When your patient tells you they lost their appetite, there is whole differential diagnosis that has to be explored. But what if your patient has multiple reasons. And what if that patient is you.
Last Thursday, I went to bed overstuffed, having eaten too much holiday peppermint bark ice cream. When I woke up in the morning, and didn't feel like eating, I thought it was GERD, took a TUMS, and walked to the train.
That was two days after my daughter's Opa, and my ex-father-in-law died. For good or for bad, he was resuscitated, and everyone has been living in limbo for the last ten days. My connectedness to his illness seemed remote, being that I am estranged to the family since my divorce, but, as the week wore on, I would have to admit that his ICU stay, and the little I knew about his case through his very non-medical son/ my ex-husband, was more distressing than I could have guessed. The financial grievances mostly over, it had cleared the way to the bigger grievances of divorce. I have lost whatever family I spent investing in for the last 15 years. Now I am outside of even their deaths, but never truly disconnected. Strangely, because of her age and the ICU policy of no visitors under the age of 16, my daughter is living this limbo also, and bearing it about as well. She is getting support from school friends, and we have talked about her Opa, and how she sees death, but it weighs on her, even if she believes he might end up, like the Wolf Pups of juvenile fiction, transported to Canus Major and Minor, to watch over her from the familiar constellations, just as her cat Nancy Drew does, from a full moon.
For 5 days, over the weekend, I was on call. The hours sound stupid (24x5 equals a ridiculous 120), but really I was free from calls all except the last night, so it was much closer to 50 hours of time on site, which shouldn't have felt so bad, but it did, and I was so exhausted by the final night, that when they called me just shy of midnight to announce the death of a man we had been expecting for 5 days, I was afraid they might need to call me in, and was planning to negotiate another in house MD to declare his death, because I did not feel safe to drive by them.
I often get too busy to eat lunch, but I wasn't feeling hungry at breakfast, or supper either. Was it my gallbladder? But it wasn't painful, just uncomfortable. I had gained some abdominal weight since the end of summer, and that would explain the GERD. Maybe I was just resetting. Maybe I was exposed to a disease during the week. I had been in rooms with C difficile diarrhea, RSV, pneumococcal pneumonia, and other unexplained respiratory and diarrheal infections. Maybe I was fighting those off, or experiencing a mild form of the cold viruses going around.
The definition of depression cannot be made unless symptoms have been experienced for at least 2 weeks. I could not be depressed, but I felt increasingly depersonalized and numb, as there were daily visits to one dying skeleton whose family spent the entire time wishing he was dead, instead of looking around at each other and taking care of the living, other visits to a young woman who had spent ten years with chronic pain as such a terrible experience that she avoided potential treatment of a newly found cancer until it was untreatable, and was still waiting for it to be worse to do anything about her new steps. There was the 90 year old woman with two doting sons who advocated for her, but she still could not decide who to choose to be her decision maker, and was not yet ready to decide for herself while she still had her faculties, because she only had metastatic renal cancer that had spread up to her lungs and stomach, but she might not die for a while yet! There was an elderly man who was no longer able to take care of himself, who had been held a virtual hostage on the floor for months, awaiting a long term care bed. Both he, and the unhappy girl with cancer had been fed this pipe-dream of the next place being better, so therefore doing nothing to make it personal, even though they had been there for weeks, and would likely be there for weeks more. It was enough to drive a sane person to insanity. Decide your level of care! Put up Christmas decorations! Let your family visit! What are you waiting for? Tomorrow could be too late!
So, when I was hungry, once or twice, I ate. Sometimes I felt weak, so I would make a salad, or eat some banana bread. I used up leftover bread in toast, and occasionally had a bowl of cereal. I had no fever, and I tried to get enough sleep, which I did. But 10 days after my daughter's Opa was revived into an incomplete recovery, and now 2 days after the skeleton finally took his last breath, I am still exhausted, and not hungry.
I don't think it's GERD, biliary obstruction, C diff, or any other colitis, pneumonia, viral respiratory illness, or other physical ailment. I know it is not depression, and could hardly explain it by grief. I know I am burnt out, and that my stamina is terrible to have it happen in 4-5 days, but that doesn't explain my loss of appetite. I don't mind for now. I haven't binged since the night of the ice cream incident a week ago, which is extraordinary. But I wonder what is truly happening, so until it passes, I will continue to increase the list of the differentials, for now avoiding the worst ones that it could be: esophageal obstruction, extrinsic duodenal obstruction from a renal mass, pancreatic cancer; all diagnoses I saw this week. I'll take a TUMS, and reach out to friends. I'll take a walk, and keep hydrated. One day soon, I expect I will be hungry again. I hope it's before my next shift.
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