A Typical Day in the Neighborhood: Island Medicine and Mental Health Visits
I spotted the season’s first iridescent blue and gold crocus poking through a patch of snow on my walk to clinic yesterday. Today, there are 6, in a small clump, and the flowers bend towards the sun. In a few days, a week at most, the petals will wilt and drop and, if the warming trend holds, other spring flowers will pick up the beat: daffodils, coltsfoot, blue violet, wild geranium. Once the forest floor thaws, carpets of mayflower and wood anemone and bunchberry will emerge, seemingly overnight.
But my favorite, the most difficult to spy before the ethereal one-half-inch white flowers disappear, is goldthread, a ground-hugging resident of the island’s spruce understory. And it’s not the flower alone which delights me; just beneath the surface is a thread-like, orange rhizome, the source of a bitter herbal remedy for cold sores and intestinal parasites. Though Peaks has been settled and farmed for hundreds of years, now that the interior meadows have been reclaimed by forest, goldthread is back. Or more likely, it never left.
I arrived at the health center a few minutes early. Setting my green satchel and day pack on my desk, I thumbed through the charts Kathryn pulled for the morning’s clinic. Today, not necessarily by design, is mental-illness day at the health center. Some of my patients have improved, either with medications alone, or in combination with counseling. Others flounder under the influence of co-existing alcohol or drug addiction. They are self-medicating their post-traumatic stress disorder or psychosis or major depression in the most destructive way possible; entangling loved ones in a web of anger, self-loathing, and sometimes, emotional and physical abuse.
There are those on today’s schedule who would deny that they have mental illness. These patients see me for their diabetes or irritable bowel syndrome or headaches or heart disease, but don’t recognize how their mental health affects their physical health. Or, if they do, their emotional baggage, their burden of sadness, is so heavy, they lack the tools to make major life-style changes.
It is these particular visits that exhaust and frustrate me because, all too often, I feel like a garage mechanic on speed dial; here’s my body, I’ll come back in a half-hour and take the pill you recommend. These are the “Yes, but…” visits. If I recommend a therapist. the patient replies, yes, but… I tried that once and it didn’t work. If I recommend walking to reduce weight and help with anxiety, the patient agrees, yes, but… I’m too exhausted, or my knees hurt, or I don’t have time.
In these patients, I have prescribed a boat-load of medications with only minor benefit. Or, as the Chinese proverb says: “If we don’t change the direction we’re headed, we’ll up where we are going.”
My first patient is an overweight woman with diabetes and unacknowledged alcoholism. I know this because most everyone on Peaks Island is aware of her heavy drinking. She lives alone and staggers into the library twice a week. On the way home, laden with books, she buys a quart of Johnnie Walker whiskey and a quart of gin at Feeney’s Market.
This is her third visit with me and she hides her sadness behind a quick wit. A few months ago, on the new patient questionnaire, under alcohol use, she wrote: “Whatever.” Under family history, she kidded, “We have a huge family that are related.” Today is her first return visit after admitting she is deeply depressed, doesn’t want to see a counselor, but is willing to start fluoxetine (Prozac). I have a vague sense that she is a suicide risk even if she won’t say whether the thought has ever crossed her mind. It’s why I’ve picked Prozac as an anti-depressant; on the current dose, the drug is nearly impossible to overdose on. I’m curious if it helped.
“Did it help? Well, to tell you the truth, I’m not really sure. Maybe. I’m borderline upright.” She stared out the window.
“Any side-effects? Have you been able to get out and walk?”
“No, I forgot about that. It’s all I can do to drag myself up and down the stairs. I feel like I have rocks in my pockets and I’m walking through a river of molasses.”
Back at my desk, I dictated a note. I wish she were engaged in her treatment plan. Her diet and alcohol use are off limits. She is an expert at pivoting the conversation and clearly doesn’t want to talk about why she’s depressed. Mostly, it seems, she just wants to take a pill to take the edge off her depression. As I placed the dictated chart back onto the rack, a free page from the back of the chart fell to the floor. I read a few lines from the note, and then stopped, and reread the note more slowly. It was from an out of state psychiatrist written more than twenty-five years ago when the patient lived in the mid-west. The note described the trauma she and her 3 sisters experienced when their mother confronted a burglar and the intruder shot the mother dead in front of the children. The murderer was eventually caught and sentenced to life in prison.
In an instant, my entire view of my patient was turned on its head. How does one survive a trauma of that magnitude? How does one have the will to go on? Where does one start? Do I share the letter with her? I decided to share my concerns with my wife Sandi; as a former family counselor, she might have some suggestions on how to connect the woman with someone far more capable of treating her than I.
Shortly after we moved to Peaks Island, Sandi briefly considered opening a part-time family therapy practice on Peaks before she left her position at Community Counseling in Portland for plumbing and electrical work. The thought of seeing her clients at the Post Office, at Feeney’s Market, or on the ferry, was too close for comfort. In Feeney’s Market, she wants to concentrate on the grocery list, not on the problem list of the young woman shopping in aisle two.
I tell myself that my case load is no different from any other rural physician’s. But that’s not necessarily true. Riding the ferry, walking, busing, or driving to an appointment, and timing the return ferry home, is a 3 to 5 hour round-trip. My psychiatry friend concluded that the more severe the psychiatric disorder, the less likely a patient will connect with a mental health professional in Portland. “You are their de facto mental health worker.” And that’s been my experience. For now, prior to each visit, I try to clear my head, don my empathy cap, and look for opportunities to make each patient’s journey a little easier
Dan is my next patient. At five-foot-eight and 125 pounds, he is chronically 30 pounds underweight. Although he had always suffered from “nervousness,” his life changed dramatically when he rear-ended a truck in Portland while nibbling on a sausage sandwich. His head struck the windshield and he fractured several ribs on the steering wheel, but it was the sausage sandwich which left the most indelible scars. When rescuers found Dan, he was frantically clawing at his partially blocked airway. The sausage was successfully removed, but the emotional trauma left him a psychological cripple.
For 5 years he has subsisted on liquid nutritional supplements despite there being no physical reason why he cannot chew and swallow solid food. His wife, a bulky, square-faced woman, brings him to appointments and sits in on our visits. She’s respectful and optimistic, believing we are only one intervention away from restoring her husband to a more normal life. But nothing seems to work. Last year, Dan was briefly admitted to the hospital when his weight dipped under 115 pounds and he suffered a grand mal seizure from an electrolyte imbalance. Psychiatry and neurology consulted and prescribed a slew of medications — crushed and suspended in a milkshake, but there was no progress towards solving the underlying swallowing disorder.
As I leafed through the chart, I reviewed the barium swallow study of the esophagus and the MRI scan of his head from that admission. Both were normal. At least we know there isn’t an unusual stroke syndrome or esophageal disorder affecting his swallowing mechanism.
Today, I have an idea. “Why don’t we begin with a tiny crumb?” I suggested. Dan and his wife considered this and agreed that it wouldn’t hurt to try. I broke off a small piece of blueberry muffin his wife bought at Lisa’s coffee shop. Then I dropped the fragment onto Dan’s outstretched palm. “Why don’t you give it a try?” I said.
Dan picked up the crumb off her palm with his free hand. He eyed the morsel skeptically, and held it up to the light and turned it this way and that, as if he were solving a puzzle. Then he placed it in his mouth.
His wife glowed, “Now we’re getting somewhere!”
Then Dan swallowed, or rather, attempted to swallow. His chin jutted forward as he made bobbing motions with his head. His eyes flared and blinked. After a few seconds, he retrieved the wet fragment and carefully divided it in half and returned it to his mouth. Tears rolled down his cheeks. More head bobbing and gagging. He spit the blueberry muffin crumb into the sink.
“I’m so proud of you for trying,” I said, and patted him on the shoulder. “You’ll do it. Maybe trying it in front of us isn’t the way to go. Pick out something you really like. What kind of food do you miss? Is there a food you can try at home?”
“I like Pop Tarts.”
“Well then, a teeny tiny piece of Pop Tart might be the ticket,” I said, trying to sound upbeat. “Maybe you can experiment. Practice chewing. When you’re ready, give it a try.”
“I’d be scared to try it by myself,” he answered. “What if I choked again and no-one was around?” His wife patted him on a thigh. The visit was, essentially, over.
“Is it okay if I draw some blood?” I said softly. “I want to make sure your electrolytes and medication levels are normal.”
“Okay,” he extended an arm. Recalling his chronic anxiety, I asked how often he was having panic attacks. He waved this off. “I can’t get too excited about having a panic attack.”
A young woman in her late 20’s was next. For the past year I have seen her with progressive fatigue, body aches, and joint pain. Her primary diagnosis is depression; her secondary diagnosis is fibromyalgia syndrome, a painful musculoskeletal pain syndrome. After each visit, I dutifully wrote down a quote in her chart summarizing her plight: “I’m getting worse,” or “The pain is excruciating,” or “I don’t know how much more I can take.” Today, she wanted to let me know she was moving to Arizona to see a special friend. She looked radiant. “I’m cured. I don’t know what I would have done without you.”
I am thinking: Each and every visit, you were worse than before, and you’re thanking me?
There are patients for whom I suspect I make a difference. An elderly man down the way from our house is next. He sees me monthly for a blood pressure check, but we focus primarily on strategies to help him deal with his wife Grace’s progressive dementia. Through our office visits I know that they’ve had a sweet, more than 45- year marriage. When he says, “I miss her,” I understand; he is no longer her friend and partner; he has become a full-time caregiver. Medications have helped Grace a bit, but each month brings a new challenge. Kathryn, at the front desk, has connected the husband with a home health aide for respite care. The aide does some light cleaning for the couple and sits with Grace while she watches television, enabling the husband to slip outside for a daily walk with a friend.
Walking is also a saving grace for Grace, who, each morning, regardless of the weather, dutifully plods the mile to Feeney’s Market to buy a pack of cigarettes and purchase a newspaper she never reads. On the way home, she may sing or whistle an old-time tune. Getting lost on an island can happen, but so far, there are enough familiar faces to point Grace in the right direction.
At the conclusion of the visit, I suggest that the husband play old records at home. “Grace might sing along — Alzheimer’s patients often recall the words and melodies to songs long after they’ve forgotten most everything else.”
“It’s worth a try,” the husband replied. “When we first met, she was a camp counselor. Believe me, she knew every verse of every camp song ever written.”
We stand and I reached out to shake his hand; I do a lot of shaking hands or patting shoulders in my practice. Ignoring my hand, he moved in for a bear hug and, releasing me, quickly walked out to the front desk to settle his bill. The next morning, I was not surprised to see him walking with his wife past our house. The two were singing softly and holding hands. Of course, with Alzheimer’s, it won’t last, but today, a melody connects them to a past that is slipping from their grasp.