(Snippets of a) Life with Bipolar Disorder Type II and Clerkship [Part III]

After five grueling months as a senior clinical clerk, my mind gave in to exhaustion.  I could no longer keep up with my responsibilities as part of the healthcare team and requirements for graduation.  Isolation seemed to have made itself more acutely and severely felt when I am in the presence of people than when I was alone.  My job has kept me almost always glued to my assigned patients if I was not called away by the staff or seniors.  We were supposed to be the “eyes and ears” of the attending, the walking monitoring and reporting machines (although we were vehemently discouraged to consider ourselves as such), the intellectual laughingstock if somebody needs to get a booster of self-esteem.  And then there were a number of shifts when I would only have one proper meal, barely two liters of fluid, and scarcely an hour to sleep or nap for 36 hours at a time.  But this is the routine I had learned to embrace and love long ago; this was the life I had chosen.  I could write as much but I would not complain.

What was relevant in that unhealthy routine was its significant impact on the prognosis of my condition.  The role of good nutrition and healthy relationships in the maintenance of physical and mental health cannot be overemphasized.  I can say much for disorders with both organic and functional components, such as mood disorders.

Let me lift a few lines right from my Psychiatry textbook.

Medications give hope but the time they take to achieve steady state levels and ultimately tangible clinical results and the necessity of regularly adjusting the dose and regimen is often frustrating.  After one year of depending on them for control, I got to the point of considering (slightly) maybe electroconvulsive therapy, which has more promising adverse effects than guaranteed permanent benefits.  But in this career, it’s all too risky.

Finding the right professional has always been a challenge.  The practice of psychiatry, among others, is deeply rooted in culture.  Forging an effective partnership between patient and healthcare provider requires certain skills, say empathy, that are not widely taught in medical schools.  It’s no wonder that when some doctors do not know how to meet their patients halfway in terms of values and health goals, frustration can result and patients are lost to follow up, or entirely lost.  Some doctors may be highly intelligent or skilled at what they do, but it requires talent to be able to work magic and truly “heal” people.

It took me more than a month to think really hard about my decision to take the rest of the year off.  But it was worth it.  I had been weak in denying I needed help.  I knew I was already falling apart.

Now I feel the urge to be vocal for all those who have been suffering in silence, afraid to come out because of the stigma and the inequity of distribution of the much needed resources, information and human. (Few realize the power of social media. It can transform lives.)  Not all mental illnesses are so debilitating that they hinder one from fulfilling his dreams and attaining his full potentials.

It’s very easy to ridicule or make sarcastic remarks about something that’s not readily understood.  Textbook descriptions may be accurate but they come nowhere close to the real experience of the illness.  When the community tries to downplay the symptoms, reducing them to the trivial ones commonly popularized in mainstream media, or to dismiss the reality of the internal struggles and relative disability, daily living can become incredibly difficult.

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The Running Man

Brgy. Magay, Compostela
November 9, 2016

My team of three nurses and one medical student (me) went up to this uphill village several kilometers from the town center.  That area was scheduled for immunizations that day.  One nurse reviewed each record, another prepared the shots, the third one posted outside the makeshift clinic to control the crowd.  The remaining role of administering the vaccines fell onto me.  Although we had warned the people that we were not catering consults, dispensing prescriptions, or providing prenatal care, I was uniquely poised to give a brief verbal advice—from pediatric to obstetric to gynecology to medical—here and there.

As we gathered to leave, a young woman stood by the door.  She wanted advice for a problem.  We kindly turned her down.  If we were going to accommodate her, word would swiftly fly; and in no time, the clinic would be flooded with consults, wave after wave like a storm.  It was almost evening and we could not risk driving on narrow, winding paths in absolute darkness.  So my team apologetically referred her to the rural health unit at the town center at a more convenient time.  But she did not stir.

Her eyes imploring, she held my gaze.  Mobility was a major deterrent in the accessibility of health services.  Motorcycles were considered a luxury.  Most people travel on foot, on beasts or by pedaled vehicles.  These geographically and economically challenged communities subsequently took advantage whenever health care workers dropped by.  Quietly, I motioned to my team to carefully look outside.  Everybody had left.  My hunger for knowledge and experience had not.  We would be quick, I promised.  The young woman pulled up a chair and I sat across her, our knees touching.

Here was a 31-year old healthy looking but anxious woman who had been recently plagued by insomnia.  She spent most of her time at home, if not taking various menial jobs like laundry to augment the household income.  She had been married for eight years but remained childless.  She had not experienced insomnia this bothersome even during the times she had felt depressed in the past.  She denied any domestic abuse.  The couple had been trying to conceive but she could not carry a pregnancy through the first trimester.  So that visit was particularly important: time was running out for her and she could not afford to lose her new baby.  She was five weeks pregnant when episodes of extreme nervousness began to interrupt her sleep.  She would wake up at night in a tremendous sweat, her heart racing and pounding painfully.  Those symptoms would last for a few minutes, and they would resolve spontaneously.  For that week, she had been experiencing the attacks with much more frequency.  She sought the advice of her family, some of whom had shared her history of multiple spontaneous abortions.  But they believed her to be a little paranoid because of the possibility of another miscarriage.  She had tried some herbs and activities but they did little to improve her symptoms or cure her.

Psychiatry and Rheumatology had been some of my weakest points.  So I wanted to cheat, open Medscape on my phone, and validate my top differential diagnoses.  But somehow I could not get my eyes off the little swell on her neck.  Wait a minute.  I asked to feel her wrist while I auscultated her heart.  Wait a minute.  Aside from that tiny bump under her apple (that wasn’t really obvious but seemed to me unusual for such a slender young woman), she appeared otherwise normal from head to foot.  No way.  Her angry pulse was bounding erratically beneath my finger pads.  My stethoscope was picking up a dangerous march of a drunken man.  This man could have been walking very briskly, if he wasn’t constantly stumbling upon himself.  I had met this man many times before.  When he started running, he could be fatal.

“You’ve never had a regular menstrual cycle, have you?”  I asked.

“Since I first bled, no.”

“In your past pregnancies, have you experienced similar anxiety attacks?”

“Yes, but very mild and few, never at night.”

“Any in the family–mom, aunts, cousins–having goiter?  Lump in the neck, you know?”

“Oh yes, my mom and sister. But it never bothered them.” She paused, reflecting. “Do you think I might have goiter?”

“Listen,” I said, leaning closer, “it could be worse.”

The man was an impending thyroid storm.

At the moment, her vital signs were within her normal range, save for the mild tachycardia and irregularly irregular rhythm.  The rest of a succeeding focused exam supported my impression: slightly enlarged, non-tender, non-lumpy, soft and squishy left thyroid lobe; no bruits.  She had none of the eye signs which usually appear in chronicity.

It is a sentiment shared among medical students that medicine is a difficult process.  The learning curve is steep; and not everyone can reach the peak intact, in time, if at all.  But those who have transitioned from armchair medicine to clinical practice would probably agree that translating bulky concepts to digestible boluses for the layman can be a daunting task.  The gift of conversation is select, as is the gift of charm.  Persuasion is a skill acquired by even fewer of the human race.

Somebody needed to run.  Faster than the drunken man.  Right now.  It was getting dark outside, my team warned.

I explained to her my thoughts, the urgency of her situation and the limitations of our local health center.  Moreover, the only doctor in the entire municipality was out of town for a seminar.  Our group of medical students basically had been overseeing the facility on his behalf.  On a scratch paper, I wrote “TSH” and “FT4” on one side, the date, her vitals and pertinent neck findings on the other.  Then with much trepidation, I stamped with my name and school and signed it.  Without an M.D. and license number though, I would not know how much authority the paper possessed.  But somehow, a message had to be carried through.  Anything was better than nothing.

“Listen carefully, ma’am,” I said. “It’s late now but you need to be seen at a bigger facility as soon as possible.  There’s a government hospital in Danao City.  These two tests can be expensive.  So if you have to pick either one, get the TSH first.  (I placed a star beside TSH.)  Bring the result to the doctor along with this paper.  He’ll take care of you.”

My team came down from the hills just before night fell upon a brewing storm.  I carried her storm with me as I returned to camp.  The feeling that I had made a terrible mistake persisted for a while, but I could not identify what it was or where it could have gone awry.

Poblacíon, Compostela
November 16, 2016

One week after the brief encounter with the running man, I had an elderly man pass out in front of me right after I removed the last sutures on his right foot under local anesthesia.  He recovered shortly but turned very pale, diaphoretic and confused.  His blood pressure dropped to 80/50, heart rate to 60.  The doctor was out and I had no time to rummage his stock for a vial of D50W and a syringe.  So I asked the crowd of witnesses and they provided me with candy and water.

We placed him on a bed, in Trendelenberg position (we had to improvise with the mattress).  Then I instructed him to put the candy under his tongue, keep some water in his mouth to help dissolve the sugar, and swallow in sips from time to time.  Sublingual and oral, it should go down fast.  But his vitals did not go up after five minutes: 80/60 on both arms; 40 regular beats per minute.  Don’t you go down on me.  We had no saline, no IV sets, no cannulas in this primary care facility.

He laid down comfortably with his feet elevated and his head below the level of his heart and began chatting animatedly with his niece.  In between sips of water, he assured me it wasn’t my fault (referring to the suture removal earlier).  Some color had already returned to his lips and nailbeds, and he started to feel warm.  I stayed by his side, staring stupidly at my beeping pulse oximeter.  Bradycardia, narrow pulse pressure, delayed capillary refill.  Don’t you go down on me. 

Fifteen minutes since his collapse, I let him sit up slowly and repeated his blood pressure: 186/120.  Twice on each arm.  Heart rate shoot up to 110.  Are you weird or what?  That was actually good enough for the moment, but I was not going to let him off easily.  I instructed him to consume another liter of water and eat bread while I attended to my other patients, two of whom were also under close monitoring at the facility for hypertensive urgency.  And then there was the new guy who had a severe allergic reaction after eating peanuts.  And we didn’t have epinephrine.  Few pharmacies sold diphenhydramine with prescription.  In thirty minutes I would reassess him.

One arm read 110/60, but his heart rate went back and further down to 37 regular beats per minute.  I listened and palpated for a full two minutes hopping I could catch some dropped beats–which is crazy (but we had no ECG machines).  Thirty-seven.  Is this really just vasovagal?  He insisted he was feeling so much better.  No headaches, lightheadedness, nausea, visual disturbances.  No abdominal or chest discomfort, however vague.  His lungs were clear.  He denied paresthesia, weakness.  Cranial nerves were basically intact.  He was a chronic hypertensive on amlodipine and ‘something else’, but had been non-adherent to his regimen, monitoring and follow up.  He could not recall either his usual or highest recorded blood pressure.  He was never worked up beyond blood pressure taking.

I called up Danao City hospital.  I introduced myself to the receiving physician who sounded glad of this distraction.  They sounded like they had much time and space–extra beds.  But he wouldn’t accept my patient for just syncope, who was already stabilized and had no neurologic deficits.  Was there something wrong with my endorsement?  Too many in fact.  I had not performed a full neurologic assessment to concretely say it’s a TIA-related syncope, or a cardiac one.  Where is the lesion?  That’s just one thing.  My ultimate concern had been the bradycardia, but I had not thought of opening a reference book in a busy facility to explain why it is worrisome in a guy who just had a fainting spell.  The patient had been poorly compliant with amlodipine or that ‘something else’ enough to rule out drug toxicity.  Syncope in itself is generally benign, unless there’s something else masquerading behind it.  Am I just being paranoid?  What was I scared of specifically?  My gut might have feelings but it could not explain itself at all.

We ended up sending the man home with a written request for a 12-L ECG (which he probably couldn’t afford even with his insurance) and to return after a week for evaluation of his antihypertensive regimen.  He never came back.  He should be running for life.  Once he stops, the storm devours him.

Unlike the drunken man who is the storm.

Many days passed.  I realized that our group of students had gained enough confidence and authority to send our patients to nearby hospitals on behalf of the lone medical officer who had to singlehandedly carry out all administrative and clinical responsibilities without us.  After all, we were running a primary care that had been ill-equipped to handle urgent and emergency care.  Then I remembered the young mother-to-be and how bad I had managed her case.  We could have brought her down the hill with us where an ambulance could have picked her up (they didn’t go beyond the reach of roads).  I sent her home with a piece of paper instead.

(Snippets of a) Life with Bipolar Disorder Type II & Clerkship [Part II]

I’m not lazy. I just don’t feel right. How can one pick a diagnosis from an intelligently collected pool of differentials, and then prepare to defend the chosen working impression when the mind refuses to stay, jumping off from isle to isle? And it goes on for days and days until physical and mental exhaustion cuts the trip. Those consecutive days of insomnia, guilt and diffuse anxiety end with short periods of relaxation and well-being. But the paperwork has been put off for an excessively long time and it is but too late to rewind time back to the deadline.

I’m not lazy. I just don’t feel right. Sometimes, when I talk to my patients, I’m surprised at the changing and stumbling pattern of my questions and physical examination. Routine often is a foreign, if not nonexistent, phenomenon. Every day is a new story in itself, requiring a constant revision of approach and perspective. At the end of the week, I don’t trust myself enough that I have mastered a system, or that I have woven a style to increase my efficiency as an interviewing, thinking, composing and monitoring machine.

I’m not lazy. I just don’t feel right at all. When I am unable to sleep for the whole of the 36-hour shift, I get cranky, groggy, weak and vulnerable to many insults—be they aimed intellectually, emotionally, psychologically, etc. After all, I am human, unadulterated by steel or ice. Like my characters in most role-playing games, my Mana and HP bars can be drained to dangerously low levels; and I am susceptible to functional disability and paralysis, if not death.

Missionaries of the Poor: A Reflection

THE ASCENT OF THE MORNING SUN signaled the start of the routine in the Missionaries of the Poor. Those children probably weren’t expecting visitors in white each day.   They ate their breakfast of enriched porridge from plastic or tin dishes or they waited patiently in their cribs for the House Parents to feed them; either way, they carried on.

We arrived at around the ninth hour, together with our medical post-graduate intern, five rehabilitation interns and their field instructor. The instructor (she had the key) opened the prospective clinic, ushered us in; and we went through the rooms methodically, surveying which room felt more comfortable for consultations for a different flock of sick people, mostly the elderly and the very young. As the day wore on, patients slowly came in queues then dissipated in two’s or solitary shadows. In a couple hours, I got to talk to two or three patients about their medical condition(s). We shared a quick lunch with the interns, our faculty and clinic staff around a long table, small talk, and bits of information about our patients’ progress. Then we checked on—or more appropriately, played with—the children in their cribs or in a spacious hall.

That was to be our routine for a week: a total of four trips to the place.

My first encounter with the children of the House brimmed with mixed emotions. Because I came fresh from a dermatology rotation, Family and Community Medicine at first felt like an offshoot of Internal Medicine, because in the Philippine setting, basically, the only fine line demarcating the fields lies ultimately in the patient’s physician preference. So I was completely unprepared to deal with the pediatric population, or worse, developmental or congenital disorders.

The more time I spent with the children, I slowly understood the necessity of pathos to appreciate or highlight the blessings received by humanity. Every smile those children with Global Developmental Delay and Cerebral Palsy made was a manifestation that even such state of physical disequilibrium can be overcome by a far greater force. Each time that infant born without eyes squirmed, babbled and cooed was a manifestation of the optimism of man to see through and survive any kind of darkness. Every time a child poured a tablespoon of yak and rice gruel into his mouth was a display of victory over the struggles that define man’s journey on earth. The longer I stayed and played with them, the better I understood that another even more powerful language unlimited by syntax, vocabulary or diction, Love, ever truly exists.

Maybe this is probably why the Brothers of the Congregation chose to hang the proverb about seeding happiness into a world where there is such scarcity. For maybe to those people who’ve spent years of study, deciphering the elusive mechanisms that characterize the children’s illnesses, happiness has become a distant hope where an indefinite dark horizon spreads over the future of those little lambs. Despite everything, that hope however far continues to shine and illuminate the world, like millions of tiny stars sprinkled over the dome of the night sky. So that even for that little girl who may have never seen a ray of the Sun, perhaps that tiny light of hope that grows from the seeds of compassion is enough to erase all malignant doubts in her heart and enable a most genuine smile to grace her beautiful small face as she turned her head towards the sound of my voice.

Hello there, little one,” I announced my presence. In a couple hours, I would reach out to enclose her little hands in mine again, and this time, to bid goodbye.

As a medical student, I worry about prognoses of the conditions I have witnessed. As a daughter, I worry about the future of the children and their biological families who may not have the courage yet to face the full magnitude of pain unconsciously inflicted upon those innocent souls. As a person, I worry about the uncertainty of men’s hearts and the frailty of the human body. And then I wonder, too, about the generosity in others, in the abundance that keep coming forth from nothing, like a spring of water emerging from a fault in our lands.

It’s incredible how those half-days stretched to seem like a fortnight of worry and wonder. At the fourth or fifth hour of the day, we return to our main affiliate hospital, our minds pregnant with worry and wonder, and our hearts with hope and compassion.

I have been to a number of immersions before, both in college and in medical school, and across the nation. I have tried my hand at political and economic approaches in community development. Most recently—just last school year, I have set my interests on public health and public policy in upgrading socioeconomic systems and the quality of life of the common Filipino. I have listened to those valiant youth and physician-leaders, who have chosen the mountains over hospitals, the marginalized sectors over the privileged urban districts. Yet in spite of everything, this experience with the Missionaries of the Poor remains a most strange encounter with the human and ethical practice of medicine.

Photo credits: Ms. Aizie Lee Lagare, Physical Therapy Intern

The Perks of Being A Junior Clerk

BLOODY WEEKEND.  After two hours of exploring the hospital wards and units, I went down to the ER to embrace the life in that post.  I had observed a difficult central venous catheter placement converted to a bloody cut down of the brachial vein from 2-5AM, then two modified radical mastectomies from 7AM-12:30PM.  But the most heartbreaking part was being at the ER and seeing all those who could not be admitted mostly for financial constraints.

I saw the country in an undignified state. At any one time, the hospitals only see 1% of the entire nation. But even in there, maybe only half (more or less) of these patients are being attended to at any one time. Though I couldn’t fully understand yet how the health system works there and where precisely are the deficiencies, but I could feel the results.

At the OR, I was trying to blend in the background while observing a surgical operation when I overheard a consultant cheerfully address a senior resident in a quiet corner:  “I’m not only telling you what to do.  I’m teaching you HOW to do it. You are a senior. You can make them do what you tell them to.  But I hope that you will be able to TEACH them as I am teaching you now.”

Mentors are indeed real treasures. One does not have to copy his role models.  They are there to suggest designs for his life.  It is up to him to weave the unique patterns of his destiny.  If my hopes and dreams were spread out like well-prepped skin, three years of medical education and training has made a great incision deep enough, that in order to close the wound, certain procedures have to be carried out with finesse.

Of the many perks of being a junior clerk, my favorite is the ability to stand back and take a good look, a bigger picture, of the systems at work around him.  He is expected to learn the principles but not master the procedure just yet. In that way, he doesn’t have to get involved.  He doesn’t have to learn by committing the mistakes himself.  He is a space-occupying lesion, albeit invisible most of the time.  He is like a drape: he sits in the middle of a procedure, with a gaping hole through which all intelligence and skill of a team are passed.  Sometimes he is clamped with the others, secured at the sides; sometimes he goes alone.  But he can only watch and wait—try not to be in a way—all the while absorbing whatever essence drips within reach.

Tips for Junior Clerkship (Surgery) in VSMMC (Cebu, Philippines)

Junior Clerkship can be confusing because nowhere in the books is the definite role of the Space-Occupying Lesion absolutely and accurately defined.  Here are some tips to help you make the most out of your Surgery rotation in VSMMC.

1)  Review at least the anatomy of (a) the abdominal wall, including male and female variations; (b) appendix; (c) transverse colon; (d) anorectal region.

2)  If asked to assist in an operation, always read your patients’ charts ahead before scrubbing in.

3)  Observe proper OR etiquette even if not practiced at all times: (a) do not abandon the patient; (b) be on time; (c) be there before the surgeon/s; (d) be courteous to all the staff.

4)  Explore the trees to understand the forest. There are two floors in the OR.  You share these with other cutting specialties (OBGYN/Pedia, Uro/TCVS/Plastics, Neuro, Ortho).  It’s usually easy to identify what department is occupying an area just by looking at the patient’s appearance (e.g. with cast/splint, pregnant, jaundiced) and positioning (e.g. lithotomy).

5)  Know the forest creatures. Except for the senior clerks, it’s pretty hard to distinguish nurses from doctors from utility personnel as they wear similar hides.  If you feel adventurous, be free as a bird and fly.  Otherwise, look for people with the school logo and tag along. The next safest crook is the anesthesiologist’s nest (i.e. anesthesia machine).

6)  Know the forest underbrush. The orange goo for scrubbing makes a brushless wash.  No more irritating iodinated solutions and vigorous scrubbing for those with sensitive skin! Sterile linen comes in the form of a gown.  Don’t look for towels or sheets. Caps can be used to cover shoes, too.

7)  If there’s nothing to do, go up and explore OR-5 (Orthopedics). With permission, go ahead and ask about the procedures and the INSTRUMENTS. Learn what you can.  Your one module in Orthopedics will not prepare you enough to handle patients, assist operations and do paperwork (especially surgical techniques) for such cases in senior clerkship.

8)  When at the anesthesiologist’s area, do not sit on their toolboxes. Familiarize their armamentarium and monitoring schemes. Some machines come with algorithms on malignant hyperthermia. Many patients are unstable or are hypertensive; ask what to do with them. What you will learn here may help you in your anesthesiology rotation next year.

9)  Don’t forget to take a group picture outside the OR.  It’s obligatory.