Swallow It

As I sit here with an ice pack and foot propped up, it occurs to me that the old adage that doctors make the worst patients should be amended to include all medical providers.  In my work, on a daily basis I dispense medical advice that I frequently ignore.  Not because I think I’m ten foot tall and bullet-proof, but because I’m busy running around taking care of other things before I realize that I haven’t had a single thing to drink all day (hence the three kidney stones), or busy running around and not watching where I’m going (hence the three sprained ankles in three years).  Is it any wonder my mother is always admonishing me to slow down?

20160328_220725.jpg

I am a firm believer in the mind-body connection.  Since I started practicing medicine, I’ve seen what stress can do to our bodies.  Like most women I know, I carry all of my stress in my neck and shoulders, the non-ergonomic office chair and computer set-up, of course, contributing to the problems.  My husband, on the other hand, feels his stress in his stomach, having difficulty eating when he feels stressed out (I wish I had that problem!).  The brain is the most powerful organ in our body with its ability to effect changes which may seem magical to those not confronted with these cases every day.

Though both branches of my family have survived wars and strife, my recognition of PTSD has grown by leaps and bounds through my work with veterans.  Time after time, I am struck by the stories my patients tell of how ill-equipped they were psychologically to deal with what they saw and did.  Many veterans came back from Vietnam or Korea, and stated that they had no problems with “shell-shock” like other veterans they knew, raising families and working steadily at jobs that built this country, until they retired.  Then suddenly, they find themselves experiencing palpitations and sweaty hands in crowds, nightmares/vivid dreams of people and places they have not thought of for years.  They come in genuinely confused, some of them undergoing cardiac testing for these symptoms which make no sense to them.  After years of looking forward and striving for the next thing, retirement affords them space and time to look backwards, and they find their past is catching up with them.

One veteran told me that shortly after he arrived in Vietnam, he spoke to his supervising officer about his doubts that he could deal with all of the death he was seeing.  This was a man whom he respected, a grizzled veteran of many military maneuvers, and so he took the man’s advice to heart.  “Swallow it,” the young soldier was told.  “If you don’t, it will eat you alive, so swallow it, because we don’t have time for it now, and your job is to stay alive.  Just stay alive.”  I am not a psychologist or expert on PTSD, but I found it interesting that the veteran’s main complaint was debilitating stomach pain with extensive gastrointestinal testing over many years which has been negative.

I’ve had other patients come in with complaints of dizziness.  In medicine, a complaint of dizziness needs to be further clarified in order to narrow the differential diagnosis.  My question to patients with dizziness or lightheadedness is usually asking them if they have a sensation of feeling woozy like they are about to pass out, a spinning sensation either of the world spinning or of themselves spinning, or a feeling of being off-balance.  I’ve learned that besides trying to figure out all of the medical reasons for a patient’s symptoms, it is important to ask questions about how the rest of their life is going as this will have an effect on their symptoms.  It never surprises me that the patients who will share that they are feeling lost or confused, will also describe their dizziness as a feeling of being off-balance, often times associated with blurry vision or tunnel vision.  Is it any wonder that those who most feel out of control emotionally have symptoms that mimic having lost sight of where they are going or where the ground is? Some have literally used the words, “I don’t know which way is up.”

The words that people use when describing their symptoms and telling their stories can be revealing.  Perhaps because I love words so much, I think they are important and I try to pay attention to how people describe their pain.  In our training as PAs, we are asked to be very specific in how we document pain.  Some patients will laugh a little at my question, ‘Would you describe the pain as sharp, stabbing, squeezing, pressure, aching, burning or something else?’ but it helps people to find the word that best describes their pain.  As medical providers, we have a lot of experience dealing with pain, and though I cannot truly “feel” their pain, I always feel that if I can help them name it, it will have less power over them.

Image result for faces of pain scale

One method frequently used to help patients categorize their sensation of pain.

As medical providers, sometimes we can be so focused on the disorder, we forget that mind-body connection.  No matter how many times we read the study about how pretending to smile actually improves a person’s mood, we point the arrow from body to mind, and forgot the power the mind has over the body.  One of my most memorable patients during my psych rotation was a woman who had been diagnosed with somatization disorder (which in the DSM-5 has now been replaced with the broader category of somatic symptom disorder in order to “remove the mind-body separation that is implied in DSM-IV”). She reported paralysis and loss of feeling from the waist down, though all testing and imaging was normal, and there was no report or sign of injury or external trauma. She had been there for weeks undergoing test after test before she was moved to the psychiatric ward. Other patients have reported blindness, others deafness. She would speak cheerfully of everything but the broken engagement that had occurred just prior to her hospitalization, that event a black hole into which all memory had vanished. Was it chance that this woman had lost half of her body, her better half perhaps? Or that she was numb, and paralyzed to the point that she could not move forward or backward?

At the time, though, I was in my first rotation in my second year of PA school. My job was only to learn everything I could about somatization disorder which was thought to be very rare in order to prepare a presentation for the rest of those in our consult service, round on this patient every morning, as well as attending to any new consults that came in that day. My job wasn’t to diagnose this woman with heartbreak, though I thought most likely it was true.

As a PA working in cardiology many years later, I would learn about Takotsubo cardiomyopathy aka stress cardiomyopathy or broken heart syndrome, in which the heart muscle function is dramatically affected in approximately 85% of cases by an emotionally or physically stressful event. Patients normally arrive at the hospital with symptoms mimicking a heart attack, including chest pain and difficulty breathing. Actual visualization of the coronary arteries usually reveals no evidence of significant atherosclerotic plaque to explain the dramatic change in the heart’s ability to pump efficiently or the change in the actual shape of the heart muscle itself.  In most instances, the heart muscle function returns to normal by the time of the patient’s discharge (usually within a week).

Figure 2.

Called Takotsubo after a Japanese ceramic pot used to trap octupi, this is a dramatic change in the normal shape of the heart (Credit: Circulation 2011; 124)

The more we learn though, the greater distance we put between ourselves and our patients.  We think we learn enough to make a difference, gaining the tools and knowledge to ease suffering and effect cures.  We gather information, nod sympathetically, lay hands on our patients, and dispense knowledge and prescriptions with impunity, doing our best with what we know. Our patients get better, mostly, but sometimes they do not, and we blame ourselves. We want that distance because we want to believe that we can help our patients. We want to believe we do know enough to make a difference. We forget though, we are ourselves human as well. It is a bitter pill to swallow–“Cure thyself!” we are told and tell ourselves, though we no more listen to our own advice than our patients might. We stumble, and curse the ground, and forget that perhaps,  our mind wants us to listen, and slow down. We learn again, what bruising, pain, and heartbreak can do, and in doing so, close the gap between us all again.

 

 

Advertisements

One thought on “Swallow It

  1. Please heal quickly!
    It’s soooo good to get this post in my email this morning!!
    I wish we could sit and visit while you are on the mend!! I miss you!!

    Liked by 1 person

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s