TILIR #8: The Clinic Strikes Back

Today was my first day of clinic since becoming a second-year resident. A lot changes from the first week of first year to the first week of second year in regards to our clinic workload. Initially we don't have much idea what we're doing, both in terms of general logistics, navigating the electronic medical record, and - ya know - practicing medicine. It is, after all, a somewhat shocking experience to suddenly be the primary care provider for children.

We start out with only one patient for an entire morning or afternoon shift in the clinic. By the second week, we are up to two patients and it stays there for a couple weeks. After that for morning clinic we see three patients and afternoon clinic we can see up to four. As second year however, we have clinic all day long, and we also increase the number of patients so we can see up to four in the morning and 6 in the afternoon. All of this means we have to be more efficient with our time or we end up having a lot of extra work at the end of the day to catch up on.

One of the more fun things that I got to experience for the first time today was working with the new interns (the first-year residents). Since I've been on an outpatient rotation the rest of the month, I haven't actually gotten to work with any of them since seeing them throughout their orientation. It was nice little dose of schadenfreude seeing these scared new doctors figure out the ropes. As we helped them throughout the day, it was a pleasant reminder how much my classmates and I have grown in the past year.

TIL: There is an old psychiatric diagnosis called the Cotard delusion or "Walking Corpse Syndrome." It is no longer a official diagnosis in the DSM-5 (the official diagnostic manual of psychiatry), but I stumbled across an old ICD-9 code in the computer for this diagnosis and I just had to look it up. Seems the vague idea used to be that this particular delusion was that the patient believed that their some or all of their body was dead or decaying. Descriptions are rather vague though, and with such a broad grouping of delusions it makes sense that they were just lumped into other somatic delusions.

WILTIMS #413-14: A systemic problem

One of the more nebulous concepts I've learned this year is the interplay between correctional facilities, law enforcement, psychiatry, and medicine. The patients that have experience with the first two likely have a prickly relationship with the latter. The rule with the last three is that they will give you the benefit of the doubt if you're nice and don't heavily abuse any one part of the system. Of course biases exist, as studies (and experience) have shown over and over again. If your community's criminal or indigent population are socioeconomically distinct from the people taking care if them, they fare worse in the system.

Yesterday my medical team got a patient that had been spurned by the other three parts of the network. He was put in jail for drug charges, treated for opioid dependency with methadone while in jail and then released without any attempt to taper the medication or set him up with a rehab facility. In an attempt to get a fix, he immediately did IV heroin for several days while living on the street. Realizing he needed help, he came to our psychiatric ER looking for help detoxing. He was released a few hours later because there weren't enough beds to admit him for detox. He was given a MetroCard and directions to rehab shelters with instructions to go to an ER if he started showing any of the dangerous symptoms of detox.

Six minutes later he checked into our medical ER. At this point he complains of some vague detox symptoms and, oddly enough, pain in his finger. Over a month ago in prison, he had cut his hand. The wound had never healed and now was deep into the joint. Sadly, he probably should have been just bandaged up and sent on his way if one ER doctor hadn't heard a heart murmur when listening to the guy's chest. We never heard the murmur again, but it was enough to get him a bed for the night as we worked-up an unlikely, but potentially serious diagnosis of ok infective endocarditis.

I find it interesting and terrifying that these entities that are meant to help people can be so temperamental. One moment, a patient is our charge to be defended by the system when the next they are a burden to be pushed to the next sap that has to take them. People who need psychiatric treatment are arrested, in jail they are kept from the psychiatric and medical treatment they need, then they are released without any hope of recovering or surviving on their own and end up either in an ER or on the way back to jail. Don't get me wrong; sometimes the system does work. But in my very short experience in medicine, I've already seen it fail more times than should be allowed.

The benevolent connection between all four of the previously mentioned groups (corrections, police, psych and med) is social work. These are the only people that seem to bridge the gaps in this societal support system. They are also frequently the only people who help the patients navigate the time between the four services.

YesterdayIL: The frog-leg test is a way to test for asterixis (flapping movements indicative of a brain infection) when the patient is unconscious. 

TIL: For a P wave to be a P wave it must come from the SA node.

Cardiac pain is midline and lasts 2-20 minutes NOT seconds or hours.

Heart pain can cause a patient to tense their chest muscles to the point where they are sore. This is good to remember because a reproducible pain usually rules out heart problems, but the muscle sprain can be reproducible even after the heart pain has subsided.

WILTIMS #334: Psych out

Quote of the day (as blurted out by a male classmate after the psychiatry clerkship director clarified some question about defense mechanisms): "Oh yeah, like Mean Girls!"

Today was the last day of our psych rotation, so we assembled at our home hospital and were lectured on important highlights of psychiatry in preparation for our shelf exam on Friday. Our teacher was the same doctor that thought us behavioral science a year and a half ago. He's eccentric and fun to learn from - traits on display today when he described several psychologic ideas in this great analogy of music:

Defense mechanisms are like notes of music; think of each defense as a key on a piano. A person's personality is like a song. Each song is a unique combination of notes, just as a personality is a unique use of defense mechanisms. Songs are grouped together into genres in the same way that personalities are grouped into personality types when they're healthy and personality disorders (PD) when unhealthy. Some types of music are fairly benign and well-liked, such as pop or classical music. Others, like jazz, are bold and eccentric, taking the listener right up to the edge of chaos, but back to traditional tones and melodies for a satisfying conclusion. This is analogous to some exciting personalities, frequently of celebrities, as their eccentricities are what make them interesting. A personality disorder is a collection of defense mechanisms that don't work for a healthy relationship with society. These are like atonal or metal genres, which don't typically bring pleasure to the vast majority of music lovers. Of course music genres are just a matter of taste - I really like some metal - whereas personality disorders can be downright dangerous.

TIL: Antisocial PD is said to be the only PD that is nigh untreatable. First of all, antisocial PD does not mean that someone is shy (that's more the avoidant or even schizoid PDs) but rather that they are unremorseful about breaking society's expectations. This means that antisocial people break laws, rules and, most relevantly, psychiatrists' prescriptions for medications and/or therapy.

[Note to readers: I will be studying for the rest of the week, but WILTIMS with return on Monday with day one of my pediatrics rotation!]

WILTIMS #332-3: My first goodbyes

Today was my last day at my first hospital. Tomorrow is a didactic day at our main hospital where all the psych clerkship students come back from their sites to review for our "shelf" exam on Friday. I get the feeling that this year is just going to fly by.

I've said goodbye to hospital staff before, when I worked and volunteered in various capacities at hospitals prior to med school. It's always a little bittersweet, but no different from other jobs. One of the things I'll miss about this bunch is their (dark) humor. The unit was getting pretty busy with more admissions today and few discharges. Someone joked that we should look into discharging patients to nursing homes around the South Bronx because the Legionnaires disease outbreak there is probably opening up beds...

But today I said goodbye to my first patients. When patients leave the hospital, it's great! They're usually doing better and often grateful for the work that we (read: almost entirely other people) have done. Today was different because I was leaving and the patient's were staying. There was no closure. I was sad to say goodbye, but more so, I was sad that I had to leave before my patients had gotten better. In a way, I almost felt like I was abandoning them to their fate; apparently it doesn't matter to my brain that I'm abandoning them to being cared for nearly exactly as they were when I was working, by wonderfully talented professionals. Still, it felt weird.

MondayIL: A diagnosis of rapid-cycling bipolar disorder is made if a patient experiences four or more mood symptoms (major depression, mania, hypomania, or a mixed state) in one year.

TIL: Brugada syndrome is a rare genetic heart anomaly caused by altered sodium channels that, among other things, may kill you at any time and makes you a pain to take care of for inpatient psychiatric care.

WILTIMS #330-331: Psych hits the road!

For the past five weeks, I've gotten a very in depth look at the sort of psychiatry practiced on a locked, inpatient psychiatric unit. This is the best place to see the most dramatic diagnoses that most medical students will never get a chance to see again in their education or careers. But the vast majority of psychiatrists don't practice in this setting. So if you're trying to educate us on not just the rare diagnoses but on this potential career in general, we need to get off the unit for a while. The past two days I got to see a couple of these other settings.

Yesterday, I got to take a mini field trip across the VA's medical campus to the long term geriatric care building. Ironically, the first patient we saw was actually crazier than any of the patients on my usual inpatient unit! Conveniently, this was the perfect case to demonstrate the difficulties of dealing with psychiatric symptoms in elderly patients. There are three things that can cause these symptoms: dementia from old age, delirium from an acute medical problem, and psychosis from a chronic psychiatric condition. The trick is figuring out which of the three are in play at any given moment.

ThursdayIL: Dementia is chronic, progressive, gets worse before bed each day, and is characterized by confabulation (making up answers to questions you don't know the answer to). Delirium is acute, waxing and waning irrespective of the time of day, and frequently presents with hallucinations and altered mental status. Psychosis is a really general term and can refer to many types of symptoms. The big ones are hallucinations, delusions and cognitive changes. As you can see, there is a decent amount of overlap that makes this differentiation difficult.

Today, I traveled another half hour north to another VA hospital that is less psychiatrically focused. Here, the chief psychiatrist primarily does consults on medical patients who have developed psychiatric symptoms during their treatment for other conditions. The other common reason for a consult is to determine the decision making capacity of a patient, either to accept/refuse treatment or to make decisions at home (like how to spent money or whether to drive a car).

FridayIL: The four attributes that you must document to determine a patient's capacity to make a medical decision are understanding (Can they describe the procedure/test/treatment?), appreciation (Can they explain what the expected outcomes/side effects are?), rationality (Do they have a rational way of making the decision?), and communication (Can they articulate a consistent choice?). Note that the rationality requirement does not require that their logic be popular or even reasonable, just that it's rational. For example, "because my obscure religious cult does not allow it" is totally fine. But if the rationalization involves a clear delusion, e.g. "President Obama told me not to through the chip that aliens implanted in my brain", then that's not ok.

WILTIMS #329: It's my birthday, I can post if I want to...

Two years ago today, I was sitting alone with my anatomy book in a desolate Taco Bell/KFC celebrating both my birthday and the first day of classes with some stale cinnamon twists. Now, as I write this, I'm riding the subway into the city to meet my SO for dinner and a show, after a long day working in a hospital. Crazy what a couple years can do.

Today's new psych clerkship experience was having a patient I only knew from walking through another unit suddenly become one of my patients. My supervising doc was very surprised at my familiarity given that I shouldn't have known him. Actually, he was one of the patients that inspired last Friday's post about the utility vs futility of talking to temporarily helpless patients.

I would walk through the hallway by his room and, even though I was a total stranger to him, he called me over and talked. At first the conversation seemed rational, but it quickly took a turn for the bizarre. He's a hard guy to just walk away from though, so I probably spent a good 20 talking to him. I wound up doing the same nearly every day last week. Part of what seemed so interesting was that I had no reason to know him; so unlike all the other patient interactions I have in the hospital, this time I wasn't searching for an answer or gathering back story - just talking.

So today his business became my business. And I quickly discovered that I already knew a lot about him even though I hadn't intentionally tried to discover anything through our prior conversations. Simply listening to people, with no need of special techniques or added motivation, is all you need to learn about them and build a relationship. TIL.

WILTIMS #328: ♪♫ She's a maniac, maniac! ♪♫

Manic patients are a pain in the butt. They're no more annoying to treat than, say, people with schizophrenia, but they are a pain to keep on the unit with the other patients. If you have a group of sick people who are confined to an inpatient psych ward to provide a calm, healing environment, having a patient (or two!) that physically can't stop talking and pestering and advising and touching and... It get's on both the patients' and staff's nerves. Sometimes half the battle for the nursing staff is just keeping the peace between patients.

TIL: When transitioning from oral dosing to long-acting injections of paliperidone (Invega^®), an atypical antipsychotic, you start with a loading dose of 234mg, then on day 8 you give a 156mg booster, and then on day 36 you start the regular monthly dose which can vary from 78 to 234mg.

In a previous post, I mentioned that lithium gets a bad rap as a dangerous drug during pregnancy. At the time, I mentioned that untreated bipolar is more dangerous than the tiny risk of an obscure birth defect associated with lithium use. This is still true, but additionally, all the other mood stabilizing drugs we use to treat bipolar disorder cause other birth defects and at greater rates. Valproic acid (Depakote^®) and carbamazepine cause neural tube defects like spina bifida in 3-5%  and 1% of pregnancies, respectively. By comparison, studies have shown lithium's Ebstein anomaly happens only 0.05-0.005% of the time.

WILTIMS #327: It's getting better all the tiiiime!

We got one back!

We've had a lot of patients, in my month on the psych ward, that came in crazy and left less so. I do find that satisfying, but seeing as I don't know where they started, I don't have any expectation to meet. Today though, a patient that I have been following closely since his arrival, final started looking like he did on that arrival date - not great, but better.

On admission, he was an eccentric (and very manic) man.  A few days later, he was a six-foot-tall two-year-old. At his worst, he couldn't string a coherent sentence together, couldn't keep his clothes on, and couldn't use the toilet. It is so much more frustrating when a patient decompensates if you know what they were like before.

Today, a few weeks into his painfully slow treatment, the fog finally began to clear. Suddenly sentences were coming through again, laughing was somewhat aligned to jokes, and he seemed to know where he was and why.

I played a vanishingly small part in his improvement, but his recovery is easily the most satisfying case I've experienced so far. I can't wait to see who awaits us each day as he continues to descend from the heights of insanity.

TIL: Discharging medications can be ordered at another facility if the patient can't wait for the pharmacy to prepare the prescriptions. This became very useful today when a particular patient decided he wanted to leave against our advice for drug withdrawal observation. Had we forced him to wait another hour for his meds, I'm pretty sure there would have been an incident.

WILTIMS #326: To chat or not to chat

Something I've been struggling with for the past few weeks is how to interact with patients who appear to be just beyond the grasp of our help. If, while walking down the hall, a patient who is very confused starts talking to me, is it worth stopping to talk? It sounds cold to even think of dismissing their conversation, but that is the status quo, and I'm not sure that it's wrong.

Think about a patient in a coma. Research has shown that talking to the unconscious patient can be beneficial to their recovery time. However, that doesn't mean that it's something you need their doctor doing. On the other end of the spectrum, several psychiatric disorders are exclusively treated with counseling. This is exactly when you want the doctor taking time to talk to the patient.

The trick comes when you see a patient that is in the weird gray area of acute schizophrenia, for example. The main symptoms^* of this are hallucinations (sensing things that aren't there), delusions (thinking things that aren't true), and disorganization (thinking in an unusual way). In the midst of an acute decompensation, we talk with the patient, but nothing they say makes sense. We still meet with them regularly, but the conversation is rarely productive. As their treatment progresses (typically once the medications start to kick in), their thoughts begin to make more sense and our interactions are more useful, both to the patient and the treatment team.

But, let's come back to my initial example. You're walking down the hall, on the way to your office but with nothing pressing on your schedule, and a patient flags you down. You stop to see what he wants, but without any perceptible end-point, the patient launches into an extremely detailed story of a friend of his from 30 years ago. Moreover, the patient has a hard time both physically speaking and finding the right words, so his speech is significantly slurred and slowed. After 10 minutes of patiently listening in the middle of the hallway, the patient seamlessly transitions his story into one about aliens from outer space.

This can be useful information to know during an admissions interview when you don't know the patient or how their mind works. But when they've been on the unit for two months and the stories haven't changed in all that time, is it useful to listen? As a medical student, I have the freedom to spend a half hour talking to a patient, so I usually do. I get to see a glimpse of what and how they're thinking, even if what I see is sometimes just a disorganized mess. But on the third, fourth, or fifth time, I'm not sure it's helping anyone anymore. Maybe I should just stop every two or three times they flag me down or once a week. I don't know. A lifetime of interacting with mostly non-psychotic people has trained me to stop and listen when someone wants to talk. I'm not sure that I want to consciously make exceptions to that rule.

TIL: It can be a giant pain in the gluteus to get someone their street clothes on a psych unit, especially when their doctor doesn't know the system yet. The patient needs to be interviewed and determined that they are level three (I don't even know what that means yet (I'll get back to you)), then a nursing order must be made in the chart (not a doctor's note, as I learned painfully today, but a general text order), then a nurse or nursing assistant can go track down the patient's effects. If you bug everyone enough to somehow get all of that to happen, you earn an appreciative smile and a vigorous handshake. Worth it.

^*These are called positive symptoms, because they are additions to or exaggerations of normal processes. There are also negative symptoms (a loss or dampening of normal processes) but they aren't as relevant to this discussion.

WILTIMS #325: You say somato, I say...

TIL: Somatoform disorders changed dramatically from DSM-IV to DSM-V. Somatoform disorders are conditions where a patient experiences some physical symptom, but medical science can't find a reason for either the existence or severity of the symptoms. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the bible of psychiatry. This is the official book of diagnoses that is revised every decade or so, and causes an uproar nearly every time. Whereas traditional medical diagnoses rarely change and when they do it's gradual, the DSM reorganizes the entire field of psychiatry every time it comes out. Whole diseases are invented, merged or deleted.

In the most recent revision of the DSM, the section of somatoform and factitious disorders was one of the most extensively reorganised. Four of the seven original somatoform disorders were removed (somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder) and one new super-disorder was created (somatic symptom disorder). Also, the wording was changed so that there is more emphasis on reassuring the patient that their symptoms are real to them. No one likes to hear that their pain or physical dysfunction is all in their head, even if it is. So instead of concentrating on a lack of medical evidence for their complaints, we are instead encouraged to rule out medical causes and then treat their symptoms using the only ways we know how - psychiatrically.

WILTIMS #324: Pepperoni with a side of paranoia

This afternoon had a beautifully comedic moment, but it was a weird situation so bear with me as I set the stage.

Throughout the day, the patients have activities that they can participate in like music therapy, art expression, board games, etc. I had finished my duties for the day, so to take a break from studying, I decided to sit in on the session and observe the patient's in this setting. The moment I walked into the room, something seemed off.

This afternoon's activity leader was a man I had never met and who, at first, I seriously thought must have been a newly admitted patient. His topic of choice seemed to be poorly informed geopolitical theory and the inevitability of nuclear war - topics I expect from the schizophrenic patients, not the people helping treat them. I love me some good ol' geopolitical debates, but talking about the coming nuclear apocalypse and World War III in a room with paranoid veterans who already have similar delusions just seems like a bad idea. Perhaps he was redirecting an inappropriate comment by a patient, I thought. A few minute of listening to the conversation quickly showed that the more coherent patients where actually giving more level-headed opinions and attempting to steer the topic back to a happier place. Some of them had surprisingly reasonable points.

There are several nurses in the area as well and we were all silently making eye contact conveying something to the effect of, This is weird, right? One nurse valiantly tried to turn the conversation into something more appropriate. "The idea," she said, "that we as a country might want to take care of our own needs before worrying about others', reminds me of our own personal basic needs. I need to take care of myself before I can take care of anyone else. What other basic needs do we have?" It was superb, but futile. A few minutes later the guest activity leader was once again talking about Iran already having a nuke and how we should have bombed China in WWII. A second nurse eventually pulled the man out of the room for a moment to talk with him about the topic, but he came back with the same enthusiasm.

The people that finally put an end to this bizarre situation were actually the worst-off patients in the room. One patient wandered over to where the man was sitting and started to talk over him to us about absolute gibberish. Another offered up his opinion about Iran by talking about eating pizza with a friend. It was beautiful. It was like when a small child says something totally right, but completely inappropriate - like yelling "Mommy, that man smells really bad!" when walking past a smoker. It's inappropriate, but you almost want to laugh and give the kid a high-five, even though they have no idea why what they did was wrong or why you enjoyed it so much.

I wanted laugh and continue the pizza topic, but instead quietly smiled as the activity leader got flustered and decided he was done for the day. Good job guys. I'm proud of you.

TIL: Research has hinted that a large proportion of the patients with comorbid schizophrenia and obsessive-compulsive symptoms may have developed the OC symptoms as a side effect of treatment with the particularly nasty antipsychotic drug, clozapine.

WILTIMS #323: To the Wayback Machine!

Today was fun. I got to leave my clerkship early to give a presentation to the incoming first year class during their orientation. Looking all the way back to when I was in their seats is a bit easier for me than most thanks to this blog. Here is the post from my Tuesday of orientation week. I think it's especially fitting that the group I was presenting on behalf of today did not exist when I was an incoming first year. Our school is always evolving and attempting to make things better. I wonder what changes this new class inspires in the years to come...

TIL: One of the several protocols for tapering a patient down from severe alcohol withdrawal is seen below. Since alcohol's sedative effects act primarily through GABA receptors, instead of giving them more alcohol in the hospital (which would be bad due to all of alcohol's other effects) we supplement with another GABA agonist, usually in the benzodiazepine class of drugs. Below is what the actual order would look like in a patient's chart. The ordering physician would also check on the patient periodically to see if the withdrawal symptoms are being appropriately managed. If not, then the orders might be altered to add another day to give the patient's body time to begin detoxifying itself.

50mg chlordiazepoxide PO Q6h on day 1
50mg chlordiazepoxide PO Q8h on day 2
50mg chlordiazepoxide PO BID on day 3
25mg chlordiazepoxide PO BID on day 4
25mg chlordiazepoxide PO QAM on day 5
25mg chlordiazepoxide PO Q4h prn breakthrough anxiety, max 3 doses/day
Vitals Q4h
If SBP < 100 or DBP < 60 or HR > 100 or pt displays marked sedation HOLD MEDS

Legend: mg = milligrams, PO = by mouth, QXh = every X hours, BID = twice daily, QAM = every morning, prn = as needed, SBP = systolic blood pressure, DBP, = diastolic blood pressure, HR = heart rate, pt = patient

WILTIMS #322: Play nice

It is a recipe for disaster when some patients on the ward have paranoid delusions and others are... well... psych patients. If you think about it, paranoid people see malicious patterns where it doesn't exist. For example, when strangers do something innocuous like making eye contact, the paranoid person interprets this as a sign the person is spying on them or otherwise means them harm.

On a psych ward, there are a lot of odd behaviors going on. People talking to people who aren't there, doing repetitive movements, silently watching a room for hours at a time, etc. Therefore it's super easy for a paranoid person to find abnormal behaviors to interpret as signs of hidden meaning. Unsurprisingly, it can be rather difficult to maintain patients' freedom to move around and keep symptomatic paranoid people happy and delusion-free.

TIL: Though dreams and nightmares occur during REM sleep, night terrors (a disorder where children wake up in extreme fear) happen during stage 3-4, aka delta wave, sleep.

WILTIMS #320-321: Padded walls

Apologies for the lack of post yesterday. That fickle mistress, Sleep, beckoned and I could not resist. The up-side is that you get a double post today!

Schizophrenic patient passing me in the hall today: "This place is a nut house."
Me: "You're not wrong."

Today I learned about a room that I missed during the brief tour on my first day: the isolation room. This is a room with the padded walls that you've seen in movies. Such rooms were incredibly common before new medications were found, starting with the antipsychotic Thorazine in the 1950s. The rooms were used in mental institutions of yore because we had no way of calming down a psychotic patient and, in their fits of confusion, they might hurt themselves. That strategy is considered kind of barbaric now (a whole 60 years later...). But every once in a while the drugs are not enough and we'll have to put a patient in a padded room. Today was one of those days.

I have described a code 66 before. The one other time I've witnessed one of these psychiatric emergencies, the whole process seemed a little overkill. A half-dozen armed police officers along with several people from the other floor joined our entire staff to really just intimidate a non-compliant patient into taking some medication. The patient didn't put up much of a fight and the code ended rather anticlimactically (which is good!).

This time I got to see the real deal. Our patient had become combative with the nurses, kicking one and pushing another. He was unwilling to take any calming medication and threatened to hurt anyone who tried to give it to him. The code was called and the usual battalion of people showed up, ready to get physical if needed. We waited on some special medication to be brought up from the pharmacy and then the whole crew, including police, firemen, nurses, managers, psychologists, and psychiatrists, marched down the hall to the room the patient was holed-up in.

It was an imposing sight. I know so because, along with a nursing student who is learning on the same unit, I was told to stay back because I hadn't gone through the physical restraint training (oh darn...). Instead we watched from down the hall as 15 or so people slowly worked their way into the patient's room, much like clowns into a circus car. From that point on, all we could do was listen. For a while you could tell they were trying to reason with him, though I can't imagine how effective that could have been with that many people standing over him in a tiny room. He yelled angrily and could clearly be heard throughout the hospital floor.

Then something changed. The patient began screaming bloody murder. Not shouting - screaming. I'm sure people outside the building heard him two stories below. Presumably this is when the various care providers determined that talking had run its course and action was needed. Afterwards, I was told about what happened in the room. I'm not sure on the details, but suffice it to say, the patient was poorly restrained, people got hurt, bitten, and spit on - but the patient did eventually get his medication.

Now for my part in the dramatic events! I got to hold the door to the antechamber of the isolation room open as the police et al. dragged the patient down the hall and put him in the padded room. Woot! That's right, 2 years of medical training to be a living door stop. [shrugs] As I told the new nursing student, I'm still just happy when I'm useful at all. She agreed.

We don't just lock away the patient once we have them in the room. They are under constant audio/video surveillance in the nurses station and a staff member must sit outside the door to observe him at all times, in case he tries to hurt himself or he needs medical attention. If the patient can remain calm for an hour, they can be released back on to the unit. It took over six hours for that to happen yesterday, which is rather unusual. The medications weren't as effective on him as for most people for some reason.

The person I felt worst for through this whole debacle was a man who was going to be discharged right before all of this happened. He had already been cleared to go, was wearing his normal clothes, and just needed the final paperwork to be completed. Then he was trapped in the activities room with the other patients for easily another hour or two. As a guy with pretty significant PTSD, he was less than thrilled about being trapped in a uncertain situation in a crowded room with lots of loud noises and yelling going on outside. Thankfully he made it through and got out without any trouble.

ThursdayIL: ICU psychosis is another term for iatrogenic (caused by medical treatment) delirium that arises in acute care units, usually as a result of electrolyte imbalances from IV fluids. As with any delirium, this is a medical emergency.

TIL: The best diagnostic question to ask someone you suspect of having PTSD is "where do you sit in restaurants?" The only two answers you'll get from a PTSD patient are 1) I sit on the back wall so that I can see all the exits or 2) I don't go to restaurants.

WILTIMS #319: Do as I say, unless you do as I do

An ongoing theme for my medical education is learning some of the hypocritical tendencies of doctors. Well, actually that's not quite right. Doctors may do things that they don't want their patients to do, but research has shown that they won't impose their hypocritical recommendations on their patients. For example, obese doctors generally don't counsel patients to lose weight. Doctors who smoke fail to counsel their smoking patients to quit. I don't think this is actually better than just being outright hypocritical.

The example brought up today was in regards to caffeine. Caffeine, like any stimulant, can trigger anxiety disorders. But there's no consistent, evidence-based recommendation for the safe amount of caffeine a day. So the "joke" goes like this:

How many cups of coffee is ok to drink?
One more than your doctor.
How many cups is too much?
Two more than your doctor.

I didn't find it all that funny.

TIL: Panic attacks can mimic many different medical conditions. Since several of those potential conditions can be life-threatening, if someone presents with panic attack symptoms but no history of panic attacks, you must give them the benefit of the doubt and work them up for dangerous conditions like a heart attack or pulmonary embolism. If nothing turns up, especially a few times, then perhaps a psych consult is indicated for treatment of an anxiety or panic disorder. However, epidemiological studies have shown that, if the patient is over ~40 years old and has never had a panic attack, then it's vanishingly unlikely that they are having their first one right now. It's probably worth taking a second look at those possible medical causes.

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.

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

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.

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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?

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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?

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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.

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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 #315: Now, class...

I'm a little burned out today thanks to working really hard repeatedly staying up late to stare into the e-abyss, so this will be a quick one.

An odd aspect of my education right now is that I am formally taught by a huge team of health care professionals. After the mornings of following a psychiatrist and interacting directly with patients, each afternoon I have 1-2 "lectures" on various topics in mental health. I'm quotation-shaming "lectures" because when it's just me and another person in their office for an hour, it feels more like a meeting or something, but not a lecture.

There are no real rules for these encounters, so it's been fun seeing each person's approach to covering their topic. Most are fond of handouts, some break out their DSM-V (the official manual of psychiatric diagnoses), one broke out a DVD, and another took me out to lunch for a change in scenery. I've noticed that several have a powerpoint all made up, but they don't actually present it to me because showing a powerpoint to one person is just awkward.

The DVD I mentioned was to provide visual representations of patients for a session on eating disorders. Finding eating disorder patients is particularly problematic at a VA hospital, not because veterans are secretive or anything, but because of the disease time course. People usually develop eating disorders in a bimodal distribution, earlier when they begin puberty or later when they move away from home. The symptoms are frequently precipitated by a life stressor. Boot camp being a phenomenal stressor and coming right after the highest risk times for disease development, an eating disorder patient is exceedingly unlikely to make it through bootcamp.

TIL:
Mindfulness is the biggest component of the most newly established behavioral therapy. Mindfulness is the purposeful attention to the present without judgement.

WILTIMS #314: Exit plan

Something that has surprised me thus far in my time on this VA psych unit is how much energy is put towards placement compared with treatment. Placement is the process of finding somewhere for each veteran to go after discharge from our unit. "Why can't they just go home?" you might reasonably ask. Well, many veterans and many psych patients are homeless, so veterans with psych issues are especially prone to not having stable housing.

The places to which people are discharged vary from another floor in our building, to any of the many other units on the VA campus, other VA facilities all over the country, drug rehab facilities, nursing homes, medical foster homes, the patients' families, or ideally to their own homes. Social workers, the unsung heros of health care, have to work with the psychiatrists to assess how good the patient is at taking care of themself, to assess the risk of psychiatric or substance abuse relapse, to find out the patient's financial situation, and, what is often the hardest part, to convince the placement site to take a patient that is really a borderline fit.

Many of these patients have been through this system several times and have burned a lot of their bridges after past discharges. The conversation with the facilities that will even consider taking the patient turns into a negotiation for what the patient must commit to to be allowed to leave. Some conditions for discharge include reliably taking meds, quitting smoking, agreeing to attend support groups and consistently taking showers.

Some of the most difficult cases we've had recently involve people we just can't find a home for. They clearly are no longer a danger to themselves or others, which are the general problems that get them locked on an inpatient unit. But even though they're better than they were upon admission, they still can't really live on their own and are just too odd or difficult for a facility to take. If we can't find a place after a long enough time, the patient may end up on our chronic psychiatric floor, from which they may never leave. We work really, really hard to avoid that.

TIL: A patient who suffers from chronic alcohol abuse who also has a history of gastric bypass surgery is at very high risk of developing a thiamine (vitamin B1) deficiency, leading to Wernicke's encephalopathy and eventually Korsakoff syndrome. Alcoholics have increased use of the vitamin, decreased storage capabilities and poor transportation through the body's tissues. Meanwhile gastric bypass surgery bypasses the main areas of absorption in the duodenum and proximal jejunum of the small intestine. The symptoms of these conditions can present very similarly to the psychotic symptoms of schizophrenia, so you must be careful when teasing apart the mental and medical issues with these patients.

WILTIMS #313: Code 66

Every hospital I've ever worked, volunteered or studied in has had a totally different set of emergency codes. Usually there are colors (e.g code blue, code red, code brown) mixed with other random codes that inexplicably ruin the theme (e.g. code triage, code zebra). You'd think some of the well known ones like code blue would stay consistent, but some hospitals just need to be different, so you have to relearn them at every facility you find yourself at.

My current hospital has two codes that I've been told to know: code 66 and code 99. Why you would pick the only superimposable numbers is beyond me. In any case, code 66 refers to a psychiatric emergency while a code 99 refers to a medical emergency. Exactly a week ago, I saw my first (false alarm) code 99. After the code was called over the campus-wide intercom, an ambulance, paramedics and eventually two doctors showed up to make sure the patient was alright medically (he was).

Today I saw my first code 66. A patient was not responding to the nurses' calls to calm down and he would not let them give him a sedating medication. Once the code was called, myself and all the psychiatric staff rushed out of the nearby offices to the area the patient was in, in case we were needed before the real help arrived. And boy did it arrive. A nurse and doctor from another floor as well as six fully armed police officers arrived to help subdue the patient until we could administer the sedative. Given the modest danger of being on a locked ward with some agitated, very physically powerful patients, it's nice to know that a whole lot of help is just a call away.

TIL: When giving a sedative in an emergency situation as mentioned above, remember to be patient and wait for the medication to take effect. It can be easy to succumbed to panicky pressure to repeatedly inject the patient until you see results, but you must remember that these drugs take time to take effect. Doubling or tripling the dose can quickly over-correct the agitation and even kill the patient.

B52 or 5-2-50 is a common concoction of medications used at an emergency sedative and antipsychotic. in each of the two names, the 5 and 2 represent 5 mg of haldol and 2 mg of lorazepam, respectively. The B and 50 refer to 50 mg of diphenhydramine, aka Benadryl.

In 2004, the FDA issued a black box warning on antidepressants that warned of an increased risk of suicide in children. Though it seems counterintuitive, the data showed that for certain patients at a specific point in their treatment, they go from being suicidal and apathetic, to still being suicidal but having enough energy to commit the act. If the kids make it through this period, they're in the clear, but the FDA thought parents should be warned. In 2005, more children committed suicide than any year on record - not because of the antidepressants, but because a large percentage parents misunderstood the tiny risk and refused to let their children take antidepressants at all.

The three classic treatments for refractory suicidal ideation are clozapine, lithium, and electroconvulsive therapy (ECT). ECT has gained a bad stigma, for good reason, as it was one of the treatments of choice during the dark ages of mid-20th century psychiatry. Though, most of the old uses had little supporting evidence, a few conditions actually respond very well to shock therapy. The big difference today is that we actually use anesthetics so that the brain is effectively given a seizure as a sort of electrical reset without disturbing the patient in any conscious way.