Category: Medicine

Into the Gray Zone by Adrian Owen

On July 4, 2017

Title: Into the Gray Zone: A Neuroscientist Explores the Border Between Life and Death
Author: Dr. Adrian Owen
Publisher: Scribner
Format: Paperback
Rating: 3 out of 5
How I got it: I was given an advanced reader’s copy in exchange for this review

About 5 years ago, I read Westlake Soul by Rio Youers. It’s a short sci-fi novel where the title character lives in a persistent vegetative state. He rests in his bed and appears unresponsive to the outside world, but inside, his mind is a ferment of activity. In his own head, Westlake is a superhero, and his nemesis is Dr. Quietus, a personification of death.

In Westlake Soul, Youers imagines the inner life of someone locked into their own body. Do such people have consciousness? Are they aware of what goes on around them, even if they’re unable to make that awareness known?

Into the Gray Zone, by London-based neurologist Adrian Owen, is a non-fiction book that answers those questions. Specifically: yes, it is possible, and even somewhat common, for people in persistent vegetative states (who are in “the gray zone”) to be fully aware of what’s going on around them.

The book describes the initial discovery of this fact, as well as the subsequent experiments that Owen and his colleagues developed to provide further proof. The experiments themselves are rather elegant. First, they needed to prove that patients in the gray zone could still perceive and and understand familiar words and images. Then, they needed to prove that these patients could display intent.

They did that by scanning the brains of gray zone patients after asking them to think of a specific activity or image. Thinking of one kind of activity (playing tennis) results in different patterns of brain usage then thinking of another (finding your way around your house). The true stroke of brilliance is that, upon realizing that these two types of thoughts result in distinct brain patterns, you can use that as the basis for getting the patients to answer simple yes/no questions. “Do you feel any pain? If yes, imagine playing tennis. If no, imagine walking around the house.”

On the surface, this discussion of how our brains work is fascinating. Being able to determine who is in the gray zone yet conscious — and even communicate with them — is a huge achievement. World-changing, even!

But, while Owen may have a knack for explaining complicated concepts clearly to the reader, I still found Into the Gray Zone hard to read. But it’s not a problem of content. Rather, it’s one of tone.

Owen claims to respect his patients. However, I get the sense that the book is more about his personal journey and career rather than the wonders and potential terrors of the human brain.

This is immediately noticeable in the first chapter, where Owen talks about one of his former patients:

One patient I worked with had minimal frontal-lobe damage but became wildly disinhibited as a result. Before his injury he was described as a “shy and intelligent young man.” Postinjury he abused strangers in the street and carried a canister of paint with him to deface any public or private surfaces he could get his hands on. His speech was littered with expletives. His wild behavior escalated: he persuaded a friend to hold his ankles while he hung from the window of a speeding train, a lunatic activity by any measure. His skull and most of the front part of his cortex were crushed when he crashed headlong into a bridge. By some circular twist of fate, his minor frontal-lobe injury led directly to major damage to the same part of his brain.

Notice anything about that passage? If not, try this one less than 2 pages further in:

My patient was a lanky youth with wild hair whom I tested for memory impairments following surgery that he had received to combat seizures. He was also the defendant in a murder trial. The victim was his own mother, strangled while she was securely locked in the house with her son. Just the two of them. The case turned on his being a martial arts expert with a history of epileptic automatisms, and he could (although the evidence remained entirely circumstantial) have killed her through a series of routine martial arts maneuvers and remained entirely unaware of this dreadful act.

When I tested his memory using what were then our state-of-the-art computerized tests, I sat near the door — a strategy I had seen in numerous TV crime dramas. I didn’t feel safe. I needed a weapon. All this now seems ludicrous, but there I was, sitting in a closed office with a man who was accused of killing his own mother with his bare hands without even knowing that he’d done it! If he had done it, could he be judged responsible? I wasn’t sure. The thinking then and now was that automatisms, rather than expressing subconscious impulses, are automatic programs firing in the brain, completely outside our control. If he had been a carpenter, he would have been sawing a piece of wood rather than karate-chopping his mom.

Both of these anecdotes display a disturbing lack of respect for his patients. A studious young man turns into a hellraiser because of a brain injury but hey, he gets his just desserts because said injury becomes the “twist of fate” that enables him to experience a horrible death. As for the second patient, how about using the phrase “karate-chopping his mom” to add a dose of levity to the idea of matricide? Sounds fun, right?

Into the Gray Zone goes into great detail about the medical advances and unpredictable developments that have allowed researchers to communicate with people in the gray zone. But through it all, I get the distinct sense that Owen needs more empathy. Or at least, the two anecdotes I’ve quoted above predisposed me towards treating this book with skepticism.

I’ve read works on similar topics by authors like Oliver Sacks and Gabor Maté. While they may be somewhat dry in places, both doctors approach talking about their patients with a sense of care and even wonder. In contrast, while Owen displays amazement about the scientific advances he’s been able to contribute to, he also spends a significant amount of time talking about how a failed relationship with a colleague named Maureen informed his practice.

Maureen, a fellow student while he was in medical school, was also studying the brain. But while he wanted to unravel its mysteries — treating the brain as a fascinating yet confounding object — she wanted to care for people with psychiatric problems. They eventually broke up; years later, she suffered an aneurysm and never recovered, becoming vegetative herself.

Her spectre haunts the book — Owen constantly talks about how his thoughts of her and his hope for an eventual cure for her condition motivated him to understand patients in the gray zone. But he also admits that it was only after both her and his own mother entered the gray zone that he truly felt empathy for people in the gray zone and the family members left behind who were trying to cope. Before that, his patients just seemed like puzzles to solve.

I’m really disturbed by this, as it just reinforces a popular stereotype that good doctors, the ones that deserve acclaim, don’t necessarily need to care about people to succeed. We see it in House and other forms of pop culture that venerate the Jerk Doctor. Now, Adrian Owen may not be a jerk, but I’m still put off by how much of the focus on Into the Gray Zone he places on himself.

Gut by Giulia Enders

By Christina

On July 19, 2016

In Medicine

Title: Gut: The Inside Story of Our Body’s Most Underrated Organ
Author: Giulia Enders (with illustrations by Jill Enders)
Publisher: Greystone Books
Format: Paperback
Rating: 3 out of 5
How I got it: I purchased a copy on sale

For the past two and a half years, I’ve had something really weird going on with my stomach: I’ll sometimes be struck with a sensation of pain, burning, and bloating that feels a lot like hunger. Because it feels like hunger, it seems like my stomach is telling me to eat — but eating food doesn’t make the sensation go away. I would sometimes take Tums or Gaviscon to ease the sensation when this first started happening, but neither solution worked consistently.

I had an ultrasound done, and everything looked normal. I even saw a gastroenterologist and had an endoscopy done, but that looked normal too. No sign of lesions or ulcers. However, over time I noticed a few factors that appear to be correlated to this weird hunger pain sensation:

Eating lots of oily, fatty food over a few meals in a row
Eating lots of tomatoes or vinegar (or other acidic food) in a single sitting
Eating food really early in the day
The time of year – it happens more often in the fall and winter than in the spring and summer

The one thing I’ve found that seems to stop these feelings before they get too intense is if, while eating, I take a pill filled with powdered hydrochloric acid (aka: stomach acid) and pepsin (a stomach enzyme). So, for some reason, I seem to need more acid in my stomach to make things work. I have no idea what the link is with the time of year, but the problem does seem to be less prevalent if I take vitamin D during the fall and winter.

All of this is an extremely long-winded way of saying this: my stomach is weird and I don’t understand it. I wish I had a diagnosis.

This was a large part of why I bought Gut by Giulia Enders — I was hoping that her book would contain some nugget of truth or casual aside that would make my digestive system and all its foibles suddenly make sense. Unfortunately, it hasn’t; I’m no nearer to figuring out what’s wrong with my stomach than I was before.

That said, Gut is a fairly comprehensive look at the entirety of the gastrointestinal tract, full of intriguing trivia, easy-to-grasp explanations of processes that seem mysterious from the outside, and more than a few squeamish tidbits.

Here’s the rub, though: it reads more like a collection of useful trivia rather than a book with a solid throughline. One can sense Enders’ enthusiasm throughout the book — she came to prominence after giving a popular talk on this topic on YouTube — but a popular video does not a book make.

For one thing, the prose contains several awkward turns of phrase and poor transitions between topics. Whether this is an artifact of the book being translated from German into English or something inherent to Enders’ writing style in her native language I am not sure, but there was overall a clunkiness to the prose that made the experience of reading it feel like being in a very herky-jerky car.

In addition, the books’ ending just falls flat. The final chapter talks about probiotics and prebiotics, but the ending pages just…hang there. There’s no sense of closure, or any attempt by Giulia Enders to round up her thoughts into the sort of fitting summary that you normally expect there to be in non-fiction books.

Finally, considering the nature of the book, it’s almost criminal that there’s no index. Even if the medical knowledge within is aimed towards a general audience, the lack of an index in the back makes the book nearly useless as a reference material.

I dunno. The whole thing just felt half-assed in retrospect.

When Breath Becomes Air by Paul Kalanithi

By Christina

On April 20, 2016

In Medicine, Non-Fiction

Title: When Breath Becomes Air
Author: Paul Kalanithi
Publisher: Random House
Format: Print
Rating: 5 out of 5
How I got it: I borrowed a copy from the library

I used to think that I had a book in me, but lately I’ve become less sure about that. My prose is clear and readable, but not breathtaking. I don’t have any striking new insights into the human condition. Most importantly, I read books like When Breath Becomes Air and become hopelessly discouraged at the protean talents of someone like Paul Kalanithi.

This man did not stop. He hungered for knowledge, he inhaled it until it filled his veins and bubbled in his blood. I mean, look at his biography:

Paul Kalanithi, M.D., was a neurosurgeon and writer. Paul grew up in Kingman, Arizona, before attending Stanford University, from which he graduated in 2000 with a B.A. and M.A. in English Literature and a B.A. in Human Biology. He earned an M.Phil in History and Philosophy of Science and Medicine from the University of Cambridge before attending medical school. In 2007, Paul graduated cum laude from the Yale School of Medicine, winning the Lewis H. Nahum Prize for outstanding research and membership in the Alpha Omega Alpha medical honor society. He returned to Stanford for residency training in Neurological Surgery and a postdoctoral fellowship in neuroscience, during which he authored over twenty scientific publications and received the American Academy of Neurological Surgery’s highest award for research.

Two B.As, an M.A, an M.Phil, a stint at the Yale School of Medicine, and a residency at one of the most prestigious medical schools in the country, where he did amazing neurological research.

All of that before he died in his late 30s from cancer.

I look at people like him, read their glittering prose, and feel that if people like this in the world exist with such gifts, any attempts of mine to compare don’t mean much.

And so we come to When Breath Becomes Air, Kalanithi’s first and only book, a meditation on trying to find the answers to life’s big questions by marrying a love of literature — the purest expression of human thought — with an understanding of the human brain — the mechanism that produces such thought. How do our minds work? Do doctors gain a deeper understanding of humanity by seeing people at their weakest and most vulnerable? Kalanithi tried reconcile these deep questions by combining his literary knowledge with his medical knowledge to study neuroscience, hoping that he could find the key to human identity.

Unfortunately, in the final year of his residency, he was diagnosed a rapidly metastizing form of cancer that left him with only years, if not months, to live. Thus he was suddenly forced to use his own lived experience to answer the questions that he spent his entire academic career investigating, rather than the second-hand experiences and knowledge of others. This dual understanding of being both a doctor and a patient gave him new insights and helped him develop more empathy for the people he treated. It also left him frail and exhausted.

Was writing this book worth it for him? I don’t know if he found an answer that was satisfactory, but I hope he did. But there are so many contributions he could have made to our understanding of the human mind that now remain unfulfilled. Reading over crystal-clear prose like this makes his absence, the loss of that potential, an even bigger wound than it already is:

The enormity of the moral mission of medicine lent my early days of med school a severe gravity. The first day, before we got to the cadavers, was CPR training, my second time doing it. The first time, back in college, had been farcical, unserious, everyone laughing: the terribly acted videos and limbless plastic mannequins couldn’t have been more artificial. But now the lurking possibility that we would have to employ these skills someday animated everything. As I repeatedly slammed my palm into the chest of a tiny plastic child, I couldn’t help but hear, along with fellow students’ jokes, real ribs cracking.

Cadavers reverse the polarity. The mannequins you pretend are real; the cadavers you pretend are fake. But that first day, you just can’t. When I faced my cadaver, slightly blue and bloated, his total deadness and total humanness were undeniable. The knowledge that in four months I would be bisecting this man’s head with a hacksaw seemed unconscionable.

I mean, this man could have seriously been the next Oliver Sacks! It’s cruel that he died so young, that he left a wife and a daughter behind just when he was on the cusp of becoming who he truly wanted to be. And it makes me sad to know such cruelty.

I started reading When Breath Becomes Air on the first anniversary of Kalanithi’s death — a completely unintentional but apropos coincidence. I hope that when the dust surrounding the books’ initial publication settles, it will join the ranks of other respected works of medical non-fiction like The Emperor of All Maladies and The Immortal Life of Henrietta Lacks.