"Vortex Of Despair"

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I’m no Trekkie, so please don’t draw any conclusions or pass any judgments from the fact that I know this, but Dr. Leonard “Bones” McCoy’s father died tragically from pyrrhoneuritis.  For those of you who don’t know, and why would you, pyrrhoneuritis is a very rare and fatal disease that was first discovered on colony worlds in the 23rd century before making its way to Earth. Weight loss and tremendous, intractable pain were hallmarks of the disease.

Dr. McCoy’s father was in such pain that he begged his son to end his life.  In perhaps the most famous example of science fiction physician-assisted suicide, Bones complied with his father’s wish and helped end his suffering.  The greater tragedy came several weeks later, when a cure for pyrrhoneuritis was discovered that would have spared his father’s life.  Dr. McCoy’s guilt followed him throughout the galaxy.

 But hey, we’ve all been there.

I had a patient several years ago that came to our emergency department all the time.  I hated her.  She would come in screaming for pain medicine.  Not, “my stomach hurts” which it did, or “please help me” which she needed, but literally screaming – you could hear her throughout the entire department, in other patients’ rooms with their doors closed, in hallways, in X-Ray and CT scan.  “Medicine, GIVE ME pain medicine!”

She would sit upright on the gurney, rubbing her stomach, rocking back and forth - just rocking and screaming.  She wouldn’t answer questions or let us examine her until she got pain medicine, and we couldn’t give her pain medicine until she talked to us and let us examine her.   She would vomit.  Explosively, forcefully, over and over.  Screaming, rocking, and vomiting.  She sucked the energy out of the emergency department like a vortex of despair.  I hated her.

Except one time.  One time I saw her and she was like a different person.  She wasn’t there for pain or vomiting or anguish or despair.  She was there for a sore throat. She looked great.  She smiled, she said “please,” she answered questions and was more than happy to cooperate with an exam.  Something miraculous happened.  So I asked her.  What was going on that you look so much better and seem so much more comfortable and so much happier?  It turns out she smoked a lot of weed.  Like, A LOT of weed.  Every day.  And her primary care provider kept telling her to stop, and she finally did, one week before this visit.  And her stomach stopped hurting, her vomiting stopped, she felt so much better.  A new person.  

That was one time.  

I saw her about a week later. We had bonded a little bit on the last visit and so this time she would talk to me, between the screams and vomiting and rocking that is.  She told me she started smoking weed again, and it was obvious, and I was pissed. But here’s the thing…she was young, and she was sick.  Not just sick from CHS or pot, but truly sick.  She was barely 30 years old.  She had diabetes that was very hard to control, her kidneys shut down, and she was on dialysis.  Almost a third of her life was spent going to and from doctor visits and hooked up to a dialysis machine.  She had no appetite, no energy, and was miserable most of the time.  That was her pyrrhoneuritis.  And who the hell was I to judge her for using the only thing she had ever found that made he feel a little less horrible?  For her, marijuana helped.  It made living bearable.  Except when it didn’t. 

So when faced with the choice between horrible bouts of vomiting and pain some of the time, or feeling weak and lethargic and helpless all of the time, she started smoking again.  And when she showed up in the ED like this, there wasn’t a whole lot I could do to make her feel better.  Instead of hating her, I now hated myself.  Since I could no longer blame her for the way she acted when she came into the emergency department, I had to blame myself for the visceral reaction I felt when she came in, and for all the times I tried to help her feel better but couldn’t.

Over the ensuing months my colleagues and I started seeing more people come to the ED with symptoms that were similar to my patient’s.  We came to know this presentation as Cannabinoid Hyperemesis Syndrome.  CHS.  I actually thought of her the first time I treated someone else that I was sure had CHS. They had the same explosive vomiting and the abdominal pain and even the rocking.  In retrospect, it made a lot of sense, especially when she seemed to get better after quitting weed for a while.  But for my patient, the answer wasn’t cessation of marijuana use.  Quitting made her worse in too many other ways.  And if I was right and she did have CHS, the good news was that I could actually help her the next time I saw her.  I could actually treat her symptoms more effectively, and she could keep smoking marijuana and not suffer through these horrible episodes, and there was even a treatment she could use at home that stood a good chance of keeping her out of the ED.  It was good news.  Really good news.

But we’ve all been there.

She died a few weeks before I figured it out. 

- Dr Z.