The Shell

Hail,

And a quick warning – the following contains frank discussions of medical and other problems.

Well, this is all rather humiliating. I am writing this from home. Not from hospital, which is good, but not from work, either. And work is where I said I was going to be, but this morning I got Sarah to ring me in sick. Third day back after close on a month away and I’m already back on sick leave.

From what a couple of people near me are saying I went back to work too early. It wasn’t planned that way. It was planned to be a gradual thing, a phased entry. Sortof like those military phased withdrawals you hear so much about. Go in there, have a non-clinical day, follow that up with a fairly mild semi-clinical day at Central, then gradually ease in to seeing patients, be back at work full time by this time next week.

And how well did that work out?

Not that good. Monday, the alleged patient-free day, I saw six. Admittedly, one was only for a breath alcohol, and another was because we’d stuffed up his appointment, and another was a decent bloke, and then someone I saw as a favour to the nurse, and the second last was a prison transfer who we had to see. And the last, as I was leaving, was the guy fixing the gutters. He saw me leaving the building with my steth around my neck and ran across the car-park to ask me about his rectal bleeding.

“I’ve been really worried” he said. “Litre, litre and a half every morning.”

“You should get that checked out” I said.

“Serious, every morning I have to get up and run to the toilet. And my dad – he had the same thing. There’s this family history of diverticulitis. That’s probably what it is, hey?”

“Maybe, maybe not” I said. “But you’ve got to get it checked out.”

“Can’t be cancer, can it?” he said, and pulled up his shirt to show me how loose his pants were. “I’ve been losing weight. I’m only twenty three.”

“Probably isn’t. But you can’t say it isn’t unless you get it checked out. You don’t want to be one of the one in a thousand”

“What if it is cancer? Is it fatal?”

This time I paused, waited long enough so that what I said would sink in. “Only if you don’t get it checked out. I reckon you should get it checked out.”

He paused. “So, go get it checked out, you reckon?”

I nodded. “Definitely. Write yourself a reminder on your phone. Get it checked out.”

And off he went, hopefully to get it checked out. Which might sound harsh, but the alternative was a thorough physical examination of his lower gastrointestinal system, which he (and I) wouldn’t have wanted in the car-park.

So, Monday I was a bit stressed. And I didn’t sleep, and Tuesday I was worse, and Wednesday I was almost useless again. The whole agitation, disturbed sleep, intrusive thoughts, the thoughts of hopelessness and despair.

Those particularly unpleasant thoughts, the thoughts that got me into Clearwater in the first place, the rationalizations and the plans and the preparations… they seem to come a lot more easily now. As if a wall has been breached and not built back up, or some weed has been torn up but the roots remain.

Gods, this is tedious to talk about. I went to a conference in Sydney a while back and learnt some stuff about ‘management of the difficult bipolar patient’ – which I am not, by the way. There was considerable talk about the “bipolar spectrum” (some people divide bipolar not only into types I to V but also types one and a half, two and a half and so on), the bipolar mixed state (which seems similar to the agitated depression with which I am familiar), and the “something to look forward to” fact that as the bipolar patient ages episodes of mania become less common and episodes of depression more common.

This plus a lifetime suicide rate in the twenties (I don’t know what to make of that, it seems remarkably high), and the extremely poor outcome of people with two or more illnesses at a time: SUD (substance use disorder), anxiety disorders, chronic pain, personality disorders plus BPAD – bad news.

Anyway, I treated the agitation by taking lots of coffee – maybe hoping it’d have the same effect as dexamphetamine does in ADD – and by the time Sarah came home I was not that good. I went out and sat by the chook-house and stared.

The baby silkies are still small enough to run in and out of the wire, flowing through like water, while the mother clucks in alarm, herself too round and plump. And the turkeys are trying to swell out of that feathered skittle shape, but most are still gangly teens. I stared at them for a while, trying to ease the pressure in my chest and the ugly thoughts in my head and get my mind somewhere where I could do something with it, but tonight it wasn’t working. It wasn’t good.

I waited out there until sunset, trying to keep hold of the idea that I was sick.

The other problem I was facing is who do I tell about these thoughts? I can write some of this in the blog but too many people I know read this. That’s good and I'm grateful and everything, but it means that this is not a forum for confession. What I needed, I felt, was someone or something that maybe only found in mythology – something out of a Greek myth, a shell found on the shore into which you whisper all your unspeakable thoughts.

In the end I rang one of my friends and spoke to him. He was surprisingly helpful. I say surprisingly because he’s a doctor, and it can be hard for both parties to separate out the “friend ringing friend” from “layperson ringing doctor” and “doctor ringing doctor” phone-calls. We ended up talking about suicide.

The thing that he was saying – from what I can work out – is that suicide is an option, but it’s an option that you have to compare to every other option. Now, if you are five hundred kilos and you are on forty mgs a day of olanzapine, and it still doesn’t work, or you have intractable, progressive pancreatic cancer, or if your every single waking hour is filled with thoughts of how your maths’ teacher sodomised you, then maybe suicide is the most sensible choice.

But for someone like me, and this is what I got out of it, for someone born into such a position of privilege, someone healthy and male and white and English speaking with all his limbs intact, “every other option” includes a hell of a lot. It includes, or if I choose, excludes, emergency medicine. It includes working on Palm Island, or Darwin, amongst the crocodiles. It includes taking five hundred dollars out the bank, getting on a bus, going out to the Nullarbor, just staying a week in a hotel there, standing outside every night, bathed in starlight. It includes giving medicine up to become a circus clown, it includes – it includes a galaxy of things.

Every other choice.

That doesn’t mean I am going to abandon those who depend on me and ride through Paris in a sports car with the warm wind in my (scant and stubbly) hair – unless I realise, pathologically or not, that that is the only non-suicidal option. But it means that if I keep the thought in my head that there are other choices I can get rid of the other thoughts, the dangerous ones.

For me I think that explains the reason that hopelessness is such a dangerous symptom in the risk assessment for suicide. Hopelessness means the disease (schizophrenia, unipolar depression, bipolar three and a half, whatever) that is driving the person towards suicide has progressed to narrowing down the thinking, making a tunnel out of the field of vision, making everything like a telescopic sight, until for that person there is only one way out. It is no longer purely a mood disorder, the disease has become a thought disorder. The person is moving further away from reality, like a boat drifting out into the river.

So, what to do?

Well, for the next three nights take the quetiapine. I pissed and moaned until I got changed to it, may as well take it. Hopefully that will reboot my sleep patterns without giving me flukes and a horizontal tail.

Ring my psych to see if I can get switched over to Dr Tesla. Not that there’s anything wrong with my guy, but I have worked with him, and he’s not someone to whom I can tell this kind of stuff.

Get a counsellr kind of person, a good one, one insulated from anyone else involved in this. Failing that, find that shell on that deserted beach and start whispering.

I should thank the good God that I have not committed myself to starting in the ED soon. I should have a Law like in the Island of Dr Moreau:

Not to take up too much too soon, that is the Law. Are we not men?

Not to draw a line which I myself then stumble over, that is the Law. Are we not men?

Not to forget there are alternatives, and that I have friends, that is the Law. Are we not men?

Not to work-up patients for rectal bleeding in the car-park, that is the Law. Are we not men?

Might have less trouble with that one than the others.

Thanks for listening.

John