Penguins have always been one of my favorite animals. I don’t remember where it all started, but I remember when I was little always pulling out the “P” section of our World Encyclopedia to look up penguins and how the largest penguins are the emperor penguins. I think what I liked about penguins is that they seemed so out of place to me at the time. Like who who have thought these awkward birds would call icy tundras and rocky cliffs their homes. They waddle about on the land, having lost the ability to fly (without a doubt the best part of being a bird), until they trip and stumble into the water where they instant transform into these slick, graceful torpedoes with an agility that probably surpasses most birds in the air, swimming at speed that allow them to launch their whole as body out of the water back onto the ice/ land where they resume their unassuming terrestrial existence.
I feel like I can relate a lot to penguins. At least to the waddling and stumbling part.
Our culture is obsessed with heroes. From superheroes we read about in comic books or see in movies, to our adoration of military veterans and frontline workers during this pandemic, we can’t get enough heroes. At times it feels like our idolatry of heroes stems from a desire to be saved, from an attitude of either “I’m not strong enough to be the ‘hero'” or “I am unwilling to make the sacrifices of a ‘hero.'” Both are reasonable in their own right, but my response to these would be, Who says? and, Why not?
At the conference last month, someone said, “We don’t need more heroes, we need better system.” And that is 100% correct. If our systems were adequately taking care of people, especially the most vulnerable we wouldn’t need heroes. If our systems prioritized safety and wellbeing over revenue and profit we wouldn’t need heroes. But thank God we do have heroes to carry the burdens of society so I can continue to live my relatively carefree lifestyle.
So let’s toast to them and make them banners and give them a day where we celebrate them and tell our kids to aspire to be like them. Anything but create better systems to support them and to make them not have to be the safety nets for all of society, especially when things go to shit, because to do so means placing some of that burden on me, which simply will not do.
Yesterday I started a challenge for the month of November to complete 10 tasks every day for the whole month. Part of this was a revisiting of the monthly challenges Alfred and I used to do for the In-Progress Report (yes we will start it up again eventually). The original intention was to help us develop better habits to work towards our various goals that would bring us closer to who we wanted to be. It was helpful as a way to remain cognizant of my daily activities and be more intentional with how I spent my time.
This time around, I want to open it up to whoever wants to join and also put some more skin in the game by adding a cash prize from a collective pool. I think utilizing community is a historically untapped (by me) resource that can be really helpful for accountability and motivation.
If you are feeling like you are in a rut or want to change things up or have been trying to develop/ change some habits you are welcome to me and the others who are challenging ourselves and each other this month. Instructions for how to join are here, sign-up by next Tuesday if you want a chance to win, but you are also welcome to join or follow along without competing.
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?).
Even though I’ve learned a lot on this rotation, it still feels like there’s so much I haven’t learned/ haven’t studied enough. Every day something comes up that feels so basic, but I’ve never encountered before. I’ve been studying more these past couple weeks, but it doesn’t feel like I’ve become that much more well-equipped to handle certain situations. As we approach the last couple days of this rotation I’m hoping to close that gap as much as I can.
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.
This week I’m back on the emergency department holding unit (EDHU) and consults service. I don’t think I commented on it before, but it was especially apparent today — the difference between the kinds of patients we see in the EDHU compared to those are in the voluntary unit I was in last week. The patients in the EDHU are just more acutely sick and I get to see a lot more active psychosis which is more interesting to me from a pathology standpoint, but somewhat less interesting to me from a patient care standpoint.
Today we had someone who thought her neighbors implanted a device in her tooth and were talking through it, another person who thought he was constantly stopping nukes from falling everywhere, and another who took off all her clothes and was hiding herself in the cubby closet.
Because of that though I don’t get the same opportunity to connect with patients that I do in the voluntary unit. But for now I look forward to seeing more of the acute stuff.