While I wasn’t crazy

The meds (Goddess be blessed) seem to have been working out and things suddenly, almost overnight, turned OK. (For those who are wondering – it’s Lamictal-Paxil, both in very low doses.) It has stifled the writing a little, as well as taking away much of interest to write about here.

I had a lot of last month off – not necessarily for fun stuff, CME type stuff and credentialing mostly, but still…not work. This was wonderful.

I’ve been able to appreciate the world again, to want to see it and love it.

Last night and into today, after being back about a week, and again on shift work, though not as brutal as before, I had nightmares all night. I know some of the readers are into that psychological stuff, so I’m going to do a highlights recap here and see what anyone thinks is fun to toss out as interpretation.

To be fair, I’m not sure at all what I believe about dreams – whether they are from the unconscious or some kind of psychological source, whether a neurological cleaning and memory mechanism (probably I mostly believe that), or something metaphysical (“One-sixtieth of every dream is true?”).

I will note the following events over the last week. When I was at the clinic, a doctor was attacked by a patient and the patient’s relative. It wasn’t particularly scary when it happened, more like a high school type fight, and I called the cops to come break it up. I was upset by it but not terribly, more at the fallout regarding how the doctor was treated by management and licensing authorities.

Second, there was a recent break-in at the neighbor’s apartment. Simple theft, about a month ago, but I felt sort of invaded. It’s not like car theft, I mean, it’s someone’s home.

Third: I have been practicing lots of meditation/metta style (though that one feels oddly selfish to me) and various other techniques. I’m in the “noble failure” stage, but am still working at it. I’ve finally come to see the value in a settled, happy person as being kinder to the world (whereas in the past, I thought, very much in line with my culture, that a degree of righteous anger and discontent was necessary to keep one working to better things). Last night I came to bed somewhat anxious, and tried the deep breathing techniques, and tonglen, which has seemed scary in the past. I’m wondering that, if you believe in it, it’s psychological resistance to trying to calm anxiety.

Fourth: I don’t write about this a lot, but I live in a part of the world embroiled in a violent conflict. Last week, the government on “my side” (if one can say that, though in this case, that kind of thinking – the my side / their side just means everyone loses) did something violent and inexcusable. And it feels like there’s nothing that anyone can do to stop this, and my partner and I have once again been wondering: United States, Australia, New Zealand? Over the last ten years, every time I am in North America, I feel like it is very shallow, everyone having these long conversations about which tile to pick out. I was there recently, though, and my partner and I promised each other that if we go there, we wouldn’t become that. And when we came back here, and this event happened, we said, Fuck…maybe the conversations about floor tiles aren’t so bad. Especially compared to the ones about casualty numbers.

Fifth, the most prosaic: it has turned hot here, and sleeping during the day (and night) means a lot of sweating and physical discomfort and icky sleep.

Dream One Woke me up at 5 AM, panicky, to the point of having to turn on the light and check the house:

It is night at the clinic, toward closing time, maybe 1 AM. We’re trying to close up – the clinic in the dream is pretty much like it is in real life, nothing distorted in the layout, same auxiliary staff, and they keep letting people in (theoretically, we see everyone who walks in by official closing time). I’m sorta pissed off because they keep letting “one last patient” in. (Note: this actually happened last night.) At the end, everything is closing up, lights are off, doors are locked, and we’re trying to see the end of the patients.

Then someone comes to the door. He’s scary. He is tall, maybe 7 feet, and thin and has shoulder-length hair and doesn’t look quite human. His eyes are dark and blank, he looks sort of like pictures of Jesus, but scary. He’s dressed in white. He has no facial expression, but he is here to be treated.

And he is terrifying, and we tell them, “Don’t let him in,” but then something about having to treat all comers and ethics pops up and they let him in. It becomes immediately apparent that he is a murderer. Also, he removes two prostheses from his lower legs, revealing bilateral Syme amputations, and he walks on the stumps, and his shins are disproportionately long anyway so he’s still tall.

He has a medical letter describing that he is part of a white supremacist motorcycle gang (not really something found in this part of the world), and lost the feet in an accident. He is also described as having had sociopathic tendencies during the hospitalization.

We are terrified, I go to call the police. On the phone I calmly tell them where we are, and fumble trying to think of the street number (Note: this is exactly what happened when I called the police for the real-life incident, we’re in a shopping center and everyone just says that and no one knows the actual number, but they asked.)

Everyone tries to hide from him around the clinic, while still trying to treat him. I wake up suddenly with the image of the man in my mind, and wonder if this will be one of those terrible dreams that are almost forgotten by morning. My beloved cat is sleeping on one side of me, my partner on the other.

In the end I turn on the light and get up and check the house.

I have no mental association of a man of that description whatsoever. Or white supremacist gangs.

Dream Two

I am lying in bed, and for some reason I am sobbing and very ill. Sweating. I hear noise outside toward the apartment door (it opens onto a courtyard), and go to see what happened. I discover that the window and door have been attempted to be broken into; the window is open, and the metal and paint around the door lock is chipped away, and the thing that covers the gap at the bottom of the door has been prised off, leaving a gap.

The gap under the door is big enough for my cat to go in and out, and he is there creeping under and playing around, along with a strange cat who I don’t want in the house. Also, I know that now I have a hole where mice and snakes can enter and I think, Shit, what can be done about this?

I decide to call the landlord and tell him this needs to be fixed. I think I am in underwear and a T-shirt and I see my neighbor (a sort of friend, my age, her husband went to med school with me) heading off for the day, and I realize that my face is all red and it is obvious that I have been crying, so I try to explain that I’m ill, not crying. Somehow it all feels like a ruse – both the illness and the crying.

At some point in this dream, I am sweating and shivering and feverish curled up on a miscellaneous shrink’s couch, being observed. I think that also somewhere in the dream, I receive an invitation to my medical school graduation ceremony, an invitation which is vaguely threatening. I am trying to make the connection between those two events.

When I wake up, I am truly sweating because it is hotter than hell in the room, being mid-day in a bedroom that gets morning sun.

Dream 3

The last dream.

I am in my mother’s room – but the house of my middle school years, where we all were desperately unhappy, not the house of childhood that I loved, or the one in late high school where my mother lives today, which is her house more than anything. Whenever I have a nightmare that takes place at a childhood home, it is in this house, and whenever I dream about this house, it is a nightmare.

In real life: We moved there in my father’s desperate attempt to climb a social class, and all went to hell there when we didn’t fit in and life did not become the dream that this McMansion was supposed to buy him. I lost my neighborhood and school friends and he became more and more miserable.

In the dream:

I am in my mother’s bedroom and she’s sitting in bed, we’re chatting. My sweet cat is there, and he has found a little kitten that looks a lot like him. (Note: in real life, my mother recently visited a friend who is bottle-raising a litter of kittens and she told me that there was one who looked like a baby version of mine.) I am trying to convince her to keep him, as he is very cute and I feel sorry for him. The two cats seem inseparable, playing around various places in the house.

The two cats keep playing around. I see that the little kitten is somewhat dirty and has fleas. I take him into the adjacent bathroom – also true to the original floor plan of the house, down to the two vanity sinks, and wait for the water to heat up to bathe him, thinking that I need to go out and buy something as a flea treatment too.

I fill the sink with water and wash the little guy, chatting with Mom all the while about how long it takes the water to warm up, how much nicer he’ll look cleaned up. But the kitten starts choking a little, and I make sure to keep his head out of the water but he keeps choking.

Somehow, he seems to be getting smaller and in more and more distress. Finally, as the water drains, I realize he has become even smaller than a newborn kitten and has died, and changed shape. The core of him seems to shed the fur and creep off down the drain. I am terrified and don’t know what happened, what I did. I saw that something inside of him, something stick-like, slithered down the drain, so I wait, not sure he could be really dead. The skin and fur are still in the sink.

Then, a fully grown green dragonfly emerges from the sink, spreads and shakes out its wings, looks like a praying mantis. It flies around and I realize that whatever the thing was, it wasn’t a cat, or it was, and became a dragonfly. It flies around the bathroom. The turn of events is horrifying – how could this have happened? How could it have not been a kitten?

Downstairs, there is someone at the door, and my beloved cat goes to see who. I don’t open the door, because I know it is someone frightening. I think it is this trashy neighbor who lived a few doors down.

And then I woke up – the phone rang.

I have very few associations with this dream, except that this house appears from time to time in my nightmares. I’m not particularly afraid of dragonflies and have no associations with them other than admiring their long lifespan in high school biology. That bedroom and bathroom were on the third floor, don’t remember any kind of bug problem there.

My cat did once bring a praying mantis home (in my current apartment, he wasn’t even born at the time we lived in that house). Why did he have a double?

* * *
The only unifying theme I can see here is doors, closed doors, intruders behind the door. As a kid, door knocks when I was home alone used to terrify me, I’d run and hide, I think as a result of being a sensitive kid shown those “Stranger Danger” type filmstrips at school. I have never been the victim of a home burglary or assault. No one scary ever came to the door in real life.

So – anyone see any other threads? For whoever likes this kind of stuff – you’re invited to go at it. Is something coming for me?

Oddly, my partner also reported a night of nightmares, making me lean more toward either the metaphysical or heat explanation.

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The Rest of My Life

I’ve been writing kind of heavy stuff lately, and I think it has skewed what this started out to be, which was a chronicle of how people who are crazy live in the normal world, how we are mostly invisible to everyone. Lately, you’d think that all I ever am is crazy.

Which is understandable. This last year my mental health has been perhaps the worst in my life (or second worst). And the Wellbutrin is making me anxious which makes me write. (Student loan panic set in tonight, which is always a symptom.) And I have been thinking a lot about my mental health, which I don’t usually do when I am well. It is the main thing on my mind, sad to say. I’m afraid many more important things have been forgotten in the mess, like the people I love.

So I thought I’d put in some balance of the perspective. Despite having an awful morning due to various symptoms, I pulled it together and worked a night shift last night that was perfectly fine. While working, or writing, or engaged in conversation, I am able to selectively ignore a lot of symptoms, just feel them less. I think it’s like sometimes when you have a flu or something, you really do feel better when you are up and moving around rather than lying around thinking about what hurts.

I thought I’d make a scattery list of things that happen in my average life, which are far underrepresented here.

1. I usually meet friends a few times a day. Having stayed more or less in the same medical system where I went to medical school, there is no shortage of acquantances and a few very close friends around all the time. Sometimes when it is very hard for me to go to work, knowing that they are there helps a lot.

My best friend is a friend from medical school who also stayed on at the hospital. We can often catch a few minutes to chat outside the building while he smokes. He’s tried SO hard to quit, and even tried taking the bupropion for that, but guess what – it gave him panic attacks and made him paranoid! He can’t believe I’m sticking with it. It does give me panic attacks (witness yesterday morning) but I find them infinitely preferable to depression.

He has a new baby and is utterly in love with her and shows me pictures on his cell phone. I haven’t been good about going to see her; haven’t given her the baby gift (partly because I can never find anything quite special enough). I am happy that he is so happy.

I’m afraid I haven’t been a very good friend lately, since all I can think or worry about is how crazy I am…and no one wants to hear about someone’s mental health, shrink problems, med problems etc forever. He has been very good about always coming to talk if I need to, though. And sometimes we just talk about normal stuff, laugh at ridiculous senior doctors, the fucked-up system we are in, and so on. If another friend joins us, it’s better sometimes because I can’t talk about crazy and it just rolls over into small talk.

2. My partner and I spend domestic time together, which is very quiet and pleasant. I tend to be something of a homebody, and he humors me. We spend a lot of nights watching DVDs of comedies (I can’t stand to watch anything sad or serious on TV. If I wanted reality, I could go to work.) We laugh a lot. We curl up and read. We are both nerds. Sometimes we talk about physics or other science topics one of us has read about. We had this weird discussion of Descartes and Maxwell after something he read a few days ago, lasted late into the night. We got into this discussion about whether mathematics is something that exists intrinsically, or something we made up.

3. I love my house. It isn’t anything fancy, and is really a rented apartment, and nothing in it is expensive, but it has my things in it, and I have set it up to be a shelter for me, a quiet place with warm colors. I think that sometimes this isn’t so good because I don’t invite people over much. But sometimes I curl up on the sofa with a book or a blanket and feel overwhelmingly content. I am surprised at how nice this feels. I guess when you grow up in a stormy, violent place, the thought of home is a strange pleasure. I’m surprised to have found one. I am overwhelmingly grateful to live so comfortably, to be safe and warm and sheltered.

Of course, because I am crazy, this can lead to worry that it will all be taken away from me somehow. But I know I can survive that too. I have been in very bad places, poor places, alone in life, and that taught me that really a human being needs very little to survive. You don’t need a bed, or a roof, or a change of clothes, or internet. You need food, and that is about it. I can be thankful for what I have now while still knowing that I could survive without it, have survived in scarcity, in violence, not knowing where I would lay my head. I love what I have and would hate to give it up, but I wouldn’t die from that.

4. Though it stretches my budget immensely, is my single biggest expense after rent, I can pay for my mental health care, for what I need to keep a job, to avoid the “bottom of the barrel” public mental health system. This makes me luckier than people thrown at the mercy of the public system. Unfortunately, this is also self-perpetuating: I am able to work because I can afford at least partial medical treatment for my condition, which is not covered by insurance. People who can’t will never get the quality of care they need to get better.

5. When I work in the emergency room, I sometimes pass through the pediatric ER just to see what is going on. Pediatricians are the nicest people in the world and I’m always able to say hi and smile. There are sometimes funny kids in there too, and they make me smile too, even though kids aren’t my thing. The best break room in the whole ER complex is in the pediatric ER and when I eat I go in there and make tea (they have the water cooler) and see nurses and staff I haven’t seen since I stopped working there. The hardest work I did was there, but also the nicest environment. And everyone there always says hello to me and smiles.

For someone as shy and introverted as I am, it is wonderful to know I have a place like that, a place where “everybody knows my name.” And not in the way the internal med docs or ER docs do – as the freak one who always was in a rage and never got along (last time I worked with them I was in a very bad state). The pediatricians know I didn’t like pediatrics and didn’t like working there much, but they like me anyway. For someone like me, it is very nice to have people who are happy to see me. Especially after this bad year, when I ruined so many working relationships.

6. Since I’ve lived in the same place since med school, the local businesses know me. I can walk in to grab quick take-out food, and see familiar faces. The nearest neighborhood with amenities is of a lower middle class to working poor area, and people haven’t gotten into the ideas of having cars for everything, so they walk and use local business. There is a sense of community that people don’t have in wealthier areas. And they know me by sight when I walk in, too.

7. I always can call someone on the phone from my cave. (Not that I usually would, but that’s a different issue altogether.) Somehow, I don’t know how it happened, I ended up having friends. I’m afraid I haven’t been as good a friend as I should always, but I am fortunate to say that I’ve never felt truly lonely. Alone, certainly, but I have received far more love in this life than I ever deserved. We don’t get together that often, but we chat, we see each other at work. Sometimes I feel guilty that I’m sick, sometimes I can’t love them back as well as I’d like. But I know that for a lot of the mentally ill, they drift out of society into increasing isolation and that loneliness is a huge factor in suicide. I think that I may have spread a lot of pain amongst the people who have loved me, but I never meant it, and I was never really left alone.

Last time I was really depressed, it was last spring. One friend, I didn’t tell him details at the time, just that I was not feeling well. Despite having a house full of kids and being a busy doctor too, he called me at least every other day to see if I was ok, and let me vent without asking for details. Since at the time I was pretty much confined to the sofa, those phone calls were incredibly meaningful to me.

He always invited me to a weekend dinner with his family and I always declined, but once when I started to feel a little better, I went. Of course, I was nearly non-reactive, and when I did speak it was a huge faux-pas with his mother-in-law. But no one ever made me feel strange about anything. Even though it wasn’t a particularly memorable evening, it marked a lot of coming back to life for me. I felt horrible, was minimally groomed, but I was out of the house and back among the living.

This incredibly kind gesture, those daily calls, which must have been miserable, for no reason, was something that stays with me until today.

And I know that if I ever really flip out and end up in a hospital, I wouldn’t languish there at the mercy of some fucked up psychiatrists. A few close friends with connections in the med world would come to my aid and beat them down from over-drugging me. I’d die of embarrassment and probably try to keep them from even knowing, but I wouldn’t be alone at the mercy of the system.

8. I read a lot, though since these episodes have been so out of control, it has been a lot harder to focus. But this month I finished two books. Not my normal rate, but better than before. It used to be a big part of my day, especially when I was a kid. It is probably some escapist coping mechanism that isn’t so healthy, but I enjoy it. In my bedroom, on my side of the bed, I have a big pile of books and note papers. My partner calls it “my world.” Whatever I’m reading, which is usually one or two new books, and a lot of old favorites for when the mood strikes, are there. There are lots of books on the edges of the sofas too, and all over the house.

9. Food: not much of a cook, when I do cook, it is healthy fare, or something that goes together quickly. A grain and a legume. I don’t cook with much that “you can’t tell where it came from.”  Often, as I said, it is takeout from a local place. There is only one that is close by. Too much fried shit, but it is quick and good. On call, I eat at one of the many coffee shops in the adjacent shopping center – salad or pasta, usually. Usually I go with whoever I happen to be working with that day, but not always.

I hate all this Atkins shit. I love carbs – pasta and potatoes and bananas and grains. I’d rather give up fat than my carbs.

I can’t cook that well, but I’m a really good baker. I make all kinds of wonderful cookies and cakes. Nothing flashy or pretty, but the kind of thing you just can’t stop eating, out of simple ingredients. I haven’t in a while because of being busy and also not wanting to eat a whole batch, but it’s my secret skill.

10. I have a ton of makeup. Nothing expensive, but I used to be a sort of punk ass kid and I still have a lot of stuff left over from high school. I don’t get to wear it anymore much, but when I’m off work, I do. I wear my long hippie dresses, my slightly gothic looking black velvet stuff, my Wuthering Heights collar jacket. I guess some of it could pass at the hospital, especially if I wore just one piece, mixed with mostly business looks. But I hate having the clothes I like “contaminated” by work. The problem is that I don’t go out a lot to other places where I can wear them.

One of the books I’m reading is a pop culture version of a book on Schema Therapy – basically cognitive therapy that people with deep problems have them from deep assumptions rooted in childhood about themselves and the world. The pop culture book tells you all these signs of which false beliefs you might have. One of them was “Dressing more conservatively than you would like.” I think that was supposed to point at an “outsider” belief: that you feel like you don’t fit it, are somehow different. This can be a “defective” belief; you feel that you are somehow basically flawed, and damn well better hide it.

And damn if I don’t feel that way in medicine a lot. Most docs come from a very different background than I do, with very different social rules. Very upper middle class and conformist. I always feel like I’m trying to ape a look that they have…and I hate myself for sticking out because I don’t ever quite like them, and I also hate myself for trying so hard.

I remember in med school, there was this one girl from a very affluent city. She was a bitch, shallow, mean, basically obnoxious. Spoiled brat, rich parents who divorced and just threw money at her. She sort of pretended to be my friend, but always with an air of, I don’t know, like she would be my social guide. I didn’t really like her, but she terrified me because she was so mean. She always criticized my makeup, my clothes, whatever. One day I was wearing fishnet stockings (probably with Doc Martens but I don’t remember; certainly not with fuck-me-pumps or anything) and she came up and rolled her eyes so hard, and said to me with a snort, “God, don’t ever wear those again.”

This girl was a caricature; she was ridiculous, and no one else ever took her seriously. But she was from “the right side of the tracks” and this rich town and seemed to know the rules that I didn’t. And every time I let her do that to me. In high school, I would have gotten into a fistfight with someone like that. And I would have taken her down.

And I never wore fishnets to med school again.

Somehow I think that story is symbolic of what med school and the doctor world has sucked out of me.

And once again, I digress into psychological topics.

But I guess I can tie that in to this post, because it is something that, apart from my crazy, is prominent in my inner world lately. I am slowly coming to the realization of just how much I have let medical school and being a doctor kill my soul. How different I am from when I started. And I think back to all the times I should have said, “No. This far, and no further.” Years ago, in maybe the second year of medical school, with the animal experiments. And a million other examples. Right now, I am working very hard to recover my soul, my woman’s wild soul, from inside the soulless monstrosity that is modern medicine.

A funny thing happened lately…I have been so depressed off and on that I finally let my meticulous makeup go and have been going to work without it, with just a little bit. And looking generally disheveled, hair uncombed, because I just can’t deal with it. (I have finally grown a half-meter of hair, which I love, but it’s just so hard to wash it all after 30 hours on my feet, and I know I’ll probably cut it, but still, I worked so hard to grow it out.)

And I’m not sure, maybe I’m just imagining it, but it seems like I’m getting less disbelief when I walk in and say I’m a doctor. Most of the girl doctors look like that.

I’m not sure what bothers me more, that I am letting myself go like that, or that no one can imagine a doctor who doesn’t look like C. Everett Koop (and even he had some goofy facial hair going on).

I also hate how many comments I’ve gotten about how I look so much more “professional” without the makeup. (One from that attending who tore me down.) Even the shrink said I was “prettier bare,” that I didn’t need to “hide behind all that.” (Was that a borderline inappropriate comment? I’m never sure.)

If I want to wear it, none of their fucking business. Women have played with masks and veils since the beginning of time. Why can’t I?

At home, though, I immediately change into sweats, warm, cozy things that I’ve had forever.

But – I love playing with makeup and looking slightly like I stepped out of the wrong time century. Even if now I just do it in the bathroom alone before I get into the shower.

11. Other things in my life every day: sometimes I promise myself a good cup of coffee on the way into the hospital and that is the thought that keeps me going as I get out of bed, get dressed in the cold bathroom, sitting on the bath mat as I brush teeth because I’m too tired and down to get up. I feel like a little kid, bribed with candy. But sometimes, that’s a big part of my day.

12. I worry about money a lot. Not paying the rent and bills and all that; and I never run up the credit card. I’ve always managed to live within my means, which at times were ridiculously meager…except for one thing: my massive student loan debt. I have no idea how I will ever pay this off. Or even make payments that make a dent in it. Once the deferments and all that are up, the payment alone will not leave me enough for rent. Hoping for a miracle. I guess I’m just like everybody else in this. I obsessively read the “get out of debt” stories, and “America’s Cheapest Family” and all that. But the thing is, there’s not much more I can cut. I don’t buy clothes, I don’t go out to bars or to eat much (the takeaway is cheaper than buying enough basic stuff to cook for me), really the only thing I do buy is books, and even most of them are used. I would try to cut back, but part of the problem with libraries is that what I read is always too obscure, or in the wrong language. No one ever thinks, when they move to another country, how much they will want to read in their native language – and how expensive it might be to find imported books.

My credit card statement is funny – it breaks the charges down by categories. All I ever have are groceries, gas, insurance payments, pharmacies, and books. Every time I open it in front of someone, they just laugh.

I guess I could go carless. I don’t really need one. Local mom and pop grocers deliver, and, while it does cost money, it’s less than a car. But after my contract is up, I don’t know where I’ll be working, and then I might need one, so I don’t want to get rid of one just yet.

13. I always keep a bus pass in my wallet, and sometimes I take the bus to the hospital. The walk to the stop is nice, and it is quicker than having to park there. The hospital is toward the end of the line, so the bus by then is usually full and I stand up. It is nice not to drive and worry about when my car is going to die.

14. I take something to write with everywhere. Often I get writing ideas that fly through my head, and if I don’t get them down immediately, they’ll go away, be forgotten. My life is full of the backs of receipts, of ticket stubs, of gum wrappers, on which are written things like the perfect end to my novel. My close friends laugh at me because they can see when I zone out into an idea, and sometimes laugh or am otherwise altered by the words that run through my head, how my attention is both in the conversation and far gone. People like that girl above think I’m weird. But the people who love me think it is just another part of me, a quirk.

* * *

I think I wanted this post to be even more about minutiae, things not concerned with my mind or medicine. I’ll try to let some more ideas come to me as I go about my day over the next few days. Maybe if I ride a bus.

* * *

Next time: remind me tomorrow to write about how I cried at the shrink’s a few days ago. I didn’t think I had tears left, I thought I was too cold. I think he kind of had contempt for what I cried over…but that’s ok, it reminded me of something important, pointed the way to me to the things I need to be able to cry about again, the things that I can’t, ever since becoming a doctor.

Today something happened to me that never happened before.

I got reprimanded at work.

I apologize for the quality of this post ahead…I’m too tired and my brain is too fried to write well. Here’s what happened.

The last few weeks went surprisingly smoothly, the anger was under control, I was performing ok, and things seemed to be moving along reasonably considering being off all meds. My mental well-being surprised even me.

I think if not for two things, I would have been ok.

One was menstruation, which always fucks me up, and the other was another marathon of on-call nights and sleep deprivation.

It started last Wednesday around 1 AM, I started to lose patience, a hand laceration came in to the ER. I didn’t feel comfortable closing it, so I wanted the plastic surgeon or ortho on call to do it. They refused…and I started to blow. I was exhausted and overwhelmed. I did not want to cause permanent nerve damage to anyone’s hand. After being so proud at how I’d held together so well, I lost it again, had a hissy fit of misery about how I hate my job. Mature, I know. I wish I could take it back. But I just snapped.

(I also ended up suturing the hand. I’m sure that after my vocal refusal and claimed lack of know-how, the patient was thrilled to receive me as his doctor.)

I was so tired, and on top of everything, the attending was jerking me around, making me see every patient (while she is paid ten times what I am paid to be there, and it is part of her job to see patients, she isn’t there as a preceptor or consultant, she’s the main doctor on call) – actually running over me about every decision I made, then going and re-seeing every patient I saw. I couldn’t figure out why she was riding me so hard. I wondered if I had recently made a mistake she had to cop to or something.

For example – a 22 year old healthy guy comes back from a long, exhausting trip with mild diarrhea as chief complaint, and, as it turns out, upper respiratory symptoms. (Why he was in the emergency room in the middle of the night, god only knows…) So I write a quick discharge: Diarrhea – Presumed Infectious/URTI. She goes in there, makes this huge deal about how it is URTI with diarrhea, tears up my whole discharge letter because I wrote it as a “diarrhea” letter, including suggesting giardia check & stool culture if it continues (he had camped and drank from streams). I got a huge lecture on how the diarrhea is part of his respiratory infection, how I went way too far…yet on a similar patient, I got also yelled at earlier for not writing a referral to a GI to rule out IBD if symptoms continue. She was just being nasty, and I didn’t know why. On one hand I got knocked for being too thorough, on the other for not being thorough enough.

This weekend I started to sink into the same old depression. I did some meditating and other things, which helped (didn’t run, though) but it hit hard this morning with a busy ER. She kept doing the same shit. Asked me to present at the level of a med student, checked everything I did. Also, though there were three of us, she sent me all the patients, including orthopedics and urology ones, who are supposed to be covered during the day by ortho and uro. She made me see them just for the sake of making me do it. Then she would return their file to the ortho/uro stacks, meaning that they would be seen by ortho and uro, that my work would be useless.

I admit, I was doing a shitty job. I didn’t miss anything big, but my brain is so slow, I just can’t think quickly like you have to in the ER, didn’t delve into anything that wouldn’t have a direct effect on treatment plan. Presented sloppily – while in my head I had a clear picture, I was scattershot about presenting. I felt so overwhelmed.

I almost got to tears, even while dealing with patients I was trying hard not to tear up; I was already teary from the damn depression. I slipped out at noon or so and called the shrink, told him I wasn’t doing very well, asked what to do. He told me to take some benzo, and I said I didn’t need anything that would slow me down even more. I asked if I should start the bupropion again or what, and he sort of got impatient.

“You’re a big girl, you’re a doctor, you do what you want, you don’t need me to start it again. I can’t deal with this on the phone.” I really am not sure where the hostility came from, except I’m getting it on so many fronts that I know that I must be provoking it.

I just wish he could have been nicer. He’s sick of me too.

I also thought: Now I’m the kind of patient that they don’t even try to limit the benzos for anymore. Take as many as you want, just shut the fuck up.

Then I went in and one of the nice nurses who is my age saw I was falling apart and gave me a hug, said it’s a hard place to work, that that attending can be a bitch to work with, everyone knows (I actually get along with her usually, and I like her). Usual girlfriendy type stuff. I was immensely grateful.

Well, the doc saw this and dragged me off into a corner (in front of other people), and started in about how she’s torturing me for a reason, that I’m lazy and just because I’m smart that doesn’t mean I can be lazy and have such a bad attitude and do a shitty job and the whole reason she’s treating me like that is that I brought it all on myself. How everyone has days they don’t feel like working and they don’t get like me.

This went on for about five minutes. In front of multiple docs. Pointing out many of my failings, personal and professional, number one among them being my laziness.

Ironically, she also said, “I just don’t get it – sometimes you have these periods when you’re so ON, do everything beautifully, you’re unstoppable. And then sometimes you just don’t care and everything you do is shit.” My heart stopped, for one heartbeat I thought she was going to accuse me, then and there, in front of everyone, of being manic-depressive. But she didn’t. She just went on shitting on me.

And get this: I didn’t even care, really. I think that’s a pretty good sign of how depressed I am. Usually something like that would send me into a shame spiral. Now, I’m too far gone to get upset. It’s not like I need any more people telling me how wonderful I used to be, how shitty I am now. I’m living it.

As it went, I just mouthed off back, agreed in that sarcastic way I always did as a kid when I got in trouble, the one that makes them just want to pound you more.

I think I thought that it was better to let them think it was laziness and bad attitude than crazy.

* * *

On the way home, I stopped and bought a sweater for my partner. For some reason, this almost made me cry too. I just wanted to do something nice for someone. Show a little love, which is another thing that has been gone from me for a long time. I wanted to give him so much more, and somehow this crappy sweater just seemed so inadequate, a mute trying to recite poetry. A symbol of the broken shards of what I wanted to be able to give. I want him to be happy. I want him to be warm. I want him to be loved. But I can’t give him any of those things. I can’t give anything to anyone anymore.

Maybe I just cried because I sort of wondered if it was going to be the last thing I ever gave him, and was sorry it was so crappy.

* * *

I then drove to my family doctor, who has office hours this evening. I knew that without an appointment I’d wait, and that was all right. Where was I going, anyway? The shrink was obviously not going to be of any help. I can’t really bring this down on any of my friends. They are under as much stress as I am. I don’t talk to my partner about these things, they aren’t the kinds of things that need to be in a relationship. I didn’t have anywhere else to go.

I brought my dark Soviet novel that I haven’t been able to concentrate on, sat down in the waiting room and tried to read with tears in my eyes. Some elderly woman sat down next to me and started chatting. She was tremendously nice, not annoying at all, but I really didn’t want to make small talk. Maybe she saw me and was trying to help, I don’t know. It was kind of nice finally being somewhere where they didn’t know I am a doctor…to have waiting-room chit-chat with someone on the outside. Someone who, thankfully, didn’t bitch about how bad her doctor is, and who wasn’t a sucking pit of need.

One of the staff members I guess had a birthday and they had a little thing with cake and candles and then passed it around the waiting room. I couldn’t even lift my eyes, though it was a nice gesture and feel in the room. The glowing candles and the singing, a little surreal.

The doc saw me sitting there and called me in fast. I don’t know if that was professional courtesy or what. Of course, having come from work, I was dressed semi-decently and still had on makeup, combed hair. I didn’t look depressed. I don’t think I ever do.

I just told him the depression was back, go ahead, pick a drug, doesn’t really matter what. He tossed me a prescription for citalopram. I also took one for bupropion. I can choose later which to take. He asked what I had taken before. I rattled off a more or less complete list. He asked why I took lithium. I told him, “Because I get like that, sometimes, too.”

He asked what about the shrink, and I told him that I think he’s just frustrated, sort of given up. “You know how it is,” I said. “The patients who don’t get better, no matter what you do. After a while, you just don’t want to see them anymore.”

He said I should try valproate, but that wasn’t his job to deal with. I told him that mostly what was bothering me is that I’d had a year of bad function and was scared I’d never be normal again. He asked in a general way about “dark thoughts,” the kind of thing I could answer, “No more than usual,” without feeling like a liar. He didn’t ask directly about suicide.

* * *

I guess I’ll start taking one or the other. Maybe the bupropion, because it worked so fast. Probably should cancel the shrink later in the week – I can’t see how it could do anything but make me feel worse.

I’m scared. I’ve had plenty of internal disasters, but I’ve always been able to hold it together externally. I know that in this last year, I’ve ruined my reputation everywhere I’ve worked, that no one wants to work with me because of my attitude, which isn’t really attitude but rather me doing my best through a granite tsunami of depression and mood problems. Mood disorders. I am mood disordered. I am disordered.

* * *

From the outside, I can’t escape a feeling that these little things are all harbingers of doom. I can’t help thinking about all those statistics and sayings, the ones about x% of people visit their regular doctor in the four months or week before suicide; about the typical case study, the perfectionist who fucks up, some seemingly inconsequential narcissistic insult that somehow is the invisible riptide that pulls him under. If I were watching this like a movie, like a novel, I couldn’t avoid the heavy-handed cues, the foreshadowing: Things do not bode well for our heroine.

On mental illness and stigma in medicine

Today I saw a patient for a pre-operative evaluation. This is a consultation for a patient that needs surgery, but who has other medical problems that make the surgeon nervous, and the surgeon basically wants someone like me to sign that I evaluated the person so that I can be blamed if something goes wrong. At least that’s my semi-cynical version of it. My fully-cynical version of it is that surgeons make relatively little money seeing a patient in clinic (though a lot more than a family doc or internist does), and they don’t want to waste time evaluating a patient when they could be operating and billing for the real benjamins.

Of course, I’m messing with the details of the story, but it went something like this: this woman was elderly, but under 80, and had the usual medical problems that go with that age, but not more – mild diabetes, mild high blood pressure, a few other things like that, but no history of smoking, no lung disease and no significant heart disease.
I think that over time I’ve collected a few doctor readers, so I’ll add this list of meds, more or less: some vitamins, a beta blocker, metformin, maybe there was an ACE inhibitor in there, can’t remember, a statin, a laxative, a bisphosphonate and some ranitidine, and a few other drugs, which I will get to in a minute.

She also had a recently discovered cancer, which was the occasion for the operation. The operation is a large one, but not “heroic” or the kind of thing they call people to come sit in the balcony to observe. It’s not a Whipple or anything close, but it’s not a lumpectomy either. It probably will not lead to a cure, but will almost certainly lengthen her life considerably, and will definitely prevent at least some of the uglier complications in the future. It is the standard of care.

Now, the rub: one of her diagnoses was “Depression.” No further explanation. In addition to the above, she also receives lithium at a healthy dose as well as paroxetine. This was the first time I saw her and she is an immigrant who does not speak any language I speak, so we had to speak through her son translating. But she was perfectly pleasant, totally coherent (able to give full medical and surgical history since childhood) as far as I could tell without speaking her language. To my shame, I didn’t ask what her profession had been. (I just didn’t think to while trying to sort out a complicated medical history.) I had never seen her before, and she came with almost no written medical information other than the recent imaging and investigations that were directly related to this cancer. I have no idea how her depression presented, why lithium was added, how long she had been stable or ill, or anything about that particular illness other than what I saw. To be fair, I also had no information about the history and control of her diabetes or blood pressure, though all three issues were controlled during my examination – blood pressure was good, sugars fine as well as HBA1C.

And then this: among all of her documents, I come across a paper that is a statement by a consultant psychiatrist that she is competent and able to both consent to and undergo the operation.

The surgeon and anesthesiologist had both refused to treat her without this evaluation. The surgeon’s referral put the demand for a full psychiatric evaluation (at the family’s expense) above cardiac, geriatric, oncologic, or functional evaluation, and refused to proceed or even make a tentative statement on her suitability for operation without this.

The surgeon, for that matter, does not speak her language either. But I assume he saw a similar patient to the one I did, as he had seen her less than 3 weeks before.

Just the fact that she came in taking certain medications, with a psychiatric diagnosis, one that, for that matter, has no bearing on her ability to decide how to live her life or to comprehend information, could have caused life-prolonging, standard-of-care treatment for cancer to have been withheld, to have been considered “inappropriate” or “unnecessary” or “unsuitable.”

In her case, fortunately, the psychiatrist did not write a full three page summary of her personal flaws (as I have seen sometimes in these types of evaluations), but rather summed it up with a line something like, “Patient understands implications of illness and treatment options and is competent to make any and all judgments blah blah blah.” But how many of these cases never make it that far? How many times, when surgery is an option, do surgeons see a diagnosis like that, or a drug like lithium and decide that the patient simply isn’t a candidate for surgery, or decide not to present all of the options?

I also wonder, if it had been an older man with “depression,” whether he would have been put through this humiliating evaluation, or whether only hysterical women need to be qualified as competent. Or if it had only been the paroxetine and not the lithium? What was it that pushed her into questionable incompetence? Does the referring doctor understand the implications of demanding an evaluation like that – that they are essentially calling into question a person’s sovereignty over their own body? I am hard-pressed to think of any kind of mental disability, including those conditions that include intellectual disability, in which a person cannot be presented with options in a manner fitting their understanding.

I don’t know whether to be angry, or to want to cry, or what. But I think mostly I’m afraid that someday I will be that little old lady with an ugly diagnosis on my chart, whose life is seen as only questionably worth saving.

Fear and Hope and Wellbutrin

For a day or two, I thought it was working well – not well, but it seemed like suddenly I fell back into myself, which is a strange expression, but only by becoming me again, I realized how swallowed up by this monster I had been, how lost I was. I speculate: where was I during this last year? Someone else, someone horrible, took over my body and life, torturing me, making a monster of me. Then I thought, maybe I was wandering around in another dimension, or inhabiting someone else’s life and body. I’ll have to think of this idea a little further, there might be a story in it, though I suspect it has been done this year with that book Atmospheric Disturbances that everyone is talking about. But maybe there is a good fantasy alter-life in it. Maybe I can write myself, or my alter self, a better year.

I did get a little manic buzz, joking, punning, quick and enthusiastic again. It was a little frightening to just pop back into my old self almost overnight, disorienting, like someone getting tossed through river rapids and rocks who suddenly finds herself washed up, and not only that, but that the river has turned mysteriously calm behind her, and she can’t quite figure out what all the bruises and breathlessness came from.

I pray this isn’t a fluke, that this drug will keep working. I’m thinking it’s similar to the nortriptyline by how I feel, right down to the little twitch in my right eyelid. So similar, in fact, that I managed to already make my way to the medical library for a big specialist book on psychopharmacology and discover that nortriptyline does have some downstream dopaminergic activity. I guess that probably is why it works like Zyban on the smoking too. And that idea that a mood stabilizer alone is enough for bipolar is bullshit – I’m proof.

I almost even wanted to forgive the shrink. I certainly can’t have been easy to deal with, and he’s been doing it for a year.

I’m not fine yet, that’s for sure, even though the improvement was so fast and so sudden that I almost felt forgiven by God. It doesn’t fix my sleep like nortriptyline, and I’m rather jittery. But I’m me. My thoughts are back, the rage has calmed, and I don’t just want to crawl into a ball and die. And little things which I only noticed afterwards. I spent the evening looking at volunteering in Ethiopia at an AIDS orphanage for when my contract is up. This doesn’t seem like much, but it is the first time in a long, long time that I looked toward the future, thought of something – anything – that I might want to someday do.

Today a bad thing happened, which set me back quite a bit. I made a mistake at work and a patient did suffer some damage from it. I probably shouldn’t write about it in this kind of public forum, for all kinds of reasons, not the least of which is legal. It was a dumb, procedural mistake/orders mix-up, something rather similar to this but without the happy, not-my-fault ending. One of those things that a safety systems investigation would shit over; I was in a new-to-me department and I’ve never in my life seen such a lack of a consistent system for orders. And there are some dumb-ass nurses who today came to pest me about ten times because I’d written an order for omeprazole 20 mg once a day, when for some reason they wanted it 10 mg twice a day (“once a day dosing,” ya idiot, if you don’t study pharmacology, don’t you at least watch the commercials? It actually has some interesting pharmacokinetics, by the way, if you’re into that). Yet a massive mistake like this, which was obviously NOT correct and they say nothing.

It wasn’t only my fault – the mistake actually was written a few days ago, but I certainly continued it. And saw it – it wasn’t like I didn’t see the previous order.

I felt so horrible. It is a fragile patient anyway. I don’t think any long term harm will come of it. I hope not. The guilt, however, is killing me. The other doc involved in the original order seemed to be able to walk out of there worry-free. But I was so upset I wanted to cry – of course, I’m still too depressed to really cry. I also, a bit, wanted to hang myself. So I guess I’m not better yet.

The other thing I wanted to say is thank you again to everyone who took the time to respond, to comment, to reassure me that I wasn’t as crazy as I thought during all this time.

And then I thought of how unequipped I am to be a doctor, how I want out of this responsibility with all my heart, how, while I might be an academic freak genius, I’m not meant to carry this burden. I don’t want this kind of responsibility, and authority over other people, telling them what to do, doesn’t suit me at all. The doc who initiated the mistake is great at bossing people around nicely. I just can’t do it. Even if I think it’s best for them, when people challenge me, which happens often because I utterly lack the self-assurance and cockiness of so many docs, I’m no good at answering, because I just ultimately believe they should do whatever they want. I offer an opinion and that’s it, take it or leave it. But that’s not really what practicing medicine is about. And that’s something they never tell you in medical school.

Doubt

I just got off one of those hellacious emergency room shifts. And now I am torturing myself. Did I miss a subtle stroke? Send away a 19 year old who fainted who will later go into cardiac arrest?

I am not sure how much of this is me and how much is the drug and how much is the general ambiguity of medicine.

The stroke – an elderly patient with multiple comorbidities, fell down. Seemed to be an inocuous story, but in the morning the patient was still dizzy, so I had to think of a vertebrobasilar stroke. Did I miss it before? Can you have a vertebrobasilar stroke without nystagmus? Should I have called neurology sooner? I don’t think he would have been a candidate for any kind of reopening anyhow. Worst of all, is the lithium slowing me down cognitively and causing me to think less clearly?

And the 19 year old with the simple faint. Most probably nothing, but you never know. Lots of “malingering” hints in the story, but that’s an easy way to make an error. The fact that this case bothers me, however, makes me wonder if I am not medicated enough – this should be open-and-shut; the fact that I doubt what I did makes me think that the problem is my doubting.

I hate being so responsible, so young, without much backup. I hate being unable to separate how much is the job, how much is me, how much is the meds. I really shouldn’t have started this new job. The contract is up in April. I definitely will not renew.

Holding on, waiting for the thunder

So far, med free. The shrink called and is back from vacation, but I’m debating whether to go back or not. I really only need to if I decide to try meds again. So far, I don’t feel so great, and STILL having some withdrawal issues, but it is a little bit nice to remember who I am underneath all the medication.

I guess I should return the call to at least inform him. Why is this like breaking up? Why is the worst, most dysfunctional relationship in my life the one I have with my shrink?

I didn’t get my nice hypomanic buzz at coming off any of these. And my hypersensitivity is setting back in – every little touch feels like pain, clothes are uncomfortable, etc. But this is who I am, raw and pure. I will take it for as long as I can.

Since this is another piece of self-indulgent bullshit, if you have been following Purple Dog at all, be sure to update and offer Jon some support right now, having lost a son to this illness in a most unexpected way.

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