The Origin of the DNR Order

By MTSOfan on flickr; click for original

I recently came across an interesting podcast interview with Dr. Mitchell Rabkin, a distinguished internist and former president of Beth Israel Hospital. The interview was conducted in the context of the 40th anniversary of his landmark paper, Orders Not to Resuscitate. Dr. Rabkin discusses the historical context–how medicine was practiced in the 1960s, when he was a resident at MGH–along with the development of DNR orders and the ethical discussions (and lack thereof) surrounding it.

Neurologists are often called upon to prognosticate with the intent to use our assessments to justify, if not a transition to comfort-oriented cares, at least implementation of DNR orders. Occasionally, there is pressure to render a grim prognosis when prudence would require acknowledgment of a bit more uncertainty. I liked this interview because it serves as a reminder that medical practices change dramatically over time–what we take for granted today was once novel. This perspective can be helpful when navigating the challenging clinical and ethical situations that arise in our specialty.

The video interview (41 min), along with a transcript and podcast link, can all be found here.

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Novel Research Methods

Here’s two interesting articles I’ve been saving up, both on the theme of studying the brain from an unusual perspective:

1. Could a Neuroscientist Understand a Microprocessor?

This is a fun and controversial (among neuroscientists) paper. The authors reverse-engineered an old microprocessor–the ones used in the Atari Video Game System and the old Apple 1 and Commodore 64 computers and then subjected it to various investigations such as “lesion studies”, connectomics, and tuning properties of the type commonly used in neuroscience. The “behaviors” being studied were whether the system would successfully boot up Donkey Kong, Pitfall!, or Space Invaders–very old friends of mine. Their premise is that their model system is one in which they know with perfection the electrical state of every transistor and the entire pattern of connections (its “connectome”). They were unable to predict the behavior of this perfectly-understood system using neuroscience methods, and raised the question of whether that has any implication for the validity of contemporary methods in neuroscience research, such as the study of EEG spectra, fMRI, etc.

2. To Unlock the Brain’s Mysteries, Purée It

This is a New York Times piece about Suzana Herculano-Houzel, a Brazilian neuroscientist now at Vanderbilt. She had the brilliant idea to ascertain the number of neurons and glia in brains not by counting them up on small histological slices, but by puréeing them, staining the neuronal and glial nuclei with different stains and counting the nuclei. She thereby arrived at very different estimates about the number of neurons and glia than was previously reported, and she has interesting ideas about brain size and neuron counts in humans vs. other animals.

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Humanism in Neurology

Whenever I find myself growing grim about the mouth; whenever it is a damp, drizzly November in my soul; whenever I find myself involuntarily pausing before coffin warehouses, and bringing up the rear of every funeral I meet; and especially whenever my hypos get such an upper hand of me, that it requires a strong moral principle to prevent me from deliberately stepping into the street, and methodically knocking people’s hats off—then, I account it high time to get to sea as soon as I can.

—Ishmael, Moby-Dick

Or, if one happens to be a neurologist feeling mired in ACGME, GMEC, TJC, LCME, OSCE, and other such things, it’s high time to reconnect with the humanistic aspects of our venerable specialty. I recently came across an oldish (2001) “special article” published by the AAN’s Ethics, Law, and Humanities committee: Humanistic Dimensions of Professionalism in the Practice of Neurology. This short paper is well-worth reading; it might even count as a “wellness activity!” Below I’ve quoted a few choice passages (emphasis added):

To encourage neurologists to resolve time pressures in their patients’ favor, and to help dispel the false and destructive notion that humanistic practices are now expendable inefficiencies, the AAN Ethics, Law, and Humanities Committee here summarizes humanistic professional attributes we consider intrinsic to good neurologic practice.

1. Developing an understanding of the complex and elegant workings of the human nervous system in health and disease.

3. Appreciating the necessity to approach the whole patient, rather than focus exclusively on what ostensibly is the “presenting” problem.

4. Recognizing that understanding the patient’s narrative—as told by the patient or, if necessary, by others—is essential to successful treatment. The neurologist should strive to understand the inner experience of patients, the meanings they attach to illness, and their personal values.

5. Appreciating that a precise and detailed neurologic examination personally performed can create a strong bond between patient and doctor.

6. Remaining sensitive to the perceptions of neurologic disorders that exist in the minds of patients and their families. Patients and families often respond with dread and a sense of helplessness to the disability produced by these disorders, and their uncertain implications for the future.

10. Understanding that neurologists should play a pivotal role in defining and administering high-quality palliative and end-of-life care.

Coincidentally, with respect to that last point about palliative and end-of-life care, ” . . . the AAN has decided to retire its 1998 position on ‘Assisted suicide, euthanasia, and the neurologist’ and to leave the decision of whether to practice or not to practice LPHD [lawful physician-hastened death] to the conscientious judgment of its members acting on behalf of their patients. The Ethics, Law and Humanities Committee and the AAN make no attempt to influence an individual member’s conscience in consideration of participation or nonparticipation in LPHD.” Here’s the link to this new position. I’m thinking that this topic would make for an excellent journal club: Is physician participation in hastening death indeed humanistic?

Let’s not end on a heavy note, however. Each year, the AAN gives out an Award for Creative Expression of Human Values in Neurology.  This year’s winner is a former mentor of mine, Dr. Madaline Harrison at the University of Virginia. She wrote a sweet essay, The 9 o’clock patient, that nicely shows her understanding not only of her patients’ neurological conditions, but also of their relationships and sources of meaning in their lives. Some of my other favorites from this past year follow:

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A Claw (Hand) by Any Other Name

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By Photo: Myrabella / Wikimedia Commons, Public Domain, https://commons.wikimedia.org/w/index.php?curid=23806944

A timely Christmas blog post! At an MS2 session yesterday, we discussed the following practice question:

Blunt trauma to the elbow may lead to the development of:
a) Wrist drop
b) Weakness of the abductor pollicis brevis
c) Claw hand or benediction sign
d) Ulnar deviation of the hand
e) Poor pronation of the forearm

There ensued a somewhat confusing (because of my own confusion) discussion of what exactly is a benediction sign, is it different from a claw hand, what specific muscles are involved, etc. We’ll take a deep dive into that below, but first let’s just address the test question itself.

Blunt trauma to the elbow will most often injure the ulnar nerve. The ulnar nerve lies in a little groove between the medial humeral epicondyle and the olecranon. Partially flex your elbow to stretch the nerve a bit and then run your fingers in there and tap on the nerve; you’ll feel a little zinger in the medial hand. The median and radial nerves run deeper in the arm and aren’t typically injured by minor elbow (“funny bone”) trauma. So, we know that we’re looking at the answer choices for an ulnar nerve lesion.

When caused by a peripheral nerve lesion, wrist drop is due to injury of the radial nerve, so a) is out.

Abductor pollicis brevis is innervated by the median nerve, so b) is out.

Ulnar deviation of the hand (most apparent upon attempted flexion at the wrist) would also be due to a median nerve injury. Why? In a (proximal) median nerve lesion, there is unopposed action of flexor carpi ulnaris (ulnar nerve), pulling the wrist medially / to the ulnar side. In contrast, an ulnar lesion would result in unopposed action of flexor carpi radialis (median nerve) and would pull the wrist laterally / to the radial side. Thus, d) is out.

Finally, weakness of pronation is also a median nerve lesion, because pronators teres and quadratus are from the median and anterior interosseus nerves, respectively (the latter is a branch of the former). So that rules out e), leaving the answer as c) Claw hand or benediction sign.

So now let’s talk about the claw hand: Continue reading

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Neuropathology

I’ve always had a place in my heart for pathology—the fundamental basis for allopathic medicine. By this I mean that in diagnosing and treating disease, we’re concerned with the structure and function of the body’s organs and systems, their pathological disruptions, and the biochemical and genetic bases for such. I don’t mean to downplay the importance of patients’ emotional experiences, existential challenges, family dynamics, and other personal and social aspects of health and disease; these are important too. But what we are not concerned with is balancing the four humors or regulating the flow of qi.

Even in psychiatric practice, one of the first tasks in any diagnostic evaluation is to rule out an “organic” cause of the patient’s mental or behavioral dysfunction. This raises extremely interesting questions about structure-function relationships in the brain—is there truly a difference between “organic” and “psychiatric” disease, or is the latter just a brain disorder where the underlying structure-function relationships haven’t been fully elucidated? These sorts of questions are in part what drew me, and many others, to neurology, but that’s a topic for another day.

The bottom line is that if one is going to diagnose and treat disease in the allopathic paradigm, one must have at least some grasp of pathology. I actually spent a year as a pathology “fellow” between my M2 and M3 years and can attest that it was very helpful in understanding the diseases I later saw on the wards. There’s a huge difference between say, reading about congestive heart failure vs. actually squeezing with one’s own fingers the edema fluid from the lungs of a deceased CHF patient, or feeling and hearing the scalpel scrape and cut through his atherosclerotic coronaries. Similarly, directly inspecting a brain’s purulent meninges, its atrophic gyri, its depigmented midbrain, its foci of infarction, etc. brings a greater depth of understanding than simply reading about these conditions or viewing the pathologies on MRI.

To that end, I want to encourage residents to take advantage of learning opportunities in neuropathology. At our institution, we’re fortunate to have a neuropathologist with over 30 years of experience teaching residents. He has dozens of gross “museum cases” and clinico-pathological case reports and hundreds of slides, all with accompanying explanatory material for self-study. And we have brain cutting twice each week, which also serves as a reminder that we should refer our deceased patients for autopsy when appropriate—again, MRI doesn’t have all of the answers.

The specific purpose of this post is to bring to the residents’ attention an outstanding web resource for neuropathology. It’s an online textbook / lecture series / self-assessment tool developed by Dr. Dimitri Agamanolis of Akron Children’s Hospital and Northeast Ohio Medical University. The meat of it is a series of chapters on neurocytology, hypoxic / ischemic injury, CNS infections, demyelinating diseases, etc. Most of the chapters have an embedded video lecture that’s also accessible on Vimeo, but the material can be perused by reading alone if desired. Clicking on the thumbnail photomicrographs reveals enlargements with detailed captions. Most chapters have an associated quiz, and I think that working through all of the chapters and all of the quizzes would be great preparation for the RITE and boards. This is a very high-quality resource that Dr. Agamanolis has graciously published to the web for free; I wish to extend to him my thanks!

(I added a link to the site in the main menu above, under Clinical Neurology Resources→General Neurology).

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Neuroimaging

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Von Hellerhoff – Eigenes Werk, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=20045205

Question: An 8 year-old girl presents with cognitive delay and incoordination. What is the diagnosis? See below for the answer.


It goes without saying that neurologists must learn to interpret radiographic images; residents look at so many CTs and MRIs that it’s almost impossible not to develop some competence in this area. It’s important to develop, like our neuroradiology colleagues, a systematic approach to image interpretation–one can’t just scan the DWI or FLAIR images for areas of bright signal. Moreover, and as the senior residents are well aware, the RITE has a bunch of unusual imaging questions like the one above; indeed the exam includes a whole booklet of questions based on radiographic and pathological images.

Residents might find a recent Continuum issue on neuroimaging to be a helpful resource. It has an introductory chapter on MRI physics, and goes on to cover advances in stroke imaging, imaging patients with epilepsy, brain tumors, spinal cord disorders, etc.

There’s a particularly good chapter on imaging congenital malformations. This high-yield chapter covers a lot of topics pertinent to both pediatric neurologists and adult neurologists taking the RITE and boards (i.e. just about everybody). In addition to being a very good issue in general, that chapter would serve very well for test preparation.

Finally, here’s a link to an interesting podcast episode from The Guardian’s Science Weekly (episode 28). It covers the history of MRI and includes a digestible explanation of MR physics.


Answer: Dandy-Walker malformation. The cerebellum is hypoplastic. The fourth ventricle and posterior fossa are enlarged, and the cerebellar remnant is displaced superiorly.

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Exam Videos

Dr. Hal Blumenfeld’s book, Neuroanatomy through Clinical Cases, is a great introductory text for neurology residents. It’s comprehensive, yet quite readable, with lots of superb drawings and illustrative cases. I think it occupies the space between Berkowitz’s Clinical Neurology and Neuroanatomy, (a new book that I recently reviewed here), and Brazis’s classic, Localization in Clinical Neurology. The former is particularly well-suited for beginners—students, interns, and junior residents who want a concise introduction to their future specialty; we give a copy to our PG1s. The latter is still my go-to for what I call “micro-localization”—when I need to refresh my memory on some precise neuroanatomical detail. It’s best digested in small chunks; we’re using it for book club this year.

Blumenfeld fits nicely between those two. It’s longer and more detailed than Berkowitz, but the layout and case discussions make it easier to digest than Brazis. Our residents are using it for their resident-led lecture series this year.

Recently, I discovered that Dr. Blumenfeld created an online companion to the book in which he demonstrates the neurological exam in a series of short videos. These are available on the web, for free, here. There’s also a longer video that includes an entire exam, but that one is gated; I assume you get access if you buy the book.

These exam videos are a great resource—there’s a big difference between reading about how to do the exam vs. seeing it done by an expert. For example, embedded below is the video on oculocephalic testing, and I added a link to the main webpage with all of the videos on the menu above, under Clinical Neurology Resources → General Neurology.


Two other video resources I’ve mentioned before (and that are also accessible via the menus above) are the Neuro-Ophthalmology Video Education Library (NOVEL) and the International Parkinson and Movement Disorder Society video library. The latter one requires a membership, but this is free for residents; the signup page is here.

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Pointing Towards Virtue

Image result for finger pointing at the moon koanThe 2017-18 year is underway, and this is usually the time for orientations, “boot camps”, links to useful resources, etc. I have some some of the last queued up for soon-to-follow posts, but first wanted to address a deeper matter.

A few weeks ago, I received a survey about character education in residency. It was comprised of questions like “Where in your residency program do trainees learn virtues such as honesty and integrity?” I found this line of questioning to be exasperating on a few counts. First, residents are adult learners—not schoolchildren. I presume that they will have developed their moral virtues well before entering residency training (at an average age of around 30). When and from whom do they learn moral virtue? Years prior, from their parents, school teachers, coaches, clergy, etc.

Moreover, to whatever extent people are lacking in certain virtues by the time they reach adulthood, they are not going to acquire them in a residency program—that ship has sailed, I thought.

Finally, I resented the implication that moral virtue could be codified as a set of behaviors or “competencies” to be checked off a list as part of yet another training milestone. If anything were to exemplify what I previously termed “competency theater“, this would serve splendidly.

And yet, as we roll into month #2 of this new year, I think that my initial reaction to this moral inquiry may have been too flippant. Consider that the Greek origin of  “character”, kharássō, means to scratch or engrave. It implies a process and not a fixed state—a process that, over time, imparts one with distinctive traits. Are residents not amenable to ongoing engraving of character? Aren’t we all?

Furthermore, it perhaps should not be taken for granted that virtues developed in the context of family life, grade school, etc., will always manifest in the context of residency training. This might be especially true when the virtue hasn’t really been tested before. Some young people might not yet have been in situations where they must choose whether or not to subordinate their own interests to those of another, or whether to be fully honest at the risk of great personal embarrassment or inconvenience. We all presumably learn about the moral virtues during our upbringing, but actually becoming virtuous in daily practice is the real challenge (and one that I don’t claim to have fully achieved).

There’s a Buddhist teaching, depicted above, that applies well to this crucial difference between the abstract knowledge of moral virtues versus their exercise: Imagine that someone is trying to show you the moon by pointing to it. One should not focus too much on the finger! With that caveat, following are some examples of how character is tested in the context of residency training; I hope that residents will find them to be useful pointers.


Humility. Neurology has become a very interdisciplinary field. Forget about the simplistic old saw that “The nurse can be your best friend or your worst enemy.” Today, we work with nurses, pharmacists, physical therapists, occupational therapists, speech/language pathologists, respiratory therapists, dietitians, social workers, case managers, etc., etc. Many of the above have graduate-level education, some doctorate-level. Most have years of experience—certainly more experience in their respective fields than a resident has in neurology. And regardless of age, each person is an expert in his or her area. I’m now PGY18 and have cared for thousands of stroke patients but I’m not as good at assessing the functional status of a stroke patient as my OT colleagues. And I’ll never be as good as they are, just like I’ll never read brain MRIs quite as well as our neuroradiology colleagues.

Therefore, when a nurse, therapist, pharmacist, or other member of the treatment team raises a concern or provides new information, it’s important to listen, consider the information on its merits, and integrate that into the case formulation. We must resist the urge to reject the information because it came from someone other than a physician (arrogance), because it doesn’t comport with our previous understanding of the patient’s condition (anchoring bias), or because acknowledging it would mean that we were wrong about something (denial).

That last point deserves emphasis: It’s OK to be wrong, as long as we remain open to correction! I know that doesn’t comport with our years of high school → college → medical school acculturation, where the point of the game, it often seemed, was to supply correct answers. But now we’re in a very different setting, where there are fewer right / wrong answers to be supplied and more assessments and plans to be made. EVERYBODY makes a sub-optimal judgment from time to time and it’s especially ridiculous to think that a PG2-4 neurology resident should be perfect in this regard. Our main mission is to take the best possible care of our patients. If there’s a piece of information or a perspective that might advance our patient’s care, we want to incorporate that as soon as is appropriate. And besides, resisting an opportunity to optimize a patient’s care or correct a mistake is much, much more injurious to a physician’s reputation than is the fact that he or she was once wrong about something. 

Honesty. Imagine a case1Perhaps this scenario seems too obvious or egregious to be true, but trust me—this kind of thing happens. where a patient presents to the ED one afternoon with a thunderclap headache and left-sided tingling. Exam is normal. CT shows no hemorrhage. CSF is colorless. Because of the focal symptoms and high-risk nature of the case, the patient stays in the ED’s observation area pending an MRI. The plan is to treat the pain, observe for some hours, and, if the clinical course and MRI/A/V are reassuring, discharge home with outpatient follow-up.

The next morning, the patient feels much better but the MRI still hasn’t been done. The ED resident informs you that the patient can only stay in the obs unit for a couple more hours—if more time is needed for the workup to be completed then he’ll need to be admitted. You make some phone calls and arrange for your patient’s MRI to be done next.

The ED resident calls again to report that the MRI is done and time is running out for an obs stay–a decision must be made now. You look at the MRI yourself (kudos!) and it looks OK. The prelim read is normal too. You call up your attending to explain that the patient is teed up for discharge, and he asks, “Do we have a final read on the MRI?”

Aaaargh! A final reading is going to take more time, and then you’ll be stuck admitting the patient only to discharge him a couple of hours later—a hassle for you both. And really, what’s the chance that the final read is going to be substantially different than the prelim? So, “Um, yeah, the MRI was read as normal,” you say. It’s sort of true, although not really. The patient goes home. And then the neuroradiology attending calls your attending a few hours later to report that they found a 2mm acomm aneurysm on the MRA. “Did that patient get discharged? We may need to bring him back . . .”

Always be honest—it’s best for the patient and, although it might not always seem that way in the moment, best for your reputation as well.

Kindness. It can be seemingly difficult to practice kindness while immersed in a challenging training program, or while running a busy clinical practice, or while managing a chaotic (e.g. child-rearing) household, or . . . you get the idea. But here’s a nice paradox: Being kind to your patient or colleague (or a family member, or perhaps especially to a stranger) is a reliable way to reduce both their suffering and yours.

And it can be really easy—I’m not talking about committing to 10 hours a week of volunteer work on top of everything else on your plate. Very simple things can go a long way: You took off the patient’s socks to check for Babinski’s sign? Put them back on. Carefully. Offer to cover her back up. Don’t forget to turn the TV back on if you turned it off. Did the nurse come in and silence the beeping IV while you assessed the patient? Thank him! Right then and there, in front of the patient. When the patient sees that you respect your colleagues, she’ll know that you respect her too. She will feel better about her care, and she will remember! She may not remember half the things you educated her about with respect to her stroke, but she *will* remember that you were kind. And once in a while, a patient will express to you, long after the fact and long after you’ve forgotten about it, her appreciation for that kindness. These are among the moments that sustain a medical career.


Obviously, this is a very limited list of virtues; please feel free to offer additional thoughts in the comments. I’d also be happy for interested residents to author guest posts. If nothing else, I hope this will get us thinking explicitly about the kind of physicians, and indeed the kind of people, we want to be.

Notes / References   [ + ]

1. Perhaps this scenario seems too obvious or egregious to be true, but trust me—this kind of thing happens.
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The Beautiful Brain: The drawings of Santiago Ramón y Cajal

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Public Domain, https://commons.wikimedia.org/w/index.php?curid=612581

Santiago Ramón y Cajal is one of the founding fathers of neuroscience. He was the foremost proponent of the neuron theory–that the nervous system is composed of interconnected but individual neurons as opposed to a continuous reticulum of nervous tissue. This conclusion stemmed from his use of the Golgi stain, which randomly stains only a fraction of the cells in a tissue sample, allowing for their individuation. He and Golgi shared a Nobel prize for this work.

Ramón y Cajal was a fantastic artist whose drawings elucidated the structure of the nervous system; the picture above shows two Purkinje cells and a few granule cells from a pigeon cerebellum. There’s now a traveling exhibit of his neuroanatomical work, with an accompanying book. It looks to be a terrific exhibition; here’s a New York Times review, which includes several more wonderful drawings. If you happen to live near one of the tour stops it might be well worth a visit.

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A Zebra for Our Times: Transient Smartphone Blindness

By Japanexperterna.se from Japan – Person looking at smartphone in the dark, CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=47395025

Here’s a neurological oddity to be aware of: Transient smartphone blindness. Per a case report in this week’s Green Journal:

When a patient lies on one side, the ipsilateral (lowermost) eye becomes functionally occluded (e.g., by a pillow) and its retina maintains adaptation to the ambient light level or may become relatively dark-adapted. Meanwhile, the contralateral (uppermost) eye becomes light-adapted while it is used to view the device, which illuminates the retina to a greater degree than ambient light (this differentiates the scenario from book reading). After the patient stops using the device and transitions to binocular vision with both retinae exposed to dim ambient light, she perceives normal vision with the dark-adapted eye but temporary blindness in the light-adapted eye.

It’s easy to see how this could be misdiagnosed as a retinal TIA, retinal migraine, functional disorder, or even MS as per the case report.

Update: Here’s an interesting and humorous commentary on the phenomenon, courtesy of Dr. Michel Accad.

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