Let me be clear: bipolar is a disease listed in the Diagnostic and Statistical Manual (DSM). It is diagnosed by psychiatrists, and treated with medication. There’s no question of its legitimacy as a medical condition. But having had the opportunity yesterday to interview a standardized patient with bipolar disease, I was awakened to the idea that these patients often disagree about being ill.

As the name suggests, bipolar involves alternations between the two extremes of mood: depression and mania. No doubt you’ve heard of and could recognize depression, but do you know what mania looks like? Manic patients are incredibly friendly and likeable; they have an elated, un-deflatable mood, and are very busy people. They rarely sleep, eat copiously, and socialize even more than they eat. They’re relatively disinhibited, and will make friends with strangers, spend money freely, and will try any new activity (including drugs). True mania is accompanied by delusions –  usually delusions of grandiosity. The typical manic believes that they are an especially remarkable person and that they will accomplish legendary success.

The “problem” with mania, is that in the extreme it can be profoundly damaging. In an episode of mania, a bipolar patient may spend all of their money, or make new sexual contacts that they later regret. Jobs are lost, relationships are strained, and medical illnesses are worsened because often the manic forgets to take their medication. Manic patients are sometimes arrested for their indiscretionary behaviour.

Bipolar disease is treated with mood stabilizers. When effective, these drugs reduce the frequency of both depressive and manic episodes. The reality is, however, that many bipolar patients don’t want to take them! The personal perception of mania is such a positive, exhilarating experience that people with bipolar look forward to, and try to prolong their manic episodes. Those who are artists have their most creative moments when manic, and those in business make the most of their money.

So whose assessment of “ill” trumps the other? It’s a very difficult question. Legally, there is guidance available to assess whether a patient is capable of making their own decisions or not. Mostly this involves determining whether the patient fully understands the options available to them, and the consequences of each one. If incapable, patients can be legally held and provided with the treatment that they need.

All of this leaves me asking the question: who am I to deem that you are too happy? When does it become the doctor’s right to decide your mood? And yet at the same time, doesn’t your doctor have the responsibility to look out for you, and advocate on your behalf when you are incapable of doing so? Even if that means protecting you from yourself?

I present all this solely to ask the question. I don’t have the answer. I’m confused and unsure about it. But asking the question is an important first step. I welcome your ideas!

Today was the first day of Psychiatry block. One day’s impression: engrossing, perplexing, and not like anything I’ve done before.

This afternoon we broke into small groups to practice the psychiatric interview. It took place at the hospital. After greater than an hour of conversation with a woman who was describing significant symptoms of depression, I felt quite involved in her story. I was disquieted by her lack of self-worth. Pangs of empathy welled up when she began to cry, and the urge to hug required active suppression. What a wretched affliction this poor woman is enduring, I thought.

It wasn’t until after the interview that I found out from my colleagues that she was acting. She was not a patient! Rather, she was a ‘Standardized Patient’, performing a role written for her by our psychiatrist instructors! What a fool ! I feel completely taken-in! She sure did her job well.

The hand is distinctly human. A thorax is just a thorax, and a shoulder is just a shoulder. In contrast, like the heart, brain, or face, a hand is not just a hand. It’s somebody’s hand.

When prosecting the hand tissue, as we did today, it’s troublingly difficult to dissociate yourself from the gruesome reality of the task – cutting apart a person’s dead body. I felt again deeply accusing guilt of invasion, and violation.

What work did he use his hands for? Perhaps he played an instrument with them. Perhaps he penned words that have out-lasted the hands that formed that. Whose hands did he lovingly hold in his?

Now his final handshake: … me, with my stinging scalpel. I greet him again in those hands, human even in death. I’m sorry for putting you through this. I’m sorry for keeping you here. Thank you, for this last meaningful action of your – always your - hands.

I’m racing to keep up, both on my feet and mentally. The Charge Nurse gives the doctor a quick run-down of the patient being brought in by the paramedics. While we wait for the ambulance to arrive, the ER Resident comes over, gives a quick but thorough description of her patient, and asks the doctor for guidance. One of the Nurses interrupts, and asks for clarification on an order. There are three patient areas to monitor. The waiting room is filling, and the Triage Nurse has been separating those out with Flu-like symptoms for segregation to a private H1N1-designated area. The doctor I’m observing with turns to me and, to my amazement, apologizes because of how slow an evening it has been! I suppose ER Docs like it chaotic.

Observerships are an incredible opportunity for us students. Meeting a real patient is incomparably more impacting (and more memorable) than anything we can learn in the classroom. They are the best chance for us to practice our skills at taking histories, examining patients, and using problem-solving clinical reasoning. Depending on your preceptor, they may also be your first chance to learn a new skill! Such was the case this past Wednesday, when the ER Resident was generous enough to teach me how to suture – first time on a real patient! The experience was exhilerating. Particularly as, the laceration was to the patient’s face, and so an aesthetic result was paramount.

Observerships also give a window into the lives of various specialities. My superficial observations of the ER team, are that they are generally fun-loving, easy-going, and active people. They’re also super friendly! After our shift, the entire doc team went for beers together (and invited me!); I understand they do this regularly! Seems like a fun group of people.

It makes a slick, slimy, wet-but-not-dripping sound as the knife glides through. Slice one. The texture is gelatinous and moldable, but it holds its shape. White and grey; there are patterns in the slice. Like cloud-gazing, you can make-believe that the shapes are mysterious life-forms.

It used to be alive. A day ago, maybe two. More than alive. That piece of tissue, now split indelicately on a slab of marble, felt emotions. It thought up ideas, and imagined shapes in the clouds it saw. It had an identity, and a personality. Now it sits cold; a lump of withered sponge, unable to defend itself from the blade that is slicing it apart.

The blade is wielded by a pathologist, demonstrating to us the gross anatomy of normal brain tissue, and some pathological (diseased) findings. Pathologists (in addition to other things) perform autopsies to determine causes of death. Dead bodies are regularly their domain. Unlike the neurosurgeon, who explores the brain while it is warm, pulsing, and ever dancing with electrical activity, the pathologist handles tissue more like damp tofu.

Evidently, the early anatomists perceived as much awe when they pro-sected cadaver brains. The names they assigned the structures sound like discoveries from an exploratory deep-sea dive: the geniculate nucleus; the hippocampus, which in Greek means sea-horse; the cerebral aqueduct. Shapes in the clouds…

Oliver Sacks is the Jane Goodall of neurology. He has spent his entire  professional career observing patients, dutifully recording in his notebooks, and publishing reports of his findings that illuminate how the mind works. Most of his published work tells personal stories of patient experiences. Most notably there is ‘The Man Who Mistook his Wife for a Hat’ (a man with visual agnosia) and ‘An Anthropologist on Mars’ (perceptions of people with autism).

In this TED Talk, Oliver Sacks explains Charles-Bonnet Syndrome –  a hallucination syndrome experienced by people who lose their vision. I was surprised to learn that up to 10% of people with vision loss experience Charles-Bonnet hallucinations, but only 1% of them report it because they are afraid of people assuming they  are going insane (which they are not).

Check it out, it’s fascinating:

Sometimes I feel burned out. Often, I get overwhelmed. Seems natural, right? Especially given the bullet-spray of unfinishable tasks that Medical Schools like to pump at you. There are days that I wind up in a despairing mess, feeling like I just got the beating of an enraged sumo-wrestler (okay… maybe that’s a very melodramatic way of describing it, but you get the idea).

I’ve found someone who claims to have the cure…

This evening, Queen’s was honoured to host the infamous Dr. Patch Adams as speaker to the H.G. Kelly lecture series. In addition to starting the ‘Gesundheit!’ Institute, Dr. Adams has an inspiring philosophy on health-care, and human-care in general. Even after journeying to the bedsides of some of the world’s most tortured and anguishing individuals, Patch claims that he never feels despair or gets burned out… because he chooses to LOVE caring.

In his speech, entitled ‘The Joy of Caring’, Patch gave seven reasons why the act of caring energizes him and prevents him from burning out. Sadly, I only remember five… nonetheless:

1. He loves people.
2. The job of caring provides opportunities to show love.
3. Good karma: caring is reciprocal.
4. Caring allows you to be outrageously enthusiastic.
5. Caring is good for your health.

What struck me after listening to Patch speak, was that this Medical School business is really only the first, least-important step. Maybe I shouldn’t make the major issue of becoming a doctor centre around school -learning facts about diseases, and practising how to act in the manner of how doctors “should act”. Of course those are both important steps, but they are really only a small mandatory hurdle before I must start the real task before me: learning how to care.

So it’s September, and I find myself back in Kingston poised on the brink of another year. Today we welcomed to Queen’s the class of 2013. It was their very first day of medical school – an experience that I still remember clearly for myself. And as the first-years were making memories, … for completely different reasons, I was also having a day that I will never forget:

After a casual lunch with my mentor-ship group, I dropped into the anatomy lab for what I thought would be a brief administrative meeting with the tutors to sort out the upcoming term schedule. I was completely unprepared for what happened next. “You know that you’re prosecting today, right?” No. I did not. Neither did any of my fellow tutors. Yipes… well, I guess we can still make a try of it.

So in the space of a few minutes I went from meeting green frosh, to meeting my (literally greenish) cadaver who I will be prosecting this year for the anatomy lab. (We use the term ‘prosecting’ as a more respectful word than ‘dissecting’ when preparing human bodies.) We were nervous; the room was so quiet that I could hear my scalpel blade go through as I made the first cut.

It strikes me after being so physically invasive to his body, that I know very little about him – only what his body itself can tell me, such as that at some point in his life he had open-heart surgery. His face, hands, and feet will be shrouded for the next few weeks until those anatomical regions are being studied.

From my cadaver, I will learn much about medicine and anatomy. I look forward to the review of gross anatomy, and to practising with the surgical tools. Today included use of a bone saw – a brutish instrument that makes a shocking roar of noise, and will leave you sweating. I also look forward to teaching the first-years their material using the samples that we prosect.

Leaving the lab four hours later than I had expected to, I must say I was grateful for the experience. Unexpected yes, but perhaps that’s exactly the way it needed to be to push me off into the deep end.

“Welcome to Lanark – Population 800″; I spun my head around to read the sign as we drove by. I had not previously appreciated that when my preceptor referred to Lanark as “the village”, this was not merely a metaphor of endearment – she had meant it quite literally.

“Week in the Country” is a program sponsored by the government of Canada to entice medical students towards rural family practice. Every medical student is required to spend at least one week shadowing a rural Family Doctor. Almost all expenses are covered, as our government is desperate to meet the growing need for doctors in under-serviced rural areas.

Lanark has one major road running through town. We were lodged extravagantly at a bed & breakfast (see photo above) on one side of town, and walked into the Community Health Centre on the directly opposite edge. The walk across all of Lanark took no more than 20 mins.

4 year-old male presents with left ear pain lasting five days, and other non-specific symptoms of an upper respiratory tract infection – our first patient. It is surprisingly difficult to look into a squirmy child’s ear! Otitis media; Amoxicillin 50mg/kg/day TID x 10 days. After Week in the Country, I can now write that with some confidence! In fact, the week was extremely valuable for gaining some proficiency at triaging common complaints, and I am now more confident in differentiating sore throats, sinus infections, headaches, and common skin rashes.

Perhaps the most memorable patient, for me, was an admirable young man trying to quit smoking. He had impressive resolve, but was profoundly impeded by addiction. I cannot imagine the frustration of fighting a war with your own brain. I learned about the arsenal of medical tools available to help. More powerful, however, was when my preceptor offered to make an appointment with this patient every other day on his way to work for the next month – a brief check-up, so that every two days there would be someone asking “Have you had a smoke?”, and “How is it going?”. What a privilege to be that source of accountability and motivation in a person’s life.

In Lanark this week I didn’t get into the OR, or the ER. We didn’t see anybody who was mortally ill. We didn’t perform any cowboy, daring, rescue procedures. But I’m not in the least disappointed. I learned how to swab a throat, how to give a vaccination, and how to detect pneumonia without the luxury of an x-ray. Less romantic perhaps, but unaccountably more useful.

Bloodletting was a common medical procedure of antiquity that involved draining sometimes large quantities of blood from ill patients. It was believed to be helpful for a plethora of diseases, including everyday ailments like fever and headaches. There were detailed medical protocols for how much blood to take, how often, and from which anatomical locations. In infants,  the entry-point of choice for bloodletting was from the anterior fontenelle, or the “soft spot” on the top of the baby’s still-forming skull.

Modern medicine has demonstrated that bloodletting has little therapeutic benefit for most of the diseases that it was standardly used for. Additionally, bloodletting introduced all sorts of horrific complications like infections, hypovolemic shock, and even brain damage when the needle went too far into the infant’s head.

That being said, I was surprised to discover that there is at least one disease for which bloodletting is effective, and still used today! The disease has to do with iron in the blood. Most people think about blood-iron in the context of iron-deficient anaemia, or not having enough iron to make adequate red blood cells. But, it is also possible to have too much iron in the blood.

Iron overloading in North America is most often due to a genetic disease called hereditary hemachromatosis. It involves a mutation for a protein that normally regulates iron absorption in the gut. As a consequence, the gut absorbs too much iron and the blood becomes “overloaded”. Iron overload can have serious consequences causing damage to the liver, pancreas, pituitary gland, and skin.

Since the body has limited capacity for excreting iron, the best treatment for hereditary hemachromatosis is regular bloodletting to remove the excess iron. Of course, nowadays we use the fancy term “plebotomy”, but the principle is still the same! Neat, eh?