Pyscho Drama

A young patient of mine suddenly decided to start speaking to the wall. He was angry, or so says his girlfriend who is next to him. So he yelled at the wall. This didn't seem too out of the ordinary at first. I mean, how many times, in the car do we mumble "are you kidding" to ourselves in traffic, or even worse things aloud, with no audience except an empty passenger seat and the radio. But then the yelling continued. He started to lash out at the wall, to humiliate the wall. And soon into this she realized that her boyfriend was having one of those moments, where one "loses it" and acts crazy. But in his case, the craziness continued on, and she called his mother who was unsuccessful at talking him down from this imaginary ledge.

Three weeks later this man is in my company. He spent the past two weeks on an inpatient psychiatric ward with frequent episodes like the one I described above. He was on 8 different antipsychotic medications. None worked. And after a few weeks they checked his blood labs and found, to their surprise, that many things were awry. The labs had been checked on admission to the psychiatric hospital and were normal. Now his liver tests were abnormal, and he was quickly shuttled over to my hospital for further evaluation. And after a few days of testing, including an careful eye exam which revealed the problem, and a liver biopsy which cemented the diagnosis, we had unfortunate news: there is nothing we can do for his psychosis.

The disease is Wilson's disease in which copper accumulates in tissues. This manifests as neurological or psychiatric symptoms and liver disease. Early in the disease, several treatments, most of which are geared towards chelating (adhering to and ridding the body of) copper are used. But in severe Wilson's disease, very little can be done for the brain, which can have irreversible damage.

So why do I share this story, other than its fascinating allure? For one, the patient was 23, and for those 3 weeks, while his brain worsened, he was diagnosed with schizophrenia, depression with psychosis, and several other psychiatric illnesses. And don't forget, those initial labs were normal. It is so easy, in medicine, after the fact, to start pointing fingers. This could be an essay about how the psychiatrists dropped the ball, or about how shitty things happen to young people- but really it's just an eye-opener for my readers: in medicine, one needs to fight every day not to corner people into their diagnoses. That's how we miss things. One needs to think outside the box- and be willing to be wrong. After all, it was the psychiatrists who sent him to us as soon as they realized there was more to the story: a metal accumulating in his organs, and driving him mad.

In your eyes

I just saw the French film "The Butterfly and The Diving Bell" which is among the most beautiful movies I've ever experienced. For anyone who doesn't know, it's the story of a man who has locked-in syndrome and can only communicate by blinking one eye. So I got to thinking about how patients communicate, or are treated by myself and my colleagues. I cannot tell you how many times I've watched a doctor or nurse enter a patient's room in an intensive care unit, and assume that they cannot hear what they are saying. I have heard flippant conversations about people spoken literally over their bodies. I have also seen much more respectful and respectable acts. I have seen hospital transporters carefully lift a hand of a patient on a stretcher over a chest to make a patient's arm more comfortable. I have seen patients try to express themselves despite a tube in their airway. I have seen patients with Brocas aphasias unable to find words but understanding everything said to them. And I have seen patient suddenly erupt in anger as they begin to process a new diagnosis- one patient even called one of my early mentors a "bitch" even though she was very thoughtfully and patiently discussing his care. In each of these scenarios, the common theme is the struggle to convey thoughts and feelings about the most difficult topic: one's health.

The truth is, doctors do receive formal training in these topics. I spent countless hours with mock patients counseling them through bad news. I spent an equal amount of time in my own clinic in residency actually breaking that news. I never took these moments lightly- when I had to look someone in the eye and let them know that, on that day, their life was changing forever. And there was always a moment, after I did my talking, of silence. A lot of doctors are uncomfortable by this silence- but even 60 seconds of silence gives a patient a moment to consider what has transpired- a moment to feel. And then, after that had passed, I would take a deep breath. Sometimes anger would follow. Sometimes tears. But most often, I was impressed by how brave people are when they need to be. Like the hero in "Butterfly," who when confronted with an impossible situation rises above it to learn to communicate and express himself, many patients are more than capable of doing the same. But will doctors allow for that crucial minute of silence that enables them to do so?

This chapter is insightful http://www.actabiomedica.it/data/2008/1_2008/wilde_menozzi.pdf and touches the issue gracefully. I read materials like this in medical school and they helped me tremendously. But what helped me most of all was taking that deep breath, and looking into a patient's eyes, waiting patiently for what transpired, and being willing to roll with whatever came my way after that moment passed. Close your eyes and imagine a moment like that. Maybe your 50, or 90- and someone tells you that you are sick. Someone tells you that you are going to get sicker and may or may not recover. Do you want them filling the next moments with forced empathy? With words or encouragement? Or do you want a moment to breathe- and to go deep inside your self. Maybe even just to blink.