Only So Much To Do

I'm about a week removed from my psychiatry rotation and one week into my neurology rotation. From a medical standpoint, I'm liking neurology more than psychiatry. From a symptomatic, pathophysiological, and diagnostic perspective there's so much more going on. And I personally find it a lot more interesting. That said, with some conditions, there's only so much that can be done sometimes. To some extent, this also rang true with psych.

Psych
PTSD: it's pretty devastating and disheartening what combat can do. There are three symptom clusters that need to be met for PTSD: reexperiencing, avoidance, and hyperarousal. (Makes sense, but vets are evaluated in detail against these criteria for diagnosis. Why? Because the VA pays PTSD disability. Obviously, some people will take advantage of this.) Each of these symptom clusters affects people in its own way, each potentially functionally and/or professionally disabling. Reexperiencing is what it sounds like - vividly having to relive whatever combat situations they went through, either spontaneously or after a triggering stimulus. Bad as that is, a fair number of vets end up using to try and prevent reliving their experiences. A large number turn to alcohol and heroin, with a decent number also using cocaine.

If they don't use, then they may overreact to seemingly benign stimuli, like walking in public or fireworks. Some vets can't be in large crowds, because they can't account for the whereabouts and actions of everyone. Some can't handle loud sounds like fireworks or the L, and end up prone on the ground for minutes at a time. It's literally a reflex they have no control over. They can also end up withdrawing socially, becoming dysphoric, anhedonic, and hopeless.

And the last complex of hyperarousal can be pretty debilitating. Some vets will stay up all night, either because they're paranoid about someone coming after them or because they're having nightmares and/or flashbacks. They can also become irritable and prone to anger outbursts.

While interviewing a Vietnam vet, he straight up told me that I made him uneasy. Although he was pleasant and cooperative, he admitted that his instincts still told him I was an enemy and that he could picture himself killing me. I'm grateful he has some control over those urges. Either way, PTSD can be a devastating and disabling condition. It can push people to do things they don't want to. It can push seemingly highly functional people to use. It can ruin the lives of people only a few years younger than us.

Neurology
MS: multiple sclerosis is basically an autoimmune process that attacks the myelin sheath surrounding neurons in the brain and spinal cord, leading to both sensory and motor deficits, which manifest for years as acute attacks and eventually deteriorate to progressive decline. It's pretty disheartening (to me anyway) to see younger people with MS attacks, e.g. becoming totally paralyzed in their legs. Granted, they usually get better after a few days of appropriate treatment, but there's still some residual weakness. On top of that, there's sensory loss, possible incontinence, and not knowing when you're next attack might happen. Not the best way to live life.

GBM: glioblastoma muliforme is a high grade tumor of the brain (astrocytes) with a very poor prognosis - 6 months without treatment and a maximum of 18 months with treatment. This is the brain tumor that Senator Kennedy had. One of my patients was diagnosed with GBM in August. He initally presented with left sided weakness and confusion. After imaging, biopsy, and pathology he was diagnosed with GBM. Since then, he's had two 3 week stays in the hospital, 2 shunts from his brain to his abdomen put in (to drain excess fluid), and 2 emergency burr holes in his skull to drain the excess fluid and edema from the tumor. He's also had a few runs of seizures and almost complete left sided paralysis at this point.

ALS: amyotrophic lateral sclerosis, AKA Lou Gehrig's disease. This is also the disease Stephen Hawking has, though his extended survival is the exception rather than the rule. ALS is a progressive motor neuron disease, affecting them at two levels of the motor pathway - both upper and lower. As such, people gradually lose all motor function, with most people dying secondary to loss of respiratory muscle function. The prognosis is grim, with a three to seven year life expectancy depending on time of diagnosis. One of my patients has this, and its at a pretty advanced stage. He's lost movement of all four extremities, and is developing trouble speaking and swallowing. At this point, his care is all palliative, e.g. a feeding tube. One of the sadder aspects of his care is getting end of life affairs in order, including a do not intubate (DNI). Reason for this is that he may end up in respiratory failure, but if he's intubated without a DNI he can actually live for quite a while - albeit while totally paralyzed. He'd also be conscious with intact sensation. Horrible.

All these patients have made me realize that while there's a lot modern medicine can do, there's a limit to its efficacy. It's mind blowing to me - it's taken me a lot of time and energy just to get the bare basics of medicine into my head, nevermind the clinical experience needed for general practice or the minutiae, protocols, and therapies for a given specialty. Basically, I know there's some stuff in my head, but I also know I don't know a lot. It's even more humbling realizing that there are some things we just can't do anything about. That's one of the tougher things to deal with, especially since we're all wanting to cure our patients - not just stand by idly providing palliative care.