BIPOLAR DISORDER…AN UNDERDIAGNOSED BUT COMMON CONDITION IN MODERN SOCIETY.

Kate, a stunningly beautiful 37-years old medical doctor was found in her surgery unconscious. She was lying in a pool blood. Her left wrist had been slashed. Busi, her secretary, quickly and tightly strapped the gaping wound and then urgently called for help. This was the second time in twelve months that her boss had tried to commit suicide. The last time, Kate had taken an overdose of aspirin tablets but luckily survived.

Kate was married for fifteen years with two children. Her husband, Rob, adored her despite her long term addiction to tranquilisers. They had met at university and had been together since. Kate had been an outstanding medical student, and frequented the honours roll. Her parents divorced when she was 18 years old.

With the assistance of a patient who had come in for a doctor’s appointment, Busi carried her stricken boss into a waiting car and took her to hospital. After her wrist wound was treated, Kate was admitted to the psychiatry ward. Her parents came to visit. Kate’s psychiatrist, Dr. Pon, was also informed. He had been treating Kate for Bipolar disorder (manic depression) for several years.

Bipolar disorder is a common but poorly understood condition. It can vary from depression to mania.  The patient characteristically has mood swings, ranging from extreme ecstasy to plumbing the depths of almost suicidal melancholy.

Some patients, like Kate, are happily married and successfully raise families. They can be highly productive and successful in their careers. But others have their lives blighted with failure. Psychosis does occur, and is often characterised by hallucinations. Some individuals may, as in Kate’s case, have problems of alcohol and substance abuse. The reason for this is unknown. It may be that some people try to “treat” their symptoms with alcohol or drugs.

Bipolar disorder usually lasts a life time. Between attacks some people are functional while others have lingering signs of the disorder. The cause of the condition is unknown. There is a theory that it may be genetic. Therefore a careful interrogation of the family history must be done. Others postulate a link with substance abuse or post-traumatic disorders.

Its onset varies. For some the symptoms begin in childhood, for at least half in their mid-twenties, and with the rest it may start late in life. Males and females are affected equally.

Treatment is medical, using mainly anti-psychotics and antidepressants. Psychotherapy is also effective, and Electro-convulsive therapy, the so-called shock therapy, has recently found favour.

Kate’s mother has recently been admitted to hospital: a late-onset sufferer of Bipolar disorder. She unfortunately has the manic variety, and has been discharged from her job as a teacher. She has received the Electro-convulsive (shock) therapy twice.

Kate survived her attempt at suicide, and she made no further attempts to take her life. Her children, who are now both young adults, are her loyal caregivers. They are watchful of her mood swings, diligently accompany her to therapy and support group sessions, and scrupulously ensure that she takes her medication. They sometimes join her in hilarious conversations with her imagined personalities.

If her children’s lives are stressful it doesn’t show. Though the humiliation of having a “mad” mother has not been easy to take, they are both thriving at university. Kate, though her life is a beguiling mixture of madness and sanity, still has a viable medical practice. Her weakness for drink and drugs also withered and fell away. She is the lucky one. Some patient’s lives are destroyed and their families ruined by this condition.

There is still very little awareness of bipolar disorders in society, particularly its subtle and atypical variants. Some people carry on undiagnosed and untreated with devastating consequences for their lives.

 

 

 

 

 

KNOWING WHEN TO SAY GOODBYE….when should treatment be stopped when life cannot be saved.

Mrs. Mayendwa a 70- year old woman was admitted to hospital with a septic right foot. She was a diabetic on insulin, and had been on kidney dialysis for five years.The infection had started as a small blister on the right big toe.This later spread to the rest of the foot. The color of the skin had changed to dark red and because gangrene was suspected, a vascular surgeon was called. The latter confirmed the diagnosis of gangrene, and recommended urgent amputation of the right lower leg.

The family asked for some time to ponder the situation, and also waited for the eldest son to arrive from Durban. Their mother had been sick for the last ten years. But everything- the diabetes, the high blood pressure and kidney function, had been well controlled. They were lucky that she had a medical aid and all the while had been getting the best care.

When the eldest son arrived 48 hours later, the situation had taken a turn for the worse. Because of the gangrene, very high levels blood sugar, and acute kidney failure Mrs. Mayendwa had slipped into a coma. The gangrenous foot had to be amputated urgently or she would die. The family had no choice but to agree to the surgery. In theatre it was found that the problem was more extensive. Thus a far bigger operation was performed than originally anticipated.

From theatre, Mrs. Mayendwa went to the ICU. After two days on a ventilator she still had not recovered consciousness. A neurologist was called who, after performing a brain scan, diagnosed a stroke. Mrs. Mayendwa also went into heart failure and liver failure. Her body’s systems were shutting down.

The family was obviously puzzled by the drastic turn in their mother’s condition. She remained in a coma for six weeks. The doctors reassured them that though the clinical condition was not good, the tests done showed some improvement. But there was another matter the family now had to deal with: their mother had now developed gangrene in the other foot.The only treatment for this was another amputation. Would the second amputation make her better? The doctors could not answer this question with any certainty.

Mrs. Mayendwa’s husband died while the family was pondering the second amputation. There was another shock for the family -the medical aid funds had been exhausted, and all treatment now was at their cost. This is when the family had to take the difficult decisions-not only for their mother but for themselves.

A fundamental problem that families and society have to face is the huge cost of looking after the dying. A significant amount of the health bill in many countries is for the treatment of the terminally ill, and in most cases it does nothing but prolong the inevitable. It leaves families devastated not only by the trauma of witnessing the prolonged suffering of a loved one but also by the financial costs incurred. Often doctor’s decisions are affected by their “tests”. They don’t often ask themselves what a normal haemoglobin level means in comatose patient after suffering a stroke twice.

Or what does a normal pulse rate mean in a patient who is unconscious due a brain infarct, with heart, renal and liver failure, and facing a second amputation? Are the normal tests the “life” that these sick patients would want to have. Is life only about its quantity and less about its quality? What support and guidance must be given to the patient’s family?

The medical profession is replete with outstanding doctors, and some are experts at managing terminal patients. But it is undeniable that for the doctors in private practice there are financial benefits in this situation no matter what decision they take. Because of this they cannot be the sole judges for the type of care a person facing the end of their life should get. The family also cannot be relied upon to take the best decision for the dying. To understand why, one has to witness the fears, doubts and desperation that afflict such families in this situation.

According to Atul Gawande: Letting go: Annals of medicine:Our system of technological medical care had failed to meet these needs, and the cost of this failure is measured in far more than dollars. The question is not how we can afford this system’s expense. It is how we can build a health care system that will actually help dying patients achieve what is most important at the end of their lives.”

The family watched their mother’s condition deteriorate. When Mrs. Mayendwa died, she had been in hospital for three months. The family had in the end, despite all the money they paid, lost a great deal: their father, their mother, and they also had to sell their home to meet the additional costs of looking after their dying mother. They felt that modern medicine had led them to financial ruin. They were bitter, angry, and felt abandoned.The eldest son even said that for all the expensive care the clinic gave their mother, she was not even able to say good bye-something that most families appreciate from their parents at the end of their lives.

Increasingly in many countries the law allows individuals to decide beforehand when unnecessary medical care should be stopped. While this should be applauded, a far important issue is to properly ascertain the role of medicine in the treatment of the dying, and to better define the point when we have to let go.

The noble purpose of medicine is to treat disease and prevent death. With the rapid and sometimes miraculous advances in medicine over the past few decades this purposes has been successfully served. What however needs to be more clearly defined is what role doctors should play when disease is incurable and death cannot be prevented. When do doctors stop treating that which cannot be treated? This issue has become pressing mainly for reasons of cost but also to protect the rights of the dying. Education about death and dying, and the costs involved has to get far more emphasis than has hitherto been the case.

 

 

A LETTER FROM A FATHER TO HIS SON

My dearest son

Strangely, in all your fifteen years this is the first letter I have written to you. So much as the Kamuka bush has snatched you from us; it provided me an opportunity to pen a letter to you. Your mother told me the other day that you did well in your poetry. I am so glad. You may not know this now, but the love of the written word brings you into the eternal wonder of life, and within the wonder of God.

You have been taught at school that the world is round. This is also true for the love parents have for their children. Every day begins and ends with parents thinking about their children. Most events in a day remind me of you son. Only yesterday they had basketball on TV, and I thought of you. A boy with dreadlocks walked into my surgery with his mom, and I again pined for you. Now that you are away, almost everything reminds me of you son.

Even though I rebel at the fact that life has to naturally take you away from me, I accept that with every moment that passes you are becoming less a child and more a man. I am also certain that one day you’d be a man that your mother, your sister and I will be very proud of.

This may all sound unduly serious and solemn, but you know that our lives are not. I miss the joy and happiness you bring into my life. I miss our chatter, and your joy when ManU loses, and your disappointment when ManC show that they are a team well below par. Your presence, together with your sister, in my life has therefore been the hand that has led me from the shadows of uncertainty, and into the light.

I hope that you enjoy the bush, and wish that with its sights, smells and sounds it will expose you to its wonders. Most importantly you will learn about its miracles and wonders not from books, but simply from living among them. I hope also while you are there that the greatness of nature and life will touch you in a very special way.

I love and miss you a lot my dear boy

Tata

GOOD LUCK TO THE PROTEAS

Yet another major cricket competition will shortly get underway. The cricket battles between some of the participating countries are more than a hundred years old. All the players bring not only their formidable talents but also the strong resolve to win every game: ingredients that have made every ICC Champions Trophy memorable. This therefore sets the scene, gives the duels their edge, and provides us with the dazzling prospects for what will be an exciting and tough cricket tournament.

I am not certain how many remember that the inaugural ICC Champions Trophy in 1998 was won by South Africa. But since then, despite the great promise of the teams we had over the years, the trophy cabinet from these knock-out competitions is bare.

Quite often we came close to winning. One still remembers Steve Waugh being “dropped” by Herschelle Gibbs early in his innings. This was the ICC World Cup in 1999. Waugh went on to play a match-winning century, and Australia became the eventual winners of that competition. The umpire adjudged that the ball didn’t stay in Gibb’s hands long enough before he chucked it into the air in celebration. The controversy about this incident still rages on.

Then there was the catastrophic run-out of Klusener and Donald, with one run to win from three balls left of play in the semi-fnals, once again against the Aussies. The Duckworth-Lewis miscalculation against Sri Lanka prematurely ended our tournament in 2003, and Shaun Pollock’s stint as the national skipper. Others may point to other instances where we had victory firmly in our grasp, only to falter in the final hurdle. I am certain for many of the players that these defeats, and the derogatory labels for our team that accompanied them, still rankle.

Yet optimism abounds once again because South Africa is a proud cricketing nation with high ambitions for their team. The public regards its national cricketers not as players but as heroes.

The Proteas will also understandably be buoyed by recent results against some of the top teams in the world and reaching the pinnacle, for a while at least, in all formats of the game. The world cup winning experience of Gary Kirsten is important, and so is the brilliance and leadership of AB de Villiers.

The absence of both Graeme Smith and Jacques Kallis, so long the backbone of our side, can cripple any side. But this could also be an opportunity for others to make their mark, and perhaps history.

Once again the battle is not just about physical and technical abilities. Most of the teams have these in abundance anyway. Unfortunately there are no novel remedies for success. Winning is about temperament, and a robust belief in our abilities. Calamity will once again befall us if these qualities are lacking in the team.

My money is on our team to win. As a nation our expectation is for the Proteas to prevail against all opposition. But the players have to beset the demons of the past and smother them to death. Given the investment made in the team and the rich promise it has shown over the past few years this expectation is neither surprising nor unreasonable.