1 Boring Old Man

I found my thoughts traveling down an odd path recently. It started by thinking about the returning soldiers I saw after the Viet Nam War and the few I’ve seen recently from our contemporary wars. Early on, I was surprised to find that often the hardest part was not what had happened to them in combat, it was the things they themselves did and felt there that haunted them. And some of their rage was at having being put in a situation that evoked behavior they didn’t know they were capable of, brought out feelings that they didn’t know were there to be felt – the dark side in modern parlance. And for many, the emotional range was blunted by the experience. After having a few close friends killed, one can become wary of attachments, or love, and almost phobic about grief or entanglements that might lead one to feel it. Likewise, on a battlefield, some proportion of the people there aim to kill you – and vice versa. That does little for interpersonal skills. In Iraq, sometimes perfectly safe looking people explode. Self preservation means more than just staying alive, and these preservative adaptations in the interior landscape can and do persist well beyond their points of origin – as elements of the post and the dis-order of post traumatic stress disorder.

Then I thought of something that happened in January in Texas. We’d visited the Alamo and were walking back to our car when my wife decided to go back and buy some item she’d seen  along the way. I sat down on a concrete wall to wait. I was lost in thought about the Alamo and Davy Crockett when a scene unfolded maybe thirty or forty feet away. Two elderly women were on the sidewalk when three adolescents, two on skateboards and one on a bike came zooming down the sidewalk, hitting one of the women who became airborne and landed in the street head first. There were scores of hotel employees nearby who ran to her aid. The kids hesitated, then panicked and hightailed it. Cell phones appeared calling for an ambulance, the police. The assembled onlookers divided into caretakers and people outraged at the boys – all upset by the scene.

From where I sat, I could see that the woman was conscious, but didn’t move. I didn’t either, but stared intently at her limbs, worried about a spinal cord injury. Within a few minutes, she moved her hands, then her feet, and was talking to the people in attendance. I was in doctor mode, even though my days of emergency medicine are well over four decades ago. The people at the scene were agitated about the irresponsibility of the kids or worried about the victim. I was closest to the boys and saw their reaction. The one on the bike was urging the others to stay, and they started to do that. They were all three obviously terrified. The two on skateboards panicked and took off with the third following yelling for them to come back to no avail. They weren’t "bad boys" – that was obvious from my perch on the wall.  The woman had actually stepped in front of them – my guess was that she was hard of hearing. They shouldn’t have been hot-dogging on the sidewalk, sure enough, but they were clearly as traumatized by what happened as the victim. The boy may have escaped the scene, but what happened will stay with him, I think.

The ambulance, a fire truck, and a police car appeared in seeming record time. The victim was now sitting up talking to the EMTs. My wife came along and wanted to hear the story. I briefly told her what I saw, gave a clinical report [conscious, talking, moving all four limbs], and said the boys seemed traumatized and would probably not be doing something like that again. I wondered if the three would even remain friends. Her reaction was like that of other bystanders – worry, outrage, upset, asking for the details.

At times like that, the things I feel are muted. I’m immediately in something of a clinical mode, scanning for the medical needs. What I feel is distinctly abnormal – some kind of hypervigilant calm – I’m sure from my ER, Code Blue days even this long after the fact. Such things have a way of sticking around indefinitely. As a young doctor, I might’ve rushed to the scene and done some hand waving and such. As an old doctor, I just watched and ticked off the things that were needed making sure all bases were covered. They were. But internally the net result was the same – in my medical mode, emotionally shut down, thinking, thinking. How in the hell did my mind get on this topic? Military Trauma? Old Doctor mentality?

I actually wrote this shortly after returning from the Texas Risperdal Trial, but put it aside because I couldn’t see where it was going. Here’s what brought it back. I’ve spent part of this week writing a letter to the editor about that Gibbons et al meta-alysis claiming to disprove the "black box" warning of suicidality and touting the effectiveness of antidepressants in kids. With help, I wrote and rewrote it, removing my emotional reactions along the way – getting it down to "the facts" in the case [and there were plenty of them]. But on the side of my mind, I was thinking How can this [the meta-analysis] be what matters about depressed kids? What about their lives? their experience? Whatever is going on with these depressed kids is laying a base for the rest of their time on the planet. Medication yes/no just isn’t the right question, and downplaying the downside just adds insult to injury. That’s the same thing I was thinking in that trial in Texas. Drug reps trying to open up the child market for Risperdal? in Foster kids? What were they thinking? At times like that, I become hyper-aware of how much of what we are is shaped by our experiences – how much individual experience directs how we feel, creates our idiosyncrasies. Thus my noticing my doctor-mode at the scene in San Antonio.