In the contemporary view melding science and its demystification of the physical self, the brain is the vessel of life and the human soul. It is the culmination of millenia of the evolutionary process: a slow refinement emphasizing the supremacy of intellect over might. And yet, at the dawn of a century that will see great explorations of the human mind, the latest frontier, I sit and stand at the bedside of individuals whose brains are in peril. How can these incredible machines be so frail despite so many years perfecting their design? Starved of their lifelines, the cells die by the million, and unless the victim arrives within a narrow window permitting more aggressive intervention, we must stand in our white coats with our fingers in the dike. Keep the temperature low, allow the blood to flow at high pressures for a few days with hopes of preserving the injured but not yet permanently damaged tissue, and do everything possible at this time to prevent a second stroke. And then wait, move those limbs and lips, and hope for recovery.
Or perhaps the electrical currents in the brain have gone awry, and the power grid is burning itself into oblivion. I had never truly understood the word “oblivion” before looking into the eyes of someone recovering from status epilepticus to the blank stare considered her baseline. Beside strokes and seizures, the brain is also under assault from the outside: infections, toxic drugs, and unknown environmental factors cause the brain to break and wither and waste away.
It is very easy to despair and submit to the overwhelming mystery and fatalistic trappings of the brain’s many demises. For a number of years, I found Neurology to be a very unappealing field because of the notion that there is little that these specialists can do for patients with neurological diseases. However, learning the ropes in the midst of a rapidly developing Stroke Service and some rising star physicians has broadened my view of Neurology and the power of specialization. Most physicians, especially generalists with a wide variety of patients, can hope to perform the “standard of care” for each of their patients. However, the standard of care, from the view of an expert, is the bare minimum: the knowledge of how things can be done so much better is empowering and mobilizing. It frustrates us and inspires us to strive to develop new programs, protocols, and treatments to improve medical care for our patients. While there is a great need for a stronger primary care base in the U.S., this does not replace the great benefit that can be derived from subspecialization that is rarely discussed in popular news at this time. How many times did I, as a mere junior medical student on the Stroke Service, have to discuss the great need for aggressive temperature control and permissive hypertension with nurses and doctors working with my patients? With a passion to cure or greatly improve the treatment and management of a disease and the energy to overcome the inertia of hospital practice, how much more of an impact might I have on my patients and my field than if I were less focused?
At the very least, I will retain the memories of the men and women whose gradually strengthening hands and smiles remind me of the great impact we can have in each field of medicine, as well as the men and women who left the hospital through another door, a testament to a future commitment and hope to do better in the future.