Book Review: Another Day in the Frontal Lobe

By Katrina Firlik.

Neurosurgeons are quirky people. I’ve yet to meet one who’s “normal”; mind you, my observation-count of this rare species is still only three, so perhaps my sample-size is just too small. In her book ‘Another Day in the Frontal Lobe’ Katrina Firlik describes the habitat, behaviours, and temperament of the neurosurgeon. Here are some of the findings (corroborated with my personal experience):

• Quirk 1: Neurosurgeons are your superior. It doesn’t matter who you are, or what you do, brain surgery tops everything. I suppose that’s the attitude that naturally comes after 11 years of speciality training in an isolated culture. Firlik notes the stereotype, confirms its accuracy, and then exemplifies it with an out-right haughty tone throughout her book.

• Quirk 2: Neurosurgeons do only a few things very well. You’d think that the neurosurgeon would be the ultimate expert on function of that mysterious organ, the brain. They’re not. In fact, neurosurgeons handle only a small subset of brain disease. This includes trauma, tumours, and seizures. Comprehensive brain/mind function is left to be studied by the psychiatrists, psychologists, and neurologists, with each one contributing a unique piece. In fact, most neurosurgeons spend most of their time operating on the spine (that’s where the most money is to be made).

• Quirk 3: Neurosurgeons are mechanics. Brain surgery is not, well, brain surgery! If there’s too much fluid in the brain causing a build-up of pressure, you drain some to restore normal pressure. If there’s a tumour compressing on brain structures, you remove it to decompress the brain. Obviously I’m vastly simplifying, but most neurosurgical work is founded upon basic mechanical principles.

• Quirk 4: Neurosurgeons are emotionally tough. This is a necessary attribute. Chances are, that once you’re willing to let someone cut into  your brain, things are looking pretty bad. The outcomes of neurosurgical patients are usually not happy stories.

You may accuse me of speciality profiling; of drawing on superficial stereotypes. I protest that, in medicine, the stereotypes are usually objectively true. Each speciality has a unique personality of doctor associated with it. And it makes sense. When you train for many years with a small, isolated, community day-in, and day-out, you tend to form an identifiable culture. When medical students choose their future directions, a large factor is often the culture with whom they get-along the best.

Neuropathology

It makes a slick, slimy, wet-but-not-dripping sound as the knife glides through. Slice one. The texture is gelatinous and moldable, but it holds its shape. White and grey; there are patterns in the slice. Like cloud-gazing, you can make-believe that the shapes are mysterious life-forms.

It used to be alive. A day ago, maybe two. More than alive. That piece of tissue, now split indelicately on a slab of marble, felt emotions. It thought up ideas, and imagined shapes in the clouds it saw. It had an identity, and a personality. Now it sits cold; a lump of withered sponge, unable to defend itself from the blade that is slicing it apart.

The blade is wielded by a pathologist, demonstrating to us the gross anatomy of normal brain tissue, and some pathological (diseased) findings. Pathologists (in addition to other things) perform autopsies to determine causes of death. Dead bodies are regularly their domain. Unlike the neurosurgeon, who explores the brain while it is warm, pulsing, and ever dancing with electrical activity, the pathologist handles tissue more like damp tofu.

Evidently, the early anatomists perceived as much awe when they pro-sected cadaver brains. The names they assigned the structures sound like discoveries from an exploratory deep-sea dive: the geniculate nucleus; the hippocampus, which in Greek means sea-horse; the cerebral aqueduct. Shapes in the clouds…

TED Talk: Oliver Sacks

Oliver Sacks is the Jane Goodall of neurology. He has spent his entire  professional career observing patients, dutifully recording in his notebooks, and publishing reports of his findings that illuminate how the mind works. Most of his published work tells personal stories of patient experiences. Most notably there is ‘The Man Who Mistook his Wife for a Hat’ (a man with visual agnosia) and ‘An Anthropologist on Mars’ (perceptions of people with autism).

In this TED Talk, Oliver Sacks explains Charles-Bonnet Syndrome –  a hallucination syndrome experienced by people who lose their vision. I was surprised to learn that up to 10% of people with vision loss experience Charles-Bonnet hallucinations, but only 1% of them report it because they are afraid of people assuming they  are going insane (which they are not).

Check it out, it’s fascinating:

Electrocutions and Mind-Reading

“This might make you feel dizzy; hold onto the arm-rests, just in case.”

With these instructions, the doctor proceeded to inject a cup of cold water steadily into my classmate’s ear . Disconcerting. Surprising. This is the field of neurological investigation.

Sure, neurologists use conventional imaging techniques like MRI and CT, but they also have an arsenal of tests up their sleeves that are more unique. Some date back more than one hundred years. Others are cutting edge. From my superficial viewpoint, however, they all have one thing common: There’s something just odd about them!

The technique I was describing is called ‘Caloric Stimulation’. Water injected into the ear canal tricks the vestibular system (your ear’s system for maintaining balance) into thinking that you are turning either to the left, or to the right, depending on the temperature of the water. The response you look for is compensatory movement of the eyeballs. Like most predators, when we move our heads, our eyes reflexively move in the opposite direction so that they remain fixed on the same target. Since the reflex relies on brainstem functioning, neurological diseases that impair the brainstem can affect this reflex. Caloric Stimulation is therefore used to assess normal or disease functioning of the brainstem.

Now if you thought Caloric Stimulation smells a little bit like a dorm-room prank, wait till you hear about Nerve Conduction Studies. The purpose of NCS is to assess the health of nerves beyond the spinal cord, for example in your arms, or in your legs. Nerves communicate with electrical energy. So, to interrogate the nerves directly, neurologists pull out their stimulators (reminiscent of cattle prods, or police tasers) and deliver electric shocks through the skin. They measure the speed of electrical impulse through the nerves, and also contraction of the muscles that the nerves enervate. Nerve disease and muscle disease can both be detected by NCS.

One surprising fact, is that there exists a wide range of sensitivity to electrical stimulation. Some people handle being electrocuted better than others. Among our small group, one classmate could easily withstand more than 100 times the amount of electrical energy than the most sensitive classmate (who swore in severe pain at even small shocks!). Both fit within the wide range of normal sensitivity.

Perhaps the oddest neurological investigation of all: Electroencephalography (EEG). Straight from the movies, this is the test where a bundle of electrodes are placed over your shaved scalp, and your brain-waves are plotted with spiky lines on graph. EEG literally reads your mind. Now if only it could read thoughts! But brain activity, even plotted neatly on a graph, is more than a little confusing to read. EEG is used to diagnose various types of seizure, and sleep disorders.

Polyradiculoneuropathy

Seriously? … Polyradiculoneuropathy? Do you really need to make it all one word? Don’t you think ten syllables is a bit much?

Seat of the Soul?

I believe in a soul. I believe there is more to “me” than a body. Neurons, blood cells, respiratory gases; physical matter – certainly I rely on these to function, but they do not control me. I am not merely physical, a puppet to the unyielding forces of physics and chemistry.

Which leads me to the interesting, and unavoidable question: where is the interface between body and soul?

Human cultures have long asked this question. The Ancient Egyptians believed that the bodily residence of the soul is in the heart. Emotions, thoughts, and choices all take place within the heart, they thought. Although we’ve since discovered that these are actually functions of the brain, even today we still carry some vague association between the physical heart and the emotions of passion.

Also in the running for seat of the soul, historically, is the pineal gland. Its heavily-protected, highly vascularized location deep within the centre of the brain has led many new-agers, and occultists to wonder about whether it has a metaphysical role.

In the US at the beginning of last century, there were physicians who would weigh bodies shortly before death, and then immediately afterwards. The idea was that the difference between the two readings could give an approximate value for the weight of a human soul. The idea strikes me as strange, since my bias is to consider the soul immaterial (and hence weightless) by definition.

With the advent of modern psychology/psychiatry/neurology, I think we’ve since narrowed down the quest for the soul’s resting place to the brain. The brain is where decisions are made, emotions are experienced, and consciousness is maintained. Of course, the brain is an awe-inspiringly big place, with a lot of complicated activity. Where exactly is does the soul have its influence? And what form does that influence take?

Let’s say I that I make a conscious decision (any decision – the content doesn’t matter). As a proponent of free will, I would suggest that my decision is not simply the net result of neurons firing in my brain. Rather, in some place, and at some point in time, my immaterial soul must initiate a material effect on the stuff of my brain to exert its willpower.

What does this event look like? Does a particular neuron fire without stimulus? Are new neurotransmitters created from nowhere to initiate a decision-cascade? You may protest that these events break the laws of electrochemistry, and the conservation of matter (the laws of nature). But that’s precisely the point. Any decision-making mechanism that is bound by the laws of nature, would be incapable of making free decisions.

Yet more unanswerable questions distracting me from what I should be doing: studying neurology. Sigh.

A Versatile Brain

The study of Neurology is haunted by a paradox: Does a human brain (like mine) have the capacity to understand the workings of … a human brain? For that is exactly the type of circular relationship that a student of neurology attempts to establish. Can thoughts fully illuminate the process of thought-generation? Can I understand the biological mechanism of understanding? Questions like these pass through my (possibly incomprehensible) brain at times when I probably should just stop procrastinating, and start studying Neuroanatomy.

Today was the first day of class. No doubt you’ve guessed by now, we are beginning Neurology. Hence the bizarre, and somewhat confused, revelations about the brain. Here’s another one:

My brain already knows Neurology. Every day, my brain sends electrical signals within itself and to the appropriate parts of my body to accomplish my daily living. It carefully sends each signal through a complex network of nerves, requiring a near-perfect “understanding” of Neuroanatomy. The problem, is that I cannot consciously access this “knowledge” that my brain puts into work on my behalf. So instead, I’ll spend the next two months studying to consciously “know” something that my brain already seems to know.

Another less-convoluted revelation from today, is that surviving medical school requires a versatile brain. This first day alone involved: setting up the technical equipment in our classroom, concentrating through four hours of Neuroanatomy lecture, a brisk trip to the rental company during lunch-break to pick up keys, getting stabbed with a vaccination needle, a group lab assignment, a Town Hall meeting with the school executives, prosection of the heart and lungs from our cadaver, and a very late dinner with friends. My head hurts! It’s going to take  me a few days to get back into the wild rhythm of life here …

Unexpected Meeting

So it’s September, and I find myself back in Kingston poised on the brink of another year. Today we welcomed to Queen’s the class of 2013. It was their very first day of medical school – an experience that I still remember clearly for myself. And as the first-years were making memories, … for completely different reasons, I was also having a day that I will never forget:

After a casual lunch with my mentor-ship group, I dropped into the anatomy lab for what I thought would be a brief administrative meeting with the tutors to sort out the upcoming term schedule. I was completely unprepared for what happened next. “You know that you’re prosecting today, right?” No. I did not. Neither did any of my fellow tutors. Yipes… well, I guess we can still make a try of it.

So in the space of a few minutes I went from meeting green frosh, to meeting my (literally greenish) cadaver who I will be prosecting this year for the anatomy lab. (We use the term ‘prosecting’ as a more respectful word than ‘dissecting’ when preparing human bodies.) We were nervous; the room was so quiet that I could hear my scalpel blade go through as I made the first cut.

It strikes me after being so physically invasive to his body, that I know very little about him – only what his body itself can tell me, such as that at some point in his life he had open-heart surgery. His face, hands, and feet will be shrouded for the next few weeks until those anatomical regions are being studied.

From my cadaver, I will learn much about medicine and anatomy. I look forward to the review of gross anatomy, and to practising with the surgical tools. Today included use of a bone saw – a brutish instrument that makes a shocking roar of noise, and will leave you sweating. I also look forward to teaching the first-years their material using the samples that we prosect.

Leaving the lab four hours later than I had expected to, I must say I was grateful for the experience. Unexpected yes, but perhaps that’s exactly the way it needed to be to push me off into the deep end.

Week in the Country

“Welcome to Lanark – Population 800″; I spun my head around to read the sign as we drove by. I had not previously appreciated that when my preceptor referred to Lanark as “the village”, this was not merely a metaphor of endearment – she had meant it quite literally.

“Week in the Country” is a program sponsored by the government of Canada to entice medical students towards rural family practice. Every medical student is required to spend at least one week shadowing a rural Family Doctor. Almost all expenses are covered, as our government is desperate to meet the growing need for doctors in under-serviced rural areas.

Lanark has one major road running through town. We were lodged extravagantly at a bed & breakfast (see photo above) on one side of town, and walked into the Community Health Centre on the directly opposite edge. The walk across all of Lanark took no more than 20 mins.

4 year-old male presents with left ear pain lasting five days, and other non-specific symptoms of an upper respiratory tract infection – our first patient. It is surprisingly difficult to look into a squirmy child’s ear! Otitis media; Amoxicillin 50mg/kg/day TID x 10 days. After Week in the Country, I can now write that with some confidence! In fact, the week was extremely valuable for gaining some proficiency at triaging common complaints, and I am now more confident in differentiating sore throats, sinus infections, headaches, and common skin rashes.

Perhaps the most memorable patient, for me, was an admirable young man trying to quit smoking. He had impressive resolve, but was profoundly impeded by addiction. I cannot imagine the frustration of fighting a war with your own brain. I learned about the arsenal of medical tools available to help. More powerful, however, was when my preceptor offered to make an appointment with this patient every other day on his way to work for the next month – a brief check-up, so that every two days there would be someone asking “Have you had a smoke?”, and “How is it going?”. What a privilege to be that source of accountability and motivation in a person’s life.

In Lanark this week I didn’t get into the OR, or the ER. We didn’t see anybody who was mortally ill. We didn’t perform any cowboy, daring, rescue procedures. But I’m not in the least disappointed. I learned how to swab a throat, how to give a vaccination, and how to detect pneumonia without the luxury of an x-ray. Less romantic perhaps, but unaccountably more useful.

 

Tragic Simplicity

Every year internationally, 1.5 million children die from diarrheal dehydration. That’s more children dying than the total number of Canadian children under 5 years old. What’s truly tragic is how preventable these deaths really are. In studying today, I ran across a set of guidelines published by the WHO for case management of diarrhea:

1. Prevent dehydration by educating parents on how to treat diarrhea at home (fluids, and good nutrition)
2. When dehydration occurs, treat with oral rehydration solution.
3. Feed appropriately both during and after diarrhea.
4. Provide antibiotics for suspected cholera, shigella dysentary, or typhoid fever.

It has been estimated that these four guidelines could prevent 90% of deaths from diarrhea dehydration. That’s 1.35 million children. So simple (no special training required for the first three guidelines, and the fourth can be performed by just about any healthcare worker), yet the barriers are numerous. Some obvious barriers are the lack of access to clean water for rehydration and inability to pay for good nutrition.