Playing God!

I find it difficult at times; to come to terms with how we predict prognosis in critically ill patients. There aren't any formulas to calculate the duration of survival and quality of life (QOL) with accuracy which take into account a patient’s personality or their will power to improve or their dreams, hopes and aspirations. A lot of perception, personal experience and surrogate decisions determine continuity of aggressive care. I find it difficult to say that if a 95 year old comes in with a massive intracerebral bleed and is comatosed; he shouldn't undergo surgical intervention perhaps because the likely complications and risks far outweigh the benefits in somebody who has perhaps lived their life. How do we know that someone has lived their lives; how can we be so sure that they didn't have unfinished business which they wanted to take care of before passing on; what I may perceive as poor QOL they might be perfectly at peace with and would want to live irrespective of how dependent they become. Perhaps, as doctors we need to enable patients and families to see beyond emotion; to see the physical, mental and emotional turmoil which lies ahead.
Medical treatments are fraught with dangers and letting well alone sometimes is the best strategy. You want to do the best for your patient and you want to be mindful of when it is best to let go and when you should go that extra mile. But the subjectivity of this process creates conflict. I have seen some patients who seemed to have no hope for survival do really well and others who I felt would pull it off with that extra push spiral down. When patients or their families talk about miracles, I don't want to be a naysayer because I don't know how these miracles happen but they sometimes do. I want to be able to give them hope but don't want them to lose all semblance of reality for I am perhaps; their only connection with reality in their time of impending loss of a loved one. I wish there was a better way to do this. Sometimes, I wish I didn't have to play God because I am so not!

Seeing is believing!

Sometime ago I met a very engaging, cheerful young lady three years after her stroke enrolled in one of the FES trials. We walked with her through her journey thus far. Being a swimmer and a marathon runner prior to her stroke put her in an advantegous position as she was a quick learner who worked very hard and knew the importance of regular exercise. As our instructor Mr. B pointed out she was someone they would have to ask to stop pushing herself so hard and slow down. She doesn't even live in this city but comes down for her therapy sessions four times every week. She was happy with her progress. When she related that she had developed an aphasia along with her weakness, I was amazed because she was speaking so normally! I have always known that a lot depends upon how much patients want to get better but since I hadn't seen many patients outside the acute inpatient setting, it was heartening to see reamarkable recovery and a testimony to will power. She had 5 implanted electrodes in the muscles of her rigth leg which weren't being used presently. I saw her work her way to almost normal components of gait with the help of FES. Having experienced the unpleasant sensations of FES, I was amazed to see how she was using it so effortlessly and beautifully! She would break into an easy smile with a compliment from Mr.B about how well she was doing and knew exactly when she wasn't doing a good job. I liked the way she was tuned in providing herself feedback! No wonder she was doing so well!
She told us about her brother who was in medical school and wanted to become a neurologist as well. As we parted ways, she wished me luck. I couldn't help but thank her for teaching us so much in just a couple of hours!

Shocking move!

Functional Electrical Stimulation (FES) is a technology which can make weak muscles move by stimulating them via electrodes which could either be implanted or be placed on the surface. A little box is used to supply current and change its amplitude and frequency. It's the power of electricity at work for you and I was very excited to experience this technology first hand, quite literally!
My heart skipped a few beats when I saw our instructor's fingers move after she let 3 ma of current run through a few muscles of her right hand. Now it was my turn. I was a little apprehensive and very excited. I had been told that the current might feel funny, almost like parasthesias and even painful. One set of tiny surface electrodes and I was ready to experience electricity! I began feeling parasthesias with a very small strength of current and before long my fingers were moving; moving at their own will. I felt pain in a few tiny muscles of my hands and we decreased the signal intensity.
Then I wondered, I was experiencing this pain for such a short duration. People with stroke or SCI who undergo therapy have to go through these unpleasant feelings repeatedly and work with it to regain functional motility of their upper or lower extremities. Of course, there are many who will have some impairment of sensation and perhaps can tolerate higher intensities of current by virtue of their impairment but it still seemed like one had to be strong to endure and prevail.
My mom says this often, "There's no gain without pain”. I wondered about how much pain is enough; how much endurance will get you to where you want to be; how much patience one must have... I wondered about that amazing Creator who planned these moves and about the power-house our neurons were a part of. Every little synapse, every molecule of neurotransmitters at work every single moment of our lives; making us think; making us move; making us fall in love; making us do things we thought we were incapable of; making us feel pain; making us the people we are; is part of the incredible magic of nature and the Creator! We are trying to replicate nature and restore function in the way it was created. I like the idea but wish it was less painful and that we were using this technology more widely.

Walking; what a gift!

As part of my neurorehab rotation, I experienced first-hand two techniques for gait-training. They are both research tools currently but have showed promising results to help people with hemiplegia and SCI (spinal cord injury) walk and walk better.
I had only seen a few pictures of what I was going to experience. The first equipment I was hooked up to was a gait-robot called the “Lokomat”. By hooked up, I literally mean hooked up! The machine comprises of a treadmill, three different computer systems, works on electricity, has weight suspensions and sockets which house straps for your ankles, knees and hips and the machine fits snugly on your pelvis to stabilize it. The process of taking the first step involves a lot of preparation. There are all these measurements which must be taken before one can actually work on the robot. There’s a lot of trial and error before the right fit can be established. As Mr. L, the very patient therapist and researcher was going over the fitting process which took a good 45 mins, he explained how since patients are usually hemiparetic/ paraparetic, they could easily tire out before the measurements are completed and that might be the end of their session! It might even take a few sessions just to get the fit right! One of the motor-learning principles which seems difficult to achieve is to be to get a movement as close to normal is one of the principles the robot works on. The way the robot works is by making your joints moved in a co-ordinated fashion to mimic normal gait and with training, the amount of work done by the machine is decreased and the amount done by the patient is increased. Walking is not really about strength but about co-ordination and hence, there’s enough hope and means to make people who do not have 5/5 power in their lower extremities walk normally.
Getting on to the treadmill with all the gear as if I was about to sky-dive was almost surreal. So, once you're on the robot, you are actually suspended in air by way of weights. As I "stood" suspended in mid-air, I almost felt like a super-hero! Not until, the robot actually started moving my legs, did I realize that this was for real. Mr. L would keep checking if I was comfortable or not or if something didn't feel right. I was trying to tell the difference between the robot-generated gait and my normal walk. The weird thing is that besides having attended a brilliant anatomy lecture on gait by Dr. SRK in my first year of medical school, I hadn’t really thought about walking and so, understanding the subtle differences was quite difficult! To think that so much of evolution got us from a quadripedal gait to a bipedal gait only seems fair when you admire the complexity and the number of muscles involved in making sure you get to your destination whether it's Mt. Everest, the moon or your refrigerator! Walking is just one of those things we take for granted, which we never think consciously about unless we are in pain. It's an amazing feat of co-ordination, endurance and almost beautiful when you think about the principles! Perhaps, today was yet another reminder to not forget to be grateful for all things we take for granted. I was almost ashamed to think of the times I've complained about walking or taken the easier way out by driving or hailing a cab! It's a gift we use every single day and what a thoughtful gift it is! Kudos to researchers and therapists trying so hard to give this simple, elegant gift back to patients who will only feel so much more independent once they can stand up on their feet again.

What hurts more; what heals faster?

I am currently doing a neuro-rehab rotation. There are two very striking things about this rotation. First, the duration for which some of these patients have been here and the other; seeing conventional rehab and innovative technologically advanced rehab at work together to enable people to do things which we don't think twice about like walking, eating, voiding, moving one's bowels etc. and fighting fiercely to be as independent as possible wrt their ADLs(activities of daily living). So far, I have essentially seen Motor rehab and not cognitive rehab. Motor rehab is supposedly easier as one might imagine but it is painfully slow, needs a lot of endurance both of the body and spirit not only of the patient but his care-givers as well. There's the SCI (Spinal Cord Injury) unit and there's the TBI (traumatic brain injury) clinic. Since it's at the VAH (Veteran's Affairs Hospital), I know each one of the gentlemen lying in their beds in the SCI unit with paraplegia (paralysis of both legs) or tetraplegia (paralysis of all four limbs) waiting for someone to feed them or dress their pressure ulcers or clean them up, served in the armed forces at some point in their lives. I have always admired people from the armed forces who I feel do selfless service for their countries and have always felt that their sense of pride about their country, their work and their being, their self-sufficiency and their discipline is what makes them who they are. I don't know what hurts these men of honour more, their physical or their psychological dependency on others. Does being a tough guy make it more difficult to come to terms with being dependent on others even for the most mindless, almost reflex things we all do day in day out? And because you're a tough guy, does sharing that pain become more difficult and does the internalization of so much suffering erode your self-esteem paradoxically?

What amazed me last week in my first, brief encounter with the SCI unit was some of these men who seemed to be made up of a different fabric! They were laughing, gleefully sharing their hunting/fishing stories, lifting their arms up (with a lot of effort) triumphantly and telling me how once they're in their motorized wheel-chairs, they can do anything or enjoying a hearty breakfast and actually wishing they could have more bacon! And watching them, brought all those thoughts I mentioned above to my mind again and I felt a sense of regret because here are people who knowing well the limitations of their bodies want to constantly challenge themselves and win; when they don't feel sorry for themselves then why must I feel sad? Then I wondered; if being a tough guy with a strong will-power makes you better-equipped to deal with such physical limitations and inspire people around you and show the world that you're unbeatable no matter what!

And then there were men who lay in bed with the saddest eyes I have ever seen; with tracheostomies, and stubborn non-healing wounds through which bones were playing peek-a-boo; with colostomies; suprapubic catheters and wounded spirits. Some of them have been here in the SCI unit for more than a year. I wonder when their wounds will heal or how much will they scar; I see some scars already with my yet untrained eyes. I can’t help but think which scars are uglier, the ones that show or the ones that don't but completely disfigure your spirit? Does paralysis of the body make you more dependent than the paresis of the mind? Which of these recovers faster and recovers more completely?

Being in the midst of such contrasting patients with similar physical maladies leaves me with more questions than answers, with more inspiration than despair.

Cold hands, Warm heart!

As physicians, I feel we are in a unique position to learn so much from people who are around and those were and those who will be! There are so many moments we experience everyday which warm the cockles of our hearts, which raise a lump in our throats, which bring tears to the brink of betraying how human we are; moments filled with anguish, pain, helplessness; moments which are so full of hope which make us believe that there will be a better tomorrow, that there will be a better answer, that there will questions which will make us think for the better...

There has been so much which I have experienced as a medical student, intern and now as a resident which has made me who I am and there's so much which continues to inspire me to become a better physician and a better person. I really want to remember all those fundamental life-changing moments as much as the subtle changes which are slowly becoming a part of who I am as a physician.

I don't know where to start but I guess I will start with every morning...
Every morning as an intern at SVH and now as a PGY2 at UH, there's something amazing I experience every morning; something which I had never experienced back home. My hands remain icy cold! I, of course try to warm them up but don't think I do such a good job of that. All my septuagenarian and octogenarian patients who are sleeping soundly under layers of blankets wake up to the sound of an energetic good morning and the touch of cold hands! Now I've started warning them that I am really sorry but that's the way my hands are...I can't recollect the number of times I've already heard this but I think I want to hear it over and over again as they laugh heartily and say, "Cold hands but warm heart!" And then I smile to myself and feel that was yet another great start to yet another promising day.