Month: September 2017

The solution seems simple enough. Just stay in hospital until the infection is under control, then  continue treatment at the CTCT, a clinic in the Downtown Eastside. If going to that area  causes too many triggers for someone fighting an addiction, then all they have to do is stay in hospital for 6 weeks to treat their infection.   So simple, but why do so many patients check themselves out of the hospital before the treatment is completed, only to return a few weeks later with a much worsened state?

Addictive behaviour can seem irrational, indeed, and it can be quite maddening at times.   There is one article related to addictions, Reflections on Treating Addictive Disorders: A psychodynamic Perspective published in the American Journal on Addictions, which broadened my understanding of addictions. I had read this in medical school, and decided to go through the article again when working on 10C and feeling discouraged by the failed treatments. The author reminds us of a very important fact: that addiction is not about “pleasure-seeking”. Rather, he summarizes that causes of addictions  are related to difficulties with feelings, self-esteem, relationships and self-care.  It’s an important distinction, as it’s much easier to get frustrated at patients who aren’t doing their part simply because they want to feel a “high”. His conclusion, after 40-50 years of experience in addictions medicine, is that, no matter the patient and his or her other comorbidities, there are a few essential elements health-care providers need to use in their work: kindness, comfort, empathy, avoiding confrontation, patience, instruction, self-awareness, climate of mutual respect and balance in listening/talking.

I believe that it’s this conclusion, so simple and humane, that had struck me when reading the article. It was oddly comforting. And so, when I rounded on a few patients  in the Urban Health Unit of St. Paul’s Hospital who had visibly used the same day and appeared very unwell, I remembered the complexity of what was driving them to use. The pleasure-seeking hypothesis made no sense in these patients who were in obvious distress after using. And I actually felt relief when watching the 10C team in action- every essential element for helping patients suffering form addictions in the list cited in the article were vividly present. Now if only other wards and environments could demonstrate the same kindness, comfort, empathy, patience and respect as seen on 10C…

 

The article: Khantzian, E. J. (2012), Reflections on Treating Addictive Disorders: A Psychodynamic Perspective. The American Journal on Addictions, 21: 274–279. doi:10.1111/j.1521-0391.2012.00234.x

“Vous êtes gentils, mais inutiles. Vous nous regardez, vous prenez des notes, vous faites des rapports, écrivez des articles. Je vous aime bien, mais vous n’avez pas l’impression, des fois, que vous vivez de notre mort?”

This quote from the book A Sunday at the Pool in Kigali describes how a wounded Rwandan views a foreign nurse volunteering during the genocide as kind, but useless.  She goes on to ask whether the nurse feels she is living from others’ sufferings. I read these lines 4 years ago when I was in Rwanda, completing an elective as a medical student.  Working in developing countries had been a dream of mine since day 1 of medical school,  but those lines reminded me of the complexity of the task. First, do no harm. My aim is be able to actually have something to offer before heading abroad- I don’t want to feel like an impostor.  I’ll study well, and avoid that dreaded feeling, I vowed.

3 years later, I find myself in an Inuit community in northern Quebec. I’m on call, and am asked to come in at 2am to settle down a patient.  When I arrive, the nurse promptly asks me to prescribe strong sedatives they can inject into the screaming patient so everyone can get some sleep.

I find a 14 year-old girl sitting with her head between her knees, crying her head off. On each side are strong, young, male, non-native police officers firmly holding her in place. The male, non-native social worker who’d just started that day as well as 2 non-native nurses were also present. The patient had fought with her  mother, and no other family wanted to take her in for the night, so they brought her to the hospital. She’s yelling in her native Inuktitut, adding: “(insults) whites, (insults) police, nobody likes me, nobody wants me!” in English. And the policemen, exhausted from touring the town looking for a shelter for the patient, stare impatiently at me. “Can you inject her?”

Sure, I knew she was a frightened and saddened young girl in need for a compassionate ear, and I tried speaking to her. I asked to police to let her go and leave the room, I asked the social worker to step out. I spoke calmly, I let her scream as much as she had to. But it was too late. We made her live through the same trauma that her parents and grandparents had to endure, at the mercy of “non-natives”. We had opened the wound, and there was no calming her down now.  I called my staff, also a new young doctor, and we both tried calming her for over 2 hours. Policemen sighing, nurses yawning. Fine, we’ll admit her and calm her…

My staff and I sat in silence as they brought the sedated patient to her room. And then came the crippling Impostor Syndrome.  We had resolved nothing, and felt we had no business meddling in a communal issue  in such an aggressive manner.

I remembered all this, in particular the unsettling feeling described, when visiting Native communities on Vancouver island. I was worried the same feeling would reemerge during the rotation. I’m happy to say it didn’t, and my experience was overall very positive.  I was with physicians who were visibly welcome and were making a difference.  They worked with closely with community members and were very respectful of their culture. Nonetheless, I vow to learn as much as I can in the upcoming few months to avoid re-living that overwhelming feeling of uselessness.