In Child neurology we are required to do a year of adult neurology. This is a year of complete culture shock. Children’s hospitals and adult hospitals are two completely different worlds. It is interesting to see the adult neurology residents complain about how chipper and upbeat the pediatrics people are. This is an odd complaint, until you realize adult neurology residents feel completely out of their comfort zone in knowing how to manage the patient. fear and discomfort are only augmented by sleep deprivation and being pulled in several directions at once, as you tend to be on call, Perhaps they can be forgiven when they really find it difficult to draw enthusiasm when awoken at 3am to hear about some “kiddo.” For me, being out of my element with adult patients is an even greater culture shock. Going from chipper to somewhat cynical and demanding is worse than the other way around.

The culture shock is particularly profound the Neuro ICU. For one thing, it is a prime site for so many spectacularly horrific things. While children with neurlogic problems can be heartbreaking, somehow I manage to deal with it. There is something about dealing with severe traumatic brain injury, brain tumors, stroke and brain hemorrhage all day that is particularly soul killing. The place is just saturated with death and loss. It was here I came to understand the phenomenon in medicine that is gallows humor.

My first day in an adult ICU involved more death than I had seen in three years with pediatrics. Talking about withdrawing support was a daily occurence in the Neuro ICU. The Nurses and Doctors actually grew resentful if the family hesitated in these cases, sometimes even when I thought it was too early to take that kind of a step. Hope can become a time and money wasting enemy. No one wants to feel they are working their tails off for a completely futile effort, yet this is what these nurses go through day in and day out. What can one do in the face of such a depressing environment?

It turns out the answer for doctors, is to laugh. During rounds we laugh at things that would absolutely horrify the outside observer. We laugh about near misses when a mistake was almost made or TPA, a clot busting medication that either breaks up your stroke or causes your brain to bleed, was given to someone who should not have had it, and they survived okay. We laugh at frustration in trying to get appropriate help from ancillary caregivers in the midst of an emergency, as their brain is swelling and they have literally minutes to live. We laugh at patient’s who simultaneously have these problems and the manpower simply is insufficient to manage both sufficiently. We laugh at the absurdity of dealing with insurance beauracracy. We laugh at inability to get the resources our patient’s need to live at home or to manage their disease. It is a mirthless, cynical laugh. I think many of things that we laugh at in life are born out of pain. We find uncomfortable truths funny. We need the natural opioids released to function and move on. In Neurocritical care I learned just how far this can go. The thing is the laughter is not because we don’t take these things seriously or that we don’t care.  It’s quite the opposite.  Sometimes situations in life are so painful, so horrible, so senseless and tragic, that all one can do is sit back and laugh.

I felt extremely guilty the first time this happened to me.  I have since learned to be more forgiving and to see this impulse for what it is, a coping mechanism. I have seen some tireless and wonderful physicians partake in this communal pain and laughter. I have also learned much about how they came to be at peace with the phenomenon. This is some of the most critical teaching I have recieved in residency.

How do we succumb to this kind of laughter and not lose our souls? The more exposure we have to these circumstances, the more our compassion deadens. It is simply too painful. I think much of the frustration with families that “prolong the inevitable” comes from the fact that caregivers suffer as the patients suffer. There is just no way to get around the fact that, for better or worse, we are profoundly changed by exposure to the pain and suffering of others. Trying to wall ourselves off from feeling is a survival mechanism. It is even glorified by some as maintaining objectivity.

To be a doctor in general and a neurologist in particular is to see people at their worst. We witness fury, anguish, anger, weeping, self pity, hopelessness all the time. Our patients are people who are sick, who are tired, people in pain, people who may be addicted or depressed, people who act out, people who often seem like an eternal pit of need. To doctor is to deal with misery. I suppose the spirituality and high minded philosophy I deal with in this blog is something of my coping mechanism. Wearing yourself out at a hospital can make you forget the good things in life. Art, music, literature, prayer, service, nature, ideas are forgotten as time is swallowed up by an punishing profession. Blogging is one way I connect with the best of humanity to remember the good and not get swallowed up by the worst. So is my spirituality escapist?

I am afraid I can’t answer that. I am too entangled in the situation to see clearly and objectively. But I do know this. Kids can deal with misery, unfairness, severe disability with a resilience that we adults can scarcely imagine. It wears off on the caregivers. Pediatric nurses and physicians gather strength from their patients. We become, as I said in the beginning, annoyingly chipper. We can’t help it. It is an instinct born within us for survival of the species.

Children have the ability to draw out a measure of hope and selflessness in us. I can’t look upon this as a trick of nature. I can only see this as what it means to be human. I think this is what childlike faith is about. Kids live in the present. Their past is too small and their future too vague and undefined. They are used to feeling powerless. These added difficulties can’t take as much away. It doesn’t stop them from seeing what there is to enjoy and revel in around them. They have an optimism untempered by failures. What I learn from children is all about potential.

My faith teaches me that I am a Child of God. That I have a spark of the divine within me. It teaches me about the potential of all mankind. It teaches me about a pipe dread called Zion, a people united in love and service. I am afraid I can’t see hope as escapist. I see it as contagious. Some may call it mass hysteria, I call it mass healing. Where others see self deception, I see self care for all that is good within myself. I cling to hope, because I cannot cling to anything worthwhile without it.