria.

One week later I was reviewing charts and saw that Mr. Winters had found his way back in to the ER with a tylenol overdose and suicide attempt.  For a brief moment my heart raced and I was nauseous. I felt a pang of guilt, but only briefly. The plans for discharge had been discussed with my senior resident, attending, and gastroenterologist, and I was following through on what we all agreed on.

One week later I continued to care for Mr. Winters when I moved to the psychiatry service.  His abdominal pain seemed to take a back seat to his suicidal depression. In fact, he stopped complaining about the abdominal pain altogether.  He spent more time discussing his sense of worthlessness and discussing how everyone had turned their back on him. His wife, his daughter, his doctors, all seemed to have abandoned him in his mind. The only thing that became clear to me at this point is that if Mr. Winters went back home alone he eventually would succeed in killing himself.  Arrangements were made for him to go to an assisted living facility where he would have a roommate and nurses to give him his medications. We spent 2 days preparing Mr. Winters for this plan and for discharge.

And then it was deja vu. On his day of discharge, he said he was not ready to leave. He complained that the food at the assisted living facility was crap and would not agree with his irritable bowel syndrome. He looked at me with pleading eyes, and begged not to be discharged on morning rounds with my attending present. But I gave my cool and by now rehearsed response. I explained that at this point there is nothing we are offering in the hospital that can't be done elsewhere. We have made arrangements for him to have the resources to continue his care in an assisted living facility. He could always call our 24 hour psychiatric resource line should his depression reach suicidal levels.

He was livid. He called me a traitor and a fraud. And then he was escorted out of the hospital by security.

On my 1 day in 7 off, I went to visit Mr. Winters in his assisted living facility one week after discharge. (To be fair, I actually had 2 day weekends on psychiatry). He was pleased to see me. He offered me an apology for the terrible things he said to me, and then told me that I was one of the few people who cared. He was visited by his brother who is a retired physician and had left some detailed instructions on his diet. Surprisingly, he had grown fond of the staff at his living facility and the food that they served.

I did not lose much sleep over Mr. Winters. Some people have illnesses that can't be cured or managed by pills. I will say that Mr. Winters has my sympathy. I'm not sure if I believe in the diagnosis of irritable bowel syndrome, but I know and understand what severe depression can feel like, and his problems were amplified 100 fold by his alienation from his family. I hope he continues to do better.

The fine line between neurologic illness and being nuts

I just finished packing my bags to return to North Carolina after a great weekend in Cincinnati. I got to catch up with a friend from medical school, spend time with my parents who remain upset that I have no plans of getting married any time soon, and the Reds beat the Dodgers yesterday on a day that the Big Red Machine was commemorated.

Recently I finished a very rough stretch of night float. I found myself in some very difficult situations where preconceived notions and biases hindered my ability to care appropriately for patients.

About 1 month prior I was called to evaluate a patient who was 28 weeks pregnant and had intermittently complained of an intractable headache. She also started to have episodes concerning for seizures that were witnessed on multiple occasions by the nursing staff. The day team had evaluated the patient and expressed concern for either a venous sinus thrombosis or an infection such as meningitis. Plans had been made for the patient to undergo a brain MRI and EEG. Unfortunately it took over 48 hours to get these studies done. During that long 48 hour period, I was constantly paged during the night to evaluate the patient when she had seizures. By the time I made it to her bedside, she was no longer seizing, and was mostly unresponsive and fatigued. In the mean time, we increased the doses of her valium and keppra in an attempt to stop the seizures.

The patient was too agitated and obese to tolerated the brain MRI so she had to have general anesthesia/intubation to be put to sleep. Her MRI was normal. We were initially all out of EEG machines so it took 48 hours to hook her up to EEG. I was again called to evaluate the patient after one of her seizure episodes; but this time after reviewing her EEG it became clearer to me that her events were not seizures at all. I was able to say with some comfort that there was nothing to do but stand back and watch, and in the morning the patient could be reassured that she wasn't having seizures.  I could not say if she was faking her events or subconsciously having involuntary spells that looked like seizures, but it did not matter much to me around 2 in the morning as whatever she was having was not life threatening.  I can say that I was fooled though; a young pregnant woman who is having a terrible headache and new onset seizures could have any number of serious conditions including a cerebral venous sinus thrombosis, eclampsia, or meningitis; however in this case the patient had nothing concerning and the epilepsy attending agreed with my assessment the next day.


About one month later I admitted an elderly woman on dialysis who had recently had a fall and sufferred a small subdural hemorrhage who was also having seizure like episodes.  Her nurse told me the patient would shake her legs, moan in pain, and ask for pain medication for about 30 minutes. She felt the episodes were pseudoseizures. These episodes had been going on for weeks.  The patient certainly had some reasons to seize; her blood pressure was high, she recently recovered from a small intracranial hemorrhage, and dialysis can predispose patients to all kinds of metabolic derrangements. On the day of admission we made arrangements for the patient to get dialysis, and then start continuous EEG monitoring to determine if she was having seizures. Again it took about 36 hours for the EEG to be hooked up. I came back the next night around 8PM and during signout the patient started having her event. She started to shake her left leg randomly and complain of pain. 5-10 minutes passed. I looked at her EEG and didn't see a clear seizure. I decided to give her 2mg of morphine. Five minutes later the patient was still in pain. She started to move all of her extremities rhythmically. Her oxygen saturation dropped to the high 80s. I decided the patient was not seizing; she got her morphine. I checked back on the patient 10 minutes later and she was comfortably eating her dinner. I decided the patient was faking these events to get narcotic medications and when my shift ended at 9AM I signed out this information to the day team and went home to sleep.

The next night when I came back to work, the intern kindly informed me that I was absolutely wrong about the patient's seizures being fake. The epilepsy attending told the team that morning that the patient was having myoclonic seizures with a prolonged secondarily generalized tonic clonic seizure. I felt terrible, but there was a slight element of disbelief. I looked at the EEG from last night again. The patient shook her leg in pain for 5-10 minutes and I did not see a seizure. I continued to review the EEG and video recordings more closely and then about 15 minutes into the spell, the patient had the rhythmic movements of all 4 extremities. I am standing bedside on the video and watching the patient seize. At this point her EEG shows an obvious generalized seizure, but I did not see this last night. So I watched as the video showed me standing around while my patient was having a prolonged seizure; and I chose to do close to nothing because I was previously convinced the patient was doing this to get narcotics.  Playing back the moment in my mind is haunting and embarassing. I am standing bedside watching a patient suffer and I chose to assume she was faking it to get narcotics. I had not reviewed the entire EEG the night before and I suddenly wished I could go back 24 hours and do things differently.

Luckily my mistake did not result in any long lasting adverse outcomes to the patient. She had been having these seizures for weeks and previously no one was sure what was going on. I apoligized the next day to my team and attending for being so incorrect (I did not apologize to the patient, but her intern did). The patient's seizure medications were adjusted and she did better.  I think if I did not get the added history from the patient's nurse that she had drug seeking behaviors, I would not have misjudged the situation so badly. I'm sure my error will be reviewed in a morbidity and mortality conference; but the chief resident and attendings were forgiving. I am sure they too have all made similar mistakes during their training; and continue to occasionally make these errors (which on rare occasions I have caught). My error weighed on me for several days, but then I decided that life is too short to be unhappy and now I have let it go.

Empiric treatment

Today is a rainy cool day in August. I am on 24/7 home call on the pediatric neurology service for 7 days and somehow I have been scheduled to work 17 days straight. My allergies are really getting the better of me. I am constantly sneezing and sniffling, and I am a walking zombie as I recently finished night float and I am struggling to get reacquainted with the days.  Yet somehow the volume has been less this time on the pediatric neurology service and I am less frustrated and depressed than last year. My brother in law who is going in to interventional radiology came and went lack week and questioned my decision to pick small town living over big city excitement, and then for a brief moment I did too.

Today I write about the case for empiric treatment. I will go back 1 month as my first day is senior on the inpatient adult neurology consult service on what was supposed to be a lazy in and out Sunday. The medicine ICU had admitted an alcoholic woman with a questionable seizure history with a chief complaint of altered mental status and staring spells/seizures. Her baseline functionality was "normal."  The senior neurology resident who saw her last night said she likely had wernicke's-korsakoff encephalopathy and that she needed IV thiamine and folate. She was hospital day 2 and still not waking up with this treatment. Her spinal  fluid was negative for any infectious processes and her MRI brain was normal. She recently had an EEG which showed no evidence of seizure.

I walked in the patient's room and she was staring out the window and appeared to be responding to some sort of external stimulus. She was delirious. She was virtually nonverbal, she was moving all 4 extremities but she certainly was not following commands. She was spiking fevers and her heart rate was elevated.  Her nurse asked me very innocently: "What's going on, why isn't she getting better?" I said the simplest explaination is usually the right one, and this could all potentially be explained by alcohol withdrawal. I told the primary team to give her scheduled valium as she was clearly having delirium tremens. Her last drink was 48 hours prior when she had 40 ounces of hard liquor...

2PM rolled around and I was hoping to roll out of the hospital and have a little alcohol myself. Then I got a page from the MICU resident that the nurse witnessed a seizure from the patient. I said she needs ativan and scheduled valium. Ativan was given, but not scheduled valium. 20 minutes later I receive a page that the nurse was witnessing the patient constantly seizing. My attending physician was skeptical, as over half of the calls we receive for seizures are not seizures. I called the EEG tech and told her that we had an emergent need for continuous EEG monitoring. She was not thrilled as it was supposed to be a lazy Sunday for her as well, and now I was holding her up to start continuous EEG monitoring on a patient who had an unremarkable EEG just 1 day prior.

By the time I get to the patient's room, the patient was being intubated. She had developed a dangerous metabolic lactic acidosis. She was constantly having what appeared to be very real focal onset seizures with secondary generalzation with at least 10 witnessed seizures. This had been ongoing for 90 minutes. This meets criteria for status epilepticus.  The definitive treatment for status epilepticus is to induce a medical coma with heavy sedation such as propofol, pentobarbitol, or versed to end the seizures. The patient was intubated and then connected to continuous EEG monitoring. The nurse was starting to get nervous. After the patient was intubated, I requested that we capture just 1 seizure on EEG, and then start the propofol drip. The patient had one last seizure, and then the propofol was started and she fell into a deep sleep.

The next day the patient's EEG was read out as negative for seizures. I questioned this read and the attending physician reviewed the tracing and agreed with me to change the impression as she clearly had a seizure right before the propofol was started. After 24 hours, her propofol was weaned off. She appeared to be purposefully following commands with her arms and blinking appropriately to command. The next day she was extubated, but her mental status worsened. She was nonresponsive, not moving her extremities, and in scientific terms, she was a vegetable. I requested an MRI brain to be ordered to see if she had suffered anoxic brain injury during her multiple seizures. The MRI was normal.

Days passed, then weeks. The patient was still not waking up. Her medicine intern asked me, why isn't she waking up? So did my attending.  Simple, she was in convulsive status epilepticus for 90 minutes from alcohol withdrawal was my response. I wanted to say that if they had been more aggressive with scheduled benzodiazepines, perhaps this would have been preventable. I was bold enough to say that perhaps if the patient stayed home and continued to drink 40 ounces of liquor a day, she wouldn't be in this state.

A new younger neurology attending came on service. She was less satisfied with my simple explaination. She demanded that the patient receive a full metabolic and autoimmune workup. She was tested for hashimotos encephalitis and various autoimmune conditions such as lupus and sjogren's syndrome. This was negative. She had a whole body CT scan to assess for cancer; this was negative. She was tested for autoimmune paraneoplastic conditions such as NMDA receptor encephalitis. 3 weeks later, all her labs came back negative. An EEG was repeated a 3rd time; this was negative.

I cringed for a moment inside. Why couldn't my simple explaination that the patient has sufferred permanent bilateral cortical damage from prolonged alcohol withdrawal seizures be enough? Why did we have to spend thousands and thousands of dollars to search for a needle in a haystack diagnosis. What if this patient were my family member? I suppose I would also want every potentially treatable cause to be explored even if the propability is infinitessimally low that these potential diagnoses were going on.

Around hospital day 7 when the patient was still not waking up; I raised the possibility of "empiric treatment." Empiric treatment is a term used when we treat for a condition even if there is no established diagnosis. It's sometimes a shot in the dark. It is done all the time in patients who come in with sepsis who are covered with multiple broad spectrum antibiotics and antiviral medications until their blood/urine/spinal fluid cultures reveal a source. In the case of my patient, we would be empirically treating her with IV steroids for something such as hashimotos encephalitis. Another option would be empirically treating her with IV IG immunoglobulins to treat for an NMDA receptor encephalitis as the lab test for this takes 1 month to come back.

Our team decided not to start empiric treatment with anything. The probability for hashimotos encephalitis was low, and there was no underlying malignancy to suggest an autoimmune process such as NMDA receptor encephalitis. But nonetheless the labs were sent even though the suspicion for these conditions were low. So we waited for 3 weeks patiently for these labs to come back; and they came back negative.

During that 3 week period, I sat down with the family. I told them that the simplest explaination is that the patient suffered permanent brain damage from prolonged alcohol withdrawal seizures. She had shown minimal if any signs of improvement, and in my humble opinion there was no reason to expect her to recover further. I wanted to use the term persistent vegetative state as the patient had no purposeful movement of her arms, legs, or eyes, and she had preserved sleep wake cycles but I chose to avoid this controversial term. I explained that we were searching for very rare autoimmune conditions which can cause treatable/reversible comas, but that I expected the results to be negative. I told them that I did not expect the patient to show significant improvement, and that there are no further treatments indicated. The patient's large African American family was upset. They cried, they gave me angry looks as if I had taken something inconceivably valuable away from them, and then her son who was in his late twenties like myself gave me an angry look and questioned if we were doing everything in our ability.  Some of the family members thanked me for my forthright explaination. I certainly don't know everything and I expressed that while this is the most likely explaination, there is always the possibility I am incorrect. I said it wouldn't surprise me if she were able to follow simple commands down the road, but there is no reason to expect she will make a significant recovery or return to the state she was in before. I've learned to give myself this out as people with end stage illnesses occasionally have unpredictable hospital courses and occasionally have inexplicable recoveries.  It surprised me that this discussion had not happened sooner. I told them that I felt it is important to honestly convey our thought process even if the news is not good news so that they could know what to expect moving forward. I patted the son on the shoulder and left the room so I could finish my notes, go home and write more notes, and respond to other mundane messages from my clinic patients who wanted medication refills and more pain medication.

The patient never did recover, but later on I would re-examine her and she clearly did have purposeful eye movements which was a slight improvement. She would follow with her eyes when I called out her name. She was still unable to do anything else. She was being fed through a feeding tube in her stomach. She was able to breath on her own. My young and new attending had requested a 3rd brain MRI even though the previous 2 were normal. I was unhappy about this, but then the results showed something I didn't expect. There was damage to the brain through the caudate nuclei which can sometimes be responsible for arousal, and there was damage of the motor tracts through the ventral pons. The MRI was suggestive of a condition called central pontine myelinosis (as well as extrapontine myelinosis). The patient was "locked in." She probably could understand the people around her, but she was unable to move her arms and legs because of the damage to the motor tracts in her ventral pons. There is no real treatment for this condition. I rotated off service and someone else was left to discuss the ramifications of this with the family. I am still confused about how the patient developed central pontine myelinosis. Typically this condition is caused by rapid fluctuations of sodium but her sodium and electrolytes were mostly normal through her hospitalization. Why didn't her previous 2 MRIs reveal this diagnosis earlier?

This remains one of the many medical mysteries that I cannot completely explain.

But let me go back to the principle of empiric treatment. Wouldn't it have been easier to just treat the patient with IV steroids at the beginning? Why waste thousands of dollars in expensive labs and hospital days waiting for labs to come back. Why not just give 5 days of IV steroids which are generally pretty safe? If that didn't work, couldn't we empirically treat with IV IG for an autoimmune receptor encephalitis? Again 5 days of IV IG isn't necessarily cheap and there are some side effects but it is usually tolerated pretty well. I guess there was never really a reason to suspect the patient had hashimotos encephalitis or NMDA receptor encephalitis. So why even test for it? These questions are difficult, and again in retrospect I think if this patient just stayed home and continued to drink, she would be in better shape today and she would not have racked up what might be a half million dollars in hospital bills.  The questions I am posing in this blog entry are difficult, and would be approached differently by different people, and at the end of the day there may not be a clear right answer.

The onion drive.

I am in the coffee shop this evening.  I was planning on writing clinic notes, but the EMR is down so I will write a blog instead about an interesting patient I saw last weekend.

On my last 24 hour Saturday call shift I was consulted to see a 30 year old woman with known abnormalities in her brainstem and whitemater on prior MRIs who comes in with balance problems, and clumsiness. She told me she had trouble walking and she felt like she was drunk (I hear that a lot from people who really aren't drunk).  She also had difficulty with simple motor tasks like buttoning her shirt and writing.  She lived on the Crystal Coast; the outer banks of North Carolina about 4 hours away.  About 2 years ago she came to UNC with symptoms of left sided weakness and her MRI showed brainstem and whitematter abnormalities. She has seen at least 3 neurologists previously; the first told her she had MS. We told her that she didn't the last time she came...

In the ED we repeated her MRI brain and it showed a round concentric onion shaped lesion extending through her parietal, occipital, and temporal lobes that is brand new along with her prior abnormalities.  Her deficits were minimal on exam. She had subtle left sided facial droop and left sided weakness. She was able to walk but she was unsteady.  But she knew something was wrong. Based on her imaging; I felt like she has Balo's variant MS; a condition with large circular whitematter lesions.  Everyone agreed with me the next morning (which is relatively unusual).  We would have to tell her that she likely does indeed have MS and that what she was told previously appears now to be incorrect. 

The above case is interesting, but the person sitting next to the patient captured my attention. It was her father.  He worked in Charlotte; about 2 hours west of Chapel Hill. His daughter lives on the outerbanks coast, about 4 hours east of Chapel Hill. She clearly was in no position to drive, so she called him and he made the drive 6 hours east to the outer banks to pick her up, and then 4 hours back west to Chapel Hill for us to see her that evening.

This reminds me of the time I broke my wrist ice skating when I was a college sophomore. I had a hunch somthing wasn't right. I wanted to see a doctor. Who was going to take me to the hospital? Who else; I called my dad at around 6 in the morning the next day and told him I think I broke my wrist. He got up out of bed and took me to the hospital. A splint was given to me and later I wore a cast for about 6 weeks (No one signed it; I didn't want that. I was 20 years old and too mature for that nonsense).

When you know something is wrong medically, it can be scarey and lonely.  The question becomes who will be there to hold your hand when you're struggling; to drive you to the hospital; to make you food and do your laundry if you need some time to recover? For me and the patient I saw last Saturday, it was dad, and I am thankful I have that support system even if I live many miles away from my parents.

Things to look forward to.

I have 3 more topics I am looking forward to writing about. They will deal with resident fatigue, guillain barre syndrome, and mysterious myopathy.  Today I am swamped in clinic notes and paperwork, but look forward to my entries next week while I am on vacation in Cincinnati; the greatest city in the world.

Neurocritical Care

Today was the last day of my 4 week neurocritical care rotation.  Every morning I woke up at 4:45AM and worked from 6AM - 6PM, 6 days a week with one 25 hour overnight call shift a week.  I am physically and emotionally exhausted.  My nickname for the neuroscience ICU is the vegetable ICU.  Patients who have sufferred devastating hemorrhagic strokes spend weeks in the ICU.  Often their strokes are caused by uncontrolled hypertension. Less commonly they are caused by arteriovascular malformations, tumors, or intrinsic arterial disease such as cerebral amyloid angiopathy. The blood thinners they were taking to prevent clot propogation/ischemic stroke ironically can indirectly cause a more devastating bleeding stroke. Trauma and aneurysm rupture are also common causes of bleeding strokes.

As a neurology resident, most of my effort and attention goes into the first 24-48 hours of a stroke.  What caused the stroke? What can be done to keep the stroke from worsening?  What are these patients' neurologic status? Can they protect their airway? Does they to be intubated and connected to a breathing machine?  Are they awake? How impaired are their abilities to follow commands and speak? Are they plegic on one side of their body, are they neglecting one half of their environment?

Patient's who have a poor exam and a CT scan which suggests they have or soon will develop elevated intracranial pressure will come to the neuro ICU.  Here they will be connected to a breathing machine if they cannot protect their airway or breath spontaneously. Their blood pressure will be monitored closely and they will receivce continuous infusions of calcium channel blockers if needed. If their neurologic exam or head CT show elevated intracranial pressure, they may need emergent craniectomies to remove parts of the skull to allow the brain to swell. Often the neurosurgery residents will drill a hole in their skull at the bedside and place a catheter into their brains to drain fluid and monitor intracranial pressure.  But if the patient's neurologic status is poor enough, the decision can be made early that all of these interventions are futile as the damage has already been done and their is nothing left to save.

Some of the younger and middle aged patients do well with early interventions. Patients with subarachnoid hemorrhages from ruptured aneurysms will get their aneurysm clipped or coiled surgically, and they are watched closely for signs of elevated intracranial pressure and vasospasm for at least 2 weeks.

Then there are the patients who are vegetables. These are the people who already had any combination of  multiple forms of high grade cancer, heart failure, end stage renal disease, and are also unfortunate enough to suffer a devastating hemorrhagic stroke. They become comatose, and are hooked up to a breathing machine. Often the only signs of life they show is the ability to locate painful/noxious stimuli with their limb that is not weak.  Somedays family members feel they are tracking and regarding them with purposeful eye movements; this can be equivocal.  They are mute, they are fed through a tube.  Days go by and they don't wake up. Often continuous EEG monitoring ("EKGs of the brain") are used to see if there are underlying seizures causing the poor mental status.

In situations like this, physicians turn to family members, the next of kin, to make decisions when a patient cannot communicate his own wishes.  This typically would be a spouse, parent, son/daughter in that order. Would the patient want his/her life prolonged in a situation like this?  In the foreseeable future there is no reason to believe the patient will walk, talk, or eat again.  Families ask will their loved one wake up, what are the chances that they will get better? The truth is there is very little data to definitively answer these questions.  To say that these vegetables will never regain any further signs of life with 100% certainty is often incorrect.

But it always baffles my mind why care is not withdrawn in patients like this. The right thing to do is to talk to families, show them all of the brain scans which explain why their loved ones are comatose, and then start the patient on a morphine drip so they can pass.  Sometimes this does not happen because families hold on to hope that their loved ones will get better and walk out of the hospital. Even if these patients didn't have strokes, they often have other serious underlying medical problems which cannot be fixed such as cancer, heart failure, or advanced underlying dementia such as alzheimers disease.  Sometimes care is not withdrawn because physicians are intentionally misleading about prognosis. No matter how sick patients are, modern medicine can keep them alive indefinitely. We have machines that can act as a patient's lungs, heart, and kidneys. Nutrition can be delievered through gastric feeding tubes. But there is no machine that can replace a damaged brain.

Sometimes extensive measures have previously been made to keep patients alive, whether it be kidney transplants, pacemaker placements, coronary artery bypass grafts, or decompressive craniectomies. I feel physicians often don't want to withdraw care because it admits defeat. Instead modern medicine is abused and patients are kept alive on life support indefinitely and sent to long term care facilities; out of sight and out of mind. And what happens to these vegetables after they leave the hospital? I don't know, I never see them again. Our residency doesn't focus on how to manage these patients, and frankly the physical act of transporting these immobile patients on mechanical ventilation is so difficult that they will never leave the long term care facility they go to, so they never come back to the hospital or clinic.

 

These experiences made neurocritical care the most difficult rotation for me thus far in my second year of residency. Maybe my feelings of disillusionment are amplified by the negative feedback I received for constantly being uninformed on the ventilator settings my patients are on or the rate of their IV infusions.  None of these things matterred to me because it doesn't change the fact that the patient is a vegetable and will continue to be for the foreseeable future.  But, for every vegetable who spends weeks in the ICU and gets shipped to a long term care facility, there are many other patients who have done well from neurosurgical intervention and close monitoring in the neuroscience ICU. However, I feel that too often uninformed decisions are made to prolong the life of patients who have sufferred severe irreversible brain damage by both family members and physicians. Few people would want to continue a life where they are unable to walk, talk, or eat.