Brain Verse

There are a few things I never thought I would see in this lifetime. 

For example, I don't expect to see conjoined twins, a 9-foot tall person, or a human being live to be 130 years old. But, up until very recently, there were two other things I never thought I would see: The first was a heart beating calmly and strongly inside a man's chest. But that is old news now, as that happened during my first clerkship in general surgery. Second, I never thought I would see a brain. I  mean, a clear and clean brain, still inside of someone's head, and prepped for examination. 

But, just this past week, I saw not one, not two, but three patients prepped in such a manner. With nearly ten professionals--nurses, doctors, PAs, anesthesiologists--standing around the room in great expectation. Three brains! Two of them undergoing a treatment for Parkinson's Disease called DBS, or Deep Brain Stimulation. 

I first heard of DBS through Michael J. Fox. Many of us know him as the famous actor who developed early Parkinson's Disease (PD) and subsequently began a foundation dedicated to treatment, education, advice and research for further treatments for PD. 

I'm going to go on a bit of a tangent about DBS because there is yet a third thing I never thought I'd see in this lifetime. In fact, it's not even something I ever "heard" of. And that is something I'm going to call brain verse. 

To begin with, DBS works for those with PD and dystonia--dystonia depicts movement disorders, in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures. DBS has also recently been used for obsessive compulsive disorder and it is currently being researched for use in those with Tourettes Syndrome, depression and even obesity. For Parkinson's, DBS works by inserting a micro-electrode, as thin as a hair, into a part of the brain called the subthalamic nucleus (STN). When this electrode is stimulated, it essentially confuses all the neurons in the STN and for those with Parkinson's, that means the relief of the majority of their symptoms, which may include dystonia, tremor, bradykinesia (slow movement), inability to talk, shuffling gait and cognitive decline, and possible psychosis due to the medications used to treat PD. 

Before surgery is done the brain is mapped--using MRI and CT scans of the head--to pinpoint exact measurements in the brain so that the electrode can be inserted, a half a millimeter at a time, until it reaches its target--in the STN. As the microelectrode is inserted, slowly, by a neurologist, this electrode records brain cell activity. What I learned from my first DBS procedure, is that different parts of the brain actually sound, well, different. Different parts have different neuronal activity and the neurons fire quicker or slower, depending on where they are in the brain. A set of speakers in the surgical suite pick up this activity, and, through them, we can hear the brain verse. The neurons of the thalamus, for example, kind of sound like an idling tractor. The entire surgical team listens to the speakers waiting for the distinctive sound of the target area, the STN. The STN, I heard, is much quieter in amplitude, but the neurons here are almost continually firing. The STN sounds like a purring kitten, with hiccups. 

Whats even stranger, is that the patient is awake--and hopefully calm and cooperative--through this mapping. And their head is placed in an archaic looking cage so that they aren't able to move, which is, of course, a good thing. 

A patient undergoing DBS placement. 

Once the electrode is in place, the neurologist turns it on, and tests it on the patient in the operating room. We all watch to see if the tremor goes away, which is why the patient must be awake. 

The first time I met a patient with PD she had a tremor so bad I could not shake her hand and she was unable to walk into the exam room. During her surgery, when the electrode was placed and stimulated, I watched her ten-year old tremor disappear. Just like that. It was as if a light switch had been thrown. I stuck my head under the surgical drape settling down over her forehead, grabbed her hand in a firm handshake, and smiled. I couldn't help it. 

I can't wait to see her walk into the office next week. 

My neurosurgical rotation is, surprisingly, already halfway done. In the past two weeks I have seen things I never thought possible. I've been present for difficult conversations about new onset Alzheimers disease, scrubbed in on multiple surgeries, helped heal chronic back pain, held many hands, shook my head a few times right along with the patients, tried to convince several neurosurgeons to hire me, worked with a world-renowned neurologist, meditated with a patient, and pretty much ran the gamut of human emotion. Needless to say, neurosurgery is captivating on all levels and I can't wait to see what the next two weeks will bring.  

Oh, and next time I need to tell you about the man with the fused backbone...

Eleven Roses

(for John)

The 12th one was left 

in the middle of the street,

by an old man waving a cane

warding off his caregivers, frail gown

snapping in the wind 

flesh,  

the color 

of a bruise.

At the hospital, after the police left,

his family never came,

his hearing aids never worked,

run out
of batteries,
his memory
never failing

to remind him

that none of this
was fair.

After two weeks 

of staring, listless, nothing
ness

someone had the heart 

to bring him batteries.

Now 

his hearing aids worked
he could tell his story

the right way

call his daughter, his only daughter

and say

"fuck you"

and begin

behaving

just well enough

for just long enough 

to go back.

The roses all wilted by now. 

Goodbye, New Friend

This is a brief ode to internal medicine, because I will miss you immensely. 

I'll miss walking the halls at 7am like I know what I'm doing. I'll miss making a sick patient laugh to the point where they good naturedly tell me to stop it because it is making their belly literally hurt. I'll miss being a friendly and familiar face for people who have no friends or family in the area. And I'll definitely miss listening to a 92 year old woman with dementia tell me she wants to go home, to her parents (who surely can't still be alive but I'm not going to tell her that), because her mom "makes the best meat loaf." 

What I won't miss is the number of times it seems that I said, either out loud or under my breath, "that sucks," or "this sucks." Because the reality is, if I am in internal medicine and I see you that means you are very sick. And most of the patient's ailments or circumstances or issues with lack of insurance or follow up care, well, it just simply sucks. It really sucks to think of so many patients I've seen in the last month that, once they are discharged, have nothing. Nowhere. No one. I won't miss reaching the first Friday of my rotation, one week down, and breaking down with sadness for them all. 

But I did learn one important thing which I guess is perhaps the most important thing: I loved it. I loved the chaos, the calm, the frantic running around, the camaraderie with the nurses, social workers, docs, the chaplain. I loved how the spiritual and social and psychological part of how we heal was recognized and acknowledged time and time again.

Best of all, I realized I could do this. 

They Call it Takotsubo

The 77 year old man found his way into the emergency room, it seemed, almost by accident. He appeared dazed, shaken, dyspneic (short of breath), was feeling nauseas, had recently vomited, and was now clutching at his chest in apparent distress. Several of the nurses knew him only as Mr. Zims. He occasioned this small town ED frequently after the death of his wife several weeks earlier. 

By all measures and algorithms, it appeared that Mr. Zims was having an acute myocardial infarction, or MI (heart attack). But that's not what was happening. In fact Mr. Zims had very few of the traditional cardiac risk factors for a heart attack. He didn't have hypertension, hyperlipidemia (high cholesterol) or diabetes. He wasn't a smoker and he didn't have a family history for cardiovascular disease. But what he did have was something far more ominous. And something that we have all experienced more than once in our lives. What Mr. Zims had, and what the diagnostic and imaging tests would confirm, was that for all intents and purposes, he was suffering from...a broken heart. 

"Broken Heart Syndrome" or Takotsubo cardiomyopathy, was first described in Japan in 1990. Takotsubo mimics acute coronary syndrome. Just like Mr. Zims, patients often present with chest pain. Their EKG's show abnormalities suggestive of MI including ST-segment elevation. These patients also have elevated cardiac enzymes. All of these findings are consistent with an MI. But, the thing is, they are not having a heart attack. 

The Japanese word Takotsubo translates to "octopus pot", because this is the shape the heart takes on when it is in this stressed state. The apex (or bottom of the heart) balloons out when the ventricles contract. But, surprisingly, there is NO significant coronary artery stenosis. Although the exact etiology is still unknown, the syndrome appears to be triggered by a significant emotional or physical stressor. For Mr. Zims, this stressor undoubtedly was the recent loss of his wife. The prognosis in Takotsubo cardiomyopathy is excellent, nearly 95% of patients experience complete recovery within 4-8 weeks. 

Octopus Pot 

I write about this "Broken Heart Syndrome" mostly because I am completely mesmerized by the fact that such a thing exists; that we can, in fact, die of a broken heart. How poetic. How horrifying. How sad. How, in some mystical way, touchingly beautiful. Mr. Zims will be okay, I am sure of that. Figuring out what was wrong with him was the first step towards his recovery. At least his physical recovery. His grief may last the rest of his days. 

In medicine, and especially in training, we all have our "bucket lists" of medical conundrums we wish to see. Learning about Takotsubo was a good fortune, mostly because I will now have it on my differential diagnosis in the future. Mr. Zims will help me help others. But there are other things, other medical phenomena that one may only read about. These are the "zebras" that we learn about. Phenomena so rare one doesn't usually think of them first when a patient arrives with a unique clinical presentation. In my PA program, witnessing a "pheochromocytoma" would be nothing short of an act of god. And not that I wish misfortune or ill will on another human being, but there are other things I hope to see. And I'm sure even more that I hope not to. 

Either way, take care of your hearts, all. They really can break. I know that now.