Back to the psych ward

I'm back from a way too short six day jaunt to the states. My oh-so-typical suburban neighborhood took on a new magical shine through the eyes of my fresh off the plane husband. (It looks just like the movies!)

Today's patient of the day: In his late 40s with syphilis inspired dementia, the only way they were able to convince him to stay in the dementia ward was to tell him that he works there. He takes his work very seriously, assisting the cleaning crews, helping the nurses wheel their carts, and moving the other patients around the ward when he isn't happy with where they're sitting. Today he assigned himself the job of watching the tea pitcher and "assisting" the other patients in pouring themselves the right amount of tea. If they pour what he perceives to be the wrong amount of tea? He chastises them, takes the cup, spills it over their head, and guides them back to their seat.

The nurse seemed to feel this was benign enough not to merit intervention so we got to watch him do this about six times during our fifteen minute tour of the ward.

In other news, I managed to get hopelessly behind my training schedule for the triathlon despite my very best intentions. Luckily there are three weeks to go so I'm going to try my very best to un-jet-lag fast, make up for the lost time over the next two weeks, and then hope for the best.

article time!

The article.

You've probably already encountered it. It's about the anti-anorexia legislation passed in France.

I have mixed feelings. I do have the feeling that it's effectively impossible to be a healthy-sized female in this western universe that we inhabit and not have a hidden suspicion that life would be just a wee bit better if we were just a wee bit smaller. So I support, 100%, the idea of legislation that attempts to change pro-anorexia/pro-skinny thinking on a large-scale basis. It's amazing really. Two years in jail! I love that it's taking a stand, a bold stand. And yes, yes, yes, a change must be made. A big one.

But on the other hand I do believe in free speech. And if we're going to prosecute websites for promoting unhealthy-and-possibly-lethal lifestyle choices, we might as well shut down half the internet.

I'm on my way out to go on a bike trip in the desert with the adolescent psychiatric ward. I love this rotation. . .

On-call in the peds ER

(details changed for confidentiality of course)

A few evenings ago I spent my on-call night in the pediatric ER, one of my very favorite places of the hospital. The majority of the night was your usual mix of earaches, coughs, diarrhea, minor head trauma, an endless stream of parents who wanted antibiotics for their children's clearly viral minor illnesses, and an adorable three year old with a toy truck in his esophagus who prompted an irritating argument with the ear-nose-throat resident who didn't feel this was an emergency and wanted the child to sit in the ER with a truck in his throat until morning surgery hours. (While we agreed that the child was technically stable it's pretty tough to explain to parents that yes, we're just going to just leave the toy there until the morning because the ENT is hoping it passes on its own).

There was also a two year old with a painless limp who'd just learned how to drink from a cup and was very excited to show this off. "Cup!!" he shouted, and there went his urine sample. He was so delighted by our shocked response that he spent much of the rest of the night running up and down the hallway screaming "pee-pee!" and looking for other sample cups to drink. (Luckily the limp slowed him down enough that we were generally able to catch him before he got anything into his mouth).

And then, around 1am there was a case that stopped me in my tracks. It started out unassumingly: a really sweet young woman in high school with a few days of high fever and muscle aches. We didn't suspect anything specific but she looked really miserable so we took x-rays, drew some blood, and did a pretty thorough exam looking for a source of fever.

Everything came back negative except her blood tests: which came back abysmal, awful, worst-case-scenario. And it was like time stopped. We're thinking we'll see something consistent with a virus, with a bacteria, maybe a normal blood count- and what we get back could be a lot of things but the only thing that really explains it well (I don't even want to write it) well, it's cancer.

There was before, when we were joking with her and the parents, and after, when we ask her questions we hadn't thought relevant before: weight loss, night sweats- and she answers yes to all them, and we now need to tell her and her family that they're not going home tonight with antibiotics like they'd imagined.

I feel mildly responsible since I'm the one who took the-blood-sample-that-changed-a-life.

I've been checking on her every day and so far there are no conclusive results. We're still ruling out viruses and gallstones and she had a CT late last night that I'm going to go over and check. So it could all turn out to be nothing. I'm endlessly optimistic.

There's just something strange about the fates that led me to be there at that *moment* when the flu turned into maybe-cancer. As a student and an EMT I've been present at so many of these turning points, before-grandpa-died to after-grandpa-died, before-my-leg-was-amputated to after.

It's strange to be a witness to these seconds that turn worlds around.

To be involved and to care and to take these stories home with me at the end of the day and yet also to be completely uninvolved, really irrelevant to what they're going through- just another face in a white coat that they'll maybe remember and maybe not.

Excerpts from psychiatric interviews

-Why are you here? "I Bit off the ear of a cat." Why? "Why not?"

- How are you feeling today? "I'd like to make hamburgers from everyone's penis."

-Reason for admission: "Killed wife with a squeegee."

-Do you speak English?
"I speak every language in the world."
Great! Do you mind if I ask you some questions?
"All the words I say are bullshit. Music is the only truth. I can only talk to you if you have a guitar."
::proceeds to sing the entire rest of the interview::

-"Hasn't slept in three days. Presented to surgery department requesting general anesthesia so he could take a nap. Refused to speak to any psychiatrist other than Freud himself."


I adore psychiatry. I've always found normal people in all their normal craziness fascinating. I love that my actual job these days is to sit and just talk and get to hear all their stories. We also get to go to morning activities with the patients. Yesterday was karaoke. The picture you have in your head of psychiatric patients singing karaoke- pretty much exactly what it was like.

A surprising number of patients stop me in the hallway and tell me that they can see my soul. One told me that he can tell I have a good soul. That's always nice to hear. Another told me that he's the manager of the world and he's going to take care of everything for me. Yay!

Of course there's a difficult side: the depression and the suicides and the medical-student-syndrome of daily diagnosing myself with every psychiatric illness I've seen that given day. There are also these absolute moments of sanity and clarity from the patients, these moments that I really connect with them and enjoy them and understand them, and all of a sudden their psychosis, hospitalization, the things they've done without understanding what they've done, the things they lost. . . it's tragic really. And hard to wrap my head around.

So I keep talking to them and enjoying them and trying to find those little moments of connection. And hey, I'm getting school credit for singing karaoke.

Joy!

Overseen at lunch today (in the psychiatric hospital quad):

A dignified looking middle-aged man strolled out onto the grass where we were eating, performed a perfect back somersault, stood up, and walked away.

Welcome to psychiatry!

Head doctor: It's a good idea to keep your name tags on you at all times. This allows the staff to know they can let you out.

Journal club: Empathy as Emotional Labor

The article.

Now this article is old news, it was published in JAMA in 2005. But our psychiatry tutor brought it up this morning and I just had to look it up.

For those of you who don't feel like reading, it's basically an article that examined the "work" involved in displaying empathy for your patients when you may or may not actually feel it and whether practicing your ability to act empathetic is a valuable component of medical education and training.

The conclusion they came to:

Although deep acting is preferred, physicians may rely on surface acting when immediate emotional and cognitive understanding of patients is impossible. Overall, we contend that physicians are more effective healers—and enjoy more professional satisfaction—when they engage in the process of empathy. We urge physicians first to recognize that their work has an element of emotional labor and, second, to consciously practice deep and surface acting to empathize with their patients.

My favorite part of the article is the flowchart demonstrating the effect of actually caring about your patients. Okay, I'm being cynical. But seriously, we now need a flowchart to show us that actually caring about patients is better than pretending to care about patients? (And that pretending to care about patients is better than nothing at all)?

The article then goes on to detail methods of acting empathetic when you're not particularly inspired to feel empathy.

I had two instant and absolutely contradictory reactions to the article.

My first reaction:
Really? We need an article teaching us how to pretend to care about patients? Really?

Because isn't this, theoretically, the entire reason most of us go into medicine? And isn't there something very very wrong that we need an article teaching us how to fake compassion for our patients?

My second reaction:
Wait a minute. Actually, we desperately need this article.

Maybe what this article means, maybe it isn't about acting, pretending, faking. Maybe this is about professionalism.

When I worked at Starbucks I smiled at every single customer no matter what. And I recommended our drink of the day with enthusiasm and cheer regardless of what I actually felt inside for said beverage. (Egg-nog latte. ::shudder::)

And isn't medicine, in its own way, customer service. We're here to make people feel better. And a hand on the shoulder, an understanding look, a sympathetic nod, is undoubtedly as important a part of healing as the medicines we prescribe (to my mind anyway).

So perhaps, who cares what you're feeling inside? Maybe it's 100% right to practice your best understanding head-tilt in the mirror. If you make the patient feel understood and cared for and that facilitates their healing and well-being, woo-hoo!

So I'm ambivalent. As much as I agree that this is the most essential, integral component of what we do, it just rubs me the wrong way that we need an article of "tips" for tricking patients into thinking we care when we don't.

What do you think?

Overseen everywhere

This is my all-time favorite hospital safety poster. (Okay, second to the one featuring a young child walking into a bonfire with a big red "no" x across it).

The title of this gem is "Earthquake Safety." It's especially dear to my heart because I have actually experienced an earthquake in Israel. Tragically, I had not yet seen this poster.

Now, having seen it, I know the right thing to do (in any situation!):

1. Am I alone? Kneel. Pray. Sit under a table and cry.
2. Alone in a hospital bed? Launch a tiny UFO.
3. In a room with a patient? Kill my patient (or balance a tiny UFO on their face? Debatable). Pray for forgiveness. Sit under the bed and cry.



I see this poster every day. I love it even more every time. (And welcome any other interpretations).

Triathlon training in the desert: the aftermath.

A photo essay.



p.s. This was with sunblock.
p.p.s. Spf 30.
p.p.p.s. At 7am.

strange fact of the day

Most schizophrenics are born in the winter.

Hmmm.

overseen in a class email

Welcome to psychiatry!

"At 0830 the group will move off to the classroom where the majority of activities will be held Which is located in the bomb shelter of ward 20. Late-comers will have to find their way alone."