The start of neurology

Hi,


I have finished my oncology rotation now and have moved onto my neurology rotation, where we study everything to do with brains, from the medical to the neurosurgical. I live with someone who studies neuroscience as a PhD, so have high hopes for this rotation. Hopefully whenever I come home confused about something regarding brains, he can help me out. This rotation has a large number of lectures in as well, but unfortunately these are all in a hospital that is an hour away from the main hospital and where I live, so a lot of time is spent this week travelling to and from the lectures and neurological wards. Neurology and neurosurgery is relatively specialist, so it is not carried out in all hospitals, rather in centres of excellence, which in this case happen to be a bit far away...

Brown–Séquard syndrome is due to a partial injury on one half of the spinal chord, giving split symptoms across one half of the body and the other, as some parts of the spine cross over after leaving, while others do not

Despite all of the lectures I am getting, reminding me of all those wonderful and interesting things we were taught about in first and second years such as Brown–Séquard syndrome, I still do get the chance to spend some time on the wards. We were put into pairs and sent to see patients, in order to report back to the doctor and guess at a diagnosis for each patients. My partner and I talked to and examined a really friendly 80 year old woman, who despite being really lovely and wanting to help us out, was very hard to examine as she could barely hear us and seemed to be unnaturally cold, so as soon as we took the blanket off of parts of her body to examine them she would shiver violently, but insist that we carried on. Our examination showed that she had a strange mix of upper and lower motor neuronal signs, suggesting that both her central nervous system (brain and spine) and her lower motor neurones (all the other nerves) were being damaged. This means that whatever disease she has is affecting both the peripheral and central nerves. The most likely disease we thought to be causing these symptoms was a motor neurone disease such as ALS, but as we didn't know what the patient was really diagnosed with, we didn't tell her what we thought in case we were very wrong, and we didn't want to scare her. You distinguish between upper and lower motor neurone disease by testing reflexes, power and looking for signs such as fasciculations. As medical students we are not very used to what 'normal' is, so it can be hard to tell when things are abnormal, especially seeing as each person is going to have different reflexes and strengths, and older people tend to be quite weak. As it was, when we presented to the consultant she agreed that motor neurone disease was the most likely diagnosis, but it was not confirmed yet, and could be a range of other diseases. She then asked us to name some of the other diseases that it could be, which didn't work out very well for us, with our list of two or three. I hope that everyone is wrong, though. Motor neurone disease doesn't have a very good prognosis, and many of the other differentials will lead to a much better life. It always seems to be the lovely patients who have the worst diseases, odd...


Later in the week, I was on the ward and chatting with a patient who had been in the hospital for a month after getting Guillain–Barré syndrome. She was a mother of two, and a great believer in herbal and alternative therapy over conventional western medicine. She explains to me that, because of this, she doesn't really believe in vaccinations at all, and has avoided them since she was 18. Despite this aversion to them, the GP managed to persuade her to have a flu vaccine a month or two ago, because she has severe asthma, and usually gets severe chest infections meaning she tends to end up in hospital over Christmas. Some days after the vaccine, she started getting a tingling in her legs, a little like pins and needles, which started to progress up her body as her legs became weaker and weaker. As this went on over a few weeks, she saw her GP a few times, who first told her that it was nothing, and then told her that it was probably a trapped nerve in the spine and gave her pain killers. Finally, on her fourth visit, the GP sent her to hospital, but by this time she couldn't walk and to get to the GP she had to be carried to the car by her husband. For the past week she had had to be washed and carried about the house by this man, because she was too weak to move. Guillain–Barré syndrome is pretty rare, which makes it hard for the GP to diagnose, but you would have hoped that he would have noticed that this woman should be sent to hospital sooner, given the fact that she was too weak to even have a bath herself. The illness paralyses muscles of the body, and progresses until it paralyses the muscles used for breathing, killing the person. At least it was caught before this happened.


Guillain–Barré syndrome is an autoimmune illness, which can rarely follow certain infections. It is due to the body's immune system getting confused and attacking the peripheral nervous system which supply the muscles, thus paralysing them. It is very very rare to get this after a flu vaccination - one in millions chance, so I feel really sorry for this poor lady who was so opposed to vaccines getting such a terrible side effect when she finally consented to having one. Once in hospital, she could go on ventilation to help her muscles breath for her, and could be given medication to help the body reverse the damage that was being done. It is very slow to get better, but people often do get better, and the day I came to talk to her she had just eaten orange squash and chocolate for the first time since this all happened. Because of the effect on swallowing muscles, and the fear of food or drink going into her lungs by accident, she had been fed by tube for some time. I was curious as to whether she was giving her children vaccines, and she was, seeming to understand the importance of them. This is good news, and not what I expected from your stereotypical unemployed mum from a rough area. Despite her poor background, this illness seemed to have given her a new lease on life. She delighted in telling me how she planned to not smoke once she was out (being confined to bed for a month had forced her to give up) and wanted to start eating more healthily and get a job. The women around the ward had clearly had part in this and were shouting out encouragement from behind the curtains where we were talking. Drawing the curtains may give privacy for an examination, but offers nothing of the sort for talking! It was really lovely to see how something so bad could have such a positive impact on someone, giving them the feeling that their life really was worth something, and making them want to do something with it. I just hope that she can stick to her decisions after leaving hospital!