#meded

We are proud to announce the publication of the next Pager Publications, Inc. print book, The Perfect Doctor, curated by Dr. Sasha Yakhkind and featuring 40 narratives written by patients, physicians and trainees about the imperfect pursuit of an ideal.

Learn more about the book at http://theperfectdoctor.org. You can purchase the book at http://tinyurl.com/theperfectdoctor.

My journey into understanding neurodivergence and my own AuDHD-ness has changed how I doctor, and sometimes I can see this when looking at things like auto text scripts I set up previously.

For example, when it comes to picky eaters, I used to do a lot of education about how to get kids to eat, discussing strategies like gamifying intake of fruits and vegetables, enforcing #-bite rules, and having cutoff times for meals. I also put a lot more weight on having a balanced, whole-food meal. The only thing I discussed that was focused on any underlying reason was involving kids in meal prep, though I didn't necessarily have a reason as to why. And, to be fair, these strategies work for picky, NT toddlers.

Contrast that to today, where I'm asking questions about texture sensitivities and taste preferences. I'm acknowledging that processed foods are more predictable than fresh. I'm discussing meal prep involvement as a means of sensory food play. I'm discussing about how stressful #-bite requirements can be and I'm encouraging having safe foods available and permissable - not as a means of giving in, but to make trying a new food less stressful. I'm also acknowledging that some food is better than no food, as long as we get the basics/macros in as we can always supplement micros with multivitamins.

These are things that weren't taught when I was in medical school or residency. I attended in 2015, just after the DSM changes and the focus then was, and largely still is, eating a "well-rounded", normativized, white, upper-middle class diet. Anything other than that was treated as subpar and is bad medicine, let alone parenting.

You know the other thing? When I started asking, do you know how many of my picky eaters DIDN'T have some kind of sensory basis to their eating patterns? Do you know just how many undiagnosed, unseen neurodivergent kids are out there, masking along, not making waves, with equally ND parents who don't know otherwise?

I was told I had to choose topics, or else my classmate would choose them for me... so, fine. Sighs. I chose three and thus am now extra-reading up on: 

symptoms and surgical treatment of chronic pancreatitis 

classification of skull fractures

determination of brain death

I chose this last one because two weeks ago, I stood beside a paramedic as she went through the steps for a fresh ED admit ... and I realized I didn’t even know what things to check before someone could be declared brain dead. In fact, I always confused the ideas of comatose, brain death and persistent vegetative state. So I’ll clear it up for myself (and perhaps others?): 

BRAIN DEATH: a state of irreversible unconsciousness (GCS 1-1-1) which meets very strict criteria. Importantly, there is an absence of brainstem reflexes, motor response, and respiratory drive. There are many other criteria as well, but for starters, the reflexes to check are the following: 

1. corneal reflex (CN V1 + CN VII)  2. oculocephalic reflex (CN VIII + CN III and CN VI) 3. gag reflex (CN IX + CN X)  4. pupillary light reflex (CN II + CN III) 5. cough reflex (CN X + CN X)  6. pain reflex (CN V + CN VII)

Because the determination of brain death is so crucial to get right, there are other criteria as well, which are explained really well on teachmesurgery.com (linked the article here). These include that the patient not be on sedatives, be apneic, have no reversible causes in the background, and many more.

Brain death differs from persistent vegetative state, although both are in an irreversible unconscious state. A patient who is brain dead cannot breathe on their own. A person in a vegetative state actually does breathe on their own. A comatose patient is also unconscious, with no reflexes, but they may be awakened -- it depends on the cause of the coma.

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In the case of the patient on that fateful day, the presentation was GCS 1-1-1, and she was intubated in the field. The husband called the ambulance because the patient had a seizure while sitting on the toilet. The toilet... yes, you guessed right. When we did a CT of her head, there was a very large subarachnoid hemorrhage. It’s a textbook case: undiagnosed cerebral aneurysm ruptures in the background of straining (i.e. being on the toilet), and if the bleed is large enough, it can be fatal. 

In her case, it was. However, you need to wait 5-6 hours to declare someone braindead, so we observed her in our ED while the family came to say goodbye. She was young... 50-something? ... and no significant medical history except smoking.

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