Thursday, July 30, 2015

WILTIMS #325: You say somato, I say...

TIL: Somatoform disorders changed dramatically from DSM-IV to DSM-V. Somatoform disorders are conditions where a patient experiences some physical symptom, but medical science can't find a reason for either the existence or severity of the symptoms. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the bible of psychiatry. This is the official book of diagnoses that is revised every decade or so, and causes an uproar nearly every time. Whereas traditional medical diagnoses rarely change and when they do it's gradual, the DSM reorganizes the entire field of psychiatry every time it comes out. Whole diseases are invented, merged or deleted.

In the most recent revision of the DSM, the section of somatoform and factitious disorders was one of the most extensively reorganised. Four of the seven original somatoform disorders were removed (somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder) and one new super-disorder was created (somatic symptom disorder). Also, the wording was changed so that there is more emphasis on reassuring the patient that their symptoms are real to them. No one likes to hear that their pain or physical dysfunction is all in their head, even if it is. So instead of concentrating on a lack of medical evidence for their complaints, we are instead encouraged to rule out medical causes and then treat their symptoms using the only ways we know how - psychiatrically.

Wednesday, July 29, 2015

WILTIMS #324: Pepperoni with a side of paranoia

This afternoon had a beautifully comedic moment, but it was a weird situation so bear with me as I set the stage.

Throughout the day, the patients have activities that they can participate in like music therapy, art expression, board games, etc. I had finished my duties for the day, so to take a break from studying, I decided to sit in on the session and observe the patient's in this setting. The moment I walked into the room, something seemed off.

This afternoon's activity leader was a man I had never met and who, at first, I seriously thought must have been a newly admitted patient. His topic of choice seemed to be poorly informed geopolitical theory and the inevitability of nuclear war - topics I expect from the schizophrenic patients, not the people helping treat them. I love me some good ol' geopolitical debates, but talking about the coming nuclear apocalypse and World War III in a room with paranoid veterans who already have similar delusions just seems like a bad idea. Perhaps he was redirecting an inappropriate comment by a patient, I thought. A few minute of listening to the conversation quickly showed that the more coherent patients where actually giving more level-headed opinions and attempting to steer the topic back to a happier place. Some of them had surprisingly reasonable points.

There are several nurses in the area as well and we were all silently making eye contact conveying something to the effect of, This is weird, right? One nurse valiantly tried to turn the conversation into something more appropriate. "The idea," she said, "that we as a country might want to take care of our own needs before worrying about others', reminds me of our own personal basic needs. I need to take care of myself before I can take care of anyone else. What other basic needs do we have?" It was superb, but futile. A few minutes later the guest activity leader was once again talking about Iran already having a nuke and how we should have bombed China in WWII. A second nurse eventually pulled the man out of the room for a moment to talk with him about the topic, but he came back with the same enthusiasm.

The people that finally put an end to this bizarre situation were actually the worst-off patients in the room. One patient wandered over to where the man was sitting and started to talk over him to us about absolute gibberish. Another offered up his opinion about Iran by talking about eating pizza with a friend. It was beautiful. It was like when a small child says something totally right, but completely inappropriate - like yelling "Mommy, that man smells really bad!" when walking past a smoker. It's inappropriate, but you almost want to laugh and give the kid a high-five, even though they have no idea why what they did was wrong or why you enjoyed it so much.

I wanted laugh and continue the pizza topic, but instead quietly smiled as the activity leader got flustered and decided he was done for the day. Good job guys. I'm proud of you.

TIL: Research has hinted that a large proportion of the patients with comorbid schizophrenia and obsessive-compulsive symptoms may have developed the OC symptoms as a side effect of treatment with the particularly nasty antipsychotic drug, clozapine.

Tuesday, July 28, 2015

WILTIMS #323: To the Wayback Machine!

Today was fun. I got to leave my clerkship early to give a presentation to the incoming first year class during their orientation. Looking all the way back to when I was in their seats is a bit easier for me than most thanks to this blog. Here is the post from my Tuesday of orientation week. I think it's especially fitting that the group I was presenting on behalf of today did not exist when I was an incoming first year. Our school is always evolving and attempting to make things better. I wonder what changes this new class inspires in the years to come...

TIL: One of the several protocols for tapering a patient down from severe alcohol withdrawal is seen below. Since alcohol's sedative effects act primarily through GABA receptors, instead of giving them more alcohol in the hospital (which would be bad due to all of alcohol's other effects) we supplement with another GABA agonist, usually in the benzodiazepine class of drugs. Below is what the actual order would look like in a patient's chart. The ordering physician would also check on the patient periodically to see if the withdrawal symptoms are being appropriately managed. If not, then the orders might be altered to add another day to give the patient's body time to begin detoxifying itself.
50mg chlordiazepoxide PO Q6h on day 1
50mg chlordiazepoxide PO Q8h on day 2
50mg chlordiazepoxide PO BID on day 3
25mg chlordiazepoxide PO BID on day 4
25mg chlordiazepoxide PO QAM on day 5
25mg chlordiazepoxide PO Q4h prn breakthrough anxiety, max 3 doses/day
Vitals Q4h
If SBP < 100 or DBP < 60 or HR > 100 or pt displays marked sedation HOLD MEDS
Legend: mg = milligrams, PO = by mouth, QXh = every X hours, BID = twice daily, QAM = every morning, prn = as needed, SBP = systolic blood pressure, DBP, = diastolic blood pressure, HR = heart rate, pt = patient

Monday, July 27, 2015

WILTIMS #322: Play nice

It is a recipe for disaster when some patients on the ward have paranoid delusions and others are... well... psych patients. If you think about it, paranoid people see malicious patterns where it doesn't exist. For example, when strangers do something innocuous like making eye contact, the paranoid person interprets this as a sign the person is spying on them or otherwise means them harm.

On a psych ward, there are a lot of odd behaviors going on. People talking to people who aren't there, doing repetitive movements, silently watching a room for hours at a time, etc. Therefore it's super easy for a paranoid person to find abnormal behaviors to interpret as signs of hidden meaning. Unsurprisingly, it can be rather difficult to maintain patients' freedom to move around and keep symptomatic paranoid people happy and delusion-free.

TIL: Though dreams and nightmares occur during REM sleep, night terrors (a disorder where children wake up in extreme fear) happen during stage 3-4, aka delta wave, sleep.

Friday, July 24, 2015

WILTIMS #320-321: Padded walls

Apologies for the lack of post yesterday. That fickle mistress, Sleep, beckoned and I could not resist. The up-side is that you get a double post today!

Schizophrenic patient passing me in the hall today: "This place is a nut house."
Me: "You're not wrong."

Today I learned about a room that I missed during the brief tour on my first day: the isolation room. This is a room with the padded walls that you've seen in movies. Such rooms were incredibly common before new medications were found, starting with the antipsychotic Thorazine in the 1950s. The rooms were used in mental institutions of yore because we had no way of calming down a psychotic patient and, in their fits of confusion, they might hurt themselves. That strategy is considered kind of barbaric now (a whole 60 years later...). But every once in a while the drugs are not enough and we'll have to put a patient in a padded room. Today was one of those days.

I have described a code 66 before. The one other time I've witnessed one of these psychiatric emergencies, the whole process seemed a little overkill. A half-dozen armed police officers along with several people from the other floor joined our entire staff to really just intimidate a non-compliant patient into taking some medication. The patient didn't put up much of a fight and the code ended rather anticlimactically (which is good!).

This time I got to see the real deal. Our patient had become combative with the nurses, kicking one and pushing another. He was unwilling to take any calming medication and threatened to hurt anyone who tried to give it to him. The code was called and the usual battalion of people showed up, ready to get physical if needed. We waited on some special medication to be brought up from the pharmacy and then the whole crew, including police, firemen, nurses, managers, psychologists, and psychiatrists, marched down the hall to the room the patient was holed-up in.

It was an imposing sight. I know so because, along with a nursing student who is learning on the same unit, I was told to stay back because I hadn't gone through the physical restraint training (oh darn...). Instead we watched from down the hall as 15 or so people slowly worked their way into the patient's room, much like clowns into a circus car. From that point on, all we could do was listen. For a while you could tell they were trying to reason with him, though I can't imagine how effective that could have been with that many people standing over him in a tiny room. He yelled angrily and could clearly be heard throughout the hospital floor.

Then something changed. The patient began screaming bloody murder. Not shouting - screaming. I'm sure people outside the building heard him two stories below. Presumably this is when the various care providers determined that talking had run its course and action was needed. Afterwards, I was told about what happened in the room. I'm not sure on the details, but suffice it to say, the patient was poorly restrained, people got hurt, bitten, and spit on - but the patient did eventually get his medication.

Now for my part in the dramatic events! I got to hold the door to the antechamber of the isolation room open as the police et al. dragged the patient down the hall and put him in the padded room. Woot! That's right, 2 years of medical training to be a living door stop. [shrugs] As I told the new nursing student, I'm still just happy when I'm useful at all. She agreed.

We don't just lock away the patient once we have them in the room. They are under constant audio/video surveillance in the nurses station and a staff member must sit outside the door to observe him at all times, in case he tries to hurt himself or he needs medical attention. If the patient can remain calm for an hour, they can be released back on to the unit. It took over six hours for that to happen yesterday, which is rather unusual. The medications weren't as effective on him as for most people for some reason.

The person I felt worst for through this whole debacle was a man who was going to be discharged right before all of this happened. He had already been cleared to go, was wearing his normal clothes, and just needed the final paperwork to be completed. Then he was trapped in the activities room with the other patients for easily another hour or two. As a guy with pretty significant PTSD, he was less than thrilled about being trapped in a uncertain situation in a crowded room with lots of loud noises and yelling going on outside. Thankfully he made it through and got out without any trouble.

ThursdayIL: ICU psychosis is another term for iatrogenic (caused by medical treatment) delirium that arises in acute care units, usually as a result of electrolyte imbalances from IV fluids. As with any delirium, this is a medical emergency.

TIL: The best diagnostic question to ask someone you suspect of having PTSD is "where do you sit in restaurants?" The only two answers you'll get from a PTSD patient are 1) I sit on the back wall so that I can see all the exits or 2) I don't go to restaurants.

Wednesday, July 22, 2015

WILTIMS #319: Do as I say, unless you do as I do

An ongoing theme for my medical education is learning some of the hypocritical tendencies of doctors. Well, actually that's not quite right. Doctors may do things that they don't want their patients to do, but research has shown that they won't impose their hypocritical recommendations on their patients. For example, obese doctors generally don't counsel patients to lose weight. Doctors who smoke fail to counsel their smoking patients to quit. I don't think this is actually better than just being outright hypocritical.

The example brought up today was in regards to caffeine. Caffeine, like any stimulant, can trigger anxiety disorders. But there's no consistent, evidence-based recommendation for the safe amount of caffeine a day. So the "joke" goes like this:
How many cups of coffee is ok to drink?
One more than your doctor.
How many cups is too much?
Two more than your doctor.
I didn't find it all that funny.

TIL: Panic attacks can mimic many different medical conditions. Since several of those potential conditions can be life-threatening, if someone presents with panic attack symptoms but no history of panic attacks, you must give them the benefit of the doubt and work them up for dangerous conditions like a heart attack or pulmonary embolism. If nothing turns up, especially a few times, then perhaps a psych consult is indicated for treatment of an anxiety or panic disorder. However, epidemiological studies have shown that, if the patient is over ~40 years old and has never had a panic attack, then it's vanishingly unlikely that they are having their first one right now. It's probably worth taking a second look at those possible medical causes.

WILTIMS #318: A psychiatric portrait in pieces

Since beginning my psych rotation, I have been trying to find a way to represent the difficulty of piecing together a story from all the different sources we tap during a patient's inpatient stay. The best I could come up with is trying to analyze a picture only adding one color at a time. Let me take you through both a patient and a picture's story. The example patient is purely made up, but based loosely on experiences from the past few weeks.

──────────────────────────────────────────────────────────────

The first perspective we get is from a nurse or police officer who only knows what they saw the patient doing when the patient was referred to us. We might get something like "the patient was found wandering the street and talking about killing himself." Ok, so perhaps we're dealing with major depression and suicidal ideation.


In the painting above, all we can see is one color. With only the red to show us the scene, we can make out a few people and perhaps some trees. If I had to guess, I'd bet the woman in the foreground on the right was the important part of the picture.

──────────────────────────────────────────────────────────────

Next we talk to the patient himself. In the admission interview, we sit for a long time and try to get as much as we can from the patient's perspective. But this is still just one data point and, particularly with psych patients, the information we get may not be reliable. "Well sure I was suicidal; I've been depressed all my life, but when my father was killed by CIA I lost it." Huh. Now this seems like more than depression. Some of this is delusional, but how much?


In the above painting, we add green to the red. The two colors blend together and show more than either alone. Suddenly, we see details that were all but invisible before. There are way more people in the background, they don't seem important though. There's a cat in the foreground... prominent, but probably unimportant as well. What about that umbrella though?

──────────────────────────────────────────────────────────────

Now that we've had a moment to peruse the patient's old medical records, we can see that some things don't add up. We see that, yes, the patient has a history of depression and that he's been treated for suicidal thoughts before. But there's a big gap in his charted history and he's been on an antipsychotic medication in the past. Now, that seems important.


Next in the picture, we've added in the third primary color, blue. With it we've confirmed a lot of what we suspected from the beginning: the woman on the right is still prominent, there are people in front of a background of trees, and a woman with an umbrella is still seeming interesting. But suddenly there are gaps in the picture that beg to be filled in: why does the grass end on the left and, most intriguingly, what's that white blob in the middle?

──────────────────────────────────────────────────────────────

In the patient's old chart we see a phone number for the patient's brother and decide to give him a call. Suddenly everything gets a little clearer once we have context. Turns out the missing time was from when the patient was committed at another facility. The brother confirms the lifelong depression and that their father passed away right before the patient was committed, but that was years ago. Lastly the brother remembers something about hearing voices.


Suddenly the whole picture changes thanks to some increased complexity. This isn't just a scene in a meadow; it's a scene on the water. Now I know that white blob in the middle is important and I'm pretty sure I know what it is.

──────────────────────────────────────────────────────────────

We return to the patient and finally get the closest we'll come to an answer. Turns out he still hears voices. They're mean voices that blame him for his dad's death and badger him to hurt himself. The depression is and always has been there, but it's the voices we need to try to treat. We can't find everything out about every patient, but we can find the important things if we get enough perspective.


Our painting is as clear as it's going to get. There are a lot of things going on, but the item that draws the eye is the little girl in the white dress. However, we can't derive any meaning from this focus without the context provided from the scene. All of this requires layers of color and detail that blur together into a complete picture.

Part of the reason I picked this painting is because it's an example pointillism rather than realism; you simply can't see every detail because the painter omitted them, just as in psychiatry you can never know every detail of a patient's life. We must be careful, then, to give each piece of art its fair share of attention, lest we miss the details that spark our understanding.

TIL: There is a higher incidence of schizophrenia in people born in winter or early spring. It's hypothesized that some seasonal infection at a critical developmental time in utero, for instance the mother getting the flu, might be the cause. This is just one of many correlations that have been found, with genetics actually being the best predictor.

Monday, July 20, 2015

WILTIMS #317: Swing and a miss

Ouch. If only to prove that I don't use this platform just to boost my ego: today's performance was less than stellar. I didn't do anything catastrophic, but I was quickly reminded that I am still very inexperienced and it's a good thing people are watching over me.

Bright and early on this miserably hot Monday morning, I was asked to begin the admissions interview on a new patient from over the weekend. I had heard the quick summary of his story during morning report, so I wasn't working off a blank slate. But those preliminary scribbles on the proverbial slate were not comforting.

This patient was very sick. I knew it was going to be a difficult interview, but I've interviewed difficult patients before. I was hoping that I could stumble through enough open-ended questions that we'd build a rapport and the conversation would gain some momentum. This is normally a skill of mine: turning a stumble into the first lunge of a steady jog.1 Well, sometimes you just fall flat on your face and that's harder to recover from.

Case and point: (the details are totally changed but, as you'll see, it hardly matters)
Me: So Mr. A, can you tell me your understanding of why you're in the hospital?
Mr. A: Because I'm cuckoo!
[Mr. A smiles heartily as I falter]
Me: Um... Well, why specifically are you here? What happened in the past few days?
Mr. A: WellIgneh... [mumbles] ...'m the Emperor and had all those people killed. [laughs] Yep, I did.
[I make a funny face somewhere between concerned and hesitantly amused]
I know that this is new. He had said some pretty disturbed things over the weekend, but never an outright delusion. But is this a delusion? The way he's laughing, it seems like a joke. But given his history of psychoses, he might think it's real, for all we know. How does one respond to a delusion-joke hybrid?
[I look to my preceptor, pleadingly]
Me: Um... well...
And my advisor takes over, to my shame and relief.

I talked with my advisor afterwards and everything was fine, but it sucks when you just freeze up. I had never gotten just random disorganized thoughts back at me from these sorts of questions and so I didn't know where to go with the conversation. Usually you start with open-ended questions and see what the patient wants to talk about. Then as you get an idea of what the important concerns are, you steer the conversation to areas that weren't touched through the natural flow of conversation. Finally, you drill in on any specifics that were missed.

When a patient gives you nothing but fantasy, what do you do?

TIL: When the above happens, you throw out the normal interview format and go straight for specifics. This way you can keep them on track and see what they are even capable of when it comes to effective communication. If they begin to settle down, you can then return to the more open-ended interview style.

1#humblebrag

Friday, July 17, 2015

WILTIMS #316: Dr. Who?

Today had another subtly new experience for me. I was asked by the doctors to call the former residence of one of our patients and try to get their perspective on the patient's deteriorating mental status. This was odd because most of the things I've done with patients are redundant; I sit there and ask questions, but the doctor usually is right there next to me and has access to the patient at any time if I forget something. This time I was the only witness and was being trusted to communicate effectively to another health professional.

I'm generally pretty confident in my ability to communicate. Me speak good. But now that an actual patient's care relies on my ability to talk gooder, I had to pause to sort out my nerves before dialling the other facility. Then when I finally made the call, I realized this was the first time I introduced myself over the phone in a medical context. Over the years of being a clerk and volunteer I have heard hundreds of doctors and nurses make the mystical call to each other. It always seemed like a secret club. "Hi this is Dr. Youcantrustme, I'm looking for Dr. Doesntreturnpages regarding his patient. Also the eagle has landed and the monkey is on the branch..."

Well, today I was part of the club. "Hi, my name is Christopher. I am a medical student under Dr. Soandso at the VA and I'm looking to talk with the caregiver for Mr. Crazierthanweexpected."

"Ok, well let me grab his chart for you..." said the nurse on the other end of the line.

"Also the eagle has landed and the monkey is on the branch..."

TIL: Prazosin, a drug we learned predominantly in the context of lowering blood pressure, can also be used to treat PTSD.

Thursday, July 16, 2015

WILTIMS #315: Now, class...

I'm a little burned out today thanks to working really hard repeatedly staying up late to stare into the e-abyss, so this will be a quick one.

An odd aspect of my education right now is that I am formally taught by a huge team of health care professionals. After the mornings of following a psychiatrist and interacting directly with patients, each afternoon I have 1-2 "lectures" on various topics in mental health. I'm quotation-shaming "lectures" because when it's just me and another person in their office for an hour, it feels more like a meeting or something, but not a lecture.

There are no real rules for these encounters, so it's been fun seeing each person's approach to covering their topic. Most are fond of handouts, some break out their DSM-V (the official manual of psychiatric diagnoses), one broke out a DVD, and another took me out to lunch for a change in scenery. I've noticed that several have a powerpoint all made up, but they don't actually present it to me because showing a powerpoint to one person is just awkward.

The DVD I mentioned was to provide visual representations of patients for a session on eating disorders. Finding eating disorder patients is particularly problematic at a VA hospital, not because veterans are secretive or anything, but because of the disease time course. People usually develop eating disorders in a bimodal distribution, earlier when they begin puberty or later when they move away from home. The symptoms are frequently precipitated by a life stressor. Boot camp being a phenomenal stressor and coming right after the highest risk times for disease development, an eating disorder patient is exceedingly unlikely to make it through bootcamp.

TIL:
Mindfulness is the biggest component of the most newly established behavioral therapy. Mindfulness is the purposeful attention to the present without judgement.

Wednesday, July 15, 2015

WILTIMS #314: Exit plan

Something that has surprised me thus far in my time on this VA psych unit is how much energy is put towards placement compared with treatment. Placement is the process of finding somewhere for each veteran to go after discharge from our unit. "Why can't they just go home?" you might reasonably ask. Well, many veterans and many psych patients are homeless, so veterans with psych issues are especially prone to not having stable housing.

The places to which people are discharged vary from another floor in our building, to any of the many other units on the VA campus, other VA facilities all over the country, drug rehab facilities, nursing homes, medical foster homes, the patients' families, or ideally to their own homes. Social workers, the unsung heros of health care, have to work with the psychiatrists to assess how good the patient is at taking care of themself, to assess the risk of psychiatric or substance abuse relapse, to find out the patient's financial situation, and, what is often the hardest part, to convince the placement site to take a patient that is really a borderline fit.

Many of these patients have been through this system several times and have burned a lot of their bridges after past discharges. The conversation with the facilities that will even consider taking the patient turns into a negotiation for what the patient must commit to to be allowed to leave. Some conditions for discharge include reliably taking meds, quitting smoking, agreeing to attend support groups and consistently taking showers.

Some of the most difficult cases we've had recently involve people we just can't find a home for. They clearly are no longer a danger to themselves or others, which are the general problems that get them locked on an inpatient unit. But even though they're better than they were upon admission, they still can't really live on their own and are just too odd or difficult for a facility to take. If we can't find a place after a long enough time, the patient may end up on our chronic psychiatric floor, from which they may never leave. We work really, really hard to avoid that.

TIL: A patient who suffers from chronic alcohol abuse who also has a history of gastric bypass surgery is at very high risk of developing a thiamine (vitamin B1) deficiency, leading to Wernicke's encephalopathy and eventually Korsakoff syndrome. Alcoholics have increased use of the vitamin, decreased storage capabilities and poor transportation through the body's tissues. Meanwhile gastric bypass surgery bypasses the main areas of absorption in the duodenum and proximal jejunum of the small intestine. The symptoms of these conditions can present very similarly to the psychotic symptoms of schizophrenia, so you must be careful when teasing apart the mental and medical issues with these patients.

Tuesday, July 14, 2015

WILTIMS #313: Code 66

Every hospital I've ever worked, volunteered or studied in has had a totally different set of emergency codes. Usually there are colors (e.g code blue, code red, code brown) mixed with other random codes that inexplicably ruin the theme (e.g. code triage, code zebra). You'd think some of the well known ones like code blue would stay consistent, but some hospitals just need to be different, so you have to relearn them at every facility you find yourself at.

My current hospital has two codes that I've been told to know: code 66 and code 99. Why you would pick the only superimposable numbers is beyond me. In any case, code 66 refers to a psychiatric emergency while a code 99 refers to a medical emergency. Exactly a week ago, I saw my first (false alarm) code 99. After the code was called over the campus-wide intercom, an ambulance, paramedics and eventually two doctors showed up to make sure the patient was alright medically (he was).

Today I saw my first code 66. A patient was not responding to the nurses' calls to calm down and he would not let them give him a sedating medication. Once the code was called, myself and all the psychiatric staff rushed out of the nearby offices to the area the patient was in, in case we were needed before the real help arrived. And boy did it arrive. A nurse and doctor from another floor as well as six fully armed police officers arrived to help subdue the patient until we could administer the sedative. Given the modest danger of being on a locked ward with some agitated, very physically powerful patients, it's nice to know that a whole lot of help is just a call away.

TIL: When giving a sedative in an emergency situation as mentioned above, remember to be patient and wait for the medication to take effect. It can be easy to succumbed to panicky pressure to repeatedly inject the patient until you see results, but you must remember that these drugs take time to take effect. Doubling or tripling the dose can quickly over-correct the agitation and even kill the patient.

B52 or 5-2-50 is a common concoction of medications used at an emergency sedative and antipsychotic. in each of the two names, the 5 and 2 represent 5 mg of haldol and 2 mg of lorazepam, respectively. The B and 50 refer to 50 mg of diphenhydramine, aka Benadryl.

In 2004, the FDA issued a black box warning on antidepressants that warned of an increased risk of suicide in children. Though it seems counterintuitive, the data showed that for certain patients at a specific point in their treatment, they go from being suicidal and apathetic, to still being suicidal but having enough energy to commit the act. If the kids make it through this period, they're in the clear, but the FDA thought parents should be warned. In 2005, more children committed suicide than any year on record - not because of the antidepressants, but because a large percentage parents misunderstood the tiny risk and refused to let their children take antidepressants at all.

The three classic treatments for refractory suicidal ideation are clozapine, lithium, and electroconvulsive therapy (ECT). ECT has gained a bad stigma, for good reason, as it was one of the treatments of choice during the dark ages of mid-20th century psychiatry. Though, most of the old uses had little supporting evidence, a few conditions actually respond very well to shock therapy. The big difference today is that we actually use anesthetics so that the brain is effectively given a seizure as a sort of electrical reset without disturbing the patient in any conscious way.

Monday, July 13, 2015

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.

Friday, July 10, 2015

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.

Thursday, July 9, 2015

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.

Wednesday, July 8, 2015

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.

Tuesday, July 7, 2015

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.

Monday, July 6, 2015

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.

Wednesday, July 1, 2015

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.