PTSD - where does it hurt?

People speak of PTSD as if it were all the same.

"He fought in Iraq and now he has PTSD." End of story, as if those 4 little letters explain it all. Oh, yes, PTSD. Now we know what he's going through.

I don't believe it. Are all physical wounds the same? Of course not. You wouldn't say, "He had a fracture" and expect his suffering to be explained. There's a big difference between a fractured pinky and a fractured pelvis. You wouldn't say, "She has a flesh wound," and leave it at that. A laceration in the leg is worlds apart from a face half blown off.

Body parts matter when it comes to understanding wounds and healing. In the same way, I think mind parts matter when it comes to wounds of the psyche. I'm not talking necessarily about sections of the brain as an organ, although there is clearly correlation between the two, but about regions of the mind. What part was hurt? What coping pathway was railroaded? What belief system was shattered? What concept of self was blasted to smithereens?

It matters.

When the body suffers a wound, it helps to know what weapon delivered the damage. What about the mind? What was the weapon, the injuring event, the final blow? We need to know. It helps assess and predict the damage. It makes a difference.

Finally, what about healing? If it is a wound of the body, do we suture? Splint and cast? Perform surgery, even, perhaps, amputate? Do we provide medicine, pills, creams, crutches? Not all treatments are equal, because not all wounds are equal. It's ludricous to think otherwise.

So too wounds of the soul. What kind of healing is right for this crushed confidence? This lacerated faith? This broken, tender self? We can't treat them all the same, with the same drug cocktail, the same kind of therapy, even the same questions. It could be as bad as trying to sew a bone. Ineffective at best, at worst, deadly.

PTSD. The wounds are as individual as the wounded.

P.S. See this blog entry and the associated blog for an eloquent view of PTSD from the inside.

Talk About Sex

I do, every day. It goes with the territory when you're a doctor. Sex matters. Having it, not having it, who you have it with and how, what you do and don't do; it can all affect your health, so, for better or worse, we'll be asking about it.

There are ways and ways to ask patients about their sex life. In med school they taught us the phrase "sexually active." We were supposed to ask the patient, "Are you sexually active?" It sounds silly to me now, but it was presented as Standard Of Care. In other words, everybody does it that way. It was deemed an efficient use of time. One question, cut to the chase.

I even did that for a while, until I realized that many people had no idea what I was talking about. I'd get the blank look far too often, and end up having to ask some other way. Or they'd focus on the "active" part of the question. One of my colleagues got the answer, "Not really. I just lie there." And I heard the opposite extreme when a young man bragged, "Oh yeah! I break condoms all the time!"

So I quit asking it that way. For a while I asked, "Do you have a sex partner?" That seemed to work okay. If they answered in the affirmative, I'd follow with, "Male or female?" and then questions about how long they had been together, whether they used safe sex practices, etc. It took a lot more questions than the one, efficient, "sexually active" query, but it got the job done.

(By the way, we don't say "safe sex" anymore, did you know? Now we're supposed to say "safer sex." Nothing, after all, is 100% safe. Or 100% anything. G-d forbid someone should sue us when they get chlamydia having "safe sex!")

Another of my colleagues tried this one out: "Are you having sex?" Until one of his patients gave him a look and said, "Well, not right NOW!"

The open-ended question is a great way to ask about most things. "Tell me about your back pain," for example. But even I would feel a little weird saying, "Tell me about your sex life" to a patient.

No matter how we ask, there will always be a way to misinterpret it. Some of the medical literature uses the term "sexual debut" for someone's first time. "A woman should have a PAP smear 3 years after her sexual debut." Isn't that priceless? It sounds like there should be a huge party with gauzy dresses and tuxedos. "Introducing the sexual debutantes!"

I finally hit on an opening question that works for me most of the time. "Do you have sex with men, women, both, or neither?" Most people seem to be able to hear that one, and respond without rancor. Interestingly, I have never seen a woman act offended by this question, whether she is straight or gay. On the other hand, quite a few straight men act appalled that I would even consider the idea of them having sex with men. "WOMEN! Only WOMEN!" they huff. I wonder: is homophobia a sex-linked trait?

The other day, I finally got "Neither" in response to my question, which made me realize it isn't quite the catchall I thought it was. Was this a virgin (not as rare as you might think at the university)? Nope. On further questioning, the person revealed that they had in fact had their sexual debut some years earlier but were currently single. No sex for...hmmm lemme think...two whole weeks now!

That brings up another whole arena: sexual definitions. "Monogamy," "long term," "sex;" you'd be surprised at some of the concepts folks have. Fodder for another post.

PTSD and the Purple Heart

What kind of recognition and recompense should go to servicemen and women with PTSD? Not the Purple Heart, as recent news has made clear. Is this fair? Well, let's look at it.

The Purple Heart is a medal given to those who suffer physical war wounds as a result of enemy action. This medal is not given to those with PTSD. Never has been, even when PTSD was called "battle fatigue." The criteria for the Purple Heart can be seen here:

http://www.usmcvta.org/pheart/phcriteria.htm

From that site: A wound is defined as an injury to any part of the body from an outside force or agent sustained under one or more of the conditions listed above A physical lesion is not required, however, the wound for which the award is made must have required treatment by a medical officer and records of medical treatment for wounds or injuries received in action must have been made a matter of official record.

It goes on to specifically exclude PTSD.

Canada has a similar medal, called the Sacrifice Medal, which, interestingly, specifically includes mental injury, as follows:

Eligible cases include but are not limited to...mental disorders that are, based on a review by a qualified mental health care practitioner, directly attributable to a hostile or perceived hostile action.

I'm not convinced that the Sacrifice Medal would cover all cases of PTSD, but it goes farther in that direction than the Purple Heart does.

So how important is a Purple Heart? I've always thought that the Purple Heart was kind of an odd medal. It is often spoken of with awe, as if the recipient did something outrageously heroic. What they did was get injured. Were they heroic? Absolutely. Anyone who puts their life on the line in service to their country is heroic. Even those who did not get injured. Do injured service men and women deserve something more than those who were not injured? Well, yes. I believe they deserve to be treated and cared for, at our expense. Including those with PTSD.

PTSD is a war wound. A wound of the mind, heart and spirit. An invisible wound, yet deeper than any that sheds blood.

We can argue about who gets what medal 'til the cows come home. Frankly, I think they all deserve a hero's medal. But what's more important is that those who need care, whether for wounds of the body or wounds of the mind, get what they need. If this controversy helps bring PTSD to the forefront and gets those guys and gals some help, it's worth it.

Silly Poems

My favorite online community is Writer's Digest, where I visit and share experiences with a variety of writers, from beginners to published professionals. One thing some of us do is make up silly poems in a thread called Dread Poet's Society. Here are a couple of my silly efforts.


1. In response to a poster who challenged me to work less and write silly poetry more:


Work, I do, I try to heal 'em
Fractures, coughs, sore throats and boils
Rashes, warts and bumps - I feel 'em,
Freeze 'em, drain 'em, coat with oils.

All day long we poke and prod,
Look for clues and try to mend
Some docs even think they're gods
We're always humbled in the end.

Yet, as much as I adore
bedpans, xrays, splints and pills
coughs and sneezes, I want more,
A place to play, to ease my ills

The Forum calls, the poets rhyme,
their sweet abandon, free and wild
with meter foul but words divine
Each silly section makes me smile.

Who knew, when Wondo started it,
this silly thread, that it would be
a testimonial to wit
the best in WD history.
........................................................................................
2. Taking a break from "real writing"


I'm s'posed to be writing a column 'bout zits
those mug-ugly bumps that give teenagers fits

How does this thing happen? Please, doctor, help!
I'm spotty, I'm pimply, I'm covered with welts!

It's awful, embarrassing, painful and worse:
My girlfriend won't touch me; she says I am cursed.

So please, give me something to clear my skin up
I beg you, have mercy on this zitty pup!

No problem, I soothe him, the answer is clear
just do what I say, you'll have nothing to fear

Go down to the grocery and ask that new bagger
to loan you a brown paper big one, then stagger

Back home with it over your head! What? My license?
You want it? Oh, what have I done, I have no sense!

I take it all back, I was giddy from deadlines
and trying to be serious: it furrows my head lines

Please calm down, relax now, don't have a conniption
I'll cure you I promise: here is a prescription!

He's gone. Now I have to get back to my writing
Be serious, scholarly, helpful, inviting

Thank goodness for Dread Poets thread- yes indeed
a place to unwind when I'm truly in need.

----------------------------------------------------------------------

3. About exotic foods


Pickled eggs I've had, and worse
The thought of frog legs makes me purse

my lips and gag, but I would try
a fresh polk salad, loaf of rye,

some crab legs, sushi (only cooked!
I'm a doc, you know, I looked

beneath the scope, I did, and ugh
what I saw would make a slug

chuck up his breakfast, so no raw
fish for me), a monkey's paw

is taking it too far as well.
I'd like a fondue, that's a smell

that makes me smile, and want to dip
a cube of bread, then take a sip

of Chardonnay, oops there I am
back at wine! alright, then, ham,

but only finest prosciuttos
will make it past my snobby nose

Chinese I'll eat (the food, I mean)
Italian, Spanish, French cuisine

Hillbilly with okra pie
Better than a stick in your eye

But ask me to avoid Whole Foods?
That goes too far, sir, almost rude!

That place is home, my second larder
Quit I won't, I'd fight much harder

For organic foods and fresh ones
even though it uses up funds

Cheap it ain't: just ask Cheapskate
Still its always worth the wait

Don't believe me? Come for dinner
You don't like it? You'll leave thinner

Uh oh, wait a minute, what's this?
I can't stop creating bupkiss

Rhyme's Disease has taken over
Get the hook! I'm done! It's over.