Tuesday, July 22, 2014

The View Sure Is Nice



Working in a county health facility that functions as the lowest safety net for organized health care delivery in one of the most economically depressed and violent areas in Northern California has been a study in the human condition. It has been a little over a year since I worked with a doctor designing a study to compare levels of violence induced trauma between people in Israel vs Vallejo. The study never got off the ground, and at the time I didn't have a full understanding of exactly what kind of insights an investigation such as this could provide; now, however -- I can appreciate why the doctor I was working with had this idea in the first place.

In my small sample size of over 5 weeks seeing family medicine, women's health and chronic viral (HCV, HBV and HIV) patients, there is one element that has played a part in almost every patient encounter. That element is addiction; whether it be the patient's own current or past addiction to drugs of all kinds or food or a patient who has major life struggles associated with a loved one struggling with addiction. I've seen patients outright change from friendly, seemingly reasonable humans with whom I felt I could properly communicate with to a tortured person exuding desperation, demanding that pain med regimens be maintained or started despite clear violations of patient-doctor contracts stating that no other drugs can be present in a screen. I've seen chronic and disabling health issues and diseases wholly attributable to addiction -- again, drugs or food. I've come to decide that there may not be any coming back from 20 years of hard drug use. This seems to be that tipping point -- 20 years of shooting and smoking meth takes a person and just destroys so much that if they managed to escape HCV or HIV from needle use and endocarditis they are left with a mind ravaged and incapable of reaching any potential ceiling of function they had. This is not to say that a person can't clean themselves and have a relatively good and satisfying life afterward, but there is a price to pay and the debt load is high after 20 years.

Tangentially related and with a risk of waxing a little philosophical -- I realized that I've been recognizing and dealing with patterns of balance on large scales. Through the lens of addiction I see people who have taken advantage of tools which allow for a life to be sped up or slowed down; there is a reason why, in general, the drugs of abuse which have the most addictive power are uppers and downers. Tweakers, or abusers of methamphetamines are on a schedule so that they are actually living more of a life (or, in some non-intentional hippy kinda way, using up 'life-force' or some esoteric idea of a person's vitality with which a person can spend as they desire as if it were currency) in the span of 24 hours compared to a "normal person," or, at least a non-tweaker. Classic downers literally use up a neurotransmitter called GABA, which is the physiological inhibitor of excitatory action -- users of benzodiazapenes or barbiturates basically speed up our brain's slow down pathway, at its most rudimentary level. I even see pharmaceutical drugs in this light, in so much that a drug may be given in the hopes that a physiological process balance be altered. Sometimes it is in efforts to return to a previous balance that has been interrupted, sometimes we push the fulcrum to a non-physiological balance for the sake of other pathologies.

Again, this whole process has been a study in the human condition, but as far as our patient population is concerned, it is an investigation of imbalance -- of a type that a trendelenburg test won't usually identify. I say all of this not to disparage the patients but as more of a fleshing out the idea of exactly what opportunities I have before me. It took me 6 weeks to wake up to the idea that maximizing my education is, most of the time, simpatico with the patients needs as well. Whether it be scouring area research centers for specialists for some rare condition, calling a patient a day after the appointment with a website for cheap prescription glasses, or trying to talk down an angry patient from whatever metaphorical ledge they're threatening to leap from, it all ads up to the type of education I've been hoping for since 2006 when I decided to go back to the school in the first place.

The actual medicine is great too, of course.

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