Thursday, April 13, 2006

It's not going good at all, is it?


Majorly depressing stuff below - you have been warned, as they say.

Firstly, the young gay guy (bipolar, HIV positive, morphine tablets...) from a few posts back? Well, he presented at a local pharmacist with some stolen scripts (not stolen from me, I might add), and was not served, and left in such a huff that he left about thirty of his stolen scripts there. So now it looks like some of his problems are solved. The accomodation problem, and the "I wish I didn't have to walk so far to get my methadone" problem, and a few others. And his social isolation, "how do I get to meet interesting new people?" problem too.

Well, it's the prison doctor's problem now. And his.

What else has been going on?

Well, I met a young woman the other day who finally convinced me I can't do this long term full time, and that I am not a creature from Jewish mythology.

Kali was there for the ten thirty appointment - I had to go out the front and call her in. I was already pissed off because it was the Thursday before Easter and the last working day, and a lot of the clients were coming in with desperate demands for last minute rule changes and exemptions: "I'm going droving in far north Queensland, I'm leaving tomorrow, so I need eighteen takeaways of methadone - I'm on a hundred and fifty. And I have to change pharmacists because the other guy shits me and I owe him lots of money. Anyway - I want to change over to bupe because this other stuff rots my teeth - and can you write me a letter to see the dentist? And can we make this quick, I'm on home D?".

The problem with the drugs and alcohol job is that everything is circumscribed and bound about by laws, so that even changing pharmacists requires the writing of a minor novel in longhand, and simple clinical decisions have to be run by seventeen different government departments. It's like I imagine the mediaeval papacy must have been, but with less wenching, and less getting drunk.

Anyway, I go out the front and get Kali in. She is one of the younger clients we have here, early twenties, wearing blue jeans, white skivvy. She's wearing makeup, but her face is almost paper pale, and it's pockmarked with the scars of cystic acne. She's nervous, and she speaks in a strange way - some slurring of her speech, some grimacing, the occasional stiff flap of her hands or movement of her shoulders she tries to turn into a shrug. Most of the time her head is tilted at an angle, as if she is listening to something.

She sits down, keeps her bag on her lap, and we start talking.

I start out with the usual questions.
Accomodation? - she's back living with her mum, things are going okay there.
Finances? - bad, but they were always bad.
Any change in relationships, with people important to her? No, she sees mostly her mum, things are going okay there.
No offence meant, but any forensic issues coming up? Nope, never been an issue. Things are going good.

And the drug use. The heroin was going good. No heroin for over a year. No withdrawal since I put her dose up to ninety. No real temptation. Any other injecting? - nothing since - oh, probably three months. Maybe once or twice in the last three months, a little bit of speed, that's all. Going good, she nodded, going good. Her mood, her general health... all going good.

I don't know that I was listening to what she said with one hundred percent of my brain. I was writing, presumably using one bit of my brain to write the appropriate things in my notes. Part of me was listening. Part of me was checking back, running through in my head the last time I'd seen her - I glanced at the notes from last March, things I'd underlined.

?increasing speed use.
Nightmares, fragmented sleep
?Meets criteria for post traumatic stress disorder?
ICU admission, pulmonary valve embolus - ?June 2000.
Check next visit for signs of depression.

And part of my brain must have been putting things together. I glanced up at her. Outside the autumn sun shone on the window, cars went by. There was a pause.

"It's not going good at all, is it?" I said.

And then the poison came out.

She was using a lot of speed. Pretty much whenever she can, every two or three days, injecting fifty, hundred, two hundred dollars at a time. Pawning all her stuff - all her stuff is in Cashie's, the local pawn shop. Trying to get it back, but it's been so long, she can't afford it. Always in debt, debts she can't pay. The dealer - he's someone she's afraid of.

The speed - she doesn't know why she does it. She's trying to stop. There's no methadone for speed, there's nothing. But she can't - without it she can't get out of bed. She can't feel anything.

I think I wanted to ask something, but she kept going.

She'd been feeling like this since - since she was fifteen. Everything was good until the year she turned fifteen. When she was fifteen her best friend moved away and the house down the road was empty for a few weeks, and then this family moved in. There was this kid, he was sixteen. Mum and Dad on methadone, they used to share it with him. She started going with him. She didn't know why.

Pretty soon she was feeling like shit, waking up feeling bad, feeling bad all the time. So she went to the doctor. The doctor said she had anxiety and depression. She started her on medications - oxazepam, fluoxetine. One of those drugs has been essentially removed from the paediatric market after it was found to cause an increased risk of suicide, another is a viciously addictive little pill that should never have been on it.

Started out on one oxazepam a day, went up to two. Tried to cut down, got the cramps, the panic, the vomiting. Pretty soon needed to go up to three. Went to see her doctor - gone. Taken away, some kind of medicare fraud thing. Never saw her again.

She went home, packed up her stuff, said she was leaving him. He hit her in the face, threw her onto the bed. Wouldn't take no for an answer.

A few weeks after that she got taken to Florey. She'd shot up something - still can't remember what it was - and got an infection. Bacteria from her skin got in through the needle site, into the bloodstream, clustered on the pulmonary valve, the big valve in the heart on the artery that channels blood into the lungs. Horribly sick, sepsis, pulmonary embolus, scattered blood clots thoughout her body. The notes I'd had faxed from Florey said DIC - disseminated intravascular coagulation, microscopic blood-clots drifting into kidney, liver, brain.

I imagined a dark constellation of blood clots moving out of the carotid arteries. Swirling downstream, lodging in narrow arterioles, jamming up against the mouth of a blood vessel. Blood stops flowing, areas of the brain darken and die. In front of me Kali tilted her head, grimaced, slurred her speech. Told the same story three different ways three times.

After that, things weren't as clear. Raped her, threw her out - first he wouldn't let her go, then he wouldn't let her stay. Kept all her clothes, even her bras and stuff.

Sometimes she thinks maybe that's why she's so depressed, she hasn't got any nice clothes any more.

Tears roll down her pale, foundation caked face.

I gaze at her, cloud-streaked blue eyes like the earth seen from space, that pockmarked forehead, imagining skin, under that subdermal fat, frontalis muscle, and bone. And the frontal lobes of her twenty two year old brain, pockmarked with scar tissue, islands of dead neurons, pale with ischaemia.

I give her a tissue, but she just holds it in her hand.

Then she moved in with her mum. He - the rapist - was in prison, things were good with her mum and her stepdad, things were okay. But he's out of prison now - I do the math, four, maximum five years, and her with a life sentence, maybe a death sentence - and lately things haven't been going good at all.

She has flashbacks, she wakes up finding herself crying, pissing the bed. Sometimes she wakes up and she can hear him breathing in the bed next to her. One time she felt him move.

It's getting tense at home. Her mum and stepdad, now they fight all the time. She doesn't know how much longer she can stay.

She wishes she could die. Every day, always. She doesn't want to kill herself, she ... she just doesn't want to be anymore. She's not alive.

She looks at me, and I think this is the bit that gets me. She looks at me, as if she is asking for something, and she speaks. "I'm not alive," she says. "I'm twenty two and this is it. This is what life is. There's things I used to like doing and I look inside and they're just gone. If I'm this young, and it's like this, what's the next forty years going to be like? I'm twenty two and I've fucked up everything, what's it going to be like for the next forty years?"

I don't know what to say. She looks at me, and I don't know that I can look back. Her eyes are that intolerable, bright baby blue.

I try to say something about help, about medications, support. Say things can get better, that there is stuff that can be done. She knows all the organisations, the mental health people, the support team, the brain injured support groups. I book her in to see me next available appointment.

And her phone goes off, and she has to go, pick up some kid or something. She gets up and walks out. I don't know if it's the rapist's kid or not.

Then the next part, the embarrassing part. I don't get up.

I sit there. I feel like I want to throw up, I get up and stand near the basin. I check the clinical signs - my heart is racing, I'm breathing deep at over twenty resps a minute. I can feel I am shaking.

I check - the door is closed. For a moment I crouch down on the floor, head in hands, deliberately slow my breathing. Sheen of sweat on my forehead. Get up, wash my face. My eyes are wet, my heart is punching at my sternum, trying to get out. Slow, shallow breaths. Calm down.

I keep thinking that in a minute I will go out and get the next one, the next client, the next patient. The patient, as we are always reminded, is the one with the disease. It's not us. But the truth is it takes me more than a minute. It takes time, and my next patient is surprised and gratified by the alacrity with which I deal with his requests for takeaways, dose changes: sure, not a problem, anything else, no, see you three months time.

In Jewish mythology there is a group of people, the thirty six. They are called the Tzadikim Nistarim, sometimes the Lamed Wufniks. Borges wrote about them, and I imagine my father would have known of them from his uncle, who I am informed was both a learned rabbi and a bad tempered son of a bitch.

The Tzadikim Nistarim are the thirty six truly righteous people upon whose righteousness depends the fate of the earth. Thousands of popular stories take note of them. Their presence is attested to everywhere. The story is that God will not destroy the world as long as there are thirty six of these 'hidden righteous' alive. So at any one time (since we can look around us and see that the world has not been destroyed) there must be thirty six of these virtuous people alive, living and dying as ordinary people, unknowing, unaware, but of infinite cosmological significance.

We know, of course, that this is nothing more than a legend, a folktale or a fairy story to be told around the fire in the dark, and that the bronze age scribes who wrote it down were utterly ignorant of cosmology or of the way the universe was formed and is maintained.

In their ignorance these primitives also speculated that in the first instants of Creation, God made a light: not normal light, but a different order of light, a light so powerful, so penetrating, that He only allowed it to last a brief time, and then took it away, and replaced it with a weaker, merely physical light. Modern, scientific cosmology tells us how little we should value this barbarous folktale.

The Talmud, by the by, tells us that if we could see things lit with that primordial light we could see from one end of the world to the other and from the beginning until the end of time.

But - the hidden righteous.

When I read about this, I remember trying to imagine what would it be to be one of these people. What is it like to be a Tzadikim Nistarim? To be not shut off from the pain of others? To be unwalled? To be open to God and man, compassion incarnate, to actually feel the pain of others?

I read somewhere, but I don't know where, or why, that when the Tzadikim Nistarim die, it takes them a thousand years to get to Paradise - whereas for the rest of us, entry is instantaneous. Some of the Nistarim are so virtuous they never get there at all.

How does this make sense?

The idea, as far as I can make it out, is that a heart which has been wounded by the suffering of people around it, a heart which has been cauterised, or frozen, or scarred, will need to be healed before it can enter Paradise. Because in Paradise all is made new, made whole and unscarred.

Most hearts, yours and mine, presumably take only a few picoseconds. But it takes God (and this is the old Jewish God, the fallible, flawed one who was feared, and was angry and felt regret, not our modern mathematically perfect and thus so much less believeable or loveable entity), it takes God a thousand years to heal the Nistarim heart enough for it to accept Paradise, and for Paradise to accept it.

Well. I tell you what. I feel now is the time to reveal myself: I can declare before the world that I am not a Tzadikim Nistarim. I am not one of the thirty six.

There are ample proofs I (and many others) could furnish for this claim, there are perhaps an infinite number. I believe could throw a random object into a crowd at the footy and bounce it off the head of a man or woman more virtuous than me. I married a person, I regularly work with and drink with and do judo with people who astound me with the weights they carry.

But the real reason I know I could not be a Tzadikim Nistarim is I know I could not endure what they must endure. This woman was only one patient. I only heard her story. I see ten or fifteen like her a day. Half of them probably have similar stories, on any given week I will hear worse.

But what I felt the other day - probably the closest I have come to crying in a good while - that was not something I could do many times again. I could not endure that.

In the end either these things continue to wound you or they cease to. There's a limited number of responses - you either bleed to death or freeze to death. Neither of these outcomes is compatible with a long career in this field, in any form of medicine - or social work, or policing, or anything where you continually deal with the damaged.

I think the secret is you have to come up with some third way, some way of separating things out, some way of dealing with the situation but keeping yourself safe, seeing but not feeling their pain. I've seen people who have done it, who can feel this stuff and carry on, doctors and nurses and writers.

I don't know how they do it, but I think I have to find out, and find out quick. Because I have to be able to do it. I don't even know if it's inherent, or if it's a thing that can be learnt, like a judo throw or a new knitting stitch, but by God if it can be I'd better get on to it quick.

Thanks for listening,

*I should point out that if any of your friends, family or workmates should claim to be one of the Tzadikim Nistarim, that is a sure sign that he or she is not one. Pick them up on it, this kind of behaviour should not go unchallenged. The true Tzadikim Nistarim does not say, and may not even know if he or she is one.


Blogger Benedict 16th said...

One patient to disclose some of this kinda stuff to me, can't bring herself to see me anymore (she still comes to my practice) I think she is too embarassed - after what she disclosed about her two older brothers.

I think your Tanakh of Job sums it up quite well, the coexistance of god and evil.*
Perhaps that is why for the doctors who survive in Drugs and Alcohol, there are so many with Aspergers or Autism.

What keeps me going with this - is, I think, If I cannot see into the face of the abyss - who else will look at them.
And I think what makes you a great doctor - is your ability to say "but for the grace of god go I"


* What about the Weather Woman's story of Africa, of the woman with a "failure to progress" being brought in from a village 3 days away. And the FTP was maggot ridden. At least it would have been soft and easy to evacuate.

PS it's been said before
Yes, 'n' how many times can a man turn his head,
Pretending he just doesn't see?

11:25 PM  
Anonymous Camilla said...

And I think what makes you a great doctor - is your ability to say "but for the grace of god go I"

Hear, hear. Sometimes I read your stories, BJ, and I don't know how you manage to keep going. I'm glad you do though. The world needs doctors like you.

3:22 AM  
Anonymous Camilla said...

ps the stuff about the Tzadikim Nistarim is fascinating. Where do you find all these things out??

3:25 AM  
Blogger Foilwoman said...

The search for the truly righteous, or the belief that they are out there somewhere, is a story that resonates. But is part of being righteous the endless capacity for empathy or is it more that one of the thirty-six simply can't shut the empathy off?

12:16 PM  
Blogger Gothqueen said...

Ahhhhhh, Vicarious Traumatisation. I've been told you can avoid it & recover from it, but I'm yet to be convinced having been hit by its steam train last year. There is a reason why medicos, cops & firemen have a morbid, twisted sense of humour. They have to. It's a form of protection from all the horror they experience. I thought I was good at it too, but everything started to unravel after a significant event last March. It took quite a while to discover what had caused the Anxiety Disorder, depression & thoughts of suicide. It was my job. I had to re-learn how to think. Cognitive Behavioural Therapy. Worked a treat. I didn't think it would, but it did. But it takes practice, lots of practice and sometimes I forget & have to remind myself that I'm human and I cant save the world. I can't save the 16 year old girl that was kicked out of the house after being accused of having an affair with her husband. The Step-Dad had been raping her since she was 10 & she only just got up the courage to tell her Mum. Is it any wonder she tries to kill herself with monotonous regularity? I too wonder whether I can continue in my profession.

2:36 PM  

Post a Comment

<< Home