Juggling mountains, real time

(This is from before the hols, forgot to post it)

So often you come across a list of symptoms and signs in a book, dot points to memorise for the exams. Receptive aphasia = Wernicke's area, expressive = Broca's, conductive = arcuate fasciculus. Easy enough. Wernickes are Wordy without making sense. Brocas have Broken speech. And then you find yourself at the bedside, running over the longwinded neuro exam in your head and launching into your well-rehearsed introductory "hi Mr X I'm a 2nd year med student and would it be ok if my friends and I asked you some questions everything you say is confidential and of course please let us know if you're uncomfortable at any time" speech....only to find that Mr X, though awake, isn't even looking at you or appearing to listen. Sudden panic. What about consent? how are you meant to proceed without a history? this isn't how it's meant to go! Then you collect your wits and think what this might mean. Is he deaf? Is he unable to understand? Does he have psychiatric problems? You try verbal and written questions, "could you close your eyes? what is your name?". Unblinking, he doesn't reply, despite several attempts. You notice his face is drooping on the right and lightbulbs start flashing. Mixed aphasia, facial paralysis...left hemisphere stroke. Lateral cortex, maybe middle cerebral artery? What next, coma scale score?

The registar comes with the answers, and shows you the physical exam tests you should be doing. Heaps of positive results. So, spasticity is when you bend his arm and it comes to a sudden stop. Hyperreflexia is when the lightest tap makes his arm jerk. Hemianopia is when he doesn't notice your fingers wiggling in one bit of his visual field. Inattention is why he didn't respond to you at all from the right side of the bed, but reacted a bit more from the left. The reg leaves. You're pretty proud you came up with a correctish diagnosis, plus seeing these signs in real life is frankly darned cool- things are starting to click. The panic has subsided, thanks to the comforting jargon and procedures.

Well, almost. You're still uneasy about what to make of this man. It doesn't seem right to speak about him as if he wasn't there. He's unable to understand you or say a word. Still, he's awake, can shift the blankets to warm himself, and seems to register your voice if not its meaning. How much does he understand? Is all communication lost to him, or just verbal language? If it is all language, can he even think? Is he trapped inside his mind, unable to express his indignation at being unceremoniously poked at by three young women? Can he be depressed? Does he retain his personality? Should you explain what you're doing, even though it seems to be useless? Some of these questions come much later when there is time for reflection, because on the spot you are preoccupied with figuring out what on earth is going on. Feeling a bit ridiculous, you look him in the eye to say "thank you Mr X" and pat his hand. Your friend snorts.

Outside, you look at his notes. He came to hospital for an elective operation, in decent shape albeit with some of the generic risk factors for stroke, cholesterol and blood pressure and all that. He didn't recover from the procedure as expected, and somehow - you're not sure if it's related or not - he ended up with this stroke, locked within himself. Among the pages and pages, a note from a social worker. It says how his wife was informed about how he will be severely disabled and would be best in professional care. She refused. He could be cared for at home in their back room. It is a few words embedded amongst measures of his vitals and physical exam results. Suddenly he's no longer a clinical puzzle, or a collection of cool signs, but a husband whose wife loves him enough to keep him by her though communications is impossible. Now you understand why there is a photo at the foot of his bed, a portrait of him with his dog, the man he was before he became a patient.