Following the Limbic System

"The problem is that humans are driven by their limbic systems. As long as things are pleasurable, they will continue to do things even if they are harmful."

The words from our neurologist.

***
Another patient had been found down after using excessive amounts of cocaine; she had a history of previous neurologic insults and intercerebral bleeds. The CT scan was consistent with an intercerebral hemorrhage in both her hemispheres.

The patient was admitted for emergency neurosurgery to evacuate the bleed and to decrease the increased intracranial pressure, an operation involving removal of part of her skull. She then went directly to the ICU for very close monitoring.

The prognosis was unclear; she was comatose and her neurologic exam did not change--her eyes remained closed and she barely responded to painful stimuli. She had seizures continuously and no matter how high we titrated the anti-epileptic medications, her seizures remained.

Her pressures started to drop. And it was decided that her prognosis was poor in the setting of her decompensation. Life-sustaining support was withdrawn and the patient expired.

She died alone in the noisy ICU surrounded by machines.

***
In many ways, my neurology rotation has been sobering. Each day, I am reminded about the devastating impact of neurologic injuries on the lives of our patients. It's dramatic; one day the patient is normal and the next day everything changes.

I see it in the faces of our patients with facial droop, I hear it in the voices of our patients with dysarthric speech, I feel it in the muscles of our patients with hemiparesis, and I sense it in the frustration of our patients with aphasia who communicate with a word salad.

You see it too in the eyes of family members, who look to you for hope that their loved ones will improve, when you know the prognosis is poor.

You localize the lesion and can explain the pathology, but sometimes have very little to offer for treatment.

***

"Will my husband every be normal again? Will he be able to walk again?," my patient's wife asked.

My patient could not move his entire right side of his body. He had bled into his left hemisphere.

The answer to her question is the same answer we give to many families.

"We do not know. We will just have to wait and see." I said.

***
I'm half-way through my Neurology rotation. I returned to SF General Hospital for this four week rotation. In taking care of patients with neurologic conditions, our focus has been on localization of lesions. Using the patient history and neurologic exam, you learn how to correlate symptoms with neuroanatomy. It's a constant puzzle; sometimes it's textbook, while other times, you struggle to put the pieces together.

More often than not, the neurologic symptoms are unusual and present in many ways depending on the location and severity of the injury. The exam is the key to help localized and clench the diagnosis before confirming with neuroimaging.

So far, I have seen a myriad of neurologic conditions--everything from ischemic and hemorrhagic strokes to headaches to intercerebral bleeds to degenerative diseases to CNS infections to Parkinson's Disease to neuropathic pain to seizures to CNS lymphoma, as well as the unclear CNS diagnoses. One of my patients remains a diagnostic dilemma. We are still trying to find an explanation about why he can't walk and why his face is weak.

***
Having returned to SF General Hospital, I am reminded about the harsh reality many of our patients face. Whether dealing with being uninsured, substance abuse, HIV, homelessness, social factors- you quickly learn about the intersections of the medical and social history, since both topics go hand in hand. Prevention sometimes is an afterthought in patients, who have had uncontrolled hypertension because they could not afford the anti-hypertensive medications or the doctor visits. It's too late, once they have a stroke.

The damage has been done. Sadly, it's irreversible.

***