(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.

Advertisements

No Sleep No Good

One month since I had my worst mental breakdown in eight months and I’m still picking up the pieces, trying to reset my circadian rhythm each time. No sleep is no good. This is my third attack of insomnia within 7 days.  People think it’s cool; no.  People suffer when they can’t be any more productive than when they are awake at daytime.  People suffer in this state of relative disability.

(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.

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.

The Shortest Semestral Break

So my friends in school had asked me, “What is a semestral break?”

A sudden coldness swept over me. I looked down and found a shard of ice, like a dagger, had pierced my chest.  My heart sustained a penetrating wound to the right ventricle.  I said I was fine but I knew I couldn’t forever conceal the skipping beats, the slowing rhythm, the increasing discomfort.  The evolution of symptoms has been rather slow relatively. Still, their constellation constitutes an emergency.  My hours are indeed numbered.  And I had done nothing but sleep, fooled into thinking that all those sleepless nights can be recovered.

Every now and then, there’s an unconventional idea that I struggle to silence. On most days I bury it under the folds of my brain, later to exhume and publicize by mouth or by hand. But tonight—just this night—I feel a sudden surge of courage to post a picture of this dreaded thing.

Here comes the sun, a most beautiful one
Off the sheets, into the road, on the run
If you think life’s given you enough shock
Tic toc, eight-oh-one, reads the bundy clock

In a smooth sweep of its hands, the short recess is ended.  The school uniform once again becomes a steady sight, a staple experience on the skin.

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.

Life with Bipolar Disorder Type II & Clerkship

Like most patients with mental illnesses, I didn’t know I had something until a critical event occurs that would bring all pertinent signs and symptoms together to reveal the hidden picture.  I used to think that I was simply eccentric since high school:  my ideas often differed, sometimes significantly, from my peers; my concepts and standards usually had been non-congruent with the norms; days to weeks of inconsolable depression and unexplainable high-energy that are degrees more amplified than in peers; and so forth.

In August 2013, one of my consultant-facilitators in my PBL subgroup pointed out the striking incongruity between my Small Group Discussion performance and my exam scores.  He sat with me for over an hour, processing and counseling.  But he was the first person to have observed and suspected that I might just have had a mental condition worth attending to.  He was right.

In November 2014, weeks well into my Pediatrics rotation in Junior Clerkship, the increasing stresses ultimately brought me to the point where my body and mind simply would refuse to rise out of bed and keep going.  My sleep started to be prolonged dangerously.  I would have less time to read my lessons or prepare for exams.  I was constantly cramming and failing—a vicious cycle, which would augment my depression.  And then there had been extraordinary times when everyone would think that I studied medicine for the extracurricular opportunities in medical school.  Despite the packed schedules, I seemed to have time to carry out my responsibilities as an officer in the Student Council, accomplish my tasks as a member of the school publication Editorial Board, maintain an active status (as former officer) in the Advisory Council of my Greek organization, organize intra- and inter-campus events, review classes for the undergraduates, participate in regional and national medical student leadership and reformist activities; the incredible list goes on.  If I had not been a medical student, I probably would have scoffed at (and probably revolted against) the first suggestion of a possibility of a bipolar disorder.

My psychiatrist maintained me on valproic acid maximum dose for about 5 months when stability was achieved and my academic performance improved.  Titration was immediately begun on reaching those end points.  However, on further work up, imaging studies revealed an incidental bilateral Polycystic Ovary Disease (PCOS), prompting withdrawal of Depakote from my regimen and a shift to lithium.

Before the shift, my ability to concentrate and attention span had gradually lengthened.  However, I was increasingly detached from my creative side.  It would take me sometimes days to compose prose for a singular idea, in contrast to a few minutes to a few hours to write a full feature article with multiple subjects.  There had been many times when I would miss my “ups,” when it was easy to communicate and swivel between introversion and extroversion.  But definitely, the abolition of the prolonged “downs” and erratic fluctuations in moods within the day had been profoundly advantageous.

Consequently, the final half of Junior Clerkship had been smooth-sailing.  The next rocky ride was in June 2015, when I was maintained completely on a double dose of lithium and I had to hydrate more than usual to flush the salts off my system as quickly as is possible.  Moreover, my visits had been reduced to at least once annually if without problems.  I was already well into my third month in Senior Clerkship or Junior Internship when such needs just could not be reconciled with the duties and demands.  I lost compliance, consumed my stocks.  My psychiatrist frequently flies out of town; and when she’s here, my 36-hour shifts every other day just would not let me meet her.

To the date of this writing, I am already on my third month off of pharmaceutical or psychotherapy.  I am more familiar of my symptoms now and have improved control.  However, it is impossible to avoid recurrences of the mood fluctuations.  I fear the day when I would recede severely enough for normal activities to be impaired.

Note:  What you have read above had been composed during an asymptomatic period.  Compare with the train of thoughts below.


* * *  D  O  W  N * * *

It feels good to cry one’s heart out every once in a while.  But when it keeps crying out each day and night, at first in a drizzle and then in a burning torrential outpouring—there’s something likely amiss. Starting over seems like a cheerful option when there still remain shards of hope to crush and consume. But when there’s none, let the world mourn until the last gust of wind from the deadest of spaces within can be extracted auspiciously, irrevocably.

At the end of this unlit tunnel certainly is a world of unlimited paths. But as to the uncanny lurking in the darkness is an absolute uncertainty. I lost track counting how many blocks, detours, traps and other surprises we’ve uncovered so far. Certainly, there is that termination of the pathway. The variations of this journey remain with how long each pilgrim has been kept blind and vulnerable on the road.

Battling this disease during a protracted course of extreme physical, mental, emotional, psychological, psychiatric and spiritual stress is probably my most difficult test in life so far. Sometimes, we have limited choices to alter circumstances, limited influence over luck. This solitary adventure has been somehow more difficult than anticipated—perhaps longer for me. Still I look forward to the close of this chapter. Survival is an outcome of persistent choice; but the persistent scars are an outcome of chance and choice.

Despite everything, this, too, shall pass.

*  *  *  *  *


* * *  U  P * * *

First of three days in my Plastic & Reconstruction Surgery elective rotation felt like being in Donna Tartt’s The Secret History. The department has been a curious clique of seemingly detached individuals from a frequently misunderstood field.  The field is a huge world of its own with ill-defined borders encompassing many disciplines. What could be more humbling and inspiring than receiving life advice from the people who’ve finished five years of General Surgery, become fellows in a society, had once been chief residents in their own times?

It’s all about finesse and the details. Beautiful and awesome take time.  I feel at home with the atmosphere of organized thought, structured meetings, intellectual discussions—even for extra-curriculars and hobbies. And somebody has finally said it: do not neglect your hobbies; have a life outside work.

Of hobbies, I have much to choose but little to say:  I miss a life outside this graveyard.  Fortunately so, seven days in Orthopedics & Traumatology—and its eccentricity and dependence on a constant slow infusion of adrenalin—did uplift my spirit.To see is to believe: my first amputation was quite clean and a little dry. But today’s IMN was a bloodbath. For what looks like the “deadest” structure of the body, the bone is as alive as the heart.

To see is to believe: if I had to choose between a cut-down and an intra-osseous, I’d choose the latter.

Some accidents are nasty, some accidents are nice
That I came upon Orthopedics, I’d paid a high price
Exhausting days, exhilarating nights
But ultimately the choice was very wise

After a round-table discussion with residents, I’m more confused than ever: PGH or another university hospital?  For sure, I prefer to earn my lessons; ergo, bone-chilling endorsements and presentations.  This is coming from an introvert who had yet to grow out of social awkwardness.  The beauty of endorsements is this: an open mind continues to learn from either the good or the bad ones.  In so saying, I don’t mind being grilled during endorsements.  The hotter the iron, the deeper the burn, the harder it is to get rid of the new scars, or wisdom.

It has been a privilege to discuss my cases, to assist in operations, to tag along during rounds, to carry out doctors’ orders, etc. I feel luckier than ever to have spent my first two months of internship in the Department of Surgery (including Orthopedics & Traumatology)—here learning can be as visual as it can be, where details, finesse and determination are as important as fooling around just to get rid of the wear from long hours in the operating room.

To my seniors, the staff and my patients, thank you.

*  *  *  *  *

The Obsolete Need To Sleep

I don’t believe in claims of association between pasta, curses and crises. And so the longest sleep I’ve had in the past four weeks lasted two hours. Otherwise, the division between today and tomorrow often is indicated by a wink, a yawn or a weary sigh. A new day begins. The hours stretch on to the 36th or 40th, or onto the minute when the conjunctivae have been completely injected, and the innervation of the orbital apparatus slowed down in concession to the call of sleep. Exhausted has become a redundant fact made not very readily obvious to the naïve passersby because of the drive of necessity and outstanding resilience of the lowly forms.

And it is precisely because of this presumed resilience that Clerkship has been structured to be often unforgiving at times.  Deadlines cave in like massive walls.  As they draw closer, what scarce time to be spared must be stretched to fulfill the requirements needed to sail through the day.

Internship has only just begun, but this chapter has been dragging on for too long now. But thank you for asking randomly after my health, anonymous doctor (I’ve never met you before).  In that brief encounter, however singular, when you saw me steal some sleep in the elevator, with a half a hotdog consumed in one hand, a stack of documents in the other, you reminded me that all things will pass with time, like time, and in time.

“Shock”

When the body enters into a decompensated state of shock, time begins to shut down a life that has been thriving for some years—one process at a time slowly and slowly until the first organ finally succumbs to asphyxiation.

The exhaustion of reserves and resources—the critical point breached—and accumulation of toxic essences fuel up a fatal momentum of consumption of hope and life. Some hours prior to the patient’s departure, the evidence of his suffering has resonated within the walls of his chest, the thin membranes of the bowels. What once has been a steadfastly galloping heart enters the marsh that muffles the sound of hooves and horses. Then the light begins to recede from the apertures of the eyes as the pupils grow irreversibly. Soon, breaths turn into sighs, and then into silent vapors that dissipate into nothingness.

These events transpire so quickly that it is often hard to mark times with absolute accuracy and remember the exact succession. The color of his pain has given his lips a duskier shade, his skin a reticulated carpet of ruddy islets in a sea of pallor—into a complex omen often described as mottling. And the lifeless form that remained splayed on the bloodied bed has become another corpse to tag, tally, and transfer out of my care.

Shock is certainly a fitting term to describe the suddenness and congruity of these phenomena. No road has been more devastating than the spiraling steady path to a slow death. What remained of that vivacity is an empty glassy look, which reflected on my face and in my wrists and fingers as they write this short testimony.

Cross sections of the Spinal Cord

descriptions will follow