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p.1
1
Birth
First days in neuropsychology
(Albert Einstein)
Opportunity
Sometimes the best stories are the ones that are true. Or maybe they are just more memorable. It is the early 1990s. After 27 years of incarceration Nelson Mandela has recently been released from prison. As if in a dream, his long awaited steps towards freedom are beamed across the world, for all to see. The iconic black and white photo of him in his distant youth is instantaneously updated in millions of minds, brought to life, in full colour. What was static, is converted to motion. Wow, thatās what he actually looks like! South Africa has temporarily stepped back from a nightmare, a deep cliff descending into unknown darkness and uncertainty. It is as if a collective breath is being held. Even though too often there is yet another return to the darkness of the past. Ready to explode again, hovering precariously close to the edge of the cliff. But, generally there is now optimism for a birth of something new. Nkosi Sikelelā iAfrica! [God bless Africa]. Nevertheless, violence remains at epidemic levels. There has not yet been a free and fair democratic election for all citizens of the country. In among all this chaos, optimism and fear, ordinary people go about their normal daily lives and jobs. Hope is the medicine that keeps everyone going. Waiting for opportunity to arrive, something new and embrace whatās on offer.
p.2
It is a beautiful morning, with a sky so blue it seems to have swallowed the universe and all its troubles, grasping every ray of light the sun has on offer today. I am at work. It is my first day here. A chance meeting while putting out the bins a few months earlier, brought me to this ward round today. I am back at the university teaching hospital where I completed my internship at the end of my clinical training in the late 1980s.
āHey Tomas, is that you, or am I dreaming?ā
āIt is indeed me, Rudi! And how are you, my man?ā
Tomas is a psychiatrist who was a registrar I worked with while an intern. He has recently returned from doing locums in Canada. Tomas and I got on very well, and I am pleased to see him back. In particular I valued his loyalty, compassion and truthfulness while we were working together.
āWhy have you come back?ā
Tomas tells me why he is back in the country. He jokes and says contrary to popular rumour the weather was not so bad in Canada. And that peopleās troubles are the same everywhere in the world. It also transpires that his master plan is to develop a neuropsychology and neuropsychiatry clinic for the hospital where we met. Although it is a bit rough around the edges, it is one of the two big university teaching hospitals in the city. While he is talking, I read between the lines that he is out on an informal recruitment drive. Anyway, that was his story on that Sunday evening the bins had to go out. If ever there was an unglamorous meeting trying to attract someone into the profession of clinical neuropsychology, this must surely be it.
p.3
The din of chairs creaking and people talking at the ward round is somewhere in the background. My mind is still with the bin evening. Tomas tells me more about his time in Canada and working with clinical neuropsychologists, neurologists and neuropsychiatrists. It sounds fascinating. Psychiatrist that he is, he must have sensed my interest.
āWhat would you think about the possibility to specialise in clinical neuropsychology, and join the team in the new clinic I am planning to develop?ā he asks with his typical poker face.
I look at him blankly.
āWhat?ā
āWe really need a specialist clinic to look after patients with brain injuries and other neurological problems. Nobody takes care of them. There are no magic drugs to cure brain injury. I am sure the department of psychiatry will be supportive of us if we said we wanted to develop a new clinicā, Tomas continues, suddenly sounding very enthusiastic.
It sounds like one of those opportunities where your gut instinct is that this does not need thinking through, or consideration of minutiae such as remuneration. Forget logic, accept now, or regret forever.
āIād be very interested, definitely count me inā, I say without thinking.
Is this the coup de foudre?
Confusion
The sounds of the ward round wrestle themselves back to consciousness and put an end to my mulling over of how I got to this place. It really is like being in another world here. Things are a bit confusing, to say the least. Everyone appears to be talking in a foreign language, as if it is their mother tongue. Fluently. Full of emotion. And fast. Anxiety provoking. People come into the ward round. Some on their own steam, others in a wheelchair, one or two with a drip in the arm. Many say nothing, some a lot, a few others look frightened and cry. Sometimes they say things so funny, it would be inappropriate not to laugh, if it were not so incongruous with their immediate surroundings. A kaleidoscope of the human condition. But I have already figured out that they all have one thing in common. They either have, or are suspected to have suffered an injury or illness of the brain. Itās a new world they enter, similar to my own journey. Can they detect my anxiety, spot the imposter in the audience? It is impossible to imagine what this new world might feel like for them. Do they even remember the old? Some persons have absolutely no physical signs of a brain injury, and walk, talk and interact just like you or me. Others the average man in the street would be able to instantly detect something is obviously wrong. Nothing makes sense to me. The first week is a blur of images, voices and smells. But above all of emotions. While I suspected the demands on the head would be significant, it dawns on me that I have been totally unprepared for what this world does to the heart. Learning the methodology of clinical reasoning will be one thing, living to live with the absence of a recipe to bring order to inner emotions quite another.
p.4
Week two brings more confusion. Everything happens too fast. How on earth can these people be helped? Patiens, Latin for patient, is a person who is suffering, a human being who is not well. Increasingly it is this āwho is well, and who is notā, and for those who are ānotā, having an idea of what āitā is that is wrong. It is this that is most confusing to me. Disorientating, like fog when a walker is temporarily lost in the mountains. A tabula rasa being suddenly deposited in a science library. Inscriptions are needed, and soon. The broad goal is to through clinical exposure and learning gradually emerge from the fog with the skills and knowledge required to speak the language of my colleagues in this new world. But not only speak the language, also the corresponding ability to, like them, actually do something useful for the never-ending conveyor belt of patients we see every day. To reduce their suffering. Thatās what is needed. Intellectually itās not that difficult to figure out, emotionally not so easy. A feeling of helplessness, and at times panic, overwhelms me every time I find it hard to keep up with the sheer volume of human suffering and new information I am supposed to absorb on a daily basis. Which is all the time. I need to figure out something, very quickly, or I am going to badly flounder. Itās an apprenticeship yes, but not like you would have thought. There is no protected time to learn. It really is the deep end. Itās impossible not to feel. Thanks to exhaustion, the nights bring a short soundtrack of lifts stopping on floors, ward doors creaking, voices, call bells, the sound of cutlery, followed by instant deep sleep.
p.5
Early one evening I go for a run with Tomas. Breath is precious when running in the heat of an African sunset. I try to surreptitiously prod him for tips as to how he thinks I would best learn the stuff I need to know for this new role, a little bit faster than is the case at the moment. In other words, how to resemble a clinical neuropsychologist, just a tiny little bit more as I go along. He asks what I have done so far. Fortunately we have started going up a steep hill. There is a bit more time to think about an answer. At the top of the short incline I mention that I did have a fair amount of training in neuropsychology while doing my clinical training, and that as he full well knows, I have done a lot of cognitive testing while an intern. I tell him that I am trying to revise what I already know, and learn new stuff through seeing patients every day. He seems pleased with that, but then says there will be a lot more to learn. Something about the Canadian neuropsychologists he worked with being able to ātake apart the frontal lobe and then put it back together againā. Or something to that effect. Only he knows exactly what he means. He suggests a plan involving systematically reading key texts. Targeted reading, to develop specific areas. No point in over-reading, he says. He will help me to identify the best ones. The classics. We have started to run downhill now. The air suddenly feels a little bit cooler, more forgiving of fatigue.
p.6
Plans
Books, the right ones, should of course be at the centre of my developmental plan. Why did I not think of that on day one? It is the early 1990s, long before Dr Google could quell your anxiety by instantaneously answering all your questions. The books eventually include those by Oliver Sacks, Kevin Walsh, Alexander. R. Luria, and a couple of years later, what was then the new edition (1995) of Muriel Lezakās ābibleā of neuropsychology. We did cover the previous edition (1983) of said ābibleā in great detail during my clinical training. Thanks to cramming at the time, now in my new job the contents of the book are, when I need it most, unfortunately too vague to confidently apply in the moment while seeing patients. Studying during the evenings helps me learn and re-learn some of the essentials of clinical neuropsychology. My apprehension starts to slightly decline as I gradually connect neuro-anatomy, psychometrics, neuropathology and clinical assessment skills to the patients I see. The plan is working reasonably well. The sheer volume of information to be absorbed makes progress achingly slow, but some things start to make more sense. In particular once I have seen it in a patientās presentation. Things are looking up. Thereās even more free time in the evenings now. A bit of a social life returns. I go out for supper with a friend one night. She is an artist and writer. I secretly admire anyone working in the arts. My first choice at university, but second choice clinical training came my way instead. Seeing Suzie will be a nice break from studying neuroscience texts.
The restaurant sounds drone on in the background. Plates clanging, people chatting about nothing, everything, life. Smiling waiters are crossing the floor like scissors, probably cursing when out of sight.
āHow are things in your new job?ā Suzie asks.
p.7
āLove it. We saw someone today who presented with memory problems. You should have seen the scan! His medial temporal lobes were necrotic. And we know the medial temporal lobes are involved in human memory. In fact more than that, weāve known since the 1930s that something called the limbic system is involved in memoryā, I mercilessly rattle off most of what I had recently read. I bet sheāll be impressed.
āWhat does necrotic mean?ā
Oh, diseased, basically wasted, like a scar, you knowā, I casually answer, as if she should know that.
āWas he OK?ā Suzie asks, looking concerned and puzzled.
I donāt quite know what she is asking and am a bit surprised.
āWhat do you mean Suzie, was he OK?ā
āWhat happened to him, does he have kids, what will become of him?ā she asks.
Her concern is now obvious. She looks at me in a distracted way, and slowly lights a cigarette.
āYou have a lot of knowledge, but you know nothingā, she spits out, and exhales a white plume of dismissal.
āAbsolutely nothing. Zero. Zilch. Niks. Lutho. Can you ask for the bill please, I have to goā, she says in a cold voice.
Life at work goes on after the āice bucket supper date disasterā with Suzie. I muddle my way through ward rounds, referral allocations and seeing patients. My artist friendās observation does, however, linger with me, like a constant sound of nagging in the background. Tiny fragments of doubt crackle their question, occasionally piercing the background din. Like static. You know nothing. Correct, perhaps I was naive, and this impulsive venture will soon be too much for me. I donāt make a real, valuable contribution to the work of the clinical team. Suzie is right. What hope have I to make better the incurable, I cannot even reliably figure out what is wrong with them. A regular āsupervisionā walk one evening on the promenade by the sea with one of my close friends, Sam Murray whom I know from clinical training, does not resolve anything. Sam, like me also works at a state hospital in a deprived area. When I ask him what he thinks he contributes to his patientsā lives, in the darkness his answer is clearly audible over the sounds of the crashing waves.
p.8
āWhat do I do for my patients? I take bread off their tables. They pay ten Rand for a taxi, and then I cannot fix any of their terrible problemsā, he says looking out over the dark sea.
āDonāt give up too soon. Otherwise all hope dies too. Maybe that is all we can offer, Sam?ā is the best I can come up with.
We continue walking in silence. Despite my words of not giving up too soon, Sam is a braver man than I, to speak the unspeakable truth in this socially broken and disabled country.
Then, one day not too long after the walk by the sea, there is a breakthrough of sorts. Perhaps not everything is futile. Having completed my clinical psychology training and subsequent internship only five years earlier, my psychopathology knowledge after a few more years of practice is still OK. I can with reasonable confidence assess and recognise when someone is clinically depressed, or suffers from say an anxiety disorder, as opposed to transiently being emotionally not as well as can be. This morning proves there to be at least one genuinely useful contribution I can make at the ward round. A patient referred from the psychiatric inpatient ward located at the block next to us requires neuropsychological testing. Bedside cognitive testing on the ward suggested she was āslow in her thinking abilitiesā, and there is a suspicion that she might have a learning difficulty. There is some uncertainty about this diagnosis, though, which is whys she has been referred for testing. Mrs Jackobson (case # 16 in my notebook) arrives at our unit with one of the ward sisters to accompany her, and her husband. I introduce myself to Mrs Jackobson and her husband who has come to visit her. I explain that I would be performing a neuropsychological assessment, and what that entails. She looks at me with an expressionless face, like wax, the disinterest in what I had just said etched in sharp lines around her mouth. Mr Jackobson looks anxious and grateful. Mrs Jackobson silently nods her agreement to be assessed.
p.9
We do the history, and clinical assessment. Her voice is quiet, as if holding something terrible down. Mrs Jackobson had a head injury, was unconscious for a whole day and can remember nothing of the following week. She has since then been unable to return to her job in a shop. Clinical assessment of her psychological status reveals that she is apathetic, suffers from early morning awakening, hypersomnia during the day and has no energy. She overeats, has gained weight, lost her libido and feels irritable and sad. I give her a break, and have a word with her husband. He tells me her problems started after the head injury. Sobs while he tells me how life, which was already not particularly comfortable for them, imploded since her injury. I call Mrs Jackobson back and proceed to test her. The ward staff were right. Her total IQ on the Wechsler Adult Scale of Intelligence is 52, and the rest of the neuropsychological tests all at or below the second percentile. But I follow my gut feeling (or perhaps I am still haunted by the parting remarks of Suzie . . . ). Yes, Mrs Jackobson has severe cognitive impairment, and yes, she is very slow. The head injury caused some of that, I suspect. But the scores are too low to on their own explain her presentation. And additionally I think she also meets most of the diagnostic criteria for a major depressive episode. It feels good to be reasonably sure of someoneās presentation for a change. Though not nearly as good as the feeling of being helpful to someone, when she later pours her heart out to a stranger willing to listen to her story. Mrs Jackobson is trying to understand and process how she finds herself in this place rather than at home with her kids. Maybe I can help her and her husband develop some understanding of why she feels so terrible, and why, plus how, her brain does not work as well as it used to.
Help
Itās been several weeks since I saw Mrs Jackobson, but the huge, imposing face-brick hospital I enter each morning remains as psychologically impenetrable as before. I am walking towards our unit, negotiating the oncoming and passing human traffic. Navigating the corridors and the wards they eventually spit you out into, is easy to learn. Settling comfortably into this vast space of human pain and suffering, is quite something else. Being a visitor you get absolutely no sense of the emoti...
