“We’re really at an infant stage in terms of our clinical ability to assess traumatic brain injury,” a medical expert said.
Before he ended his life, Ryan Larkin made his family promise to donate his brain to science.
The 29-year-old Navy SEAL was convinced years of exposure to blasts had badly damaged his brain, despite doctors telling him otherwise. He had downloaded dozens of research papers on traumatic brain injury out of frustration that no one was taking him seriously, his father said.
“He knew,” Frank Larkin said. “I’ve grown to understand that he was out to prove that he was hurt, and he wasn’t crazy.”
In 2017, a postmortem study found that Ryan Larkin, a combat medic and instructor who taught SEALs how to breach buildings with explosives, had a pattern of brain scarring unique to service members who’ve endured repeated explosions.
Why is it so hard for doctors to take people seriously sometimes? I guess probably because of crazy people insisting there are worms in their skin, but it’s still unfortunate
Because we don’t want doctors guessing or being creative. They’re not the R&D creating engines, they’re the mechanics.
“hi my car is making a noise that sounds exactly like a faulty wheel bearing. I think my wheel bearing is broken.”
“No, it’s not. You can go now.”
I don’t see how this analogy makes their arrogant dismissals any better.
I recall a mechanic changing a flat on my motorcycle acting pissy I was watching. I just had nothing better to do, far from home with a delaminating tire at shop out of walking distance to anywhere. I happened to catch him torquing the rear axle to sealed bearing specs. “DUDE…those are taper bearings in that hub” he quit giving me dirty looks. Now see a doctor would have yelled at me for googling how to pack a taper bearing 5 years before, and learning the difference years before that. Because of shitty doctors, I’ve also learned to prelimary determine if it’s appendicitis or not. We both fucling well knew it wasn’t a UTI but weren’t getting much help, but at least set our.minds at ease she probably wasn’t dying.
Their actions are correct. The attitudes are not. That’s absolutely fair. They need to just say “I don’t know”.
Telling people to leave because they don’t know is also not okay.
I’m confused. Then what should a doctor say when they don’t know the answer?
“I don’t know but let’s find out together”. Requires confidence to say though.
They can damn well explain why they disregard some symptoms and why my online diagnosis is unlikely
They disregard certain symptoms because they went to med school, had a residency and are a practicing doctor for 10 years. They see so many hypochondriacs, that if they did that, they could only see half the people, or even less.
The rule of medicine is “if you hear hooves, think horsey, not zebra”. People googling their symptoms won’t find their disease 99.999% of the time. You won’t beat their experience by googling, that’s not how it works.
Sure. And yet it would benefit us all to have a better understanding of how our bodies work and where online models work or don’t work. Do people really just want an answer with no reason? I want to hear hat Zebra are not native to this region, and the symptoms don’t include stripes. Otherwise, how will I learn not to expect zebras next time?
Because most of the time without expensive diagnostic testing the only thing you have to go off is the sound of hoofbeats. It’d be a collosal waste of resources to order every diagnostic test that is associated with the differential diagnoses for every patient. If the symptoms begin to worsen or become more frequent, then you have a patient history of recurring symptoms that can justify further tests.
You learn that simply by never expecting zebras and letting doctors do their job. Do you go to the used car lot and expect the dealer to explain to you the innerworkings of the internal combustion engine, what the little ticking sound is in the car and how blinkers know to disable themselves, or do you expect him to sell you a car?
I expect him to answer questions with some technical detail and minimal bs about the pros and cons of that vehicle, potential causes of common problems and how to avoid them and how best to take care of it. If he doesn’t, I find a different salesperson, or dealership .
I also hold my doctor to higher ethical standards than a car salesman
Okay, so you expect him to not do his actual job and humor you. While you come in and basically insult him by trying to do his job for him by using google, and being wrong all the time.
A doctors job is to cure people, not explain everything in minute detail to everyone that comes in.
If I ask the mechanic if it’s the flasher unit or a bad ground, I want a straight answer, not up front maybe but after.
And if you come in and keep asking if it’s the blinker fluid, and expect the mechanic to explain in a very detailed fashion that it is not and that you are an idiot?
Although you may beat their knowledge by reading the research, which is what this guy seemingly did. That’s why you go to school, to learn knowledge and also learn how to analyze the new research as it comes. If they’re ignoring the research that this guy explicitly points out correlates to his experience, and has done all the digging for them and checked the legitimacy and methods (which I’m not claiming he did), then the doctors should have at least double checked.
Eh. No. You don’t have knowledge by “researching” online because you can’t even diagnose yourself because you lack the knowledge and research. This isn’t someone looking for a service manual and changing out something simple in their car. This is medicine.
Medicine isn’t magic. You can gain better specific knowledge through research. That’s literally how you get it, whether through school or otherwise. There are people around the world who have self trained and become very competent at things other people go to university to learn. Assuming someone needs to be a doctor in order to gain knowledge is so stupid.
Because they’re arrogant bastards, no more intelligent than your average person, but convinced of their inherent superiority by education and surroundings.
I find that medical doctors and engineers both commonly suffer from huge superiority complexes and/or narcissistic tendencies (and I say that as someone with an engineering degree). I think a huge part of it is that everyone is constantly fawning over them and telling them how smart they must be to have made it through the schooling that they begin to believe it (combined with the fact that many people conflate academic success with intelligence).
As a chemistry major, I went to undergrad with tons of pre-meds that went on to become medical doctors and then I went to grad school in an engineering department. Believe me, plenty of idiots hold a degree (even an advanced degree) in these areas. Most medical doctors are just mechanics that specialize in troubleshooting one particularly poorly designed device, and many engineers are convinced that because they know how to fix or optimize one problem, they can spend a few days/weeks to learn more than experts in unrelated fields.
As an engineer (had to, very sorry) I noticed there is a 50/50 split between the “I am always right” and a massive imposter complex.
Doctors, never see the imposter complex. It’s kind of ridiculous. We also have to remember that science and engineering lead the advances in medicine, and most doctors fight us tooth and nail for the last several decades. They didn’t want to even wash their hands. Surgeons refuse to follow checklists thinking they are infallible, but when they do there is a measurable drop in patient mortality and infection.
Doctors and surgeons are glorified tech workers that need to be taken down several notches.
I definitely agree that the issue seems much more pervasive in doctors. Even my brother-in-law, who is about the least confident, most “imposter syndrome prone” person I’ve ever met has changed significantly since he graduated from med school, becoming first confident, then overconfident, so I definitely think it’s a culture issue.
And while my experience with engineers was much more than 50% in the “I’m always right” camp, I am not a practicing engineer and most of my experience is from my time in a ChemE PhD program, so I was definitely seeing a skewed population.
Most medical doctors are just mechanics that specialize in troubleshooting one particularly poorly designed device,
I see a similarity to lawyers here.
TBF, yes, but doctors who also study engineering disciplines are a bit better.
Still, I’ve met a few very arrogant over, say, things I do for years vs them having had a few seminars, but I think this concerns people who study well in general. They can’t psychologically accept that a person with ADHD who just won’t have the patience for their studies can know some narrow subject much better due to hobbies and simply job experience.
This is my experience with IBD and drs. I have to explain the disease to them for them to understand so they can make decisions. I don’t know why my consultant doesn’t just make the decisions instead when he’s the expert.
It reminds me of this video. The biotech girl with a PhD in cancer biology was so sure she was the smartest person in the room until she took an IQ test and ranked behind the military guy everyone picked for last.
The video is making a decent point, but doing it in a very, very flawed way. IQ tests are far from unbiased and don’t really test intelligence; they test how well you can take an IQ test. And since the structure and questions on IQ tests are very biased against every demographic that’s not “white, upper/middle class, male” all this video really shows is that a dude in the military knows how to take an IQ test.
I only linked it to support OP’s point that doctors are just normal people but tend to be very overconfident. Your point is correct but I don’t think it detracts from what I’m using the video to illustrate.
The whole video is a fun watch to see how people behave in tense social situations with strangers.
The biotech girl with a PhD in cancer biology was so sure she was the smartest person in the room until she took an IQ test and ranked behind the military guy everyone picked for last.
Apparently you really want to think that an unscientific “intelligence test” designed by a Nazi (look it up) better summarizes a person than a PhD in cancer biology.
Being smart is different from being fit for IQ tests, or for human computer job, I think these people would score well in IQ tests, but nobody would consider them smarter than engineers and scientists for whom they’d make calculations.
I haven’t yet finished watching the video, but judging by the quality of recommendation, she might really have been
the smartest person in the room
.
OK, at this point I’ve finished watching it and that girl ranked people based on what she called “social intelligence”, saying that explicitly, in contradiction with what she said in the beginning of the video. She seems to worry about that a lot, and that appears to be her weaker side, so - oops.
“The military guy”, I think, just wasn’t distracted by the situation, makes sense.
In his ranking, 6 - really cares about his appearance, wastes emotional resources unnecessarily, 5 - a bit of the same, and also arrogance, 4 - not too much arrogance, but a lot of nervous attempts to be social, 3 - similar to 4, but less nervous, 2 - still a bit strained, 1 - himself.
EDIT: and it makes sense that 6 noticed the same emotional problem in 4, LOL.
Anyway, I’ve scored ~120 one time, ~170 another time, I can’t take them (EDIT: these tests) seriously.
Would you be more likely to visit a doctor who could confidently diagnose everything, or was willing to admit they aren’t 100% sure? Most people want answers, and would change doctors if they don’t get an answer, or an answer they want.
That is true. But it sounds like he had decent evidence?
I agree with the fact that doctors shouldn’t just diagnose everything because someone says that’s what they’ve got.
A doctor who can confidently diagnose everything wrong is the worst kind of doctor. Even one who confidently diagnoses a smaller portion of things wrong is dangerous, because they will ignore evidence to the contrary. I’d much rather have one who says, “I think this is what you’ve got but we’re going to test to be sure.”
It’s not so much they don’t admit they don’t know, it’s that they tell you nothing is wrong.
I really appreciate that my doctor will regularly admit they aren’t 100% sure, and often sends me to specialists and for labwork to eliminate worst case scenarios and run things down.
I’d be more concerned if they just wrote off my concerns and symptoms because they couldn’t immediately connect it to anything other than say, stress and lack of sleep.
That said, my relationship with my doctor is probably not the norm due to some lifelong health stuff that keeps me going in every 3 months or so, and I’ve had the same provider for a good number of years. We’ve had enough time together for them to know how I approach my symptoms and health.
I’m also privileged that I have decent enough insurance, salary, and job that allows me to go and actually do all that. Most people don’t.
Back to the point though:
I totally understand the “just fix it!” mindset, but I feel like anyone who has had to spend a decent amount of time troubleshooting anything should realize that isn’t always possible. Especially with things regarding the human body.
How many different things can go wrong with a car, a computer, or a business process, that from the outside all look like the same issue? None of these are realistically comparable to the complexity of a person. You’re going to expect someone to just listen to a few minutes of your whining, pat you on the back, and send you off with an 100% reliable solution for an issue with something as mind bogglingly complex as a human body?
You can’t just drop your body off at the shop, have a crew of people take their time diagnosing and fixing it, and get it back when they’re done. You’re going to have to hual that death trap junk heap from place to place yourself to get it in front of the right people first. They might have to call in a guy who’s familiar with your specific make and model, or a guy that’s experienced with electrical systems.
I dunno, the idea of some sort of “quick result” doctor visit that solves your exact issues and doesn’t tell you things you don’t want to hear just seems incredibly naive.
Agree completely, I too have lifelong health issues and I relate a lot to what you’re saying. I hope you find better health and peace soon.
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I guess probably because of crazy people insisting there are worms in their skin
That sometimes happens.
I was once almost killed by a doctor who wouldn’t believe me when I said I thought I had pulmonary embolism and sent me home without treatment, saying to “not use Google to diagnose myself”.
I’d be dead today had I not returned to see another doctor the next day.
I think if you name a suspected medical condition at the admission they are far less likely to believe you.
I know I’m a minority but as someone who works in emergency medicine I think the opposite.
If you come in thinking you have something there’s probably good reason, and I damn well better be sure you don’t have it if I’m going to send you home. You know your body better than me. It may not mean we test for it, but I need solid clinical decision making tools to support not testing for it
Usually that tool is that I’m a woman
It could be an embolism, but first let’s check to make sure you aren’t pregnant…
True, they might end up in prison for treating you…
I don’t understand, do you mean risk stratification in a specific clinical practice guideline based on gender?
I mean that doctors (emergency or otherwise) tend not to listen to me because I am a woman.
This changes when a (cis, white) man is present.
Happened to my ex wife, and I assume it keeps happening. She has Graves disease for years and told Drs something was wrong, but since she was heavy they just told her to lose weight.
It was left so long by the time they caught it that the cognitive decline that thyroid problems give you, were irreversible
Thats terrible :( I am so sorry
I’m sorry that happens to you. Unfortunately it’s a documented phenomenon (especially with rheumatologic diagnoses—I’ve explained that to residents a lot).
Here’s to hoping more attention to this leads to better education which can prevent it.
Thank you - and thank you for doing your part to educate residents!
That’s how it should be. It’s astonishing to me that some doctors don’t take the chance that the patient might be right
I just don’t understand how you can ethically practice with the opening assumption that your patient is wrong.
I get just as angry when staff get judgy about who goes to the ER when. Everyone defines their own emergencies. It’s why we’re there 24/7/365. For a lot of people we are the only no questions asked lifeline that’s always open (at least in the US)
Was also sadly my experience. Got a cut because of a collapse, told them that I have heart failure since a kid and this felt strange, but they never did any tests, just wanted to send me to the psych unit.
That was a pretty fucked evening…
What’s the rest of the story? (If you don’t mind sharing) This feels wildly incomplete.
Well, the doctor that sewed my cut was quite reasonable and I could at least leave.
All that happened because of an anonymous call, that I just had a long term relationship behind me.
Thing is, that they just ignored my initial report, as they immediately switched to the story of an anonymous caller. Which is a pretty shitty move
Anything more in details, and I’ll completely lose my pseudonymity, sorry
No worries, and thank you for sharing.
Yeah, you’re definitely in the minority.
It’s a shame too. A lot of this occurs due to the egos of medical professionals, rather than genuine concern that the patient might be going off the basis of misinformation.
#notanexpert . my understanding that ER/ED basically only have moderate responsibility to judge that you will not die and sue them in the next ~24h after an event. they tell you to seek further primary care when discharged.
The job of EM is stabilization and resuscitation. That takes a wide array of forms depending on your presenting condition. There is no “time limit” on what entails a safely dischargeable condition—if you present with chest pain, we CT you, and don’t find an immediately emergent cause of your chest pain, but in the process we fail to tell you about the lung nodule on your CT that turns out to be a CA that kills you in several years we are still liable. Maybe in certain states we are not medical legally liable at that point, but I would argue that we ethically still are. We are still all physicians (unless you’re getting treated by an APP).
In the context of stabilization and resuscitation I personally have the take that if you present with something I can’t adequately diagnose in the ED (let’s say I can rule out life threats but you still have a condition that is compromising your quality of life) then for the next step I really have to ensure adequate follow up for you (subspecialty referral, etc). That goes for the underinsured as well. It can get tricky, but that’s what case managers and social workers are for. Maybe I’m just biased because I work in academics. In general if you need emergency care I highly recommend that you go out of your way to get to an academic center because you’ll be more likely to get plugged in in this regard.
Thank the opioid era for that.
It’s only slightly worse now. The problem has always been bad, it’s just that a lot more people have had occassion to notice it now.
I was 25 when I was diagnosed with Ulcerative Colitis (IBD) I went down to A and E because I had bad swelling on my feet and I couldn’t walk at all, the doc told me it was muscular and have epsom salt baths. Next day swelling was worse so I made an emergency appointment with my GP who did tests and sent me to A and E for further tests. Basically after being admitted to hospital they realised that I had an infection from my ibd and I had lost a lot of blood that they gave me a transfusion. If I listened to the first Dr at A and E I could be dead now.
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Oh wow, yeah it would be tough to go to emergency care if it costed money. I hope that never happens in other places and you guys eventually get that fixed. There should be nothing stopping you or making you second guess if it’s a good idea to save your life.
ED bills are sent afterward in the US, we never have to think about it up front. It’s governed by a federal law called EMTALA. This led to some predatory “out of network” billing in the past which thankfully was shot down (in all things) during the Trump admin. It’s not perfect, but getting better.
I guess it’s just very difficult for the doctor if their interpretation of the evidence says that you are ok. They must choose whether to believe their patient, or to trust in their own knowledge and training. In your case, the doctor made the wrong decision and it almost cost you your life. And in other cases people definitely do die due to mistakes made by doctors. … or at least, the people would not have died if the mistake wasn’t make - that doesn’t always mean it was the doctor’s fault though. People are imperfect - especially when under pressure; and sometimes the strategies that save lives are the same strategies that let other people down.
I’m reminded of a TV series that I enjoyed, called “This is going to hurt”.
“Your injuries are not service related”
“Best I can do is 50%”
“But that would make me 130% disabled…”
“Best I can do is 90%”
Ah yes, the VA, the only institution that has its very own math. 50+50+30+10=70
Where 60% is 100%, if you can get it.
VA math:
50%=50%
+50%=50%×50%+50%=75%
+30%=25%×30%+75%=82.5%
+10%=17.5%×10%+82.5%=84.25%
I want to rewrite that scene from Liar Liar when Jim Carey yells at the impound driver to fit the VA claims process.
Oh yeah!
“What are you gonna do…”
NOTHING! Because you will just lose my paperwork and make me resubmit for years! Then you will send me to a doctor that is 105 years old and hates that the sun came up. Your board will look at my gunshot wound and say it’s not service related. So I am going to piss and moan like an implant jerk.
That just makes me want to scream all over again. It took me nearly a decade and a AL judge to get the VA to listen to me.
Yeah… it definitely sucks, but explains what was going on and why the guy seemed to lose his mind.
I wonder how much longer we’ll see people playing sports like football or UFC as brain trauma becomes better understood.
That’s a good question as sports are ingrained and you can’t take away people’s tribal entertainment without consequences. Panem et circenses and all that.
But we can switch to things like tennis or fortnite which don’t carry the risk - knowing that just from training your kid could get brain damage wouldn’t you try to encourage them into something safer?
I tried watching some Fortnite streamers, pretty sure it left me with more brain damage than my two deployments.
It’s really interesting reading all the information coming out of rugby right now. It’s changed so much over time.
From my memory it went.
Concussion can kill you but if you get up with no symptoms you’re fine. If you have symptoms wait until they go away then you’re fine.
If you get a concussion and get up and you are fine but have another concussion shortly after you can die. You just need rest and then you are fine.
If you don’t get knocked out you might still have concussion.
Repeated concussions can cause permanent damage and that damage can stack and make you more prone to new ones.
You can get brain damage from non knocked out big hits. This can manifest itself years later
Then when shit really hit the fan. Basic bog standard training sessions where you have no negative symptoms can cause brain damage if you do them too often. This is where we are now. Maximum contact training is in place. Players are getting g force sensors in their gum shield.
I can see this going futher to having longer breaks in games with recovery periods. They have changed the rules a about as much as they can. Head guards will probably be mandatory soon.
Finally the game might even die. But I expect the risk of brain damage when managed is less than the pros that come partaking in the sport.
deaths related to a second impact are not fully understood. some believe it may just be underdiagnosed latent brain bleeds.
Similarly in ice hockey I believe
The last 15 years have been weird.
I watched some documentary about enforcers and some guy ended up having cte.
Both games have changed so much from what it was like in my dads generation, it was part of the game trying to hurt people.
There is no reason to doubt that concussive force concusses the brain. I imagine getting insurance assholes and the military brass to give more of a shit about it is nigh impossible though…
This is not justifying the shitty treatment of vets by the VA or by insurance companies.
The problem is that medicine has long focused on severe acute traumatic injuries. The kind sustained by military individual are mild repeated concussive injuries without an immediate onset of symptoms. We have only very recent learned about the additive effects of long term repeated trauma to the brain like those suffered by American football players, boxers and military individuals.
i didnt read the article or all the comments.
but my impression is a good MRI would be more than enough. no?
maybe the interpretation of the results were not done carefully.
#notanexpert
pretty obvious that DAI is certainly a recognized thing.
maybe DAI is less studied than open head injuries in humans.Neuroradiologist here. 👋🏻
The short answer is not necessarily.
I think the main reason for this difficulty on the imaging side is that the brain is such a highly tuned, precise instrument that doing small areas of microscopic damage (below the threshold of medical imaging to detect) can still result in noticeable dysfunction (so a brain can look normal on MRI but have damage too small to see). Secondly, the MRI appearance of chronic trauma overlaps hugely with other, more common conditions.
In a research/university setting there is improved ability to detect some of these cases using advanced or experimental techniques that aren’t common out in the community setting, but even so I would wager that there are a significant number of cases that fall into the “looks normal” category.
What the VA told me was that blast injury is like CTE in a football player’s brain. They aren’t detectable before death because the damage is widespread at the microscopic levels. Basically trillions of brain cells connections that didn’t heal right each time you get a concussion. It’s not one big thing that shows up on imaging. They have to put slices of brain on a microscope to see the damage.
And no that did not make me feel good about getting older…
maybe the interpretation of the results were not done carefully.
That’s a weird assumption to make, without any facts in evidence to the contrary.
