Free Associating in the MRI Scanner…

 

I finished my second MRI scan this year earlier this afternoon. So far lifetime – I have had 5 and will have 6 by the end of next month.  I am sure that many people reading this have had the experience and I would not rate it as pleasant at all.  Just the obsessive checklist that must be completed prior to the scan is enough to raise the anxiety level. Is my body free of implanted or tattooed or accidentally placed metals?  When they were scanning my pancreas – my first thought was: “What about that laparoscopic cholecystectomy I had done in 2019?”  I had read the operative report and it described two permanent clips being placed on the cystic duct prior to dividing it and removing the gallbladder.  I contacted the surgeon about that and he was certain the clips were not ferromagnetic.

One of the last questions is: “Are you claustrophobic?”  And if you are is your primary care doctor prescribing a sedative and if you take that sedative is there somebody here who can drive you home?” I would be hard pressed to think of many people who would not be claustrophobic in an MRI tube.  After all you are in a tight space with very loud noises for a prolonged period. As the radio frequency waves are generated the tube heats up.  It is better than hurtling through space in a larger tube during air travel – and I smiled to myself as I thought of the comparison.

In all cases I have been given a headset and asked about musical preferences and volume.  So far, the headsets don’t block the sound of the machine and obviously are not noise cancellation devices. It did lead me to think about designing headsets without ferromagnetic materials and what that might involve. The only designs I have seen so far use air conduction through tubes rather than electrical connections.

Music selection is as much of a problem as the low-fi headset.  I forgot to ask if I could use my own playlist – but it was safely locked up far away from the 1.5T magnet. I tried to be more specific this time: “Have you got any Canned Heat?”  My most recent play list starts with 3 Canned Heat songs from 1967 – but looking at the tech I estimated he was born in 1980 and the other in the 1990s.  When they rolled me out of the tube one had been replaced by a woman with brightly colored hair who may have been born in the 21^st century.  I changed my answer to “Classic rock.”  That can be a disappointing genre because too much of it is bubble gum music.  Over the 30 minutes in the tube, the heaviest it got was AC/DC Highway to Hell and James Gang Funk 49.  I did enjoy Steve Perry (Journey)  and was tempted to sing along like I do in the car.  But I am sure that would have not been a good idea and may have resulted in additional imaging time and I can no longer hit the high notes.

My mind wandered to fMRI research. How in the world can research subjects be expected to produce real world results from inside the catastrophic MRI world?  I decided not to include my real catastrophic thinking in this post because it is idiosyncratic and I don't want to affect anyone else's decision to get an MRI scan.  And today I just had one or two brief thoughts. I spend most of the time in the tube actively distracting myself and doing sigh breathing exercises to control my heart rate.  Today I opened my eyes in the tube – briefly for the first time.  All I could see was an expanse of whiteness in front of my face with a row of fasteners bisecting the field.  I was pleasantly surprised to find it was about 6 inches away – farther than I had imagined it.  

While I was thinking about research, I also thought about all of the MRI scans I had ordered on my patients.  Going through the procedure yourself leads to questions about the how it is presented to patients for informed consent. I was careful to describe the issues with confined space and noise as well as the advantage of no radiation and better resolution.  Being hospital based, I had the advantage of an anesthesia team being available to sedate and monitor patients who were unable to tolerate it. As I was showing one person their results by holding the film against a window in their room they fainted and I was able to catch them on the way down.  The realistic appearance of the brain in that scan led to that reaction.

Forty years ago, I was an intern in this hospital. My very first rotation was Internal Medicine.  Back in those days it was a county hospital.  Today it is a massive flagship hospital of one of the largest health care organizations in Minnesota. That included a building program to the tune of hundreds of millions of dollars. The original hospital remains at the center, but it is obscured by new wings and buildings. The parking lot I parked in did not exist at the time.  There was a lot out front that you accessed with a magnetic card.  One night I was working late and a guy approached me for money as I entered that lot. I handed him $20 to avoid what I thought might be coming. It was a tough neighborhood.

Once you enter the building – you can step back in time where old meets new.  One of those places is medical imaging. During internship and in the 22 years I worked there radiology (as we used to call it) was one of my favorite haunts. I knew the radiologists and knew I could ask them questions about films.  Surprisingly many of them had questions about psychiatry. Before the electronic health record, I would make a drawing of the positive findings from CT and MRI scans and redraw it in the patient’s chart.  As radiology became digitized it was easier to cut and past images.  I could still discuss images with the neuroradiologist.  I missed all of that when I left that practice.

The MRI tech comes over the headphones:  “OK we are going to come in and inject the contrast.”  They know I had a mild reaction to CT scan contrast but the MRI contrast is gadolinium based and I have had it before.  The last time they checked my pre and post creatinine levels, but at this facility that is replaced by questions about renal insufficiency and dialysis.  That seems like a high bar.  He checks in again in 5 minutes to make sure that I am not having a reaction.

Another sequence of radiofrequency waves starts and there is a pulsating beat that reminds me of a rock and roll song.  I try to recall the song just based on the beat.  I check my muscle tension and realize my shoulders are rolled forward – so I force myself to relax, move my neck, and do some patterned breathing. I would really like to hear some Nirvana at this point.

The tech is on the headphones again.  “OK you are doing great – 5 minutes left.”  That reminded me of a previous scan when I got a similar message and remembered all of the songs that played afterwards.  This time ZZ Top LaGrange comes on. It is a 4 minute song.  At the end – they roll me out of the tube and tell me I have done a great job.

Last night I was wondering whether I was getting progressively more anxious about MRI scans or whether this was a form of exposure therapy. I was surprisingly calm during this one and more confident that I will live to MRI another day.

 

George Dawson, MD, DFAPA

Supplementary:  I have received some early feedback on why I am getting these MRI scans. First and foremost - I am interested in addressing serious problems and preventing disability. I personally know many people who were disabled as the result of spinal injuries that occurred from seemingly trivial events like turning to see someone walking through the door or turning over in bed. I am also aware of age related injuries that occur in active people. Falling off your bike at age 70 is not the same as falling off your bike at age 30 or 40.  All of these scenarios suggest to me that numerous age-related changes in the spine in the absence of any course of effective strengthening can lead to catastrophic problems.   

In addition to the symptoms, I would like to get an opinion of whether it is safe to do aspects of my exercise routine.  I would really like to get back out on the ice speedskating - but I am not going to if it means I will get progressively disabled from spinal problems.  I saw Lindsey Vonn speak to this recently.  I am certainly not comparing myself directly to one of the greatest skiers of all time - but I could relate to why she finally decided to quit.  

“My body is broken beyond repair and it isn’t letting me have the final season I dreamed of,” Vonn said. “My body is screaming at me to STOP and it’s time for me to listen.”   

A lot of aging athletes like myself have the thought that as long as we exercise and stay very active - we will be able to continue in sports as long as we want.  In retrospect, I think I have shown that you can certainly push it much farther than expected and much farther than average - but like the best there is a breaking point. 

Without yet knowing the result of this scan - the possibilities are significant. In the ideal world, it will show age related changes and that would just indicate continuing the physical therapy that I have been doing for 20 years.  If a potential surgical problem shows up that is more complicated.  I do know skaters who have had back surgery and most back surgery has highly variable results. I have also observed and assisted on many back surgeries in medical school where neurosurgery was my preferred surgical rotation - but I assume surgical technique has improved greatly since then.  Would I get back surgery if there was a high likelihood of symptomatic relief and I could return to skating?  Would I get back surgery without that guarantee?  All of that is up in the air at this point. 

Image Credit:  Image credit and Creative Commons licensing can be obtained by clicking directly on the image at the top of this post.

The Tomorrow River

 

The Tomorrow River is a small Wisconsin stream that crosses US Highway 10 three or four times between Fremont and Waupaca.  It eventually runs into a creek and becomes the Waupaca River.  I crossed all those tributaries twice on a trip last weekend. It gave me the usual opportunity to free associate to my past life. Two memories came immediately to mind – both from about 1977.  I was freshly out of the Peace Corps and trying to establish myself in a job as a research assistant cloning trees at an Institute in the area. That involved a lot of travel down Highway 51 to Highway 10 and I did not have a car.

One day I was travelling on a Greyhound bus heading to my apartment.  That was the first time I caught the Tomorrow River sign, as I looked up from a letter I was writing to my friend Glenn. I had a good experience in the Peace Corps entirely due to the Americans I met in my group.  They were bright, excitable, and energetic. We had gatherings where we listened to music, ate pizza, and played basketball.  We had long discussions into the night about what was important, what art meant, literature, music, math, science, and the meaning our work as high school teachers in the Peace Corps. We read the hipster literature of our time – Kerouac, Pirsig, Kesey, Brautigan, Wolfe, and others.  There were animated discussions and arguments.  All of that probably influenced the letter I was writing and then I saw the sign. The letter took on a surrealistic quality that Glenn appreciated in a letter he sent back to me.  As I visualized that decades old experience – it was a good feeling. I still feel a connection to my Peace Corps friends even though it has been decades and we rarely see one another or communicate.  I know that when I do – we will pick things up the way they have always been.

Between the second or third Tomorrow River sign there is an uphill curve in the road that bends to the left when you are traveling east. It is a long half mile bend. Later that same year just after Thanksgiving – I was getting a ride to my apartment from my friend Walt.  We went to the same high school and college. He was two years younger than me. Walt’s personality was completely the opposite of me. He was spontaneous, outgoing, and engaging. He could joke about anything.  I was the lab assistant in his organic chemistry section and one day his condenser hose broke loose and started spraying water just over the top of a freshly cut pile of sodium metal. I was able to grab the hose and redirect it.  Luckily there was no contact with the sodium, but after that point he started referring to himself and his lab partner as Captain Sodium.  On that day he was dropping me off and heading to his graduate program in endocrinology in Chicago.  The weather was not cooperating.  On that bend – the traffic that was usually travelling at 65-70 mph was at a dead stop in an ice storm and backed up for miles.  We both got out for a better view and realized it was impossible to stand on the road. Even  maintaining your balance, you eventually slid from the highest to the lowest part of the road and were forced to crawl back across the lane of oncoming traffic. We got back in the car and spent a long time joking about his bright reddish orange Dodge sports car and all of the trash talk he got from people in our home town about that car.  When he walked into a local bar he would hear: "Here comes the Fire Chief!"  We eventually completed the trip and I would see him from time to time over the next decades as he completed his PhD, then medical school, then residency in anesthesiology.  He became one of the top anesthesiologists in the country. And then several years ago, I got the news that he had died suddenly after a brief illness.  He was at the top of his game at the time – a department head and national expert in neurosurgical anesthesia.  I felt badly about not seeing him and not congratulating him on all of his success. I always feel badly when people don’t make it to retirement and a lot worse if I know them.  

Even before I went into the Peace Corps, I spent a lot of time navigating these roads with my friend Al.  We did that mostly in a 20-year-old Volkswagen beetle with a defective gasoline heater. When you tried to turn the heater on it might blow the hood open. Al was a mathematical genius and had accumulated almost enough math credits for a major when he was in high school - all self-taught by reading the texts. He decided to go to medical school and that led him to spend an additional 2 years as an undergrad taking the prerequisite courses.  Somewhere along the line driven by my insomnia and his sense of adventure, we ended up driving long distances to other towns at night to see movies or bands that we knew would never come farther north to our college town.  When you drive on roads in Wisconsin, Minnesota, and Michigan unusual things can happen.  When the pitch-black night is underlit by the snow cover – anything can happen. One night at about 2 AM we were on a road running parallel to Hwy 51 north when suddenly – an old model Chevrolet was airborne about 50 feet in front of us.  By airborne I mean it crashed over the top of a 5- or 6-foot snowbank at a high rate of speed and crossed our highway in a perpendicular path.   It landed on the other side of the road clipping the top of that snowbank first.  Turning around it was obvious that this was a planned attempt to launch the car from a parking lot outside of a bar to the other side of the road.  A few seconds later would have resulted in our Volkswagen being T-boned. That night we were able to turn up the radio and keep going.

These are the kinds of associations I have when I am driving these roads.  The paragraphs seem flat compared to the images in my head. I can envision my friends, our youth, images of what happened, the associated emotions, and the thoughts I have stacked on these events over the past 40-50 years. People I knew then often in a casual way.  People who I wanted to know better. People who – if I had interacted with them differently – would have drastically altered the course of my life and the people who did alter the course of my life. People who I wish would call me or send me an email.  People who I regularly think about and dream about.  But then I tell myself – “This is your own weird perspective on life – most people don’t think like this.”  Generally, that is good to know but at the same time – people do reach out from the past. They seem to realize that we are not the same people we used to be – but the common experience means something.  In many cases, it means a lot.  At my 50^th high school reunion, I was sitting outside of the main room when a classmate approached me and asked if she could sit down. I have known her for over 50 years and yet, that conversation was the longest I had ever spoken with her. It was longer than all of the conversations I ever had with her combined.  It was probably the best experience of the reunion.

I should probably clarify that I have no regrets and consider myself to be very fortunate.  All of these thoughts about the past don't cause regret - but there is often that feeling that you get when you go back to your home town for the first time. You see things in a different light.  You realize that you can't go back to the way things used to be. These thoughts have continuity with the present and the future.

At some point in the drive, I do a memory check.  I use the autobiographical memory test format and think of famous movie stars, visualize their image, and try to match names.  So far – so good.

I fantasize - primarily generative fantasies. I first encountered that term in the writings of the late Ethel Persons, MD.  She was an American psychoanalyst I found when I started to research fantasies in the 1990s.  She seemed to be one of the few psychiatrists writing about it. Generative fantasies are primarily problem solving fantasies that are more stimulating than coming up with lists in your head or your software. As I type that I am reminded of another road trip (east of Duluth on Hwy 2) when my wife asked me: "Do you ever have fantasies?' I told her I was fantasizing right at that time and she was very interested in the content. "I was thinking about what it would be like to win the men's 500M in the Olympics." She knew immediately that I was thinking about speedskating. I took up speedskating during residency and got quite good at it in my 40s. I was never an elite speedskater by any means, but I had the movements down, could endure the pain, and skated a lot of laps.  Part of learning the movement had to do with fantasies and thinking about the skaters I was seeing in the Olympics and racing against and remembering any advice I had received. I always have plenty of these thought patterns that seem focused on a hypothetical future.

 As a student of consciousness, I always wonder about how all of these thoughts are generated and (as a psychiatrist) what they might mean. Twenty years ago, I did a presentation on what I called the bus theory of the human brain. In computers, a bus is any system that connects components and allows data transfer between those components.  I decided that there was not enough emphasis on white matter and studied those tracts, their fiber content, and tried to calculate the bandwidth of those fiber tracts. At about the same time, I was wrapping up a course that I taught for many years on dementia diagnosis and cortical localization that was more of a behavioral neurology approach to the problem.  I tried to think of all of the recent papers I had pulled on hippocampal connectivity and recent papers on the neurochemistry of the hippocampus.  I thought about a paper I recently read on entropy and consciousness and whether thermodynamics could be a granular explanation for conscious states.  I am still a skeptic.

My wife wakes up.  We are driving home from her high school class reunion. There is a significant celebrity in her class and he sent a video when he could not make the reunion. The audio-visual equipment did not work, but we could see his projected image. We start to talk about the events of the night and what some of them might mean.  We talk about the A-V problems and the celebrity who clearly has become a projective test for everyone in her class. We talk about how good it will be to get back home and what we will need to do to reestablish the routine.

Thinking is a big part of life for me and life is very good…..

 

George Dawson, MD, DFAPA  

 

Photo credit for this one goes to my wife.  That is a Tomorrow River sign shot alongside Highway 10 last weekend.

References:

1:  Osanai H, Nair IR, Kitamura T. Dissecting cell-type-specific pathways in medial entorhinal cortical-hippocampal network for episodic memory. J Neurochem. 2023 May 30. doi: 10.1111/jnc.15850. Epub ahead of print. PMID: 37248771.