Appointment Slips, Drawing Pads and Saying Goodbye to My Box of Patients' Charts

CHAPTER 1: Appointment Slips

For a person who spent more than half of his life out of touch with reality, there is a window by which another can glimpse his soul. It's not always through the eyes, as the famous dictum goes. Most of the time, it's less obvious. Sometimes, they're like puzzle pieces or clues and you have to be keen and intuitive to spot them. And then keen and intuitive to try and figure out what they mean.

Windows.

A portal into another person's mind.

For this one patient, it was his appointment slips.

I've been seeing him for almost 3 years now. He was endorsed as a case of chronic schizophrenia with irrefutable delusions of being perpetually targeted by two big business companies. He could not get over it. And when he's at his most paranoid, he became religiously preoccupied. For him, all his life's problems are because these two companies are preventing him from happiness and success.

I could't break through the delusions. Even without the hallucinations, he held on to these delusions like a life boat. I was never sure if he was getting better on not.

Until I started noticing his appointment slips.

This is how our OPD appointment slips look like.

The following are some of this patient's appointment slips since 2011.

August 21, 2011

October 12, 2011

January 4, 2012

April 18, 2012

August 23, 2012

November 15, 2012

January 17, 2013

April 10, 2013

Pretty tough two years, I know. But despite these persistent delusions, this patient has been fairly functional. He works for his church with a zeal that actually drives others to becoming better. His chronic illness became his legacy of courage and faith despite the perpetual battle against the voices that even Jehovah would not hush.

Then one day he came to follow up with a clean appointment slip.

Then again...

And again...

... and these clean appointment slips coincided with reports of improved functionality, improved mood, good continuous and restful sleep, and the prospect of a good paying job. All I did was change his first generation antipsychotic medications to a second generation SDA (and stuffed his arms chock-full of free samples). But his previous doctors have been doing that in the past 10-15 years, only so he could end up unable to maintain compliance due to dire financial difficulties.

I have discovered a window by which I could glimpse some parts of his inner world, but what to make of it is a completely different matter.

I honestly don't know what I did that made him better, so in one of our sessions, I asked him how he thinks our sessions helped.

And his answer astounded me. It went something like this:

"Alam ko naman doc na hindi mo kaya gamutin ang isang sakit na wala naman talagang lunas. Alam ko naman na ang gamot na meron tayo pansamantalang pinapawala lang ang mga boses. Pero sa totoo lang, naging bahagi na nga sila ng buhay ko, hindi ko alam kung anong gagawin ko pag nawala na sila. Tanggap ko naman na talagang naririyan sila. Kung nasa plano ng Diyos na samahan nila ako habang buhay, tanggap ko na po. Nakakaluwag lang po talaga sa dibdib ang may nakakausap ka tungkol sa mga boses na hindi ka nahuhusgahan. Dito ko lang po nararamdaman na may kumakausap sa akin na para akong normal."

I spent the rest of that afternoon in the call room, in our Ling-bed, in fetal position wondering why that was such an unsettling experience for me. We talk about empathy and putting ourselves in another person's shoes, but the truth is, I could never know what it's truly like to wake up to these voices everyday of my life and learn to greet them like friends.

CHAPTER 2: Drawing Pads

This next patient doesn't even talk to me. When he talks, he only echoes my own words. He's one of those persons who seem like they're trapped in childhood.

There is a lovely book by Alan Lightman entitled Einstein's Dreams. It's one of my favourites. It fictionalises Albert Einstein as a young man dreaming about his theory of relativity and every chapter depicts time in a very picturesque way. One chapter talks about the odd characters who are afraid to move or cause any form of change in the universe so they end up trapped in themselves, fearful of making eye contact, or causing so much as a breeze in the air.

He pretty much described my patient.

Except of course that Alan Lightman also describes them as characters lost in time. People misplaced in the fabric of time and space that they are afraid to change anything in perpetual fear that if their breath causes as much as a ripple in the air that would change the course of history, they would vanish in an instant. :)

I do that. Yes. I add colour to the people I meet that way. :) And mind you, some the people I have met in the past 3 years are like characters that have popped out of a book.

But anyway, I was going to tell you about this patient's drawing pads. He brings me little works of art usually copied from a grade school work book. Sometimes I miss a session for some reason and I know that he's mad at me when he doesn't bring me anything. They're like love letters in cuneiform. Mostly birds and flowers in a neat line. I have more drawings than chart entries in his records.

I asked him to draw a tree, a house and a family one time and this is what he gave me.

"How old is that child?" asked Nanay Ring when she saw me studying it one night.

I had to smile.

"He's forty two."


CHAPTER 3: Saying Goodbye to My Box of Patients' Charts


I'm not done yet. I've been writing and writing endorsement notes for days now and I'm still not done. In fact, parang hindi nababawasan ang kailangan kong isulat.

Perhaps because I keep getting all sentimental going through three years of chart entries, mostly with side notes in post-its to myself like: "this patient just made me cry inside" or "this patient can be very annoying when you forget that he has no one else to talk to other than you" and my personal favourite "patient looks hungry, next time bring food from call room: patient looks like he hasn't eaten for a week."

I worked in a government hospital, catering to the mentally ill of Metro Manila and most of them come from the lowest socio-economic class that even their travel fare is equivalent to a day's meal. I have one patient who has to start walking from his little shanty at 5am just to get to my cubicle at 9. In fact, I think I'm supersaturated with cases like these that I get short tempered when I come across a patient who complains of "the world ending" when they lose one of their properties in say, Forbes. They slash their wrists for it or swallow a dose of silver jewellery cleaner and that's serious too. But sometimes I wonder if God made a mistake giving all that wealth to someone who put too much or too little value in it while another person from the slums can afford to be grateful for the little that they have but still manage to shrug their shoulders at the losses they have to deal with everyday.

It's a short-coming of mine and I've been working on it. I am in no position to judge. In fact, my job is to be non-judgemental because everyone has a story that deserves to be listened to. The social injustice just screams at you when you're working for a government institution. It's pretty hard to ignore.

So anyway, as I was going through my charts, I realised that these people whose life stories are in my hands have become a very significant part of my own growth. Perhaps the reason why I'm taking so long writing these endorsement notes is because going through all these stories of people who have become a significant part of my life for the past three years just feels so much like going through a stack of old photo albums. You can't help but get a little sentimental and sentimentality takes time.

I suppose the most meaningful lesson I'll be taking home with me is that the mentally ill are just as capable of changing another human being's view of the world in ways you least expect. They're just as human and just as capable of touching your heart, of showing you courage, of teaching you faith and humility, and some of them could blow you away with their ability for simple acceptance.

I've seen two patients fall in love and walk away from the emergency room hand in hand knowing full well the battles they have to face together. I've witnessed patients becoming mothers and battling their inner demons for the ability to actually be mothers. I've seen an old man getting his "Cinderfella" story despite his debilitating OCD.

There are a lot of dreadful stories too, of course, but even those carry with them an opportunity for insight and introspection.

In a way, I've been their chronicler.

I hope I was more than just a chronicler to them though. I was their doctor, and I sincerely hope I was able to make their lives just a little bit better.

The Old Man Who Wouldn't Stop Cleaning

Beer bottles are such tricky things. To wash, I mean. He's used up three bars of Champion and the stains are still there. His wife told him that it's no use cleaning the bottles if he's only going to sell them to the man with the cart. But of course, they've been through this routine before. She would tell him to do or not to do something and he would smile his kindly smile, telling her that he believes her. But his hands would not stop scrubbing. Everything in life is a matter of choice, you see. He would rather clean beer bottles until their labels have been scrubbed away, than let his mind go idle and then there would not be a moment's rest.

"I fell off the bed this morning Lolo," his grandson told him when he discovered a blue patch the shape of Mindanao on his small arm. There are more wars in his household than there will ever be in Mindanao, he thought, but he gave the boy a reassuring smile. The kind of smile that made his grandson think the lie had been successful. "Go help your Lola in the kitchen." And when the boy turned there was another blue patch the shape of a crescent moon. The old man dropped the bottle he was washing and it fell onto the dirt. When he picked it up, there was also a crescent moon where it fell. The moon belongs in the sky, he thought, not in the dirt, nor on my grandson’s shoulder blades.

When he was a little boy himself, he did not get crescent moons or Mindanao maps on his skin. Instead he always had chicken pox. At least that’s what he told his friends whenever they saw his lesions. One or two or three, here and there, little circles that burned, and new ones keep popping up before the old ones could even start healing. He hated smokers then and he hated them now. Whenever he saw jeepney drivers smoking on the job, he has to fight the urge to throw his coins at them. When he became assistant supervisor in the textile factory where he worked as a younger man, he almost got fired for being particularly strict, bordering cruel, to the workers who spend lunch break whiffing Phillip Morris by the side walk. When he discovered that one of his sons smoked Fortune in the sari-sari store across their home, he broke his porcelain money bank and counted his coins all night long, wondering why he could not stop. They amounted to no less than a couple of hundreds in 5’s and ten centavos and one peso coins. But he did it over and over again because he was afraid he would hurl the glass jar onto his son’s head if he stopped.

“Tay, ayan ka nanaman,” his wife would casually tell him, but he knew that deep down, she was afraid for him whenever he started counting his money. “Akala mo naman yayaman tayo kapag binilang mo yang pera mo ng paulit-ulit.” Gentle was her voice and loving was her manner of reminding him, but he was never quite sure if she understood the battle he was fighting.

But he loved her. She was Cinderella who found a prince in a pauper. She was Cinderella who threw away her glass slippers and chose to hold the cinders in his hand. They worked hard for their life, poor as they were. He worked in a textile factory and she did laundry and cleaned other peoples’ houses. They have four children and did right by them. Their eldest boy was their most precious treasure. He was the smartest and the bravest. He went out into the world to look for his magic beans and came home with a wife instead. The little shanty of a house built illegally on some forgotten government property slowly became a 3-storey shanty. The old man and his wife lived on the first floor, his married son on the second, and all his other unmarried children on the third. This cardboard tower grew and grew until they were like the old woman who lived in a shoe. So many children and grandchildren, they did not know what to do. But they were happy, and for the longest time, he was able to put off counting his money for another day. Always for another day. For the longest time, his sleep was restful and his dreams were kind.

It was his wife who cured him of the perennial chicken pox. Long ago, she gave him a reason to run away from home. He simply followed her and never turned back, and just like that, the chicken pox stopped coming. For that, he was eternally grateful, but also, eternally angry. He could not understand it. He would dream of it and wake in the middle of the night, crying. He did not understand why he was angry though he understood that he was angry at the necessity of the chicken pox lie. He eventually knew it was not chicken pox, of course, but the lie was planted so deep inside him that it took a lot of strength for him to even accept that he allowed it to happen. That despite all the screaming inside his heart, he was able to deliver this lie with a straight and convincing face for so long. For so long he did not realize that all that lying was detrimental only to himself.

“Forgive yourself, you were just a boy.” His Cinderella always told him. And she broke her glass slippers so she could tell him this every day. And for a while he was content. With their hard work, they did not need any fairy god mothers. They lived happily despite his episodes of oddities that his Cinderella allowed him, with watchful care and from a loving distance.

Their makeshift home was the most beautiful in the area. The old man would spend sleepless nights setting things in order, over and over again. Once, when he lost his job in the textile factory, he spent the whole night washing the dishes. There were only 4 at the time for they were then just a small family, but it took him all night. His hands were red and blistered. The water was running low. Only when his wife turned off the tap and held him gently as he sobbed was he able to stop. At first he was just upset about the loss of his job, it wasn't much and he has other jobs. He felt like he did not deserve being laid off just like he did not deserve his childhood chicken pox. But when he started washing the dishes and found that he could not stop, he began to be more upset about not being able to stop. And he just went on and on until his Cinderella kissed him wake. She always kissed him wake. She’s been kissing him awake for almost 50 years and before he realized it, he’s lived his fairy tale life.

I suppose it is part of the reason why he’s angry again. He was ready for the happy ending. He thought he has mastered the anger, but it turns out, it was just sleeping. He’s old now, with a family grown, still a pauper and a prince in one. But, looking back, he was generally happy with how his life turned out, until his son came home one day with a pregnant woman in tow. When his son brought home his lovely wife at 20 years old, the old man knew right away that her loveliness was all there is to her. She was cruel to her husband and was never content in his home. She forced him to work abroad in a foreign land so they could have more money, which she spent on beer and cigarettes and goodness knows what else. The old man was certain she did not spend it on her children for his pension was spent entirely for them. By the time he and his wife were 72, they were still selling newspapers by the sidewalk for money to spend for their grandchildren’s needs. He loves them dearly, of course, and he was concerned for his son, all alone in a strange land and his last request from his father was to protect his wife and his children. Little did he know that what he asked of his father were two very, very conflicting things.

It started out as a recurrence of the odd chicken pox of his childhood. He saw it, first, on the arms of his youngest granddaughter. It threw him into an internal rage where his heart seemed to have stopped beating and the nerves behind his neck started to throb. But all his life he has mastered feigning composure when an attack comes. Although he has not had one for the longest, longest time and it caught him off guard, but this new threat in his family’s well-being, undeserved and unjust, woke impulses he thought long gone and thoughts he believed well buried. He called his son and informed him of the matter and there was an argument between his son and his wife. She was not so lovely when angry. In fact, she was terribly un-pretty when her desires are questioned. There was a week long silence thereafter but the pox like lesions never appeared again. But something else brought sickness into his household and it was causing his family terrible unrest. The children were terrified of their mother. They were more terrified of her than they loved him. For what could an old man do against the strong lovely woman who held his son’s heart a captive?

She’s confused, he told himself when she threatened him one day. She mentioned telling her husband that it was him and not her who abused the children. She begged him to take her away from this horrible house where she never found happiness. She told her husband so many things but somehow she forgot to mention the Mindanao maps and the crescent moons. Sometimes there were triangular marks as well, for those times when she thought she would be a housewife and iron some clothes. Perhaps she forgot to take the clothes off her children when she thought they needed ironing.

The lies he tells himself.

Feeble and desperate.

But powerful enough to make him do nothing.

“We have to do our best for them, my love.” His Cinderella told him. “It’s the only way we can make our son believe.”

But it took years and years and the children have grown and still the faraway father did not believe. By the time the youngest grandchild had turned 14, the old man and his Cinderella were too frail to keep trying. The maps and crescent moons have become parts of their daily life. The children have grown up lying about them just as the old man lied about the chicken pox. And there are rumors in the neighborhood that his son’s wife was dating the new baranggay captain. She has become a powerful woman in the small neighborhood of makeshift shanties and cardboard houses.

Then one day, he was cleaning beer bottles and thought how such tricky things they are to wash. He's used up three bars of Champion and the stains are still there. He was only going to sell them to the man with the cart, but he spent half the morning and into the afternoon scrubbing them anyway. His wife told him that it's no use, but of course, they've been through this routine before. She would tell him to do or not to do something and he would smile his kindly smile telling her that he believes her. But his hands would not stop scrubbing. Everything in life is a matter of choice, you see. He would rather clean beer bottles until their labels have been scrubbed away than accept the fact that he was angry at his son’s wife for hurting his grandchildren and angrier at himself for not having done anything all these years. He saw them as old and frail and scrubbing down bottles of beer just as he was doing because he failed to protect them from having to lie to the world. Mindanao maps and crescent moons did not belong in children’s bodies. But he was always, always immobilized by something he could not explain. Every time there is a new mark or a new bruise, there is a terrible, terrible feeling of fear and anger that he could not explain, and he could not allow himself to lose control for fear of what he might do.

So he did the things that he could explain, like counting a handful of coins over and over all night, or washing dishes more than 50 times, or scrubbing away the stains on the beer bottles that his daughter in law brought in from her night out in the town. He has grown to truly, truly believe that the nightmare would end if he could just scrub one more beer bottle clean.

But it was a nightmare even his Cinderella could not wake him from. So he scrubbed away the image of the archangel spearing Satan and concentrated on the invisible dot that he had to remove.

It was the safer thought.

It was the safer thought.

It was the safer thought.

This bottle is filthy.

I need to clean it.

This bottle is filthy.

I cannot bear what happens if I stop scrubbing.

I do not know what happens if I stop scrubbing.

I have to keep scrubbing.

I have to sweep the crescent moon from the dirt.

I have to keep scrubbing.

The spot is still there.

I need to keep scrubbing.

There is a crash from inside the house.

I need to keep scrubbing.

There’s still a spot left.

I need to clean this bottle.

Someone is calling me.

But the bottle is still in my hand.

I don’t know how, but my feet have carried me into the upstairs bedroom.

I need to clean this bottle.

My son’s wife is throttling my youngest granddaughter against the wall. She cannot breathe. She’s turning blue. She is trying to call my name but I can’t hear her. A minute ago the whole world was in a riot so I would not hear her. But I did. And now that I’m listening, the world has grown mute. And slow. So terribly, terribly slow.

My granddaughter's fingers are bleeding and so dirty.

There’s blood on the blades of the electric fan.

There’s blood on my granddaughter’s fingers.

There's blood in my eyes.

There’s blood in my hands.

There is blood on the bed.

There is blood on my son’s wife.

A long gash that ran from her nose to her navel.

She has stopped moving.

She is free from the despair that is her marriage to my son.

I hope.

But there is blood everywhere.

There’s even blood on the beer bottle I was washing.

I have to keep scrubbing.

The dirty spot is still there.

I have to keep scrubbing.

It’s broken, the bottle.

I somehow broke it.

And blood is dripping from the shards.

I barely feel my granddaughter wrapping me in a tight embrace. She is crying. I can tell from the tears that wet the side of my shoulder. She is saying something, but I could not understand it. I just need to clean the dirty spot from this bottle in my hand.

It’s filthy.

This bottle.

It's filthy.