mahiwaga

Skipping merrily along the random fractured paths of the Internet, I somehow found my way from the sad fact that Cody’s Books on Telegraph and Dwight has closed (hat tip to Jamie Grove to the revelation that such a thing as a Twitter political debate exists, and that it sucked immensely (with commentary penned by the lovely Jennifer Van Grove) From there I discovered that there is now a patron saint to Twitter: tweetjeebus.

Somehow, this led me to some meme watching: check out I am aware of all Internet traditions (spawned by John Cole) and Nuking the Fridge (which I was led to by Jason Kottke)

Eventually, I found myself reading Edgar Allan Poe’s classic poem “The Raven.”

Nevermore.

If there really is a balm from Gilead, I wonder if the active ingredient will be gileadensol, gileadensone, gileadensamine, or gileadensic acid?

And apparently, while nepenthe refers to (probably) opium (not surprising, coming from Edgar Allan Poe), a compound called nepenthol would probably have to be a barbiturate. Still, it would be nice to not be depressed, but have my memories intact.

I may have missed my stop. Passed my exit.

My sense of timing really stinks.

I’m betting that if I fall, I’ll fall by myself, and find myself waking up at the bottom of an old, familiar ditch. Pit, more likely. Abyss, even.

So I won’t. Easier to struggle mightily against gravity than to climb out of that damned hole again. Easy to say at 11 a.m. on a Saturday when no one is gnawing and rasping at your soul, but I’ll say it anyway.

When you’re tired of struggling, you’re tired of life.

So I gave up on my psychiatrist because she’s been pretty adamant about me making timely follow-up appointments. Unfortunately, part of my problem is that my executive function is seriously fucked. I’m just not very good at making plans. Seriously. It must be at least a minor miracle that I’ve made it this far without ending up dead.

I don’t know whether to blame this on depression, or whether I really do have some type of brain injury.

The problem with not having a psychiatrist is that I can’t get my psychotropic medications. This, too, would be OK if venlafaxine didn’t have such awful withdrawal symptoms.

• neurological/psychiatric symptoms
  1. vertigo
  2. “brain zaps”
  3. akathisia
  4. excessive day-time sleepiness
  5. insomnia
  6. diaphoresis
• ENT symptoms
  1. facial discomfort/sinus pain
  2. constantly runny nose
• GI symptoms
  1. nausea
  2. bloating
  3. frequent bowel movements

Most of these can be dealt with perseverance. But the akathisia and the constant feeling of wanting to throw-up all the time made me want to throw myself off of a tall building. Add to this the brain-zaps, and it’s a wonder that more people don’t kill themselves while trying to get off this stinking drug.

The last time I decided to flush it out of my system was a couple of years ago. This was, in retrospect, probably a really bad idea. The work I was doing was kind of high-stress to a degree, and while I managed to cope, I could’ve worked on timing it a little better. I managed to do OK off of the meds for a couple of months. That’s when I realized I needed serious help.

But what I found that sort of worked were all the anti-cholinergic (really, anti-muscarinic) drugs that you can get over-the-counter. Things like diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton). Meclizine (Antivert) was useful, too. At the very least, all these drugs helped with the constant nausea and dizziness.

The problem was that these drugs also make you excessively somnolent. I mean, I really shouldn’t’ve been driving while taking this toxic cocktail of over-the-counter meds, much less working.

I’m thinking it all abated after a week of intense suffering.

This time, I just couldn’t take the brain zaps. For those who aren’t familiar, what this is is a sensation of some kind of force discharging through your cranium. It’s really hard to describe, actually. But I think some of it is the fact that your facial muscles contract suddenly and forcefully. Even the tensor tympani seems to contract, and this may account for most of the nausea and dizziness, now that I think of it. The zaps tend to occur when you’re moving your head. It’s like the worst case of motion-sickness you’ve ever encountered. I mean, I could do fine if I held my head rigidly, with neck flexed. But any slight deviation, and the zap would happen. It’s actually quite a miserable way to live. Maybe not the most miserable, but it’s pretty bad.

The idea is that this happens the most with venlafaxine because it’s such a short acting drug. Without the XR formulation, you’d have to take it three-times a day to maintain a steady state, for one thing. And even with the XR formulation, I’d get withdrawal symptoms if I went more than 24 hours out without taking my next dose. This makes taking overnight call slightly painful if you fail to plan ahead, like I tend to.

So I have some sertraline (Zoloft), fluoxetine (Prozac), and escitalopram (Lexapro) lying around from long-ago attempts at finding the right drug for me. It’s only a handful of pills, so I’ve had to use them exceedingly sparingly.

I’m coming down from venlafaxine XR 300 mg daily. The maximum dose recommended in the monogram is actually only 225 mg, but I’ve seen psychiatrists use this dose once in a while, particularly for resistant cases. If I had a way of partitioning the capsules, it might’ve been feasible to do an extended taper, but all I’ve got are 150 mg pills, and going from 150 to zero is god-awful. At first, I tried to subsist on my toxic cocktail of OTC anti-cholinergics, but that left me way too somnolent and I was basically in bed all day. So I tried the sertraline. It’s only 25 mg, so it barely has any effect on the withdrawal symptoms, and it, too, has a short half-life. When I realized this, I went with the fluoxetine.

The great thing about Prozac is that it stays forever in your system. It would probably be feasible to do every-other-day dosing once you’re on a maintenance regimen. Even at the base dose of 20 mg, it has managed to abolish most of the symptoms for the past 48 hours.

Except for the brain zaps. Damn them.

Lexapro has a much shorter half-life than Prozac, but it’s still longer than either Zoloft or Effexor, so I took 10 mg of that after the brain zaps started making me crazy. The dose I took yesterday is probably still sitting in my system, though. I had to take another dose of Prozac this morning. I’m trying to get to fluoxetine 20 mg every other day, with escitalopram or maybe even sertraline for breakthrough. I’m trying not to touch the venlafaxine ever again, but I may have to resort to opening up the XR capsules, crushing the spherules inside, and finding some gelatin caps to make my own 37.5 mg doses.

I think it’s been a week since I took any Effexor, though. Going cold-turkey, I think it took a total of two weeks to finally be rid of the withdrawal symptoms. With this taper I’m doing, it might take way longer than that. I’m hoping I have enough pills to survive before I start thinking about throwing myself off of a tall building again.

The interesting thing I learned about this escapade is that the antihistamines were actually attempts at making more selective anti-depressants. This was back in the day when all they had were the nasty tricyclic antidepressants (TCAs), which include amitriptyline (Elavil), nortriptyline (Pamelor), imipramine (Tofranil), and desipramine (Norpramin). So they came up with diphenhydramine and chlorpheniramine. Basically, Chlortrimeton and Benadryl are the scaffolding for all the SSRIs. The first SSRI was zimelidine, based on chlorpheniramine, which unfortunately caused Guillame-Barré syndrome and drug rash with eosinophilia and systemic symptoms (DRESS). The second SSRI, as I’m sure we all know, is fluoxetine, based on diphenhydramine. And the rest is history.

What would be neat is if I could find the affinity constants for diphenhydramine and chlorpheniramine for the serotonin receptors, but I’m sure all that stuff has been shredded by the drug companies who are more interested in you buying the latest and greatest drugs on the market. I’m also certain that the doses they’re recommending for allergy symptoms aren’t anywhere near the effective doses for serotonin reuptake inhibition. I also now understand why all the junkies want their Benadryl IV.

Wow. Just, wow. Good thing I’m a little drunk.

I suppose it was fitting that today Ben exhorted me to go the Bay Area once I’ve served my sentence completed my residency down here in S.D. While ostentatiously there are several reasons why I would want to stay here, there really was only one, and as of 7:59 p.m., I’ve come to realize once again that such reasons are always perilous.

There is a part of me that is gnawing upon itself in agony, wondering why I keep getting trapped in these temporal loops of complete, utter despair. There is another part of me that is perversely rejoicing, because it saw this coming from miles away, like an ICBM arcing towards its target with the utmost accuracy.

My mom grilled me again this past weekend about whether or not I have a girlfriend. I hate that question. I hate it a lot. Enough to make me not want to come home very often. But it must be endured. As I’ve mentioned a multitude of times, my mom really wants grandkids. I don’t know why she keeps bugging me about them. My brother and my sister are both in long-term relationships. Let them take care of that filial duty.

Mχ asked me if I was going to bring anyone to Mχs and L’s baby shower. (That kid is going to be super-lucky to have them as parents, I swear.) When I told him no, he used the term “terminal bachelorhood” and I had to laugh out loud. It’s odd, that. That where I am now is where I’m going to be when I die.

Part of it is that I’m on a geriatrics rotation right now, and prior to that, I was on an elective ICU rotation. Either way you slice it, the people I’ve been interacting with are all pretty much on death’s doorstep. So certain songs have taken on some rather dark, deep, depressing, and morbid interpretations.

(see also: [Radiohead’s live performances][a]) [a]: http://fabiocchi.altervista.org/ “Radiohead’s live performances”

I thought of some really morbid, macabre imagery to go along with this song. I imagine someone in the ICU, intubated and on a ventilator, with multiple lines going in and out of him. Someone like the soldier in white from Catch-22, almost entirely covered by bandages, so much so that you can’t even tell if there’s anyone in there.

That there.
That’s not me.

The main drive of the short narrative is the decision to withdraw care. So they go through the process of terminal extubation.

In a little while
I’ll be gone.
The moments already passed
Yeah, it’s gone

As the patient goes into agonal respirations, scenes from his life/my life are interspersed. Going out with his girlfriend. Talking to his parents and siblings. Living life, being happy and healthy.

The other song I think about is “What Sarah Said” by Death Cab for Cutie (who is apparently currently having a concert at the Greek Theater in Berkeley.)

Christian Sinclair, M.D. deconstructs the song expertly, bringing to mind exactly all the things that I think of whenever I hear this song, and I seriously always cry at least silent tears whenever I hear this song, and if I’m in a really bad or vulnerable mood, it will leave me bawling.

But I sort of have a different take on the instruments in the final passage, relegating them strictly to ICU noises, and leaving the emotional aspect more muted

• single guitar strum: inhalation/forced ventilator breath
• cymbals: oximeter alarm > agonal respirations
• organ: cardiac monitoring > asystole alarm
• continuous guitar strumming: tachyarrhythmia/vtach/vfib alarm
• snare drum: CPR/stop watch/clock ticking > death march rhythm > S1, 4/6 harsh sounding systolic murmur then S2
• bass drum: heart beat (on auscultation)
• descending piano: ventilator alarm (circuit disconnected)
• ascending piano: blood pressure alarm (A-line pressure tracing non-pulsatile)
• random instruments: all the alarms going off dyssynchronously
• doorbell: the elevator as they wheel the body away to the morgue

The cymbals are the first thing you hear, as your patient desats. The slowest rhythm is the single guitar strum, signifying a ventilator breath. The snare drum keeps time as code blue is called, but it also has the flavor of a march. It also happens to sound like critical aortic stenosis. The insistent continuous guitar strum reminds me of a tachyarrhythmia alarm, with the heart rate racing into the 200s, and then 300s-400s in v. flutter. The organ keeps the actual rhythm of cardiac electrical activity, which doesn’t match the bass drum because despite the flurry of electric impulses, the heart really isn’t pumping very effectively. As the code blue progresses, you start hearing the descending piano melody, as ventilation becomes compromised. One of the last thing you hear is the ascending piano melody as blood pressure tanks precipitously and irrevocably. Eventually, all you hear is the organ, now playing whole notes, reminding me of the asystole alarm. The cymbals start fading out, too, and they start sounding like unassisted breaths, or ineffective ventilator breaths. And then silence, and a quiet cacophony (is that even possible?) of dyssynchronous instruments as you take all the monitors off the body, letting the alarms go off willy-nilly.

Sinclair interprets the last sound as a doorbell, which may signify the arrival of the elevator car that leads to the morgue, but to me, it sounds like an old-school end-of-tape signal, both on cassettes and video cassettes.