Tuesday, December 23, 2008

All I Want For Christmas is My Sanity


I'm beginning to think that everyone is a little bit crazy. The only difference is, do you know how to blend in?

When I first started in the psych unit we had this patient who is practically paralyzed by anxiety. She wanders the halls and has fixed delusions that spell doom for her. She watches the windows afraid that a van is going to come up to take her away somewhere. Where the heck would we send her? She's already in the psych unit! I could not understand how she was letting her days pass by in this tortured state of anxiety. Surely, I thought, sooner or later she's going to just let it go or decide that even though she's afraid, she wants to leave.

I suppose I will never quite be able to let my own experience color my assessments. Just because I have a loving generous fiance and family to look forward to going home to doesn't mean she does. Or maybe she's so deep in delusion that she couldn't recognize it even if she did.

As days are growing shorter and I go to work and come home in the dark, I noticed I'm starting to feel more anxious too. I worry about the weather and whether my fiance is going to make it home safely. I worry about getting sick, or someone I love dying. Sometimes my mind is consumed, obsessively playing little movies about all the bad things that could happen. It's a horrible feeling. I try to think about something else or just remember sometimes there's nothing I can do about it. Sometimes it works and I can let go, sometimes it doesn't and instead my mind races through every aspect of a situation logically working through the odds of each scenario and the best actions to prevent or deal with it. Usually it's just time that takes care of it. What goes on in my patient's head? Is that where she is stuck? When do you tell if someone needs medication?

What a fragile balance between having a detailed mind and an obsessive one. I always wonder how much I can really affect my thoughts, or if it's just another way my ego thinks I am in control. You know doctors have such God complexes. :-) I used to have a prejudice in the back of my head that anxiety medication was the easy way out. That if you tried hard enough or trained your mind you could change it. I don't know anymore. Maybe it's just chemicals in your brain. Maybe it's a combination. Maybe the things that make me a good medical student are also things that could send me to the psych ward myself.

Wednesday, December 17, 2008

Prayers needed.

Please say a prayer for my cousin Kari, her family, and especially the little one on the way.

And maybe a little prayer of thanks to her doctors who took a lump in a young woman seriously the first time.

Monday, December 15, 2008

Who's the crazy one?

I just started Psychiatry last Monday. Woohoo! Nothing like the holidays to bring out the crazy in people. I really should have thought about that before I scheduled this.

A wise TV character once said "People are bastard-coated bastards with bastard filling" (it's a quote Mom, so don't judge me for that one.) I usually try not to take that approach with patients, and give them the benefit of the doubt when it comes to telling me what's going on. With psych patients, however, all bets are off. That doesn't just apply to the patients, either.

Yesterday we were getting a history on someone with suspected antisocial behaviors. He seemed perfectly pleasant and cooperative, except for a few legal troubles here, a minor for a girlfriend there (not legal), you know, the usual. We were trying to get a childhood history from Mom, who said "He was perfect! Blah Blah Blah blah his psychiatrist..." Jigga What? Why, pray tell, did he have a psychiatrist ma'am? "Because he burned the house down when he was 5".

After blinking a few times, I thought: Surely she didn't just say this. Nope, there she was looking at me with a straight face. Ok, maybe he was playing with matches out of curiosity and oops, the house caught on fire. So I asked. "Well, he took a lit candle and went around setting the curtains and the furniture on fire."

Are you kidding me? I never would have found out about this if I hadn't completely blanked on my next question and just let her talk. My psychiatrist is a pro at talking to people and getting the real dirty. I apparently am a mere amoeba when comparing interview skills.

Needless to say, after that particular conversation I am much more probing when talking to patients. And I always ask if a patient has ever burned a house down.

"So, Timmy, have you scalped any kitties lately?"

Thursday, December 11, 2008

Mental Health Needs Parity.

Since I started psychiatry, I've begun to hear stories that would break just about anybody. What an experience to go from 3 strictly medical rotations where mental health was a somewhat ignored side note to psychiatry where we actually have the time (and urgency) to explore people's lives and motivations.

As the practice of medicine improves with new technologies and medications, we routinely save patients who 30,15, sometimes even 10 years ago would have died. What I now realize is that we focus so much on keeping patients alive, but overwhelmingly neglect what happens to them after they leave the hospital. How many times do you hear of an accident on the news and wonder "Did he/she survive?" How many times do you think of what permanent injuries they will have if they do survive? Will they be able to work? Will their brains change?

One patient I spoke with this morning survived a horrible work injury. Among other sequelae, it left him blind. He went from a hard-working functioning man to someone completely dependent on others. He feels like he is no longer a complete person. He was unable to be the father he thought he should be. To make things worse, his caregivers are cheating him out of his injury settlement, tearing his family--the people he loves the most in the world--apart.

I especially wonder about patients with traumatic brain injury. A brain injury, especially to your frontal lobes, can completely change your personality. A son who was described as a "gentle, docile man" is now threatening to stab his dad over a glass of milk. What happens to a marriage when one partner's personality completely changes? Is he the same person you married? Do you stay and try to help even though he could be a danger? If you divorce, who takes care of him? Where will his anger go next? When a wife is now out of work and in a severe depression, how does a father of two young girls pay the bills? What happens to the kids when Mom and Dad are so far sunk in drugs and alcohol that they can't even think to put a coat on them when it's 18 degrees outside?

It is so easy to look at people in a mental health unit and think that their lives are different than mine. I came into this without any idea of the stressors some people live with, or that one really can make a difference in their (and their children's) lives. This unit provides an invaluable service to society. Here the social workers and doctors and nurses attempt to untangle the complicated mess of mental illness and societal stressors that precipitate psychotic breaks or suicide attempts or all the other manifestations of a mind in trouble. Here is often the refuge where these patients are actually listened to--the whole story, not just the runny nose or the risky sexual history or even the mild depression that leaves out the fact that the patient was abused as a child. We NEED more money in mental health care. Familes are often too stretched and unable to care for these people. Where are they supposed to go? Leave them on the streets?

It's unconsionable to me that as a society we abandon these people. I hate that Missouri had such a fight in the state capitol over mental health parity--as if it is something that if we ignore, it will just go away. We are fiercely on fighting over abortion as a "Pro-life, pro-family" issue but fail to take care of families that are breaking apart. It's inhumane.

Anyway. I am already learning so much on this rotation. I hope to take away more understanding and compassion, and maybe give a little help or at least comfort while I'm here.

Thursday, December 4, 2008

Do you think I'm cute too?

Nothing like an ego boost....from your friendly psych/neuro patients.

A few examples before I crash:

"You made my day though, you're CUTE!" --Younger alcoholic patient

"May I ask you a few questions?" --Me
"I'm already married, but you sure are cute." --Older alcoholic patient

"I gotta tell you doc, she's cuter than you" --Pretty hilarious elderly patient...with dementia.

I don't know what's more disturbing, the consistent independent use of the word "cute" to describe me (must be the new bangs) or the fact that the last time I got this much male attention I was on the wards at the Veteran's Hospital.

I suppose if the med school thing doesn't work out, I could easily entrance an alcoholic demented rich old man...provided I got to him first. And of course, that my fiance ok'd it.

Monday, December 1, 2008

Too Frickin Tired

I will post more later probably...but it's going to be a bit of a dry spell until I work fewer than 12 hours a day. I have to have some time to read so I don't look stupid the next day. And by some I mean a lot.

I will leave this one story, however: picture it, a young (younger than me) woman, pregnant with No. 2, refuses to take her multiple sclerosis meds even when she isn't in the family way because she "doesn't want to be dependent on her medications". I think underneath that statement were some problems with the side effects, but seriously. Half of patients diagnosed with MS are in a wheelchair in 15 years. How's that for dependent? I never understand when people say they don't want to be dependent on something but can't look a little farther down the line to see the consequences. Like the smoker who couldn't quit smoking but wouldn't take his Advair every day because he--you guessed it.

Why do they even come to the doctor?