nANIMOv

We’re finished. Coming into this rotation I definitely had conflicting feelings. On the one hand I recognize how important psychiatry is and I also really enjoy talking to patients and having the opportunity and privilege to walk next to patients during some of the most vulnerable moments of their lives. On the other hand, I felt like management of a lot of psychiatric illness felt like a crapshoot even with the use of evidence based strategies. You are often reliant not only on individual response to medications, but also personalities or pathology that make adherence sometimes even more difficult than it is with the less-psychiatric population.

I think through this experience I got a lot of really great opportunities to talk to emotionally and mentally fragile (often times due to them being pushed to their edge) or volatile patients, and practice skills in dealing with stressful and delicate situations. I think I learned a lot about management of psychiatry illness and everything that goes into making decisions about patient’s medications. I learned about ways we can try to regain the trust of people who have felt abandoned and/ or betrayed by our healthcare systems and by doctors.

There were a lot of valuable lessons and the are just a few. While I the field of psychiatry is probably not for me, I will definitely try to bring (and likely will have to whether I like it or not) all that I learned to wherever I end up.

It was a true Halloween day on the EDHU today. One of our patients was telling us about how there was an invisible man living in her house. Whispering to her while she mops the floor, lying down in bed next to her, reaching out from the toilet. Truly frightening stuff. To make matters worse in the middle of our interview, one of the blinds, all of which were pulled down, snapped up all of a sudden, and our patient goes, “Did you see him?”

The day also included pitch black vomit and a bone chilling scream.

Anyways, it second to last day of the rotation and while I’m going to miss the people I worked with and talking to the patients, I will not be missing psychiatry all that much as of this moment. That said I won’t rule it all the way out quite yet because there are a lot of part about psychiatry that I do like and I don’t want to throw away the baby the bathwater as they say (do they say that?).

Our healthcare system is so fucked up. The fact that a person’s insurance determines the quality of their care, or whether they even get certain kinds of care made available to them in the first place is fucked up. The fact that physicians have to dance around the greed of insurance companies in order to provide patients what they think is appropriate is fucked up. On multiple occasions we’ve had patients who care was delayed because insurance companies were fighting over who should pay. We’ve had local mental health services say, nope we don’t want to deal with this patient, but them on a bus and send them to LA to establish care there. Sad day.

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.