bereavement

III. Bereavement
     As death of a loved one is filled with anguish and pain it should come as no surprise that grief is one of the most painful human emotions.  It is not clear how long grief should last (even if the category of 2-6 months is currently popular).

     The final lecture from my Behavioral Science class this block was about grief.  How appropriate.  And the above came from the reading.  The two to six months part is laughable to me, as it was to the psychiatrist who gave the lecture.  "My dad passed away during my residency and it takes a lot longer than 2-6 months.  I'm not sure where they got this number," she informed us.  The lecture then delved into how we as physicians need to try to distinguish appropriate grief from a major depressive disorder in our patients.  A very real and substantial part of me appreciates the contributions of a medical model of looking at the darker aspects of moods.  It has utility and it has value.  I've seen what happens when depression goes untreated and results in suicide.
     But as I read more and more about grief vs. depression, I began to think that there's something lacking in substance to the medical model.  Medicine seeks to treat or event prevent diseases.  If there's a broken bone, we reset the bone, immobilize it and allow it to heal properly.  For viral infections, we administer vaccines to eradicate the scurge of polio.  Antibiotics have made rheumatic heart disease a thing of the past. 
     But how does that work for someone's psyche?  The psyche is broken and we seek to fix it.  There's a certain material logic to it.  If someone is suicidal, we'd certainly like to prevent that.  But taking the "fixit" analogy can cut the journey short when 'fixing' equals 'happy'.  There is something quintessentially dark about the human spirit.  Jung called it the shadow side and the older I get, the more I think there's something to it.  Our society places way too much emphasis on being happy or content as the goal of life.  Pain avoidance, I suppose.  There's even a whole body of medicine trying to link positive moods with life extenstion, nevermind the countless self-help books on being happy or positive.  But life is more than the number of days.  Don't believe me?  Name any great story that has endured the test of time.  The overwhelming majority involve soul wrenching pain and suffering.  Very few are happy-go-lucky stories.  Greek tragedies, anything by Shakespeare, you get the idea.  Yes, there may be hope and triumph involved but at the base is still suffering.  There's a reason for that.  Every single human being will be faced with it at some point in their life.  It is part and parcel of the human condition where literature and philosophy have as much to say, if not more than medicine has to say. 
     So I think about that lecture and how I approach that from my own experiences and how I will (probably) approach that with my patients down the road.  And at the end of the day, I do not choose to differentiate between appropriate bereavement and major depression.  They seem one and the same to me, a part of the human condition with artificial labels.

il faut d'abord durer

     Hemingway was known to sign personal letters with the French phrase il faut d'abord durer.  Idiomatically, it translates as "first, to endure".  It's been my motto ever since my brother died.  And it's a hard axiom for me.  I always enjoyed excelling.  Being above average was fun for me.  In football, I played to win.  And you don't get into med school by being middle of the road.  So it's a hard pill to swallow to set my sights at this point on merely surviving.  It feels like I'm settling.  But with the trifecta of med school, death, and my dad's condition.....I remind myself that it's a lofty and noble goal at this point.  If I can just get through all of this intact, that's no small victory.  So entering into the next round of exams, woefully unprepared, I remind myself, "first, to endure."  Go easy on myself and let go of the notion of honors and be content to endure.

anhedonia

     Lack of desire.  Devoid of pleasure or joy.  In a nutshell, it's not giving a shit.  About anything.  In medicine, we call that anhedonia.  Hedonism is to heedlessly indulge in pleasures.  Throw the negative prefix 'an-' in front of it and you're left with a mental state devoid of joy.  I like that term.  And usually, I'm not one to be partial to fancy medical mumbo-jumbo.  We make up all sorts of ridiculous and pompous sounding terms like using erythematous instead of red.  But anhedonia, I can get behind because it describes my mood perfectly.
     And I'm not sure why it took me awhile to understand that term and be able to apply it to myself.  This summer while studying grief, research suggested that the depression phase of the Kubler-Ross model of grief peaks at around five to six months.  And sure enough, it's been six months since my brother passed away.  When I read that, I envisioned the pain of grief getting worse.  But that's not it.  Not at all.  Tears are mostly gone now.  The everpresent anger is now a memory of the past.  But in many ways, what replaced it is far worse in it's subtlety and devastation.  Gut wrenching anguish is replaced by emptiness.  It's a void that insidiously covers your soul.  It's not caring whether I stare at a wall or have my nose in my books.  It's utter and complete apathy.  It robs you of your desire for anything be it worthy and noble or simple and sweet.  And you don't realize it until you are too far along into that long dark night of the soul.  Anhedonia.

pre giving of thanks

     "Open up and say 'ahhh'."  We're all familiar with that routine at the doctor's office.  But you ever try it with yourself in the mirror trying to see your own tonsils?  Not as easy.  With my pen light and a knife substituting as a tongue depressor I was able to manage it early this morning.  In doing so, I have really good firsthand knowledge of what an overgrowth of Streptococus pyogenes looks like.  It's better known as strep throat and even though my case wasn't a typical presentation, it made me suspicious enough to drag my infirmed body to the doc on a Saturday.  I knew there had to be something more devious at work on my throat than a common cold.  It felt like I was eating shards of glass everytime I swallowed.  Needless to say, studying (and blogging) have been out of the question.  It was so painful I couldn't even sleep.  Heading into Thanksgiving, I'm thankful for the people that developed the rapid strep antigen test, the NP who was willing to run the strep test even though mine was not classical, and whomever made the amoxicillin.  Hopefully, I'll be able to actually study in a day or two in order to make up for all the lost time.  Well, first I'll need to catch up on sleep.

game day

     In my football days, there was always at least one practice a week that was meant to simulate a game situation.  Any coach worth his salt knew that practice and the actual game are very, very different psychologically.  So they'd try to simulate that intensity and unpredictable nature of the real thing.  Same is true with interviewing patients and taking a physical.  We trained on actors who were healthy and mobile.  They did their best to pretend at being ill but even when they were acting sick, it was something simple like a stomache ache from an ulcer.  Acted pain and real pain are worlds apart.  The patients I'm seeing at MD Anderson?  They are hospitalized.  And people aren't hospitalized for no reason.  They are truly sick.  So all that practice I did on the actors, my wife, even my dog, went right out the window when you're trying to interview a patient who's lungs are so full of fluid they have difficulty completing a sentence.  Or, the patient in his twenties on methadone who's eye movements and acute sensitivity to nausea are EXACTLY like what my brother experienced.  And so on.  Nothing much prepares you for that except the real thing.  And as hard as it is, I'm grateful for the opportunity.

first encounter

     "I have a patient for each of you.  One," the doctor pauses here, "I'm not so sure about but we'll see how it goes.  The other is straight forward."
     He knocks on the door and introduces me to the patient as doctor which strains against any humble nature I have because it just feels cool.  I figure I've worked hard enough to get to this point that I can enjoy a bit of brief vanity, even if I'm technically not a doctor yet.  We're given nothing about the patient other than the last name.  That's it.  We're supposed to take a full medical history and give a full physical flying solo.  We then report back to the doctor overseeing us with our findings.  He takes us back to the patient so we can present our findings, shreds (deservedly so) our technique, educates us on a better way, and then we're on our merry way.  Repeat about weekly.
     Given his pregnant pause, I went out on a limb and guessed that I got the "not so sure one".  The daughter is in the room and I wait for her to finish up.  Then an occupational therapist goes in and I move further toward the back of the line.  As a med student, I think we're somewhere above the faucet but below the coffee machine in the hierarchy.  I wait about 45 minutes which is not really any big deal for me at MD Anderson.  I'm quite used to waiting here and I joked with my dad that they even keep their trainees waiting. 
     I finally get the green light and I'm in the room introducing myself to the patient.  One quick glance and I now know that I got the difficult patient.  She has a nasogastric tube emerging from her nose.  I look at the tube and notice the green fluid in it.  It's obviously not to feed her.  The green is the stomach fluid which is being emptied.  Her stomach is swollen to the size of a large watermelon and as hard.  I begin to gently question her and after many long pauses, her eyes focus on the window.  She slowly raises her hand and begins waiving.  I query as to whom she's waving.  "My daughter," as a half smile erupts on her face.  Keep in mind we're on the 10th floor of the hospital wing and absolutely no one is out there.  It's more than a little heart breaking to see a cancer patient in poor condition who is hallucinating but I cordone off that part of me, at least for now.  I do have a job to do.  I recover my senses and conclude the interviewing part isn't going to work so I try to salvage what I can and move to the physical exam.  After a very few quick parts, she says to the entering nurse, "I need to spend more time with you, and less time with him."  And with that, my first patient encounter lasts about 5 minutes and is over.

sick

     As a kid, I got sick a LOT.  I almost didn't graduate high school on time because I missed about a third of my senior year.  Since I didn't like school too much, it was a sort of guilty pleasure to enjoy the missing school part, though not being sick.  Now that I'm in med school, it's a completely different story.  Being sick sucks.  School marches on unabated and the work piles up relentlessly.  Fortunately, I'm back on me feet and ready to start digging out of the hole.