19 November 2017
[Above photo: One of our mango trees is going nuts!]
We have finally gotten official permission from Peace Corps to break evening curfew for Thanksgiving dinner. We’ll do it at Chez Nous—Linda loves to do a big and excellent feed for everyone and between the GHSP vols and the SMMHEP vols and some friends, 12-15 people will crowd into our small cottage and celebrate, give thanks, for the year past and the year in front. We all have plenty to be thankful for, especially compared to those for whom we care, mostly. No turkeys in sight so we’ll do a number of roast chickens with stuffing, home made bread, roast potatoes, salad from our garden, pies, and so forth. I skipped lunch, as we often do on Sunday, which in part accounts for my detailing Thursday’s menu.
I was asked to do lectures on Psychopharmacology and Neuroanatomy and Physiology for 3rd year Mental Health nursing students at Kamuzu College of Nursing, where Linda teaches. Except I’m teaching at the new campus out of town. It is on a hill, beautiful new buildings with lots of natural light and air and splendid views. The plan was, and the hope is, to build a new district teaching hospital on the grounds which will be handy for the faculty and nursing students. Anyway, the psychopharm lecture was for 3 hours and went well in a rather warm room with only one of nineteen students briefly dozing off and one standing in the back to keep from doing so. I mentioned that my wife took a photo at the end of her 4 hour class last year in an overheated room and that everyone was either stretched out asleep on their desk or pacing at the back of the room. They all yelled, “Linda!” with cheer and gusto and she was very pleased that evening to hear it.
I’ve been putting together the 3 hour neuro lecture all day. I haven’t carefully looked at that material since medical school—well, some of it during my year of medical residency when I rotated through the Neurology service at Harborview Hospital in Seattle. 48 years ago! I am, again, amazed at how much of it stuck. It isn’t that I recall it with enough precision to locate a patient’s cryptic neurological lesion from their gait, their history and a physical examination but I can rapidly make sense of the subject as I assemble the lecture. I can’t believe it, but it is kind of fun! (Don’t worry, I can think of more fun things to do! I haven’t gone entirely off the rails.)
One of the registrars asked me to consult with him about a 70yo woman who has had many admissions to Zomba Mental Hospital for schizophrenia. She lives with her son. She has been non-compliant with her medications and recently had a dream that she had sex with him. The dream was so real for her, in her state of mind, that she is overwhelmed with guilt and shame, refuses to go to church or see her friends as she thinks they all will know the cause of her shame (thought broadcasting), and feels like her life is over. As we interviewed her, her daughter mentioned that she had drunk ¼ of a cup of OMO, a pretty fierce laundry detergent, yesterday, then vomited. She had been looking for a rope to hang herself and was just stopped from plunging a long sharp knife into her chest by her daughters. It was clear that she needed both regular antipsychotic medication and protective custody, so we sent her back to the hospital. It is a tough dilemma for a person with schizophrenia. The side effects of the medications are often quite unpleasant and compliance with taking them after hospitalization is less than 50% in a year in the US, from what I’ve read. But not taking it leaves them vulnerable to the kind of imagining and thinking from which the above woman was trying to escape permanently.
Reading about neuroanatomy and neurophysiology, I am amazed at how little our knowledge base has grown in almost 50 years, despite many very bright, committed people using very fancy equipment and clever experimental designs to try to unravel it. We really don’t know Love, at all, in the words of Judy Collins. Or much else, let alone how to intervene decisively for people suffering from schizophrenia or autism, to name just two common illnesses. We can work around the edges and can make some differences in their lives; we just don’t understand the root causes of either and so cannot definitively address or correct them.
I have seen a man a few times over the past year who complains of feeling weak, tired, and without any sex drive for 10-12 years. He’s had a remarkable workup here and I even consulted a senior endocrinologist at Harvard about him. His lack of sexual interest, he feels, caused the demise of his first marriage and is threatening the second. His testosterone levels, and all other laboratory, including endocrine, parameters, are normal. He doesn’t appear depressed, although he has been unsuccessfully treated several times for depression with adequate doses of amitriptyline and fluoxetine. I wondered aloud with him if, possibly, he was gay. No. As he was detailing his complaints and I was trying not to fade out, I realized he may have what in the US is not an uncommon diagnosis: Chronic Fatigue Syndrome, whatever that is. So little we know about the mind-body. He seems to want us to listen to him but there is always an implicit demand that we cannot meet, which makes it difficult for both the patient and the physician.
I recall an article from the ‘70’s in the New England Journal of Medicine about the 4 types of patients physicians hate to see in their waiting room. The only one I recall is the “Help-rejecting complainer”. When I did a recent lecture on somatization and conversion (dissociative) disorders, I set up a role-play for the students in which the patient was a woman with multiple and shifting complaints. Sore knees, sore low back, headache, bowel difficulties, pain in the elbow, etc. The student who played her was excellent, letting the complaints gradually drip out. Her irritated and fed-up husband was also in role and the medical student and consultant interviewing her were stumped, finally bursting into frustrated and impatient laughter at the impossibility of meeting the patient’s requests for relief. It was instructive for us all, in part on the limitations of our ability to heal or help. It was easy to re-direct the medical student and consultant to think about the psycho and social in the BioPsychoSocial Model of illness, health, and patient care in which we instruct them. And easy to demonstrate that only that kind of embrace of the patient’s complaints could begin to address them. Still…
So, Linda is whipping up ideas for a Signature Cocktail for Thanksgiving and what better way to celebrate this season than with a mango puree, ginger-infused vodka drink. Maybe with a splash of Savannah Dry (cider). And some stuffed roast chickens. On the side.
Post-script: The drink is mango puree, ginger, mint, Rose’s lime juice, vodka and a dry cider splash to finish. A smash hit!