Saturday, November 14, 2015

3rd Year Chronicles: Psychiatry

It saddens me to say that “psycation” is over. So ends the third rotation of third year. Ah well.

Psychosis Is Contagious

For this six week rotation, I spent the entire time at a state-run short-term mental health facility. If that conjures up a picture of old and slightly creepy-looking facilities, limited staff (budget cuts, of course), and the occasional co-worker or two that may have spent a bit too much time in psych facility – well, you wouldn’t be too far off. It isn’t the place that most people end up when they are sick – only the really, really sick ones that typically have no insurance.

I will say staff there were pretty great. Additionally, most of the patients there were very nice and wanted to be there (ok, well, maybe that last part isn’t so true) to get help. That said, a large number of patients were really actively sick with whatever psychiatric condition they had and as a result had fairly poor insight into what was going on and what needed to happen for them to get better. As a student, this meant that this was a great site to see people who were actively psychotic, manic, depressed, withdrawing, or what have you. It’s one thing to read about this stuff but then spend most of your rotation at a run-of-the-mill clinic and see people who are generally well-controlled and doing ok. It’s another thing to deal with this stuff every day for about six weeks, and I thought it was a great learning experience. 

The other cool thing about the psychiatry rotation in general was the fact that we were able to stick around one place for the duration of the rotation instead of switching gears every two weeks or so. This really allowed me to get to know a lot of the staff and patients and play more of a role (at least, as much as a third year can) in the treatment team.

Psychiatry in particular is very focused on peoples’ stories. Unlike most other specialties where diagnoses are made often from lab or imaging studies, in psychiatry you have to delve into people’s lives with them to sort out what is going on. As such, it’s probably fitting to include a few here – some shorter, some longer, some ridiculous, others more mundane, but all memorable and all of which played an important role in my experience. As I went through the rotation, I tried to jot down some of the more interesting ones and have included some of them below.

I should also note that, while some of the stories are humorous, my intention is to relate some of the stories that stuck with me for some reason – not to make fun of people for stuff that happens when they are sick. That said… you can’t make it through even six weeks of psychiatry without at least being able to appreciate the humor you encounter.

A Few Quick Stories...
  • The very first patient that I saw was being spiritually drained by his "three baby mamas," which family later told us weren't even real. He later told us they only came to him when he was sleeping at night or napping during the day, and that they found him to be "seductive" because of how he dressed. He was diagnosed with bipolar disorder – he was actively manic when he came in and actually improved quite a bit before he left. Even when he left, though, he really wanted that baby mama thing to be real.
  • Another patient was hearing voices. He had come in initially because people were trying to track him through the computer and hurt his sister, leading him to destroy the computer and whatnot. But now the voices were telling him to participate in community meetings and read a lot. So he did - found him initially with maybe twenty magazines meticulously folded in half on his bunk. I guess at least those are the good voices. 
  • A couple of patients tried to have sex. That didn't go over so well. Not exactly a place ripe for ability to give consent. Also... public rooms. Enough said.
  • There was one patient that was there when I arrived and left shortly after. I didn’t know her too well, but she usually just paced around with what psychiatrists call a “flat affect” and other “negative symptoms” of schizophrenia (essentially, she displayed very little emotion and tended to be more withdrawn, but would also just stand and stare at you). I tried to talk to her, but she quickly became agitated and said she didn't "want to be your project." Also said she was "trying to confuse herself." Why, you might ask? Her answer consisted of monkeys and zebras and jungles. I was confused too. 
  • One patient told me “I think you are a Klingon.” 
  • Another patient came in on PCP. Hit about 5-6 people over the weekend. He was acting up again Monday morning and put in seclusion. Proceeded to pee all over the floor, moon the staff that was watching over him, and then write on the window in the door using his feces. Don’t do drugs, kids. 
...And A Few Longer Ones

A little background for this one. So in the last week, two different things happened in different areas of the facility. First, one patient was brought into the conference room with the staff for a meeting to let him know that he needed to stay a little longer. He didn't like it, blew up, threw a coffee mug at the doctor (bad aim, fortunately), flipped a heavy wooden table, trashed the place, and scared everyone. Second, at intake, some dude broke one security guard's nose, another's wrist, and sprained or broke another guy's arm.

That brings us to today. Similar situation – we had brought a previously psychotic (found naked on street "running from cops" and paranoid) and still somewhat manic guy in to let him know we needed him to stay a bit longer. He didn't like it and became agitated. We herded him out of the conference room (to avoid a repeat of the previous scenario). I tried to pull him aside and have him sit down – we had a decent relationship before this. He came with me and sat down, but as soon as he saw the doctor who said he wasn't leaving yet again, he jumped up and started posturing and yelling at him – lots of pleasantries that won't be repeated here. He proceeded to do this for about forty-five minutes. We cleared the main area, called security, and tried to verbally de-escalate him. It wasn't working, but security wanted to keep trying (to avoid situation two). We finally ended up having to grab him, restrained him, and gave him some emergency meds that calm you down and make you a little sleepy.

Shawshank Seizures

We had a patient that tried to escape a few times. His first try was a little bit after I left for lectures in the afternoon – he tried to grab a staff member’s key and make a break for it, attempting to kick down several doors in the process. Everyone there at the time tackled him, and pretty much everyone was sore or had a scrape or bruise to show off the next day. Then, the next morning, he tried to use a chair to break through the winder in his room. That didn't work, thanks to the shatter-proof glass.

The real topper happened a couple of days later. He suddenly seemed to be short of breath and having chest pain. Now, this guy is in his early twenties, hadn't had access to any drugs in the past several days, etc. Seemed like he was most likely having a panic attack (or faking symptoms to get to the ER, where it might be easier to escape). That seemed to pass, he stood up, and actually fell down and started seizing. He had about four ~30 second seizures in about fifteen minutes. We supported him as best as we could while trying to protect his head and airway. EMS came, took him to the ER, where he finally woke up and made a break for it. No luck there, though - security caught him, brought him back to the ED, he eventually returned to the facility.

The interesting thing about this guy is that he probably was having seizures. It turns out that you can have what are called “secondary psychogenic non-epileptic seizures,” which basically just means that you don’t have a seizure disorder or any pre-existing focus of abnormal electrical activity in your brain, but sometimes under severe stress/anxiety/emotionality, you can actually cause your brain to discharge abnormally and – bam – you are having a real seizure. Interesting stuff.

When Freud is Your Patient
In one memorable two day period, I had patients start to come at me three different times. The first time was with an old vet with a number of issues who really didn't want to be at the mental facility (no one does).  He started to raise his clenched fists as if he were about to throw a punch, but we talked through it. The next two times happened on the same day with another patient, 50-something year old male with active schizophrenia. We'll call him Paul. He was actually the patient of another doctor on the unit. He had been found wandering around some rail-road tracks. No one knew where he had come from – it sounds like he had a history of being a sexual offender and some other pleasant backgrounds. We later found out that he had worn out his welcome at several local nursing homes, and the last one apparently “forgot” to report that he went missing or something. Hmm.

Now, this guy was extremely disorganized, irritable, and very difficult to understand. He also was (as psychiatrists like to say) very "sexually preoccupied." What that actually meant is that he spent his first weekend running around exposing himself at the nurses' station, masturbating in the common area, peeing everywhere, and trying to get handsy with some of the female patients.  

So I walk in Monday morning and see this guy standing right outside the locked door separating the nurses' station from the common area. Hmm. It's not uncommon for schizophrenic patients to sort of just stand and stare for long periods of time, but I hadn't seen this guy before. I walk out into the common area and try to introduce myself. 

"Hello - what's your name?"

"(Incoherent mumbling....)"

"What's that?"

"Sigmund Freud" 

"Oh...ok.... Nice to meet you."  

"(More mumbling....)"

Hmm. Alright.

That was our first interaction. Later, I was walking through the common area and he approached me again.

"(Incoherent mumbling...)" 

"I'm sorry, what was that?" 

"(More mumbling...) ....Freud .... (mumbling) .... dissertation..."

"... Are you asking if I know Freud's dissertation?"

He nodded.  

"I'm not familiar with any particular there something in particular you are wondering about?" 

That's where it all went downhill the first time. After that, he just glared at me and went off on a rant about what I can only guess was about how inept the entire staff at the facility was. He started to come close to me, and it wasn't in an "I want to give you a hug" kind of way. I stepped back, but he kept coming and now I noticed that his left fist was clenched and heading my direction, as if he was threatening me or about to punch me. That's no good.

What I should have done at this point was just walked away. Unfortunately, my first reaction was to make more space and control what I perceived to be a threat. So I stepped back while placing my hand on his chest and used my other had to lightly redirected his left fist back to his side. We then had a fairly nonproductive conversation about how that type of action is inappropriate and not helping him, etc., and I left (and washed my hands immediately. This guy wasn't exactly an example of stellar hygiene).  

Later in the day, I was out in the commons area again on my way to whatever my next task was. I don't even remember what started things this time, but this guy wasn't too fond of me now. He comes up to me and starts to incoherently mumble rather aggressively in my general direction. 

"Can I do something for you?" 

"(Angry mumbling)” 

"...Ok. I'm sorry, I'm having a difficult time understanding what you are saying." 

Now he steps towards me again and quickly grabs my tie. Nope - that's not going to end well. I grabbed it back before he did anything and just walked away. He was just looking for trouble at this point. 

Fast forward to the next day. Just as I walked in, this patient had hit another patient in the jaw. Nice. The day after that, I walk in to him getting into it with the staff because he had stolen some clothes that belonged to another patient and refused to give them back. We finally convinced him to give them up, but he almost immediately walks over and tries to take another patient's set of colored markers.

"Paul, you can't take those markers. They don't belong to you."



At this point he mumbled something about how it didn't matter, and wanted to know how much she paid for them. 

"None of that matters. They don't belong to you, and you can't take them. Go sit in that chair." 

"It does matter!" 

Every once and a while, a coherent phrase slipped through his "mumbliness" – that was actually a somewhat encouraging sign. 

We went back and forth a little bit. I eventually walked away after the other patient had recovered her belongings to take care of another task, but no sooner walked back to the nurses' station when I looked back and now Paul was trying to corner another patient. The other patient slipped around Paul and around a corner out of sight, presumably into his room. But then Paul followed. Of course.  

I walked back out into the commons area and over to that patient's room. Paul was standing in front of the closed door, tugging at the door handle. I couldn't tell if he was trying to get in or barricade the door so the patient couldn't get out. Either way, this wasn't ok.

"Paul, stop that. You can't go into other patients' rooms." 

"(Mumbling...) why not... (mumbling)?"

"You aren't allowed in there. You can go into your room, though." I pointed at his door, just down the hall.

At this point he changes course and starts asking me questions. I make out something to the effect of "who are you?" and told him I'm a medical student. He said something about " anatomy... " and I said yes, we do study anatomy. He then appeared to want to challenge me again and seemed to ask something about phalanges. I responded with something about fingers and he seemed pleased. At least I finally got a smile out of the guy. 

Shawshank, Part Two

One Friday, I was sitting out in the common area during my lunch break trying to study a bit. We had just received a new patient. Now, upon arriving, most patients' first question was something along the lines of "When can I leave?" This patient in particular – we'll call him Timothy – did not want to be here. He came out of his room and started pacing around, talking about how he didn't need to be here and how he was going to pick up a chair and smash through the (shatter-proof) glass door leading outside (to a secure patio) and escape if he didn't get out of here in five days. He eventually calmed down after a staff member started talking to him and offered to play ping pong with him.
Fast forward about twenty minutes down the road. I'm now sitting in the office with the doctor I'm working with, and we hear a loud BANG BANG BANG coming from somewhere outside the door. Initially, we thought it was Paul again – he would get riled up every once and a while about something or the other, usually about how he wanted a cigarette. I walked outside of his office expecting to see Paul at it again, but the noise was coming from the side of the facility opposite Paul's room. Uh oh.

We all run over to the room that the sound is coming from and crack open the closed door to reveal Timothy using a small bed-side table to repeatedly hit the (once again, shatter-proof) window in his room. Oh boy. He sees us and starts to charge at us with a crazy look in his eyes and the table over his head. 

That door was closed so fast you wouldn't believe it.

At this point, we signaled the nursing station to call security. After a moment, Timothy realized he wasn't getting anywhere with the table vs. window scenario and stormed out of his room. He was empty-handed, but didn't exactly look to be in the greatest of moods. We tried to verbally de-escalate him, but he wanted nothing to do with it. He stomped on over to the middle of the common area, picked up a chair, and started throwing it against the door leading to the enclosed patio.

Well, he wasn't kidding earlier, apparently. 

Unfortunately for him, these doors and windows had been built with this type of scenario in mind. After a couple of tries at the door, he gave up and ran over to the nurses' station. Now, the station was enclosed with the same type of glass, but I guess I figured that body-slamming it might work.

It didn't. 

By this time, security had finally started to arrive. Once again, they tried to verbally de-escalate him, and once again, Timothy wanted nothing to do with it. He continued to be aggressive - making fists, threatening staff, cussing his heart out, the whole nine yards. After a bit, security realized this wasn't going anywhere and took advantage of an opening in his tirade to tackle him.

Now, Timothy was a smaller guy, but he was strong. Three big security guys were having a difficult time just controlling his upper body while he was down, so the doctor and I jumped in to help hold his legs. We eventually got him back into the private room for restraints, and after a little bit of scuffling and spitting (on his part, anyway) finally had things under control. 

The next Monday when I came in, I heard that he did well over the weekend from the nurses. That's good. I walked into the common area, saw him sitting in a chair, and nodded at him to say hello. He glared back at me a little, but nodded in return. Good enough. 

Later in the day, I had just finished lunch and went back into the common area to study a little bit while things were quiet. All the patients were eating lunch. This one new patient we had who was actively psychotic for some reason had it in his head that Timothy was out to get him and kept intermittently yelling at him from across the room. To his credit, Timothy kept his cool and mostly ignored him. 

Mr. Psychotic, however, wasn't done. Once he finished his lunch (smart man), he got up and made his way towards Timothy, yelling all the while. We all started heading their direction, but Timothy had had enough by this point.

"I see where this is going." he grumbled. 

He got up quickly, took off his jacket, and before you knew it those two were going at it. Now, most people that fight at this mental facility honestly don't really even know how to throw a punch. Which is a good thing. But these guys - well, it obviously wasn't their first rodeo. Once again, security was called. 

We cleared the other patients out of the common area and circled around Timothy and Mr. Psychotic. For the most part, we don't have the staff to safely intervene between two aggressive patients so we just try to keep the other patients out of the way and only step in between the fighting patients if someone is really about to get hurt. These two were pretty much just grappling around on the ground at this point, so we were going to let them do their thing until security arrived. Timothy, though, was actually doing well in the sense that he was really just trying to hold the other guy and keep him from doing anything stupid. He quickly became fatigued, though, and Mr. Psychotic managed to get him in a headlock. That's no good. 

At this point, we jumped in and separated them. Security finally arrived after we got them apart. Mr. Psychotic got emergency medication and restraints; Timothy just requested some medication to help him calm down. 

Does Somebody Need a Hug?
On my last day, the staff all pitched in and brought various breakfast items to the morning meeting. It was very nice of them and it was really a pleasure to work with them all. At one point during to the day, though, I hear a commotion coming from the doctor's office off of the common area. Paul had somehow managed to get into the office and was refusing to leave, despite a tech's urgings. He sat down in a chair in the office and refused to move.
"I'm a doctor! I'm a psychiatrist!" he slurred.

Oh, Paul.

This tech had had enough. Paul had been in rare form all morning, and now he had bought himself a ticket to seclusion. The tech was determined to get him there. She pushed Paul in the chair he was sitting on all the way across the common area. It actually worked to get him into the back hallway, but then he plopped down onto the floor. Now, he had done this before. He would just lay down in some inappropriate place and just stay there, but he couldn't stay here and he knew it. He latched on to another tech's leg with a death grip and refused to let go. I got in there, pried his hands off, but then he latched on to my leg.

(At this point, he started to untie my shoe with his other hand and start mumbling about how they were his shoes or something. Oh, Paul...). 

He was just lying there at this point, latched on to me. I had him just stay there until security got there and while we administered some emergency medication, then extricated myself again from his death grip. But not to be outdone, he grabbed on to a nearby chart rack and shoved his head under it. 


We sort of all stood around him rather perplexed. Come on, man, really?

Finally, we pry first one hand ("Got it! Here hold this arm.") and then the other ("He's free! Pull him out!"). We tried to bring a wheelchair back, but ended up just carrying him back to the seclusion room.

I'll miss you too, Paul. I guess he just wanted a hug. 

The Verdict

I don’t see myself going into psychiatry, but I was surprised by how much I did really enjoy it. I think I would miss more conventional “medicine” too much. Also, I was surprised by how mentally draining it was. This may have been a bit unique to the environment I was in, but unfortunately really sick psychiatric patients tend to have very little insight into their illness and the fact that they really need treatment to get back on their feet. This means that, for most of their 5-10 day stay with you, you are repeatedly trying to convince them to take their medication and meet with their therapists and whatnot. Sometimes people do amazingly, turn around, and have an amazing recovery. But you’ve still been fighting with them for the previous week and a half to get them there. Additionally, some patients are so sick or have been sick so many times that their level of functioning is markedly reduced (like Paul). While occasionally encounters like these can be entertaining, it’s usually just really tiring and more importantly pretty sad for the patient. All of this sort of combined to make this rotation particularly mentally and emotionally demanding, which I wasn’t really expecting.

That said, it’s an awesome field with many discoveries yet to be made. It’s probably actually somewhere on my list of possible specialties now (I really wasn’t considering it at all before), albeit low on that list (as in, if absolutely nothing else in the rest of third year jumps out at me, I might consider psychiatry). The people who go into psychiatry, especially a lot of the newer residents, tend to be awesome and fun to be around. It’s also a field where you can achieve a pretty decent work-life balance – at the risk of sounding like a whiny millennial, my family is important to me and while I’m all for working hard while you are at work and working particularly hard over the next few years and during residency, afterwards I’d like to be able to not spend every waking moment in the hospital.

My next rotation will be family medicine. It’ll be an adjustment going back to more “regular” or conventional medicine, but I’m looking forward to it. I’ve heard good things about the site I’ll be rotating at – it should be very interesting and a lot of fun.