"The Chief Function of the Body is to Carry the Brain Around"-Edison

I've always talked a big game when it came to the brain. When people have asked me what I want to do in medicine, it has always been my go-to answer to say "something brain related". Yet, the reason why it is fascinating to me, is also the reason why it's heartbreaking, and actually a struggle to commit to as a career: so much is unknown. In research, unknown means that you have the opportunity to REALLY change something, and that you could be the person to discover something that could help a lot of people. But, in clinical care, unknown means...dying patients, demented patients, and patients there is really nothing you can do to help.

To learn more about neurology, we were assigned to one doctor to take a group of us to see patients. Armed with tuning forks and reflex hammers, and a semester lost of neuroanatomy, we followed blindly to our first bedside (all while secretly hoping we remembered something about spinal cord pathways and brain circulation). I have seen many "stereotypical" stroke patients as portrayed on television, or pointed out to me in public because of their gait or lopsided smiles, but I have never really examined one, especially one within days of a stroke occurring. What was most fascinating about this patient was not the loss of light touch sensation on one side (something I would expect), or even the loss of vision on that same side, but it was the fact that despite almost full strength in the muscles on both sides, the patient really could not control the arm on that side. During the exam, that arm would be flailing in the air, or resting above the patient's head, or crossing over the patient's body, but when asked what the arm was doing, the patient would simply say it was resting on the bed, or, alternatively, the patient wouldn't even respond to the question. At times it looked like the arm really had a mind of its own, something we later learned was, in fact, pretty much true, as the patient had developed something called a phantom limb. At one point in the past (we didn't witness it), the patient even thought someone else (a grandmother) was touching the patient's side because the patient literally had no awareness of what that arm was doing (or even who it belonged to). I had heard about people who lost their arms in war developing such a thing, but never from a stroke. The patient may have been in high spirits, giggling at most questions, and out-witting us on several, but the whole time all I did was stare at that arm and hope that with therapy the patient will be able to use it someday.

Unlike the previous patient, whose mental status was completely in check (even preempting our questions with answers--ie. BARACK OBAMA--, as the orientation to time and place questions are quite overused), the next patient we saw was one of the hardest cases I have seen so far. Physically, it was obvious something was wrong with this patient's brain as you could see that literally half of the skull cap was missing (from something called a hemicraniectomy). Yet, it was the mental status exam, and the way the patient responded to our questioning, that really made me think.

When examining a patient with this degree of loss, apparently you are supposed to decide which is worse, the patient's word comprehension or the patient's actual speech (language production), as this can let you know what type of aphasia you are witnessing. To the questions we asked, the patient would respond "yes" or "no", but never really at the right time. For example, the doctor asked"what is your name", and the patient responded with a surname. The doctor followed this up by asking what was the patient's first name, and he received no response. This lead our highly qualified mentor to then give the patient a few names and ask if those were the patient's first name. Though the patient responded "yes" to the actual answer, the patient also responded "yes" to 2 subsequent name choices given.Then, if asked what a number was, the patient's answer "15" or "7" was never the correct number of fingers that were being held up, "5" or "1". To check if this was actually comprehension problem, the patient was asked to reproduce the number on the good hand, and quickly 5 fingers (the right answer) went up. This was a clear sign that the patient's ability to comprehend was probably still in tact...slowly directing us towards a diagnosis. The patient could also follow commands (shut your eyes, for example), but could not repeat words, often responding "no" (after trying to get a word out) when asked to repeat a word and only really successfully repeating one. When a command was written down ("close your eyes") and the patient was asked to read it, not one of the words that were read out loud were on that paper. One of them, we postulated, even appeared to be jumbled from something else the patient was thinking ("examination", as in "I am getting an examination" or "please stop this examination").

Ultimately, we determined that the patient suffered from anomia (google it, there are some interesting videos on it), which explains the word finding difficulty and also, pretty severe Broca's Aphagia--google this too-- (diagnoses that were all pretty much determined by my neurosurgery interested classmate who has been shadowing often, and knows and remembers much more brain anatomy and disease than ANY of the rest of us, who mostly were just silent...or well...wrong). While it is true that the patient also had paralysis, pain, and weakness, it was the mental findings that were the most...intriguing...for lack of a better word. It is hard to say something so depressing is so interesting, but there really is no other way to describe it. At times I had to remind myself that the patient wasn't joking or being facetious when responding "no" to a command, and even had to stop myself from laughing at his attitude about it more than once, but, in my defense, I had never met someone like this before....I had only heard about it in textbooks (or watched the same google videos you will probably watch later).

When as a group we talked about the patients we saw and looked at their CT scans to learn a little bit more about them, I couldn't help but think to myself...is this life (the one post-stroke and surgery in the second patient) REALLY worth living? Wouldn't the patient have been better off if the doctors just let the patient die? True, the doctors SAVED a life, and stopped the massive brain swelling caused by the stroke, but the look on this patient's face when answering questions, or searching for words, was heartbreaking. Like others with Broca's, this patient was utterly and completely aware of the situation and the difficulties, but there was no way for the patient to actually talk about it. I felt, a bit, like I was watching someone trapped in their own body: A serious and depressed affect showed me what the patient was thinking, but I really couldn't help make anything better.

I turned toward my classmate and asked him (well,whispered so the doctor wouldn't hear) if it was wrong that I would rather have died in this situation (or that I was thinking this as a future caregiver myself). To which my friend replied, astutely and always to the point, "this is why I can never be a neurologist. It's just...too hard". With that answer, I now know I need to stop blindly saying that the brain is what I want to do, or that this is what I want to be...and open my options and realize it really might not be.