Laughter

Dear Zahir,

Thank you for the opportunity to tell our stories and relay what our patients endure. Something about being a physician and hearing the worst of the worst kind of rubs off. It can really affect us and change us. We become a part of the patient’s suffering. We suffer too through their suffering. At first pass, this is tragic and can be hard, but then we can become grateful for it, strangely enough. If we allow ourselves to open, to really sit with their suffering, it can change us for the better. Ultimately, it can make us a more compassionate physician, which is kind of the point, right?

I remember being an intern on Emergency medicine rotation with you, my friend, Zahir. And we were little assholes in a sense. Just running around that Emergency Department seeing patients, learning on the fly, making mistakes, being humbled, laughing the whole way through. We had to cope somehow with the monstrosities we were witnessing. I remember this dude came in and I don’t even think either one us picked up this guy because he had abdominal pain and was retching unbelievably loud.  We heard it a couple times and didn’t make much of it. We were seeing other patients. But, as the night wore on this poor guy kept retching, loudly. It was after the fourth or fifth retch that we both kind of looked at each other and just started cracking up, for no reason other than the awkwardness of this poor guy’s abdominal catastrophe that was manifesting with super loud noises that the whole department could hear. It was kind of the same feeling you have during the calculus test in high school when the quiet math nerd lets out an awkward sneeze and you know you can’t laugh because it’s a test and you’re supposed to be quiet, but that makes it harder not to laugh so you just end up laughing harder than originally planned. I remember having weird mixed feelings about this poor retching guy. It was clearly funny at the time on a superficial level because I’m immature by nature and this sort of thing created the tendency for me to giggle inside. But, on a deeper level it bothered me. I recognized I didn’t know how to cope well. I felt guilty about it.

It’s funny now, because I’m older and I’ve got 3 kids and my two older girls sleep together. My daughter has a ‘phobia’ of her older sister retching. It actually happened once a year ago where she woke up feeling sick and began retching for a couple minutes before she vomited and it terrified her younger sister. She didn’t know what was going on at first. She didn’t like the noise. Instead of making her laugh, like it did me, it made her terrified because she’s a little girl and doesn’t have the defense mechanism built in yet of turning someone’s suffering into humor. On a basic concrete level, she didn’t want her sister to vomit and now any weird noise from Bea at night is sometimes misinterpreted as retching. This is our human tendency...we don’t want others or ourselves to suffer and we try to protect ourselves from it with laughter or with fear and avoidance.    

As I’ve become older in my practice now in neurology and caring for a lot of patients with epilepsy, I realize I’m no better. I still laugh at others’ suffering. But, it doesn’t bother me in the same way. I don’t feel as guilty and I’ve noticed I cry with them too. Let me tell you a story about an amazing patient I have that illustrates my sentiment.

He is an Iraq and Afghanistan war veteran. He was blown up at close range by an IED in Iraq, throwing him 30 feet into a brick wall. Miraculously, he didn’t die, but he was left with a right arm plexopathy, complex regional pain syndrome, ulnar nerve pattern weakness, cervical vertebral fracture, mild spinal cord trauma and has seizures thought to be related to his traumatic brain injury (TBI). Side note, his fellow soldier was blown to hell right next to him and died instantly.

I reviewed some of his records and saw that he had epileptiform discharges on EEG monitoring but that his ‘seizures’ were captured and found to be non-epileptic. Every neurologist’s worst nightmare, the dreaded epileptic seizures and nonepileptic spells in the same person. Anyways, I would periodically get calls from various hospitals’ emergency departments wanting to know what to do with his meds and management when he would present in status every 3 months. I finally got fed up wondering what the hell was going on, why he would go into status so much. I asked his wife to bring in a video of him in status. She did and I reviewed it and saw that the typical episode he was presenting for in ‘status’ was clearly a nonepileptic spell. So clear in fact that it made me laugh. The spell kind of looked ridiculous with his hips rocking and legs doing funny stuff and I wondered why his wife (or anyone for that matter) would think he was actually having a seizure.

He then told me how the last time he was in the ER they were holding his arm up and letting it drop in his face and gently poking his closed eye with a finger during the spell because they obviously thought he was putting them on and had some control over it. He didn’t think it was funny. I recollected myself and kindly explained to him that these episodes were not in fact seizures, but psychogenic nonepileptic seizures or spells, which is basically an exaggerated maladaptive coping mechanism to severe stress. It’s a form of dissociation where the body acts out the stored mental distress. It is seen often in patients with prior trauma, chronic pain syndromes and especially prevalent in people who have had sexual trauma as a child. Often in childhood these patients are forced to learn that dissociation from the here and now can be protective and shield them from further pain, but as they get older and their bodies’ continue to hold on to the trauma, it can manifest with abnormal movements or events that resemble convulsions. Of course, we all have physical reactions to the stresses we are put under. Interestingly, I see this quite a bit in “normal” patients without typical psychiatric comorbidities. There’s a hypothesis that their brains are networked differently, kind of like in ADHD. Finally, he looked at me bewildered for a sec and said, “yeah doc, I know that’s what it is...I was blown up by an IED and worse yet, I saw my best friend in the Marines blown up and bleed to death right next to me. I think most people who experienced what I saw would have weird events. My brain just kind of seizes up, but it’s psychological, I get it. Now, how are we gonna get the ER docs to stop poking me in the eye?!!”

This encounter changed my life, literally. You see, I always sort of knew from my training that nonepileptic spells and various other types of conversion disorder were an exaggerated coping mechanism to stress, and quite honestly, they’re funny to look at when you learn to recognize what they are. Seeing these events in people pointed me down an interesting pathway of leading to the deeper riddle of what the heck is conscious, anyways? Some patients are aware during the episodes and some are not. There’s a fine line and often the line is blurred. What sort of network activity is going on to allow this altered state to take place? It’s sort of like the prefrontal cortex is under anesthesia, but the rest of the body is still getting messages to shake violently. Is the default mode network, a set of connected locations involving emotional and memory centers, which gives a human being a reference of ‘self’ taken offline during these events? The person’s sense of self is clearly altered, but how does this happen? Furthermore, how do we approach a meaningful therapy that addresses the individual’s feelings and emotions surrounding the self? These are interesting questions. What I realized slowly is that we all have these events at different times in our lives and for different reasons, but on a spectrum. What my patient so thoroughly taught me is that the more severe events can happen to anybody, even war heroes... and furthermore, these people aren’t crazy. This is a phenomenon that happens to everyone, it just happens on a spectrum. And the more severe the trauma, with more of an individual tendency to dissociate from the pain of the trauma, it’s not surprising to see more severe events. What these events really speak to is that blurred line between mind and body. Ultimately, there is no line, the mind and body are an interconnected process and these events illustrate this concept in a tangible way.

The other thing I didn’t say yet about this patient is that he is the CEO of his own company whose motivation is to get veterans back in the work force. He pairs vets with specific skills to jobs they would thrive in. He sets them up for success. He works with various businesses in the area and networks to find the best fit for his people. He sees a counselor for PTSD and he is treated with different neuropathic pain meds, anti-epileptic drugs and medical cannabis for his chronic pain, mental health issues and for seizures. This man has literally gone through hell and continues to go through hell every day yet continues to make opportunities for other people. He is literally my personal hero.

What I realized is that the laughing is part of being the witness to human suffering. It’s our coping mechanism because sometimes it’s too much, we just have to laugh. But, it’s not a malicious laugh...it’s sort of a cosmic giggle, you can’t help it. It just comes out. That’s ok. That’s part of being a doctor or healer or whatever. If you can’t laugh at what you see, then there’s a problem. And the other thing I realized is that these patients are not crazy. Or let me rephrase that...maybe we’re all crazy and they are no different. Think of the last time you fought with your spouse or the first time you really fell in love with someone. I remember fervently believing that Dave Matthews was brought into this world for the sole purpose of writing a specific song that described perfectly my feelings for my future wife. I literally had that thought. Think about your dad’s weird tendencies or that freaky uncle or whoever. We’re all batshit crazy at different times but these folks with spells and conversion disorder are no different. And when you hear what they have to say, it tends not to make you laugh, it makes you cry, because it’s usually a story of impossible suffering. The childhood sexual trauma patients are the worst. For me as a caregiver, that’s the hardest thing to deal with. I just imagine them so helpless. So, cry when you hear their stories, laugh when you see their events, but then look them in the eye, tell them they’re not crazy or crazy just like you (whichever you prefer) and give them a hug or offer some kind words. That’s usually the best treatment...just being there to offer support and to understand that they have suffered, we’ve all suffered and that on some level that is what connects us, which is pretty amazing.

-Charlie Braun

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