Courage

I met a man with ALS today. That's Amyotrophic Lateral Sclerosis, or Lou Gehrig's Disease. It causes progressive demyelination of your lower motor neurons; bit by bit, you lose the ability to use your muscles and they weaken and atrophy, though your mind remains completely unaffected. It is irreversible. And fatal.

We just finished a section on neurology, got to meet some "real" patients in the Clinical Skills Center today (as opposed to the actors who we usually see there). Each had a different type of neurological problem: cerebellar atrophy, myasthenia gravis, Parkinson's disease, Guillain-Barre syndrome, stroke. Learning from these patients really made the information stick. I know I have read that treatments for Parkinson's can actually give patients dyskinesia (involuntary movements), but I will never forget seeing the woman today who, having taken her medication an hour earlier, had exchanged the slow shuffling gait and other movement difficulties of Parkinson's for the constant tic-like motion in her arms and legs.

Then we entered the last room, and were instructed to do a motor exam on the man sitting in front of us, who appeared to be approximately 50. His arms were strong - normal biceps and triceps - but his fingers were weaker in comparison. His thighs showed normal strength, but his lower legs and feet did not; he could not push down on the student's hand with his foot, or lift up his foot at all. The physician in the room mentioned that, normally, a good way to test strength in all the leg muscles is to have the patient stand up and then do a squat, but that this was not an option in this patient. Oh no, I thought. I think I know what this is. Please, please let me be wrong.

No such luck. The patient told us that he started noticing weakness and cramping in his legs about 18 months ago. He now has a diagnosis of ALS, and the loss of muscle control continues spreading up his legs and is beginning to affect his hands and wrists.

He told us his story calmly, and got a kick out of the fact that he knew the steps of the motor exam better than we did, as he has been examined by so many neurologists at so many different institutions. He was incredibly generous to allow group after group of students to practice their skills on him. If he saw pity or distress on our faces, he did not show it. In his case, it is not just the clinical findings but his courage and grace that I will remember.