Sunday, 17 September 2017

Diagnostician

I remember my mother’s response when I first told her I’d been accepted to medical school. I hadn’t even hinted that I’d wanted it until then and her expression of astonished delight was my short lived reward. What was I going to be? A surgeon? A therapist?

“A diagnostician.”

She fought hard to hide it, but I saw her pain and despair in the way the light went out of her eyes, and I heard it in the quiet praise which contained equal measures of pride and sorrow. It’s certainly a lucrative profession, but the overwhelming majority of people would refuse to do it; especially on a day like today.

This morning I have an NHS referral. We aren’t part of the basic cover – a full diagnostician is far too expensive so we mostly see private patients. An NHS referral only comes when multiple specialists are convinced the sufferer has a real complaint and none of them have been able to isolate a cause. It takes years and a great deal of suffering to get to me via them, and they always come with the same desperate hope.

She walks into the room and immediately fixes her gaze onto me – and I see exactly what I expect. That unblinking, unwavering guilty expression that wonders if they’re a fraud and I’m about to tell them all their pain is imaginary. The fear that if I confirm their suffering, it still won’t be fixable. The hope that it is; that this is finally the end.

I wave her into the seat opposite and introduce myself. I explain the process as simply as I can. She isn’t listening, none of them ever do. Our function is well known to our patients and they don’t really care about the how. Once I’ve covered that, I move on to establishing a base line.

“Before we begin, can you tell me how you are feeling today?”

She is surprised, but quickly succumbs to my air of quiet expectation.

“I’m OK, actually. It’s been a pretty good week.”

“No pain? No nausea, stiffness or other symptoms?” The way she sits tells me she isn’t feeling well, despite her statement.

“Only mild discomfort, really.” Her thumb nail scores her finger absentmindedly as she speaks. It’s pain management and I suspect it’s unconscious.

“OK. And on a normal day? What would you expect to feel?”

“Pain, generally. It gets difficult to walk, my stomach hurts and I stiffen up a lot.”

“It must be tiring.”

“I guess. I’m not a great sleeper, so I’m tired most of the time anyway.”

“OK.” I make a mental note. “And on a bad day?”

She shudders involuntarily – a slight tremor only, but her thumbnail works rapidly back and forwards, drawing a sharp distress line to distract her from the discomfort she feels elsewhere.

“It’s… it’s not good. I can’t eat or drink. On bad days I can only just about get out of bed and into the bathroom. I have to roll out and land on my hands and knees before working my way upright. The pain is all over on those days.”

“And is it a stabbing pain, or a burning pain?”

“I don’t know – just, a lot and constant.”

“OK, so we’ll get set up now and begin. Are you ready?”

She nods and the nurse who has been hovering in the background begins to fix bits onto her as I settle into my chair. With familiar ease I nestle into its depths and trigger the link.

Before the nurse steps away from her I can already feel the shape of her thoughts; mostly revolving around me and the uncertainty. I can feel her pain – a constant tearing feeling that is bearable if she remains stationary. She is uncomfortable, wanting to shift, not wanting to hurt, and she is mostly appallingly conscious of me.

“To synchronise us, I will need you to sing something.” It’s a lie, but a useful one. I hate having patients who are thinking about me. “What’s your favourite song?”

She’s immediately paralysed by choice and frantically tries to remember any words. Into the silence I prompt: “Do you know Bohemian Rhapsody?”

“Yes!” The link isn’t required to feel her relief.

“OK, then. Whenever you’re ready.” I choose this one for its duration more than anything; I’ve now heard it sung in every possible way, by the worst and best the world has to offer.

“Is this the real life….”

Her thoughts and emotions coalesce around the memory of the song as her conscious mind is trapped by the singing process. It leaves me clear to access her older experiences.

The mind is a funny thing – experiential data is stored in perfect format. Our memories are made from that data, but we can only access them through several layers of self protection filters. I can’t afford to be misled by how she remembers her illness; I need to burrow through to the truth and experience it for myself.

I dive through her mind to her earliest experiences and slip forwards looking for anything at least one standard deviation outside the norm. A broken bone doesn’t count, and nor do growing pains. This ability to judge events as they happen is what makes diagnostic links so complicated. People are used to the idea of simple links, although most have only encountered them in the workplace for brainstorming - instantaneous sharing of ideas. Professional and recreational links are deeper, but even they are relatively uncontrollable. A justice link will simply replay the experience of the crime and its impact; it’s completely immersive. An X-link will give you mutual access to the here and now of the person or people you are linked with, adding all of their sensory feedback to your own. Even a standard medical link only looks at the current trauma, and has a basic array of medical logs to compare it to – diagnosis then relies on the accuracy of the practitioner’s memories of the experience.

The diagnostic link not only looks through the whole history, it also allows me to keep my self-conscious active, while living the patients’ life and maintaining my whole array of medical knowledge. I can simultaneously experience her life at at any speed I wish, diagnose her symptoms and relay notes to my nurse.

Everything about her experience is within the realms of normality until she reaches adolescence. Her first period is absolute agony. No-one is impressed by it – she is assured this is normal and she should stop being dramatic.

Over the years it fluctuates; always bad, sometimes worse, and she persists in the belief it is normal. This then becomes her standard measure for a reasonable amount of pain. My hand writes “Endometriosis?”

I’m oddly conscious that although her experiences pass in real time and my handwriting feels as though I’m moving at normal speed I’ve blasted through six years of her life before the word is written. It seems like a long song won’t be necessary.

The nurse moves behind me and glances down at the notebook. She prefers when I dictate to her, but it isn’t always wise or kind to the patient to say things out loud.

“Caught in a landslide…”

Something new registers; a stomach pain. A strange tightness that builds gradually over a few months. Along with it is a funny sensation of not-quite-pins-and-needles down the right hand side of the body. I can feel her not really caring about it. It’s painful, but much less than her periods, so she ignores it.

It becomes worse. I interrogate it. What is the specific kind of pain? What made it worse or better? Heat? Cold? Stretching? Compressing?

As I feel her pain, I feel deep compassion. It’s a hazard of the profession. If this were a basic medical link I’d only have a snapshot and would not have the separation of personality – I’d believe I was her for the duration. But I can be me and her simultaneously, so although I’m going through it there is a tiny part of me that knows it isn’t real and uncomfortable as it is I can make it stop any time I want.

My mother still hasn’t realised what a difference that makes.

As I dig deeper I become more convinced this poor woman has both endometriosis and Multiple Sclerosis. She hasn’t been able to accurately report her symptoms to anyone thanks to the misguidance she received in her adolescence and now she’s perpetually exhausted, depressed (I check off a note as I recognise a familiar pattern of long term despair and hopelessness becoming a severe mental illness) and losing motor function.

“No escape from reality…”

I’m caught up with her symptoms and I drift away from her. I reach up and detach the head piece.

She stops singing and stares at me in confusion.

“Is it broken?” she asks.

“No, not at all.” It’s difficult to form words – although I didn’t physically suffer, I have endured almost two decades of mental suffering in a few seconds and my brain can’t easily adjust. I gesture to the nurse and she takes over.

“The Dr has been able to study your symptoms – the process is very quick when you have this level of skill. I have some information here for you and the Dr will be able to give you a fuller explanation once the analysis is complete – but right now I need to take you away to ensure there are no remnants of the link.”

It’s another useful lie. The link goes as soon as the headpiece is removed, but I need an hour of privacy to overcome the trauma I’ve just experienced. The nurse will keep her busy, make her feel like something substantial has happened. We learned early on that patients just don’t believe the process is accurate unless there is some heavy duty “uhmm”ing and “ahh”ing, or at least some indication that it’s been challenging. On the other hand, when they were exposed to the reality of the diagnostic process, many of them – like mother – couldn’t handle the guilt, so we have to make it seem as though the impact on us is minimal.

As soon as I’m alone I begin to shake and have an overwhelming urge to vomit. I learned long ago it’s best to get it over with, so I grab the bucket stashed under my chair and empty out my guts. Hot and cold sweats rush over me and every time I blink I’m trapped in a world where time has no meaning and pain is intense. I fixate on the loud ticking of the clock to track the true passage of time.

As my brain realises the shape of my body is different to the shape of pain it has so recently experienced, it stops trying to purge. No matter how many years you do this job, it’s always the same. All the systems and process that are out of our conscious control kick in to try and “cure” whatever we experience; first the physical symptoms and then the mental.

Ironically, it’s the one thing that protects our justice system from psychopaths. Although most people find the idea of having to experience being a victim of the crime they committed a terrible penalty, there were once those who committed crimes and let themselves be caught so that they might have the satisfaction of feeling the suffering of their victims. The satisfaction – and the few who were willing to work with us honestly remarked that it was intense – is fleeting, and this readjustment to normality may take years, depending on the depth of the trauma suffered. With the X link people consider it a fair trade off; although many couples prefer to adapt to the link on a permanent basis rather than suffer through frequent separations.

This separation is particularly brutal. Despite the brevity of the session, my immersion was deep and physical recovery is slow. I can’t stand yet – I’ll fall over. I shudder at the memory of the pain and my muscles tense in preparation for the onset of another wave of distress. It doesn’t come and I feel involuntary relief. Despite my best efforts I have not been able to rationalise away the fear that one day my brain will forget that I don’t have these illnesses and keep producing pain in an effort to protect me.

I am getting old. My body has lived through 37 years but my mind has lived over 600 and the vast majority of my experiences are torturous. I am tired and afraid of breaking.

Maybe it’s time to stop.