Fish Bowl

Marilyn was obviously alive.  She sat before me, somewhat haggard and disheveled, but unequivocally awake and breathing.  She had a pulse and her blood pressure was respectable, but she complained.  She complained of weakness and agitation, of insomnia and excessive drowsiness, of uncontrollable anger and irrepressible apathy, of diffuse body aches and focal joint pain. Not the least of her disclosures was that she lived, worked, shopped and suffered in Connecticut. The central question in a situation like that which Marilyn presented was “Why are you here?”  What could motivate a rational person to fight rush hour traffic to leave a state with numerous highly regarded hospitals and come to New York City for medical advice?

She had not booked tickets for a Broadway show and opted to get a medical consultation before the curtain went up.  She had no obsession with shopping at some of the most over-priced venues in the world. Surely, there was something amiss with this woman that eluded detection by the more than dozen physicians, chiropractors, acupuncturists, homeopaths, and pharmacists in Connecticut that she had consulted.  Alternatively, she might just be a lunatic.   

We talked about her children and her pets, her work and her husband, her home and her husband, her doctors and her husband. Several of the people she had consulted suggested that her husband was the problem. I had the prejudice that all marriages are problematic and that dissolving them, in the absence of explicit abuse, was not usually therapeutic.  People talk of growing apart, but they actually seem to shrink apart. When they are in full bloom, they overlap in numerous ways, like a fresh bouquet of flowers.  As they wilt, they lose touch with each other.  Her marriage might be boring, but it was an unlikely source of her numerous and varied complaints. Marilyn was no more miserable than many middle-aged people, but her complaints had a distinctly chemical flavor to them.

What shed light on the problem, as the cliché goes, was her list of medications.  She was on heart pills, water pills, antihypertensives, cholesterol-lowering drugs, thyroid supplements, weight loss tablets, antidepressants, sleep aids, and a blue and purple capsule for which she had no explanation. I asked how she kept track of what to take and when.  She explained that she approximated the times to take her pills and ended up self-administering this concoction at 6 p.m., 11 a.m., 1 p.m., 6 p.m. and 9 p.m.

“Concoction” was her word. Most people, even those from Connecticut, do not usually describe their medication regimen as a concoction. She obviously had a routine for the timing of her dosing, but she left unexplained how she managed to take the appropriate pills at the appropriate time. “And so how do you keep track of which pills to take at each of these times?” I inquired.    

She shrugged her shoulders and offered an uninformative, “You know. I just take them.” To people who use the phrase “You know,” even if it just a place-filler alternative to “like,” “um,” “er” or “ah,” I feel obliged to comment, “No, I don’t know!”

Again, I asked, “How do you keep track of which pills you are supposed to take at each of these times?” Walk me through it.  You get prescriptions from six different doctors, and then what?”

“Well,” she explained, “I get all of them filled at the same pharmacy.  When I get home, I put them in a fish bowl and take out six of them at each of the times I gave you. I take them with water.”

“Why do you put them in a fish bowl?” I asked

“They are easier to get that way,” she replied. “Otherwise, they could drop on the floor.”

“But isn’t it more clumsy to have to get all of these pill bottles out of a fish bowl, rather than just lining them up on a shelf,” I asked.

“Oh, no,” she explained. “I don’t put the pill bottles in the fish bowl…just the pills.”

“How do you know which pills to take?” I asked. “Don’t many of them look similar?”

And then she provided the Reveal. “I just take out six pills at a time.  I figure over the course of the day I’ll get the right combination of pills.”

Indeed, she would grab six random pills out of her fish bowl, and she was relying on chance to provide the correct daily dose of prescribed medications. With the approach she had adopted to manage the impossible task of taking 30 pills daily, statistics favored her being dead. I was amazed by her resilience. For months she had overdosed herself on some thing, that thing varying from day to day, and yet she lived. Her kidneys and liver and other such defenses against self-inflicted harm were superhuman.

I explained the dangers inherent in her unusual approach to pill-taking.  She asked what she should do differently. I summed it up in a word, “Stop.” She followed this instruction.  Off all medicines, including the blue and purple capsules, for a month, she felt fine.  Her blood pressure, pulse, breathing, and sleep were all normal.  Even her thyroid studies were normal off the supplements she had been taking. What the physicians, chiropractors, acupuncturists, homeopaths, and pharmacists in Connecticut had failed to recognize was that she was healthy…middle-aged, middle-class, medium height, average weight, average intelligence and healthy.  Medical treatments introduced to manage an apparently transient problem led to a cascade of chemical interventions that made her sick.

A healthcare provider more experienced than I told me that when the patient or the family or even your colleagues are yelling, “Don’t just stand there. Do something!” you should wake the voice inside you that says, “Don’t just do something. Stand there!”  The tools in hand to improve life are capable of diminishing it. There is always the risk that the next prescription will be dumped into the fish bowl on top of all the others.

Dr. Lechtenberg is an Easton resident who graduated from Tufts University and Tufts Medical School in Massachusetts and subsequently trained at The Mount Sinai Hospital and Columbia-Presbyterian Medical Center in Manhattan.  He worked as a neurologist at several New York Hospitals, including Kings County and The Long Island College Hospital, while maintaining a private practice, teaching at SUNY Downstate Medical School, and publishing 15 books on a variety of medical topics. He worked in drug development in the USA, as well as in England, Germany, and France.

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