Heal yourself!
It's that time of the year when you sit and reflect on things. So many cases and so many stories! There is however one case that stands out for me...
One of the days just as I entered the hospital I saw this familiar face waiting impatiently outside my consultation room. A lady whom I quickly recognised as a retired staff nurse. She had worked in a government hospital for a long time. Very knowledgeable and helpful was how I remembered her. A month ago, her sister was diagnosed with Carcinoma of the breast. She was operated and I was the primary physician taking care of her.
This time however though her brother was in the hospital. He was a 72 year old gentleman came with difficulty in walking since last few hours and generalised weakness. He was a diabetic and hypertensive and compliant with his medications. On clinical examination, he had Dysarthria: difficulty in speaking. He was trying hard to speak and there was a noticeable slurring. There was clumsiness in left lower limb and muscle power was slightly reduced in left lower limb. Reflexes were normal and all the other neurological examinations at this point were normal. His blood pressure was on higher side 160/90 mmHg.
Localisation in Neurology is critical. It was a big deal to "localise" when you were presenting a case to your Senior Doctor during under graduation and post graduation days. I would always break into a sweat while presenting a Neurology case back then. Over a period of time I gained confidence and knowledge - thanks to all my great teachers and mentors (Dr.H.V.Srinivas in particular who helped me and many Physicians like me to fall in love with Neurology and diagnose with confidence). Sophisticated Neuroimaging tests like MRI/CT Scans are available round the clock. But neuroimaging tests results should finally coincide with the clinical signs.
Back to this patient, Dysarthria and Ataxic Hemiparesis localises to what is called as a "Pontine Lesion".
The Pons is a region of the brain located in the brainstem. The Pons is relatively small and it is located in the lower part of the brain connecting the cerebral cortex with the medulla oblongata. The Pons contains nerves and nerve tracts (pathways) that integrate brain functions such as movement and sensory messages between the brain and the body. That's right - it is a messenger box. The Pons also coordinates balance in the head, neck and body and plays a primary role in eye movement, sleeping, dreaming, digestion, swallowing, breathing, and the heartbeat. A small part of your brain controls so many vital functions of your body!
MRI confirmed the diagnosis. It was a small Pontine infarct. Infarct is a blood clot: When a blood clot forms it interrupts the blood flow to that part of the brain causing brain cells to die in that part of the brain. Cause being his underlying co-morbid conditions diabetes and hypertension.
Patient was started on treatment with antiplatelet, neuroprotective agents and supportive treatment. Patient had difficulty in swallowing by that evening so a naso gastric tube was placed. A tube is placed through nose, past the throat and into the stomach and feeding is done through this tube.
Patient's clinical condition remained stable over next 48-72 hours. His BP and other vital parameters remained normal. His lower limb weakness and clumsiness started to improve and patient was able to mobilise with little help. While we were happy with his progress, patient remained unusually silent. He still had slurring of speech and difficulty in swallowing. This old gentleman was running an NGO in his village helping lot of kids by providing them education. The visitors poured in to wish him well.
He was ready for discharge. But he was depressed that he had to depend on somebody for feeding him. His sister, the staff nurse took great care.
On his next visit, week later, patient had developed cough and fever. It looked like he developed an aspiration pneumonia. He was absolutely frustrated with the naso-gastric feeding and refusing feeds, thereby dehydrated. He was readmitted to the hospital and was put on IV antibiotics and IV fluids. His pneumonia improved. He was counselled repeatedly about dangers of aspiration and reassured that his swallowing will improve gradually.
Week after week, during his OPD visits he had only one question: "WILL I EVER EAT NORMALLY? I don't see any point living this way, feeding through a tube."
10 weeks after his infarct I saw him - Elegantly dressed in his starched white dhoti and white shirt with his tube plastered to his nose. He cheerfully said "I am able to swallow my saliva without pain or difficulty. I haven't tried sipping water yet, I am waiting for your permission."
There he was sitting by my side in the examination stool. His sister was standing by his side. Nurse got a glass of water with a spoon to give him few sips. The whole scene felt so surreal! It was as if everyone was saying a silent prayer. She gave him a spoon of water, he swallowed it without any difficulty and no cough. He took more and more sips of water until he gulped down a glass of water with tears flowing down his cheeks!!! All of us in the room were teary eyed. These are those tiny moments of joy experienced in our profession which cannot be truly expressed in words. He drank more water, ate biscuits and finally embraced me.
That's how beautifully a part of brain which was dead, slowly regenerated few new fibres and Healed itself!
This year, I have experienced a few crests and many troughs and each time healed myself and evolved into a better person (or should I say a better Doctor). This story is a reminder that we can heal ourselves. Just have courage and have patience.
Wishing you all a very Happy, Healthy, Fulfilling year 2019 ahead!!!
One of the days just as I entered the hospital I saw this familiar face waiting impatiently outside my consultation room. A lady whom I quickly recognised as a retired staff nurse. She had worked in a government hospital for a long time. Very knowledgeable and helpful was how I remembered her. A month ago, her sister was diagnosed with Carcinoma of the breast. She was operated and I was the primary physician taking care of her.
This time however though her brother was in the hospital. He was a 72 year old gentleman came with difficulty in walking since last few hours and generalised weakness. He was a diabetic and hypertensive and compliant with his medications. On clinical examination, he had Dysarthria: difficulty in speaking. He was trying hard to speak and there was a noticeable slurring. There was clumsiness in left lower limb and muscle power was slightly reduced in left lower limb. Reflexes were normal and all the other neurological examinations at this point were normal. His blood pressure was on higher side 160/90 mmHg.
Localisation in Neurology is critical. It was a big deal to "localise" when you were presenting a case to your Senior Doctor during under graduation and post graduation days. I would always break into a sweat while presenting a Neurology case back then. Over a period of time I gained confidence and knowledge - thanks to all my great teachers and mentors (Dr.H.V.Srinivas in particular who helped me and many Physicians like me to fall in love with Neurology and diagnose with confidence). Sophisticated Neuroimaging tests like MRI/CT Scans are available round the clock. But neuroimaging tests results should finally coincide with the clinical signs.
Back to this patient, Dysarthria and Ataxic Hemiparesis localises to what is called as a "Pontine Lesion".
The Pons is a region of the brain located in the brainstem. The Pons is relatively small and it is located in the lower part of the brain connecting the cerebral cortex with the medulla oblongata. The Pons contains nerves and nerve tracts (pathways) that integrate brain functions such as movement and sensory messages between the brain and the body. That's right - it is a messenger box. The Pons also coordinates balance in the head, neck and body and plays a primary role in eye movement, sleeping, dreaming, digestion, swallowing, breathing, and the heartbeat. A small part of your brain controls so many vital functions of your body!
MRI confirmed the diagnosis. It was a small Pontine infarct. Infarct is a blood clot: When a blood clot forms it interrupts the blood flow to that part of the brain causing brain cells to die in that part of the brain. Cause being his underlying co-morbid conditions diabetes and hypertension.
Patient was started on treatment with antiplatelet, neuroprotective agents and supportive treatment. Patient had difficulty in swallowing by that evening so a naso gastric tube was placed. A tube is placed through nose, past the throat and into the stomach and feeding is done through this tube.
Patient's clinical condition remained stable over next 48-72 hours. His BP and other vital parameters remained normal. His lower limb weakness and clumsiness started to improve and patient was able to mobilise with little help. While we were happy with his progress, patient remained unusually silent. He still had slurring of speech and difficulty in swallowing. This old gentleman was running an NGO in his village helping lot of kids by providing them education. The visitors poured in to wish him well.
He was ready for discharge. But he was depressed that he had to depend on somebody for feeding him. His sister, the staff nurse took great care.
On his next visit, week later, patient had developed cough and fever. It looked like he developed an aspiration pneumonia. He was absolutely frustrated with the naso-gastric feeding and refusing feeds, thereby dehydrated. He was readmitted to the hospital and was put on IV antibiotics and IV fluids. His pneumonia improved. He was counselled repeatedly about dangers of aspiration and reassured that his swallowing will improve gradually.
Week after week, during his OPD visits he had only one question: "WILL I EVER EAT NORMALLY? I don't see any point living this way, feeding through a tube."
10 weeks after his infarct I saw him - Elegantly dressed in his starched white dhoti and white shirt with his tube plastered to his nose. He cheerfully said "I am able to swallow my saliva without pain or difficulty. I haven't tried sipping water yet, I am waiting for your permission."
There he was sitting by my side in the examination stool. His sister was standing by his side. Nurse got a glass of water with a spoon to give him few sips. The whole scene felt so surreal! It was as if everyone was saying a silent prayer. She gave him a spoon of water, he swallowed it without any difficulty and no cough. He took more and more sips of water until he gulped down a glass of water with tears flowing down his cheeks!!! All of us in the room were teary eyed. These are those tiny moments of joy experienced in our profession which cannot be truly expressed in words. He drank more water, ate biscuits and finally embraced me.
That's how beautifully a part of brain which was dead, slowly regenerated few new fibres and Healed itself!
This year, I have experienced a few crests and many troughs and each time healed myself and evolved into a better person (or should I say a better Doctor). This story is a reminder that we can heal ourselves. Just have courage and have patience.
Wishing you all a very Happy, Healthy, Fulfilling year 2019 ahead!!!