The crazy things we do

A few years ago, as a fourth-year medical student, I did something naughty. Something you're not supposed to do. I took something out of a patient's chart. I only removed it for a few hours, but I left the hospital premises with it and made a color photocopy. No one knew that it ever was missing. Still, it was wrong. It was the kind of act that would result in expulsion from medical school. It was stupid. Why would I do such a thing? The document I took was nothing more than an esophogastroduonoscopy (EGD) result. Just a series of nine small pink photos taken with a small fiberoptic camera of the inside of his belly. Here is why I did it.

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While working on the psychiatry consult service I was asked to see a 29-year-old Hispanic male on the surgical service. He had been admitted to the University Hospital in Albuquerque for the treatment of a large mass discovered in his belly. He was from a town three hours south of Albuquerque called Truth or Consequences. He had presented to the emergency room there with intractable vomiting. Everything he ate, within a matter of hours, came back up. He had not passed a stool in over a week. The physicians in T or C had x-rayed his abdomen and discovered a strange mass. It was in his stomach and it was so large that his stomach had sunk from the middle of the abdomen to the pelvic floor where it was dangerously squeezing his other visceral organs. When he began to vomit blood, they transferred him by helicopter to Albuquerque for treatment by surgeons if needed. They ordered a CT scan and an EGD—as well as a psychiatry consult.

Psychiatry was consulted because the patient carried a diagnosis of Obsessive Compulsive Disorder (OCD) but had not seen his psychiatrist in a month, had stopped all his medication, and was difficult to interview, suspicious of any one who tried to ask probing questions. When I arrived to interview the patient he was no more willing to speak with me than anyone else. The only thing he revealed to me was the name of his psychiatrist. This was useful information. I called directory assistance and amazingly within minutes was speaking with his shrink. As the patient was wheeled down to the Gastroenterology unit for his EGD where doctors were about to discover the contents of his stomach, I was learning the rough contents of his mind.

His psychiatrist revealed that he had been this patient's doctor for the last two years. He had started seeing the patient after the death of the patient's mother when he was enrolled in a boarding home for patients on social security disability (SSD). He apparently had a long history of OCD and depression; before the end of high school he had been hospitalized for a suicide attempt and had been sick enough to qualify for SSD. He had seen a number of psychiatrists over the years, but not regularly. He was relatively stable living under his mother's care. He collected Star Wars figures and kept them carefully placed around his bedroom.

After his mother's death and the transition to a boarding home, this patient had been reluctant to attend appointments with his new psychiatrist. As a result the doctor had tried unusual methods. He had started bribing the patient to come to visits. The patient apparently really liked Sunkist soda, so the doctor would buy him a soda every time he came to a visit. On the way out the door the doctor gave him two quarters to buy one. This method seemed to work. The patient came every month for his med checks, and was functioning quite well. That is, until one month ago when the patient missed his first appointment. The doctor had no good idea what had happened. As far as he or the staff at the boarding home knew, nothing had changed in the patient's life. He asked to be contacted if something were discovered.

That was about to happen. The EGD result revealed a complete blockage of the pyloric sphincter, the outlet from the stomach to the duodenum, the first part of the small intestine. The obstruction was a large mass of metal. The photos showed a pile of coins. Quarters. The photos are so vivid you can read the dates on a few of the coins. The patient was rushed to surgery and within a few hours the stomach was opened and the quarters removed. Six dollars and fifty cents. Twenty-six quarters. The surgery successfully cleared the sphincter and the surgeons anticipated that the patient would again be able to pass food through his stomach. The stretching injury of the stomach and the crushing weight on the other organs did not show any permanent signs of damage. The patient would return to “normal.” My psychiatry attending pronounced the diagnosis as Pica and the case was closed. The fantastic case was recounted by residents and students in the cafeterias and in hallways. It was a great story. And one student quietly made a photocopy of the EGD results for his files.

Pica (pronounced like 'biker') is a diagnosis made of people who compulsively eat non-nutritious substances, like soil, plaster, paper, or ice. The word Pica comes from the Latin word for Magpie, a bird with an indiscriminate and goat-like appetite. The disease is said to occur most commonly in people who are deficient in certain metals or elements. In pregnancy, women often crave ice or strange substances and are found to be iron-deficient and with iron supplementation those cravings disappear. However, in most cases of Pica, no deficiencies are noted in lab tests and the origin of the cravings are undetermined. In the case of the coin-eating patient, no deficiencies were found. Lab abnormalities are not a requirement for the diagnosis of Pica, just the presence of ingesting strange substances.

Now, years later, as a fourth-year psychiatry resident, my reflections on the case lead me to think of it in new ways. The diagnosis of Pica essentially rests on a biological understanding of the illness. The brain detects a deficiency of a necessary substance, thus triggering a craving for things that contain that substance. It is a simple and physiologically-sound explanation. The biological model of disease is quite satisfying. However, it is inadequate. It ignores many things, among them the complexity of mind. And by the complexity of mind I refer to that great spectrum of fears, drives, and wishes that unconsciously motivates so many of our behaviors. After working with patients for several years, I am more attuned to the ways in which people long to carry their connections to their external world—even unaware of that impulse. Human beings naturally seek to carry physical objects as tangible reminders of their relation to reality.

I wear a wedding ring. I carry pictures of my son in my wallet. I wear t-shirts that connect me to bands and causes I like—to social groups I identify with. I once wore a sacred underwear that connected me to a religious family. I rarely think of these things, but physical objects like these are fundamental ways of maintaining my sense of meaning and identity.

Now a few years later, when I think of that patient, I am much less fascinated, less horrified and excited. I recognize that all illness involves a degree of regression—a reverting to an earlier phase of being. Picture the simplest illness, a case of the common cold, and think of the regressive positions we take and the things we crave: fetal positions, long naps, blankets, warm drinks, hot baths. All those things that mother provided. The greater the illness, the more regressive we become. I see my son, now 16 months old, and his most basic urge is still to put disturbing things in his mouth–catfood being his favorite, but shiny coins running a close second. Thus, on one level, Pica is but a regression to one of our earliest states of development. A return to our instinctive desire to connect to the outside world through our mouths.

So I understand the motherless patient with OCD who longs to feel connected. I understand how the physical gift of coins given by his doctor must have meant so much. And it is not difficult to see how a sick patient like that would concretize the gift, regress to an earlier stage, and wish to internalize the coins, not the soda. It is but a mere reversion to an older stage in that strange developmental process of becoming fully human.

Looking at those EGD photos, years after the fact, I am left with this humble question: what crazy things do all of us swallow in our endless attempt to feel connected to this world? Coins and catfood are just the smallest part of that longing. In some manner, the magpie never really leaves a nest it made in all of us.


15 responses to “The crazy things we do”

  1. Rachel says:

    Great post, Farrell. In a truly bizarre coincidence, last night dreamed that I ate an entire roll of quarters and then couldn’t get them out. And here I was thinking it was just a job anxiety dream….That’s why we pay you psychiatrists the big bucks.
    P.S. Always buy the soda yourself!

  2. Adriana says:

    Wow, what a thoughtful and compassionate analysis — and facinating to think about the things we hold onto and carry around to feel connected to the world. This is a post I’ll mulling over all day.


  3. Riptide says:

    Pica is quite common for dogs. My dog had it bad. A blog about dog psychology would be nice, starting with the study of the border collie Rico who demonstrated the ability to reason by process of elimination. Or dogs’ lack of awareness of the passing of time and absence of short-term memory, which coincidentally happens to humans who smoke pot—the link being suppression of neuroactivity in the hippocampus.

  4. Lisa Parrish says:

    Speaking of which, the dog here in Vermont has been trying to eat goat poop. A fabulous mystery of nature — explained!

  5. G-Lock says:

    Positively awesome!

  6. andrea says:

    A friend of mine craved paint and dirt while she was pregnant…we had to watch her like a hawk! And our dog with pica would love a bit of goat poop, or dirt, or ice, …

  7. Bryan Waterman says:

    Farrell: I read this first about 12 hours ago, and have read it twice since. I’ve thought about it all day.

    Here’s what’s puzzling me: You begin and end with a personal transgression–removing the charts from the hospital, making illegal photocopies. In this sense, “The Crazy Things We Do” could apply to your rash, high-risk behavior. But I can’t peg the motivation: what drove you to do it? And does it relate to ingestion or regression of some sort?

    This is my favorite thing ThGrWhatsit has published so far.

    xo — bw

  8. Jeremy Zitter says:

    I agree with Bryan. This and Dave’s Ghosts post have been my favorites. I was also thinking the same thing, that your need to possess the EGD photos seems akin to your patient’s need to ingest the quarters…

  9. Bryan Waterman says:

    when you put it like that the connection seems obvious, jeremy. maybe i was dense. when you go back to the line from the opener — “Just a series of nine small pink photos taken with a small fiberoptic camera of the inside of his belly” — the photos almost seem quarter-like.

  10. WW says:

    This is slightly at an angle to your wonderful essay, but reading your last paragraph, I began to think about the longings we swallow as we grow older. We swear off sugar or nicotine or blondes or the urge to dye brown hair electric blue. These are things we swallow so that we can be thin, fit in, pass as a grown up. Things we swallow to feel more connected. We hope that by swallowing these urges, they will digest and pass through our systems. Sometimes they do and sometimes you still want a cupcake, a cigarette, a kiss, a cerulean swirl. We are cairns of adult corrections (laughing or crying) stacked on top of our deepest feelings (crying or laughing). We carry these longings, but shrugging them off – or the struggle to shrug – is how we carry ourselves.

  11. Farrell says:

    Thanks for all of your kind and thoughtful comments. I’ve been thinking about the question that Bryan and Jeremy have been discussing: what drove me to to take from the chart? I”ve thought about this and how to answer it. The simple answer is ‘for the glory’–something akin to owning a letter written by a president or a martini glass owned by sammy davis jr. It had ‘cool’ currency. But our motivations to do things are rarely so simple. I have only shown the photo to one person. So how was my ego fed? Where is the glory? Four years later, I am struck by how our understanding of choices that we make in life evolves over the years. As our understanding or ourselves changes with age and experience, our motivations for doing things in the past get revised accordingly. Now I wonder if possessing the photos was fundamentally a longing to remember. But it might have been a longing to belong to the club of psychiatry–“see, i have case files.” Or perhaps just juvenile thrill-seeking, another version of shop-lifting or binge-drinking. Can we ever really know our reasons for doing something? I hate thinking that we can’t. But it just might be.

  12. Eric Jones says:

    Exceptionally nice, Farrell. Thanks.

  13. robert wire says:

    first- that is truly poignant and insightful.
    secondly- was he a prisoner?

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  15. Anynomous says:

    Guess this is what psychiatrists is for, too bad they’re so damn expensive