September 2013

The Medicine

In the body and in the mind

By Karen Hitchcock
How do you provide medical treatment for a non-medical problem?

Among registrars, Mike’s clinical acumen was legendary: he’d touch his stethoscope to a patient’s skin and hear the heart murmuring secrets that none of us could yet hear. In the first weeks of my physician training, he was scheduled to give us a seminar on Chronic Fatigue Syndrome (CFS). I thought it was a joke; I thought the lecture would turn out to be on heart failure or sleep apnoea or some other disease that renders patients tired. But he walked in wearing pinstriped trousers and started talking about chronic fatigue, the syndrome.

I couldn’t believe it. Wasn’t he a real doctor?

“No one knows what’s going on with this,” he said. “Is it a disorder of the immune system, of the autonomic nervous system? Is it a symptom of unexpressed emotion?”

I searched his face: Was he dementing?

He met my gaze. “Someone has to care for these patients.”

A few weeks later a pale woman in dark sunglasses named Jane was carried into the emergency department by her mother and father. She claimed to be suffering acute adrenal insufficiency, caused by CFS. She told the triage nurse that if she wasn’t immediately given large doses of intravenous hydrocortisone she would die. The nurse hesitated. The patient’s entire body went flaccid. “I’m crashing,” she cried. “I’m crashing.” Her parents were hysterical. The nurse called a code and Jane was rushed to a resuscitation bay. Her blood pressure was on the low side (but high enough to perfuse her brain); her heart rate was slightly elevated (but slow enough to circulate blood effectively). Despite this haemodynamic stability and the absence of any other hard clinical signs of adrenal insufficiency, Jane’s distress and authority were such that out of pure anxiety the treating team administered the drug she’d demanded – any doctor would have done so, given the dire consequences should she have needed it and the minimal side effects of a single dose. They urgently sent off bloods, the fluid trickled into her vein and everyone calmed down. The intensivist examined the patient, checked the results and hypothesised that she may not have been “crashing” after all. He called me to admit Jane to a ward and help work out what the hell was going on.

Jane insisted that her room be kept perfectly dark, her bed absolutely horizontal. Any noise could set off her symptoms: headache, full body electrification, paralysis, blindness, brain fog, skin pain, stomach cramps or a “crash”. Her mother unpacked Jane’s bag of pills onto the bedside table – there were 25 bottles, including three of hydrocortisone, prescribed by three different doctors. Jane sighed gigantically when I asked her for details of her medical history and, without turning her head, handed me a copy of her 40-page “illness diary”. I walked out of the room and called Mike.

Over the following days I wondered if we’d been transported back in time to Freud’s Vienna. “Let’s get this straight,” Mike told me. “This is not your typical fatigued patient.”

Jane’s abdomen became the focus of her suffering. I had my interns request notes from specialists and hospitals all over Australia so we didn’t replicate investigations. She’d had gastroscopies and colonoscopies, biopsies and scans. She’d even had her abdomen split and surgically explored. Everything looked and worked like healthy organs should. They just didn’t feel that way to Jane. Her parents grew increasingly agitated: what were we going to do about her pain? When were we going to scan her, scope her, give her monoclonal antibodies? Didn’t she need an operation?

Jane’s last hospitalisation had ended with the offer of admission to the psychiatric unit for treatment of severe somatisation disorder, the delusional belief that the body is diseased. Our psychiatrists agreed. They came to blows with the patient: Yes, it is. No, it isn’t. Moralism warped the ward: “What she needs is a good spanking,” one nurse said.

I’d never really thought about how to respond in an ethically sound and humane way to a demand for medical treatment for a “non-medical problem”. The situation is very common, with Jane the extreme example. Take the 68-year-old woman who has experienced an intense and sleep-disruptive burning in her breasts since the death of her husband. Or the young man with a paralysed leg and tingling lips. They have each seen a number of specialists, all the tests are normal, but the patients feel real symptoms in their bodies. Do I reassure and dismiss? Recommend a psychiatrist the patient will not accept? We tend to split our understanding down a Cartesian line: it’s all in your body (but we just don’t know where yet), or it’s all in your mind (but you just don’t accept that yet). If belief in a sugar pill – or in your physician – can lower your blood pressure, your heart rate, or make your brain produce extra dopamine, when words can alter physiology, this famous line must be like the Milky Way: vast and shattered and spread. Where’s the book that bridges Harrison’s Principles of Internal Medicine and the latest Diagnostic and Statistical Manual of Mental Disorders?

“I know you think there’s something terribly wrong with your body.” Mike puts his hand on Jane’s forearm and squeezes. “I believe you, but you have to believe me: we’ve looked and we can’t find it.” She turns to him, the first time I have seen her eyes in the light. They are the palest blue. “And I’m scared that if we keep looking we’re going to cause you real harm.”

Jane closes her eyes and lies back on the pillow: “I understand.” Mike squeezes her arm again. “We’ve got some work to do, my friend,” he says.

Karen Hitchcock

Karen Hitchcock is a doctor and writer. She is the author of a collection of short fiction, Little White Slips, and the Quarterly Essay Dear Life: On Caring for the Elderly.

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