Strokes

Hi,
I saw a lot of strokes this week, as I am sure you can guess by the title. In fact this was a week of the rotation where I was meant to be on a 'stroke' rotation. Strokes can be very sad: Sometimes patients seem to make a complete or very good recovery, walking out of the hospital days later and other patients are confined to a mental prison. Either trapped in their paralysed bodies or stuck with a brain that will not do what they want it to do. Strokes cause a variety of problems that I'm sure you know of from the FAST campaigns currently on.

Part of stroke that these campaigns don't mention is the dysphasic effects it can cause. I find myself talking to patients who cannot understand what I am saying (receptive dysphasia) but have little problem speaking themselves or patients who can understand what I am saying to them but cannot get words out in the order they want, or use the correct words (expressive dysphasia). Some patients have what is called anomic dysphasia where they can have problems naming everyday objects. This latter dysphasia is common in many types of stroke, but can just occur on its own. This can be strange, talking to a patient relativity normally and then when you ask them to name something (such as a pen or a watch) they cannot. Sometimes they know what to do with the object, they just do not know the name. One elderly lady thought a comb was a phone and tried speaking into it. If it wasn't so terribly sad then this would be almost funny. All of these different effects a stroke has on the body can tell the doctor what is wrong with the patient, showing what area of the brain has been affected. Many of the mental disturbances remind me of "The Man Who Mistook His Wife For a Hat" - psychiatry is exceptionally interesting. Patients can seem crazy.



Anyway, I like writing about the patients I have met this week (maintaining privacy and retaining identifiable facts etc. of course), and as I have received no complaints that is what I will do!
I missed seeing a thrombolysis this week, unfortunately, due to a couple of very eager students rushing off when we were told only 2 of our group could go and watch. I suppose this means I should be a little more in-your-face and just go rather than asking people what they want to do. It was an emergency I suppose, having to run down to A&E, so no time for a nice chat. This is the sort of area of medicine that I find exciting, I should be getting stuck in there, not hanging back being polite! Either way, the half of the group that went didn't get to see it anyway as the patient did not fit the scoring system needed. Patients can be disappointingly well.

The worst off patient I saw this week had a GCS of 4, meaning they are just one step off of being dead. Severe brain injury is usually a score of 8 or below, so this is very bad. It was very sad watching a patient be ventilated, tubes running in from various machines and with no way to talk to them or contact them. You know they are going to die sometime soon. Perhaps it makes it easier to think of them as already dead. I didn't envy the consultant who had to go and talk to the family and tell them that there was nothing that could be done, and we just had to wait and see. Patients can die.

On a more upbeat note, there was an 80-something year old elderly man who I spent some time speaking to who was full of amazing stories. Biking until he got into an accident around 68 where he had a knee replacement due to the damage, the man had been hang-gliding last year in Turkey. When I am older I wish I could be like this! Positive attitude really helps most areas of medicine, and having a positive attitude after a stroke means all that effort can go into rehabilitation and making you better. This man didn't just want to lie there, he wanted to work out how to cope with the new weakness and problems he had, so he could carry on his active life. This man was home before the week was over. I always had a smile on my face after chatting with him! As well as you helping the patients, patients can help you as well.

One of the elderly ladies who had recovered almost fully from a stroke spent some time trying to persuade me to come to her house and take some un-puncturable bike tires that they no longer used. We had started off just having a nice chat because she looked lonely and had been put in a side room. Some patients like side rooms as they are a lot more private and away from the hustle and bustle of the ward, meaning you can get a (comparatively) good nights sleep. This lady was not keen on being in the side ward, as she wanted to see what was going on and talk to people, as she had not been badly affected by the stroke at all. After chatting with her for some time about her life it turned out she had been a keen cyclist up to a few years ago. Very impressive seeing as she had just hit her 90s! I chatted about cycling as well, having a bike myself and all that, and she started offering me these aforementioned tires. Made of squishy but solid rubber these sound great for avoiding punctures, if not a little solid if used on my racing bike. I was unsure what to say. I don't want to go around taking gifts off of poor old ladies, and I dont even know where to begin regarding the ethics of taking backhanders from patients. I just had to keep changing the subject whenever she tried offering them to me - very hard. In retrospect I think the best thing to do would have just to say no, but it seemed rude at the time...  It would have been better if she had stuck with buying chocolate for the nurses. Patients can be over-generous!

There is always the chance to make a difference in hospitals, whatever your role. Even as a lowly medical student, with what seems like next to no knowledge when a consultant starts quizzing you, can help people's days go a little easier. Perhaps being a medical student gives you that perfect bridge between doctors and patients. Doctors and Nurses are very busy, rushed off of their feet and overworked, but that is just the NHS. Medical students are busy, yes, but we can choose what we do with our time, from practising histories and examinations to trying to sneak chocolates from the nurses station.
I felt I had done something useful this week when I talked with a patient who had come in with a possible stroke, but the consultant decided it was more likely to be a seizure. On a busy ward round, all the consultant really had time to say was that it was much more likely to be a seizure than a stroke from the history. We had to organise an MRI to confirm this, and if they were right and it was a fit then the patient would not be able to drive for a year. This is a rule the DVLA imposes. I suppose sense, as having a seizure while behind the wheel of a car could easily cause an accident. The patient had also developed homonymous hemianopsia, a type of partial blindness which may stop her from driving as well. Unfortunately, driving is an integral part of many peoples lives, especially a 40 year old like this patient, with a busy work, social and family life. The patient looked stunned at this news, and all the round could do was move onto the next patient. With somewhere between 10 and 20 patients to see, treat and listen to in a morning, especially with the complex neurological tests that need to be carried out, and the slow slurred speech many patients suffer from, this is a struggle.
Fortunately, I had some time left at the end of the round before I had to go off to another ward. I thought it would be worthwhile going back to this lady and talking with her about what the doctor had said, and see if she had understood it. After chatting for nearly an hour she seemed a lot happier, but still shocked by the news. Much of the conversation was around how she could now cope and the lingering possibility that it could have 'just' been a stroke. I have never seen someone hoping that they had a stroke before! I have seen this state of hopeful denial plenty of times when I was working in obstetrics, where women would hope that all the doctors they had seen were still wrong and their baby would still be fine, despite having been told many times they had misscarried. It is always sad, but I suppose it fits in with the 5 stages of grief. I think its important to be honest in these sort of cases. When there is a possibility that the patient's hopes may be correct I think its best to be honest about the possibilities and keep it realistic. It isn't fair to foster false hope in someone, as while it may make them happier momentarily, someone is going to have to pick up the pieces afterwards. It was a lot easier to talk with her as she was in a side room. Most wards in this hospital are large rooms with 10-20 patients in them, and a curtain doesn't really offer conversational privacy. It is terrible, seeing someone's life turned upside down within a minute like this. The woman was very upset as she had recently started living a lot healthier and stopped smoking, eating bad food, had taken up exercising, the lot. I suppose sometimes life is just not fair. Its never too late to start living healthily though!
In the end when the MRI came back, it turned out that it was indeed a seizure, and she had to be put on sodium valproate to stop another occurring. I suppose sad things like this happen in hospitals all the time. Patients can often need support.

There was another much happier story about another patient I saw across the week. This elderly gentleman (around 80) had been in the ward for some time due to his extreme condition. He had a lot of expressive dysphasic symptoms and could hardly speak. When I started seeing him he could count up to 8 and name 2 colours. Over the week, I saw him starting off very depressed about his condition, and the failure to get his brain to do what he wanted to was clearly annoying him. As the week went on, with some intensive speech and language therapy from a trained specialist, I saw him slowly get better and become more aware of his condition. Stroke patients are often very depressed, but he worked through it and build on his communication. Often very smiley when I saw him he found it a lot easier to give thumbs up and smiles compared to words. When I last saw him at the end of this week he could name all of the normal objects on his bedside table, count up to twenty and attempt a (very basic) conversation. He understood absolutely everything that we said to him, however, as it was only the part of his brain that used words to speak that was damaged. I remember on the last day seeing him, we asked him to show us his teeth, which is part of a neuro exam that checks the facial muscles which let you smile. He must have been asked to do this dozens of times in hospital, as it a bog standard test, but he still lifted a piece of tissue paper in his hand and looked at us quizzically. We asked him again and he just looked at the tissue paper. What was going on? Had he started suffering from receptive dysphasia as well? It look us a little time to realise that the patient had taken out his false teeth and put them in the tissue paper which was in his hand. What an awesome man - joking around despite the severity of his surroundings! Never lose respect for your patients. Patients can be inspiring!

Anyway, I could go on about more patients I have seen and more of the stuff I have got up to, but I think this is plenty long enough for now. Saturday was a bit of a shame, as I had a hiccup in planning a medical elective for my 4th year. This elective involves picking any country and practising medicine there for a month or two. The selection is enormous. Do you go to the USA and work with NASA? Do you go to sub-Saharan Africa and work in a 10 bed hospital supplying an area the size of Wales? I chose the latter, and was planning on going to a meeting at the British Library. Unfortunately they did not tell me the time or location until the day of the meeting, about 15 minutes before it started. I didn't stand a chance of getting there in time. Hopefully I can go to another one. The hospital I am thinking of applying for has no running water or electricity, apart from for one hour a day on a generator to do operations. At night you have to help people give birth or care for people by gas lamp. Water is transported around in buckets. I know it doesn't sound like everyone's cup of tea, but this sounds like an amazing chance to make a difference and get some experience in a different setting. I will get some cheap medical text books off of Amazon and Ebay for the hospital, and hopefully build up a rucksack of medications to replenish the low supplies!

Anyway, enjoy your week, and I will be back next week. Remember FAST! If you get to hospital and treatment within 3 hours you are much more likely to get completely better!