Laura Riley perched her spectacles on her nose, ran a hand through her auburn hair and got ready to shatter a few stereotypes. It was Sept. 6, her first encounter with the eager, all-female class of Vet Tech 208: Large Animal Disease.
"Today we're going to talk about safety and restraint with large animals. I can't teach you guys experience, unfor"- her voice wobbled - "tunately, but I can share mine with you."
She told the students at that horses kick backward, that cows kick-box to the side and that some horses kick like cows. Swung back suddenly, she said, a horse's head can land an unprepared tech in a Medevac helicopter.
Dr. Riley's warnings carried authority. Working with horses, the 4-foot-11 veterinarian had suffered a broken collarbone, a fractured pelvis, a chipped kneecap, several broken fingers and two broken ribs. A brush with a llama ruptured two discs in her neck.
She looked perfectly healthy now, standing there in her tiny clogs, sipping from her water bottle. Who would have guessed she had faced such challenges?
Or that she was grappling with something even more dangerous?
The teacher did not tell her students about the new scar behind her high-collared blouse. Nor did she explain the reason her voice periodically faded in and out like a weak station on a car radio.
That story was too unsettling - far worse than any barnyard accident. And it was still unfolding. Medicine had not yet learned how to handle the illness that had hospitalized Laura Riley a dozen times. No one knew how to restrain the beast she called the black dog.
Instead, the veterinarian shared tales about horses, cows, alpacas and emus. She dispensed insights into difficult animals and difficult people. She issued challenges.
"How do horses get sick?"
The students, some wearing lab coats decorated with kittens and puppies, balked.
"Anyone else? Have I extracted every little thought from the collective mind of the class?" she teased.
Her own search for medical answers had recently pushed her beyond conventional wisdom. Laura Riley, DVM, had become a scientific guinea pig. It would be months before she would learn whether her experimental treatment would help. But large animal medicine had taught her the power of patience.
Often, she told her students, the secret to gaining the upper hand over skittish, unpredictable animals was to hang tight until they calmed down. The trick was to outwait them.
The vet techs scribbled down her words, nodding enthusiastically.
By the end of class, Laura Riley shared their optimism. Her thoughts were flowing; her spirits were high. Despite her trembling voice, she had pulled off a darn good course introduction. Teaching was another step forward into her new life, one that no longer tolerated the pressures of private veterinary practice.
This was a day about hope.
The country veterinarian had arrived late to her dream of a James Herriott career. Already in her 30s when she worked her way through college, and then veterinary school, she spent five years in an established practice before striking out on her own. Word spread through north Baltimore and Harford counties that 40-year-old Laura Riley was quick to arrive, capable and consoling on the job, generous with the follow-up calls. It was clear that the petite doctor with russet pigtails not only understood large animals, but also knew how to handle their owners.
Before long, she was treating roughly 600 patients for 250 clients. It was a demanding job for a single woman in a solo practice. And if that had been all she had to deal with, life would have seemed ideal.
But Laura Riley was also sick.
For a long time, the veterinarian had not known the name of the demon she was fighting. But she kept a journal of its visits, noting physical changes that signaled trouble, such as the high-pitched ringing in her head that sounded like revving jet engines. Changes in her psyche were more difficult to describe.
"It is sort of a waking nightmare in which one is alone in the dark, and there is a large and loathsome presence gaining on you. This evil intruder, this black dog nipping at my soul. . .You can smell its fetid breath and feel the warm moistness as it exhales around your neck. You attempt evasive movements to no avail, and your energy drains from you as sap from a dying tree until you can move no more."
At its worst, the black dog shredded her cognition and swallowed her sense of time. One minute could seem like 60. When her body could no longer feel what time meant, there was no way to reassure herself that her mood would pass - in an hour, or two, or by tomorrow. The most hellish moments found her pinned between agitation and paralysis, her mind racing, her body frozen.
"It is like being buried alive with a discrete allotment of oxygen and the ability to know the rate at which you are using it up," she wrote. "You watch yourself die ever so slowly. ... That which is confining you gets closer and closer and hotter and hotter until you beg the powers that be to let you die now ... or better yet, to kill you."
There were days when the veterinarian was so leaden with despair and exhaustion that she could no longer perform the simplest tasks. Why is it taking so long to put on my coat? she wondered one afternoon as she tried to get ready for an appointment. This coat no longer seems to fit. Have I grown somehow since yesterday? Is it someone else's? She wrestled with the garment for a long time before realizing she was trying to put it on upside down.
Such slow-motion fatigue could alternate with high-gear euphoria. Some nights, she haunted 24-hour supermarkets; some days, her thoughts raced faster than anyone could keep pace.
One day in the spring of 1997 - one she remembers as the best day of her life - the veterinarian felt unusually clear-headed, strong and purposeful, ideas flowing like a river. Why, she even felt tall.
Who would think to call a doctor?
Three days later, the 42-year-old woman had crashed into a depression so severe that she wanted to kill herself.
"Suicide: I am sitting here looking at a bottle of Beuthanasia solution," she wrote. "It is neon pink. I guess so that you can't mistake it for any other injectable. I use 120 cc to put down the average horse. That is a little heavy-handed but I want to be sure that all goes smoothly. For me, I would put it in a one liter bag of saline and open it up wide ... "
When she could no longer control such thoughts, she drove herself to the emergency room and was admitted into the psychiatric unit.
It was not until her second hospitalization later that year that Laura Riley learned she was dealing with bipolar disorder, a condition she had known of as manic depression. Her illness combined episodes of major depression with hypomania, a mental state with abnormally elevated, or irritable, moods. Although no one knew what caused the neurochemical imbalances in Laura's brain, doctors thought they were probably triggered by genetic tendencies combined with physical or emotional stress.
Nearly two-thirds of those with bipolar disorder had abused drugs or alcohol - and Laura was no exception. During the years she had struggled to make a life for herself, alcohol had smoothed the edges. Eventually concerned that drinking might affect her work, the veterinarian gave up alcohol altogether and turned for support to a self-help group. Just two weeks after becoming sober, her dangerously unpredictable moods surfaced. The timing seemed too precise for coincidence: Could alcohol have masked her condition? It seemed likely.
Laura's manic depression was characterized by "mixed mood states." In transit from one mental state to another, some bipolar patients become frozen in overlapping moods. Laura could find herself paralyzed by a combination of depression, morbid thoughts and agitated energy that made her long for death.
"I used to think that people killed themselves on a whim. That they didn't understand that if they hung in there, things would get better," she wrote. "I used to think that suicides were reactions. I also used to think that the majority were cowardly acts committed by people too afraid to trade some of their pain for this miracle of life.
"Now I know there is another sort of person who takes his own life. The person whose quality of life is nonexistent. Whose pain is capricious and as headstrong as a sulky child. The exhausted person. The beaten person. The hopeless person who has agreed to every treatment modality no matter how demoralizing, terrorizing, nauseating, expensive, disruptive."
Laura's body would not tolerate lithium, the drug most effective for manic-depression. Instead, she set out on a frustrating, often sickening, path of trial and error. One drug made her so dizzy that she fainted if she stood up too suddenly; another made her hair fall out. Some drugs drained her energy and robbed her memory. Others made her vomit. Some made her lose weight, but most made her gain it.
In time, she would try more than 30 medications and a course of electroconvulsive therapy - electrical stimulation to the brain - to combat her suicidal depressions. She would discover that no physician understood the neurochemistry of her disorder - and that nothing stabilized it for long.
From April 1997 to January 2001, she spent almost 110 days in psychiatric wards.
Unknown to her clients, she returned many of their pager calls from the hospital. Often she could put out "little fires" this way, scheduling future appointments while her colleagues filled in on emergencies.
Only a handful of people knew she was sick. One of the most painful parts of mental illness, she discovered, is how few people understand it. Laura kept her condition and its treatment to herself. It was all too stigmatizing.
Instead, she coped with manic depression by writing about it. It was one way to bear witness, to keep distance between herself and the enemy.
Perhaps her descriptions could reveal something that could save her, or provide a trail of breadcrumbs to rescue someone else. At the very least, perhaps she could help translate the living hell of this disorder for those less able to explain it. She would try to make her sickness visible. By erasing some of its mystery, she might drain some of its power.
So Laura wrote as she sat in emergency rooms and doctors' waiting areas. She wrote behind the locked doors in hospital wards. She described medical blunders and compassionate caretakers. She wrote through highs and, when she could summon the energy, through lows. She wrote of hope and fear and gratitude. Armed with a laptop, she sat on the small couch in the small living room of her small house trying to escape the claustrophobia of her condition.
While she was writing, the words could temporarily draw a magic circle around her. Sentences formed spells against the black dog's deadly plots.
Just as she had hunted down treatments for sick animals, the veterinarian trusted she could find a route to her own recovery. After all, she was a doctor with many contacts in the world of medicine. She understood drugs. She knew how to read research papers. She was resourceful.
In January 2000, she went in search of a psychiatrist to stay the course with her, a seasoned coach who could provide encouragement and perspective. It took six months to find Mark Crandall, a sage and kindly man whose slightly rumpled and careworn demeanor reminded Laura of the Velveteen Rabbit. The perfect partnership formed, and not a minute too soon.
Her disease was draining her. She could no longer handle the middle-of-the-night phone calls, the surging emotions of people desperately concerned about their animals. And she worried that her judgment, impaired by depression, might compromise the care of her patients.
She was also having manic symptoms. At first, she merely felt smart enough to solve all of her friends' problems. Then she discovered a clever way to talk on the phone and trim the lawn at the same time: She would cut the grass with scissors! Next she took apart every fan in the house - including the motors - to rid them of dust.
There were other signs: Laura was talking louder, and talking a lot; a close friend warned that she was having another "tall day." Laura set aside 40 one-dollar bills in case she felt the overpowering urge to shop. Visiting The Dollar Store could satisfy her craving without catapulting her into debt.
Keenly aware of the dangers of Laura's disorder, Dr. Crandall was always ready to schedule an extra session or tinker with her medications. Laura's moods could shift suddenly without much warning. One day she would be labeling furniture to give to friends who survived her. The next day, she would be sitting in the dentist's chair, an appointment she'd never keep if she were planning to die.
"My malady is ... an evil sprite toying with its prey," she wrote. Being alert to infinitesimal changes in mood and spirit - Laura called it "looking for the snowflakes that predicted the avalanche" - had virtually become a full-time job.
Her real job was simply too much.
In July 2000, she disconnected her business phone and told her clients she was taking an extended leave of absence. With Dr. Crandall's help, it was time to redefine herself. It would prove the toughest chapter in her history of transformations.
Laura had grown up in a tumultuous household with an alcoholic father who disappeared periodically into rehab programs. When her mother suffered a major stroke, the girl assumed even more adult responsibilities, until life at home overwhelmed her. She dropped out of high school in Morristown, N.J., and explored the freedoms and sorrows of "little girls who end up on the streets."
By the age of 20, however, she had moved to the Greenspring Valley to exercise thoroughbred horses at Sagamore Farm - the heart of Maryland horse country. She loved the graceful animals, which had always served as an escape from her family. And she had a plan that fitted her 90-pound frame: She would train to become a jockey. When a track accident dissolved that dream, Laura set her heart on becoming a large animal veterinarian. She proved her dedication by earning scholarships to help continue her education.
Now, facing another hardship, she needed a new goal. Laura's family had also included teachers of the first rank: dedicated women who ran Head Start programs and inspired first-graders. She believed she had inherited the gift of communication. Maybe, through writing and teaching, she could use her experiences to benefit others.
As for money, part-time teaching wouldn't bring much. The costs of running her own business - and paying off student loans - had not left the veterinarian wealthy. But she had always paid the bills. Now she faced $6,000 a year in health insurance premiums alone. She would have to apply for permanent disability.
Only 45, the self-made woman cringed at the notion of dependency. But mental illness also brought smaller humiliations that could wound deeply. Before she got sick, Laura enjoyed a respectful relationship with the medical staff of hospitals. Now, admitting staff tended not to listen when she told them she'd had a hysterectomy. Each time, before they gave her a new medication, she would endure another pregnancy test.
I told you I can't be pregnant, she would say. My uterus hit the pan years ago. It's all there on my chart.
Some would apologize later. But it was safer, easier, to do an unnecessary test than to listen to her. Even her peers no longer saw her as a medical professional, she realized. She had become just another "psych patient."
Sitting in Dr. Crandall's waiting room one day in September 2000, leafing through a copy of Readers Digest, Laura found a short article about an experimental treatment for depression. A new device called a vagus nerve stimulator, a "pacemaker for the brain," showed promise in controlling certain forms of depression that resisted conventional therapies.
The story seemed tailor-made for her situation. Was someone giving her a sign?
She read on: A surgeon implanted the pocket-watch-sized generator into the upper left side of your chest, then fished wires underneath your skin to be attached to the vagus nerve in your neck. At regular intervals, electrical impulses would stimulate the nerve, which, in turn, would stimulate neuro-chemicals in the mood and emotional center of the brain.
The device successfully controlled epileptic seizures in some people. Now the federal Food and Drug Administration was studying its effectiveness at treating certain forms of mental illness.
Laura could not wait to tell Dr. Crandall. Was this something that might work for her? Her illness certainly qualified as "resistant."
Dr. Crandall had heard of vagus nerve stimulation. Although it presented a real possibility, he told his patient, they would need more information before considering such a big step.
After years of trial-and-error therapy, Laura carried no illusions about new treatments. She knew the psychiatric arsenal comprised medications discovered by chance.
It's all quackery, she would say whenever she discussed her psychiatric regimen. To call it an inexact science is putting it lightly. When you're mentally ill, the doctors can't measure what's wrong with you. The science is still in the Dark Ages. They're still throwing drugs at you to see how you respond.
As late summer turned to fall, Laura's state of mind began to deteriorate. Her disorder was influenced by the seasons, and she dreaded the battle of the dark winter months. For the last three years, October had brought a painful stay in the psychiatric ward. This year would be no exception.
Laura was hospitalized with her worst agitated depression yet. Desperate, frantic, she begged the doctors and nurses, anyone who came into her room, to kill her. Treated with very high doses of an anti-depressant, her mood eventually stabilized. But Raymond DePaulo, then director of the affective disorders unit at Johns Hopkins, told her he had seen only one other disease cause such agony - rabies.
Just three months later, in January 2001, the veterinarian returned to Hopkins for her 12th psychiatric hospitalization. But this time, when she pondered the words of a physician who once treated her - you don't get better when this disease has a progression like yours - she found strange comfort.
It was time to stop trying to win back her old life, she realized, time to formulate a new existence within the constraints of her illness. She was ready to try experimental therapy.
Twenty-one hospitals were conducting double-blind clinical trials of the vagus nerve stimulator with qualified patients. One site was in Baltimore, run by the University of Maryland School of Medicine at its hospital and the Baltimore VA Medical Center. But Laura was also willing to move to Pittsburgh if she could get into the trial there.
She knew better than to expect too much from such a venture. Experience had been a harsh teacher. If her disorder was like an octopus with eight tangled legs, the "brain pacemaker" might briefly untangle one of them. But that still made the risk worthwhile.
If there was anything Laura Riley wanted to convey to someone else tormented by mental illness, it was this: The quest for treatment, although barely tolerable, can become more manageable with the glimmers of hope she called "tiny life jackets."
With Dr. DePaulo's recommendation, Laura began the exhaustive admissions process. Afraid that she wouldn't get in the study, she was also afraid she would. Being accepted was further confirmation that her brain was permanently broken, her condition so grave it had led to this crossroads.
By the end of May 2001, Laura's paperwork was approved by Cyberonics, the Texas company that developed the device. As a study participant, she would receive the $15,000 generator free of charge. Surgery was scheduled for early June.
The night before her operation, Laura Riley thought about what hope looked like. Hope was traveling away from home without fear of needing psychiatric help. It was resuming, or rebuilding, friendships.
Perhaps most of all, hope meant freedom from herself.
Tomorrow: Laura has the vagus nerve stimulator - a "pacemaker for the brain" - implanted, and discovers additional ways to confront her bipolar disorder.
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