A Mind of its Own

The mind- the most complex structure in the human body, the abstract organ encased in the pulsing brain. Yes the brain pulses, heaves up and down, glistening brightly with each to and fro movement. It appears to be breathing with each beat of the heart, up-down, up-down, just as your chest rises with each inspiration and expiration couplet. The first time I saw it, I had to gently put my gloved index finger on the exposed brain for tactile confirmation. During my two month exposure to neurology and psychiatry, I further established that the central nervous system is absolutely everything, capable of all, yet exceedingly fragile beneath the protective barrier of the skull and vulnerable to unfortunate disaster. The nervous system- a hub that functions at enormous complexity and serves as the main operating system with miniature tendricles reaching into the periphery snaking their way through every tissue in the body. It shrinks further in size when you consider the infinitesimally smaller molecules that float from one nerve ending to another signaling, communicating, powering.

The functions of the nervous system are infinite. My medical experiences have made this very evident. From the psychological functions to motor and sensation, the abilities are endless. This makes the disabilities also endless. While on psychiatry, I rotated through the inpatient ward at the VA hospital, the only emergency room in the state dedicated to psychiatric problems, the office of a primarily Spanish speaking child psychiatrist, and the ward at UNM. I had spent the first two years of medical school learning about mental illness, learning how to diagnose and treat and even learning about the struggles of the mentally ill. But it’s not until you’re in the midst of experiencing it that you truly recognize the sorrow that comes along with a psychiatric disease. Psychiatry is a great reminder of how powerful emotion is, how debilitating thoughts are, and how personality can make or break anything. Suicide attempts were a common theme, the breaking point that landed most of people in their situations. A man with his infant daughter’s handprint tattooed on his arm had just learned his daughter was the product of an affair with another man. He cried like a child, unable to cope, unable to reason. A pill overdose was his escape from the overwhelming pain. A wandering man, a vagabond, a lifelong hitchhiker had made a plan to walk in front of the next car that drove by, because he could no longer deal with the depression that held him captive… The next car that zoomed by happened to be an 18 wheeler and a memory of his abusive dad, who was a truck driver, caused him to think twice. He said, “If someone had thrown themselves in front of my dad’s truck, he would have been so angry to clean that shit up.” The fear his father that was instilled in him hadn’t withered, so he checked himself into the psych unit instead.

I witnessed depression of all sorts. A man ashamed of his sadness had driven half way across the country and falsified a business trip to admit himself to the inpatient psychiatric unit without his wife’s knowledge. I witnessed depression refractory to any pill that had been prescribed leaving only one option: electroconvulsive therapy. What seems like a barbaric attempt to free the body of evil spirits… but is actually an effective method of shocking the brain into reset mode was performed in front of my very eyes. The body of an older man had been paralyzed with the exception of his foot, which had been constricted in a blood pressure cuff to prevent the intravenous medicine from flowing to the muscles of his right foot, so we could witness the strength of the seizure we were about to induce. The electrodes were haphazardly placed on his skull. A large mouth guard was placed between his teeth to prevent them from breaking. An EKG was placed to monitor the electricity of the heart and an EEG was placed to monitor the soon-to-be-tampered-with electricity of the brain. The squiggly lines, which printed on long sheets of graph paper went from peaceful peaks and valleys to an atrocious blob of hectic lines jutting up and down, so close together they darkly stained the paper with a large box of black ink. This was an exchange for shedding light in the darkness of his mind. As the body was shocked into an artificial grand mal seizure in the anesthetized patient, the corners of his eyes tensed as every muscle yanked from one attachment to the other. The jaw bit down ferociously, tightly grasping the previously placed mouthpiece and despite the paralyzing agent that flowed through the body, the body tensed ever so slightly. The foot that was spared of the paralytic, angrily contracted. Each tiny muscle becoming more defined as the tension caused the muscles to fight against the skin that encased them. And then it stops, the man slept for a bit, awoke to an incredibly sore body, and hopefully in a more cheerful mood. It’s a bizarre and desperate attempt at normalization of a mind that’s trapped in a depressive episode.  

I witnessed mania of all sorts. A man, the son of a mafia father, a member of Hell’s angels, a minister, a Frisbee playing fanatic had been a “little-off” his whole life, as he described it. He lived in a cabin in the woods of another state, but had found his way to Albuquerque somehow and had managed to threaten a clinic secretary. Another man had his first break of mania and had been dropped off at the VA doorstep by his wife. She instructed him to not come home until he got help. He told me an elaborate story about a book he was writing, which he was planning to send to Oprah to get featured on her book club. Another gentleman believed that trigonometry was the key to saving the world, the key to our nation’s debt and terrorism problems. The first lesson of mania: believe with caution.

I witnessed schizophrenia of all sorts. I met Nobel Prize winners, keepers of angels, and targets of government surveillance. One man had even tried to carve his eyes out, because he believed the government had implanted them with spy devices. The worst cases were always the first breaks of schizophrenia- the ones who were “normal” just months prior, the ones who had been smiling with family and the ones who had been innocently romanticizing with crushes, the ones going about their everyday life and then, BAM, the disease takes over, steals their thoughts and infuses them with non-existing ones. It overwhelms their ability to reason, creates false beliefs that then create a storm of paranoia. It overtook a kid whose only problem was occasional weed smoking. Schizophrenia stole his brain from all the people who loved him. It took another teenager, a great student and outdoorsy kid and forced him to put a gun to his head and pull the trigger in fear of the new thoughts that surrounded him. Their lives and their deaths were reminders of the power of the human mind, the power to instill fear, to create, and to misfire.

And then you have the other functions; motor, sensory, speech, vision… all at the mercy of a well functioning brain, a healthy brain free of stroke and tumor. All at the mercy of luck. When my neurology attending, a man who was prematurely balding, but still sporting the mullet, said that our new patient was lucky, I couldn’t help but re-evaluate my definition of luck. The young guy, who was a father, a teacher, an avid athlete, and a friend, had become the victim of a malicious attack to the nervous system. Following a freak accident, his vertebral artery dissected, which means the vessel that transports blood, oxygen and nutrients to a big chunk of his brain ripped open and couldn’t deliver these vital ingredients. This muscular man with a sculpted jaw line, chiseled chest and perfect complexion stroked out at the tender age of 30 something. He was hemiplegic and had lost much of his ability to express emotion… but he was “lucky” because the stroke had spared his speech. In a right-handed person, a stroke like his should have wiped his speech making him incapable of language usage. But somehow he escaped that insult and could speak and understand, although with terrible slurring because of the paralysis in his face and with obvious slowing because of the swelling that was still surrounding his brain. He went from running marathons and playing soccer to an unforeseen future of months to years of rehabbing without certainty of the level of function he would regain. Luck. Misfortune. Disaster. Welcome to medicine, I thought.

I had patients who demonstrated the many attacks to the brain and nervous system. I met a 9 year survivor of non-accident trauma, or child abuse. She was the victim of shaken baby syndrome. She had been stripped of normalcy and she only performed rudimentary functions, but she smiled and laughed abundantly. I worked with a teenage boy who had gone from waterboy of his football team to devastatingly disabled. He was born with hydrocephalus, or too much cerebrospinal fluid in the ventricles of the brain causing increased pressure and suboptimal brain functioning. With the amazing advancements of medical technology, he was given a shunt to divert extra fluid into the abdominal cavity. Late in his teen years, this technology malfunctioned and failed him. He was left without use of his limbs, no speech, no emotion… he sat in his wheel chair free of expression and blinked his eyes spontaneously. His parents sat by his side… with heartache sketched into their faces. Another teenage girl had a hemicraniectomy following intractable seizures. She was slowly learning to re-live with only half of her brain. She sat with an awkward erect posture and walked with a unique bounce. Her personality was skewed, but it was her new norm. Another man was a paraplegic times two! He had his broke his back as a young man in the military, which had left him with a spinal cord injury that prevented him from using anything below the belly button. He became a paraplegic (just at a slightly higher level) again over two decades later after a car accident broke his back again… Now that’s bad luck. I saw him in the hospital just days after his accident and he joked about the event. I laughed along with him, because it was the only thing I could do.

I found that when a patient suffers from neurological trauma, you spend a lot of time also taking care of the patient’s families. A man who I rounded on for several days had slowly been defeated by dementia. He had come to the point where he could no longer speak. He mumbled loudly, writhed in bed, kicked and screamed and was ultimately left alone in the hospital. He had been my patient and each day I visited him he had not improved, but each day his wife sat at his bedside. One morning I went to round on him and he was in the same state, but alone. When I asked the nurse about the wife’s whereabouts, because she liked to be updated on the daily plan, the nurse calmly and simply said, “She left. She said this wasn’t her husband anymore.” I called her on the phone to confirm the story. She had flown back home to be with her family. She had said her goodbyes, and she never planned to return. He had dementia, but they were both defeated. Another man, whose daughters lived at his bedside, had an unusual stroke that involved bilateral Anterior Cerebral Arteries, likely because of an underlying tumor or vascular malformation. The stroke took out both sides of his frontal cortex, the part of the brain that controls impulse, will, personality, executive functioning. The most interesting effect is no motivation. In fact people with this problem are called akinetic mutes. Akinetic- meaning they don’t move not because they can’t, but because they don’t want to. They literally just don’t have the motivation to produce actions. They’re mute for the same reason, they just refuse to speak because they have no desire to. He died… despite his daughters attempts of encouraging him to eat, move, speak, try… One night his heart stopped for no apparent reason.  He died, probably because he no longer had the will to live.

Neurology, Psychiatry, Neurosurgery were all opportunities to recognize the power of the brain, the forces it is capable of, and the fragility that it exudes. Psychiatric diseases permeate the defenseless brain, neurological disease attack without warning, and people and their families learn to live a new life, a life that is often modified and disrupted, but more importantly they learn to live.