WILTIMS #422-6: End of January catch-up post

Tuesday was a good day. As I assume is the case with most jobs (not that this is quite my job, yet), most days are OK, some suck, and a precious few validate all the work I do the rest of the time. On this medicine rotation I've had a surprising amount of moments that remind me why I love medicine (the royal medicine, not just internal medicine). Tuesday just had a few more than normal and it felt nice.

I explained atrial fibrillation, in extreme detail (diagrams included!), to the elderly daughter of an even more elderly patient and she was super grateful. Then I correctly called that that rhythm wasn't actually atrial fibrillation even though my supervising intern and resident both thought it was. (It turned out to be MAT). Then I saw another patient in the ER and spent more time asking questions than anyone else on the team (because I need to know useless answers to useless questions for assignments that residents don't have time to ask). After asking if she had any questions or needed anything else, she said no thanks and to tell my parents that they should be proud of how they raised me. Not bad!

Unfortunately, I next had to go up and tell that first patient's daughter that the elaborate explanation of AFib that I gave earlier (and the CT scan we sent her mother for) were unnecessary due to that misdiagnosis. So I redrew the diagram and honestly explained why we changed our mind and why that's a good thing. To my surprise the daughter wasn't mad. In fact she thanked me with big hug (after asking if that was ok).

Some days being in medical school is miserable. We rarely do anything useful and we mostly get in the way. Tuesday was not typical, but it was a needed reminder of why we suffer through the rest of the days.

MondayIL: BIBEMS is an acronym for brought in by emergency medical services.

TuesdayIL: The dosing scheme for azithromycin is different depending on what you're treating. For an STI, like chlamydia, you give 1 gram one time, but for pneumonia, you give 500 mg on the first day and 250 mg for the next four days.

WednesdayIL: The MAZE procedure is a really stupid, really cool surgical treatment for atrial fibrillation. As a last ditch effort to keep the heart beating normally, if a surgeon is already doing open heart surgery for another reason, they can slice or burn up the arium, literally making a maze for the aberrant atrial pulses. The SA node gets a straight path and can beat the sickly AFib depolarization to the AV node. This is a terrible way to fix this problem, due to the numerous complications of... you know... purposely scarring the hell out of the heart.

ThursdayIL: *Those really annoying standardized patients - the ones that torture us by not giving useful information until you ask about one very specific part of their history - are actually very accurate representations of many patients. I had a patient today that we were medically clearing for the psychiatric team. So, knowing that, I very gently asked about her current mood and then pressed a little to find out what had made her depressed. She listed a couple things but it didn't seem like enough to put her on suicide watch. Flash forward to ten minutes later. I'm asking about her smoking/drinking/drug habits (just to be thorough) when I learn that she is 30-something years sober. Great! ...also, uh... from what and why? Turns out she heavily used alcohol and cocaine after her husband and two children were killed in an accident. Only at this point did she offer up that this might still be part of why she's depressed. It can be hard to know what questions will get the patient to offer up that crucial detail.

FridayIL: The rheumatologist at my hospital teaches his subject matter with the ease that a dentist pulls teeth; even with ample pain medication it still hurts like a bitch. But after a tortuous half an hour of asking non-rhetorical questions to a room of unknowing and uncaring med student, we did eventually start learning a thing or two about messed-up-looking hands. Some takeaways:

If it looks like twisty-boney joint deformities: osteoarthritis. If the DIP joints are hyperflexed, the PIP joints are hyperextended, and the MCP and wrist joints are swollen: rheumatoid arthritis. If an old woman with fluid-filled solitary joint enlargement: gouty arthritis.

*Patient details changed for anonymity*

WILTIMS #318: A psychiatric portrait in pieces

Since beginning my psych rotation, I have been trying to find a way to represent the difficulty of piecing together a story from all the different sources we tap during a patient's inpatient stay. The best I could come up with is trying to analyze a picture only adding one color at a time. Let me take you through both a patient and a picture's story. The example patient is purely made up, but based loosely on experiences from the past few weeks.

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The first perspective we get is from a nurse or police officer who only knows what they saw the patient doing when the patient was referred to us. We might get something like "the patient was found wandering the street and talking about killing himself." Ok, so perhaps we're dealing with major depression and suicidal ideation.

In the painting above, all we can see is one color. With only the red to show us the scene, we can make out a few people and perhaps some trees. If I had to guess, I'd bet the woman in the foreground on the right was the important part of the picture.

──────────────────────────────────────────────────────────────

Next we talk to the patient himself. In the admission interview, we sit for a long time and try to get as much as we can from the patient's perspective. But this is still just one data point and, particularly with psych patients, the information we get may not be reliable. "Well sure I was suicidal; I've been depressed all my life, but when my father was killed by CIA I lost it." Huh. Now this seems like more than depression. Some of this is delusional, but how much?

In the above painting, we add green to the red. The two colors blend together and show more than either alone. Suddenly, we see details that were all but invisible before. There are way more people in the background, they don't seem important though. There's a cat in the foreground... prominent, but probably unimportant as well. What about that umbrella though?

──────────────────────────────────────────────────────────────

Now that we've had a moment to peruse the patient's old medical records, we can see that some things don't add up. We see that, yes, the patient has a history of depression and that he's been treated for suicidal thoughts before. But there's a big gap in his charted history and he's been on an antipsychotic medication in the past. Now, that seems important.

Next in the picture, we've added in the third primary color, blue. With it we've confirmed a lot of what we suspected from the beginning: the woman on the right is still prominent, there are people in front of a background of trees, and a woman with an umbrella is still seeming interesting. But suddenly there are gaps in the picture that beg to be filled in: why does the grass end on the left and, most intriguingly, what's that white blob in the middle?

──────────────────────────────────────────────────────────────

In the patient's old chart we see a phone number for the patient's brother and decide to give him a call. Suddenly everything gets a little clearer once we have context. Turns out the missing time was from when the patient was committed at another facility. The brother confirms the lifelong depression and that their father passed away right before the patient was committed, but that was years ago. Lastly the brother remembers something about hearing voices.

Suddenly the whole picture changes thanks to some increased complexity. This isn't just a scene in a meadow; it's a scene on the water. Now I know that white blob in the middle is important and I'm pretty sure I know what it is.

──────────────────────────────────────────────────────────────

We return to the patient and finally get the closest we'll come to an answer. Turns out he still hears voices. They're mean voices that blame him for his dad's death and badger him to hurt himself. The depression is and always has been there, but it's the voices we need to try to treat. We can't find everything out about every patient, but we can find the important things if we get enough perspective.

Our painting is as clear as it's going to get. There are a lot of things going on, but the item that draws the eye is the little girl in the white dress. However, we can't derive any meaning from this focus without the context provided from the scene. All of this requires layers of color and detail that blur together into a complete picture.

Part of the reason I picked this painting is because it's an example pointillism rather than realism; you simply can't see every detail because the painter omitted them, just as in psychiatry you can never know every detail of a patient's life. We must be careful, then, to give each piece of art its fair share of attention, lest we miss the details that spark our understanding.

TIL: There is a higher incidence of schizophrenia in people born in winter or early spring. It's hypothesized that some seasonal infection at a critical developmental time in utero, for instance the mother getting the flu, might be the cause. This is just one of many correlations that have been found, with genetics actually being the best predictor.

WILTIMS #317: Swing and a miss

Ouch. If only to prove that I don't use this platform just to boost my ego: today's performance was less than stellar. I didn't do anything catastrophic, but I was quickly reminded that I am still very inexperienced and it's a good thing people are watching over me.

Bright and early on this miserably hot Monday morning, I was asked to begin the admissions interview on a new patient from over the weekend. I had heard the quick summary of his story during morning report, so I wasn't working off a blank slate. But those preliminary scribbles on the proverbial slate were not comforting.

This patient was very sick. I knew it was going to be a difficult interview, but I've interviewed difficult patients before. I was hoping that I could stumble through enough open-ended questions that we'd build a rapport and the conversation would gain some momentum. This is normally a skill of mine: turning a stumble into the first lunge of a steady jog.¹ Well, sometimes you just fall flat on your face and that's harder to recover from.

Case and point: (the details are totally changed but, as you'll see, it hardly matters)

Me: So Mr. A, can you tell me your understanding of why you're in the hospital?
Mr. A: Because I'm cuckoo!
[Mr. A smiles heartily as I falter]
Me: Um... Well, why specifically are you here? What happened in the past few days?
Mr. A: WellIgneh... [mumbles] ...'m the Emperor and had all those people killed. [laughs] Yep, I did.
[I make a funny face somewhere between concerned and hesitantly amused]

I know that this is new. He had said some pretty disturbed things over the weekend, but never an outright delusion. But is this a delusion? The way he's laughing, it seems like a joke. But given his history of psychoses, he might think it's real, for all we know. How does one respond to a delusion-joke hybrid?

[I look to my preceptor, pleadingly]
Me: Um... well...

And my advisor takes over, to my shame and relief.

I talked with my advisor afterwards and everything was fine, but it sucks when you just freeze up. I had never gotten just random disorganized thoughts back at me from these sorts of questions and so I didn't know where to go with the conversation. Usually you start with open-ended questions and see what the patient wants to talk about. Then as you get an idea of what the important concerns are, you steer the conversation to areas that weren't touched through the natural flow of conversation. Finally, you drill in on any specifics that were missed.

When a patient gives you nothing but fantasy, what do you do?

TIL: When the above happens, you throw out the normal interview format and go straight for specifics. This way you can keep them on track and see what they are even capable of when it comes to effective communication. If they begin to settle down, you can then return to the more open-ended interview style.

¹#humblebrag

WILTIMS #159: The beginning of the end

Today included our last didactic lecture of the first year. We have a neuroanatomy practical final tomorrow morning which begins two weeks of the typical hellish exams. I think tomorrow will be my final WILTIMS post of the year!

The other activity today was a behavioral health conference where we watched a psychiatrist interview a patient, for probably the eighth time this term (five of those times were in smaller sessions led by a student). Something I've learned from these encounters is that you never know if the important information will come out 5 or 45 minutes into the interview.

You can't explicitly ask the patient about every possible delusion or symptom. Most of the time is spent getting a feel for the person and trying to hit upon the biggest aspects of their current and past mental disturbances. The most out-there story might not be elicited until near the end of the time and by the most innocuous of questions. Learning the knack for stumbling upon those triggers is truly more art than science.

TIL: Certain bone fracture patterns are characteristic of child abuse. Since juvenile tendons and ligaments are proportionally stronger compared to bone than in adults, traction (pulling) or torsion (twisting) injuries can result in nasty fractures along the epiphyseal-metaphyseal junction (the ends of long bones near the growth plate). One such pattern is called a bucket-handle fracture, seen to the left.

WILTIMS #154: The interviewee becomes the interviewer

Today I had my last behavioral health clinical conference at our main teaching hospital. These are the sessions where we split into groups of ten, disperse around this and several other hospitals, and watch as one student interviews an actual psychiatric patient about their life and the difficulties that led to their inpatient stay. Typically, there are also a couple other students either on their third year psychiatry rotation or part of a different program. I reluctantly volunteered to do today's interview and it went surprisingly well.

While I sat waiting for the overseeing doctor to fetch the patient, one of the third year students turned to me and asked, rather cryptically, "Do you remember me?" Though she did seem vaguely familiar, I couldn't think of any reason I would know a third year, let alone why a third year would know me. She continued, "I interviewed you last year."

Now, in a flash of confusion due to the setting and an overactive imagination, I briefly thought, "But I haven't ever been a psych patient..." before realizing that she had in fact been one of my interviewers for admission to this med school. Our school uses the multiple mini interview (MMI) system, with eight rapid-fire six-minute sessions. The interviewers are a diverse assortment of people including professors (both researchers and physicians), administrators, and often one student. Recognition finally dawning, I told her that I did, in fact, remember her and the questions she asked me.

She, and I'm not making this up, said that she remembered giving me the highest marks of all the interviewees that day. I abashedly thanked her and pointed out that she may have made the difference that put me in the seat next to her today. How's that for a nice boost of confidence before taking the hot seat?

TIL: Psychosomatic medicine is a subspecialty of psychiatry, formerly known as consult-liaison psychiatry, that deals with the interplay of psychological disorders with medical ones. This can mean both psych symptoms as a reaction to a medical diagnosis and physical symptoms experienced as a manifestation of an underlying physiological illness.

WILTIMS #149: Psychiatric sci-fi

After the last couple behavioral science clinical conferences, I came to the conclusion that psychiatrists have to have an amazing imagination. In order to get a delusional or hallucinating patient to divulge their psychoses, you have to put them at ease. If you look at them like they're crazy when they talk about hearing voices, they'll close up and not talk about them anymore. You have to be totally at ease with even the craziest things that your patient says, so that they feel safe discussing things that they likely know most people don't understand.

The best psychiatrists have to be able to nod sympathetically when they hear about alien observers, ESP powers, and NSA conspiracies (admittedly that last one is more plausible nowadays than it was in the near past). I feel like sci-fi nerds could have the biggest advantage here.

Question of the Day: Is it ethical to treat a patient on death row for a psychiatric disorder that prevents them from being executed? You cannot be executed if you don't understand that you will die and that your death is the result of a judgement made against you for your actions. So helping someone reach that realization effectively condemns them.

TIL: Psychologists have a 5 year waiting period before they can begin romantic relations with a former patient.

Trichotillomania is the pathological pulling out of one's own hair.

WILTIMS #123: Oh, behave! (-ioral science)

Today I had my first behavioral science case conference and it was one of the most captivating experiences I have had yet in med school. A quarter of our class (about 50 students) decked out in our white coats filed into a small room in the behavioral health center at the nearby hospital and watched our professor interview an actual psychiatric patient. I won't share any specifics due to patient confidentiality but I think we were all surprised by the level of delusion we witnessed today.

Some thoughts from that session:

• When interviewing a possibly psychotic patient you must always remain calm and understanding. The patient will be watching to see if you can handle the story they're telling before they are willing to reveal everything.
• When appropriate, only challenge the delusion once - just to see how solid it is. Then back off and regain the patient's trust. Challenge in this case means merely asking if the patient has ever doubted that the delusion is real - not yelling at them or anything truly confrontational.
• You must be careful about your emotions when dealing with medication non-compliance. Whereas it might be frustrating with other more physical medical problems, remember that non-compliance is actually part of the illness with psychiatric disorders.

TIL: Deer Hunter is a messed up movie. I'm pretty sure our professor wanted to teach us about PTSD by giving us PTSD using the most disturbing parts of this movie.

If a person with depression has one manic episode ever, then they are diagnosed as having a bipolar disorder.

Generally, bipolar patients who are undergoing treatment maintain the same level of symptoms throughout their lives while schizophrenic patients progressively decline.

1 in 7 people with untreated depression and 1 in 5 with untreated bipolar disorder will die from suicide. There is an emphasis on untreated here, but these numbers are still frighteningly high.

WILTIMS #41: Uno!

We started today being bombarded with the intricacies of the arm and forearm. For some semantic reason we are calling the upper arm simply the arm. This made for some confusing statements such as, "The median and ulnar nerves don't innervate anything in the arm; instead, they travel all the way through the arm and innervate the muscles of the forearm."

We had to change into our white coats and professional attire for the second half of the day as we had the privilege of watching a sample patient interview by one of our professors of an actual patient. The patient was a kick in the pants and even though we were packed like sweaty alabaster sardines, we really enjoyed the lecture. Afterwards we broke up into smaller groups in the modular rooms upstairs to discuss the process of interviewing patients, specifically in regard to showing empathy.

I had a nice pair of experiences that I think beautifully show both my inexperience and potential. We were asked what we would say to a patient who we had just informed that she had mononucleosis. My first response was,

What's mononucleosis!? I feel like I know this... Is it a cancer? What has one nucleus? Who let me into this school anyway?

Meanwhile, one of my classmates responds by saying that she'd ask about the patient's medical history and try to find out where she contracted it from. I'm still beating myself up:

How does everyone else know what this is!? We don't take pathology until next year!

Then a second classmate takes a stab at it, saying that he'd want to find out what treatments are available and relay that to the patient since mono is treatable.

MONO!? How did I not know that mononucleosis is the full name for mono! Of course this disease isn't named the equivalent of "uno."

Hey wait, I know the answer to this and it nothing to do with the disease!

"Anyone else?" my professor asked, clearly frustrated at the direction my fellow classmates had headed with the question.

I raise my hand. "Well, I think I would first try to reassure her that..."

"THANK YOU!" The professor abruptly cuts me off. "Reassurance is exactly the word I was going for." She goes on to explain how to best reassure patients after giving hard diagnoses, while I start to feel better about my mono mental lapse.

TIL: In the loosely transcribed words of our example patient: "There are only two people you don't lie to - your doctor and your priest... and your mom!" Noted.