In which I italicize.

We’re on the home stretch of Neurology now. Some snapshots of the weeks:

1. Death.

In my first week in the Neuro ICU, I saw a family decide to terminate life support for a critically ill patient. We had gathered in a magnificent paneled conference room to discuss the treatment choices going onward. My attending, resident, and I were late, so we silently joined the table. There was not enough space for me to sit. I stood in a corner and did my best to pretend not to exist, as I watched one of the younger daughters cry. After the meeting (it was quick), everyone dispersed through various doors. I had to head up to the ICU again, and while waiting for the elevator, the same family came to wait. Of course, they were going to the same floor as me. I thought, should I introduce myself? Would I be too presumptuous if I did? How would it help? Would it be less intrusive to continue not to interact with them? I was paralyzed. I defaulted to pretending not to exist. The elevator took an eternity to arrive. We silently ascended to our shared floor, none of us speaking, none of us making eye contact. Maybe if we didn’t acknowledge our shared space, we could pretend we didn’t share one.

Later that week, I was writing a note for another patient, stationed right next to the monitor that displayed the vitals of all the patients on the service. I didn’t notice until quite a large group had gathered that there was something going on in a patient room near me. The family had come back; it was their last day. Behind me, almost all the floor’s nurses had gathered, the NP, and the residents. They exchanged knowing looks. I realized then that the vitals for the patient across the hall, on the monitor right next to my laptop, had started to drop. Apnea came immediately. Then the blips of the heart rate started to slow, and the O2 saturation slid downward, as well.

Is this how I am to be introduced to death in a hospital? I wondered. I never realized how long it took for someone to die. The heart rate and O2 sat stubbornly persisted for endless minutes. The small cohort behind my seat were only giving sidelong glances every few minutes; my resident continued to type out her patient notes. The family was holding each other. My thoughts cycled like a merry-go-round. I prayed.

A few eternities later, the family was gone, and all the workers on the floor had returned to their various pursuits. The room was to be cleaned. It was empty for the first time in weeks. I overheard two nurses joking about their strategies to avoid having to take on a new patient by encouraging the family of the last patient to stay as long as possible with their loved one. It felt so contradictory. Something happened, but did anything happen? By the next hour, I had put the incident out of my mind. I had notes to write, patients to follow, material to study.

2. Bad news.

My friend did an initial neurological evaluation on a woman with recently diagnosed breast cancer. She and her husband had weathered through the battery of surgery and chemotherapy for the last three months. Now she was in the ER for unexplained weakness in her face and arms. My attending swept into the room, and like obedient ducklings, my peers and I followed. She asked the patient to do a series of tasks, like a very serious game of Simon says. “Follow my finger with your eyes. Close your eyes. Smile. Say ahh. Shrug your shoulders. Stick out your tongue. Stretch out your arms. Close your eyes, hold them there… keep them up! Do you feel me touching your arms and legs? What side am I touching?” I was used to seeing some classic symptoms. Asymmetric muscle weakness, difficulty finding familiar words, facial droop. I wasn’t used to the look of panic on the face of the patient, nor her husband, as she struggled, teeth clenched and veins bulging, to move a suddenly alien limb.

Even more terrifying are the cognitive tasks. My attending pulled out a card that showed a picture of a domestic scene. “Tell me what you see on this card.”

She took the card. In a shaky voice, she said, “A window. A tree. A sink. A faucet.”

My attending joked, “I can tell you like houses.”

“I used to be an architect.”

“Go on, what else?”

“A woman washing dishes. The sink is overflowing. A counter with more dishes…”

My attending prompted further. “What else do you see? What’s going on in the picture?”

“A woman is washing dishes.”

“Okay, but do you see anything else?” The patient’s husband came around the back of the bed to see the picture, too.

“Well… there are cookies in the window. A child is taking the cookies. He is standing on a chair. He’s about to fall!”

“How many children are there?”

“There’s one… oh, there’s two.”

“Can you point to them?”

Clearly mystified now, she pointed at the two children trying to steal cookies. “One, two.”

“What about the one on the left?”

She started. “Oh my goodness. There’s one right there. I didn’t notice her at all. Was she there the whole time? I completely didn’t see her until you pointed her out.”

I came over and finally caught a glimpse of the picture. It had turned out that the patient had described everything from the very right border of the picture, slowly inching towards the left, and stopping just short of the child in the leftmost part of the picture.

The attending pulled out a long strip of fabric. “Point to the midpoint of this scarf.” The patient’s finger hovered in the right half of the scarf. Her husband’s eyes widened. She looked at her husband, and back at us. “Did I do that right? I’m getting pretty freaked out. Why didn’t I see that child in the picture?”

Neglect is a classic sign of dysfunction somewhere in the right parietal cortex of the brain. It causes one not to pay attention to one half of one’s perception. Some cases are so severe that patients would only look to one side, or react to sounds from one side, or read only the right half of words on a page. I had never seen it in person before. The descriptions in my textbooks were always too outlandish for me to believe. But this was real.

Given the propensity for breast cancers to metastasize to the brain, and a clean read of the CT angiogram, my attending had to tell the couple her clinical suspicion: that the cancer, so newly found, may have spread to her brain. The patient asked, “Does that mean I can’t leave the hospital tonight?”

“I’m afraid not. We’ll transfer you to a room upstairs. I’m sorry, I know even the breast cancer is new for you.”

The patient gripped her husband’s hand. “Well, we’ve come this far. We’ll see where this goes.”

3. Better news.

The next day, some clouds had cleared. Turns out we had missed a big carotid clot in the CT angiogram. A new CT showed tiny punctate emboli scattered throughout the cortex. Not metastasis, as we feared—just good old strokes. Tiny ones, at that. I was never so happy to see a stroke diagnosis in my life.

I was sent to do the follow-up neurological exam, and the patient and I swapped jokes the whole time. Her hemineglect had more or less resolved (it’s one of the first neurological symptoms to be regained after an acute stroke), and her strength had returned, though it still required substantial effort to raise her arm. “It could have been that your arm weakness yesterday was from the neglect. Your body may have had a harder time paying attention to your left arm.”

Her husband proudly said, “She’s been working on her strength this entire day. That’s how she is. There isn’t a thing she can’t do. She’s going to give 110% effort. Stroke or cancer, she’s going to give 110%.” When he looked at her, the sunlight through the windows seemed brighter.

Neurology covers a lot of conditions that have no solution. But sharing in the joy of that patient and her husband, reveling in the miraculous plasticity and mystery of the human brain, showed me a little slice of why people choose to specialize in neurology.

When I don’t have audiobooks on, I talk to the Lord. No filter, just whatever I’m thinking. I had careened about my day in my usual haphazard fashion, and when I was talking to the Lord about it, I just had to repent. Lord, I may say so much about absoluteness, consecration, service, and love, but I am nowhere near this. Lord, I can’t walk my talk. Then the verse came up in me, “If we live by the Spirit, let us also walk by the Spirit.” I mused on the word walk for a while. Thank You, Lord, that this walk is not second person singular. Thank You it’s first person plural. I’m so glad that this walk is not just an injunction for me, but a shared experience between me and You. Thank You for conjugating this word in such a sweet way. Then I thought about the word conjugate. Con-iugo. To join together. Thank You for being our conjugate. Thank You that as spouses (spice?) we’re conjugated to each other; we’re conjugal.

Hymn 628
(Fellow-pilgrims, art thou numbered
With the men the world calls dead?)
Thence we rise, and live with Jesus,
Throned above the world’s mad strife,
Gladly forfeiting forever,
All that worldlings count as life.