spirit salt

Says the wise patient of the week,

"If you remain righteous in your salt, your mouth tastes salty. That helps you realize that the spirit is eternal and the body is not; you're supposed to thirst for righteousness, and there is a secret ancient ritual you can do to fill your thirst without drinking water".

"Do you hear voices telling you these things?"

"My mouth speaks to me and tells me all these wonderful things".

The nurses are against giving her extra salt at mealtimes. She is improved from admission, when she wore an improvised hijab complete with veil fashioned from a towel, and covered her hands in old socks to avoid exposing her skin. Do we suppose she was tachycardic at vitals check because of a medication side effect? Or, perhaps, water deprivation? Hmmmm.

Yes, it's been a quiet week here on B6/5; where all the men are alcoholic, the women are psychotically depressed, and the children, clever ones, are on another unit. I have one week left, and it can't pass quickly enough. I drift from one steel white door to another, asking in a strangely depersonalized tone about the voices that continue, the suicidal ideations that are either decreased or increased or the same, all my questions asked to the accompaniment of wails.

Not screams, wails. Thin, high, reedy wails that may be factitious, since the origin was able to speak clearly when asked for the address of her parents in Mexico that she wanted to obtain a special dispensation for, but then lapsed instantly back into catatonic, rocking stupor.

Down the hall, our tune-up on JL didn't work for more than a week; discharged my second week after family meetings and adjustments in her intrasynaptic serotonin levels, she went home to her parents' house (she's 53) and curled up in a ball for a week, until she decided she had enough energy to consider walking in front of a semi again. She's back, and pounding her fist into her hand wondering why she's so f---ed up. To myself, I wonder the same thing. In good medical student fashion, I handle the situation by running off to the computer so I can look up the manifestions of serotonin syndrome. For your information, I find that it is a clinical diagnosis marked by flushing, autonomic instability with possible raging hypertension, hyperthermia, and hyperreflexia.

JL is super hyperreflexic on exam, and flushed, and agitated. And she feels warm. I'm stoked. The attending is not. He figures it's just situational anxiety. And another attempt at 'making a difference' is shot. Just like they shot down my idea to screen for PSC in T, who has an isolated high GGT without a drinking history and a family history of ulcerative colitis, which is linked to PSC. Never mind none of his other liver enzymes are elevated.

That's all right, I've had my triumphs. The ear drops I perscribed for MH's ear wax were a hit, resolving her ceruminous trauma within hours. See, I think. It is possible to make a difference.

That's the main problem. JL's failed tune-up is proof that change is not often to be found on the unit. The best we can often hope for is a tweak of the meds, a passing of the acute hurricane of psychosis or suicidal ideation, and a discharge into an uncertain world which is no kinder than when last we saw it.

See how I say 'we'. I'm stuck in here, in the bin, with them. I identified symptoms of hyperarousal a few nights ago. I am paralytically anhedonic when faced with the prospect of dictating even more scintillating discharge summaries. Family meetings make me hypersomnolent. Dear Lord, save me from any more countertransferance, transferance, empathy, identification--anything that points out to me more clearly the thin thread of sanity that, for some unknown reason, has held firm for the first 32 years of my life and kept me from the abyss of command hallucinations telling me to throw bananas at passing horses on State Street in order to save Western Kazakhstan from nuclear annihilation. And, you know, I have a personal connection to the Lord. Mostly, because I put extra salt on my Pop Tarts.

'Night.

A Hairball of Souls

The voices in her head are like 'a hairball of souls', she said as the intertwined her fingers and rolled her hands around, creating a picture of some tumultuous, chaotic interface between herself and realities both real and dreamed.

Her psychosis is distinct from the manic patient; it doesn't fit, doesn't match. Blauer, in first describing schizophreia, described psychosis as a loss of self. She speaks of the voices and the experiences as though looking through soundproof glass at herself, at once acutely aware and immersed in the gumbo of her thoughts, but also different. "Mood incongruent", I write in the note.

Of course the word choice of 'soul' is significant. Satan and God and the bible play a strong role in her life; more than many of us who may say "I'm a spiritual person", she means it that Satan has recently chased her through the streets in the middle of a frigid night with a cohort of demons. Were they close to her? Was it just a sense of dread, or did she turn and look over her shoulder and see them coming on? The whole time, she recounts the story with the tone of an unimpressed, nonchalant twenty-something relaying a recent visit to Starbucks with her friends.

She wants to get on with her life, even says the second morning here that 'it's probably not a good idea to live according to the voices in your head', and the whole time she has an odd mix of psychosis and insight into her condition; the voices are at times external, at times her own voice acting out a part.

After a week and a half, dignity begins to appear for me in madness. The people on the ward are sick, but at the same time, just as an elderly veteran might suffer in dignified stoicism with advanced peripheral vascular disease or heart failure, these patients have their own sources of strength that they call on in the midst of the chaotic milieu of unusual inner dialogues (see, it's happening--I never would've used the word milieu on a Surgery rotation. Pretty soon I'll have to get sweater vests and jackets with elbow patches).