Monday Evening, Case 3

This a referral from a local rehabilitation hospital. The patient is a 61 year old gentleman who had a recent myocardial infarction while at work as a computer programmer. Someone at work attempted CPR and started chest compressions. When the EMTs arrived an external defibrillator was repeatedly used in order to restart his heart. After 25 minutes and five shocks with the defibrillator, a cardiac rhythm was reestablished; unfortunately, the patient's brain had been hypoxic for an extended period of time. The physical effects of this incident were minimal (no paralysis or motoric weakness), the cognitive effects; however, were profound. Upon meeting the patient the patient's mental confusion was very evident. He had a bewildered expression on his face, and his eyes darted around the hospital room attempting to make sense of his current situation and surroundings. I introduced myself to him and he said "Who's Dr. AH?" I said "I am." He responded "Who's Dr. AH?" This exchange happened so many times that it became an Abbott and Costello routine ("Whose on first?"). The clinical interview revealed an individual with severe receptive and expressive aphasia, impaired short-term memory, distractibility, dyslexia without dysgraphia, and either prosopagnosia or a visual apperceptive agnosia. He also exhibited an environmental dependency syndrome, temporal disorientation, and geographical disorientation. He was unable to recognize members of his family, he kept taking off his portable external defibrillator; and he would raise objects up to his nose and sniff them intently, apparently trying to determine what the objects were and if they were edible. When shown a photograph of a recent family reunion, he was unable to recognize himself. "Who are these people?" he asked.

Monday Afternoon, Case 2

This afternoon I travel to the home of a 91 year old patient. This is a new referral and I have no information about the patient--just the name and address. As I park in the driveway, another gentleman is leaving, he looks distraught. I approach the front door, and am greeted by elderly woman in a nightgown. I ask if she is the patient, "No" she answers. She invites me in and introduces me to her mother who is laying on a daybed. The house is clean but decorated with a cacophony of family photographs, dolls of various sizes, decorated Easter eggs, and an artificial Christmas tree. The tree prominently fills the corner of the dining room and it is so covered with ornaments that the limbs of the tree are concealed. The patient slowly sits up and glares at me. "Who let you in? Are you here to kills us?" I try to introduce myself but the patient continues her verbal barrage--"What did you take? Are you here to steal my things? Is that a gun? Do you have a gun?" I attempt to calm her, but she only becomes more agitated. The other woman, the patient's 66 year old daughter, tries to intervene. "Shut up you!" yells that patient. The patient begins to pace, accusing me of stealing, plotting to kill her, planning to take everything that is hers. She briefly leaves the room and returns with a metal quad-cane. She approaches me and begins to brandish the cane in my face. Her daughter tries to appeal to her, but the patient quickly includes her into a conspiracy of her own making, we are now both part of the plot to kill her. "I'll knock your head off!" the patient screams, then she swings the cane at me, indeed aiming at my head. She then lashes out at her daughter with kicks, followed by a swing of the cane. "I'll call the law! You're a bunch of thieving bastards! I'll cut your heads off!" Her face is contorted in anger, her eyes are glazed with hate, and spittle runs down her chin. The daughter is apologizing for her mother's behavior; she pleads, "She only gets like this sometimes." A granddaughter with her two children enter the front door for a family visit, but they are not recognized and are immediately assimilated into the patient's self-derived conspiracy. The great grandchildren have "evil intent" in their eyes, and she waves the cane at them. The granddaughter is the one who "contacted" me and "let [me] in." She swings again at me with the cane and tries to kick, then bite, her daughter. The granddaughter and grandchildren leave, the children looking a little un-nerved . The patient begins to relax and says that if I am to be "friends with her daughter" that is fine with her.

Monday Morning, Case 1

Mondays start the same, I travel to a patient's house to provide cognitive rehabilitation and psychotherapy. This individual was involved in a head-on automobile collision with a drunk driver some 20 years ago. He sustained a significant brain injury that involved the frontal precortex, or the so-called 'dashboard' of the brain. He was in a coma for several months following this unfortunate accident, and he was left permanently disabled as a result of his injuries. If seated and involved in casual conversation, he may appear a bit guff, but most of his cognitive deficits would go unnoticed. When he attempts to walk, or tries to manipulate objects with his hands; however, limitations in his ability to coordinate purposeful movement become painfully apparent. Today we are planning to build a game board for the game "Othello." The board that he currently has uses small glass beads for the game pieces, objects that are very difficulty for the patient to place accurately on the game board. A trip to several stores and we have some pegboard for the game board and golf tees for the game pieces. We then discuss the dimensions for the board and discuss how to elevate the board so that the golf tees will stand perpendicular to the board. We consider the pros and cons of raising the board versus shortening the golf tees. After drawing the dimensions on the pegboard we play a game of chess. The patient beats me once again--he played chess for ten years prior to his accident, I, on the other hand, am a novice player. After the game I tell him that I noticed how he staggers his pawns in order to defend aggressive attacks, and he beams with pride that he has taught me something. Most people (family included) familiar with this patient treat him like a child and only put up with him for a minimum amount of time. He is discredited by others, viewed as 'damaged,' and considered a burden. He is frequently socially inappropriate, occasionally responds to others with sexually explicit comments, and becomes temperamental when his needs are not immediately met. He reminds me of fraternity brothers in my past.