Those days.

The 26th Law of Psychiatry (The Law of Therapeutic Charity): Give yourself credit for being the one in the room.

I had one of those days.

I haven’t written about it much so far, but I spend a lot of my time helping people with a nasty genetic condition. It’s called sickle cell disease (SCD).

SCD is very high on the list of things you do not want to have. It’s caused by a defect in hemoglobin, but the main problem it causes is pain. Early on, it’s episodes of bonecrushing pain called crises. Later, for reasons nobody really gets, the pain tends to turn chronic. Chronic pain is not an easy thing to treat.

Most of my patients were told they wouldn’t live to adulthood, though now they have a 50/50 chance of making it past their mid-40s. With longer life comes more cumulative complications. Strokes, joint and bone damage, all sorts of organ injuries, blood clots, and on and on. Not everybody gets all that, of course. The disease is amazingly protean considering how uniform the cause is. That said, it’s a bad disease. Where there is brain injury and chronic pain, there is depression. Of course, it’s depression that’s harder to treat.

I have really, really good days. Walking three inches off the ground good days. Days when I see the first smile of the patient who’s been miserable for months. Days when, after uncountable complicated, ambiguous decisions; I push my head up over the waves and realize my patient has been out of the hospital for a solid year when he used to be in every month. Days when somebody who was utterly gorked on pain meds and in godawful pain finally comes out of the haze and gives me that stunned, “I think my pain’s actually better,” speech. Days when I’m pretty sure somebody’s way better off because of me.

Most days aren’t like that. Usually I don’t know if what I’m doing is working.

Part of that is just plain ol’ statistics. Clinical trials can tell you that if you do the thing for a large group of people, more of them will get better than if you don’t do the thing. They can’t tell you if the particular patient you’re doing the thing for will get better, or if he would have gotten better with time, with or without you. (If you just started singing a U2 song, shame on you. This is a serious post, you Philistine.)

Clinical trials also don’t enroll my patients. You can find a randomized trial with bajillions of people with major depressive disorder (north of 5% of the population). You aren’t going to find a single one with people with SCD (around 0.03% of the population), two strokes, bone infarction, bad kidneys, iron overload from multiple transfusions, chronic pain, and depression. There may be a dozen of those people in a given state, and they’re probably going to be in my waiting room.

I know that what I do works. I seldom know if what I’m doing is working. Such is doctoring.

With uncomfortable regularity, I find myself in a room with someone and we’re three tricks deep into my bag, digging around for numbers four and five. Thus it was on the day in question.

He’s been one of my flock for years now. Since then, he’s developed various painful complications, and his insurance is crap, so he can’t get some interventions that might help. He’s lived about three decades longer than he ever expected to live. He’s also got a grinding chronic depression, and partly due to all the dirt SCD does to your insides, our options for medications are limited and we’re already pretty deep into that bag of tricks. Some things are better – his mood has lifted some, he’s not holed up in his room all the time, he’s spending more time with his kids, and he’s more active than he used to be. Still, better ain’t great; and we both know it.

He and I share a certain sense of humor. We get on, he and I.

To wit:

“How’s it going?”

“Well, I haven’t thrown myself out a window yet.”

“That’s good. It would certainly reflect badly on me if you did.”

“I would hate to inconvenience you.”

Like I said, we get on. Aside from all the bad jokes, we’ve also had some serious conversations about suicide, and we’ll have another one at the end of this session. He’s been straight with me about what he’s thinking. He’s decided to stay alive, come what may. I’ve told him I’m never going to give up on him. That’s the understanding. He’s an honorable guy, with a lot of integrity under his rough edges. Or perhaps in his rough edges. I have decided to believe in him. He has decided to show up. So, on we go.

This particular day, he was dealing with an ongoing problem with his family. Underneath that problem is that he depends on them, and he’s not the sort who likes depending on anybody else. We talked it through, came up with some concrete things to try to improve his interactions. As he walked out, he said, “All right. I’ll give it a try.”

Then, “Thanks.”

There are times people thank you, and there are times people thank you. This was the latter. My chest ached. I watched him struggle out of the chair and limp out to make the next appointment. Everything I haven’t been able to do for him hit me, hard.

I had to give myself that talk. The one I give supervisees who are stuck between the simultaneous realities that you can always find another way to help, and that you never quite know if anything’s going to work until it does.

You are the one in the room with him. 

It might be that there are dozens of other docs out there who know stuff I don’t know, and who would have made a bigger difference. They’re not here. I still am, and I’m hoping if nothing else, that makes some difference all by itself.

So, on we go.