Getting Over It

Yerevan

Yerevan

I’ve returned to Vermont, but I’m not letting go of Yerevan. There’s something about this city, at once wide open to imagination, and rife with wicked problems. It’s responsibility, not disaffection, that drives the breakup–I’ve got to return to my post.  But I don’t want to get over Yerevan.

Case. 5 month old with recurrent intracranial hemorrhages–can you help us with this problem? The neurosurgeon opens up the CD for us. The hemorrhages are sub- and epi-dural, bilateral, of varying ages. The collections undoubtedly explain the child’s hypotonia, even as he looks alert, tuned in. Whatever the cause, there is no fix, other than tender loving care. The child’s brain will have to heal itself up. “Hypotonia is the least of this child’s problems” says the surgeon.

Why these hemorrhages? No known trauma or bleeding problems. But “non-accidental trauma,” as the euphemism goes, typically presents with the history “no trauma.” I suggest long bone films, an eye exam, for evidence of mistreatment. My colleague looks doubtful. “No, we don’t see this … because in Armenia, children are gold” she responds. They are gold everywhere, I think, even if parents, in non-accidental fits of physical rage, sometimes forget.

Brain injury in abused infants stems ultimately from an interaction that, while not accidental, has lost track of its intent. The caretakers’ anger blinds them to their responsibility to get over frustration, to not let a tempest in their brain’s limbic system shut down their restraining frontal lobes.  I’m sorry for the jailed parents who lost their moral compass in an emotional storm, and for their battered children.

Gohar Droshagiryan's Drawing for Like Water On Stone, animation of Dana's novel.

Gohar Droshagiryan’s Drawing for Like Water On Stone, animation of Dana’s novel.

Getting through such a storm, autonomically speaking, is a journey through some woolly peaks and valleys, and it’s a little different for each of us. You can divide us according to the alacrity with which our stress responses erupt with sweat, fear, and pounding heart, and how quickly they simmer down. If we quarrel, I may have thought things through (all right, you apologized, I accept …) before you’ve really settled down (but I’m still upset about it and we’ll both just have to deal with that until …“)? Reconciliation doesn’t happen all at once.

Case 3 year old boy, losing weight, and hakarak, aggressiva–increasingly contrary and aggressive. But his weight seems OK, and he won’t let go of the doctor’s chocolate snacks for the gait examination. Off to play therapy. Play, among other things, is a good way to learn how to go in and out of frustration in peace.

Neuro-responsibility. At what age do we lose that gold, that innocence that should assure us respect as children? And how can we verify the capacity for knowing intention that makes us responsible, culpable for our mistakes? In the 19th century, there was a trend for some poor mothers to plead temporary insanity when their babies were found murdered. And the juries were sympathetic.

Temporary insanity was a well-established legal defense in Europe–a gift of the psychologists to the lawyers you might say–when, in a Berlin street in 1922, an Armenian shot and killed Talaat Pasha, one of the primary architects of the Armenian genocide. The assassin was acquitted–temporary insanity. His defense lawyers made the case with photos and narratives of a horror whose legacy was still in its infancy. That trial brought Armenia as close as it ever came to a proper public disgracing of its frenzied murderers. The evidence gathered became a study guide for Raphael Lemkin, who later coined the term genocide.

Music. Aram, my oud teacher, has brought his duduk-playing friend Sevada so that I can purchase one of his duduks for Jeff, back home. A flute made from an apricot tree, and resonated by a bamboo reed, the duduk makes one of the most soulful sounds you can hear. Before we close the purchase, Aram and Seva play Hov Arek, Come Breeze, by Komitas, who is said to have been driven insane following his imprisonment in Istanbul in 1915. It pulls my heartstrings, this tune, and I pull back. I keep re-playing it, but I still haven’t gotten over it.

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Dance Dana shoots her left foot out 3 feet behind her and the young man passing by almost trips over her leg. He better watch out, the women are dancing Madzoon, “stirring the yogurt,” in a circle at the Naregatsi Center, where a hundred dancing bodies are heating up with Armenian rhythms. We greet our dancing buddies, who take our hands again.

Intensive Care. A one month old with seizures, absent corpus callosum–the problem is ultimately genetic, though chromosomes were normal. What about a DNA test? In clinical work, genetics presents a jagged coastline–the closer you come, the longer it gets. You couldn’t explore all its fjords in a lifetime.

“We have one more case for you.” This 12 year old girl’s delicate face is marred by a naso-gastric feeding tube-she has been vomiting for 20 days. No other symptoms–“the story is long, and yet with nothing else to tell” say my colleagues. I find a watchful, thin girl with no nystagmus, a normal exam. This can’t be labyrinthitis. GI workup was extensive, negative. As I coax her to sit she abruptly falls back, eyes close, pulse steady. In 3 seconds, she wakes up, fluent. “What is this?” asks the intensivist. Conversion Disorder–psychosomatic. One doctor says this is rare in Yerevan, but I wonder if he’s really stepped back to measure.

Performance Review. To teach, alas, is to judge. When a trainee seems weak, our responsibility to her future patients demands that we single her out, as we say “we don’t want you to feel singled out.” Is she over-confident, self-abnegating? It’s a Goldilocks thing, medical confidence.

We strive to pool perspectives to get the best view. Often, our impressions scatter with the coherence of bugs on a windshield–a good sign of reviewers’ independence. Wisdom of Crowds (Surowiecki) makes the point that it’s often better to trust the pooled opinion of 100 independent lay folk than that of a few experts. Can we be both?

Clinic. The parents, sitting opposite my colleague, each hold a twin. The 5 month old brothers study their doctor intently over the pleasant bodily wobbles common to their age. When their head ultrasounds were done, as premature newborns, both showed the ominous echo pattern of white matter injury that strongly predicts cerebral palsy. But their neuro exam doesn’t yet show definite signs.

So put down that reflex hammer and step back, take a look at their General Movements. This is a kind of gestalt impression of spontaneous infant behavior, introduced around the same time as the head ultrasound, though much more melodic. See the fidgety movement–good sign! The GM assessment was devised by Heinz Prechtl, an Austrian ethologist and bird-watcher, whose baby-watching methods are catching on. One brother shows ominous cramped, synchronous movement. But I’m un-sure if the parents would welcome this long view. I don’t let on.

Martyrs Day. This week the Armenian nation commemorates one of a series of massive stuttering slaughters of its people in what is now western Turkey–1895, 1909, 1915. These were the serial genocides conducted by Ottomans, who deployed some of their cruelest citizens, some even released from jail for the purpose, to kill Armenians, or lead them into the desert to starve. Frustrated by governments’ denial, historians went pointillistic, bringing thousands of accounts to international tribunals. Though you can hardly meet someone in Yerevan whose family wasn’t affected, the Turkish government dismissed these histories, as though the Armenian people were suffering an epidemic psychosomatic disorder, a confabulated Freudian memory of childhood abuse. I wonder how often in history, if ever, has an ethnic group’s sub-conscious produced confabulations of murder, persisting over 3 generations? Do nations cry wolf in this way? Meanwhile, “1915: I Remember and Demand” say the street signs. Agreeing on history sometimes requires a long hard look at the big picture.

Cameraman and Mt. Ararat at Tsitsernakaberd, the Armenian Genocide Memorial

Cameraman and Mt. Ararat at Tzitzernakaberd, the Armenian Genocide Memorial

"I Remember and Demand"

“I Remember and Demand”

Strange Territory

Arriving to Yerevan sets off dozens of soothing little clicks in my brain. Like suddenly remembering that Marshrutka #29 goes to Nora Gyugh, that my feet can trace out the steps of the Papuri dance in unison with a score of strangers, that my colleague’s office is up on Mamikoniants Street, half way down the hall on the right. There is comfort, a sense of mind and body aligning, in suddenly remembering the arrangements of streets, of the people on them, of their beautiful faces. Like a dream, or finding that some old clothes I’d nearly forgotten suit me as well as ever; it’s a perception that works like the mind’s own hospitality ethic, the one that lives in a dozen ancient cultures–make yourself at home.

With classic, joyous hospitality, Dana's cousins swooped us from the airport to a feast in their home

With classic, joyous hospitality, Dana’s cousins swooped us from the airport to a feast in their home

Travel also re-arranges geography in a pleasant way: when I’m here, Yerevan moves closer to Vermont than it was, or seemed to be, when I was in Vermont. So it may be with other kinds of fields–the intellectual kind. A trainee in child psychiatry joins me weekly, in clinic at UVM, and I strive to extend hospitality, make her feel at home by focusing our discussions on the psychological dimensions of the cases. Opportunities for this kind of intellectual hospitality arise when we see cases like one I saw last week in Arabkir Clinic, Yerevan:

Clinic. He is 10, and sits with the emotionless stillness, the poise I remember from Armenian children at this age, even though their brains have just cranked through a programmed developmental revolution, the kind that changes the furniture arrangements. I hear that he was referred here by a logotherapist–a speech therapist.

My colleague turns to me and asks whether in my work as a pediatric neurologist I see referrals for stuttering. “Not since the last time I was here.” She laughs, that happy-side-of-despairing laugh, for this referral signals a mis-understanding in her medical ecosystem, and she explains as much to the mother. But then there’s more–he can’t feel his palms. Just like that, the chief complaint around which the encounter should orbit has just re-positioned by 1000 light years. We don’t de-brief, historicize the numbness–but get right to brass tacks. Well nothing that sharp really. We check his nervous system.

The neurologist breaks a wooden swab and tests him–sharp vs. dull–through his face, shoulders, neck, arms, and finally his palms. He pauses longer, but identifies the sensation correctly throughout. Dismissed.

This is a scene I recognize: one care is addressed, and another swims to the surface, and none of the concerns speak of any serious pathology, just bewildering phantasms emerging in a Sisyphean interview. Why this tsav–hurt–that our tools can’t heal? We merely predict that it will pass, and then it does. But not before the parent leaves our office wondering, “an artifice of my child’s mind? Why?”

Back in Vermont, discussing such cases with my child psychiatry trainee, I venture that, perhaps for both the child and his parent, this un-satisfactory transaction exemplifies what the psychiatrist Chefetz has identified as the mind’s imposition of a “phony coherence that is better than confusion”: for the child, if they are at the doctor’s office, there should be a reason; for the parent, being a medical puzzle may make more sense than their child’s confusing somatizations.

At the end of the day, my child psychiatry trainee confides that she feels more comfortable here in Neurology Clinic than she had expected. Success! But then, I want her to be more daring, to venture further with her curiosity into Neurology’s dark forests. Curiosity, like music, signals a sense of safety, of security, and sometimes inviting curiosity, nudging it a little, can catalyze that safe feeling. Especially if the music is from the heart, if the questions come from wonder at the strange territories around us.