“Does the walker choose the path, or the path the walker?” ~ Garth Nix
Technically, I should have written this about 3 ½ months ago, my one-year anniversary from starting a new job in the U.S. after completing a 5 year mission term at Buea 7th day Adventist Health Centre in Cameroon.
One year would have been December 15, 2015. That date was a day overflowing with memories. Good memories from Cameroon but paralysing fears regarding the future.
I used to have goals to work toward. There was always something in the future that infused meaning into the present labour. There was a confidence that the present trouble was a stepping-stone for reaching higher and better accomplishments.
Now I wonder if the past five years in Cameroon were the pinnacle? Will my identity culminate with living overseas for five years? Was service in Cameroon my destiny? Is there anything left for the future?
The Pacific North western culture is different. The art of medicine is different here as well. I haven’t seen a single case of malaria. There’s been only a small handful of cases of traveller’s diarrhoea, none of which were Typhoid. A typical clinic visit might be exemplified by Ms Ariel:
Ms Ariel is a hybrid that represents a commonly encountered scenario that occurs on a daily basis in my office. In the interest of privacy, I have created an amalgamation that preserves the essence of my work in American healthcare but doesn’t identify any personal details of one individual.
I knock on the patient’s door.
“Come in,” she answers absently from the chair she’s seated in scrolling through her Face book alerts on her iPhone.
As I seat myself on the stool in the room and log into her electronic medical record on the computer, she eventually tucks her phone away in her purse and turns to face me.
“Cool hair,” I comment on her recently dyed tri-coloured hair, transitioning from royal blue to aqua turquoise. It is eye-catching and somehow seems to fit with her multiple body piercings that compliment her tie-dye skirt and tall leather boots.
“Thanks,” she smiles.
“Did you dye it yourself?”
“No, my friend wanted to practice,” she shakes her head. “She’s going to cosmetology school.”
Now that I have her attention, I glance down at the paper in my hands on which my medical assistant has written the main concern today, “palpitations”. The paper also reminds me to ask Ms Ariel to schedule her pap smear and get her flu shot while also filling out the questionnaires to screen for alcohol abuse and depression.
“Yea, in the past few weeks I keep feeling like my heart is going to jump out of my chest,” Ms Ariel begins. “I feel like I can’t breath sometimes. I can feel my heart flip flopping like a fish inside my chest, especially when I’m in bed trying to sleep.” She stops.
“Anything else you notice with these feelings of your heart beating too fast?” I prod. “Other symptoms that seem to be associated or bring them on? Did anything change in your life recently before these palpations began?”
“I get headaches sometimes,” she replies. Her iPhone rings and she reaches over to retrieve it and turn off the ringer.
I wait. “Is there more stress in your life recently? Have you ever had these palpitations in the past?
“I recently started a second job at the service centre,” she remembers. “My boyfriend and I broke up after that. I haven’t been sleeping well either. And, that’s another thing I wanted to mention, doctor,” she looks at me. “I need something to help me sleep at night. I can’t fall asleep until after midnight and then I wake up after a couple hours. My friend gave me one of her sleeping pills and it helped. I want to see if you can give me a prescription today.”
I nod in recognition of her change in topic. “And has your lack of sleep made your palpitations worse?” I try to steer her back to her original reason for consulting.
“Yes, I think so,” she answers after a pause. “I had palpitations before when I was a teenager, I think,” she continues. “The doctor gave me some kind of medication and eventually they went away. I stopped taking the medicine. I don’t remember what it was now.”
“Have you ever fainted during these spells? How long do they typically last? Do they just go away on their own eventually?” I attempt to garner more information to assess the severity of her palpitations.
“No, I have never passed out,” she answers, “except for that one time when I was really sick with some GI virus and I was vomiting and having diarrhoea. I was headed to the bathroom when all of a sudden the next thing I knew I was on the bathroom floor. I couldn’t remember how I got there. My mom says I fainted. I don’t know how long I was out. Probably only a few minutes. I guess I was sicker than I thought. I was also feeling dizzy at that time too…”
I take a deep breath and interrupt her meanderings to direct her back to our original problem. “So what do you think is going on with your palpitations? Do you think they might be related to the recent stressors in your life?”
“Probably,” she answers after a thoughtful pause. “They don’t really bother me except that one time when I was at work and my boss had just brought me back to tell me I needed to meet certain deadlines. She was upset and it made me upset and then I started having a panic attack and I couldn’t breath and the room was going all dark and my heart was beating too fast. I actually had to take the rest of the day off, doctor.” She looked at me for a moment then continued. “Usually these episodes I feel now go away in a few minutes. Really I haven’t tried anything for them because they’re not that much of a bother. I know I can be a bit of a hypochondriac about my health but I just don’t want things to get worse, you see.”
I nod while she continues her monologue.
“Honestly, I think the palpitations will go away on their own. I don’t think they’re really dangerous, do you doctor?” Without waiting for a reply she continues, “Anyway, I don’t want to take any medication. I don’t like having to be dependant on a pill every day. Maybe you could just write me a prescription for that sleeping medication that my friend let me try? That way I could use it as needed when I can’t sleep. I tried melatonin already and then my naturopath suggested some teas and meditation techniques but really, they’re not the same as taking that pill when I really just need to knock myself out.”
Attempting to reorient myself to her new concern, I answer. “So, you think your palpitations are related to more stress and not sleeping. And, if you can sleep, you feel your palpitations will go away?”
Ms Ariel nods and taps a reply on her phone. “My friend just texted me the medication name, “She says it’s called lor-az-e-pam. I’m sorry if I didn’t pronounce it correctly.”
“You did fine,” I reassure her. “I understood the name.”
“And what kind of things do you think will help you manage your stress better so you can avoid the heart palpitations, the panic attacks, and the sleeping pills?” I query as we negotiate the safety concerns of a benzodiazepine.
Ms Ariel shrugs. “I don’t know.
“Would you be interested in talking with a counsellor to learn some strategies for handling stress better?”
“I don’t think I have time, doctor.”
“I’ll give you some things you can practise at home with deep breathing and progressive muscle relaxation,” I add with a resigned nod regarding her thoughts on stress management. “You might also find yoga helpful. It’s good for the brain and your muscles, particularly your core back muscles. It could help the lower back pain you’ve had before.”
“Oh, that’s another thing I wanted to ask you,” Ms Ariel suddenly remembers as I type my orders into the medical record and complete her printed visit summary. “Can I have another referral to my chiropractor? I’ve been having pain in my neck recently.”
Already past our appointed time, I sign back into her electronic records and we go through the requirements of a chiropractic referral.
As I type in the orders and fill in the allotted questions, Ms Ariel watches. Suddenly she blurts out, “You know, I think I might have ADHD. I can never remember anything and I can’t seem to concentrate at work. My boss is always reminding me to focus. I’m always forgetting something. I should probably be evaluated for it. I was thinking that I might be allergic to gluten too. Maybe I should get tested for that?”
I complete the entry for the chiropractic referral. “Let’s try to get you sleeping regularly and in a better place with stress levels, first. We can talk about your concerns with concentration and focus at your next visit, ok?”
As I finish typing her note in my office at the end of the day, I sigh. Ms Ariel represents a multitude of relatively young, stressed-out, women that I see every day. So many life stressors that affect their health in ways they can’t imagine, or are willing to admit. And there never seems to be enough coping skills and supportive relationships to help mitigate the affects of such stress.
From a physician’s perspective, it’s often less-than-satisfying to identify the problem and yet be unable to vanquish the problem. I cannot eliminate Ms Ariel’s stressful job. I cannot be that nurturing shoulder to cry on as she goes through the break-up with her boyfriend. I cannot find her a replacement boyfriend. I cannot force her to exercise, go to yoga class, practise deep breathing and relaxation techniques, eliminate caffeine and incessant texting, and choose healthier food options. A sleeping pill, even the less addicting option that we agreed upon today, is only a temporary patch for the real problem that keeps her awake at night. Her spinal pain will continue to plague her. I doubt she has clinical ADHD. She’s an intelligent, functioning women. She’s also distracted and under enormous stress without the time or relationship skills to cope.
I should have written this 3 ½ months ago. I was distracted and unprepared to cope though. I have a tough time concentrating and focusing. I have difficulty finishing tasks and find it impossible to sit down and actually type a complete thought. Perhaps I have adult ADHD? Haha. Perhaps I just need to turn off my technology and take a real holiday.
Happy International Women’s Day!!! (March 8)