Diagnosing One's Identity

I have started my psychiatry clerkship and I think I'm in love.

The staff is nice, funny, accommodating, kind. The physicians are crazy in their own way. The patients, well, the patients are all fascinating--there's something so complex about mental illnesses that makes it hard to reduce any one person to simply medicine alone.

And yet, with my patients, I feel like I keep reducing them to their diagnoses.

We are always told that patients are people--that we are treating them, not their illness. But with mental problems, the person is their illness because, well.... hmmm....

What is identity? It is the way we interact with our environment. It is our behavior. It is our thoughts, are consciousness. It is who we see ourselves as. It's what comes to your mind when you're asked to define yourself. Throughout college I told people I was "biracial, bisexual, and bipolar," because 1) I liked the way it sounded and 2) it seemed to partially capture the fact that my entire life I've seen myself as someone stuck in a huge gray area between the black and white poles of the various identities constructed by society. Definitively nothing, unquestionably everything: Elora Kathryn Apantaku.

But back to psychiatry and patients and their identities. I didn't realize how chronic most psychiatric disorders were. A lot of the older patients--in their fifties and sixties--a lot of them have been suffering from these illnesses--manic depression, major depression, schizophrenia--for decades. Their lives are so strongly influenced by their diseases... and although medication and therapy can help them stay out of the psych ward, their presence on the floor argues that they are doomed to continually function in a way that is maladaptive--either to their family, their friends, or to society.

The Barometric Mind

I woke up this morning around 5:30, very briefly--thirty seconds maybe--because it was raining, and although the sound of rain beating on my apartment's giant windows overlooking the South Loop is usually really calming, the water dripping through my roof, through my ceiling, and onto my already stained carpet is quite distressing. But I didn't stay awake because at this point, a stained carpet is very low on my list of worries.

I'm thinking about away rotations and my grades and how to make myself look good for residencies. Am I forgetting paperwork? Probably. Where should I go next year? Do I want to go to Maine? Stay with my sister? Or should I go somewhere I've never been before, working in a hospital in Mississippi all by myself. Do I want to do family medicine rotations or psychiatric ones? These are the things I've been worrying about, but I recognize that my worries are not really important, just bothersome.

The patients in the psych ward, now their worries are real. Your family can't tolerate your manic outbursts anymore so they have you admitted--you promise to adhere to your medications from now on, but your family doesn't trust you any longer so now you don't have a home. Where do you go? In this already stressed out health care system, you run a real risk of becoming homeless--or as the hospital I'm working at calls it: undomiciled. That's a worry. Or let's say you're psychotic. Then the voices can give you a whole new set of things to worry about: "you're going to die as soon as you leave here" they might tell you, or "you need to be back on heroin again--that's the only thing that can help you, this anti-psychotic sh*t isn't helping and you and I both know it."

I arrive to the inpatient psych floor at 9:30. One of my patients, on the spectrum of schizophrenic to bipolar, is standing in the hallway, leaning against a wall. She looks terrible. "Good morning Miss [HIPPA compliant], you look tired, did you sleep well?" She says no. I stand next to her for a good fifteen seconds, waiting for her to elaborate, but she does not, so I slowly walk away, looking back at her as if she'll suddenly want to tell me more. Later, when I follow the doctor around like her own personal shadow, we stop by to see my patient. "This morning the nurses said you were banging against the wall and screaming, why was that?" My patient answers back something about "the voices" which I was almost positive had been alleviated by her sudden acceptance of her anti-psychotic meds.

Another patient, depressive with psychotic features, also has a similar complaint. The medications had helped reduce the voices to whispers, muttering always, no longer commanding. But this morning, they woke her up again, yelling at her. She looks tired today--much more so than yesterday.

I am a scientist--but I am a bad one. For me, personal anecdotal evidence is much more powerful than studies that have thousands of patients arranged into double blind groups and blah blah blah.... This is why when I think of sickle cell disease--how my dad's a carrier, my mom's not, but yet all three of their daughters have the trait--I think that there's more than coincidence going on with how it's inherited--either magic or some genetic translocation oddities.

Which is why I know believe that weather can make you psychotic. Two patients woke up in the middle of the night, around the time I woke up freaking out about the rain, and were brought back to their presenting level of psychosis. Maybe the pressure drop affected the neurotransmitters as much as it affected the forecast.

Just a silly, crazy, insane thought.

Death, Dying, and a Defense Mechanism

So our school often has us write silly things to talk about our feelings. Which is dumb, since I no longer have any (a lie, but I don't seem to have any today). But sometimes they help me write random things for this blog, like Fixed and Dilated. Anyway, here was the prompt:

 Write about your interactions with a patient who died or was very ill. What sources of inspiration did you find in caring for this patient? How did your team manage the patient’s and the family’s  hope in the face of a poor prognosis or outcome?

And here was my response:

I’ve taken care of a lot of patients that later died.

And now that I think about it: I didn’t do anything special to comfort any single one of them. Because death is a terrible thing, and I wouldn’t want to share my last few days on earth being “comforted” by a medical student. So no, I haven’t actually jumped up to volunteer to annoy someone and their beleaguered family in their last days of life.

[Also, we haven’t been taught how to deal with death, right? Because that wasn’t a lecture and I’m not comfortable dealing with it now.]

But back to me thinking about how I’d want to die…. if I’m still mentally alert, I think I’d want two things: as many pain meds and anti-anxiolytics as I can tolerate and to be surrounded by my closest friends and all my living family members. I also wouldn’t want to be in a frickin’ hospital, but the odds are in favor of that so I guess I should start preparing now. One could make the argument that as you get older, and if you’re dying of a slowly progressive disease, your psychology changes to accept death, which is something I haven’t had to do yet as a “healthy” twenty-something. But I think that’s dumb. I had a patient tell me he was superman, that he was going to somehow defeat/prolong his battle with metastatic prostate cancer—and then I sat outside his hospital room and listened to his freshly-minted widow cry when he died five weeks later.

And I did nothing.

I could only find comfort in the fact that I had at one time spent a good thirty minutes with the patient explaining why we were holding him in the hospital overnight those five weeks earlier. But now I’m not sure if my need to talk through disease processes and hospital operations to the patients and their families is my way of comforting or just the defense mechanism of intellectualization. Because I have nothing to say. You’re going to die. I wish I could do something. I wish we could keep chatting about your interracial grandchildren, or about how pretty my earrings are, or clarifying that you’re at MOUNT SINAI HOSPITAL not in the KOREAN WAR, but I can’t stop your death. I can hold your hand. I can call your children. I can maintain eye contact. And I can tell you as much as I know. Which isn’t a lot.

Fixed and Dilated.

Two weeks into internal medicine, my resident asks me to listen to the heart and lungs of a man in room 605. He has metastatic prostate cancer and we are giving him fluids to clear out his kidneys—which is mildly dangerous because the spreading cancer has been compressing his right ureter.

The first thing I notice about the man is that he looks like a fish… or maybe a frog. The second thing I notice after I introduce myself and listen to his well-demarcated and steady heart beat and all of his lung fields, is that he reminds me of my father when he says, “God’s thrown a lot of nonsense my way but I keep fighting it--I'm like Superman.” My dad used to call himself Superman when I was younger, when all of the world seemed terrifying—when my young hydrophobic cousin was afraid of drowning in my pool and my dad told him he could walk on water if he failed to stay afloat.

I affirm that he is not fluid overloaded and go to a computer to look up his history. It's unsettling. There's cancer in his liver and in his lungs. That night, when I present him to our attending, the doctor asks us: “How long do you think this guy is going to live for?” The intern says 2 months, the resident says 6 months, I say a year—more out of hope than knowledge. “I bet you this guy is going to live for 5 more years,” he says with his Eastern African accent, smiling. Apparently, prostate cancer can be slow to spread, even when it's already spread so far. We discuss other patients. I feel better. Five years seems like a good amount of time. If my mom or my dad found out that they were dying, hell if I found out I was dying, but that I still had five years left… I wouldn't be able to do everything I'd ever wanted to do, but I could tie up lose ends with my loved ones, get some closure, prepare a little bit, I guess….

The next morning I pre-round on the patient and their is blood in his foley bag, and he's having excruciating, right sided back pain every 15 minutes. I furiously whisper to myself, "I know what he has!" as I rush to the resident's room to annoy my intern with my first ever in-hospital complication diagnosis: kidney stone. I keep badgering him to write an order for painkillers and to give him more fluids. I feel happy with myself. I'm affecting patient care. I matter. 

In the afternoon I stop by room 605 to ask him how he feels. But there's already a student in their from the oncology team. They are in a bit of a tussle--not out of anger, per se, but because the patient doesn't know when he can go home with his wife, and the oncologist hasn't yet rounded on him to tell him what more tests he'll need. The student is just collecting information for his higher ups, and as commonly happens, we aren't able to hand any information back to the patient. I clarify a few points of confusion between the patient and the other student, then I sit down at the bedside and ask him if he has any more questions. "Yea, I got a few…"

I try to answer all of them the best I can. I am surprised when he doesn't seem to understand how the various imaging tests we have ordered for him will help change our management--shouldn't like, a doctor be telling him this? So I slowly talk through all of the order sets that are sitting in meditech that I've written down in my own notes--the medications and the imaging requests. He seems slightly less upset now that he knows that even though it will probably take all day today and most of the day tomorrow to get everything over with, the tests will be important. I think he's happier that someone just took some time to, at the very least, explain what was going on. 

It's the weekend, and when I return on Monday the patient has been discharged, with instructions to follow up with urology in two weeks.

Then, exactly 29 days later, the patient is back. He had a surgery to place a stent in his ureter, but it failed, and he was now recovering poorly on the surgery floor. He was having some trouble that I guess surgery felt more comfortable with medicine handling, so he was readmitted to our service. When the resident asks me if I remember this patient, I am mildly insulted. "Of course I remember [name redacted, thanks HIPPA]! He's one of my favorite patients!" The resident updates me on the patient's condition and it doesn't sound good.  He's in moderate respiratory distress. We go in to talk to him and he looks like he's drowning--he's not able to talk back to us. His eyes dart around behind his glasses, panicking, when we walk into the room, then he goes back to staring at the muted television screen indefinitely. 

I was going to introduce myself, ask him how he's doing, but I realize that I'm not able to say anything. I'm so scared by what's going on, I'm unable to even hold eye contact. The resident and the nurses are making quick bedside assessments and all I'm able to do is count how many breathes he takes in a full minute: it's thirty-four. I can't leave the room soon enough. At one time I felt almost essential to this patient's well being, but now I feel absolutely useless. The patient's family is going to be asked about in-house hospice. 

A few days pass by. The residents keep mentioning the patient. And he's declining more and more.

Then one day we get paged to room 607 because the patient is unconscious and very close to death. Our team sits outside the room, at a computer terminal. The door is open, but I don't have the courage to walk inside. I've only seen his wife and his family once. Death has always seemed like a very private thing to me. I don't want to interrupt anything. I know he's dead not when I hear a monitor flatline, but when his freshly widowed wife begins crying and I no longer feel the need to pay attention to what the resident is telling the intern one has to do to certify a patient has died. Because this woman has just lost the love of her life, her partner for over fifty years, and the fact that his pupils are fixed and dilated doesn't really seem like a significant detail. Someone asks me a question. I respond by turning around and pointing to room 605. "Less than two months he was in there. He was fine. His doctor said he'd live five more years."

And in my head I'm thinking to myself how my grandfather died before I was ever born, most likely from prostate cancer, although since preventive care is almost nonexistent in Nigeria, nobody actually knows how he died. But that was my dad's hypothesis and I wonder if that's how my grandfather--a man who my dad truly admires to this day--died. And what a terrible way to die.

Death, Dying, and A Defense Mechanism

So our school often has us write silly things to talk about our feelings. Which is dumb, since I no longer have any (a lie, but I don't seem to have any today). But sometimes they help me write random things for this blog, like Fixed and Dilated. Anyway, here was the prompt:

 Write about your interactions with a patient who died or was very ill. What sources of inspiration did you find in caring for this patient? How did your team manage the patient’s and the family’s  hope in the face of a poor prognosis or outcome?

And here was my response:

I’ve taken care of a lot of patients that later died.

And now that I think about it: I didn’t do anything special to comfort any single one of them. Because death is a terrible thing, and I wouldn’t want to share my last few days on earth being “comforted” by a medical student. So no, I haven’t actually jumped up to volunteer to annoy someone and their beleaguered family in their last days of life.

[Also, we haven’t been taught how to deal with death, right? Because that wasn’t a lecture and I’m not comfortable dealing with it now.]

But back to me thinking about how I’d want to die…. if I’m still mentally alert, I think I’d want two things: as many pain meds and anti-anxiolytics as I can tolerate and to be surrounded by my closest friends andall my living family members. I also wouldn’t want to be in a frickin’ hospital, but the odds are in favor of that so I guess I should start preparing now. One could make the argument that as you get older, and if you’re dying of a slowly progressive disease, your psychology changes to accept death, which is something I haven’t had to do yet as a “healthy” twenty-something. But I think that’s dumb. I had a patient tell me he was superman, that he was going to somehow defeat/prolong his battle with metastatic prostate cancer—and then I sat outside his hospital room and listened to his freshly-minted widow cry when he died five weeks later.

And I did nothing.

I could only find comfort in the fact that I had at one time spent a good thirty minutes with the patient explaining why we were holding him in the hospital overnight those five weeks earlier. But now I’m not sure if my need to talk through disease processes and hospital operations to the patients and their families is my way of comforting or just the defense mechanism of intellectualization. Because I have nothing to say. You’re going to die. I wish I could do something. I wish we could keep chatting about your interracial grandchildren, or about how pretty my earrings are, or clarifying that you’re at MOUNT SINAI HOSPITAL not in the KOREAN WAR, but I can’t stop your death. I can hold your hand. I can call your children. I can maintain eye contact. And I can tell you as much as I know. Which isn’t a lot.

Insulin and Eugenics... I am upset. This is a rant.

As a type 1 diabetic, I am often very angry. Usually this is secondary to hypoglycemia or an ability to eat something because I inadvertently left my insulin at home.

But today I am upset because I am running out of insulin and I only have $600 left in student loans until late February. Why is this a problem? Because as someone with good medical insurance, my doctors have always prescribed me humalog and lantus, which are bloody expensive without a prescription (and are actually still really expensive with a prescription and insurance: $50 each for what I need in a month). But as a medical student I don't have time to go see a doctor to get a prescription to get my bloody f***ing insulin. I am really upset because as I speak I have about enough humalog (lispro, short-acting insulin) to get me through to Monday, after which I guess I'll start employing a poor man's metformin: large amounts of acetaminophen and straight hard liquor. Your liver transaminases skyrocket, but you've effectively bludgeoned your body's best organ so badly that it stops going through with gluconeogenesis. Oh, and a ton of aerobic exercise makes your body more sensitive to the effects of lantus (glargine, long-acting insulin), so I guess I can look forward to dropping a few pant sizes and... cirrhosis. Lots of preventable, freaking cirrhosis.

I don't know what I'm supposed to do. There must be type 1's who are busier than me and have less time to see doctors. And I know there are type 1's who don't have health insurance because this country is absolutely terrible. So how can I get insulin at a reasonable price without having to see a doctor? Because, honestly, I've had diabetes for over ten years and I know my body's personalized ways of dealing with this disease in a way that literally no other health professional could understand. I know the tricks. I know the secrets of my metabolism. My A1c is always under 7.0 and my hypoglycemic events are now well controlled. I know what I'm doing.

SIDENOTE... no wait, MAIN POINT: I think it is absolute bullshit that people need prescriptions for something that their body erroneously stopped producing. Almost everyone else around me is making insulin, but just because my body f***ed up when I was thirteen, I have to spend thousands of dollars on a month's worth of high quality insulin? What kind of justice is that? Answer: it's not. It's wrong. It's condemning people to a constant economical disadvantage on top of the disease they've contracted who's co-morbidities will likely kill them if they don't control the aforementioned disease. In a country where medications aren't regulated to make them fairly priced (hell, I think they should be bloody f***ing free but I realize I'm incredibly biased) and health insurance is severely limited, we are essentially killing off diabetics. I realize that many type 1 diabetics can make it to reproductive age without dying first, but I've seen a 24 year old diabetic with f***ing gastroparesis--that's really severe neuropathy. And now that I've gone through OB-GYN, it becomes apparent that type 1 diabetics with A1c's of 13.6, like this 24 year old, would never be able to carry a healthy child to term. She will likely never produce any children because why? Because our health system is unjust? What sick kind of world is this?

And you know what's worse? The type 1 diabetic population that is under insured and hurting the most is minorities, specifically blacks. And you know what's f***ing insane about that? DIABETES IN AFRICAN POPULATIONS HAS NO DISCERNABLE GENETIC COMPONENT. Whereas caucasian type 1 diabetics usually have some weird HLA inherited predisposition sh*t. And yet, at least in Chicago, those people will be preferentially allowed to live with a disease that could be greatly reduced within the human population if only they were put to the slow and painful death that awaits most uninsured type 1 diabetics.



[edit]: Okay. So I calmed down a little bit. Let me just say that I recognize that a lot of white people don't have health insurance either. But at least in Chicago, economics and race are obnoxiously linked in a way that has already started to upset my psyche. So I'm sorry about that. The truth is, all type 1 diabetics are in an equally unfortunate place in a society where close health maintenance is ludicrously expensive.

And also, I don't think I do a good job of separating my emotion's from the job. Especially other type 1 diabetics so far along. Seeing another black, 24-year-old, type 1 diabetic, laying on a bed in the emergency department, clutching at her stomach and moaning for morphine, secondary to gastroparesis and then her resultant addiction to painkillers, really upset me I guess. I want to help them but I know that it's literally too late because you don't recover from severe autonomic neuropathy. You just suffer until you die. From something completely preventable.

I guess this whole thing bothers me, not just because on the whole diabetics are treated very poorly, but because I'm now a healthcare professional, and I am surrounded by physicians every day, but I don't think I can just ask them to write me a prescription for insulin because I'd rather go to work than call the doctor's office to set up an appointment, then call the dean of student affairs (another physician), and then the clerkship director (also a physician), and then drive to god knows where for a fifteen minute conversation with the doctor to write me a prescription so I can save $350 for something that almost everyone in the world doesn't think about.

It's upsetting. If I had my way, everyone with a type of medical/biochemical deficiency would be able to get whatever they need for next to nothing because that's what equality is. Hypothyroid? You get thyroxine, no problem. Chronically depressed? We'll get you an SSRI or maybe even some SNRI's if you're lucky and need more norepinephrine. Diabetic? We'll get you all the insulin you want. Because giving you anything less than that is a crime.




So this is where I read that Diabetes in blacks and asians is often idiopathic: http://www.aafp.org/afp/1998/1015/p1355.html
Although since I am both caucasian and african, I won't know if I have the idiopathic form until either A) my entire genome gets sequenced (I hear it's only $1000 now!) or B) they look for islet cell antibodies in my serum.