REACHING DOWN THE RABBIT HOLE - ALAN ROPPER AND B.D.BURREL


EXTRAORDINARY JOURNEYS INTO THE HUMAN BRAIN

My summary and notes


- Confused patients have misperception and illusion, topographic and spatial difficulty (can't draw, can't copy boxes), loss of temporal coherence (difficulty connecting one moment to the next) and hard-to-define language troubles.

- The fact that electrical activity between nerve cells is highly disordered in most confusional states, does show up in the slowing of the EEG waves.

- Psychosis is a special type of confusion with its own reality an internal reality that is consistent only with itself It does feature a connected, ever-flowing "stream of thought".

- If the psychosis is not completely detached from reality and its causes are addressed, the patient will get better. It just takes time. If the causes are not addressed, the confusion takes over.

- TGA: transient global amnesia, an entirely benign condition of memory loss that usually resolves itself within hours, with no permanent damage. Can be triggered by nothing at all, or a strongly emotional event: swimming in cold water, sex. If anything else accompanies it, e.g. unsteady gait, or it lasts over a day, it is something else.

- Anterograde memory - the ability to form memories forward

- Retrograde memory - the ability to retain memories of the past

These two are inextricably linked, when you lose one, you lose the other.

- Medial temporal lobes are important for memory, and very susceptible to low blood flow.

- Korsakoffs syndrome: a permanent retrograde and anterograde amnesia caused by low blood flow to the medal temporal lobes. They can get stuck in a certain year, remember nothing after it, and cannot retain any new information for more than 30s.

- Conversion disorders: the conversion of psychic distress into physical symptoms.

- A woman who claimed she couldn't walk because her knees kept buckling still managed the very difficult walk without falling, showing very good functioning of her frontal lobes, cerebellum, basal ganglia and spinal chord. It is a psychological problem.

- People may claim to be blind when they are not. However, they will almost always follow their own eyes in a mirror before their face, or the movement of a £100 bill in front of them.

- Ataxia: wild limb/arm movements

- Aneurysm: a rounded patch of one of the blood vessels at the bottom of the brain. If it reaches a critical size or form, it can burst open with the entire force of the body's blood pressure. Blood then fills the spaces around the brain in a split second and causes a thunderbolt of a headache that one doesn't forge and many don't survive. A third of survivors have a re-rupture in days. Half of these die.

- Medicine is like the laughing and crying masks of the theatre: comedy and drama. There never is one side that is right and another that is wrong. The risk calculations are in the doctor's head, and no algorithm has yet to do better. Yet ultimately, as far as the hospital is concerned, the patient is always right because personal authority trumps probabilistic outcomes. You have to respect their wishes as human beings, we're told. But if you ask me whether the customer is always right, I would say "not at all". The patient is so very often dead wrong, and very much so when it comes to his own brain.

- The interdependency that is built into a modern hospital, our reliance on checklists, hierarchies, consultations and each other, protects us individually from taking all of the blame when things go wrong. We can and do man mistakes, but in theory someone is there to catch and correct them.

- The last skill medical residents acquire is in many ways the most important one, and the most difficult. They need to master the executive skills required to make things they need to happen, happen for they patients. If you need your countries best hand surgeon to come in and reattach a and at two o'clock in the morning you'd better be able to make that happen. You'll catch hell for it, but you've got to save your guy.

- The history of medical discovery is instructive, not merely anecdotal, but they are part of a tradition. The practice of medicine benefits from resisting the discoveries of the past. For a doctor, seeing further means looking over the shoulders of giants.

- The benefits of autopsies are that looking at a patient hours after he died and learning with precision how your actions contributed to their death. The event will be embedded in your memory forever. you learn things you would have to read about in a more practical way.

- The secret to consciousness is in the eyes. If the creature has human eyes and it looks at you, then it is conscious to you.

- An overdoes of barbiturates will make you look dead - no pupils, no eye movements, no vestibular ocular reflex, no EEG, nothing.

- The cranial nerves are key because they come out of the brain stem segmentally. That is why we begin with the eyes. We can't test smell because that requires cooperation, and test pain, the 5th cranial nerve. The eyes include cranial nerves 2, 3, 4, 6 so you can go from 2 to 6 by looking at the eyes.

- "Death by brain criteria" is used rather than "brain dead" because it doesn't confuse the public to into considering what is then alive.

- Squirting ice water into one ear, then the other causes a potent stimulus to eye movements through a hard-wired circuit in the brainstem, if its functioning at all. It tests the integrity of the pons, the middle part of the brainstem and is called the caloric reflex.

- Apnea test: removal from ventilator to check if the patient can breathe on its own. Many brain dead patients, after the ventilator removal, exhibit the lazarus sign: arms spontaneously contracting and their hands coming up to their chests as though they're grabbing the endotracheal tube.

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