ECT

I have written before about my brief career in a white coat. You can read that post here.  In my defense, that piece was a very early blog effort, and rereading it now, I’ve got to say, I’ve become a lot more direct in my writing since then. Hopefully readers will appreciate how far I’ve come, getting to the point, saying what I mean, meaning what I say, not dithering too much going round in circles on our way from point A to point B.

 

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There’s a new psychiatry piece in the current New Yorker and you can read it here. Unlike the last one I mentioned above which was written by a white coat  (Jerome Groopman, MD), this one was written by a writer (Donald Antrim) who experienced the doctor-patient relationship from the other side of the fence. Hospitalized 4 months for severe depression, he recovered after treatment with electro-convulsive therapy. And I am here to tell you that his prose post-ECT is as fine as it was pre-ECT. Score one for the guys in the white coats.

All of that brings to mind for me one particularly memorable patient I had when I was a resident. But more on that later.

 

 

This is Antrim’s detailed description of the ECT process. I can say, having been there, he’s got the details down cold.

 

This is how it goes: You lie on the table in your gown and your socks. You’re looking up at the white ceiling. The ECT nurse sticks electrodes to your head, chest, arms, and legs. Wires run from the electrodes, across your body. You nod to the anesthesiologist, who is usually pretty friendly and who sticks you with a needle, to set up the I.V.

Maybe you speak to the administering physician, the team leader. This doctor stands behind your head, programming the shock. You look up at the doctor’s face. The ECT nurse fits a pulse oximeter over your index finger, and then binds your ankle with a blood-pressure cuff. The cuff will remain inflated throughout the procedure. It blocks the muscle relaxant, succinylcholine, from entering your foot. This allows your toes to twitch, visible evidence of convulsion. Vital-signs monitors beep. You are having right unilateral ECT. The convulsion should last half a minute.

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If other patients are doing ECT, your buddies on the ward, you may glimpse them asleep on gurneys in the recovery area. You feel something like fellowship, as if you were all at war together, or had survived the same dreadful accident. You ask the ECT nurse to hold your hand, and you squeeze hard. The anesthesiologist says, “Atropine.” Atropine keeps the heart beating. You are crying. You’ve been in tears the whole time. You tell the doctors that you want to get better. You’ve only ever wanted to get better.

There is a bite block on the metal table beside the anesthesiologist. The nurse fits the oxygen mask over your face. The anesthesiologist inserts a syringe into the pipette connected to the needle in your arm. The anesthetic trickles down the tube. You can smell it. It has a sweet smell. You count backward, a hundred, ninety-nine, ninety-eight, and then the anesthetic reaches your blood, and a second passes, and you feel that you are falling—and then blackness. The succinylcholine goes in, and you no longer breathe on your own; you are on life support, and your body will not shudder or shake.

 

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And now you are awake—did anything happen? Is it about to begin? A voice asks you where you are, and you reply that you are in the General Clinical Research Unit, on the fifth floor of the New York State Psychiatric Institute, at 1051 Riverside Drive, in Manhattan. You are behind a curtain, recovering in bed. You have had general anesthesia. Your mouth is dry. Your friends in treatment have already woken and been returned to the ward, and, in fact, you are done; it is over.

 

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My own memorable ECT patient was a patrician old gal from one of the ritzier  L.A. neighborhoods near UCLA: Brentwood? Pacific Palisades? One of those. She’d been in before and knew she’d get temporary relief from her severe intractable depressive symptoms with a 10-day course of ECT. She knew the drill and wanted the treatment. That made her the perfect patient for me, greenhorn first year resident, eager to learn the trade.

What made her so memorable was not the mundane medical details Antrim expertly lays out above; but rather, how she came to be admitted to the hospital in the first place. Her desire to die when in the grips of her depression was so strong that she had lain down behind her husband’s Caddy early of a Saturday morning as he was on his way out to the golf course. Riviera Country Club? Yeah, most likely. They had the U.S. Open there once as I recall.

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Anyway, she had placed her head behind his right rear wheel just inside the garage door where he couldn’t see, and made not a peep as he started to back over her. Sensing something was not right – had he left his golf bag propped against the rear bumper? He WAS getting forgetful of late – he stopped, put it in park, and found her back there with tire marks on her forehead and a misshapen skull.

She explained all this to me on intake in a monotone whisper. She’d wanted to die. This seemed to her the most logical way to get it done. It isn’t a story you easily forget. I guess it’s the sort of thing that makes the rigors of ECT pale by comparison. In any case, a week and a half later she was up and about and back to her normal self, smiling and conversing in a normal tone of voice with the staff. She was discharged to the care of her husband who, let it be noted, came to the hospital in full golf attire.

Like I said – memorable all around.