The Days of an Intern - Neurology Reflections

During my one month in the Neurology department, whether it was the honing of academic knowledge or the transformation of my state of mind, I reaped abundant rewards amidst a busy life.

Looking back on my early days in Neurology, I took over a patient whose medical record documented a diagnosis of TB meningitis. Half-understanding, I continued to administer antibiotics according to the handover and consultation instructions, only to receive an earnest reprimand from the attending physician. Afterwards, we reviewed the possible diagnostic reasoning, including the medical history and Lab data for CSF Total protein, Glucose, and Pleocytosis. What made this patient peculiar was that after starting TB-specific antibiotics, the patient's Neuro symptoms improved within a week; however, when CSF was drawn again in the second week of admission, Total protein and Pleocytosis had actually increased slightly.

During the handover at the beginning of the month, the teacher performed another Neuro Examination during ward rounds and found Gait disturbance and Dysmetria on FNF test, but no Nystagmus. Since the patient had an underlying history of alcoholism, the attending added Wernicke's encephalopathy to the DDx alongside the original primary impression of TB meningitis r/o Virus meningitis, and encouraged me to look up literature on CSF Data in Wernicke's encephalopathy. However, after the Infectious Disease consultation, they still leaned towards TB meningitis, providing literature to support the conjecture that the abnormal elevation in CSF data might be a Paradoxical Response—a rebound immune reaction of the body to the release of TB bacterial material from within macrophages—thus recommending the continuation of antibiotics.

Through this case, in addition to diagnostic reasoning and the application of EBM Based medicine, I also experienced the full picture of a medical team's rigorous operations. Although an Intern is relatively at the bottom of the team, functioning more in an executional role, compared to a Clerk, being in the team offers a much more concrete sense of participation. I could listen to the exposition of comprehensive academic knowledge and experience from all sides, rather than just one-sidedly understanding the story of disease progression from the medical chart. The greatest blessing for an intern is perhaps still retaining the purity of a blank slate, learning the essence steeped over years by every senior physician through execution!

Shouldering the responsibility of patient care, I began to apply what I had learned, explaining medical conditions, diagnoses, and treatment plans to patients. From my initial timidity to facing patient families and addressing problems slightly more comfortably, although I was nowhere near as composed as my seniors, I also began to give reassuring replies based on experience, while still retaining the leeway to inform them of medical risks. While caring for inpatients, there was one case that left a deep impression on me: a 93 y/r gentleman whose chief complaint was Acute onset right-sided hemiplegia. However, the CT simultaneously revealed an SDH and a small area of cerebellar Infarction. During the ER handover, we were informed that Neurosurgery thought the symptoms looked more like a stroke, and regarding the SDH, due to risks such as his age, surgery was not recommended; hence, he was sent up to the ward.

I had already mapped out the stroke-related assessment tasks and what I might need to explain to the family in my mind. Unexpectedly, upon coming up, he presented with a productive cough, choking, fever, and pulmonary infiltrates. Furthermore, his Conscious state was not entirely Clear and was even deteriorating, and Muscle Power on his left side also began to decline. In that moment, I was burning with anxiety; vague thoughts of IICP Sign and Cushing's triad assessments flashed through my mind. The patient's blood pressure had indeed risen, and his heart rate had slowed, but I didn't quite know how to proceed with treatment.

Because the Neurology Ward Run meeting was taking place at the time and all the seniors were inside, I could not call for help directly. Judging that a neurosurgeon might need to take over, I directly called the day-shift consulting physician, explained the deterioration in Conscious state and Muscle Power, and asked him to come over quickly. Since the family was already on site, even though I didn't know how to medically explain the current situation and was in extreme panic, a surge of courage from somewhere unknown allowed me to try my best to explain to the family that the current situation was not optimistic. I frankly stated that this might not be curable with simple stroke management. For the internal medicine admission aspect, we would do our best to control the lung infection, while for the bleeding aspect, we would ask a neurosurgeon to come evaluate it again. After the neurosurgeon arrived and discussed it in more detail with the family, the family decided against surgery and signed a DNR.

I must admit that in front of the family, when asked what would happen to the patient in the future and the suffering he might endure during emergency resuscitation, my hands and feet were probably trembling. But a doctor must be a lighthouse amidst raging winds and waves; thinking that if I, wearing a white coat, couldn't even remain composed, how could I reassure the family? I suppressed my own inner unease, persuaded the family about the parts where we could only do our human best, and suggested that if he truly could not be saved, we should let him suffer less, helping the family to accept this earlier. Fortunately, a few days later, perhaps because the antibiotics successfully treated the pneumonia and brought down the fever, the gentleman's consciousness and left-sided paralysis recovered to their previous levels, leaving only the right-sided Muscle power still somewhat reduced. As his condition stabilized, he was transferred to the Neurosurgery outpatient clinic. When preparing for discharge, probably because things turned out much better than originally expected, the family thanked us incessantly.

If one could say that being a Clerk in the past was like gazing at the majesty of a valley from afar, becoming an Intern brings a constant sense of crisis, like walking along the edge of a cliff. And this patient was the time I came closest to the cliff's edge; the sound of my heartbeat back then, along with the family's voices of gratitude, are still buzzing in my ears to this day.