Category Archives: A Doctor’s Diary

Addiction Diaries: Lucky Boy

Addiction is an irresistible craving for a drug, leading to out of control use, and continued use despite consequences. 

As a physician practicing in acute care I’ve seen many terrible things. But what has surprised, shocked and saddened me the most is when I’ve dealt with cases of addiction. The consequences can be severe, even fatal. It’s important to talk about it and acknowledge that it exists. Because addiction is a long term problem and social/family support is perhaps the most important factor for recovery. The aim of this series is to inform and raise awareness, not to sensationalize. Whatever I write is based on facts and facts alone.

The following is based on true events:

RM is only 21. “Don’t be surprised doc. He’s tiny!” His nurse informed me before I stepped into the room. So he was. Tiny (barely over 5 ft, under a hundred lbs) and young. His innocent face belied the colorful life he’d led so far. RM had been admitted because he had popped a couple of fentanyl tablets he’d bought on the street  (the same drug that was found in Prince’s and Tom Petty’s system). When I inquired why, he said he’d been taking the drug for the past 6 months or so; 2 to 3 a day “to get high that’s all” he informed me as if talking about the weather. “No, I don’t want to kill myself but I get depressed sometimes;” was his response when I asked if he’d had any intention to cause harm to himself. I tried to maintain a straight professional face but I was flabbergasted. I was shocked he was still alive. The lethal dose of fentanyl is very small– a quarter of a milligram, and this young man had consumed several times that. He was one hell of a lucky boy. 

Fentanyl is the most powerful opioid/narcotic drug—100 times more potent than morphine (the usual drug used to treat pain) and 50 times more potent than heroin (the common street drug). All opioids bind to the opioid receptors in the brain and block pain signals (hence are used to treat pain), at the same time they produce sedation and euphoria by increasing the levels of the neurotransmitter dopamine producing the ‘High’ or ‘Feel good’ sensation we commonly hear about and what people get addicted to. Opioids also depress the breathing center in the brain thereby causing respiratory arrest which is the usual cause of death. Fentanyl is a highly controlled opioid and is usually prescribed to treat severe chronic pain in the form of slow release patches and as lozenges, lollipops and tablets for breakthrough cancer pain. In the hospital it is administered intravenously under closely monitored state. It is vital to know that Fentanyl should not be used to treat acute/short term pain and in someone who is opioid naive (has never been prescribed/taken opioids). 

The details about my patient poured in gradually. I learned the young man was on parole. He’d gotten into trouble for an alcohol related problem– and had been ordered by the court to attend rehabilitation classes. So, as he could no longer drink, he switched to another source (not an uncommon occurrence under such circumstances). And no, this young man was not a derelict or an orphan. He had a very caring mother who told me how terrified she was as she didn’t know when she was going to lose him. She was at the end of her wits. In fact, it was she who’d saved his life. She was his chaperone who was driving him home from the class when he passed out in the back seat then went ‘blue’ and started convulsing. She drove him to the ER which luckily happened to be just around the block. He was immediately administered a fast acting antidote called Naloxone, and revived. His life was saved, following which he was admitted for observation. What had happened is that Fentanyl, had suppressed the breathing center in RM’s brain, causing him to stop breathing. He’d have been dead if the effects hadn’t been reversed in a timely fashion. 

His mother was a brave soul. I guess she’d been through similar circumstances before hence had acted quickly. Many victims aren’t so lucky. Though her son had overcome death for the time being, there was no guarantee this wouldn’t happen in the future. She begged me to send him to rehab. She was tired and exhausted. At the end of her wits. I didn’t want to be in her shoes. I too have a teen daughter. I can’t imagine how I’d have reacted in a similar situation.  Even though RM appeared motivated to quit (or so he told me) the likelihood for relapse was very high, despite rehab, family support and so on. I know since I’ve seen it because these drugs bring about long lasting changes in the brain.Therefore, it’s important to avoid triggers and not give up hope even if relapse occurs. 

Young people are curious. They want to conquer the world. They want to experiment. It’s in their nature to be impulsive. They are also defiant and would rather go against than heed good advice. The teenage years are the most crucial as seeds of addiction are most readily sown during this time. Not that adults are spared. It takes only a few days to get addicted to a certain drug– so next time your dentist prescribes something for a toothache think twice and if you do indeed have to take the drug do so for the shortest time.  

But as we are all aware addictive substances are available on the streets under various names and formulations causing various effects, but did you know they are also available OTC (over the counter) in your local medical store or pharmacy? Things like cough and allergy medicine, decongestants, motion sickness pills. Sometimes when one drug doesn’t produce the desired effect, people take a cocktail which can include pain pills, sleeping pills, antidepressants, muscle relaxants, cough medicine. 

My advice to everyone out there (young and old) is to say NO– to drugs, alcohol, tobacco etc. You never know when that one glass of wine becomes two, or three or more, or that one pill becomes a dozen. If they say it’s cool to do so, tell them it’s not cool to lose your life.  

Dear parents- Talk to your kids, learn about their likes and dislikes, encourage them to share their fears and anxieties. Inquire about their friends and peers. Keep the channels of conversation open all the time. Assure them of your support. 

And if you choose to smoke, drink or indulge in risky behavior avoid doing it before them– as young people tend to mimic their parents. 

PS: Please feel free to share your thoughts and experiences as well. Thanks for reading!

simi blog imageDr. Simi K. Rao, creator and founder of The MedBag is a board certified internist and hospitalist currently practising in the Denver area. She has special interest in preventive medicine. She is also a published author. You can learn more about her work at https://simikrao.com//

 

 

Women Who Inspire: Anandibai Joshi

The path for women physicians hasn’t been easy. For the longest time we were considered inferior to our male counterparts. But we have come a long way. According to a recent study it was found that patients cared for by women doctors  have a lower mortality rate. They tend to live longer and fare better.

Today on Women’s Day I’d like to narrate the story of a brave woman who led the way– Dr. Anandibai Joshi.

Dr. Anandibai Joshi (1865-1887)

Indian women pioneered many things not just in India but also in the west becoming a source of inspiration for women and women’s movement across the world. Early in my residency and sometimes even now, I’m made to perceive that I’m not good enough to be a doctor just because I’m a woman. Once an elderly lady told me to my face that she’d prefer a male doctor to do her gynecological exam. I was stunned to comprehend the degree of prejudice women have to face particularly those in the fields of science. So when I read about Anandibai Joshi and women like her, I’m dumbfounded by their bravery and the degree of resistance they had to overcome.

Anandibai Joshi was among the first Indian women qualified to practice western medicine.

Dr. Joshi belonged to an orthodox Brahmin family of rich landlords in Kalyan. At the tender age of nine she was pressured to marry a widower, a man twenty years her senior Gopalrao Joshi. The beginning of a typical Indian story? No. Anandibai was just thirteen when she had her first child.Unfortunately the child died when he was just ten days old. She was heartbroken and angered to realize that her son would have survived if he had received proper medical care. This sparked in her the desire to study medicine and her liberal husband stood fully behind her.

Why would an Indian woman go so far away for medical school?

Because it was the best way to serve her country was the gist of Anandibai’s answer. The reason Anandibai had to look to the west is because in India, Hindu women, particularly those belonging to higher castes were not welcome in the profession.They were pushed to become midwives instead. If they insisted they could enroll in Chennai, to be taught by reluctant male instructors, and receive an incomplete training. It was easier if they converted to Christianity as they could wear a dress and that wouldn’t cause a scandal. Since Anandibai and her husband had no desire to convert, she decided to turn to the America. She applied with the assistance of Presbyterian missionaries. She enrolled and subsequently received her degree in 1886, from the Women’s Medical College in Pennsylvania. Her achievement was lauded, to the extent the dean of her school wrote about it to Queen Victoria, Empress of India. Anandibai was invited to become the physician-in-charge of the women’s department at the Albert Edward Hospital in the princely state of Kolhapur, where she also had the opportunity to instruct women medical students. Unfortunately, before she could embark triumphantly in her career, it was destroyed by the diagnosis of tuberculosis and she breathed her last in the arms of her mother, a month before her 22nd birthday.

Dr. Anandibai Joshi lived a very short life but she achieved a lot. She broke barriers not just for women but also for the Hindu community. Even now we can look to her life and gain strength and inspiration. 

Happy Women’s Day!

 

simi blog imageDr. Simi K. Rao, creator and founder of The MedBag is a board certified internist and hospitalist currently practising in the Denver area. She has special interest in preventive medicine. She is also a published author of four novels. Her newest book of poems and short stories ‘Under the Shade of The Banyan Tree’ will be published in December ’18. You can learn more about her work at https://simikrao.com//

 

The White Room (A Poem About Dementia)

The White Room

I lie on the bed

in the white room

They sit around me

These strangers with familiar voices

I think we are waiting for something

or someone.

These strangers, they look at me

They mutter words I don’t understand

A man in a white coat walks in

He stands next to my bed.

He speaks not to me,

but to these strangers

They are talking about me, I know.

About what, I don’t understand.

Irritated, I kick off the covers.

Mother! They chide me and pull them back.

About the poem: This is a poem about dementia, the hallmark of the disease being loss of memory. I write about a scene I came across during my rounds in the hospital—an elderly woman in the advanced stages of dementia is lying on the bed surrounded by her caring relatives. It’s difficult to know what’s going on in the poor woman’s mind because she has lost the ability to speak, even comprehend. Yet it’s apparent she’s unaware of her ailment. She doesn’t even know where she is or who she is with.

Dementia is a syndrome that results in gradual and progressive decline of previously acquired mental abilities that results in a loss of social and occupational functioning and ultimately to loss of independence. It is imperative to distinguish this from normal aging- normal aging never results in loss of independence. For the diagnosis of dementia there should be impairment in at least 2 of the following– memory/learning new information, executive function (ability to perform usual tasks such as handle finances that one was able to do before), perception (recognize people, hallucinations) and motor abilities (ability to write, draw, walk, coordination), language, social cognition. Alzheimer disease is the most common type (60-80%) followed by vascular dementia (in those who have suffered strokes). Other types such as Lewy body, Parkinson’s dementia, frontotemporal dementia are less common. Aging is the major risk factor. For vascular dementia risk factors are diabetes, HTN, heart disease, smoking and obesity (same as for heart disease). Other risk factors include history of head injury, APOE e4 allele, mid-late life depression, alcohol abuse, HIV infection. On the other hand, higher education and occupational advancement can lead to reduced risk or delayed onset of dementia. Dementia also results in reduced life expectancy–an average of 4 yrs for vascular and 8 yrs for Alzheimer’s and Lewy body dementia.

Therefore, if you are aware of someone who is missing appointments and arriving at the wrong time/date all the time, is not able to follow instructions, is losing weight, is failing to thrive, has new or worsening depression and or anxiety, is exhibiting changes in behavior, poor judgment, loss of initiative, he or she could have dementia and it is important get an evaluation. Though at present there is no specific pharmacologic treatment that can halt or reverse neurodegeneration there are a few drugs that have been shown to slow down the symptoms of dementia. What is most important is understanding what a loved one with dementia is going through and providing them support and a loving and safe environment.

Here is an excellent website that provides guidance for caregivers.

simi blog imageDr. Simi K. Rao, is a board certified internist and hospitalist currently practising in the Denver area. She has special interest in preventive medicine. She is also a published author of four novels. Her newest book of poems and short stories ‘Under the Shade of The Banyan Tree’ will be published in December ’18. You can learn more about her work at https://simikrao.com//