The Dreaded Mini Mental State Exam

For the uninitiated, the Mini Mental State Exam (or MMSE) is a fairly quick way of assessing a patient's cognition.

Academic side: Though it has reasonably high sensitivity and specificity (i.e. low false positives and false negatives) it can be somewhat biased in favor of younger patients with higher levels of education.

Reality side: It is a horrible, annoying, frustrating test for many elderly people. Either they are sharp as a razor and the test is insulting, i.e "tell me where you are, the month, name this object, write me a sentence", or they are mildly demented and get quite upset and befuddled when you ask them to do things like count backwards from 100 in increments of 7.

I thought that there was no way that administering a MMSE could get any more heartbreaking and painful than having to conduct it on someone who had Alzheimer's.

Well today I found out that there is one more thing which is worse: having to watch it conducted by a train of medical students, in front of about 20 people, on a mildly demented patient. Oh, yeah.

It was sad. And I felt so awkward and uncomfortable watching this burly, checkered-shirt-wearing retired farmer trying to scrawl a sentence on his knee.

The session was conducted professionally, I must say, but it still made me think that if it had been my Grandad up there I'd have probably swooped to the front of the class (created a scene) and escorted him out for an afternoon of fishing.

Affirmation

It truly was nothing short of a medical miracle.

Today a woman came to speak to our class about what it was like to have Parkinson's.

She told us about how she had diagnosed herself 14 years ago while watching the 1996 Olympic Games. As Muhammad Ali lit the cauldron at the opening ceremonies the commentators made reference to his Parkinson's disease, and in that moment her life changed. She recognized the symptoms he showed as the same ones she had been developing, and trying to ignore.

The woman spoke about when her suspicions were finally confirmed. How she went home from the appointment lost and afraid for her future. She talked about the horrible side effects she suffered from the medication treatment and how walking had become an impossible feat.

As she told her story I started thinking, "hang on...she doesn't appear to have that severe of symptoms". I couldn't see much of a tremor, she didn't appear stiff or show the Parkinson's mask, her gait seemed almost completely normal.

She then spoke about deep brain stimulation (DBS) and how she had had the treatment several years earlier. I vaguely recalled some lecture during nursing school where they mentioned this treatment but I couldn't grab on to any info in my brain. I thought, "wow the treatment must have really worked for her!" Still thinking that they just drilled into your skull, inserted the electrodes, zapped and then took them out.

But she went on to talk about the plastic grommets that the wires go through on her skull and how the pacemaker was near her waist, that she could turn the DBS on or off, or adjust it (within parameters) at will. Apparently some people develop slurred speech or other unwanted side effects so they only turn it on (or up) when they want to move.

I was now sitting straight up. This is clearly a much cooler procedure than I had thought.

The National Institute on Health gives a good summary of the procedure here, but in brief:

"DBS uses a surgically implanted, battery-operated medical device called a neurostimulator—similar to a heart pacemaker and approximately the size of a stopwatch—to deliver electrical stimulation to targeted areas in the brain that control movement, blocking the abnormal nerve signals that cause tremor and PD symptoms.

Before the procedure, a neurosurgeon uses magnetic resonance imaging (MRI) or computed tomography (CT) scanning to identify and locate the exact target within the brain where electrical nerve signals generate the PD symptoms. Some surgeons may use microelectrode recording—which involves a small wire that monitors the activity of nerve cells in the target area—to more specifically identify the precise brain target that will be stimulated. Generally, these targets are the thalamus, subthalamic nucleus, and globus pallidus."

She finished her lecture and then said, "ok now I am going to turn the DBS off so you can see what happens".

With that she pulled a remote-control looking device, held it to her abdomen and clicked a button.

Within moments her arms shook with pronounced tremors, her face changed to an unexpressive stare, and she slowly turned her body in an attempt to walk. She lifted up a jerky arm to show us her attempt to count on each finger but only a profound tremor showed. Her speech became slow but her voice cleared of what sounded like a mild sore throat. She explained that the 'resident frog' in her throat was the only mild side effect the DBS had in her case. With a difficult maneuver she switched the DBS on again by clicking the button.

Her tremor vanished. The frog in her voice returned, her speech slowly returned to its normal tempo and she turned back toward the podium.

I was actually on the verge of tears, even now as I am typing this. I really don't think I am able to convey the impact this demonstration had on me. She was two different people with the press of a button. One would have been unable to drink from a cup and the other had just given a one hour presentation. I really believe that I witnessed a miracle. And I don't use that term lightly. I have been in the room when people who were without a pulse or breath in their body were brought back to life using medications and electricity.

But this moved me in a completely different way.

Suddenly all of the stress, and studying, financial burden, and lack of sleep, became worth it.

Medical conventions often get under my skin. I wonder some days why I am going into a profession that pushes drugs, ignores preventative health, and sees peoples lives as a business.

But if modern medicine means I get to be in the field of work that can do that for patients, I am happy.

Thrilled in fact. And strangely humbled.

It has been a good day.

What Gets You?

Everyone (and I mean everyone) who works in healthcare has an Achilles heel. Of course anatomically speaking we all have a tendo calcaneus but that is not what I am talking about.

Nope. What I am referring to is the bodily fluid, odor, sight, sound, sensation, taste, texture, illness, task, procedure, or person that you just can't stomach. That 'thing' that 'gets you'. It makes you weak in the knees (in a bad way), causes your vision to go a little red and fuzzy around the edges, your blood pressure to drop, your gag reflex to fire, sweat to bead, and hands to become clammy.

From geriatric lab techs to weather-worn nurses, crusty old doctors to gritty respiratory therapists--they have at least one 'thing'. And if they say they don't, they're lying.

I was having this discussion with a newbie medical student a couple of weeks ago saying how it'll be interesting to watch everyone in our class discover what their medical Achilles heel is. I know what mine is. Well, if I am completely honest I have quite a few Achilles heels. I always thought that over time they would disappear, but even several years of working in emergency departments hasn't numbed me to a few shudder inducing 'things' that still 'get me'.

1) Nails. I mean finger or toe nails. When they are severely deformed or overrun with fungus, shattered, or split I feel a shiver go through me. The last time I almost fainted in the ED was from attempting to overcome this issue by pulling out the shattered bits of finger nail from a crush injury.  My feeble attempt at medical aversion therapy. I'm getting better with them but still don't think I could watch an ingrown toe nail surgery.

2) Crepitus. That is the crunchiness you feel when there is broken bone under the skin (you can also have crepitus for other reasons which do not creep me out so I am not discussing those types). I am talking about bone crepitus.

My 2006 almost-faint-during-procedure was in Whistler where we dealt with countless fractures that required skill at removing ski-boots/snowboard boots/bib-pants/long-underwear etc. Contrary to media portrayal we *do not* cut clothes off people most of the time, especially there when a pair of good ski pants can run you over $500! So you've got to hold on to the crunchy, floppy, limb while a colleague pulls the fabric or boot off. This I am borderline ok with most of the time but sometimes during reductions or casting it makes me get all sweaty and pale. The worst one occurred was while I was holding traction on a 4 year old boy who had broken his leg. I still remember that purple cast and the wave of nausea taking over me as I felt those little bones shift under my fingers."Don't faint! DO NOT FAINT" was my mantra for the entire task.

Bones in general freak me out actually. The feeling of ribs cracking when doing CPR is really unsettling, seeing ribs cut during autopsy also makes me almost hit the floor. Though strangely, compound fractures (i.e the bone sticking out of the skin) don't bother me. There is no rhyme or reason to these aversions.  But I suppose this eliminates 'orthopod' from future residency options.

3) Pseudomonas. Once you smell it you'll remember it for life. The best way that I can describe it is a putrefied, sickly-sweet, heavy, rotten smell. And I swear---with no scientific evidence whatsoever to back this statement---that the odor molecules from this microbe are larger and stickier than any other. Once you breathe it in it seems like the odor attaches itself to your nasal passages for days. Days, people! I am not exaggerating. You're riding your bike or eating dinner or watching a movie, you inhale and BAM!! it's there again, like you're face is right in a giant petri dish of the stuff. When a patient has an infection of this flavor I need to put a little clove oil under my nose to make it through the shift, or a dab of friars balsam on the neck of my scrub top. Trust me, it's bad.

Those are probably my top three shudder-inducers. I always find it interesting to poll my medical colleagues as to what theirs are, and often it is not what you'd think. It's almost never the big things that jump to mind as the offensive bodily fluids. It's almost always bizarre and random phobias. I have co-workers whose 'achilles' is a thing like: knees (they don't want to touch them, especially if there is something wrong with them), or suctioning sputum (spit), touching feet, seeing greasy hair, assessing rashes, etc. Some of them I can understand but others (knees?) are beyond me.

To work in places like the emergency department or an operating theater I suppose it is adaptive that we aren't disturbed by the usual suspects, otherwise we couldn't do our jobs. But it is funny how certain aversions (or phobias) still manage to leak out and remind us that we are not bullet proof to the bodily aspect of the human condition.

What gets you?

More Amazing Brain Development Information

Ok. If you have a few hours to kill in a car (like I always seem to...) let me recommend listening to this radio show. It is from one of my favorite podcasts, "Ideas" on CBC.

This feature, The Brains of Babes, especially episode one, has some fascinating discussion about studies linking heart disease and diabetes to fetal/early childhood health as well as pre-pregnancy maternal health.

And while we are on the matter of fetal/early childhood development can I also mention that the two most recent books that left my jaw on the floor were, "The Brain that Changes Itself" by Doidge and "In the Realm of Hungry Ghosts" by Mate. Really, if these books don't fascinate you to the point where everyone around you rolls your eyes when you begin yet another sentence with "so I was reading today..." then send me your copy and I'll send you the money for it. :)

My apologies if I've mentioned these books before on Asystole, but listening to those features on Ideas just reminded me and I wanted to give them the props they deserve.

So there you have your summer light reading list.

Oh, and add "Book of Negroes" by Hill to that. Finished it today.

Wow. What a book.

(I know that is the weakest review of a book ever, but seriously...just read it.)