Normalcy

It occurred to be today, as I surreptitiously took a pill and washed it down with soda from Noon Conference, that I'm actually pretty normal. Yeah, I've had my issues- and I've started the process of telling my story via my blog, but right now, I take medication, I see my doctor every so often, and I'm actually living a relatively normal life.

Of course, I have the aggravation that goes along with having a chronic illness- I have to make sure I've always got health insurance. Sometimes my health insurance doesn't cover the full cost of my medications (as in right now) and I have to beg the drug companies to supply me with free meds. Also, I have to make sure when I travel that I bring my medications with me, enough not only for the duration of my trip, but also a little bit extra should something unexpected occur. I was on vacation earlier this year and had the opportunity to stay longer than initially planned. Sadly, I didn't have enough medication. I could have had my doctor call in a few days of medication, but I would have had to pay out of pocket. So, I went home as initially planned. Had I actually had extra medication, I am sure my sunburn would have been much worse than it was. So maybe I was lucky. But, anyway, it's just one of those issues anyone with a chronic illness can probably relate to.

In a way this helps me with patient care. I'll ask patients if they can afford their meds. When they cannot, I actually can point them in the direction of helpful resources.

Another advantage is that I am very knowledgable abut the meds that I take, and this can sometimes give me the appearance of having read a lot. On rounds, when I pipe up, "Well, perhaps Wellbutrin isn't the best because it lowers the seizure threshold..." it might appear that I spent the previous day poring over UpToDate.

"Mentally Ill" Hopkins Resident

I'm still planning on recounting my story through this blog, but that project's on hiatus right now 'cause I'm busy with other things (clerkships, studying...)

Anyway, I happened to come across some news articles online regarding this Hopkins surgery resident who was fired from his program for being "mentally ill." Mentally ill? What do they even mean by that? You can't fire someone simply for being mentally ill. They have to be mentally ill and posing a danger to patients, or some other such thing. It's really odd that this guy's whole career is on the line because someone has decided to label him "mentally ill." Now, technically, depression is a "mental illness" So, all you depressed people out there? Everyone on an SSRI? You're all mentally ill. And you can't work at Hopkins. Schizophrenia is also a mental illness. So, I'm sad to say that if you're schizophrenic, you also will not be able to successfully complete a surgical residency at Hopkins should your secret get out. As for myself, any hope I had of becoming a Hopkins surgery resident was dashed to pieces when I found that those who are "mentally ill" are not welcome.

It's interesting to me that this guy was placed in a broad category that includes severely ill schizophrenics, histrionics with borderline personality disorder, and the depressed. I'm trying to figure out which disorder this guy probably had.

Maybe he had paranoid schizophrenia and was having delusions that those at Johns Hopkins were coaching residents on what to report on an ACGME survey. I think that's it, the most likely diagnosis. The resident, at age 30, presented with paranoid delusions. And anyone who thinks that Hopkins would try to hide anything from the ACGME is crazy, totally nuts. There was that guy a few years ago who seemed to think that "hours" should be "regulated" at Hopkins. That's not really a paranoid delusions, I would call that a bizarre delusion, perhaps. I'm not even sure if that's correct. Well, then he started having paranoid delusions. He held the belief that everyone at Hopkins KNEW that he was the one who complained about these alleged "hours regulations." What a nut case.

I hadn’t wanted to go to the emergency room but I hadn’t wanted to go anywhere, just away from my life and suicide seemed like the best option. In psychiatry class they say that one of the signs that someone is suicidal includes a messy room, as well as poor grooming, accruing an arsenal of guns, Tylenol, or sleeping pills. I hadn’t wanted to burden my family or roommates so when I decided life was too painful, not worth living, I had been thinking about cleaning my room. They also say, if you notice someone is getting his affairs in order, that’s a sign. I always wonder how people think they’d be able to tell if someone was getting his affairs in order. It wasn’t like my roommates knew I’d balanced my checkbook, organized my file cabinets so anyone would be able to find a record of credit cards, bank accounts, and possessions. I’d also made a list of who I thought should get what. I thought my sister should take my surf board because she likes to get into new sports and I knew she liked the beach. I’d doled out my laptop, athletic equipment, printer, everything I thought anyone would want, and I’d put it on a list on the desktop of my computer. I figured if I died someone would turn on my computer and nobody could miss the file named OPEN IF EMILY IS DEAD. But nobody knew about this. And nobody knew I’d thrown out my socks and underwear, things nobody would want once I was dead.

My doctor later told me that I didn’t really want to die and that’s why I called her. I called her to say goodbye but I had to call her emergency cell phone because I wanted to make sure I could actually speak to her before gathering the Tylenol and vodka. Our short conversation ended with, “Emily, do you think you should go to the emergency room right now? “No,” I’d answered. The emergency room was where you go when you’re certifiable. If I went, I would be alive, but I’d also be crazy. I wanted to go out without a label.

After I’d hung up on my doctor, I heard a slam and the bump bump bump of someone walking in the hallway of my house. My roommate came to the doorway of my room. “Hey,” she said.

“Hi,” I said. “Where’ve you been?” a stupid question. I knew she’d been at the hospital, in an operating room probably. She was doing a surgery rotation.

“In the OR,” she said. When someone has thyroid disease, their eyes pop out a little so you can see white all around the iris. Normally the top and bottom of the iris end behind the upper and lower lids so you only see white to the sides. My roommate didn’t have thyroid disease, but I could see white around her eyes, the sides, top and bottom. “Are you ok?”

“Yes,” I said. “I think I’m going to go to my friend’s house tonight, my friend in Springdale. I think I’ll go there.” My roommate still had temporary thyroid problems.

“Oh.” Pause. Pause. “Do you need anything?”

“No, I’m just going to Springdale. What’s wrong with you? You look like I’m going to the gallows or something.” Staring. Thyroid problems.

“Are you sure?”

“I’m just going to Springdale to hang out with my friend. You look like you’re sending me off to die.” I found an old backpack and was putting a book and deodorant into it. My roommate stared. I found a thong in my drawer and put that in the backpack. I’d really only thrown away the used underwear and because thongs tend to go cave diving in your rear end while you walk around, I’d not worn a number of my thongs. I would have liked to pack underwear, but they were neatly packed in a plastic bag somewhere, probably surrounded by other plastic bags filled with soured milk, paper towels, squishy fruit… My underwear was gone so I would be forced to wear thongs for the rest of what was supposed to be a rather short life.

“Are you sure you’re ok?” there was a plastic Vons bag full of discarded socks next to my bed. An empty beer bottle was barely obscured by the closet door. I assured my roommate that all was fine; that I’d mysteriously decided to go to a friend’s house in Springdale, a town I'd never actually been to, and that I was packing the bag so I’d have things to change into the next morning. When I woke up in Springdale. I left about fifteen minutes later. My phone kept lighting up with the words Dr. Feldman dancing across the screen. I usually kept the ringer off because the noise startled me so I usually missed it when people called. But I was paying attention to my phone and I hadn’t missed the fact that my doctor seemed like she really wanted to speak to me again.

I backed my car down the driveway, turned the wheel sharply, and drove away.

(Note- this describes events occuring two years ago- I am NOT actively suicidal)

My Bedroom

When I arrived home that evening, I had to step carefully when I entered my bedroom. My clothes were strewn about; I thought it a waste of time to fold and carefully put away clothing that would only be unfolded and worn, so I had dumped my clean laundry on the carpet. I didn't see the point in dropping my dirty laundry into the hamper so I left it on the floor too, where it mingled with the clean laundry. I could tell the difference because I thought the dirty clothes were spread more diffusely. The closer something was to the main pile by the door, the more likely it was to be clean.

There were some dishes; the night previous I'd cooked myself spaghetti, my favorite food, but had put it aside and the spaghetti had hardened into what appeared to be curly straw covered with congealing red sauce. There was a sideways can of soda-pop on the rug next to a brown stain. I kicked aside a pair of jeans and a running shoe, sending two hidden beer bottles rolling and clanking off the carpet to the hard-wood floor.

My bed was a swirl of sheets, comforter, blankets, and pillows. Yesterday's breakfast, the rice krispies bloated in the stagnating milk, sat at the bedside. When I tapped the side of the bowl, the milk and rice krispies moved grudgingly as a single gelatanous unit. A slight miscalculation when reaching for the Snooze button in the morning could result in a smooshy surprise.

I wanted to clean but did not know where to begin.

The Final Straw

I plugged along for one week at [] hospital. I came into the hospital early in the morning to round on my patients, but there was always something missing when I reported to my resident, a kind and patient third year named William. Actually, there was always a lot missing. I usually hadn't talked to the nurse about overnight events, I usually hadn't looked up the vital signs, I may have looked at the Electronic Medical Record, but I often hadn't looked in the Paper Chart.

As an aside, electronic medical records promise to solve the problems and confusion arising from scattered notes written in illegible handwriting. The hospital was trying to upgrade to a completely electronic system, but, while some of the electronically written notes were easy to read, the changes were creating even more chaos. There were two computer systems- one was older, and the hospital was trying to phase it out. Unfortunately, the new computer system wasn't as user friendly so those used to the old system shied away. And then some people didn't use either, preferring to leave scrawls in the old fashioned "paper chart."

So, when I came in each morning, I was supposed to look up the vitals, carefully recorded by the nurses overnight at 4 hour intervals, in the newer of the two computer systems. Then, I was supposed to check for notes. While in a hospital, a patient may be followed by a particular service, in this case Medicine. But, while there, any number of consults may be called. The patient suddenly develops numbness and tingling? Call Neurology. Questions about a new antibiotic regimen? Call Infectious Diseases. The patient has chest pain? Call Cardiology. Funny vaginal discharge? Call Obstetrics and Gynecology. Broken bones? Orthopedics. So, during the day, any number of clinicians may have visited each patient. And, each department tended to leave notes in different places. Neurology invariably left notes in the new computer system. Obstetrics and Gynecology used both computer systems, so any notes discussing the possible etiologies of vaginal discharge could be found in either. Of course, there were individuals from every consult service who preferred the Paper Chart, leaving an actual tangible note there.

The nurses basically serve as the eyes and ears of the service. Teams of medical students, attendings, and residents constantly switch. A particular resident, for instance, may be on one of the Internal Medicine services for a few weeks and then switch to another service, vacation, or outpatient clinic. Medical students only stayed five weeks in any particular place. And, the attending physicians seemed to rotate as well. A single patient staying in the hospital for any length of time would see a great number of medical students and doctors passing through. Teams of nurses, however, tend to remain on the same floor. Not only that, during their shifts, they actually stay on their assigned floors. Doctors and medical students might be running around to clinics, the operating room, rounds, teaching sessions, or any number of activities, but the nurses are actually present, on the floors, at all times. So every morning, nurses can provide information on how a patient has done overnight. Did the patient spike a fever? Sleep well?

It was generally the job of the medical student to gather and consolidate data in the morning. But with my sudden pathological forgetfullness, this became a nearly impossible task. William took me aside, saying, "Are you confused about what you're supposed to do in the mornings?" I nodded. "I already told you this, you go to the PAPER chart, you go to the COMPUTER, you talk to the NURSES, you talk to the PATIENT, you gather ALL THAT DATA, and then you report to me..." He stopped, looking at me, and then wondered aloud about whether there was something wrong with me. William generally had a look of kind understanding. He was the sort lauded on good bedside manner, the type patients could trust, and the type not to be annoyed without good reason.

"I think I could be a good doctor one day..." I tried to explain that I wasn't usually this forgetful, that this wasn't me, that I didn't know what was wrong, but that I was sure if it was fixed, that eventually, I could function as a doctor. But the mounting tears prevented me from speaking.

"Did you have trouble during first and second year?" asked the resident. The look of kind understanding reappeared on his face. I didn't answer- a tear rolled down my cheek and another threatened to join it. The fact that I had done well during the first two years, that my board scores were excellent, almost made things worse. The resident likely took my silence as agreement. Our conversation ended with him pausing and saying "I don't think you can function in a hospital." He spoke carefully, as though delivering bad news to a patient. He paused, looking at me with a mixture of sympathy, confusion, and annoyance.

The fact that William was mild mannered and didn't routinely abuse those around him made our conversation even worse. I couldn't complain to my classmates over drinks about yet another injustice incurred at the hospital. I couldn't dismiss this or laugh about it later.

I knew he was right. I left the hospital that night and didn't return for nearly a year.

(The above post describes past events, right now I'm in school and doing fine)

Candy

As I travel through third year, rotating from service to service, hospital to hospital, my life is filled with a barrage of unfamiliar faces, strange new computer systems, new keypad codes for new supply rooms... and I search for the slightest bit of comfort, something that I already know, something that I don't have to figure out... and that thing is usually candy.

Wherever I am, whatever I'm doing, I always make sure I know where the nearest candy machines are, which ones charge only 75 cents for the candies, which ones try to get away with charging a dollar fifty. I know which soda machines sell diet coke in a can (Pepsi isn't the same thing, and diet coke in a plastic bottle isn't the same thing...) and I know which ones are generally well stocked, which ones take the crumpled dollar bills...

So, as my life spins out of control, I can sip Diet Coke and nibble on Starbursts as I jot down new supply room door codes, try to memorize the new names and faces that will be evaluating me, and try to figure out the new computer system.

The Descent Continues

My medication change, my talk with the Site Director, my realization that if I just kept getting up in the morning, going to the hospital, coming home, taking Ambien, going to sleep, and getting up again, I could go on indefinitely. And that's what I did- I slogged back and forth between the student housing and the hospital. I ate, I slept, I did all the things and ordinary human being is supposed to do during his or her time on earth. And I fell into an equilibrium.

Realizing that things were better, but not great, I again called Dean Stewart to ask about taking time off. “Now that you’re psychiatrically stabilized, I don’t see that there’s any benefit to you taking time off…” I wanted her to understand that while I felt my feet were becoming more firmly planted beneath me, that things weren’t right. I was functioning in the hospital, puttering about, writing notes, presenting on topics; and while I wasn’t excelling, I was now certainly up to standards. She advocated self care, telling me that perhaps I should take a day off on the weekends as opposed to voluntarily going in to the hospital to see my patients.

I eventually finished my 5 weeks of internal medicine at Glendale and returned to my home hospital at [] medical school for the final five weeks of the rotation. When I arrived I’d been branded as a “student in trouble,” a distinction which awarded me “extra help” in the form of constant suggestions during my presentations. Were I not to have been branded, I believe, a lot of those little mistakes would have gone unnoticed, or would have appeared in my evaluation as qualifications to my otherwise stellar performance. But instead, my preceptor, desiring to “help” me decided to do so by bringing our preceptor sessions to a screeching halt when he sensed that I did not understand something. The other 3 people in the sessions politely waited as my presentations were drawn out and picked apart. Did I understand the difference between infection, and vasculitis? Yes, I stammered, turning red; the preceptor was doubtful that my response reflected true understanding and launched into a long explanation.