Saturday, July 31, 2010

Heat Stroke -- NOT!

I've seen 2 patients this summer misdiagnosed as "heat stroke" who actually had a "stroke stroke".

Heat Stroke

This is an unfortunate nomenclature which has nothing to do with strokes as an ischemic problem in the brain. What is happening in heat stroke is that you are exposed to heat for a prolonged period, and after a certain amount of time, your body's coping mechanisms break down, for one thing, your sweat glands peter out. Since
sweating is one of the primary ways that your body copes with heat, this leads quickly to a rise in body temperature. The other issue with temperature control is that it has its limits as well.

Your brain has something like a thermostat that reacts to body temperature.

This graph to the right in all of its imprecision is meant to illustrate how the brain responds. The "set point" of your brain is this trough in the middle of this curve. So whether your body temperature is going up or going down, to a certain extent your body will respond. But the important thing to see is that beyond some limit, that
response actually diminishes, so when body temperature gets too high or too low, there is a decompensation and associated dropoff in whatever response your brain has to a temperature which is too high or too low. So above or below a certain point, temperature continues to rise or fall. As we get older, the graph gradually flattens, which explains why the elderly are at higher risk for both hypothermia and hyperthermia.

The key elements of diagnosing heat stroke are an excessively high temperature and the absence of sweating, along with other physiologic results of hyperthermia.

If you do not measure an abnormal temperature, then the brain should be functioning normally. If it isn't, then you need to look further. Needless to say, if an MRI had been done in either of these patients, a stroke (as in stroke stroke) would have been diagnosed immediately.

Tuesday, July 27, 2010


About a year ago, after some 20+ years in practice, I was working harder than I ever have, and this includes my residency and yes, even internship.

Internship is marked by uncertainty more than absolute work, since at that stage, you never know what's coming.

The scenario of this late in career period of time was that I was the lone member of my group covering a particular hospital. Over the years the number of neurologists, neurology groups seeing inpatients had shrunk, so that the bulk of the work was being done by some self-proclaimed neurologist hospitalists, in other words, they were not under contract with the hospital, but having announced themselves as such, had adsobed much of the inpatient work.

A series of events ensued, one of which was that my group became employees of said hospital corporation. The other shoe dropping was that this hospitalist group of 2 broke up from internal issues, and the remaining member, "disenchanted", decided to abandon ship, i.e., leave this hospital for coverage.

Suddenly, a 400+ bed hospital had for all intents one neurology group for neurology consultations, and de facto I was the sole recipient of these daily consultations. As if a switch were flipped, my days were driven by the steady yet erratic influx of double-figure consultation requests. So my days began earlier and ran later, starting at 6am, running to 9pm, 10pm, 11pm, and even later as I tried to keep up with the influx. I might technically be done at 9pm, but then get a request at that moment, and yes, I could put it off until tomorrow, but overnight there might be 3, 4, 5 more, so better to just see that 9pm consult tonight so I go to bed with a clean slate.

At the time and even in retrospect, the most disturbing thing to me as this materialized was the content of my dreams was replaced by dreams of being in the hospital seeing patients. Entirely. I found this disquieting, since this became a 24/7 experience for me. I have to say, I would not have believed that daytime behavior could so radically affect dreams. One begins to fear for sanity.

I don't know what signs became apparent, but finally the other members of the group stepped in to pick up some of the pressure, and once again dreams were transformed, to something more recognizable as normal, but of course what is a normal dream?

Saturday, July 17, 2010


I can feel the rhythm now.
Sometimes I can hear the distant
drumbeats or organ-pedal tones
playing out their sequence of ominous low notes.

We've already heard the other shoe drop
long ago, and so many others have dropped
that each time we think the closet is empty
another falling shoe shows up.

So now we have this constant yet variable
queasiness in our solitude,
and we sometimes wonder if it's Sartre's nausea we feel,
even though he has long ceased those corporal feelings.
Did he pass it on?

Restless slumber, disquieting moments during the day
watching some interaction play itself out
to an incomplete resolution.
Another uncomfortable state of existence.

Thursday, July 15, 2010


One of the things neurologists do, of course, is assess memory, yet it's also something that all of us deal with on a daily basis unrelated to concern about some pathological disorder of memory.

There are many "memory experts" who have written about the ways they have little tricks to remember things, but there are so many potential things to remember that this only goes so far.

Recently, I saw a doctor that I hadn't seen in years, called out to him, and was hoping to use his name in the conversation, since it's always a good thing socially to not only remember that you know someone, but also show that you remember who they are.

The best I could do was Leonard. I knew that was right, he just looked like Leonard, but the last name? Yipes. The only thing that kept surfacing was Leonard Cohen, and if there was anything I knew, it was that I didn't personally know anyone named Leonard Cohen. But the harder I tried, the more times I tried, I could get past it. Bummer.

I ended up using his first name, which may have pleasantly surprised him enough that things were Ok -- after all, he never used my name, so he may have been having the same experience.

Later, I did what I often do in this situation, an alphabetical search. I start at the beginning of the alphabet, with Leonard A, Leonard B, Leonard C, and so on. And within no time I had it, and I'll say, it is not a common last name either.

So what is this, some mnemonic device? I would consider a technique, but it's certainly not like the usual sorts of methods that might more logically be called by that term. I would consider it a way of blocking intrusive and wrong memories. The problem I was having was my mind kept getting locked up in the kneejerk Leonard >> Cohen connection, so what this alphabetic search does is attempt to break that connection and force some other last name first letter in there. And it worked, really within less than a minute. It's always impressive when something works that well and that fast.

Sunday, July 11, 2010

Howard Schultz on Health Insurance

The first obvious question for many will be "Who is Howard Schultz?" He is the founder and CEO of Starbucks. The July-August issue Harvard Business Review has published an interview, most of which is about his return as CEO a couple of years ago in a successful effort to turn the company around.

I'm not a big consumer of Starbucks coffee, but his answer to one question in particular caught my eye:

What's an example of a decision you've made that Wall Street didn't like?

Health care.Our health care costs over the past 12 months were approximately $300 million. [Starbucks offers health care benefits to any eligible employee who works at least 20 hours per week.] The thought that we could cut that benefit -- I couldn't do it. Within the past year I got a call from one of our institutional shareholders. He said, "You've never had more cover to cut health care than you do now. No one will criticize you." And I just said, "I could cut $300 million out of a lot of things, but do you want me to kill the company, and kill the trust in what this company stands for? There is no way I will do it, and if that is what you want us to do, you should sell your stock."

If there were more CEO Howard Schultzes out their, we might still need health care reform, but it might not be such a difficult problem.