That was the case today. My mind drifted back to when I was an intern at the same hospital where I trained as a student. A big third-level referral centre* with the faculties of Medicine, Nursing, Microbiology, Physiotherapy and Nutrition Science attached to it and the off-campus Ophthalmology and Cardiovascular hospitals a stone throw away.
It was a big hospital, and we had some of the best brains of the country working there. We managed the most complicated cases and our area of influence included several provinces. FYI, the Medical School I attended to is one of the top five in the country and it has been awarded the best Medical School for several years (including my class) based on a test all graduating doctors take on their last year of school.
Why am I telling you all this? Not to brag, that’s for sure. But it is relevant as you will see if I haven’t bored you to death and you can manage to keep reading.
During my obstetrics rotation, a patient was brought to one of the beds assigned to me. Young woman. High risk pregnancy. Bulky clinical history. The first thing that caught my eye was how huge her file was. Even by our hospital standards. The second, how beautiful she looked, in her quietness. Not your standard pretty face but with beauty that irradiated from within. I could tell it was a face that had known suffering and pain. I introduced myself, exchanged a few encouraging words with her and set to read the several tomes of her clinical records.
What I learned made me very sad.
Most of the bulk of it was from her treating psychiatrist – who happened to be a friend of mine, and who had graduated in the same class as my [no ex] husband. A very smart man in my opinion. I read pages and pages on his handwriting. Outstanding data recording techniques. Impressive clinical thinking. Everything I “needed” to know was there. A beautiful example of how clinical records should be kept.
This woman had been in physical pain most of her life. She had been lead to believe it was all in her head.
Now, don’t get me wrong.
- I am not saying my friend and colleague didn’t do all he was taught to do during his residency in Psychiatry. I’d say he probably did it better than most.
- I know that psychological pain and phantom pain can be as excruciating as “real” somatic pain. That’s not what made/makes me angry.
What made me angry was that nowhere in the records, any kind of somatic illness was discussed after all the standard tests for arthritis came back negative. That was it. If the rheumatologist says it’s not physical, then it must be all in your head.
Not even once, the differential diagnosis of fibromyalgia was considered.
Every single real symptom this young, beautiful mother-to-be was dismissed as not “real”.
Take one of her symptoms, for example. She “felt” a tingling sensation on her upper back, on each side of her spine close to her neck. A textbook fibromyalgia symptom, the kind of sensation when your leg goes numb after you’re been sitting on it for too long.
Non-psychiatrists doctors refer to it as paresthesia. Sometimes it means nothing, just a temporary and completely reversible lack of blood around the nerve (you just fell asleep on your hand) but sometimes it means nerve damage. It’s important to know. It’s important to keep in mind when your working the night shift and that drunk person comes to the ER at 4 am because they can’t feel their arm. And then we find out it’s a just numb arm because they fell asleep at the table in a funny position. But they forgot about it, woke up, didn’t feel their arm and panicked. But that’s good. It’s nice when we can tell people that it’s nothing to worry about. Wish we could say that more often.
But then some good medical students go on doing a residence in psychiatry. And then they re-learn that what they knew as paresthesia is really a hallucination of the tactile kind. See what they did there?
No? Let me explain further.
Here are the definitions of the words by the MedlinePlus/Merriam-Webster Medical Dictionary © 2012 by Merriam-Webster, Incorporated. Emphasis mine.
par·es·the·siaVariant(s): or chiefly British par·aes·the·sia \ˌpar-es-ˈthē- zh(ē-)ə\Function: nounA sensation of pricking, tingling, or creeping on the skin having no objective cause and usually associated with injury or irritation of a sensory nerve or nerve root.
hal·lu·ci·na·tionPronunciation: \hə-ˌlüs-ən-ˈā-shən\Function: nounA perception of something (as a visual image or a sound) with no external cause usually arising from a disorder of the nervous system (as in delirium tremens or in functional psychosis without known neurological disease) or in response to drugs (as LSD).
Two words to describe the same thing. And yet, they carry such different connotations.**
You would think that doctors working at a third-level referral centre would know better than to stick labels on a person without judiciously considering all the alternatives. This is not a matter of an obscure doctor of an obscure small town.
This is not about third-world, second-class-citizen medical care. We were the best the country had to offer. And we failed her.
We failed her because from the point she was diagnosed on, she had to second-guess every single medical problem she had. We failed her because instead of offering the treatment she needed, we gave her endless hours on a chair, talking about the hallucinations trying to convince her that what she was feeling was not real pain. We failed her because we gave her the wrong medication. We failed her because we made her family afraid of her, dreading that moment when that psychosis was going to take a turn for the worst.
Instead of helping her, we stigmatized her.*** Once the mental illness label was there, they just wouldn’t consider other options. And that to me is unacceptable. Not to mention it was not fair to the patient.
* In case you are wondering what all that third level gibberish means:
- First Level: First contact level with a health centre (smaller health centres may be called dispensaries, health stations, health posts) Normally they don’t have beds and they focus on prevention and treatment of non life-threatening conditions.
- First referral level: A district hospital that provides a 24-hour intramural medical care which represents a higher level of competence than the source of referral, e.g. health centre.
- Secondary referral level: A more sophisticated hospital (may be a provincial hospital) providing multi-specialist intra- and extramural care
- Last referral (Third) level: A most sophisticated hospital located in a national or provincial capital or other big city, typically a University Teaching Hospital, providing the highest level of medical care available in the country or a region.
Source: World Health Organization LEVELS OF HEALTH SERVICES
** I remember being shocked, irritated, ireful even when I learn this while taking Psychopathology. I asked my professors about it. This thing you call a tactile hallucination, that sounds a lot like a paresthesia to me, I said. Yes, was the answer, they’re the same thing. Why the need to give it a different name, I asked. Dumbfounded faces was the answer. What, no one thought of asking this question before, I asked. Still no logical answers. There may not be measurable nerve damage but that doesn’t mean there isn’t something wrong at the molecular level. Our inability to measure something only means we don’t have the right tools.
*** To be fair, I am sure she also had a mental illness. And I was glad that at least she was getting some help for that. Anxiety and depression very often co-exist with fibromyalgia.
© Summer Solstice Girl and A Canvas Of The Minds 2012. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author and/or owner is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Summer Solstice Girl and A Canvas Of The Minds with appropriate and specific direction to the original content.