Category: Medical

One thing I have noticed these past few weeks that was especially apparent today is how tenuous our ties to reality and to our lives as we know them can be; how easy it is to lose control. I’ve met a lot of people whose lives have been ruined by substance use, and for all their differences, a lot of the stories are somewhat similar. Alcohol, weed, cocaine, opiates, etc., it all starts as a coping mechanism — a way to relieve whatever kind of mental or spiritual pain they are experiencing (whether they are cognizant of it or not). Control gives way to the illusion of control and to dependence, tolerance, expansion, things that can be harmful to a person. I’ve seen alcohol give way to loss of custody, weed give way to psychosis (hallucinations, delusions, derealization), benzos give way to homelessness, and various other permutations.

On a regular basis in psychiatry you are talking to people during perhaps some of the most vulnerable moments of their lives, which is a scary thing, but also something I find beautiful about psychiatry.

Today was pretty quiet in the EDHU. The major learning point from today was benign vs debilitating psychosis. We had 2 older ladies, both presenting with some kind of psychotic episode/ decompensation. the difference was one of them was still able to function and carry out her daily activities and care for herself; the other was very disorganized mentally and so there was high concern for whether or not she could take care of herself.

I’ve been finding that the line between the two is very fine. Sometimes a simple word or brief phrase can make the difference that teeters the assessment to the patient being gravely disabled. Though my attending told me that even if a patient is able to hide their psychosis by saying all the “right things” in order to get discharged or whatever, that is an improvement and shows a recognition and understanding of what is socially/ culturally appropriate.

Part of me is curious what it is like to have hallucinations, to experience delusions. Pretty scary I imagine.

I had to give a small presentation today. I chose to do it on psychedelics, specifically psilocybin because I love mushrooms (as a group of organisms). When my attending assigned me this project he said bonus points if teach him something new. Turns out he’s a part of the Multidisciplinary Association for Psychedelic Studies…

It turned out ok, even if I literally taught him nothing and likely embarrassed myself with my limited knowledge of psychedelics and my butchering of the studies I talked about, we had a good discussion and I learned a lot and I think maybe I got bonus points for bringing up a topic that is near and dear to him.

Overall it was a tougher week with this attending, but I think I grew a lot. I just need to bring that with me into this final stretch in psychiatry.

I got to see a lot of interesting psychiatric pathology today. One of our patients is very well known for cussing people out as soon as the get into the room. I had the good fortune one being able to come in the room during round. He kept repeating himself and wasn’t responding to questions. Everyone once in a while something would get through and he would respond in his own uncooperative way, often with a bunch of F-bombs thrown in. At one point he mentioned how he just wanted to watch Harry Potter which was playing on the TV. My attending attempted to latch on to that and asked which Harry Potter movie it was and he goes, “It’s Harry Potter and the Fuck You.”

The next guy we saw had some pretty severe Korsakoff syndrome, way beyond the guy I saw at the LA county hospital when I was on IM. He was just nearly talking is word salad, almost completely incomprehensible except for a few brief moments of linguistic clarity, though he has pretty consistent intention. I actually wanna say there is something else going on besides Korsakoff because as far as I know, though I could be wrong, while both Wernicke and Korsakoff can present with confusion and amnesia, word salad is not super characteristic of these. I never saw the chart so maybe there is some addition diagnosis that was not mentioned to me.

I still miss doing physical exams and looking at labs and asking where it hurts.

I blanked on a lot of questions today, things I should know, and were in the recesses of my mind, but it’s always hard when you’re put on the spot. As painful as it is to make a fool out of myself, I think few things are more motivating that embarrassment (for better or worse), and it’s the lesson you learn in the setting of embarrassment that often are the stickiest (and the only who is ever really gonna remember is you).

Another things I’ve noticed that I’m not the biggest fan of in psychiatry is the patient who are closed off and don’t want to talk to you, which often times is reasonable. These are often the folks with severe depression or anxiety who are tired of being asked how they are feeling. I don’t blame them, I’m sure it sucks to have to essentially be constantly admitting your pain to some strangers who likely have little understanding if what you are feeling. And in acknowledging that I feel guilty about asking them or even trying to engage them at all.

That said it is gratifying when you can get through to them and that is again part of the art.

Also it balances out because those closed off patient’s are often far outnumbered by the patients that will talk your ear off with all sorts of interesting and sometimes outlandish or ridiculous things.

My first solo History & Physical on this voluntary inpatient psychiatric unit. I thought it went pretty well. The patient had been experiencing some questionable delusions and paranoia (I say questionable because they themselves were questioning whether or not what they were experiencing was based in reality), and I thought I did a decent job of making the patient feel heard without necessarily validating their delusions.

As frustrating as I find management of psychiatric illness, what I do find interesting about it is the challenge of working with patients, with people, similar to the challenge that draws me to primary care. A lot of people are reluctant to receive psych treatment because it’s either unknown territory or because they have been burned by psychiatric treatment in the past (side effects, refractory illness, mistreatment, etc). The challenge is: how do I reach this patient who is scared and closed-off for whatever reason, and get them to a place where they are able to be open minded to the possible of trying a new approach? How do I get this person to trust me despite having relatively good reason not to? This is where more of the “art” of medicine comes into play, and I think there is a lot of opportunity for that in psychiatry.

This was the longest day I spent in the hospital since starting in psych. It was a bit of a shock compared to what I had gotten used to, but nothing crazy. If anything it’s what probably more of what I expected. I feel like I’m learning a bit more, but also I feel like there’s more pressure that I am not prepared for. I have been growing in my confidence in talking with patients and management of some of the more “bread-and-butter” diagnoses, but as soon as they deviate from a classic clinical picture I sometimes get stumped. We’re getting there though. I think it’s going to be a good week.

The attending I’ve been working with this week has been very chill. He is working via telehealth and so I’ve mostly just been bringing patients into the room and essentially shadowing while he interviews them other than my occasional side/ clarifying questions.

Today I asked if I could take the lead on a new patient interview and he was happy to oblige. What was nice about this case was that he was able to observe me in real time. One of the things about other rotations is I’m often unsupervised when talking with patients so my attendings don’t really know what my interviewing is like. Talking to patients is one of the things I am relatively confident in and feel strong at, which lies perhaps in stark contrast to sometimes accurately convey the contents of those interviews in my presentations.

The patient I interview was a pretty interesting case filled with drama and intrigue. After it was over my attending had very encouraging words which felt good and a nice dose of affirmation among an otherwise poor performance by me on this rotation.

TTITF:
Decaf coffee, curly fries, sun showers

One of the gratifying things about inpatient psychiatry is seeing improvements in mood, more or less in real time. We’ve had patients who came in on the verge of suicide, who over the course of their stay seem like completely different people; smiling, laughing, hopeful.

The sad part is sometimes when patients come in for their discharge interview I can’t help but feel like there’s something hidden behind an almost-too bright smile and cheery mood.

It’s not that I don’t believe that they are doing better or that I don’t think that they are capable of getting “better.” I just know that if was somewhere I didn’t want to be for whatever reason, and I knew putting on a smile would help get me out, I could easily fake it as long as I needed to (speaking from experience). Hell, I’d put on a whole damn show.

My concern is not simply whether or not they are faking it, but more so the implications if that’s true. It means we failed. It means we were no better than all the others that came before proclaiming that we care and that we want to help, but we didn’t do enough, and they will think twice next time about coming to us for help.

This is all existing in my overthinking brain though. I’m somewhat assured by the fact that patients seem to do well after they leave. And many patients do voluntarily return if things take a turn for the worse. But is also in the setting of recognizing that our mental health systems are far from perfect and people deserve better than what we are currently offering.

After spending a week in the Psych holding unit and now a few days in the voluntary psych unit of my hometown hospital, I will say the experience was a bit different from what I expected.

Before saying anything else I would like to say this: no doubt all the people who were there needed to be there for one reason or another, and the hospital is doing a good job (at least from my unqualified opinion) of treating patients effectively and compassionately. Many of the patients coming in have psychiatric issues despite being relatively well-off, having supportive families, and other strong protective factors. Of course many of them simultaneously have tragic and traumatic pasts which contribute to their risk, and we do what we can to set them up with the support and follow-up to help them reach their goals for their health, psychiatric goals, and lives as much as we can within the limits of our abilities (and healthcare system and personal/ professional boundaries).

Having come from my last rotation at the county hospital and is the street medicine symposium I can’t help but think about all the patients with complex medical and psychiatric needs that we aren’t seeing. Often times we aren’t seeing these patients because they don’t have the means or the capacity or the insight to come to the hospital when they are in crisis. Maybe they have been burned from the hospital for whatever reason. Maybe they have other social or financial barriers. It’s easy to have one’s perspective skewed by your immediate surrounding, and I’ve noticed that happening with myself recently. The people we are seeing, though perhaps no less in need, are often those who have means and those who have some form of existing support system (even if tenuous). They are like the WWII ships that came in with all the holes making the engineers think the places where the holes were are the places they need to fortify. And it’s easy to forget about the planes that didn’t make it back, and the damage they sustained which prevented their return.

I’m not saying it’s the responsibility of the hospital or of psychiatrist to round up and treat all the forgotten, “invisible” people suffering from psychiatric illness. I don’t know what the solution is here, I think more than anything this is a reminder to myself that medicine and healthcare, their benefits and their shortcomings aren’t confined to the walls of a hospital or clinic.