Errors

Yesterday there were mistakes. These are very tricky things. I saw a patient from Vocational Rehab. She was young, in the early twenties. She was injured when a heavy box of CDs fell onto her head in March. That's six months ago. Ever since then, she has pretty severe pain in the neck on the right side. She was treated with physical therapy, pain medications, and muscle relaxants. She isn't getting any better. I reviewed what the physical therapy people did with her. She is not on any at-home exercise program. She wasn't sent to me for her neck pain. She was sent over by Dr. L, a semi-retired excellent Neurosurgeon, who wanted nerve testing done to make sure there wasn't any nerve injury. She doesn't have normal neck range of motion. She can't bend or twist the neck properly. It isn't the same on the two sides. The left side moves normal, but the right side has limited motion. This indicates that the muslces don't stretch out normally, they're too tight. That problem has a very simple solution: stretch the muscles. Muscle stretching takes a long time with very consistent effort. The yoga people are very limber, and their range of motion increases with constant stretching. But that hasn't been tried yet. So I told her to do it. If she does it every day, twice a day, then she's going to be better in about three months. It's ridiculous that she hasn't had that done. It's upsetting, but that happens. I'm glad I got to see her, though. It's not because I like to see people make mistakes; not because I want to think I'm smarter than that other person: because now she'll probably (finally) get better.
I saw an eighteen year old who gets shakey. She feels just not right, and at various times in school she starts to shake. She shakes inside which is the most disturbing. It is variable in intensity. Now this girl is quite strikingly thin. Her bones aren't showing. She's just REALLY thin. I think most people would think that she's too thin, although I didn't figure out her BMI (Body Mass Index), the real way to tell if she's truly "underweight". So I asked her about her exercise habits, but she laughed at me (She doesn't like exercise). So I asked her about her eating. She doesn't really eat. She has a piece of toast for breakfast, and then she has a tuna sandwich after school. She has some candy. She says she only drinks water in the day time, but her mother thinks she takes a lot of coke and tea. She only takes those with dinner. I don't know, really. I want to believe that she's only taking the caffeine with dinner. You never can really tell. Anyway, not eating any food makes you shake. Eating nothing and then having candy makes you shake more. But no one told her to eat. Instead they checked her blood. She faints when her blood is taken. She told the people who drew her blood. People who faint with blood draws need to be lying down so they don't faint. But they didn't lay her down. So she fainted, and then had a seizure. Seizures that occur from fainting are called "syncopal seizures". They are a well known thing. They are one of the "provoked seizures". That is, seizures that are a normal reaction of the brain to a certain stress (like fainting). The reason she had that is that when she fainted, the chair that she was in held her up. If she had fallen down, then she wouldn't have had a seizure (she probably wouldn't have even fainted if she was laying down.) The proper treatment for THAT is to not draw her blood sitting up, making her not faint, and eliminating the seizures. Instead, she was given an MRI of the brain and an EEG which were both interpreted as abnormal and indicating seizures from epilepsy. Epilepsy is two or more UNPROVOKED seizures. That's the definition. So she can't have that diagnosis, no matter what the tests say. I had a great professor who told me "If there's any way possible you should always ignore test results from tests that shouldn't have been ordered. Never order a test that isn't crucial." Well, I should ignore the tests (MRI and EEG), especially if they have some subjective component to them (which these do). So she was placed on Depakote which is a fairly dangerous anti-epilepsy (and definitely NOT anti-syncopal seizure) medication. Luckily, that hasn't made her sick yet. I told her to stop that. The girl just needs to eat some food. Actually, she is a little high strung and she needs to relax a little bit too.
We all make mistakes, so it's going to happen. I have a fabulous patient who had surgery with an excellent neurosurgeon in town. He forgot to put the patient back on his coumadin right after surgery, so he had a stroke. That was a mistake. Our mistakes cause physical harm to people. I've made them. There are different causes. Some people just aren't very good at what they do. There's so many reasons for that. Some of them don't have the aptitude, and some of them have become totally "burned out". Some of them don't care enough, or don't try hard enough. Some are depressed, or they're ill and they don't know it.
Some people are good at what they do, but sometimes they make mistakes. Some of those are going to harm the patients. We miss simple things. We miss details. We go too fast and don't see things. We get tired. We do really stupid things because we refuse to go home with a migraine, or we took a medicine that made us goofy. We get emotional and believe patients when we shouldn't or don't when we should, or don't listen. I think it's us and how we are. We aren't really here a lot. We aren't focused on this very moment with this very person and this very person. We're distracted with all the things that are "stressing us out". We're thinking of another thing when we're with someone. We're carrying too many plates. Life isn't simple. So we should slow down. We should just take a breath. Maybe we should blog. Most importantly, we have to always try to find a way to let go of the past and forgive our mistakes. If it's possible, we should try to forgive the mistakes of the other people too.

Words

It is the nature of neurology to see things that are difficult to diagnose. We commonly see people who seem to have problems that no one can explain. One of my colleagues said to me that if he didn't know what was going on, then it was Neurology. I had a GI doctor consult me for evaluation of a patient who had stomach pain. He couldn't explain why there was stomach pain, so he called me. (I think it was what we call "stress".) Sometimes I diagnose the problem but I've become very comfortable not knowing what's wrong with patients. I've decided that even when I think I know what's going on, I should wonder if I really know. One of the most common mistakes that physicians make is having the wrong diagnosis but failing to question the first diagnosis and come up with a new one. The diagnoses that I make which others (sometimes many others) have not seen are almost all due to language. We don't get a good history. Actually, it isn't really that the doctors fail to get a good history. It's different. It's that doctors fail to properly translate. The patients speak English (for the most part). The physicians think in Medicine. Many times, the languages just don't translate well. For example, there is "weakness". When people say "weakness" it means nothing at all. That particular word means "ZXCDL". What is that? That's nothing. They may as well not have said anything at all. It's the same thing with the words "dizziness" and "numbness". These are common words. You would think that common words like these have a meaning that we all understand. I don't understand these words at all. Neither, I think, do most doctors. Some of them think that they know what these words mean. I see them get wrong diagnoses because they think that they understand these words but they don't. Most physicians think that "weakness" implies loss of muscular power, which would be indicated by the maximum amount of force that a muscle or group of muscles or all muscles can exert against resistance. Patients often think weakness means lack of ability to do what they were previously able to do. This may be due to what we call "exercise intolerance" or easy fatiguablitiy. It is sometimes due to lack of coordination, inability to walk, generalized lack of initiative, or shortness of breath. It may be due to many other things as well. I have twice now fixed "weakness" by treating the sleep apnea that hadn't been diagnosed. So in my mind it meant "sleepiness". In the patient's mind it meant "weakness". It's a communication problem.
Even when we listen to each other very carefully, we don't hear what we say to each other properly. We don't understand each other. We think that we know what we've said, but what the other person hears isn't what we intended them to hear. We live in different worlds with different languages. Every person walks around with their own language. This makes life challenging. This creates conflicts between people. It creates great difficulty with others. When we don't understand someone, we should realize that we don't understand them. This way, we can still have compassion for them. When we don't understand our patients too many of us think that their problems aren't real. We think that they're making it up too much. I very rarely think that patients have psychogenic illness. In fact, I think I'm very bad with that diagnosis. I don't think that many people come to doctors because they enjoy it as entertainment. I think they've found something wrong in their body. We just don't understand them. It seems to me most of us don't even understand our own husbands, wives, children, siblings and parents. We don't understand our friends and co-workers. The "closeness" we feel with some of the people some of the time is directly related to our ability to "connect" which comes from the ability to communicate, to understand each other. When simple words like "weakness" are so hard to understand it's no wonder that we find it hard to get along.

Clear Thinking

What we need is more clear thinking. B asked: "What do I do -- just live with it?" He has pain. It got so bad that he had to go to the emergency room. The pain is in the chest, on the left side. It is very intense. He's had it for several years. It comes and goes for no clear reason. The pain typically lasts about twenty minutes, although it can be more. It is a very sharp intense pain, "like stabbing". There is a sensation that is also similar to a "cramp", like a "charley horse." He has had ECG tests, GI tests and finally me, the neurologist. He had nerve tests, MRI of the spine, and GI endoscopy. There is no very clear, specific diagnosis. It's just "chest pain".
He doesn't like the lack of a specific disease name. It makes him feel nervous. We don't know what he has, according to his way of thinking.

This is not clear thinking. At some level, we know nothing. We certainly know nothing when you get down to the real details. I tell my patients, sometimes, "You have peripheral neuropathy." That makes them somewhat happy. There is a real diagnosis! They ask "What is peripheral neuropathy?" But even so, they are happy because now we "know" what they have. In reality, we don't know very much. We know that the nerves are damaged, and that's about it. Then, there are many kinds of neuropathy. There are many causes. Much of the time, we don't find the cause. We end up saying "Chronic Idiopathic Axonal Polyneuropathy." That's what they have. That, in short, is nerve damage that we don't understand. This isn't very different than what B has. It just has a fancy name. I don't know what causes either one. And that is clear thinking.

So we know what we know. We know he has this type of pain with this type of intensity in this location occurring intermittently with this frequency. We know that. It's his experience. It could be given a name, but that really doesn't change anything. It doesn't change the reality or the experience or the nature of the problem. Yet we allow the existence of the diagnosis to alter our perceptions of the reality. The reality is improved somehow with the name.

This sort of thinking is allowing us to fool ourselves; it's allowing others to fool us. Since the presence of just a name changes our perception of reality it's very easy to change our perception of reality. We need to be careful about these things. I suppose I could take advantage of that. I could give people fancy names and then tell them what I know about what they have with an authoratative presentation. It would make them feel better, maybe. But I wonder if we're "dummying down" by refusing to accept the very high level of uncertainty that truly exists. We need to become comfortable with the reality of uncertainty. Everything is uncertain.