Murphy’s Law Of Medicine At Work
The next person to see me made a dramatic entrance. First, she had gotten a head start on her crying in the waiting room. But more than the sound of her crying and sobbing, she could barely make it through the waiting room door. I am no good at guessing someone’s weight. She later admitted to being 380 pounds. I took her word, as our clinic’s scale only went to 300. Her general appearance was that she was swollen with water – a human sponge. The edema bloated every part of her body, and her crying eyes were nearly swollen shut. I started by asking her when her problems began. She was now 42, and said she had thought everything was okay until age 15, when she had been raped by a “friend of the family.” This man was not really a friend, he was a person who went to the same church. Moreover, he was a Sunday school teacher. You would think that by now everyone would know that being a Sunday school teacher does not make someone a saint. But this family had not yet figured it out. In many such cases, this type of person is shielded by the religious community, and even the victim’s parents are often in denial. This woman was lucky. Her parents told her that they were going to prosecute this sinner to the extent of the law.
There was a trial, and she had testified. She thought everything had turned out great, and so did her parents. The rapist was convicted and sent to jail. Again, those who are experienced in these things know that this type of trauma is never over quite so easily. The woman went on with her life and ended up in a really abusive relationship — the kind where someone locks you up and won’t let you leave the house and beats you if you look out the window. By the time she got the courage to escape this living hell and seek a shelter, had a peck of kids. They lived in this shelter for over a year before she found that she had what it takes to start over. She went to school, gained some clerical skills, and started over. She was actually doing pretty well until something happened that triggered a demon she didn’t know had possessed her. She was called for jury duty and went, with pride, wanting to do her civic duty. She couldn’t. She had a panic attack as soon as she entered the courtroom. She ran to the ladies’ room, threw up, and tried to enter the courtroom again – and it was even worse. People thought she was having a heart attack, and they sent an ambulance for her. I do not recommend this means of getting out of jury duty, although it sure worked for her.
This was a text-book case of Post-Traumatic Stress Disorder (PTSD). I discuss this problem at length in my private newsletter – which you can get for free if you register for it. PTSD is much more common than everybody thinks – even trained shrinks.
This victim had the same classical triad of symptoms that you would look for in a military veteran who served in a war zone. All of a sudden, she could think of nothing but her rape. She tried to avoid thinking about it, but she thought about it anyway. And she was really sensitive to sudden moves or noises. “I had to teach my family to talk to me before they walk up to me, because if they startle me, I can go through the roof.”
The symptoms she – and all PTSD victims – experience are:
1). Re-experiencing the trauma – flashbacks whether waking or dreaming that result in sweating, racing heart, shortness of breath, and even more severe things.
2.) Avoidance of any situations remotely reminding her of the trauma. That includes movies and TV shows, certain song lyrics, seeing people in a public place – such as fighting in a supermarket or on the street.
3.) Hyperarousal – the “going through the roof” over relatively minor stimuli.
Yes – she had them all, and in spades. When I was still in training – back long ago, I remember learning that even then the majority of psychotropic drugs dispensed were given out by general physicians – and the percentage was rising. 75%, 80%, 85% or more of the antidepressants, anxiety medicines and other psycho-active drugs were dispensed by family practice doctors or their designated “physician extenders” (Physicians’ Assistants, Nurse Practitioners, etc.) who had no more than a cursory knowledge of how to use these specialized drugs. I spent a year in a special fellowship to learn about these things, but in the interest of cutting costs and keeping the patient flow going, this had all been shoved off on lower-level people who often proved Murphy’s Law in practice. If they can do anything wrong – they will. How difficult can it be, most people would think? Certainly the regulators who pass laws allowing barely-qualified people to handle such things think this way. After all, you just read the package insert or do what the nice pharmaceutical sales rep tells you to do. I suppose that you can argue that psychotropic medication prescription is not rocket science. Actually, I think human beings are a lot more precious than rockets. This PTSD sufferer was a perfect example. Her general physician put her on alprazolam (Xanax) and told her it was an antidepressant. Surprise, surprise, it is a DEPRESSANT – an anxiety drug. I think there was one study about 15 years ago suggesting it was some help with depression – mainly because it calmed the nerves, but that has long been debunked. It is an anti-anxiety drug, similar in its effects to booze, and highly addictive. Also, fatal if abused. The patient claimed nobody had told her about this. Doctors are supposed to detail benefits and risks when giving out a prescription, but most are too rushed to process patients in the ER or clinics. Besides, the pharmacist always consults with a patient when filling a prescription, right? Except she was a little too stressed to read the handouts from the pharmacist “in detail.” She took some Xanax and then some more to keep “feeling better” and when she finished the prescription early, she called her pharmacist and asked for an early renewal. The pharmacist asked the doctor, who declined. Doctors can get in trouble for prescribing too much of these types of drugs. You can’t just stop these drugs cold turkey, though. They must be weaned off gradually. Otherwise, the can have what promptly happened to our unfortunate PTSD victim: she had a grand mal seizure. As you can imagine, this scared the living daylights out of her family — who had never seen her before in that kind of shape, so they took her to the emergency room. When this happens, the seizure must (by law) be reported to the department of motor vehicles, so she could not drive for one year. She still has about 8 months to go until her license might get reinstated. Loss of independence, when she most needed it. Her doctor thought maybe ” another” antidepressant would be helpful, and started her on the cheapest available — generic Prozac. They say that even a broken clock is right twice a day. And actually I have attended a lot of patients who are on the wrong medicine for the wrong diagnosis, but it actually works out for them. In this case, Prozac does decrease the frequency and intensity of the flashbacks of PTSD. So what if the doctor thought he was treating depression? By dumb luck, it worked for her. But the patient – an addict of the strong anxiety medicine — begged for her Xanax back. It felt so good. And — like a good little doctor — her family practitioner gave back the Xanax. But now, it seemed more effective. Hallelujah!
So, was all well? No — the patient had insomnia. So the doctor added some amitryptyline, thinking this was a good, non-addictive choice for sleep. The only problem was that the patient was now sleepy all of the time. Not being trained in the pharmacology of psychotropic drugs, the doctor didn’t realize that Prozac raises amitryptyline levels, so the patient was probably toxic. Incidentally, it also raises Xanax levels a bit. A decent pharmacist would have noticed these things, but the patient got some of her prescriptions through a pharmacy for the indigent and others somewhere else. Perhaps you can understand how I was getting frustrated – angry — because I was supposed to assess this woman, but the treatment was so bad, I was wondering if this was a contest to see how many mistakes could be made in a single case.
1. Wrong diagnosis. No matter what kind of therapy you think works, this case needs a therapist.
2. Use of an anti-anxiety drug instead of an antidepressant.
3. Patient’s lack of understanding of risk of increasing doses on a benzodiazepine.
4. Inadequate monitoring of drug interactions.
The patient could have died of any one of these problems. Instead, she sat in my office obese, depressed and crying, and sleepy. I was supposed to assess this, and did not much want to tell her how many kinds of an idiot her doctor was. Being the lovable and diplomatic lady shrink that I pride myself in being, I took a different approach. I said pretty much this: “There will soon be a revolution in medicine. I think it is started already. It will not come from the doctors who are too overworked and tired and can’t scrape up enough energy for much of anything. It will come from the patients. “If you are taking treatment for a few months and you don’t get better, question the diagnosis. Look it up on the internet. Psychiatric diagnosis right now is not a hard thing. It is a bunch of checklists. Find yours on the internet and read it and see if it sounds right. If it does not, either put your printout under your doctor’s nose, or send it to them in a registered letter where they have to have a receipt, signed and must put it in your chart.” I actually heard it said once that a doctor’s diagnosis is as precious to him/her as a woman’s baby born of her body. Neither wants to let go. But the baby — well, you can’t usually be mistaken about who the mother is. But doctors can sure be wrong about a diagnosis, especially when they have too many patients, not enough time and are forced to practice in a specialty where they have little or no experience. Check out your medications. Start with a pharmacy printout, or one from the internet. Read it. If it is not in language that makes sense, call the drug company. Check medication interactions. Your pharmacist can only do it if he or she knows what medications you are actually on. More and more people are using reduced cost programs, so there is no tracking. Either track it yourself using a site like drugs.com, or get a pharmacist to do it. Or a doctor (good luck with that!). If you do not do these things, you are laying yourself open to the possibility of more horrible things than you can imagine. Incidentally, the doctor of the poor lady who came to see me wanted to fire this patient for being too fat to take care of. I’m still naïve enough to think that medicine is supposed to help us, and that a person should feel better after seeing a doctor – not worse. Is there any hope for me?