Fieldset
Postcards (and phone-calls) from the edge

Maya makes a phone-call to Kural at the very last minute.

Maya makes a phone-call to Kural at the very last minute.

She is on the brink of killing herself and then (thank goodness, thank goodness, thank goodness) she phones our councillor Kural. I think she phoned, not because this was some half-hearted attempt, or a cry for help, but because her feelings were so alien to her and she just needed to check them with someone.

There are a few things that I know I will never, ever forget (one of these is Gulzabira’s death). And there are a few things for which I will be eternally and immeasurably grateful. I will always be grateful that Maya called Kural and did not commit suicide.

Kural knew our MoH (Ministry of Health) doctor Tleubergen was geographically closest to Maya at that moment and raised the alarm. Tleubergen arrived just in time to find Maya standing under a beam with a chair placed under it.

So close.

Too close.

We immediately assemble a ‘crisis’ team, including our two new MSF psychiatrists and by the evening Maya is safe. Safer. We stop her drug-resistant tuberculosis drugs, put her on the best anti-depressant we have available and admit her to the safest place we have: our TB in-patient department (with round the clock, albeit, not psychiatrically trained, nursing staff). The duty MoH psychiatrist visits, but says Maya will not qualify for admission to the psychiatric hospital as she did not actually get as far as the physically attempting the suicide, nor is Maya floridly psychotic. I cannot quite believe this qualifies as a specialist opinion nor a sound operational policy, but I am not about to fight to get my patient committed to an institution of whose quality I know nothing.

I check my feelings.

I am really stressed.

I phone my MTL (medical team leader) to update her about the events, but soon realise my rambling stream of consciousness must have her not worrying solely about the psychiatric wellbeing of my patient. Could I have managed things differently…better…earlier? Maya had turned up at Tleubergen’s house last week and told him that for the first time in her life she had the desire to kill herself. I rushed to see her then, but she seemed okay. She was making good eye contact and giggling with me, making positive plans for the future about wanting to learn to speak Russian and told me she did not mean what she had said and that she regretted it. But I was falsely reassured by these pick-ups we’re trained to look for in medical school. Falsely reassured because two months ago I had started her on a cocktail of drug-resistant tuberculosis drugs, including cycloserine. Cycloserine is a filthy, filthy drug with the potential for apocalyptical neurological and psychiatric toxicity. From my experience, the psychiatric toxicity of cycloserine does not display itself with typical signs and symptoms of depression. Instead, it is as if the drug suddenly pops harmful thoughts into the heads of our confused and bedazzled patients, who then feel overwhelmingly compelled to act on them. And then, like a bad dream, within days of stopping cycloserine and starting an anti-depressant these feelings seem to evaporate. But, we have no choice at present but to prescribe regimens containing cycloserine, because we currently have no better drugs available.

My previous nasty encounter with cycloserine was in March, when one of my patients, with no known previous aggressive behaviour, nearly beat his wife to death, two months after being commenced on the drug.

Furthermore, the gruesome shadow of a few ‘successful’ suicides in recent history hangs over our project.

There can be no denying that other social and psychological stresses contribute to these events. The stigma of being a TB patient, the prison sentence of the prolonged pill-burden and the noose of potentially succumbing to the disease hangs over all our patients every second of every day.

Plus it appears that patients with psychological issues are most vulnerable to cycloserine’s dirty little tricks. Another of my patients, who had suicidal ideation three months after starting cycloserine, is an alcoholic. Maya experienced a desperately difficult and tragic early adulthood (which I do not want to divulge here for fear of betraying her identity).

In fact, I knew Maya was high risk for cycloserine from the start – I inked this in her notes the day we started her TB treatment when she confided in me her personal history. But when I first found Maya effectively waiting for a slow and painful death from drug-resistant TB, she had already exhausted most other TB treatment options and I feared that without cycloserine, her TB regimen would be too weak and would not work.

Back in the office I share stories with the other doctors. One colleague tells me her patient turned up at the DOTS [Directly Observed Treatment, Short-course] corner last week with ligature marks around her neck asking to borrow a rope. Another colleague has also just had another near miss with a patient seemingly intent on killing himself and she now looks like she just needs to spend the next two weeks lying on a beach. But she cannot. We need to plough on. There are no real other safety nets here: if our little team misses a trick, the consequences could be fatal. It is quite a burden of responsibility we carry, even if we are qualified doctors, trying to keep everyone alive whilst attempting to preserve our own mental health.

The morning after the evening before, I sit outside in the sun with Maya on a topchan and we talk. She says she has not thought of harming herself again since we found her yesterday, but then states that she is so knocked out by the drugs we have now put her on that she is struggling to keep her eyes open, let alone think. I tell her that I almost cannot express my relief that she rang Kural when she did and that I would be have been beside myself if she had killed herself. She asks me if I can learn from her case and if I will share her stories with others and I agree I will. I apologise to her that I did not stop her cycloserine the day she first turned up at Tleubergen’s house. She shrugs and asks me when she can start taking her TB drugs again because she was rather enjoying no longer having a cough. And I wonder how and why it came to pass that us two young women are sitting here in the sun talking together, both trying to cope as best we can with immeasurable millstones around our necks, rather than drinking cocktails and reading trashy magazines together.

And in the end it boils down to the same thing. Every. Single. Time. I could practically cut and paste my concluding paragraph from all my previous blogs here once more: our drugs stink. Once more they have taken one of my beloved patients right to the edge of life and again they have me doubting my own strength and abilities. I reiterate, dear pharmaceutical industry and governments, I beg/implore/beseech you – put this disease on your agenda and give us doctors and patients what we so desperately need: new compounds for drug-resistant TB. Because really, this great burden of responsibility should not weigh on my stressed-out little shoulders, nor on those of my colleagues. But on yours.

You can read more about the MSF Access Campaign for new TB drugs here: http://www.msfaccess.org/our-work/tuberculosis

You can access help (worldwide) if you are suffering from depression or anxiety by following this link: http://www.befrienders.org/directory