Chapter 6: So, what happened?

I guess things are getting real here people, so I better take a little pause from my pre-diagnosis adventures and actually get to the interesting part of the story before the neurosurgeons scoop a big part of my brain out later today. I hope they leave in my good side.

I’m a little embarrassed to share such a half-assed draft of manuscript below as I am usually an over-the-top perfectionist in my academic pursuits. I’m going to give myself a pass for this one and blame the poor grammar below on the massive tumor, I think.

Tuesday, January 23rd, 2020:

I had a fun, normal day at work today followed by an awesome adventure to China Town with my “Thai nurse mom” and friend Ms. A. Ms. A is a wonderful woman and nurse in the palliative care department I met around one week ago who took one look at me and asked, “do you like to shop?” with a big smile on her face. I agreed, and we became instant friends. Ms. A took me under her wing and invited me to her favorite market in town after work that day. We hopped in a red songthaew and drove to the market. We explored a seemingly endless market, filled with amazing, locally made goods crafted by many hill tribe villagers. With a little convincing, Ms. A had me try on a handmade jacket which I purchased for an unbelievable price of $4 USD. After this splurge, we headed deeper into China Town to explore some of the oldest Buddhist temples in Chiang Mai (Ms. A, along with many of my other Thai friends, were very surprised to learn that I consider myself a Buddhist as they do not meet many Westerners who practice this faith.). We then headed to a hilarious, tiny “country western” themed restaurant nearby for a family-style feast. Ms. A told me during dinner that she is in her mid-50s. You’d never know this looking at her; like many Thai women, she could be 20+ years younger or older than her stated age. She looks amazing. When she tossed out the age of 53, my jaw flopped to the floor and I asked her “What’s your secret, Ms. A? How do you stay so young?” Without any hesitation, Ms. A giggled hysterically and said “EAT!” So, eat we did.

Wednesday, January 24th 2020

Up until this point, my time in Thailand was filled with endless wonderful adventures. I was working in a global health rotation associated with Chiang Mai University Hospital. This experience allowed me to spend one week rotating with hematology/oncology, two weeks with palliative care, and one week with the Thai Traditional and Complimentary Medicine clinic. So far, I had been having the most amazing experiences in all of these areas. I met wonderful teams of physicians, nurses, residents, students and was able to see an entirely different yet equally wonderful style of medical care.

Throughout all of this, I felt absolutely normal. Healthy. Apart from the depression I mentioned in chapter three, I’ve always been a healthy person. No history of neurologic issues, definitely no history of seizures. On Wednesday, January 24th I was scheduled to work my first shift in the Thai Traditional and Complimentary Medicine clinic. I was so excited for this day, unbelievably excited. When I woke up that morning, however, I felt like I had a subjective fever. I was chilled, diaphoretic, and generally felt like I was getting a nasty cold. I took some Dayquil, threw on a mask, and decided to walk the 30 minutes into clinic anyways since this type of medical educational and cultural experience doesn’t come along every day. Physicians often make pretty terrible patients.

My cold-like symptoms improved with my walk into clinic. It was a beautiful, sunny day as usual in Chiang Mai. I arrived to clinic and was quickly ushered into the Chinese Medicine department of the clinic where a physician asked if I wanted to try acupuncture. I happily agreed, having never tried this before. As I lay on the table, face down, needles covering my back and neck, I started to feel my fever return. I had chills, bad ones. I really wanted to finish the session but had to call the nurse over to remove the needles early due to extreme chills. The team was clearly worried about me at this point. I let them know I felt that I should head home and take the day off to prevent exposing other patients to my own cold, walked 30 minutes home, and crawled back into bed.

Arriving home, the fever seemed to come back in full force. I didn’t have a thermometer in Thailand, so this personal case report is sadly lacking in quantitative data. However, I can tell you I definitely had rigoring chills only minimally improved with anti-pyretic medications. During one episode of chills, perhaps around 3-4pm, I was lying in bed and felt my muscles contracting rapidly near my left hand. Odd. I had never had such extreme rigors and figured my temperature was damn high. I drank some water, took another Advil, and napped for the rest of the afternoon.

I woke up that evening and felt much better. My fever was down. S and I went out to dinner. I managed to eat a pretty good bowl of comforting noodles followed by a delicious ice cream bar before deciding to head to bed early. The next morning, Thursday January 24th, I continued to feel sick with cold-like symptoms. I actually asked my clinic preceptor if it was ok for me to take the day off, something I don’t think I’ve ever done in my entire adult career. I felt terrible doing this, but also didn’t want to expose my patients to what I had caught. I slept in until noon and then actually started to feel pretty decent. I walked 20-minutes down Nimman Road to a cute café for a delicious latte and actually spent a few hours shopping after this. My low-grade fever and sore throat continued, however, so I figured another massage might be a more relaxing idea to pass the time. I stopped into a beautiful spa for a lovely 90-minute massage and left feeling wonderful. S and I met for dinner at a nice little outdoor bistro following this. I ordered Chiang Mai’s famous spicy papaya salad, a mango smoothie, and Pad Thai. I felt like myself. Hooray!

Friday, January 25th, 2020

What a wonderful day! Today I woke up feeling healthy and rested. Nothing a little spa day can’t fix. I was scheduled to go on my first home care visit today to a very adorable 95-year old Thai woman’s home accompanied by the family medicine department. This experience was incredible, and I felt healthy throughout the visit. We finished with our clinic day early, around noon, and I was granted the afternoon off to explore the city.

For those who don’t know me well, I am a fairly avid yogi. I love to exercise and I love to practice yoga. At home, I practice yoga at least 1-2 times weekly and exercise in some fashion nearly every day (it has helped keep my depressive symptoms at bay). Yoga in Chiang Mai was very similar to yoga at home in Minnesota. I found a nice little studio a few blocks from my apartment and enjoyed my nightly routine of a fast-paced vinyasa flow taught in English. Many of the fellow yogis were “digital nomads” or other world travelers who brought a nice sense of community to the practice. I met a friend at yoga and we decided to meet for dinner later that evening at one of my favorite spots, Kao Soi Nimman. If you ever have the chance to eat in Chiang Mai, do not miss this spot! Around 7pm, I started on the 20-minute walk to Kao Soi to meet my friend for dinner. I felt fine on this walk until around 2 blocks before arriving at the restaurant. Suddenly, I had a sensation of hand cramping in my left hand. It was brief, maybe 10-20 seconds, but intense. This was followed by a sensation of dysphagia, or an inability to swallow well. Now this was really odd. The sensation, as disgusting as this is to tell you all, was that of not being able to swallow my saliva. This too was incredibly brief. I was awake, conscious, alert the entire time. The whole ordeal lasted maybe 20 seconds and then I felt completely back to normal. Maybe I shouldn’t have ignored this weird event, but it was the first time anything like this had ever happened, it was brief, and it was over. I figured I had a muscle cramp or some strange symptom of anxiety prior to my dinner event and continued on with the night.

Dinner was great. The spicy, coconut curry Kao Soi dish was as delicious as always. I felt fine all evening with no return of strange muscle cramping.

Saturday-Sunday, January 25th and 26th, 2020:

The next morning marked the start of one of the adventures I was most excited for in Thailand. On Saturday and Sunday, January 25-26, I had booked an overnight solo excursion at the Elephant Nature Park, an ethical and incredible elephant sanctuary that I absolutely recommend everyone to visit. Or if not visit, at least watch the heartbreaking and eye-opening documentary “Love and Bananas” by Ashley Bell. I want to tell you all so much more about this incredible weekend at the elephant sanctuary, but I also want to get the rest of this personal case report typed up before my surgery so my residency friends have something interesting to present at next year’s conferences.

Let me just say, I had the most amazing, incredible, life-changing weekend at the Elephant Nature Park. I fell absolutely in love with these magical giants. I felt happier than I have felt in a very long time. I was symptom-free, felt healthy, had no “muscle cramping” events, and played with elephants all weekend long. This was the good life.

I returned back to Chiang Mai on Sunday evening, January 26th, feeling tired and happy. I took myself out for a solo diner experience at “The Salad Concept,” a healthy (although touristy) café down the road from my apartment. I had a quinoa salad, a peanut-butter banana smoothie, and fresh focaccia bread slathered in basil butter. Yum. I went home, relaxed, and watched an hour of Netflix before heading to sleep.

Monday, January 27th 2020:

I woke up with symptoms of my cold returning today. Damn. I figured I overdid it with the elephants while the virus was still lingering. I didn’t feel like I had a fever today, so I decided to go into work as usual and wear a face mask (this was not abnormal at all give the simultaneous concern for Chinese Coronavirus at the time….more to come on that fascinating medical adventure later). I spent the day working with the palliative care team. Apart from a little runny nose and sore throat, I felt ok and made it through the day. I finished work around 3pm and did a little shopping at a local market on my way home. While walking towards the market, quite suddenly, I felt the return of that damn left hand cramping quite abruptly. I paused, trying to relax my hand and calm down. Medically, I will describe this cramping as increased tone throughout my left hand, primarily located in my left thumb and left 3rd finger. There was mild preceding tingling in these same areas. There was no hand numbness, no radiation of symptoms farther up my arm, and no weakness. This was simply a 10-20 second event of strange hand cramping. This wouldn’t have concerned me much to be honest, but a few seconds later that odd swallowing issue returned. The inability to swallow your own saliva is incredibly frightening. I had no pain but felt the sensation of my throat closing or swelling very briefly. Again, maybe this should have concerned me more at the time. The whole event, between hand cramping and swallowing difficulty, however, lasted no more than 60 seconds. I was awake and walking the entire time. I felt completely fine afterwards. Honestly, I figured I was dehydrated and having electrolyte imbalance leading to muscle cramping from my recent viral URI followed by a busy elephant adventuring weekend. Partial seizure did cross my mind, though. I will admit it. But why? As a 29-year old, otherwise healthy female with no systemic symptoms and no reason for a seizure, I just brushed this off and said I’d worry more if it happened again.

Tuesday, January 28th, 2020:

I woke up feeling just fine today.. I still had a bit of a lingering cold with a mild sore throat, but no fever. I packed up and headed to work for the day. I don’t remember any strange muscle cramping events on Tuesday at work. All seemed normal. I decided it was a good evening for yoga after having taken a break during my recent cold. I went to a fabulous 60-minute power vinyasa class complete with time for headstand practice. Ironically, I had never done a yoga headstand until around one month prior to my visit to Thailand. A friend and yoga instructor back home in MN had shown me a safe way to practice yoga headstands and, as I don’t like to be a quitter, I figured I better learn to do the damn thing. Why I’m telling you about yoga headstands at all is that, if my brain works well enough to publish this case report for myself someday, I’m calling it “How A Yoga Headstand Diagnosed a Brain Tumor.”

In my mind, this was the turning point in my diagnosis of my own symptoms. As I mentioned, I went to yoga, had a fantastic class, and actually got myself up into a decently graceful headstand at the end of class. Walking out of yoga around 10 minutes later, however, I suddenly experienced the now too familiar sensation of left hand cramping. Damn. I panicked a little more than before as my mind started to create its own differential diagnosis. Ok, I just finished yoga. Am I dehydrated? Did I pull a muscle? Maybe I need some electrolytes. I continued to walk and tried to will the hand cramping to end. I honestly figured I could be having a mild anxiety/panic attack and wanted to see if I could just ignore the cramping which could give me my answer. The cramping lasted 10-20 seconds and then the dysphagia started. Fuck. Now I was really getting worried. I had a water bottle with me from yoga class and decided I would try to drink some water during this sensation, just to see if I was actually having trouble swallowing or if I was simply going insane. I took a drink of water and felt it pool and fall out of the corner of my mouth. This was not good. I tried to calm my mind, find my inner zen. I stood on the corner near a 7/11 for around 30 seconds until this episode ended, took a normal drink of water, and walked home. Arriving home, I felt fine. My mind was really sending me some strange warning signals and I had a tough time forgetting about this event. I decided to ask a neurology resident friend back home if I should consider a focal, or partial, seizure as a cause of these symptoms if it happened again. I didn’t want to worry anyone unnecessarily and still wasn’t sure what to make of only two isolated cramping incidents.

I relaxed that evening after yoga and tried to really increase my fluid intake in case this was a dehydration issue. I felt ok until around 9pm, however, then another event occurred. Same damn thing. Left hand cramping (milder this time) for 10 seconds followed immediately by 10-20 seconds of dysphagia. I may not have studied as much neurology as I should have so far in residency, but I knew if my patient told me these symptoms I would not be able to ignore focal, partial seizure on my differential.

For some of my medically interested readers, here was the differential in my mind at this point:

- Focal, partial seizure triggered by recent fever and/or irritation post-yoga headstand

- Pseudoseizure (a “seizure-like” event triggered by anxiety). I wasn’t sure why I would be having this but felt a little insane even thinking I could be seizing.

- Muscle cramping due to electrolyte imbalance. As I said before, I take sertraline. I figured I could be hyponatremic and hypovolemic due to the combination of recent fever, exercise, and decreased fluid intake. I decided to hold my sertraline that evening.

- Infection. I had spent the previous weekend with elephants, bathing them in streams. Could I have a parasitic infection? Cysticercosis? Japanese encephalitis? I really did not want to have to obtain a lumbar puncture for myself in Thailand but kept the option open.

Fortunately, I was able to reach out to a neurology resident home in MN who agreed with my differential and said at that point, it was probably smart to at least rule out a partial seizure as the underlying cause. Keep in mind, at this point it was around 10pm on a Tuesday evening in Thailand. The emergency medical system works differently there, and I was not about to spend the next multiple hours sitting in an emergency triage center without any ability to effectively describe my symptoms in Thai. I texted my emergency contact at Chiang Mai University, feeling horribly guilty to do so given the incredibly busy day all of the physicians were already having given the Coronavirus scare there. I told her I was worried I was having focal partial seizures and needed to see a neurologist. I asked if she could help coordinate this for me in the morning. She acted rapidly and had a neurology fellow based in Bangkok give me a call a few minutes later. I described my symptoms to him. He felt like this pattern “did not really fit a seizure” but said he would talk to his attending and get back to me. I felt like a damn fool but also really do like my brain so figured I shouldn’t give up on it quite so easily.

Very fortunately, the attending physician I was working with on the palliative care service was also a board-certified neurologist. After this less than confidence-inducing call with the fellow, I sent her a direct text message, knowing how absolutely insane I must sound but also knowing I really needed some reassurance and didn’t totally feel I would get this from this fellow in Bangkok. Dr. P responded to my text immediately. She called me and listened to my symptoms. She said that the pattern of symptoms I was describing could absolutely indicate a focal seizure and she agreed I should see a neurologist for an MRI in the morning. I told her I would meet her at 9am and thanked her profusely. That night, around 4am, I woke up with left hand cramping followed by dysphagia. I was alert during this episode. It lasted less than 30 seconds. At this point, I was convinced I was having focal seizures and sat awake in bed feeling reassured in my decision to pursue additional care.

Wednesday January 29th 2020

This morning, I was an anxious mess, but my body felt physically healthy. I walked 30 minutes into clinic to meet Dr. P and we walked together from her office into the neurology clinic. I waited around 60-minutes to see the neurologist in a busy, understaffed clinic where very little English was spoken. My neurologist, fortunately, spoke some English. I explained my symptoms to him but also jumped right into the point. I had noticed that culturally, medicine in Thailand works quite differently than in the US. I don’t have time to get into these differences now but hope to share more later. One of the key issues I worried about was timing. I knew I would have around 2-5 minutes with this physician; he would write his orders on a paper record, and I would likely never see him again or have any way to contact him (given my lack of cell phone service in Thailand). So, slightly braver and bossier than usual, I told him this:“I am a physician. I am having symptoms concerning for focal, partial seizures and I am worried about a brain mass or an infection given my recent exposure to tropical illness at an elephant sanctuary. I would like an urgent MRI.”

He starred at me, not quite sure what to do with this bossy, small American girl but eventually did a neurologic exam and caught signs of very mild left hand weakness (I’d guess 4+/5) along with slight finger-nose-finger dis-coordination on the left. Based on this, he agreed with my request and placed an order for an MRI. I asked if he was also planning to draw some labs given my concern for possible underlying infectious etiology. He wasn’t so sure what to make of this, but he obliged with me.

After a brief lab draw, I was transported to the hospital entrance and ushered into the back of an ambulance with the feeling I was stepping back in time. There were 4 other patients in the ambulance with me. This ambulance was used as a transport vehicle to bring patients to the imaging center where MRIs were performed, off-site from the main hospital. No one spoke English in this ambulance. I sat quietly, thinking the whole ride that if one of these other, actually ill, patients had a medical emergency I would have to jump into action.

Fortunately, we made it safely to the imaging center and I was ushered into a fairly modern appearing lobby where I proceeded to wait around 60 minutes for my scan. In Thailand, financial agreements in the medical field seem to be much more straightforward than in the US. Before nearly any procedure, lab, image, etc the patient is asked to sign off on a bill agreeing to pay a pre-determined charge. This becomes important in my story later. I signed a bill agreeing to pay 8000 Thai bait for my MRI scan and waited.

Heading into the MRI machine, I was amazed at the differences in technology from home. In particular, this MRI machine was large, bulky, and semi-frightening to look at. I did not receive any comfy headphones playing relaxing classical music to lull me to sleep. There was some fairly intense Thai-pop dance music playing in the tech suite which I thought might be a good way to induce a seizure during my scan but I kept quiet about that.

I lay in the MRI scanner for around 45 minutes. The MRI tech walked back into the room and I expected him to say I was finished. Instead, however, he brought out another bill. In limited English, he asked “is it ok to charge you another 8000 Thai bait for the surgical planning MRI now?” Hmm. This was unexpected news. Surgical planning MRI you say?

I asked him, “So, does this mean you found something abnormal?” He said “yes.” I tried to keep my questions brief for maximum understanding. I asked, “Did you find one mass or multiple masses?” He said, “one mass.” Ok. Not great news.

I agreed to pay the 8000 Thai bait (less than $300 USD) for the “surgical planning scan” and spent the next 45 minutes running through an updated differential in my mind.

Again, for those medically inclined, here was where my mind went during the longest 45 minutes of my life:

- Differential diagnosis for one brain mass associated with focal, partial seizures of fairly acute onset one week ago: Primary brain tumor, brain abscess, complete crap technology with a smudge on the camera.

- Focusing in on likely brain tumor or brain abscess, I tried to come up with my next plan of action. The neurologist I met earlier in the day told me that a radiologist would not read my scan until the following day. He wanted me to return to clinic in 24 hours to go over the results. I knew this would not do if a brain abscess was in the differential.

- The scan ended. I told the MRI tech the following. “I am a physician. I would like to see my scans and take a few pictures.” I did not wait for a reply. I grabbed my cell phone and walked right into the imaging control room, feeling a little guilty at how bad I was making bossy Americans look across the world but continued forward regardless.

- I looked at the scan through medical eyes. I am no radiologist, or neurologist, but you did not need to be medically inclined to see the giant-ass abnormality located in the right frontal lobe of my brain. Hmm. This mass looks like a tumor, I thought. Abscess is possible but seems less likely. Cysticercosis could still be a thought, but it would be strange to present in this way.

- The radiology tech said “Ok, that’s enough time” and kicked me out of the room. I had taken around 5 pictures on my cell phone of my scan by this point and went to go sign my bill. The MRI secretary said, “the radiologist will send you an email with the results tomorrow” and kicked me out the front door.

Ok. Brain tumor. Brain abscess? Neither great. I decided I should probably be admitted to the hospital. I texted a picture of my scan to Dr. P and told her my concerns. She agreed and arranged for me to have a direct admission to the hospital (the same hospital I had been working in the preceding weeks) later that evening. I met up with S and showed him the scans, just to make sure I wasn’t crazy. Yep, there was a big old mass in there, we couldn’t deny it. He agreed I should pursue hospital admission and told me he would take me to the hospital. I must have looked slightly shocked at this point because usually I refuse to take cabs, preferring walking over anything else. In a state of planning brilliance, S told me we should stop at my apartment and pack my things. We packed up the whole place in 10 minutes and called a cab to take me into hospital where a room was supposedly waiting for me. S became my hero and lifelong friend over the upcoming 48 hours and I cannot thank him enough.

Fondly,

Courtney

© CB2020