Posts Tagged ‘depression’

A moral dwarf amongst real veterans

March 14, 2019

Technically, you can call me a vet

Though I never faced much of a threat

And now the VA,

Making up for bad pay,

Is paying off Uncle Sam’s debt. 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada.  Any identifiable patient information has been used with permission.

Bethany and I drove up to the Sioux Falls VA hospital for my annual rheumatology appointment.

I have ankylosing spondylitis, a close cousin of rheumatoid arthritis which primarily affecting the spine.  It hurt me since before I turned 18 until my first injection of Enbrel in 2000.  It kept me out of Viet Nam, but not out of the Public Health Service.

So that I now qualify for Veterans’ Benefits, including health care.  The VA pays for an injectable medication which would retail at over $60,000 per year.  When I need a refill, I make a call and it appears on my doorstep in a Styrofoam insulated box in 2 or 3 days.

By comparison to the price, one 2-hour drive and 4 lab appointments yearly rates as a Best Buy.

Because I hurt for so many decades, by the time the pain stopped my body had gotten really good at generating and recognizing endorphins.  All in all, I feel better than I did when I was 18.

And when I sit in public places, I never stop my physician observations, even when I’m a patient.

I watched and listened to the Real Veterans in the waiting rooms today, and I made diagnoses.  The swollen knuckles of rheumatoid arthritis.  The blotchy facial redness and bags under the eyes of alcoholism.  The bug eyes of hyperthyroidism.  The slowness, shuffle and tremor of Parkinson’s.  Way too many “thousand-yard stares” of PTSD.  The scalp scars, cane, and abnormal gait of a traumatic brain injury.  Too many missing limbs to count.  Behind me, the conversation’s speed and volume (loud enough to hear, too fast to understand) of bipolar mania.  The hopeless faces of depression.   And attentive spouses steering veterans in wheelchairs.

While the lab tech (who gave me permission to write this) drew my blood, I noticed swelling in the front lower part of her neck.  I told her to get her thyroid checked, specifying thyroid stimulating hormone (TSH), and anti-thyroid peroxidase (TPO); and an ultrasound if those tests come up normal.

It doesn’t take much historical knowledge to be able to recognize the conflict that modified the hero.  Although, with two fronts ongoing for the last 25 years, I can’t tell the Iraq vets from their Afghanistan contemporaries.  Some served in both theatres.  Some Korean vets served in Viet Nam.

I don’t feel myself a veteran in the presence of the real ones, I feel a moral dwarf.  I never faced a greater danger than a drunk’s slow punch in the ER.  I put up with bad pay and bad management for 5 years.  I lost income, my fellow beneficiaries lost things that cannot be replaced.

Still, the VA treats me the same as they treat the Real Veterans.  Part of the culture of VA employees involves a lot of caring and warmth that people bring from their hearts but the Federal Government does not pay them for.

For my time in the Public Health Service I got 5 years of cross-cultural experiences that could never be purchased.  And now I get benefits equal in value to a good full-time job.




End of the Summer of Urgent Care

October 25, 2015

I could do as much as I’d dare

Sometimes not a moment to spare

From the first to the last,

It sure went by fast,

The summer I did Urgent Care.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, and two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.

The vast majority of Family Practice involves delayed gratification or out-and-out frustration, the exceptional case, where the patient leaves better than when they walked in, comes as a treat.  When I owned my own private practice, I would have one or two a week.  Two would make a day, but a standard Urgent Care shift might include six.  Drain an abscess, stitch a laceration, remove a foreign body, clean out ear wax, splint a fracture, or take off a tick or any fraction thereof.

But I couldn’t give the anxious and depressed people my version of hit-and-run counselling.  Nor could I do much with the rather fascinating cases that required labs or sophisticated x-rays.  And if an x-ray showed a problem needing further imaging such as CT or MRI, I wouldn’t be part of the resolution.

I sent so many patients out by ambulance for chest pain that I can write about the aggregate without revealing any unique patient information, but I can say that people mainly concerned with chest pain shouldn’t come to Urgent Care.  I can say the same of the people who have the worst headache of their lives, severe abdominal pain, or anything problem related to pregnancy.  I won’t know what happened to those patients, nor the final diagnosis.

I saw very unusual x-rays and physical findings, but Urgent Care by its nature doesn’t involve follow-up, and I’ve resigned myself to not knowing.

When I took care of a person with a substance abuse problem, I had to make do with the briefest of interventions, but I suspect I did as much good, if not more, as I did in those cases where I had 45 minutes to spend.

I cared for 47 patients over the course of 12 hours my last day (this go round) in Urgent Care. I sent for the ambulance 3 times, I urged 4 more to the ER as soon as they could get there.  Out of 4 x-rays, 2 showed fractures.  For every patient for whom I prescribed antibiotics, I advised 4 that antibiotics would probably do more harm than good.  This late in the year I diagnosed poison ivy 4 times, with reactions much lighter than those I saw back in June.

I washed my hands or used alcohol based hand rub twice, minimum, for each of those patients, and I don’t anticipate the skin on my hands recovering for a week.

With that kind of patient flow I didn’t get a chance to talk to people about their lives.  I didn’t get to the fine points of social context leading to disease.  I missed quizzing people about the details of their occupations and hobbies, and learning about the wider world from the contact.

So I found the summer of Urgent Care gratifying but not satisfying.  Long, hot days have passed and the leaves are turning.  One morning I had to scrape frost from the windshield.  The action and immediate gratification might bring me back but for the time being I’ll work on something else.

Another road trip 8: diagnosing in public

June 15, 2015

I can write about things that I see

In public, where the viewing is free

The many, the few,

With no interview

It’s observation, that is the key.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, and I just finished an assignment in rural Iowa. Right now I’m working in suburban Pennsylvania, combining work with a family visit.

Confidentiality applies to my patient population; it doesn’t have anything to do with what I can observe in public.

In 1977, when I was junior medical student, I went out for a walk with my first-year family practice resident roommate in Saginaw, Michigan.  We walked past a man with coarse features, a very broad nose and heavy jaw, and outlandishly heavy bones over his eyes.  “Acromegaly?” I asked after we’d past him, referring to a pituitary tumor that starts in adulthood, after the growth plates have fused.  He concurred.

I never stop being a doctor; Even before I had a license, I diagnosed based on observation.

A couple of months ago I sat next to a friend, waiting to get dismissed from jury duty.  I looked down at his right hand, and saw the muscles between the thumb and the forefinger twitching; the medical term, fasciculations, don’t care the evocative quality of “bag of worms.”  I asked if he had Parkinson’s.

Today, my skills kicked in full force at a social gathering.

The bug eyes of Grave’s disease are easy to spot.  The thyroid lump that some people have in the lower part of the front of the neck, goiter, sometimes goes with it.

I saw two cases of scoliosis.  In the crowd I spotted the moon face and “buffalo hump” (enlargement of the fat pad between the top of the back and the bottom of the neck) that signals Cushing’s, from too much steroids (whether made by the body or taken for other problems.)  I could diagnose autism in the young man who rocked and didn’t make any eye contact at all.  From one woman’s rolling gait I could tell she’d had a failed hip replacement.  Several of the elderly showed early osteoporosis.  Several men showed testosterone deficiency by their prematurely narrowed shoulders.

When a person looks at the floor, moves slowly, and dresses in muted colors, I don’t have to do an interview to diagnose depression.

An extraordinarily tall young woman with very long, thin fingers showed all the signs of Marfan’s syndrome; her male relative at 6’8” probably had the same problem, but I didn’t get a chance to see his hands.

I heard the whistle at the end of the cough that tells me that person has asthma.

When another person sneezed three times in a row, I didn’t even have to turn around to diagnose allergic rhinitis.

Short lines of communication, unusual prescriptions, and vitamin B12 deficiency

May 6, 2015

Morning rounds before Thanksgiving.

November 22, 2012

I started my work in the dark,

At the hospital next to the park.

Up and down floors

And in and out doors

The contrast and irony stark.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

I enjoy starting early.  On Mondays and Wednesdays I do my group’s hospital rounds, and I like being in that first wave of doctors that hits the nursing floor before the chaos of shift change.

The more efficient I get, the more I enjoy inpatient work.  A doc can save a lot of time if he or she starts at the top and works down but today I started with the sickest patient admitted overnight, on the fourth floor, not the sixth.

I gained time because comatose patients don’t talk, and lost every minute trying unsuccessfully to access the outpatient record electronically.   Faced with an unconscious, non-English speaking patient, no available family members or other source of data, I did the best I could.  I left orders for social workers with interpreters to locate family and clarify the Do Not Resuscitate status.

Down the hall, the next patient, also requiring a history and physical, presented a dilemma: a narcotics addict with a legitimate, acutely painful physical problem.  I wrote orders for generous doses of narcotics in a patient-controlled anesthesia (PCA) pump.

I dealt with nurses panicking about a rumored bedbug found in the ER, pointing out that wearing infection control gowns , gloves, and caps wouldn’t do anything to prevent the spread of real bedbugs.

On the other side of the nurses’ station, I discharged a large patient with a 14 item problem list, who will need outpatient IVs for weeks.

I didn’t see the last patient on that floor, absent for treatments across town, but the ward clerk told me when to return.

Five minutes here and there add up, chasing patients wastes time, and I could feel efficiency fleeing in front of me.

I set off upstairs.

Some people don’t stop unhealthy behaviors soon enough, and physicians like me sometimes have to sit down with families and talk about time expectations measured in a week or two.  We discuss ventilators, resuscitation, and the vital business of saying what you have to say to the people in your life NOW because you might not be around to say it on Monday.  The patient said, “I’ve had a good life.  I’m not afraid to die.”  I talked with the consulting subspecialist who confirmed a very poor life expectancy, and gave me a decades-old formula . My calculator came to 63 when anything over 32 means less than a dozen days.

Three doors down I discharged another patient, mixing Spanish and English, and getting pieces of a fascinating life story, an odyssey crossing and re-crossing international boundaries.

On the other side of the building, inside the locked doors of the psychiatric unit, I discharged a person showing remarkable insight and taking complete personal responsibility, after a discussion of the fine points of a borderline vitamin B12 levels.

Two stories down, I discharged another from the orthopedic floor, who also had vitamin B12 problems and severe vitamin D deficiency.  Two doors up the hallway, the patient showed progress but not enough to leave.

Up the stairs again on the fourth floor, five minutes fled while the patient arrived from across town.  Optimism suffused the visit with four family members and a patient with a grim diagnosis and a good attitude.

Two floors down another admission involved a newborn, with the shortest of histories and the most efficient of complete physicals.  I spent more time talking with the parents than actually examining the patient.

Thus in the course of my hospital morning, I took care of 8 patients including 3 admissions and 3 discharges (with discharge summaries).  Diagnoses included metastatic cancer, end-stage liver disease, hip fracture, kidney failure, dementia, end-stage pulmonary disease, bipolar, alcoholism, depression, diastolic heart failure, sepsis, epididymitis, diabetes, hypertension, coronary artery disease, stroke, narcotics addiction, sepsis, urinary tract infection, and completely normal.  Life expectancy ranged from less than a week to 86 years.  Family involvement went from none to surrounded by warmth, and emotional impact of disease ran the spectrum from despairing acceptance to outright joy.

Contrast is the essence of meaning.  I finished before noon.  I lunched with my colleagues in the doctors’ lounge, discussing hospitalized patients with consultants. The erudition beat the chili.

Taking the pulse to get through the denial

November 19, 2012

How do we know what we know,

In a patient denying it’s so?

A two-week-old start

For a pain from the heart

Was part of a tale of woe.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

A doctor has to listen as carefully to what the patient says as to what the patient doesn’t say.  I don’t think any of the standardized tests given to doctors measure the ability of a physician to detect deception and denial in the history given, nor how to sneak through the web of drama and irony to get through to the truth.

I nodded while I listened to a patient talking about symptoms identical to the last three visits.  Taking full responsibility for the ruination of a perfectly good set of lungs, the patient seemed to me a little too cheerful.  In the middle of a digression I reached out my hand to the patient’s, and feeling the pulse, waited till the smile faded a little and I could speak without interrupting. 

“I think you had crushing chest pain for hours, going up into both sides of your jaw, with sweating and nausea and shortness of breath even worse than usual, about two weeks ago, and it went away and ever since then you’ve felt just terrible.”

The gaze dropped and the sigh came through over the gentle hiss of the oxygen as the smile faded. “That’s about the size of it.”  I kept my index and middle fingers on the pulse and I waited.  “You don’t think it was a heart attack, do you?”

“I do,” I said. 

“Well, I guess I thought so to, or else I wouldn’t have made the appointment.  I just didn’t want my daughter to know, she’d have made me go to the hospital.”  We looked at each other and burst into laughter.  “That sounded pretty stupid,” the patient said.

“There’s a difference between fear of hospitals and stupidity,” I said.  “We need an electrocardiogram and a chest x-ray.”

After the lab studies confirmed what I already knew, I started into the part of the interview known as the Review of Systems.  “Any depression?” I asked.

A shake of the head, followed by, “No, no, not at all.  Not anything worse than usual.”  I reached my hand out again and the patient’s forced smile fled.  “Yeah, I guess I’ve been pretty depressed ever since.”  I nodded and we laughed again and then we laughed because we were laughing about depression.

The patient gave me permission to write a good deal more information than I have, about a visit stretching over an hour and a half, and touching on issues of intergenerational conflict, ripples of familial dysfunction getting worse and getting better in children and grandchildren and great-grandchildren, nosology, intellectual honesty, freedom of choice, and game theory. 

I ended up giving bad news and reassuring at the same time.  I arranged for proper follow-up and explained new medications. 

Of course when that patient left I went on to the next one and apologized for running late.


Alcohol: truth and fantasy

September 20, 2012

It seems to me this is bunk,

The uncomplicated life of a drunk

With a true loving wife

And a well-ordered life

And insight that comes by the chunk.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

I read over the information about the male patient, age 42.  The main reason given for the visit came down to concern with alcohol use.

He drinks 6 Jack and Cokes a night, 4 nights out of 7, more on the weekend.  Doesn’t smoke.  Married.  Employed.  Wife concerned he’s drinking more than he used to, and he confirms that over the last 4 years his alcohol use has accelerated.  He doesn’t have problems at work.

He maintains a normal blood pressure and pulse.  His blood work came back as normal with the exception of the liver functions, which, unsurprisingly, run high though not dramatic.  I asked for and received an acute hepatitis profile which came back normal, and I couldn’t order an ultrasound.

He has tried to cut down, he gets complaints from his wife about his drinking, those complaints annoy him.  But he has never had to have an eye opener, a drink to get going first thing in the morning.

I find no family history of alcoholism; he has no symptoms of depression, no tremor, no headache, and absolutely no sleep disturbance.  Sure that he is not an alcoholic, he notes that most of his friends drink more than he does and that most of his socializing has to do with alcohol.

And so the motivational interviewing starts.  No judgmental statements, just questions, like What is important to you?  How does your drinking fit in with that?  Visit after visit, he makes more and more progress whittling away at his tippling and then he starts going months without any alcohol at all. He changes friends, and he gets closer with his patient and loving wife.

The patient didn’t give me permission to write these details because the patient does not exist.  The information came to me in a case scenario, a clinical simulation, during my preparation for Family Practice recertification, in the module called Health Behavior.

The case presentation doesn’t match with the reality of my alcoholic patients.  As a group, none sleep well, all have family histories of alcoholism, all live in a continuous state of household chaos, going from one crisis to another, sabotaging success and intimacy.  A few have normal bowel habits, fewer live without headaches.   Most of my alcoholic patients have scintillating, quirky personalities and great senses of humor; yet prone to fits of unreasoning anger, occasional rages, and unrealistic demands on the people around them.  Despite tremendous generosity, they betray friends, lovers, spouses and children.  Embarrassing others in public leads to progressive isolation.  All but the homeless drunks have an enabler, who will sabotage progress towards sobriety.  They rarely stay dry without a 12 step program.

Even when sober, they generate chaos, though if they get religion (AA is a religion) they generate less chaos as time goes by.

With all their problems, they’re still fun and exciting to be around. Unlike patient case scenarios.


Bipolar disease unmasked by the Christchurch earthquake

May 3, 2011

When the ground starts to tremble and shake

The people and buildings might break

     And after the panic

     A soul could go manic

In the aftermath of a big quake.

 Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical and backing from the brink of burnout, while my one year non compete clause ticks away, I’m having adventures and working in out-of-the-way places.  Currently, I’m working in Matakana, on the North Island of New Zealand.

This weekend Bethany and I took a road trip north from Matakana.  Our first stop, to Bennett’s chocolate factory in Mangawai, left us euphoric.  We visited David and Ursula, who live in the area.

An electrician, David has helped a great deal in Christchurch since the earthquake on February 22.

The familiar news photos show the destroyed central business district, and fail to depict the drama and irony of the day-to-day human situation.

The temblor cut communication to the eastern suburbs; telephone, electric, sewer, water, everything.  Flying his own helicopter at his own expense initially, a local man delivered load after load of hot food to parks until the Red Cross took over (some would say they didn’t do as good a job).

Disposal of waste became an immediate problem.   Portaloos got shipped in by the thousand, but the limited supply meant some people faced a walk of a kilometer.  Fights broke out over access to basic facilities. 

Two plumbers in their early 20’s sat down in a garage, and in the course of an evening figured out how to turn five gallon (twenty liter) plastic buckets into toilets at a cost of $20 each, assembling jigs and putting together instructions.

David and his son James were asked to help with the project, mainly with obtaining the money required (by way of donation) and the organisation of the production of the emergency toilets.  In the process of assembling 4800 of the devices, David has made a few trips to Christchurch and has a lot of observations about what really happens on the ground in the wake of a disaster.

Many people have quit the city, some forever; some have left the country.  Rebuilding will require more than ten years.  Earthquakes pose immense technical barriers to sewer, gas, and water service. 

And the earthquakes haven’t ended.  Aftershocks of 5.3 on the Richter scale continue, robbing the night of peace and stealing rest from the inhabitants.  You can see it on their faces, he said, and some have snapped.

He described a woman who abdicated all accountability to her family and now flies around the country with no particular goal.

I said, “She starts a sentence, and by the time she finishes you’ve lost track of what it was she was trying to say.” 

David got a strange look on his face, as if to ask if I’d been in the room.

“In the business,” I said, “we call it press of speech, flight of ideas, and tangential associations.”

“You’ve just described her to a T,” he said.

I turned to Bethany.  “What’s your diagnosis?”

“Bipolar disease, manic phase,” she said, and grinned.

Avoiding pedantry, I let Bethany do the talking.  By now she has acquired an immense fund of knowledge by watching the disease progress in so many people.

A wave of mania and depression, and uncovering of bipolar disease, in the wake of severe stress followed by sleep deprivation, makes perfect sense to me.

Ursula said, “And compared to Fukushima, can you imagine what they’re going through?”

For David, the work in the disaster area has been a life-changing event; he and Ursula agree he’s a lot easier to live with.  “He doesn’t sweat the small stuff anymore,” she said.  “It puts things into perspective.

 My thanks to David for his help with this post.

Bipolar improvement, and Synergy’s swan song at Pepe’s North of the Border

July 17, 2010

At the end of the day there’s no droop

Though I’ve been jumping through clinical hoops

    I don’t think I lose it

     After making great music,

And saying goodbye to the group.

A lot of bipolar disease masquerades as depression, though depression runs rampant in twenty-first century America (elsewhere, too).  I start to suspect bipolar if the patient has been on more than three antidepressants, if there’s a family history of severe mental illness (institutionalization, or suicide), or if a particular antidepressant works for a while, then stops working.

What doctors and the popular press used to call manic-depression now carries the label of bipolar.  Seventy-five percent hereditary, it runs in families.  Everyone has good days and bad days, but bipolar patients cycle between extremely great moods and profound depression.  Every day spent feeling good brings an average of four days feeling down.  While manic they may feel invulnerable and engage in risky behavior, ruining their family relationships, finances, and health; while depressed they may commit suicide.

If I suspect the patient of being bipolar, I ask, “Have you ever had an episode lasting at least four days when you felt great, got a lot done, slept less than four hours a night, and didn’t miss the sleep?”  A yes answer confirms the diagnosis though a no doesn’t exclude it.

The textbooks break bipolar disease into the more severe bipolar I and the less severe bipolar II, but I think the disease runs a spectrum.  Diagnosing the extreme cases comes easily, less severe disease is more subtle.

A few days after my arrival in Barrow I diagnosed a patient as bipolar; at the time she was compulsively picking at herself.  I recommended she change her current antidepressant (a selective serotonin reuptake inhibitor or SSRI) and start topiramate or Topamax.  Of course the drug is not on the formulary and I had to get special approval to prescribe it.

You can’t just start taking Topamax; the dosage starts low and gets increased slowly.  The medication has a lot of side effects, one of which is appetite suppression.  Its tolerability ranges widely.  Currently under investigation by the FDA for approval for the indication of weight loss, people lose an average of thirty pounds when they take it.

The FDA approved it for use in bipolar disease, migraines and seizures; my impression has been that it’s good at damping binge eating.

They say the young doctor knows twenty drugs that will treat one disease, and the old doctor knows one drug that will treat twenty diseases.  The choice for Topamax was a clear slam-dunk for the patient, who gave her permission to give this information.

She was in today.  She stopped picking at her breasts, face and nails, those sores have healed.  She lost about fifteen pounds so far, and she’s a lot happier.  We agreed making an appropriate diagnosis of bipolar disease is a worthwhile goal because it leads to a different, more effective treatment.

My background is littered with bipolar people.  In high school my jazz trio turned out to consist of a bipolar drummer, a bipolar pianist, and me.

I had a good time in music back then.  I didn’t see music as an end in itself, I thought it could be a means to a living, and if you have great business sense, great musical talent, and great luck, it can be.  I lacked the talent and I lacked the desire to practice enough to maximize the talent I had.

Here in Barrow, closer to the North Pole than to the state capital, I have found very good musicians to hang out with.  Shortly after I got here I was recruited into the band Synergy, and I’ve been practicing hours a day and loving it. 

Eight weeks ago, half an hour of practice exhausted my lips.

Today I played half an hour in the morning, another half hour in the afternoon, and we just finished a three hour gig at Pepe’s North of the Border.  It was our swan song.

Our trumpeter will be going south for the summer; long before he comes back I will have left.

We played seven gigs together.  In the time I’ve been here my lip strength has improved; I have my chops back.  In the last number of our last gig I played well; I had control of my reed, the notes were under my fingers.

We were the last customers at the restaurant.  I had a steak afterwards; the French fries were excellent but the beef wasn’t up to Iowa standards (won’t I ever learn?).  Our trumpeter and his wife, my wife and I, the guitarist and the vocalist sat over pie and ice cream and chatted with Fran, the owner of Pepe’s, who deserves her own post or five.  

In the fog that follows an all-day and all-night rain, we piled the equipment into the taxi, but most of us walked from the restaurant to the guitarist’s house and then back to the hospital.

It was a good gig.

Three bipolar patients, two of them out of control

April 21, 2010

I have a story I’ll tell

Bipolar depression is hell

     I’ll justify panic

     If the patient goes manic

And I might prescribe Seroquel


Back from four days in Florida, a mini vacation, and I’m feeling wonderful and well rested.

Care Initiatives Hospice will graduate another patient; removing Seroquel from the medication list has done a world of good.

Seroquel does well for certain phases of bipolar disease, but not so well when used, way off label, in the elderly who flip out and hit the people. 

The makers of Seroquel brought  a very good speaker to Sioux City a few years ago. They paid for a fine meal and drinks at Bev’s On The River, one of Sioux City’s four upscale restaurants.  I abstained from the drinks, and I listened and learned a great deal about bipolar disease from the lecture.

I prescribed Seroquel a lot right after that talk.  Since that time I’ve used Seroquel less and less, in favor of some of the older seizure drugs like Depakote and Lamictal.  I use lithium as a last resort.

Bipolar used to be called manic-depressive.  Mostly hereditary, found in all societies, it doesn’t hit any particular group harder than any other.  I’m not convinced of the accepted division between the more severe form, Bipolar I, and the less severe form, Bipolar II; I think of the disease as a spectrum.

During the manic phase the patient feels great.  They don’t need much sleep, they get a lot done.  But they engage in a lot of risky behaviors like gambling, drugs, drinking, and promiscuity.  They spend a lot of money and they tend to delocalize geographically.  Sometimes they lose contact with reality and become psychotic.

In the days when I hitchhiked I got picked up by a lot of manics.  In 1971, I rode from one end of Kansas to the other with one person who talked so fast I couldn’t understand him.  About every fifteen seconds I had to say “Yeah” to prove I was listening but aside from that I couldn’t get a word in.  He grew hoarser and hoarser till he let me off in Julesburg.

Those who cycled into mania have a lot of regret afterwards.  Having to have a spouse bail out your credit card debts every seven years is bad, but not as bad as having to come crawling back to your spouse after a six-week affair, or explain to a judge why you alone survived a suicide pact. 

The depressed phase of bipolar illness sinks the patient to the bottom of the blackest pit.  Partly the patient has tremendous remorse, seeing what a mess they’ve made of their lives, but mostly the biochemistry of their brains lets them down.  The majority of suicides turn out to have been bipolar. 

But the Seroquel speaker made me more sensitive to the less severe forms of the disease.  My touchstone question is:  “Have you ever had an episode lasting at least four days when you felt great, got a lot done, slept less than four hours a night, and didn’t miss the sleep?”

An awful lot of depressed people turn out to bipolar, and need to NOT be on SSRI’s like Prozac and Lexapro.  The tend to do much better on seizure drugs than on antidepressants, and a lot of epilepsy pills have been approved by the FDA for use in Bipolar I and II.

Vitamin D deficiency, a recurring theme in this blog, turns out to be very important in both seizures and bipolar illness.

This morning I saw three Bipolar I patients.  One takes the prescription as directed and the others don’t.

The one spent more years hospitalized than not till a psychiatrist started the patient on Depakote twent- five years ago.   After coming to terms with a disabling disease, the patient rejoined a strong social structure.  Generally coming in every year to get some blood tests, the patient hasn’t needed hospitalization for a very long time

Another patient readily admitted missing doses two or three times a week, and asked for something stronger.  After a bit of consideration we agreed that forgetting to take a more powerful pill brings the same result as forgetting to take a less powerful pill.

A third patient, smiling, was very up front about not taking the medication.  He was pleasant, and told me how great he was sleeping, awakening feeling rested an hour or so before the alarm went off.

Those last two patients were cycling into mania.  Telling them they’re not thinking straight does no good, though I told them anyway.  Then I told them they needed to take their prescriptions as directed.

I didn’t argue with them.

Never argue with a drunk, a crazy person, or a woman in labor.