I felt silly sitting in the doctor’s office.

He was running late. Although I was expecting this, I still felt somewhat surprised: In therapy for psychiatry, we generally make a (relatively) big deal about timeliness because… well, because of “boundaries” so that we all “maintain the frame”. This maintenance of “the frame” is what provides the intellectual fodder for situations involving its disruption, such as, “Why is it that he’s always ten minutes late? What does that mean?” Blah blah blah.

I already knew that there were several other ways—all more expedient than this—to address my health. I was fortunate to secure the appointment when I did; many of the receptionists I spoke to flatly informed me that the physicians did not have openings for new patients for over six weeks.

You’re a doctor, I thought. You could prescribe antibiotics to yourself. I knew my own history and listened to my own heart and lungs, looked at my throat with my penlight and mirror, and felt my neck for swollen lymph nodes. I knew that this episode of illness was out of the bounds of “normal” for me and my symptoms were not improving. Writing a prescription for myself for a short course of oral antibiotics wouldn’t raise any red flags—antibiotics are cheap, there is a minimal black market for them, they don’t have any abuse potential (God forbid I ever hear anyone tell me how they crushed up penicillin to snort it), and I’d be doing my part in optimizing public health—the sooner I get better, the more patients I can see without spreading my germs around.

And yet, I hesitated.

You’re not objective when evaluating yourself.

There is little data (”good” or not) on the subject of physicians treating themselves. (There is only a little more information about physicians prescribing substances with abuse potential—narcotics, sedatives, etc.—psychiatrists, emergency physicians, and anesthesiologists rank high in that arena.) The consensus, though, is that physicians generally don’t see other physicians “formally” when they have health issues; “most general practitioners manage their own health care“. Some (sadly) recommend that “teaching of appropriate help-seeking responses should be part of medical education” and suggest that “strategies are needed to challenge the culture of self-reliance“. Residents engage in self-prescription as well, causing some authors to raise questions about “the source of these medications and the lack of oversight of medication use“.

While receiving rejections from all the local clinics for an appointment for acute care, I (very briefly) considered visiting the “fast track” portion of the local emergency room (particularly after the night when I had problems breathing). This, however, was obviously inappropriate. I was still walking, talking, and breathing. I was not having a heart attack; my esophagus had not torn apart; no one had stabbed my spleen; I hadn’t shattered my femur and pelvis. I had respiratory complaints. Moving on….

I could consult my colleagues—they’re doctors. In fact, I could have obtained “free” evaluations from internists, a pediatrician, an anesthesiologist (to evaluate my airway), neurologists (to evaluate for encephalitis), OB-GYNs (um…), an ophthalmologist (to evaluate for increased intracranial pressure?), and, of course, psychiatrists (to help me cope?).

Again, I hesitated.

It’s not outlandishly weird to ask doctorly friends for medical advice—but it’s still weird. Although most of us don’t have huge qualms about discussing the quality and quantity of gunk we’re coughing up, that’s not the basis of our relationships. Although I wouldn’t be entirely put off knowing that my colleague had a nasty case of watery diarrhea due to Giardia after a camping trip, it still puts me in an awkward position: Do I say, “Hey, that’s terrible,” and offer my sympathies? Do I become medically geeky and ask if he saw the microscopy of his stool (”didya see any of them?”)? Do I make sure he’s gotten the prescription for metronidazole?

Plus, they’re residents, they’re busy, and they, though more objective than me, are still not as objective as they could be. (I know, of course, that no medical provider is ever completely objective.)

So that’s why I decided to see a doctor. The doctor happened to be a resident, though not one that I know. I did learn, however, that he is in his final year of training, which made me feel more relieved than I had anticipated.

So… do I tell him that I’m a resident myself?

I demurred. How would that change his evaluation and treatment of me? Would he be more or less stringent? Would he wonder why I wasn’t treating myself? How much more weird would it be for him to know that he was treating a doctor? Though we had never crossed paths before, we still might in the remainder of the academic year.

Not even two minutes into our interaction, while reviewing the paperwork I filled out, he asked a question that required an explanation that included that I am a resident.

“Oh!” he remarked, his face relaxing a bit. The medical jargon came out, the history was abbreviated, and the dialogue was concise.

I was surprised when he eventually gave me a prescription for an antibiotic. I hadn’t asked for one; he wasn’t certain that I actually needed it. “If your symptoms get worse,” he recommended, “you may want to fill it and take the full course.”

Truth be told, I didn’t wait. I filled the prescription the same day.

I’ve been ill with a significant respiratory illness over the course of this past week (facilitating creative excuses such as, “I shall not attend the meeting because I would like to spare you the gory details should my trachea snap in half during a forceful fit of coughing”). My thoughts regarding this illness have ranged from the fairly legitimate:

• Do I have pneumonia?

to the intellectually curious:

• I wonder if there are opacities on my chest X-ray (if I actually got one)… or would the radiologists call it atelectasis?
• I wonder how many B cells my bone marrow is churning out right now?
• Did I develop a bacterial infection on top of a viral infection?
• Just how many liters of snot am I producing each day?
• What are the speeds of my coughs?

to frank catastrophizing:

• What if I become septic?
• What if my diaphragm tears apart from coughing?
• What if my tonsils get so swollen that my airway is closed off? (What would my ventilation parameters be?)
• What if I am infected with some multi-drug resistant strain of something that is going to devour both of my lungs overnight?
• If I am hospitalized for this, should I ask for a “do not resuscitate” order?
• Am I thinking these thoughts because I have encephalitis?

While laying in bed, sweating through three layers of pajamas, feeling my coughs rattle through my ribcage and jiggle all of my internal organs, I realized, with sadness, that maybe this is what it is like to age.

While donating blood over a month ago, the volunteer cookie and juice provider inquired into who I was and what I did. When she learned that I am a doctor, she commented, “Wow… you know you’re getting old when doctors look so young.” She clearly said this to herself, not to me. I didn’t know what to say, so I simply smiled at her.

Infirmity sucks. Laying under all of those blankets, wondering when the illness will pass, is uncomfortable. I am still at that age where I can confidently assure myself that I will get better, that soon, I’ll be running around and effortlessly expending energy. Not everyone has that luxury, that security that their bodies will heal and regain its youthful function and grace.

There will (may?) come a time when my joints will frequently ache regardless if I am ill. Feeling lackluster and depleted of energy may become a fact of life. My muscles may feel this amount of soreness from only a quarter of the dancing I do now.

And the righteous indignation I feel from being ill! We already “waste” a third of our lives sleeping; how much more time must I “waste” being ill? I will never get these minutes, hours, days back. (”Waste” is subjective word; I read Ishiguro’s Never Let Me Go in about a day and am now making my way through de Graaf’s Affluenza. I certainly could not have accomplished these wonderfully pleasant tasks had I not removed myself from my usual scheduled template.) What could I be doing right now if I was not ill? How is this illness interfering with plans? How are my productivity ratings falling as I type this???

Of course, this is what this is; perhaps illness is an involuntary method of instilling mindfulness. Being aware of all the uncomfortable sensations of illness now can remind us to be more aware of all the glorious sensations we experience when we are not ill. Instead of lamenting the loss of what we had or what we may have had if this had not occurred, we can train ourselves to be more grateful for what we do have in the present moment. When it does fade away (as all things do), we at least know that we experienced it fully when it was still in our lives.

Despite that moment of clarity, I still occasionally wonder if I am going to have a stroke as a result of increased intracranial pressure from all of this powerful coughing.

“How would you do it?”

“Oh, I think I’d take a whole bunch of pills.”

“Have you actually poured ‘a whole bunch of pills’ out into your hand?”

“No, never… it’s just something that’s crossed my mind.”

“Do you have access to a gun?”

“No—and even if I did, I wouldn’t use a gun. It’s too messy. I wouldn’t want to leave a mess behind for them to clean up…”

(Tangent: Some people seem to believe a bloody mess is more distressing than self-destruction. To me, this is a distortion of logic: When we learn of people killing themselves, are we more disturbed that they killed themselves or that the surrounding environment required disinfection? Seeing a pool of blood on the floor can be sickening, yes, but seeing a dead body due to a self-inflicted injury is horrifying.)

“… I just want it all to go away. You know, there’s no pain this way; just take a whole bunch of pills and fall asleep, never wake up.”

While it is occasionally true that swallowing a “whole bunch of pills” may induce immediate loss of consciousness (which is not “sleep”) and, eventually, death, this is not always true. People seem to believe that upon swallowing a large number of pills, their bodies will immediately shut down (within minutes, if not seconds, of the ingestion), thus resulting in sleep, and then they will die shortly thereafter. They romanticize suicide by pill overdose.

In fact, the following events are what may actually happen after swallowing a large number of pills:

>> Nothing. People often start checking the clock, wondering why “nothing is happening”. They start to feel frustrated that their efforts did not produce any results. A few people have told me that, after attempting suicide by overdose where nothing happened, they never attempted suicide again: “It didn’t work, so why bother?”

>> Cerebral edema. This is the fancy term for “brain swelling”. Because the skull holds a fixed volume, a swelling brain eventually ends up oozing out of the base of the skull, which can end life. This, however, is not a rapid event; it can take hours. People may be awake while their brains are swelling; they may notice that their breathing rates are irregular (which is psychologically distressing; think anxiety and panic). Sometimes they notice that their muscles get tight, thus making it more difficult to move. Their pulse rate may also drop, which can lead to dizziness and chest discomfort. Brain swelling is not a comfortable experience.

>> Renal failure. This means that the kidneys are either significantly impaired or they stop working. This also does not occur immediately; it usually occurs on the order of hours. Again, people may be completely awake and alert while this is happening, though they may start feeling nauseated and begin to barf. (Though nausea is not a type of pain, many people find nausea less tolerable.) Their appetites may drop, as well as the amount of urine they produce. If one is not peeing, one is not getting rid of body water, which means one may start bloat. The areas around the kidneys (”flanks”) may begin to hurt. Failing kidneys result in a miserable experience, which is why so many patients who do not attend their dialysis runs regularly often show up at the emergency room when they are “overdue” because the nausea and other sensations are simply intolerable.

>> Nausea, vomiting, diarrhea. This can occur independently of renal failure. The stomach lining may be irritated upon digestion of the large number of pills. Again, nausea isn’t pain, but it still sucks.

>> Tinnitus. (Debate rages whether this is pronounced “TIN-uh-tis” or “tin-EYE-tus”.) This refers to “ear ringing”. Not painful, but pretty dang annoying.

>> Hypokalemia. This is the fancy word for “low potassium”. This, too, does not occur immediately (there is a pattern here)—our bodies are amazing machines that try to adapt to physiologic stressors as effectively as possible. If the body does not have enough potassium, muscle function is compromised: One may start to feel numbness of tingling in various places; this can ultimately lead to paralysis. The diaphragm, which facilitates breathing, is a muscle. When one is not in control of one’s breathing, one freaks out. Choking and suffocation are both psychologically and physiologically distressing events. The muscles of the gastrointestinal tract can also be affected; see “nausea, vomiting, diarrhea” above. The heart, too, is a muscle; irregular heart rhythms can lead to chest discomfort—sometimes pressure, sometimes pain, but always uncomfortable and distressing.

>> Hyponatremia. This is the technical term for “low sodium”. Again, not immediate. See “nausea” above. People also experience headaches, body aches, and possibly seizures. People can eventually succumb to comas… unless they stop breathing first (see “when one is not in control of one’s breathing, one freaks out”).

>> Hypoglycemia. “Low sugar.” People with diabetes are often more familiar with this symptom than any of us would like to admit. This, too, is not an immediate event. When hypoglycemic, people report feeling hunger… and irritability. They also start to sweat, feel anxious, and experience unusual heart rhythms. People can also develop “neuroglycopenia”, which is the ornate name for “changes in thinking because of low blood sugar to the brain”. People can get confused and behave strangely… and, ultimately, if the blood sugar is not corrected, will pass out.

>> Coagulopathy. “Bleeding abnormalities.” Not immediate. People don’t melt into pools of blood, but if they bonk an elbow—or even firmly touch something with a leg—they may bruise significantly. Maybe their gums will start to ooze blood. If they’re endlessly oozing on the outside from minimal trauma, that also means it can happen on the inside, like in the gastrointestinal lining, in the lungs, in the spleen… and those have associated, uncomfortable symptoms.

Overdosing on pills is not a guaranteed method of painless suicide. In fact, the event may precipitate more problems than it solves (like a trip to the emergency room, hospitalization, an interview with one of those weird psychiatrists, a five-digit financial bill, and disruption in social support). Although suicide is always an option, it is one that we hope that people do not elect to pursue because, like overdosing, suicide may precipitate more problems than it solves—and is quite possibly the ultimate act of avoidance.

UpToDate provided the information to help me review the physiologic consequences of toxic ingestions.