Wednesday, November 07, 2007

PBL, Hearing, Vestibular, and Clinical Correlations

Today's PBL session was kind of nuts. We had a few other mini cases besides the one we started on Monday, and it was just really disjointed. "After seeing Patient A and prescribing her medication Y, Dr. X goes into the next room to see patient B. Patient B's symptoms are...." So it wound up being a list of symptoms that we used to figure out what kind of headaches the patients were having. We found one of the patient descriptions almost word-for-word on the internet. I don't know if that says more about the case writer's lack of creativity or the medical students' mad googling skills.

I didn't get a chance to do the reading for either seminar today, but it was ok because I was able to skim through the chapters during the seminars. The first seminar was about the vestibular system, and the seminar leader, although a nice guy and clearly trying to do his best, was way overambitious. He had 69 slides for a 50-minute seminar! Unsurprisingly, he had to deliver his talk at breakneck speed, and we ran way over. The second seminar was about hearing. It was given by two audiologists. I hadn't realized that any audiologists worked at CCF, but there are at least two. Audiologists treat patients with hearing or vestibular problems, but they aren't physicians. They have their own degree called a doctorate of audiology. These two audiologists were both really nice too, but their seminar had the opposite problem--it was kind of repetitive and not the most interesting.

In the afternoon, I had two clinical correlations. The first one was for doing neurological exams on patients with neuro disorders, and it was really great. We saw patients with Parkinson's disease (PD) and multiple sclerosis. One of the PD patients has a deep brain stimulator (DBS) implanted, and he turned it off for us so that we could see how bad his tremors were without it. DBS is incredibly cool technology and its use in PD is becoming more common. In a nutshell, the patient gets a sort of pacemaker implanted into an area of their brain called the globus pallidus. The neurons there are part of a movement pathway from another area called the substantia nigra, and neurons from the substantia nigra get destroyed in PD. The pathways are pretty complex, but the end result is a lack of volitional movement, and that's what DBS can help overcome. (If you're interested in DBS, you can read more about it here.)

The second clinical correlation wasn't very good, but apparently some of the other groups had a better experience. My group wound up waiting for half an hour at the desk in the neuro ICU. The secretary paged the doctor for us, and he said he would come get us, but no one ever came. So finally, we started wandering around the neuro ICU until we ran into another doc who took us in to see one of the comatose patients and went through the general procedure of how they examine these patients. We didn't get to actually examine the patient though, and I didn't really get much out of it. It was especially hard to concentrate on what the doctor was saying because the TV was blaring overhead. I'm not into watching soap operas, but I think I learned more about two of the characters' plans to set up another character than I did about examining a comatose patient.

The one thing though that I did take away from this otherwise useless experience was a better understanding of why it is so difficult for physicians and family members to disconnect brain-dead patients from respirators and feeding tubes. Our patient was in a persistent vegetative state, but sometimes he would spontaneously open his eyes, start breathing harder as if he were gasping for air, and make other slight movements. Even though his higher brain function is completely gone, he does not respond in any way whatsoever to painful stimuli, and there is no chance that he will ever wake up, seeing him make those spontaneous movements gives the observer an impression like he's still aware on some level. I can only imagine if I felt that way how an emotional family member with no medical training and a fervent desire to have their loved one back would refuse to believe that this person could never wake up. As it turns out, this particular patient's family does not want to disconnect him from the respirator.

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