May 30, 2014

the suffering itself

     My wife and I were out eating in yet another attempt to continue to live life.  One of the specific foods appealed to my wife and she remarked fondly that our son would've enjoyed it, as well.  The statement was one of remembrance and fondness.  A happy memory.  And without so much of a word between either of us, a heavy stillness fell.  We were both thinking the same thing but in a choked voice I said, "it's painful to think about happy memories, isn't it?"  We both started to have tears well up in our eyes and it was time to leave the restaurant.  What kind of personal hell is it that to have good memories cause pain?  How does one continue to live life, much less enjoy it when even happiness causes excruciating pain?  And if a pleasant thought can cause torture, how much more worse is the pain in the bad times? 

May 27, 2014

the foreshadowing of suffering

     Humans are a superstitious lot, especially when undergoing suffering.  We ask what did we do to deserve this?  What act must be atoned for?  Guilt plays heavily because in the clarity of hindsight, I had direct foreshadowing of my son's coming struggle.  I wrote this over a year before his disease became self evident.  But did I see a hint of it in him?  I had to have or I would not have been able to write this.  And if so, the guilt of missing it weighs even heavier on my heart.
The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.
Spirits turned bitter by the poison of envy
Always angry and dissatisfied
Even the lost ones, the frightened and mean ones
Even the ones with a devil inside
Thank your stars you're not that way
Turn your back and walk away
Don't even pause and ask them why
Turn around and say goodbye
People who judge without a measure of mercy
All the victims who will never learn
Even the lost ones, you can only give up on
Even the ones who make you burn
Even though you're going through hell
Just keep on going
Let the demons dwell
Just wish them well
"wish them well" by n. peart

      Admitted on a Monday night while I was on call, she was gone by the end of the week.  She left AMA (against medical advice).  She was fed up with her bipolar nature, with the staff, with the hospital, with her life.  She had tried every medication and every street drug and nothing helped.  Her previous suicide attempt had been halted only by a rather miraculous medical intervention. We spoke with the mother over the phone. Unable to listen, the patient stormed out in a fit of rage after only a few minutes. The mother continued her story for a good half an hour.  She corroborated everything the daughter said, even adding details the daughter didn’t get to. This one was not faking, not exagerating, not just a drug seeker. The mother told us:
Look, I appreciate everything you’ve tried, I really do, but you have to realize that she’s been worked up countless times.  She had an extensive psych and neuro workup – everything – at multiple institutions and they couldn’t do anything to help her.  She’s been to so many doctors and nothing. Everything we've tried....nothing. We’ve given her places to live and she’s destroyed them. I’m still paying off the damages at her last place. She's my daughter and I lover her dearly and I know this sounds cold and heartless, but I’m surprised she’s still alive.
      Many of the staff hated the patient.  Her raging temper was set off by saying the wrong thing, even by a wrong look.  And she herself hated it.  She hated herself for not being able to stop it.  You could see her speech begin to speed up fasterfasterfaster as her lips struggled to keep up with her racing thoughts.  She wanted it to stop.  She said so but then two minutes later she was cussing someone out.  There's a fine line sometimes between distinguishing an asshole from someone with mental illness. There was no doubt in my mind she belonged to the latter.  Nor the doc who sadly but realistically doubted this patient would survive the year. 

    And yet the patient had never raised her voice at me.  She never got angry with me.  She never threatened me. The attending, exasperated, finally relegated the patient to me since she seemed not to be able to talk to anyone else without becoming frankly violent. To be honest, I’m not sure why I was able to talk to her. When it comes down to it, I think I saw my son there. My wife’s family has mental illness running in its past and I thought to myself, “if my son had been born into that situation, this could be him.” It scared me tremendously to know that the genetic possibility was there. So I talked to the patient as if she were my own son. But that wasn't enough.

​      Before the patient left, I went to say goodbye to her. I told her, “I wish you well." It's all that I had left to give.

     And that’s the part that bothers me the most. The patient was cognizant enough to know that she needed help.  She knew that she was headed for a bad ending. Her entire being was unraveling. But she was powerless to stop it. And so were we. We had nothing in our bag of tricks to help. Was she too broken for us to fix? Was there ever even a point in her life that interventions could have changed her path? Had the medical system failed her by not being able to permanently institutionalize him? Was she just a bad person who continued to choose drugs over treatment? Was she just trying to manipulate me?

     She’s the one that got away. The patient that I couldn’t treat. But more than that, she was a broken human being that could not be helped. We are taught never to give up. To never quit on a patient. But that doesn’t work in real life. Tragedies do happen. Horrible things do occur. I learned that first hand from my brother. And we as doctors, as human beings, are all too often unable to do anything about. In that regards, serious mental illness is no different than cancer, than heart disease, than HIV. They all tragically take human life.  Her life was indeed tragic and his story will stick with me always.

May 23, 2014

revelations in suffering

     As I am graduating mid year, I have to make sure that my scheduling doesn't fall through the cracks and I get enrolled in the things that need to happen so I periodically meet with the Dean to ensure I'm still on track.  The very act of going through those motions should prove to myself that I still very much want to be a doctor and finish.  Hey, nothing can be taken for granted at this stage.
     But lately, I have been reliving the last few weeks of my brother's life and the role I personally played.  It's not as if I'm wanting to relive this as it piles stress and pain on to an already broken psyche.  I tell my wife that I'm held together by duct tape.  And I'm serious.  The only person who truly understood the toll from a first hand view that the last 2 days of my brother's life took on me was my mom (my wife was at home in Houston).  It became a shared bond between us.  And for reasons that are not entirely clear to me, I recently decided to tell my eldest brother.  Now he is a highly bright, highly intense man who has served our country as a Ranger and lived through combat.  He has wounds, though, like most military men, he is modest about his service and ill at ease to talk about it.  I wrote him a long email describing all that happened.  His reply was one word.  PTSD.  That response radically changed my self perception of my struggles.  Hearing it from him carried the heft of authority far more than having a doctor diagnose me.  He of all people would know.
     During my meeting with the Dean, I briefly relayed this story to her to give her an example of how I was doing.  She said, "well, of course," as if I was blind.  She remarked, "how you are even still here is a testament to your will."  I don't know that it changes anything practically for me as I'm doing everything possible to keep putting one leg in front of the other.  But it did grant me no small amount of vindication.  It's possible to feel weak, wounded and destitute yet still be incredibly strong.

May 22, 2014

ave atque vale

Three years later, I have more thoughts on these words:

Through many countries and over many seas
I have come, Brother, to these melancholy rites,
To show this final honour to the dead,
And speak (to what purpose?) to your silent ashes,
Since now fate takes you, even you, from me.
Oh, Brother, ripped away from me so cruelly,
Now at least take these last offerings, blessed
By the tradition of our parents, gifts to the dead.
Accept, by custom, what a brother’s tears drown,
And, for eternity, Brother, ave atque vale
‘Hail and Farewell.’

     My healing of grief became interrupted.  Medically speaking, it would be called complex grief, at least it was in the old DSM IV.  My dad's illness was and still is a battle as evidenced by a recent trip to the ER.  My son's illness has taken an immense toll on me.  And all three of these are intimately tied to my career choice.  How does one even begin to unwind the different threads?  I'm not sure it's even wise to do that at this point.  Pull on a thread long enough and there may be nothing left.
     I was speaking with a faculty member more interested in the philosophy and humanity of being a physician that was offering me a sympathetic ear.  I gave him the abbreviated version.  He asked me, "how are you still here?  I mean, med school is stressful enough but what you've been through...."  I had no answer.  I still don't.  Though I promised him that if I ever figure it out, I'll let him know.  I do know the words above will always fill the space in my life with tears that my brother occupied.

May 20, 2014

the repetition of suffering

     Every morning it is the same.  As the light of day begins to replace the dark of night, before I am even awake, a small seed of irritation starts to sprout.  The night is the closest thing to relief despite not sleeping well or having my subconscious shine lights into the darker spots of psyche in the form of nightmares.  The light of day intrudes upon that respite, no matter how small.  The more awake I become, the more the irritation builds into anger.  The anger then gives way to a rage which is all consuming.  It is to become a thing of fury and the absence of light:
What it was could not be seen: it was like a great shadow, in the middle of which was a dark form, of man-shape maybe, yet greater; and a power and terror seemed to be in it and go before it...Its streaming mane kindled and blazed behind it. In its right hand was a blade like a stabbing tongue of fire; in its left it held a whip of many thongs....His enemy halted again, facing him, and the shadows about it reached out like two vast wings. It raised the whip, and the thongs whined and cracked. Fire came from its nostrils.               - JRR Tolkien
      When confronted by such a self destructive force I have few options.  I could all too easily turn to drug or drink.  I could become incredibly self destructive.  Or, I can workout, and that is to say not a workout in the traditional sense of the word.  This is not for fitness or stress relief or health.  This is to fight for my very life.  Daily.  Such a Sisyphean task wears one down.  Each day, the multiple joints in my back hurt a bit more and the will is a bit weaker.  I secretly wonder how long can I last at this?  Despite it all, physically, I grow stronger.  Does that translate into mental resilience?  One might as well ask why the sun?  It keeps me alive one more day.

May 16, 2014

the giving in to suffering

"Do I hope that if feeling disguises itself as thought I shall feel less?  Aren't all these notes the senseless writhings of a man who won't accept the fact that there is nothing we can do with suffering except to suffer it?  Who still thinks there is some device (if only he could find it) which will make pain not be pain.  It doesn't really matter whether you grip the arms of the dentist's chair or let your hands lie in your lap.  The drill drills on."  CS Lewis from A Grief Observed

May 13, 2014

the giving up in suffering

     The patient had lost his job and his wife was threatening to leave him.  The suffering became overwhelming.  Deliberately, he assembled a mass of various pills, a bottle of Jack Daniels and his hunting knife used to field dress deer.  The knife performed the same function on deer as it did on its master.  Both wrists had to be stapled close along with a massive slash along his neck.  This man truly intended to give up.  How he lived is beyond any medical explanation.  He admitted so himself.  He downed a bottle of pills with a bottle of Jack Daniels and then cut himself in three places where major bleeding IS going to occur.  But somehow he lived.  I don't know what became of him.  Did he get the help he needed?  Or more importantly, was the help even enough?  Or, like a statistic, did he repeat his grisly task only this time completing the grim task?
     So with this patient in mind, when people try to reassure me that the suffering will pass, I wince inside.  It is not always so.  It takes vast amounts of emotional fortitude to step away from that cliff.  It often requires a deliberate choice requiring more will power than many people have.  So that choice is far from a foregone conclusion.  Suffering can, and does, win.  The bodies taken by suicide or the broken human beings who live in constant tension of that dynamic of choosing life or giving up and embracing death are a bodily testament to that fact.

May 9, 2014

the resistance in suffering

     Those who are not aware of the Battle of Thermopylae would do well to learn about it not for just its historic significance but also its significance on the Will of the human spirit (and no, that movie 300 doesn't even come close).  In a nutshell, the Persian king Xerxes had assembled a massive army which grew daily as his conquests of Asia, the Mediterranean and northern Africa continued.  His sight was set on Europe next.  Standing in the way was the small country of Greece - the birthplace of western thought which includes our republic, our sense of liberty, our morals, nearly every major philosophical building block of the Western World.  Only, these wonderful ideas of freedom were only just beginning to bud and branch out at the time.  They had not yet sufficient time to grow, much less spread and the Persian army was about to wipe away that potential in one fell stroke.  Sparta sent 300 of its most skilled and noble army who had already given birth to a son to resist the massive army of Persia.  There would be no retreat in order to give time for the rest of Greece to marshal its forces.  The King of Sparta sought to make his stand at the hot springs of Thermopylae as it narrowed and would lessen the great advantage of the Persian's superior numbers. 
     Shortly before the battle began, an envoy from the Persians were sent to the Greeks.  They offered the Spartans wealth and fame beyond their wildest dreams if they would only bend their knee.  In exchange, they must lie down their weapons.  The reply King Leonidas gave was extraordinary in its bravery and brevity.  He merely said, "MOLON LABE" which translates as "come and take them."  He knew pain would come.  He knew suffering would come.  He knew death would come.  He knew everyone of his sword brothers on this mission with him would die with him.  All for the chance to for their offspring to remain free men.  There is a grim determination that would say while suffering in the 9th layer of Hell, "molon labe".  Come and take me. 

May 6, 2014

the stillness in suffering

     "What are you going to do with your time off?" is a common question I overhear other students exchange.  They are young and the world is their oyster.  Me?  What do I do?  Wrestle the demons with full attention that had to be put off in order to finish a rotation.  With free time, their is little else to do but confront those demons.  I write both privately and publicly.  I exercise, not for health benefits but to burn off the anger that builds anew each day.  I do yoga in part to help my back but just as much to yoke my spirit to my body.  I read, mostly books about suffering.  I meditate, or at least try to as my current state of mind makes that difficult.  And I think a great deal.  After all, the other stuff does not encompass an entire day.  In my field where constant movement and work are the norm, my day is contrasted by much stillness.  Laziness would be the term the western world would use to describe it.  I call it trying to reconstruct my world and the way I view it brick by brick by brick.  After all, it does keep getting torn down.  The stillness in suffering is hard work.

May 2, 2014

physical vs spiritual pain

     The patient was terminal and was well aware of his condition.  He was also in intractable pain.  No matter what pain management strategy was employed, it failed.  At last, a chaplain was called in to speak to the man.  The conversation that ensued was between them and their God yet the pain in the man went from a consistent 9/10 to a 2/10.  Some may conclude that he just needed faith and the power of prayer.  Others would say it was all in his head.  I would consider both unwise conclusions.  The man's pain derived from his existential anxiety.  Medication cannot treat the deepest set fears of the soul and heart.  And who among us would deny another person this pain, this suffering by trivializing.  Only by honoring it was that mystery entered.