What is the universe trying to tell me with this?

As far as how I’m doing, it’s close to an exact copy of this post, so I won’t go into it. I had a very nice call night, though, now that I’m feeling slightly better. Actually, it was a horrific call night, in that patients kept coming in nonstop for the whole night. The volume was one of the highest I have ever seen. I did not eat, drink, or take a piss for 16 hours. There was no five minute break to catch my breath, to smoke. When I sat down to write letters, I felt my heart pounding from dehydration, but didn’t even have time for a glass of water.

But once I felt better, I enjoyed the patients again. I found my sense of agape for them again, for all their funny ways. Also, the excessive patient load meant that there was no time for dinner so I didn’t have to spend an hour listening to some docs talk about the usual medical politics and their crap. Everyone was so busy that I was spared interaction with the other docs…and the other two were both decent ones, two young women, who are on the low end of the jerk scale for the internal med folks. One even has a nose ring – I wanted to ask her if anyone ever said anything about it.

Even though it was brutal, I liked the work and felt useful again, and only had brief moments of an overwhelmed feeling.

Here is the funny thing from the universe: I saw about 6 psych patients in a row, all sent for medical clearance. Our emergency room is run by specialists at night – there are no “ER docs.” The on-call physician (resident) for each department covers the ER, and triage directs the patients to the appropriate specialty. When I work there, I am either working as an ER surgeon or internist, doing either the stitches or the heart attacks, but not both.

Sometimes patients come in and are triaged to be seen by more than one specialty. This is a horrible system, an excess of a tertiary care, behemoth university hospital – people never get out of there, and often the nurse who does the triage is not very good. Most of the patients  could be handled by a primary care person, but they aren’t.

An example would be a minor head trauma. Someone gets hit by a baseball, and gets a black eye and a big lump on his forehead, let’s even add that he needs three stitches above their eyebrow. Low impact trauma, no loss of consciousness, no vomiting, no reason to think of a fracture. If this person were to go to his regular family doc, he’d get a quick evaluation of the eye and eye movements, brief neuro eval and explanation of dangerous signs to watch for, a stitch-up, and be sent on his way.

If he goes to our major tertiary care center, the triage nurse, who is often also not an RN, will triage him to ophthalmology, neurosurgery (they clear all head trauma), and plastic surgery. The plastic surgeon is in the theater, so that’s a wait of three hours. The neurosurgeon on call refuses to see patients without a CT, so that’s extra radiation and cost. The eye doc is a typical eye doc and refuses to leave the eye department in another building to come to the ER, so the guy has to get sent over there with medical escort. What could have been a fifteen minute in-and-out turns into an 8 hour ordeal. Don’t even get me started on this subject because I will FLIP OUT.

Here’s the weird “message from the universe” part. After I suddenly started feeling better and being able to work again, on that very same call night, I ended up seeing six patients who were triaged to internal medicine + psychiatry. That’s really rare. Usually I go weeks at a time without seeing a psych patient who comes for both psych and physical illness.

Trying to fix their psych problems would drive me crazy, be so protracted and Sisyphean that I’d lose patience. But seeing them for medical problems made me feel like I was in the right place, like I had a calling. I knew that a lot of doctors wouldn’t treat them as people, would lose patience, would count them off as crazy. I was glad to see them, without judging.

I actually felt like I was good at what I was doing, mixing medicine with the humanity that only recently started to come back. I’m, of course, changing a lot of details, though no case was particularly unusual, all were the kinds of things seen in any ER shift.

For the first time in a long time, I didn’t want to run away from clinical medicine. While I’d never choose to have the kind of suffering I have, I felt that maybe my being crazy had given me a gift; I’m not sure how to describe it without slipping into a cliche that I don’t mean. Not the “gift of empathy” or anything bullshit thing like that. Something less specific, something amorphous. Appreciation for crazy, and the people living with it wiggling around in them, maybe.

The first forty-ish guy was talking incredibly fast with circumstantial thinking who kept returning to telling me about his stress at work. I couldn’t even get out of him why he was in the ER except that when he started his monologue there was some phrase like “funny feeling all day.” I let him go on for maybe 5-10 minutes, waiting for the story to come out. It didn’t.

The ER docs hate me for this, that I don’t interrupt patients (it feels rude to me, but my go-with-the-flow approach often makes me look unauthoritative) because they want always a very quick, single complaint, direct history in two minutes. But if you let them go, most patients get to the point within a minute or two anyway, and I don’t feel rude.

This guy didn’t. He just recapped all the events of his day in a very flight-of-ideas manner about how much pressure he was under. Then, in the middle of a run-on sentence about his soon-t0-be-ex wife and how today he had to fill in for someone else at work and said, in the same racing speech, almost incidentally, “Oh, there it is, the pain again…then I was at work and at the last minute they told me I needed to do something for Paul and I got nervous…” He kept going, apparently undisturbed, but also turned gray and started sweating during the same monologue.

“Wait, stop, we’ll talk about work in a minute, but what pain? Where does it hurt?”

“You know, like today when I was going upstairs at the last minute to fill in for Paul, butterfly feeling here in my chest.” He then did the classic heart attack hand thing.

I immediately went and grabbed the nearest EKG machine (didn’t want to wait for the technician to show up), and hooked him up, while all the while he was talking undisturbed, but also looking just like a guy having a major heart attack. Sure enough – huge anterolateral infarct.

It was a strange thing – easily could have been dismissed. If he had been seen in the first ten minutes, between the pains, with no story other than “butterflies,” he could have been discharged and dropped dead in the street. I could have dismissed him as crazy if I had been feeling less well and less patient myself, if I had been depressed like I had been the week before.

But I didn’t miss it.

I’m not saying, oh look, I’m a great doctor, I listen and help, and those ER docs don’t. I could have missed it as easily as any one of them. If I had seen him in the standard 7 minute visit, it is entirely possible that I would have heard “funny feeling in my chest” in a patient who young, was obviously highly agitated and under a lot of external stressors, without seeing the heart attack. Anyone could have dismissed him under the heading of anxiety.

This particular day, I had started to feel better, to want to help people, felt once again able to care. And this particular same day, there were six patients who, I think, were uniquely helped by me. It seemed well beyond coincidence.

* * *

Another patient I saw had catatonic schizophrenia, first outbreak. I don’t know much about that state, I think it is kind of rare. There was the waxy posturing. Eyes closed, she was unresponsive to speech and much of anything, except by breathing and swallowing. I was called to rule out a medical cause, though the story was classic for schizophrenia.

I was curious. I don’t know what exactly that state is, other than recognition of the clinical definition of it. I don’t know what it is like inside, whether it is a result of a psychotic delusion or hallucination that instructs them to stop moving, or a reaction to overwhelming internal stimuli, or a movement disorder related to dopamine disturbances at the core of the disease process. I still can’t find an answer to the internal experience of it – only phenomenology. If anyone knows what it is like inside or can find a description, let me know, please.

I didn’t know what was going on inside, but I decided to assume that she could hear outside stimuli as well as whatever the internal ones were, it seemed like she changed breathing patterns sometimes in relation to things her family was saying to her. And in my past experience, external stimuli get through the overwhelming internal stimuli. You can communicate, at least partially, with someone in a psychotic episode. My gut feeling was that it was an overwhelming internal delusion that forbid her to move. I thought that if it was a terrifying experience, if something was threatening her not to move, that a physical examination would probably be a pretty horrible experience.

So I tried to explain in the most non-threatening voice possible that I was a doctor, I was going to examine her, it wouldn’t hurt, and if I touched something that hurt, to please give me some kind of sign so I could help her. I have no idea if she heard or not. There was no way to make any connection with her, but I hope that at least it was as gentle and nonthreatening as possible.

* * *

A girl was brought in by her parents the morning after taking an overdose of a benzo. It was far from the first time, though she was young, college-aged. She’s the one I mentioned in the last post. The quick way she slipped into anger and the surrounding entourage meant to me that most probably she had borderline traits/disorder, but she was a person, with a million other qualities besides that.

By the time she got to me, the short acting benzo, of which she hadn’t taken that much anyway, was far out of her system and there was, as they say, nothing to see. The first thing she asked me was if she was going to get an NG tube. Ah, the voice of experience. I didn’t want to do the whole psych evaluation, I didn’t want to be so clinical. I just asked her if anything particular had happened last night, and she said no, just a buildup of being sick of it all, a collective sense of hopelessness and exhaustion of never being better.

I just said, “Yeah, it’s like that sometimes.” I meant it. I liked her.

While examining her, I asked what she thought would happen when she did it. She got some tears in her eyes and said, “I didn’t want to wake up.” But she didn’t mean it. They were those forced tears, trying to show me how miserable she was, one of those bids for sympathy, an inability to be able to name her problem and express it. She was trying to show me how much it hurt in the only way she could.

Instead, I joked with her a little and she laughed. I wanted her to get a good consult, so I told her, “Let me go see who the psychiatrist is today, if it’s someone ok. If not, maybe we’ll just talk.”

She laughed, and said, “Yeah, you wouldn’t believe some of the ones I’ve been to.” I laughed too. “I know what you mean.” God knows I know what she meant.

I left her behind the curtain with her parents. I didn’t know the psych on call, if he was any good or who he was even. I called him to let him know he had a consult. Pretty soon there was yelling from behind the curtains, but I didn’t hear the specifics. I didn’t get involved.

One of the things I like about dealing with people with borderline is that they’re so changeable. By the time they actually get to the emergency room, they’ve usually chilled out. They’re mercurial, like quicksilver. It’s not like dealing with someone who is depressed, with that heavy atmosphere, the hopelessness. With the right attitude, you can almost always share a laugh with them, joke them out of their misery and into some human contact for a minute or two at least. If they’re furious at you, it’s ok, because it will blow over sooner or later and you can go back to being cool.

* * *

I’d like to write about one more case, but I’m pretty busy and have to attend to some things today. Tomorrow I’m back on call, but in the surgical ER instead.

The point of all this was that it was such a strange coincidence. On the exact same day that I returned to function, I got all these psych patients who I really liked, who were a good fit for me as a doctor. Maybe that’s my niche. Not psychiatry – I’m not interested in trying to fix the mental health problems, I mean, as far as my opinion on that, people are what they are, and if they’re crazy, well, that’s just what they are and it’s not my place to pass judgment.

But maybe I should just be their doctor, one who can look past the crazy, or understand it, or even like them better for it. Maybe that’s the right place for me to be.

* * *
I started the new year with a visit to the shrink. It was alright. I am more normal now than I have been for a while. And inexplicably, he said he didn’t like the bupropion on me. I have no fucking idea why. I kept asking, and not getting a real answer. “It has side effects, and we want something that is going to be long-term.” I said I can live with the side effects (eye tic, panic attacks), that I feel normal again, that even the good old drug had lots of side effects.

I never know where the fuck he is coming from.

It’s odd, even though I feel better than I have in a while, all the sudden he’s saying I’m not ok. For once, I was actually present, not through the filter of depression or a hypo/irritable state, and I get a really bad reaction from him. I just don’t get it. I left there with a very unsettled feeling about the whole thing. I meant to address this directly (the phone call, and I guess today is an extension of it). I have no idea if the problem is with me, or with him. But I ran out of time before bringing it up.

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7 Comments

  1. Excellent call, Sara on the Cardiac case. And i really liked the way you were with the psych patients. Interesting thoughts on Borderline… All ’round excellent post,
    thabks, tracy

  2. If everyone wants to hear the other cases, if this turns out to be the kind of post people like, I’ll try to put them up too.

  3. Hi Sara,
    Yes…please write about the other cases. I love these posts. It puts you in a context and I see how skillful you are at helping patients who needed to see you…not anyone else, but you. I love the idea of you being a dr. for people with mental illness (not a pdoc) but a primary care doc. It sounds like you have a nack for helping those of us with both mental and physical health issues.

    The man having the heart troubles was blessed to have met you as his dr. and not someone else who might dismiss him because they didn’t take the time to listen to what was going on behind all his rapid and disconnected speech.

    Happy New Years and a happy year to you. I am glad to hear you are feeling a bit better.
    …aqua

  4. Awesome. I like knowing that you’re feeling better. I also love hearing about your cases (as much as you can write about them… I know it’s a very fine line).

    I admire you very much.

    Are you by chance getting a 2nd opinion on the Bupropion?

  5. Sounds good that you might be finding the job for you, or as you say where you fit in the universe kind of thing.

    Sounded like good doctoring to me that you do

    graffiti

  6. Hey everyone,

    I will try to put up the other cases. But I’m headed back to a call night now (Friday night, yikes) so it will be a couple days.

    I am not getting a second opinion on the bupropion, but I’m not quitting it either – did I give that impression? I’ll give it a couple weeks, see if the nausea dies down and also see if once the secondary change effects kick in it might turn down the anxiety too. I would rather augment this with something for anxiety if I have to than toss it altogether and start the roulette game again.

    I wish I didn’t have to work 30 hours straight. I’d like everything – job, life, patients – so much better.

  7. no Sara, it is alright… please say it and say it out loud: you are a great doctor. please don’t be ashamed. i imagine myself being kicked out of the emergency room for not being able to explain my problem. and be ignored, but you did not ignore him, you saved his life and this is because you are special and have a gift and are a great doctor indeed.
    lots of love and hugs from your friend Milo.


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