Comment by rcpt | Hacker News Reader

Comment by rcpt | Hacker News Reader

“The so-called ‘psychotically depressed’ person who tries to kill herself doesn’t do so out of quote ‘hopelessness’ or any abstract conviction that life’s assets and debits do not square. And surely not because death seems suddenly appealing. The person in whom Its invisible agony reaches a certain unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise. Make no mistake about people who leap from burning windows. Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the same window just checking out the view; i.e. the fear of falling remains a constant. The variable here is the other terror, the fire’s flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors. It’s not desiring the fall; it’s terror of the flames. And yet nobody down on the sidewalk, looking up and yelling ‘Don’t!’ and ‘Hang on!’, can understand the jump. Not really. You’d have to have personally been trapped and felt flames to really understand a terror way beyond falling.”

-David Foster Wallace

Authors who end up taking their own lives often pen some of the most haunting and poignant passages on death:

"It was useless to try to do anything. One could only watch the extraordinary efforts made by those tiny legs against an oncoming doom which could, had it chosen, have submerged an entire city, not merely a city, but masses of human beings; nothing, I knew had any chance against death."

- Virginia Woolf, Death of a Moth

This is where my wife was, a week or so ago.

She was initially admitted to hospital for low Sodium (hyponatremia) with no obvious symptoms - we actually went for something else which was benign. They corrected the low Sodium, but they corrected it quickly - possibly too quickly [1]. The next day she started to become non-responsive, and the day after was completely non-responsive - didn't react to pain stimuli, dropping her hand over her face just made her hand hit her face, couldn't open her eyes etc.

They gave her anti-depressant drugs and she seemed to snap out of it. They kept her in for another couple of days (which the insurance are now arguing over, but that's another tragedy) and then discharged her.

A few days later she stopped being able to walk, she's in constant pain, her legs are tremoring all the time now, her chest is constricted and she's frequently hyperventilating for hours at a time in order to breathe. She gets told she's "anxious", and it's in her head by her PCP. We visit ER several times because she can't breathe properly, and every time she's put on an IV, they maybe give her some sedation (Ativan) and then discharge her a few hours later once she's calmed down due to the drugs.

After 6 weeks of constant pain, next to no sleep, and being told she's fine (when she clearly isn't "fine") she starts talking about how she needs to find peace, and she can't take this any more. She's been building up to it, but I didn't take it seriously enough. Mea culpa. We don't have a gun in the house, she phones friends, asking them if they have a gun, and she'd "take care of everything".

One friend of hers calls it in. Police, Fire-brigade (EMT) and eventually an ambulance appear outside the house as she's sectioned on a 3-day hold. They actually released her the next day, and now she's terrified of "going back". I'm not saying the officials did anything wrong - they didn't - they were courteous but implacable, but they were just doing an unpleasant job. On the plus side, she's not mentioned anything about taking her life since.

A doctor mentions that there is such a thing as Osmotic Demylination Syndrome [2], which can happen when hyponatremia is "fixed" too rapidly. It would explain all the symptoms we're seeing, including the non-responsiveness. Apparently there's an MRI test to see if this has happened. Our next (7th ? I lose track) visit to ER, I get them to do this MRI. She doesn't have it, from what we can see on the data. I ask for the data to send to the neurologist.

Finally, 8 weeks since this all started, the various specialist referrals start to kick in: Endocrinologist, Cardiologist, Neurologist, Gastroenterologist, Psychiatrist... Her PCP hasn't been much help other than to give referrals, and in fact seems to be out of her depth - the last visit to the PCP we were told that the PCP refused to prescribe any more Ativan. That would be reasonable (these aren't drugs to take lightly) if she were to be weaned off them, but no - cold turkey it has to be. I ask the PCP to talk to the neurologist, who seems a bit more human, and the prescription is passed to the neurologist to fulfil.

I won't go into me finding a lump on my balls, and the subsequent worry over cancer (it was just a cyst), or the maybe-heart-attack last weekend that has me seeing the same cardiologist as my wife 'STAT'. This isn't about me. But if I'm out of the picture, well, there's just me, her and our son, the rest of family is 6000 miles away....

So here I am, still trying to sound positive to an intelligent woman who knows just how far she's fallen. Still trying to sound upbeat when she's literally crying in pain (oh yeah, the pain-specialist appointment is still to happen) throughout the night, and OTC pain-killers don't have any effect. Still trying to make it sound like we're making progress even though I can't see it myself. Still trying to answer "why won't someone help me ?" without sounding trite and jaded.

Hopelessness is an insidious poison for the mind. I don't feel the same way, but I can understand how she'd ask about the gun...

1: https://imgur.com/jtGTdn3

2: https://medlineplus.gov/ency/article/000775.htm

What a terrible experience you are going through. I hope it makes a turn for the better, and soon. I'm curious what you mean by one of your closing comments:

>Still trying to answer "why won't someone help me ?" without sounding trite and jaded

Not looking to debate, but genuinely curious.

Because I agree with her that she's not getting the help she needs, but I don't know where else to go.

- Her PCP seems useless - basically a glorified project manager for other expert opinions, and the time taken to get appointments with these experts is straining.

- Going to urgent care, or doing an 'online Dr visit' just gets the advice to go to ER instead, because of the breathing.

- Going to ER (which we have, several times) just gets her admitted to the ER beds, put on an IV for fluids, maybe a chest X-Ray taken, and then discharged after a few hours with a recommendation to go see her PCP.

- the neurologist has been the best of them so far, but she's 30 miles away and we get to see her once per month. I'm grateful for the help we've had from the neurologist, but it's not much use at 3am when she can't breath, again, is in pain, again, and feels like her chest has a bar pressing down across it, again. Going to ER because of this is covered above.

No-one wants to take ownership, everyone (with the exception so far of our neurologist) wants to try and get someone else to "manage this case". It doesn't leave one with the warm fuzzies, especially given the last couple of months.

It has actually reached the point where I've considered - not seriously yet, but it's still there - selling up, leaving the US and going back home to the UK. Myself and my son are citizens by right, I have enough cash/equivalents that getting a spousal visa wouldn't be an issue, and we'd pay the NHS surcharge for a few years - still a lot less than my insurance here. We could even be closer to family for better support. The largest factor against, in fact, is the logistics of simply getting her there, taking a plane seems like a poor option atm, and she gets very seasick even on cruise liners. Once there, having bought a house with the proceeds of the sale of this one, retirement would be pretty easy on me, and maybe a health service more focussed on making people better, over making money, might be better for her.

Can you find a new PCP? One that may not be a good family doctor but can coordinate care.

You are probably already doing it, but I have heard that it is really important to have advocate when patient can't organize themselves. If you can, go to appointments, take notes, and ask lots of questions. Push on uncertainty until get tests and answers. Try and solve separate problems, like Ativan dependency, so can focus on the big one and she feels better. One question I had is what does the treatment for raising sodium too quickly look like and is it worth doing even if the MRI was negative.

Also, I vaguely remember reading about group of doctors that solve medical mysteries. I found an article, https://www.nytimes.com/2019/01/07/health/patients-medical-m..., but not sure one I read.

I'm in the process of looking for a new PCP - although now we actually do have access to the specialists that I think we needed to, and our interaction is more or less just "send a non-urgent message" on the web-platform, and get a referral back the next working day.

I am at every single one of these appointments - I was in a better position to recall how things went down, and I am very much her advocate. She's had many many tests - which have ruled out a lot of truly terrifying things, but there is still no affirmative diagnosis of what it is she has. The last discharge from ER listed her as having "restless leg syndrome" - which is obviously not a diagnosis. The tremors in her legs are a symptom, not a cause, and they only started after the sodium levels were raised.

The treatment was the prednisone that the neurologist put her on prior to getting the MRI data, but prednisone has its own side-effects, so we were told to stop taking it once the MRI data was obtained.

The "Undiagnosed diseases network" is a great find - thank you. I have just enrolled her case in "Teladoc" which can give 'expert medical opinions' using her release notes and visit documentation. I'm hopeful they might find something, but the UDN looks like 'House' for real. I'll definitely look into it :)

This could be absurd but have you tried ChatGPT for clues?

Wild guess (I am not a doctor in the slightest): could it be some kind of dopamine regulation problem?

>Dopamine has been shown to facilitate anti-diuretic hormone (ADH) release, driving the dilute urine excretion which causes hyponatraemia

https://www.e-jmd.org/journal/view.php?number=194

>Previous research has shown dopamine receptors to be altered in fibromyalgia, burning mouth syndrome, and atypical facial pain

https://www.practicalpainmanagement.com/resources/news-and-r...

>We may have been looking at the wrong thing all along, or we may find that both dopamine and glutamate pathways play a role in RLS.

https://www.hopkinsmedicine.org/news/media/releases/restless...

Hey, I've read a few of your replies on this thread and wanted to give a (not official advice) medical perspective. I can't imagine what you and your wife are going through at the moment. As someone working in Australia, the US healthcare system sounds even worse than the stories.

Firstly, her sodium was initially pretty drastically low for just diarrhoea - almost to the point of seizures - unless she was permanently on the toilet and vomiting, and guzzling water (without electrolytes) - suggesting there may be some other underlying cause worth looking into, if she doesn't have major organ failure normally - heart, liver, kidneys.

Secondly, it was absolutely replaced too quickly - though osmotic demyelination syndrome is typically in chronic hyponatraemics whereas if your wife is normally healthy, her sodium should be in the normal range and an acute diarrhoeal illness, whilst a unlikely but possible cause of severe hyponatraemia, would generally be a more acute process. The pathophysiology is essentially that your brain adapts to low sodium and then when electrolytes are replaced rapidly, the brain shrinks rapidly which causes damage to the cells.

Thirdly, benzodiazepine withdrawal is absolutely not pleasant and could definitely contribute/worsen symptoms so that sounds like a terrible idea stopping without a taper.

Personally, I have never seen ODS/myelinolysis but a normal MRI is reassuring and it technically means the diagnosis is no longer possible - there are cases where early MRIs haven't demonstrated any changes but the evidence states that typically by 4 weeks if there is any damage, a scan should show it.

Obviously I don't know what other investigations have been done already, but I hope you and your wife reach a satisfactory resolution, even if it doesn't result in a definite diagnosis - unfortunately there are still many aspects of human health that we don't know about and definitely things exist that we cannot explain. For example, some aspects of the story that you've described make me think of fibromyalgia, which we don't have any good clinical diagnostic test for at this stage - it's just a clinical diagnosis. I'm not saying to give up, but sometimes chasing a definitive diagnosis often ends up proving futile and worsening the whole prognosis - just think about what you and your wife's goals are.

Also, on a sidenote, restless legs syndrome is a real condition (I'm not saying she has it but yes, it is real).

Thanks for the insight, it's much appreciated :)

I guess I didn't get across what I was trying to say about the "diagnosis" - be it restless-leg syndrome (which I totally agree is a real thing, not trying to downplay it) or one of the many other things they've come up with. The point I was failing :) to make was that they haven't come up with a diagnosis at all really - they're just throwing out there anything that might correspond to one of her symptoms, without addressing something that might be a root cause. IMNSHO :)

FWIW, she didn't have any significant diarrhoea - she had a mild instance of it. The thing is that we don't know if she had chronic or acute hyponatremia - she hadn't been for blood tests that would have picked it up in, well, forever, previously to going into hospital. It was news to us that she had it at all - we went in for an unrelated reason (which they told us was benign).

From my limited understanding having read up on it, it's possible she did have a long-term hyponatremia issue going on, and her body was just coping with it until it was discovered. They have done lots of blood-tests (metabolic panels, liver-function, urinalysis, various disease-specific tests, etc,) Her blood-work and imaging all come back fine.

Anyway, she has more CT and MRI scans over the next week or two, ordered by various specialists. Here's hoping they find something to explain it. I still come back to "9 weeks ago, she was without any of these symptoms. Rapidly fixing the hyponatremia has ruined her life". I don't believe too much in coincidence, so for her to suddenly come down with something else at the same time as a medical treatment that made her go completely non-responsive where she couldn't even say her name is stretching credulity too far for me, unless some extraordinary evidence is uncovered.

Thanks, I see now. For some reason I thought you were talking about non-medical help for yourself. I guess you are in some sense looking for non-medical help navigating the medical system itself.

I'm guessing any advice I offer you would have already thought of, but maybe you can pay over the counter for a medical consultant in the UK or anywhere for that matter

You might see if a destination medical establishment like the Mayo Clinic or Cleveland Clinic could be more responsive. These kinds of places are setup so people can fly in, see a bunch of specialists, and get a bunch of tests in a single trip.

It sounds like you're going through a real-life nightmare!

This whole story sounds insane (assuming you're not leaving out essential details), with multiple overlapping failures. I am not a medical professional, so take this all with a grain of salt (no pun intended).

First off, idiopathic hyponatremia in non-elderly, non-pregnant, otherwise healthy people is unusual - why was your wife hyponatremic to begin with? This is worth investigating.

It's amazing to me that it took weeks for you to be told about the risks involved in raising sodium too quickly.

It's ludicrous that a doctor would prescribe daily Ativan for treatment of generalized anxiety in 2023 (Ativan and related benzodiazepine drugs are extremely habit forming, wreck your memory, and don't show evidence of improving anxiety endpoints in the long term. Great for infrequent occasional use, e.g. panic attacks though).

It's even more ludicrous that they would want her to quit cold-turkey if she's been taking Ativan daily for longer than a few weeks. Benzodiazepine withdrawal is unpleasant and dangerous. That said, not being on daily Ativan for anxiety is a good thing. If you want to read up on withdrawing from benzos safely, the Ashton Manual is a popular (although older) source a lot of medical and recreational users have used to get clean[1].

As for the psychological aspects of this ordeal: The only way out is through - you just have to keep going and keep advocating for yourselves. If you haven't already, I highly recommend getting set up with regular therapy for both of yourselves. Falling down happens to us all- getting back up is an difficult but essential part of life, and having a third party there to remind you of your forward progress and push/encourage you when you need it is very valuable.

[1] https://www.benzoinfo.com/wp-content/uploads/2022/07/Ashton-...

Thanks for the info :)

Regarding leaving stuff out. I'm really not. My only concern here is getting my wife well, and she absolutely had none of these symptoms previously, or any hint of them, and whilst I haven't described every individual visit to ER in detail, they all follow the same pattern as recounted. We've just had the first round of specialists, and I don't have a very high opinion of her PCP, but now that we have the specialists, I'm more hopeful that something might get done.

None of the doctors involved told us about the dangers of raising Sodium quickly. The neurologist agreed that it might be and put my wife on Prednisone/something-to-help-her-stomach after our first visit. It was actually my boss' wife (she's a doctor) that mentioned ODS to him and hence to us. FWIW, work has been outstandingly supportive over the last couple of months, the only real shining light.

The MRI doesn't seem to support ODS though, but I personally think it's too much of a coincidence that she responded so poorly, and then symptoms very similar to it emerged later. It might not be ODS, but something happened. She had none of these symptoms before going in.

As for why she had hyponatremia, she had diarrhoea the week previously, and the hospital put it down to that. We had no idea her sodium was low - as I said we went in for something unrelated (that turned out to be benign).

The PCP put her on Ativan, right up until she said "I don't feel comfortable prescribing this any more, so I'm not going to". Cue the argument about withdrawal and the PCP saying she'd talk to the neurologist and see if the neurologist would take over. I get the feeling the PCP is very much a "fair weather" doctor - fine for when things are fine...

The neurologist has changed away from Ativan to another benzo, but has also prescribed mirtazapine as a more long-term solution. We have another visit with her scheduled at the end of the month.

> They actually released her the next day, and now she's terrified of "going back". I'm not saying the officials did anything wrong - they didn't - they were courteous but implacable, but they were just doing an unpleasant job.

I do not know your experience obviously, but this reads like more weight is put on how they handled it and less on your wife's experience. I'm glad they didn't handle it poorly (which is already too common), but being held against your will can be a seriously traumatizing experience. Regardless of if they did the "right" or "wrong" thing, the fear of losing your rights again can be severe and cause even more damage in the long term. I just want to make sure her likely terrible experience isn't overlooked because the medics followed their instructions.

In my personal experience, I had a traumatic experience after talking about suicide as well. I didn't talk to anyone about it for many years afterwords because of that experience and the fear of it happening again. Arguably, I'm worse off because of that, since I have felt significantly better after eventually opening up and (luckily) not having a second traumatizing experience. But I recognize that even though everyone followed their orders properly, it can be terrifying to the individual.

> On the plus side, she's not mentioned anything about taking her life since.

Again, I don't know your personal experience, but I would strongly suggest you talk to her about this. Not mentioning it does not mean not thinking about it, especially if there's been a traumatizing experience in the past related to openly discussing suicide. She might be on edge discussing this topic with anyone, including you, because of the experience she had. I know what helped me is knowing I had someone that I could talk to without risk of being "turned in," which I suspect you wouldn't want to subject her to again. You can fact check me on this: talking about it won't "plant the idea" back in her head or anything.

You sound like you care a lot about her. Someone like you is the reason I'm here still, so you're doing something right :)

It did come up - it's hard to avoid an elephant in a room, despite the saying... I'm not going to go into details, but we did and do talk.

I also don't want to give the impression that my concern is more for the process than my wife - while writing, I didn't want to be seen to be blaming them for enforcing the 3-day hold. Once someone's called it in, and the police making the house-call decide it's plausible, they don't deviate. They were kind, but firm, is all I was trying to say.

Good to hear! I didn't mean to imply anything; just wanted to make sure that wasn't overlooked having been on the other end of it. Good luck to both of you

I'm so sorry your wife (and you) are going through this. When the medical system fails, it fails hard. I don't know what to say except that I hope you all get to the bottom of this quickly and she gets the help she needs.

> Still trying to answer "why won't someone help me ?" without sounding trite and jaded.

It's a combination excessive bureaucracy/control/legalization of the medical profession in addition to incompetence, apathy etc. You are unfortunately on your own, as is everyone else. A lame "I feel sorry for you", is all I can say, that you have to go through it

(for those interested in starting some kind of parallel medicine, and willing to do what it takes to learn the ropes, see my profile and get in touch with me.)

While some people really do have to make a choice between fire and falling, many who think they're in that situation may actually be hallucinating of the fire. They don't have to fall; they can be helped.

This is pretty good considering the fact that David Foster Wallace took his own life in the end. I read the whole quote before I saw at the end it’s from him.

Takes one to know one, as we used to say...

It also might be revealing to read the account of the guy that jumped off the Golden Gate Bridge and survived.

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