I do not think that there can ever be enough books about anything and I say that knowing that some of them are going to be about Pilates.The more knowledge the better seems like a solid rule of thumb, even though I have watched enough science fiction films to accept that humanity’s unchecked pursuit of learning will end with robots taking over the world.-Sarah Vowell

Monday, August 15, 2016

Carrying the Black Bag: A Neurologist's Bedside Tales by Tom Hutton, M.D.

Dr. Hutton's stories and life are quite interesting. He graduated from Baylor medical college and got his "black bag" upon graduation and that bag meant more to him than anything as it represented everything that a doctor is.  He went on do his internship at the the Hennepin County General Hospital (also known as "The General") in Minneapolis, a teaching hospital for the University of Minnesota, where he would would do his neurology residency. Eventually, he would take the job as neurology chief resident of the VA Medical Center in Minneapolis.  Then he and his family would move back to Texas in Lubbock where he would have an associate professor's job at a developing medical school where he would be creating a neurological clinical, teaching, and research program where none had existed before that would churn out not trained specialists, but primary care physicians. On top of this he would do a great deal of research into Parkinson's.

During his internship at The General he bemoans the fact that doctors can no longer do what he and others doctors did back then. Around midnight things would calm down and the house doctors would all be in the cafeteria getting something to eat and it would generally be a time for a bull session among interns and residents about cases that could sometimes lead to answers that saved lives.  Sometimes it was just a chance to let off steam about life in general.  These days doctors have little cubbie holes and don't as a rule meet in large groups to have bull sessions together like that anymore. On the other hand, The General is a much nicer hospital now than it was then when it was falling apart at the seams.

His first rotation scared him the most as it was the NICU and sure enough something went wrong. He went to change a boy's diaper and turned his back when suddenly the heat lamp exploded and shards of broken glass landed on the baby's body giving him temporary first degree burns. He completely freaks at what he believes to be a horrendous accident caused by faulty equipment, until a nurse comes in to help him and remarks that the kid must have the aim of Wild Bill Hickok. When he looks at her confused (as do I since I have a daughter not a son) she tells him that as soon as he took the diaper off the boy shot a stream of urine straight up and hit the heat lamp dead on causing the light to burst.  The baby boy was fine once the ointment was put on.  And he learned, as all parents of boys do, to watch out for the boys when changing their diapers.

When he did his maternity rotation the last thing he expected was that he might have to deliver his own kid.  It was one of the worst winters in Minnesota memory and Dr. Hutton's mother had come up from Texas to be with his wife Trudy.  However, when she went into labor even Minnesotans weren't driving out in the weather and the ambulance drivers weren't going out in it, either. So his mother, who had never driven in snow in her life, but was a crazy, and stubborn Texan set out to get her daughter-in-law to the hospital and did in fact get her there, though her son had to give her a Valium when she got there as her nerves were a bit shot. Dr. Hutton had delivered over 200 babies so this should be a piece of cake so long as nothing goes wrong. Something of course, went wrong. His wife was going to require a C-Section and the on-call doctor had already told him that he was snowed in at his house. Dr. Hutton had never even seen a C-Section done much less done one. Never mind doing one on his own wife. He went down and had a chat with the ambulance driver about what was at stake.  I like to think that maybe he shamed him a bit by telling him that his Texas mother made it there and she's never driven in snow before.  Nonetheless the ambulance driver went out and in an hour got the doctor and brought him back to perform the procedure.  Dr. Hutton and his wife had a beautiful baby boy named Andy.  A daughter Katie would follow a few years later.

One of his more memorable patients at the clinic in Texas was Mr. Woodley, an ornery seventy-five-year-old man from Muleshoe who had had Parkinson's for eight years when he first meets him. His wife has been dead for three years and his kids, with whom he is not close with, don't live in the state.  It takes some beating about the bush as to what is going on with Mr. Woodley. It turns out Mr. Woodley is having trouble shuffling cards and wants help with that.  If finally comes out that he plays pinochle with three dogs, a large yellow Labrador named Yellow Dawg, a black-and-white border collie named Skipper, and a small white-and-light-brown cocker spaniel named Coco. He makes sandwiches for them to eat and everything.  The whole scene reminds you of one of those dogs playing poker paintings. Hallucinations can be caused by medication for Parkinson's and as a doctor he should adjust the meds so Mr. Woodley no longer sees the dogs. But the more he talks to him the more he comes to realize how detrimental this would be to the man as he is so lonely out on his farm and the hallucinations are harmless.  This would not be the last problem he would have with Mr. Woodley. The other one would be much worse than this, which is saying a lot.

As a professor and not just a doctor, he had to do research. Publish or perish really does exist in academic circles.  He presented two scientific papers at an international conference in Vancouver, British Columbia. The first "on eye movements and Parkinson's disease, was carefully crafted and painstakingly presented, representing twenty years of my research. While politely received, the paper, I fear, was soon forgotten. My second, more speculative presentation, I had developed over the prior six months. It dealt with Hitler's Parkinson's disease and how his illness might have influenced the Battle of Normandy. My Hitler presentation, to my amazement, created great enthusiasm and immediately went viral."  After about ten years, Parkinson's can cause damage to the frontal lobe of the brain leading to impairment in the the ability to plan, execute, and determine effectiveness of decisions. The author is quick to note that this has nothing to do with any moral or ethical decisions he made during his time as leader of Germany, as he was not impaired that way at all. This is more along the lines of when he should attack the USSR. The idea was to attack them in 1944 when they had all their advanced weaponry, but he moved it up. He also failed to send in reinforcements at Normandy for two days which was a possible game changer in the war.   He refused to change his mind about the Allies attacking in Calais.  He was incapable of delegating smaller decisions to others and got mired down in the details.  The History Channel did a program on it called High Hitler, as Hitler's doctor treated him with some questionable drugs. Dr. Hutton worked on the United Kingdom's Chanel 4 on a program that was called Hitler's Hidden Drug Habit and in the United States it was on the National Geographic Chanel as Hitler the Junkie.

At the clinic, in order to have time to do his research he took on a nurse practitioner who is a real dynamo and a redhead, but I repeat myself.  Her name is Vicki and she has causes that stretch the length of Texas because her heart is so big and so fierce. In the book there are stories of the two of them working cases, but the big one is the cruise at the end of the book. At some point he began to take Parkinson's patients from wherever as long as they passed the physical, on a cruise of the Bahamas and that area. He and his staff would be the ship's specialists along with the on board doctor.  Over the years the cruise had grown in numbers and this last one he describes going on is like the cruise from hell in some aspects as things that had never gone wrong before are going wrong now, as doctors are green lighting patients who maybe should not be there.  At the same time, it's a joy to watch the indomitable human spirit as it refuses to give up and these men and women go on shore excursions or swimming with everything they have.

I really loved this book. Dr. Hutton really cares about his patients. In 1974 he had just embarked on the US-USSR Health Exchange Program to the University of Moscow fellowship. He got to work with the greatest Soviet neurologist Dr. Luria who taught him the importance of reading mysteries in preparing to be a doctor.  He also taught him the importance of viewing a patient's story from their perspective and of medical storytelling, which means getting a detailed account from the patient themselves as to what is going on in their lives, not just what the problem is, because it could all be connected.  This is a doctor that believes in sitting down with you and talking with you for a bit before he digs into to trying to figure out how to solve your problem because the two can be connected and because he cares.  He's not ashamed to admit when he openly weeps over a patient he barely knew for a short period of time.  These stories are sometimes a bit funny, or miraculous, or heartbreaking. They are all thought provoking and while he has retired from practicing medicine, the black bag is always at the ready.

 I asked Professor Luria what he considered to be good preparation for becoming a neuropsychologist and neurologist. The eminent clinician surprised me by answering that reading mysteries was a fine background. He revealed that identifying and cobbling together clues was really no different for making neurological diagnosis than it was for solving crimes. Sherlock Holmes and Hercule Poirot, I suppose, would have made fine neurologists.

-Tom Hutton, M.D. (Carrying the Bag: A Neurologist’s Bedside Tales p 10)
 Babylon in all its desolation is a sight no so awful/As that of the human mind in ruins.

-Scrope Berdmore Davies
 There is and elasticity in the human mind, capable of bearing much, but which will not show itself, until a certain weight of affliction be put upon it; its powers may be compared to those vehicles whose springs are so contrived that they get on smoothly enough when loaded, but jolt confoundedly when they have nothing to bear.

-Charles Caleb Colton
Link to Amazon: https://www.amazon.com/Carrying-Black-Bag-Neurologists-Bedside/dp/0896729540/ref=sr_1_1?s=books&ie=UTF8&qid=1471270812&sr=1-1&keywords=carrying+the+black+bag


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