(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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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.

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

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.

*  *  *  *  *