Her eyes started across the sparse hospital room into eternity, my presence unacknowledged. I introduced myself as a student from neurology, and explained that we were asked to assess her situation by the main team caring for her. I scanned her 78 year-old frame for any signs of trauma or external manifestations of disease. She laid motionless, angular with knees drawn into her body. Her illness was hidden from my inspection, but I knew having read her history that she was wracked by severe Alzheimer's Disease. She did not blink and she did not speak, rather her mouth remained half open, hoarse gurgling sounds streaming forth with every exhalation. I continued speaking in a calming tone as I examined her, knowing that her mind did not register a word I was saying. In retrospect, my unnecessary one-way conversation was almost certainly to calm my own nerves. After all, inflicting pain in a hospital should always come after the civilities.
The neuro exam is often difficult for patients to endure. For high functioning patients the low-level cognitive function tests and repetitive movements must seem mere child's play, while those with true neurological deficits must experience a great deal of frustration when faced with the reality that motions and sensations that were previously second nature can now be impossible. Even more difficult is the exam conducted on a comatose or severely demented patient, who is entirely unable to cooperate or verbalize sensations, cognitive ability, or fluency or comprehension of language. This forces the examiner to become a physical exam instrument, testing sensation in all limbs by compressing nailbeds to inflict pain and monitoring for a response. More often than not, at this point of the exam I find myself wincing in sympathetic pain as I press down fiercely on the patient's nailbed with the metal handle of my reflex hammer. More often than not, the patient is so obtunded that they do not even flinch with the inflicted pain.
After thanking the patient for her cooperation, despite her inability to utter a single syllable during the entire exam, I left the room to report my findings to my resident and attending physician. I "presented" the case to the entire team as we stood outside her room, the time-honored manner in which physicians learn to transmit a patient's story to each other in a thorough and logical manner. Soon our patient was being wheeled back into her room, cutting a swath through the crowd of white coats. Following closely was an elderly man, slightly overweight and walking with a strong gait. He appeared well enough to play 18 holes of golf more days than not. As he waited outside of the room while our patient was being transferred back into her bed, it became obvious to me that this was the woman's husband that was mentioned in her chart. The chart indicated that he cared for his wife in their home, only getting respite twice a week for a few hours. Even skimming our patient's story and having a crude understanding of the severity of her disease before seeing her for myself, I quickly understood that the care of his wife was a huge undertaking. I remember feeling a vague sense of admiration when learning that she lived at home, yet I couldn't suppress the feeling that maybe he really did not fully understand just how advanced her condition was.
My preconceptions were blown away with one look at his face. The care, love, and concern that he showed for his wife, who must have been a frail shell of her former self, was enough to rend my heart. I struggled to finish my presentation of his wife's case in the impartial and highly scientific manner that is encouraged in the medical field, regardless of the specialty, fully aware that he stood mere yards away, listening to every word. It was obvious that his world was hanging on my assessment of the situation. I continued spouting medical terminology as I fumbled for a reason why his wife's Alzheimer's had worsened overnight, but for him I had no words.
Upon finishing my presentation, I watched as my attending ushered him into the patient's room, asking questions along the way about recent events and changes that might have led to her current state. Wounded, I stared at my shuffling feet as I tailed behind the team, dreading the moment when I would finally have to look up and see this strong man coaxing his wife to speak words that would never come.