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I'm beginning this on Thur 2/16.
I had my last chemotherapy, Alimta, on Friday 2/10 in Dr. Palchak's office in Arroyo Grande CA. It was a very short infusion--about an hour or so. He convinced me that the Alimta was unlikely to be the culprit from the prior round which whipped me so badly--that it was more likely to have been from the Zometa, a drug that is used to prevent bone fractures.
Dr. Palchak was right. The chemo last week was reasonably mild. On Saturday I was able to drive my RV down to the beach where Archie and I parked in the Sun and watched the activities around the Morro Rock. My friend, Bob, joined us for an hour or so.
By Sunday I was becoming more tired and out of breath. On Monday I slept for 17 of 24 hours. Tuesday was the worst day--no wind and no energy. When I awoke that morning and looked in the mirror I was shocked to see the face of death or at least the absence of life.
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| Some Hair is Growing Back |
These feelings and thoughts were particularly acute on Tuesday. The weather was miserable. There were scattered showers throughout the day but the rain became serious while Archie and I were in the Albertson's Supermarket Parking Lot. I have been wearing Crocs as my full-time footwear and I was concerned about slipperiness and falling, so I grabbed a grocery cart to use as my support and walker. We don't have a KFC or PopEyes in Morro Bay. The closest take is Albertson's fried chicken--really quite good. So I picked up a bag of chicken and wended my way to the self-service checkout line. The store was very crowded and all of the checkout lines were packed. The line for self-service snaked around a bit through a mass of humanity.
So, I'm waiting at the end of this crooked line and a young family of three pulls in behind me. The man and his wife appear to be in their early to mid-twenties. They have a five year old boy who is rolling around on the floor and ignoring their entreaties to do something else. Suddenly, in a loud voice, the young man points out that I am using a full size grocery cart to hold a lunch bag worth of fried chicken.
"The truth is that I'm sick. This grocery cart is my walker. It's holding me up." As I am giving this explanation, I can feel anger welling up that is directed at this blabbermouth. His eyes are opened pretty widely now and he is becoming more uncomfortable. I find that as he appears to be more frightened I feel more angry. Then he hits upon the real magic, "Why don't you calm down?"
Surprisingly, that didn't help. "Why don't you mind your own damn business!" popped right out without thought or restraint.
People are looking at us now. I'm embarrassed. Suddenly a checkout machine comes open and others in line are very quick to point it out to me. So, I go to the machine and I'm determined to demonstrate to the world that I am in control and possess complete mastery of grocery technology in my home town. I scan my chicken. I deposit my $10. My change is $6.01. Cooly I scoop up the penny. I grab the bag of chicken and leave the store and the $6.00 in bills behind!
I've spent the last two days in an effort to refinance our home mortgage to a better interest rate. For those of you who have missed such an exercise in tedium, it involves finding a ton of documents and scanning them into PDF files and then uploading the data to prospective lenders. I know I'll feel better when this is sorted out. Jasmine is working full-time and looking after me by cooking and squiring me to doctors' visits. Doing chores is a normal part of life--and we're still a partnership.
Today was my last scheduled visit for radiation to my spine for pain control. There was a timing glitch and I was asked to wait for a few minutes in a little examining room while the patient ahead of me was processed. While I was waiting, Dr. Stella walked in and was surprised to find me there. This is his medical practice and it was the first time that we had an opportunity to talk outside of a scheduled office visit. Normally I detect a little bit of an emotional distance when we meet, but there was none of that today. He asked me how I was handling all of this and I pointed out that I been lucky to have had so many teachers in the course of a life time of medical practice. He came over and shook hands with me and said that he was sorry that this was happening to me. I told him how much I appreciated all of the help with the back pain. I told him that the pain was much better but wondered if there was more that could be done to allow me to lift my left leg without pain. He pointed out that a lot depended upon the stability of the vertebrae and the amount of strong bone that remained. I enjoyed seeing him this morning when he had his guard down and we met as two people.
Albuquerque II
After my rotation on Dr. Hammond's ward, I moved over to Dr. B., one of the laziest physicians I've ever encountered. At the time, I was 51 years old, exactly one year older than the head of the department. Dr. B was in his thirties and the son of an internist. Dr. B had a very high opinion of his medical knowledge and capabilities. I only saw self-deception.
One of the perks of being in a teaching program is the ability to utilize residents and medical students to do the medical work of the hospital. In return, the attending physicians, like Dr. B., are expected to teach, to guide, to mentor. In addition to being lazy, Dr. B. was caught up in the great frauds of the era--satanic ritual abuse and dissociative identity disorders (multiple personality disorders). Dr. B always had two or three "multiple personality disorder" patients on his ward and he took a special pride in their presence. He spent a great deal of time with these patients reaffirming the "split" in their concept of self. Almost all authorities recognize that this is counterproductive or even destructive.
Sandra
Although diagnosed as having multiple personalities in 1995, the County Mental Health Program had been treating this woman for more than 15 years. The veteran nurses were quick to point out that Sandra's claim of witches' gatherings and torture had only surfaced in the past few years while she was being treated as the long-term therapy patient of one of the faculty. Prior to developing such a popular psychiatric diagnosis, Sandra had been diagnosed with Borderline Personality Disorder with self-injurious behaviors. Halloween occurred during my rotation on Dr. B's ward. Sandra was admitted as a precaution for Halloween.
With Sandra, there was evidence in her own medical records that the diagnosis had expanded from a personality disorder and that she relished the attention and control that she was able to exert as a "multiple personality."
Patient Dumping and Cobra
There were some serious administrative problems in Albuquerque when it came to mental illness inpatient care. In general, hospitals would prefer that the uninsured and poor go elsewhere for care. Otherwise, the hospital itself becomes responsible for providing the care. In the 1980s certain hospitals became quite adept at "dumping," i.e. physically transporting patients to other facilities, typically large, urban public and charity institutions. Congress responded with a bill known as "Cobra" during the mid 1980s which made dumping illegal and subject to fines. Transfers between institutions had to be cleared on both ends and data collected at the first hospital had to be provided to the second one in the path.
Although these regulations had been in effect for more than 5 years nationwide, they appeared not to have made it into general awareness in Albuquerque when it came to mental illness. While working on call at night in the mental health center it was fairly common for ambulances to roll in from other hospitals and emergency rooms without prior notice. Despite complaints to the Department of Psychiatry nothing appeared to have been done about it.
Drawing A Line in the Sand
One Friday I was working on Dr. B's ward. The other resident was either off or sick and this left me responsible for all the patients for the day. Rather than work, Dr. B. decided that he was going to give me some personal instruction in the treatment of Alcohol and Drug Abuse. He had just passed his subspecialty certification examination. (At the time it was possible for a psychiatrist to be labelled an expert in addiction medicine by paying to take an examination and passing it. The pass rates were very high. The process looked more like the exchange of a credential for a sum of money.)
Of course Dr. B's personal experience with drug and alcohol treatment was rather limited. I had done full-time work in the field for more than a year in Baltimore with opiates. While I was in Billings I had been one of the attending physicians at the alcohol detox program. (In Billings, subzero temperatures are the rule during the winter months. One cannot discharge an inebriated patient to the street in severe weather. Therefore, Billings had developed a model alcohol detox program that guaranteed anyone a bed for the night. The sleeping space was monitored by RNs and a physician arrived in the morning to re-examine the patients to minimize the risk that there were medical problems other than alcohol intoxication that contributed to the clinical picture.)
After listening to Dr. B for an hour I went back to work and he disappeared. Since I was alone, I was responsible for all the admissions, discharges, and rounds. It was very busy but doable if I could just keep plugging away at the workload.
The nursing change of shift occurred at around 3:30 P.M. and I was still very busy. The charge nurse identified a problem that she believed I needed to address promptly. I thought it was less urgent than some of what I was doing and I promised to get to it as soon as I could. She bugged me about it again and I firmly put her off again. Shortly after 5 P.M. a medical student approached me with the nurse's request--again!
Rather than just ignoring the nurse's behavior, I took it personally and read her the riot act. I'm sure my face was flushed and my voice was up and I expressed particular displeasure in her manipulation of the medical student.
Gradually my anger passed and I got back to work and walked out of the ward at about 8 P.M. instead of the more usual 5 P.M.
The following week, I was called into the office of the training director, Dr. Morrison. She wanted to know the circumstances behind my outburst. She knew that I had been seeing a local therapist and that I was taking an antidepressant. She asked me an open-ended question. "What's it like working at the Mental Health Center?"
"Generally it is okay during the day. Being on call is very difficult. I feel like I am in a 50 foot hole trying to shovel it out. Over top of me are a series of sewer pipes, each one leading from an Albuquerque hospital. At night the pipes open and it gets flooded in the hole."
"Is there anything positive about working working there?"
"Where else could I learn to create multiple personality disorder?"
This incident contributed to my reputation as a somewhat "prickly" individual.
This was reinforced a few months later when I was on call for the V.A. hospital one evening. I was paged and told that there was a young airman who needed to be involuntarily committed to the V.A. hospital for a mood disorder. I drove out to the V.A. hospital and met the young man and proceeded to do a psychiatric evaluation. The airman was irritable but not disrespectful. He was not suicidal and denied any intent to harm others. He was not gravely disabled. In short, there were no findings to suggest that he met criteria for involuntary commitment.
We began a discussion. The airman told me that his superiors were trying to create "a mental health jacket" so that it would be easier to transfer him on. He pointed out to me that if I committed him to the hospital, I would be violating his rights. He asked me not to do so.
As I thought about it, I had to agree that I didn't have a basis for committing him. As a licensed physician, I was responsible for my own medical decisions. I could not avoid responsibility by claiming that I had been ordered to do something by military authorities. I told the patient that I would have to discuss the case with superiors and that it was unlikely that I would be the physician with the final word on his situation.
I left the airman and called the faculty member responsible for the V.A. for that month and told him that I had examined the patient but could find no rationale for a commitment. The faculty member told me that the commanding officer for the base and hospital had ordered the airman committed-- and I was urged to admit the patient. I told the faculty member that it was my medical license and my judgment and that I could not oblige. I offered to remain at the hospital until some higher authority arrived to relieve me and take responsibility for the patient. I was told to go home.
The reaction among the young residents was interesting. They generally believed that it had been my duty to obey the order and saw my resistance as arrogance.
Kathryn
The case of Kathryn was one of the most blatant that I witnessed. She was a patient of Dr. B. She had a confrontation with a police officer in the parking lot of supermarket. The officer reached into her driver side window to grab her keys. As he did so, Kathryn sped away with the police officer trapped in the window for several feet. She left the parking lot and headed for the Mental Health Center with the police in pursuit.
By coincidence, Dr. B was outside the entrance to the mental health center. Dr. B, Kathryn, and the police all arrived at the same spot at about the same time. Immediately Dr. B began to address "Kathryn" as "Jane," supposedly the "bad-ass" alter and made a commitment to an immediate hospitalization for Kathryn that allowed her to avoid immediate responsibility for her actions with the police. To me it looked like Dr. B showing off to the police and choosing to be an idiot.
Teaching and Peter Thompson, M.D.
I believe that the quality of teaching in New Mexico was very good. The weakness was a lack of overall structure--we were thrown onto the DSM-III and DSM-IV, laundry lists of diagnoses and criteria. One of the rotations was the outpatient clinic at the Mental Health Center. At about 3:30 or 4:00 PM one or more faculty members would come to the clinic and begin to review the cases for the day. Whenever I was available at that time, I attended those sessions and learned a lot.
One of the teachers whom I totally misread was Peter Thompson, M.D. He arrived in Albuquerque at about the same time as I did. There appeared to be a touch of arrogance (and I'm sure that would fit me as well.) A few months later, I was assigned to the outpatient mental health service, where Dr. Thompson was in charge.
It was during this time that I had become interested in John Money's idea of lovemaps (discussed in at least one previous post). A lovemap is a guide to an individual's personal preferences with respect to sexuality and sexual expression. The fact that lovemaps were dynamic was especially stimulating. After all, at age 6 my blonde friend, Nora, was "hot." At age 51, such thoughts of "hot" would be suspicious for pedophilia. So, how did this evolution of lovemaps occur?
One morning I was scheduled to see a young gay female who had been taking prozac for relief of depression and anxiety. She was having some problems with hair loss, probably due to the prozac. The scheduled visit was for medication evaluation and renewal. It was not for psychotherapy. However, I believed that I had established a good rapport with the patient and I decided to talk about "lovemaps." I explained that in my own life, I was aware that changes had occurred from the age of 6. I inquired about the patient's experiences. From the expression on the patient's face, I knew immediately that I had made a mistake. The right thing to have done at that point was to immediately grab my supervisor to try to right the ship. Instead, I just clammed up and wrote the prescription for prozac.
A few weeks later, I received a copy of a letter that the patient had written to the Department of Psychiatry. She apparently believed that I was confiding to her that I was a pedophile and related her recollections of our prior meeting.
Naturally I was mortified. I went to see Peter Thompson. He was wonderful.
"Eric. Everyone in psychiatry has a letter like this in their file. It happens to everyone. It is one of the principle reasons that you go through training programs."
A year later, I managed to get small monograph published, The Difficult Patient. Peter Thompson was the only faculty member who congratulated me on the accomplishment.
The Wonders of New Mexico
I loved my time in New Mexico--the scenery, the history, the culture, and the food--particularly the food. One can go to any little town in New Mexico and eat like a king. The New Mexico question is "Red or Green?" This refers to your preference to green chile or red chile.
Hatch, New Mexico is the chili capital of the world.
http://en.wikipedia.org/wiki/Hatch,_New_Mexico
In the autumn, thousands head out from Santa Fe and Albuquerque to Hatch to gather their chilis for the year, bushels of green chilis of different heats. There is a method for measuring the heat of various types of peppers.
http://en.wikipedia.org/wiki/Scoville_scale
In the autumn, large chili roasters can be found in the parking lots of many supermarkets in Albuquerque. The smells are wonderful. The roasted product is taken home, peeled, and frozen in order to provide the next year's supply of the base material for so many New Mexico dishes.
Used Cars
One of the pleasures of New Mexico was used car hunting. When I first moved to New Mexico, the independent Volvo mechanic called over his two employees to show them what happened to automobiles on the east coast. The rust was amazing to them. The dry climate of New Mexico preserved the past. Along Coors Boulevard on the West side of the Rio Grande there were a couple of areas where cars were parked with "For Sale" signs. I was an enthusiastic follower of this market. During my time there I bought a 1978 4 cylinder Toyota truck for Brian and a 1980 Celica Supra for Keith. I traded one Volvo to my mechanic for work done on the other car and purchased a used Acura Legend with 150,000 miles for about $3000 that I drove for three years. I still miss looking at the used cars.
The Next Step
As the second year of my psychiatry residency wound down, I had to begin to think about my own plans after residency. Much as I liked New Mexico, it would be a hard place to make a living. Almost all psychiatrists ended up in the larger cities, Albuquerque, Santa Fe, and Las Cruces. Salaries were low and there were service taxes for those attempting to work on a fee-for-service basis.
At the time that I had begun looking for a residency, I had thought to return to the Eastern Shore of Maryland and to join the group that included the psychiatrists that I had worked with in the prison.
However, while a resident in New Mexico, I had the opportunity to observe psychiatrists interacting with patients who were felons or standing trial. It appeared that the physicians accepted many statements at face value with very little work exerted to expose weaknesses in the stories. Having spent years dealing with inmate medical complaints in prison, I knew that was terribly naive.
One of my psychotherapy supervisors, John Lauriello, M.D. suggested that I consider "forensic psychiatry" as a career. Forensic psychiatry is the intersection between psychiatry and the legal system and issues such child welfare, competency to stand trial, not guilty by reason of insanity, capacity to handle one's affairs, etc. John told me that Atascadero State Hospital inc California paid a very good salary for those who decided to spend a year training there in Forensics.
When I went to the California map to find Atascadero, California, I was suprised to find that it was within about 15 miles of San Luis Obispo. Curiously, I had spent time there on New Years Day 1995. While living in New Mexico, I decided to spend Christmas 1994 in San Francisco. I got a good price on a great hotel for a week and headed that way. Unfortunately, I had recently traded in my Prozac for Venlafaxine, a relatively new antidepressant. Venlafaxine made me predictably sick each afternoon, but I had no idea of the cause. I had a great hotel room but I was not feeling well-enough to enjoy the wonderful food of China Town in San Francisco.
A couple of days prior to New Years, I started back to New Mexico. The first leg was down the coast through Monterrey and Big Sur. The tight turns in the road made my sickness worse and I checked into a motel at San Simeon in mid afternoon. It was a very mild day with a slight breeze. I'll never forget the sensuous delight of a gentle breeze through my motel room that evening. A couple of days later, I was sitting in an outdoor cafe in warm sunlight in the middle of San Luis Obispo and I was taken by the charm of this mission town.
Atascadero was only a few minutes from San Luis Obispo and only 17 miles from the ocean at Morro Bay. Beginning in the summer of 1996, I started to make arrangements to move further west to Atascadero.
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