WILTIMS #312: I'll do it in a GIFfy!

I am a PRN of lorazepam! I'm taking this as a compliment from my supervising psychiatrist, but I bet it needs more explanation before most of you will see why.

My supervisor asked me to interview a new patient near the end of the day. We had heard that he was a little upset about being admitted against his will, which seems understandable. My supervisor thought I could handle him (but it would probably be best to keep around the nurse assigned to watch him). Brimming with confidence, I set out to find the patient.

About 30 seconds later, having found the nursing station abandoned, no staff members in sight, and realizing I have no idea who this patient is, what he looks like, or where to find him, my confidence returned to Toby Turtle levels. After awkwardly walking in circles enough that schizophrenic patients came over and asked if I was ok, I finally figured out that a nurse was already talking to the new patient in a private room.

Disappointed and dejected, I shuffled back to my supervisor and explained that the patient was busy talking to a nurse and was unlikely to be free or willing to talk with me in the near future. He listened and shrugged. He said (paraphrasing), "Oh, well that's ok. I was really just going to use you to calm him down a bit and if he's already isolated and talking to someone, that's probably fine. You just have such a soothing presence; you're like a PRN of lorazepam." [Translation: you're like an as-needed anti-anxiety drug] - I think this is a good thing. Also, I know that a few of my readers (e.g. my siblings) would take issue with this description of me.

TIL: The major cause of death for patients who die from complications of eating disorders is hypokalemia (low potassium).

It is important to remember that when psychiatric patients decide to stop taking their medications, they usually stop taking all of their medications. Thus it is not uncommon to see patients with decompensated diabetes, sudden hypothyroidism, or severe high blood pressure.

Though we're warned when studying for boards about the rare heart birth defect caused by lithium use during pregnancy, called Ebstein's anomaly, in real life the risk is so much lower than the risk of untreated bipolar disorder, especially with a suddenly discovered, unplanned pregnancy, that often lithium is actually the best choice for treatment.

WILTIMS #311: One week down!

*Disclaimer: This post contains stories about actual patients. Any identifiable traits of said patients have been changed, and any non-pertinent details have been either changed or omitted. Whenever possible, permission was sought to write even the vague, altered descriptions below. As I am currently at a VA, all patients will be referred to as male, even if that is not the case, as a female patient would be relatively identifiable. If you suspect that I have overstepped my bounds and breached someone's confidentiality, please notify me immediately at CDMinNY@gmail.com*

There sure is a steep learning curve, but after making it to the end of the first week of my first clerkship, today felt good. Building off my semi-usefulness from yesterday, I think I actually brought something to a patient's care today that no one else on the team could bring.

This morning was crazy. The unit was packed with patients - some that had just arrived and needed to be processed for their inpatient stay and others who were being discharged and were itching to leave. On top of it all, the doctor I normally follow was taking the day off, so the med student burden was passed to another doctor who already was dealing with more than her fair share of work. She tried to have me interview one of the newly admitted patients with whom she was already pretty familiar, but the patient declined, as he has every right to do. So, I twiddled my thumbs a bit and tried to stay out of the way until an opportunity to be helpful presented itself, which it eventually did.

A patient I had been getting to know the past few days had been irritating the staff and other patients, rather uncharacteristically, last night. He was supposedly acting up again this morning and the nurses complained that something needed to be done to isolate him and hopefully calm him down. I'd talked to him one-on-one for over an hour the other day, so I actually knew him better than anyone. Since I felt pretty comfortable with him, and I honestly was curious and concerned about what had changed since I last spoke to him, I offered to go talk with him in a separate room and see what I could find out. The overworked doctor and case worker could not have looked more surprised or relieved. After all, I was killing two birds with one stone: distracting the problem patient and getting myself out of their hair.

We sat down in a secluded room and I asked him how he was doing. He definitely seemed a little off from yesterday and, as he explained his perspective of the past 24 hours, I learned why. In this environment you have to take everything a patient claims with a grain of salt, but I felt I could trust his narrative. I tried to get across that while I don't always agree with his methods of handling situations, that I was sympathetic to his perceived slights. And after a little more digging, it turned out that some of the things that had bugged the staff actually had very reasonable explanations.

One problem in particular involved his worry that because he wasn't quite as upbeat as he was in recent days, that the nursing staff would think he was slipping back into the depression that was part of why he was admitted in the first place. This is an especially dangerous line of thought, because anxiety about seeming depressed can make you more depressed in a sort of self-fulfilling spiral of negativity. I tried to reassure him that no one involved in his discharge planning was thinking along those lines and that, although he doesn't seem quite as chipper as the past couple days, after hitting the low of attempted suicide and the high of the initial rebound, it may take some time to see where his new baseline is.

I also reminded him that he's a fairly normal guy on an inpatient psych ward. When another patient seems to be pressing his buttons, he needs to remember that they are likely very sick. It can be very hard when you just want to keep to yourself but your ability to walk away from a situation is actively restricted, as it is at certain times of day in this unit.

By the end of our talk, I think we really connected and he seemed to feel a little better. I felt vindicated that the reports from staff that seemed so inconsistent with my understanding of him were clarified by hearing his side of the story. After we parted ways, I went back to the nurses station and explained his story. I was pleasantly surprised how willing the nurses were to accept the patient's explanation for things once I was able to advocate for him.

It's a nice reminder that the psychiatric population is one of the most vulnerable we deal with in medicine. They frequently get the terrible double whammy of behaving in ways that are hard to interpret from a normal perspective and being unable to advocate for themselves when those odd behaviors are inevitably misinterpreted. Our school leaders told us that this year we would be at the bottom of the totem pole, but that we would have the best chance of our careers to really advocate for our patients. Glad that prediction is already coming true.

TIL: At the VA, veterans only receive free care for conditions directly caused by their service. This gets a bit murky when the problem is psychiatric rather than physical. Obviously if you're shot in the leg while on active duty, then the injury was service related. But is it really the VA's responsibility if a veteran had psychiatric symptoms before their tour of service? What if there was an underlying condition but the service exacerbated it? In these instances, the VA has a complicated bureaucratic system for determining exactly how service related a condition is as a percentage. If a condition is determined to be more than 50% service-related, then it's treated free of charge. Less than that and your insurance kicks in, likely with some copay.

WILTIMS #310: Sometimes, just ask

I actually did something productive! I was joking on Tuesday that my only helpful attribute was being male so that I could check the bathrooms for the missing veteran (who has since been found BTW). Well today, I finally did something useful in my capacity as a medical student. It was reported by the nursing staff in morning report that a normally compliant patient refused to take his medication last night. This came as a bit of a disappointment to the medical staff as we had had a very pleasant meeting with him the previous day about reducing that medication but in a safe, controlled way. As my supervising doctor was very busy this morning with some new admissions, I was given the task of interviewing the handful of his patients that I'm familiar with, one of the goals being to figure out why the patient had refused his meds. A common reason on a psych ward is a paranoid delusion that the meds are doing something other than what the doctors/nurses say they're doing.

The answer turned out to be very simple. I asked him why he refused the medication and he very reasonably explained that the nurses were giving the medication later at night than the patient was comfortable with. All it took was someone (like me!) to ask and for the doctor to schedule to medication at the evening dispensary time instead of the night one and we were good to go.

I know this is a tiny action and the mystery would definitely have been solved by someone else if I weren't there, but it still felt nice to be actively involved in improving a patient's care.

This case actually has another interesting point. The medication was at the center of our efforts to pin down what was ailing the patient. He had been on this med for years, but we are concerned that it may be treating a condition he doesn't have. So we began weaning down the dose to see if one of three things happens:

1. The patient gets worse, showing that the meds were doing something right
2. The patient gets better, showing that the side effects were severe
3. Nothing happens, showing that the medication wasn't doing anything and should be discontinued

TIL: Don't prescribe benzodiazepines to recovering opiate abusers as both drug classes depress respiratory function and if the patient falls off the wagon, they risk life threatening drug interactions.

Double depression is a term for when a patient with dysthymia (chronic atypical depression) develops a major depressive episode as well.

WILTIMS #309: Keyed up

I finally got keys! There is nothing more annoying while working on a psych ward than having to ask someone to let you in and out of every room ...except perhaps being the person that has to let me in and out of every room. So to the relief of everyone, I finally got my own set of keys.

Speaking of keys, inpatient psych wards don't have traditional door knobs. Knobs or handles, as well as anything else you could loop a noose around are strictly prohibited, as are all items out of which you can easily make a noose, like shoelaces.

A safe door handle

A safe shower handle

Another psych special arrangement is the panic buttons in every office. The office that I've been using the past few days has three separate panic buttons: a button on the wall, a stomp pedal under the desk and a secret code on the computer keyboard. I've been warned that, if I should ever hit one, a whole lot of people will show up very quickly.

TIL: Ailurophobia is the fear of cats.

Noesis is a word for cognition or the process of thinking. Why we need another word for this is confusing. This word is actually far older and more complicated than the others and relates to an ancient greek philosophical concept of the duality of the process and object of thought, represented by noesis and noema respectively.

Perseveration is the term for a pathologic repetition of an action or speech. Often the action starts out due to a normal stimulus but then continues far beyond the socially acceptable time period.

WILTIMS #308: The VA

So out of the ~25 people in my class doing their psychiatry clerkship right now, I am the only one at a Veteran Affairs (VA) hospital. I wasn't terribly worried about it being a VA, but being alone on my first clerkship seemed a daunting experience. After two days at the hospital, I think my division of anxiety was spot on.

Everyone I have interacted with at the VA has been wonderful. It might just be culture shock after driving 45 minutes north from my apartment in the Bronx, but I swear every person you walk past in the halls or on the sidewalk makes eye contact and says something to the effect of "Good morning" or "How's it going?" or, at the very least, gives a smile and a nod. If you tried any of that in my neighborhood you would, at best, get weird looks and, at worst, get stabbed^*.

Today a veteran with relatively loose restrictions on staying in the building ran away. The psychiatrist I was following was frustrated, bordering on irate throughout the whole ordeal. At first, I was a little put off by the doctor's emotional response and shortness with the police officers that showed up to get information on the missing person. Then I recognised this reaction. It's the reaction of a family member when someone close to them does something stupid and dangerous. It's the "if he survives. I'm gonna kill him" sort of mentality. Everyone at this campus cares about the patients as if they were family. Sometimes family disappoints you or makes you angry, but that doesn't mean you don't care. And when your patient is like family, you can't help but care about them as you care for them.

TIL: A general rule for psychoactive medications is that you have to wait ~5 days for the blood levels to level out before doing a blood test to see how the patient metabolizes the medication. And when you do draw the blood level, it should be as close as possible to halfway between doses (so for a once a day drug, wait 12 hours after the last dose).

If you're ever a psych patient and you have a sarcastic sense of humor, you may want to lay off the jokes during your interactions with the staff. The whole way that sarcasm works is by saying something that is out of character or opposite of the obvious reaction. A sane person might say the same thing sarcastically that a psychotic person might say seriously. You do not want a doctor/nurse to rely on tone of voice to understand which you mean.

The treatment for lithium overdose is emergency dialysis.

*Jenni would like me to point out that this is a bit hyperbolic as our neighborhood is not that bad.

WILTIMS #307: Psych!

Today was my first day of my first clerkship of third year. A reminder to those who are rightfully confused about the various stages of traditional medical education in the US: third year consists of a series of 6-8 week clerkships where students work in a hospital or outpatient setting to learn about the different major areas of medicine. During these clerkships, the medical students get to join a medical team and actually take care of (very few) patients (under extra-super-duper supervision).

My first clerkship is in psychiatry and today we had an introductory meeting with the school-wide clerkship director. He is also the course director for the behavioural science course at the end of first year and it was fun to experience his unique teaching style again. Here are some highlights of his spiel:

• Unlike nearly every other specialty, the S in SOAP is most important part of the progress report for psychiatry. Usually in medicine, we are all about the objective. We want physical findings, vital signs, test results, etc. Our clinical judgement is just icing on the cake that ties together everything we discovered in the objective section. In psychiatry, however, nearly all you have is your clinical judgement, so it takes far greater importance.
• Psych is a field that treats the most vulnerable populations.
• Psych is useful to non-future psychiatrists for a few reasons. First, the vast majority of people with psychiatric conditions are treated on an ongoing basis by their primary care physicians. For example, regardless what specialty I go into, I will always be treating patients on antidepressants. Thus it would behoove me to know the basics of depression and its treatment. A second reason to pay attention to this clerkship is to be able to properly identify when a patient needs a psychiatry consult. I may not base my future career around patients with psychoses, but some of my patients will develop psychoses while being treated for something else under my care.
• The inpatient setting, regardless of the specialty, is like working on a submarine; if a problem arises, you need to take care of it yourself because there is nowhere else to punt the problem to.

TIL: Defining the problem for a psychiatric patient in a modified psychiatric progress note requires explaining the impairment, not the diagnosis. As I said a long time ago during behavioral science, hearing voices isn't a problem until it negatively impacts your life.

"mre" is an abbreviation for "most recent episode". An example usage is "Dx: bipolar d/o mre depression" which translates to "Diagnosis: bipolar disorder with the most recent episode being depression rather than mania".

PHQ-9 is one of a series of diagnostic tools for mood disorders. The number, in this case 9, indicated how many questions are used. PHQ-2, for example only uses two questions and thus has the tradeoff of being much quicker to administer, but is much less specific - leading to false positives and less useful results.

WILTIMS #306: Entering the panopticon

In a continuing, entirely accidental, theme for the day, we were repeatedly told today of the similarities of third year and entering prison. Our first tale was of the panopticon, an eighteenth century prison design that allowed one prison guard to watch all prisoners simultaneously. This was, of course, impossible to actually do, but because the prisoners couldn't see who was being watched at any particular moment, they had to assume they themselves were being watched and adjust their behavior accordingly. The corollary for us is that, even if our attending physician isn't directly visible, our actions may still be judged by other members of the medical team, so best to always be on one's best behavior.

The next pearl of wisdom came from my advisory dean. He is amazingly adept at saying borderline impolitic things in deceptively discrete ways. As my house (not Ravenclaw but you've got the right idea) sat with this dean for lunch, he described what he calls the fee-for-service system of the medical hierarchy. Playing off the payment system doctors use to bill patients, the idea is that if you want something from the resident (i.e. to scrub in on the next surgical case) you may better your chances by offering to do some of the menial work the resident needs done. Essentially, there can be an element of quid pro quo, tit for tat, or, in the words of Matron Mamma Morton:

That's not to say we don't have a right to our well-payed-for education as medical students, just that we can make things a whole lot easier on ourselves if we make things easier on the even more overworked people above us.

We were also reminded that the residents we will be working under for our first clerkships are just as new as we are, with most of them starting residency on July 1st, having been "doctors" for a grand total of a month. If they are from international medical schools, as is often the case at a couple of our hospitals, they may not even have gone through a similar system or know what what is expected of us. So, we shouldn't be afraid to let someone know if something seems off.

The final item of the day and of our entire transition to clerkship week, was a somewhat awkward ceremony where we heard various speeches about the wonders of third year, we recited a decidedly non-Hippocratic oath, and we watched fourth year students present awards to residents they appreciated during their third year. This is kinda like making newly sentenced inmates watch a ceremony for the best prison guards as voted on by their soon to be cell mates. I guess it's sorta nice to see who are some good mentors for next year, but I'm already so overwhelmed with all the other things going on that I doubt I'll remember any of these people when I get to the wards. And the folks who would most appreciate watching these residents be recognized, such as the vast majority fourth years who have actually learned from them, aren't present. Anyways, odd. Not bad, just odd.

And with that, we concluded our transition from the classroom to clerkships. We have a glorious five-day weekend to exercise any remaining demons (or just exercise) before donning our mini-white coats and buckling down for what has been billed as our most exhausting and exhilarating year of med school.

TIL: If your supervising physician tells you to go home, go home. This is not a test. Your grade will not be affected. Leave. Use the extra time to stock up on one of those basic needs you've been ignoring, such as food or sleep.