Psych is Going Quickly

I just realized with glee the other day that I'm already 3/4 done with this rotation. Then I realized that I've been enjoying it and I'll be somewhat sad to move on. I typically have about a 2-week limit on rotations before they become drudgery, but for psych I've held out this long. Surprisingly, along the way, psychiatry has moved up my ranking of specialties. It's still not at the top, but I would actually consider doing it in an inpatient setting if surgery didn't work out.

Speaking of surgery not working out, I've been in some denial about a tremor I developed this past spring. It started off barely noticeable for an hour or two in the morning, but it's gradually become worse. It's such a slow progression I keep hoping it's plateaued, but I'm not sure. In any case, my psych rotation has somehow made me able to accept the thought of life without surgery and I've been thinking of other specialties I would enjoy. As mentioned, psych is at least on the table, but I'm leaning toward pathology and maybe radiology, both of which require little interaction with people. Ironically, one of the therapists at the hospital says I'm too personable to be a surgeon (and I suppose by extension, a pathologist or radiologist), but the thing is, being personable is not natural to me and it's very draining. Perhaps I should get this tremor checked out, but mumble, mumble, mumble, mumble. I'd probably just get put on a beta-blocker, anyway.

I'll post more case presentations as the week progresses.

Scott

Critical Mass

Apparently, putting a dozen troubled little boys and a couple of adolescents together causes a spontaneous reaction. Between two wards, you can only separate so many volatile patient pairs. There are obvious laws about male and female patients not sharing the same room, but other laws also limit the age difference between roommates to 36 months. Then, there's also a law or hospital policy preventing a patient who has a history of sexual misconduct from even being in the room at the same time as the roommate, so at night they have to take turns sleeping out in the common area. In case you're not adequately disturbed, keep in mind I've been working with kids. On one ward, there's a 9-year-old who has a history of sexual misconduct, and the other ward has a 13-year-old in the same love boat... er, same boat (I'm sure that's an example the type of twisted humor you develop to help cope with the knowledge of what's been done to these kids and what they in turn do to others). The 9-year-old is annoyed with not being allowed in the (single-occupancy) bathrooms at the same time as the 7-year-olds. My preceptor described "insight" as the ability to appreciate the consequences of one's actions and the effect of those actions on others. I'm seeing a lot of patients, even older kids, who are totally clueless about cause and effect of their actions.

Anyway, all this logistic juggling is made worse by the fact that both wards are near capacity. Several kids on the more full one decided to lose their cool today. It was a rough afternoon. I learned I am not naturally gifted with the patience to deal with the loud, outbursting types of patients day in and day out. One little boy had a penchant for loudly screaming a couple octaves higher than should be possible and slamming doors repeatedly. Another decided to make it his personal mission to attack a younger kid who's kind of an outcast and just mopes about all day. Then there is a teenage girl who has borderline personality disorder (alternates between desperately clinging to you and beating the crap out of you, not always figuratively). Bradley, a boy she knows, was admitted today. So, with the aggravation of little boys screaming and the desire to show off for her newly-formed soul mate, she reverted to her coping method of choice: regressing to the maturity level of a three-year-old. On the way back from one of several trips to the seclusion room and after a boat load of meds, she yelled, "It's ok, Bradley, it's ok! I'm calm now! It's ok, Bradley!" She's screaming this, mind you.

While I'm discussing totally odd behavior, there was a certain teenage boy admitted for combative, defiant behavior. He was one of the first patients I saw here, and the doctor said to imprint him in my mind as a classic case of bipolar, which is apparently overdiagnosed these days. During his stay on acute, this guy had one or two run-ins with staff, being physically aggressive and just defiant. I saw the staff bodily drag him to the seclusion room; if all you could have seen was his face, you'd have though he was just enjoying a competitive sport. No wild psychosis glinting in his eye, no hatred seething out of his pores. They asked him at one point why he was acting this way and he said, "I don't know. It's fun." His behavior eventually leveled out, so he was transferred to the residential unit, which allows more freedoms while still providing intensive treatment. Last week, he decided it would be a good idea to fill his toothbrush holder with feces. I'm not sure if that was "fun," or if there was some other driving force. My attending said it was a subconcious way of testing others' acceptance of him. "Here's a part of me, what do you think of it?"

Not all the patients are so oddly colorful, however. One was a teenage girl who was just dealing with several stressors and started cutting and having some suicidal thoughts. Her family is supportive, and she just needed some quick inpatient therapy before being set up with outpatient follow-up. She had a positive outlook on life in general and got along with people well and should be fine.

Back to cutting and other self-destructive behavior. Cutting and similar actions are distinctly different from suicidality. Cutting is not an action meant to harm or kill; it's like sighing long and hard at a complex problem. It's an emotional release. It's a way of transferring abstract, intangible, inner distress to a tangible, concrete, external locus. It does some other things, too, but that seems to be the consistent theme amongst cutters. They probably won't have thought it out in such detail, though.

As a poor analogy, think of suicidality and cutting as being like flames and smoke. They often coexist, but it depends on what's being heated, and they are two separate entities. Smoke and flames are simply the obvious signs of the combustion process, which is what really needs to be stopped. Similarly, putting an end to the angst and depression leading to suicidal ideation and cutting is the only effective treatment for them. If you want to treat the symptoms, the best action you can take to prevent these thoughts/actions directly is to equip the patient with healthier coping mechanisms. You can't cure suicidality. You can't cure cutting. You can't cure suicidality. You can't cure cutting. Should I say it again? You have to cure the underlying cause. If I seem emphatic on these topics, it's due to personal experience with both. I should specify that's past experience, so don't go locking me up.

Speaking of personal experience, it's both a benefit and a detriment. On the one hand, I'm non-reactive when patients relate suicidality and cutting, which facilitates their sharing, plus I understand their thought processes fairly well. One the other hand, I feel detaining most of these patients is such overkill (no twisted pun intended). I keep thinking, "so they cut themselves and want to die, what's the big deal? I had the same thoughts and I'm still here. (And I walked five miles to school in the dark barefoot in the snow uphill both ways and in my day...)"

So as not to leave on a negative note, consider this: this sentence has seventy-five letters... q.

Scott

Family Medicine Test Results

I found out today I passed the Family Medicine Shelf exam! Aside from the bit of Family Medicine on my next set of boards, I'm done with it forever!!

I'm getting a bit more interaction with patients. I'm still forgetting stupid stuff. I'll remember to ask one thing and forget another. Then remember the other and forget the one. It helps that the place I'm at has interview sheets bearing a separate section for each part of the interview: chief complaint, history of present illness, past medical history, etc. Once I get more experience, I'll know what types of things are relevant to a certain type of presentation, but right now I feel like I'm still rehearsing a script. Poorly.

I'm finding my motivation to study for each rotation lasts about a week and a half. We should switch from monthly rotations to fortnightly ones. I'll pull through, though. I'll be switching doctors for a couple of days next week, so that should mix things up a bit.

Scott

First Real Psych Interview

Well, it finally happened. It wasn't very smooth, but I have greatly improved in my patient interaction skills over the past three months. Back then, I was hesitant and intimidated by a plain old interview with an adult patient. I've now come to the point where I am hesitant and intimidated by a psychiatric interview with a 13-year-old girl. Three biggies there: psychiatric, so emotionally or mentally, things are not ideal; 13yo, and I'm turning into an old fart, so I'm out of touch; and girl, and I obviously have limited firsthand experience dealing with the struggles facing females. I was much better at maintaining cohesion of the interview even during times I knew I was tanking (maintaining cohesion = me not curling up on the floor and weeping silently). I'm sure she would rather pull out her toenails than go through that again, but I was so glad to see the progress I'm making.


I was still able to critique myself, though. I need to work on not letting the mood get down: I'm afraid to minimize their negative experiences and thoughts, but while acknowledging those things, I need to stay upbeat throughout so I don't get the patient in a negatively-focused rut. I need to improve my ability to allow a conversation to flow and direct it so I can simultaneously build rapport and gather info. The doc I'm with asked a patient if she's into texting and Facebook, to which she said yes. In his dictation, he mentioned she's sociable, so he was not only just talking to build rapport, but learning about her interests and evaluating her sociability. I was thinking later that one could also infer a certain amount about her intelligence, technological aptitude, cultural awareness, etc.


I just remembered the last physical I gave last month. I did a prostate exam and totally forgot to give the poor guy some tissue to clean off the lubricant! I did remember once his pants were back in place, but he declined when I finally offered -- A-W-K-W-A-R-D! Live and learn, I guess. Much respect for the patient patients.


Scott

Bipolar and Trauma

I got assigned to a doctor today. We saw an adolescent male with bipolar, which is rare, though is over-diagnosed. His symptoms of mania were bouts of aggression, violence, assertion, not thinking of or caring about consequences (bought a car and drove it around town before having a license), and not needing much sleep. His depression manifested as suicidality and maybe some other stuff (I'm trying to rush through this to get back to studying; I've finally been assigned reading again). He had been put on an anti-depressant, which is the last thing you want to use for bipolar since it can cause wild mood swings, hold the person in mania, or even keep them depressed. The doc switched him to valproic acid, a mood stabilizer.

I was amazed how all the kids we saw were so matter-of-fact and open talking about their experiences such as physical, emotional, sexual abuse; drug use; cutting; suicidal thoughts and attempts. At the same time, one girl had a moment's hesitation when admitting she was sexually active. I'm not sure if they're open talking about their past because it's already been brought to light in previous sessions or if they are able to emotionally detach from those aspects of life in such a way that they can talk about them like everyday topics. As opposed to the one girl's reluctance to admit to a sex life, which she may still hold on to as a private or positive part of her life (or could just feel reluctant to talk about it with two males). It will be interesting seeing what trends like this develop.

I mentioned trauma because almost every kid we saw today had had some sort of emotional trauma. This disillusions them by shattering their basic assumptions of life. The doc said researchers have boiled down the inborn assumptions everyone has: The world is safe, I'm worthy of love, My caretaker is competent, Life is worth living. Most psychiatric disorders can be traced to one or more of these being shattered by negative experiences. But, genetics is a big part of the mix, too, so lots to think about.

Scott

First Day of Psych

That's somewhat misleading, as I didn't really have any exposure to psychiatry today. My two classmates and I met with the HR lady, found out we hadn't been given all the paperwork we needed, waited for a doctor to come meet with us, and were given a tour of the facility. After that, they let us go home, to return tomorrow morning to work out schedules and remaining paperwork. Despite the logistic issues, I'm excited for this rotation. I have no desire to work in psychiatry and I'm rather nervous about interacting with patients, but I find behavioral health fascinating. That and my desire to get better at my interviewing skills should make this a really good month.

I spent a good portion of today looking into joining El Paso County Search and Rescue. After all my research, it looks like I won't be able to hack the time commitment for training with my unpredictable rotation schedule. Also, they basically expect you to stay on for at least several years, but I could only manage another year and a half before I start rotating out of state and eventually move to my residency, which will almost assuredly be out of state and definitely will not be in El Paso county. I wish I hadn't spent all that time looking into this instead of brushing up on psych or reading the volumes of regulations regarding the facility I'll be at. Though, it's good to know what to consider when I finally do have time in life to do this type of thing.

Somehow Mom found out that Grandma has been having belly discomfort; I called Grandma, got a brief history, and urged her to go to the ER if she doesn't improve. We're all hoping for the best here.

Scott