Done with Psych, but Not...

Last week was the end of my first clinical rotation.  I parted ways with my patient the Friday before that, which was actually quite sad.  He said that he would miss me.  I didn't know what to say.  Hopefully he continues to get the help that he needs and can eventually become well enough to leave the hospital.

This week, I began my Ob/Gyn rotation at Jacobi Medical Center, our next-door city-owned teaching affiliate.  I happen to be starting off on the Labor and Delivery floor for the first ~1.5 weeks.  Today, my first day up on the floor, I witnessed 4 births: two natural, and a pair of twins by C-section.  Theoretically the C-section was interesting and cool to see (my first time ever in an operating room!), but really it just made me resolute that, given the choice, I would never want to go through that.  The mother couldn't really see what was going on, and thank goodness.  Surgery is, by its nature, a violent act (cutting open tissues that, in this case at least, are perfectly healthy), but on top of that, the surgeons aren't exactly what I would call gentle.  I'll leave it at that.

Obviously this is a lot different from my psychiatry rotation.  That doesn't mean, however, that I'm entirely done with psych.  Today, I saw a patient who believed she was 42 weeks pregnant and scheduled to be induced this evening.  She believed.  Well, she wasn't pregnant, not even a little bit.  She probably has pseudocyesis, a condition in which patients believe and even experience symptoms of pregnancy without actually being pregnant.  I felt well prepared to talk to her and her family, who were obviously all going through some very intense emotions when they found out that she actually wasn't pregnant and about to deliver a baby.  It was really rewarding that the doctor and nurses allowed me to essentially take on the patient for myself.  Mostly, they didn't especially feel like dealing with someone who wasn't actually supposed to be there (no baby = no reason to be on Labor and Delivery floor), but one of the nurses later told me that I did a good job.  That was rewarding.  I had a feeling psych would come in handy after the rotation was over...

A Pulse

My patient had been refusing his medications for several weeks.  His schizophrenic delusions became more vivid by the day.  Upon receiving a court order to medicate him against his will, the staff found it necessary to restrain him forcefully to give him the haldol injection he needed.  I was not there, but I spoke with him the day after, and a few days later, and a few days later…

He became withdrawn.  Before the treatment, he had been talkative, indulging me with details about his family, his education, and most importantly, his delusions.  Now he stared more into the distance, choosing not to look me in the eyes.  When he spoke, it was only to give direct answers to my questions; he no longer volunteered information.  His body had begun to shake.  It was most likely a side effect from the medication, but when I saw how it worsened when he spoke about his most pressing concerns, I realized that it could also have been from anxiety.  He was suffering.

A week after the treatment, I spent nearly 90 minutes with him.  The only substance of our conversation was his desire to go to “the hospital,” since he did not believe that he was currently in one.  He was concerned about the shaking but also about his heart.  For the past few weeks, he had become convinced that his heart was not working; he thought that it sometimes stopped.  I asked him if he had ever tried taking his pulse.  He awoke from his trance, looked me in the eyes, and said that he did not know how.  He quickly took me up on my offer to teach him, his eyes widening with wonder when he felt the beating of the radial artery under his fingertips.  I told him that he could try to check it when he felt that his heart was not working.

He withdrew again, telling me that the pulse was not connected to the heart, unconvinced of my explanations of how the circulatory system works.  I gave him the option, several times, to leave if he no longer felt like talking, but he always chose to stay.  Even though I felt as if I was doing nothing for him, I could tell that simply being there together was somehow comforting.  I am the only person he talks to; he doesn’t talk to the other patients, the nurses, the social workers, or anyone.  Just me.  I think of that moment when he felt his pulse for the first time ever, and I hope that I am helping him – and I choose not to think of what will happen to him when I leave for good.  I don’t want to imagine the pain.

This Is Where I Work

Halfway through my psychiatry rotation at the Bronx Psychiatric Center, I've gotten a better sense of what kind of a place it is.  In a sentence, it's the end of the road for psychiatric patients who have failed treatment, run out of insurance, or had criminal pasts.  The patients are kept in wards behind double-locked doors.  We all have panic buttons.  We have to swipe our ID's to get both in and out of the building.  My impression of it two years ago, in first-year ICM, was that it was a depressing place; how could anyone work with patients who had so little hope of getting better?  At least, so little hope of getting well enough to leave?

First impressions go a long way.  Halfway through my rotation, however, I've realized that there is so much more to be said for this place.  Up on Ward 12, the patients are prepared for living in society again after months or years of treatment.  They take classes, go to off-site programs, learn how to care for themselves.  They have community meetings, where they all gather and voice their opinions and concerns about life on the ward in an open forum.  These are people who have committed heinous crimes in the past - molesters, murderers, drug dealers, anything you can imagine - but it truly feels like a community, and the patients are people you would want to chat with in a grocery line.  Their lives have been turned around by proper recognition of their mental illnesses and appropriate (and oftentimes heavy) treatment of their diseases.

Ward 7, however, is slightly different.  An all-male admissions ward that houses patients with acute exacerbations of long-standing disease, it's where I've been assigned to work for these six weeks.  These patients have similar stories as the ones on Ward 12, but they're not well controlled by treatment.  Several times a week, there are incidents involving emergency medications for acute psychosis, injuries to one another, attempts to escape, and defiant behavior (e.g. moving furniture around at night with disregard to roommates).  My patient has been - and still is - refusing to take his medication, insisting that he does not have psychiatric illness.  His hallucinations and delusions are complex and concrete, like the fact that he has billions of dollars, that Mayor Bloomberg is trying to kill him, and that Magic Johnson manages his bank accounts.  This is a smart man who has completed high levels of education, but his illness has taken over his ability to function in society.  We learned about schizophrenia during second year, but I never imagined that it would be so recognizable and real.

Halfway through my psychiatry rotation, I'm beginning to understand the devastating reality of mental illness.

Bronx Psychiatric Center

A Road Trip Recounted

...all in pictures, because I've been too busy to take the time to do this properly.  And here goes our southern whirlwind:

 In Washington, D.C., my friends were surprisingly accommodating of my ridiculous insistence on seeing all things aerospace-related.

We had a chance to stop by my favorite monument in D.C. 

At Gravelly Point Park, you can watch (and feel!) the planes land at Reagan from very close range. 

On our drive through Tennessee, we stopped briefly at Great Smoky Mountains National Park. 

In Nashville, we witnessed the end of the Great Cicada Invasion of 2011. 

 Nashville also provided us with great entertainment.  Here is the end of the Music City Roots, a weekly live radio show held at the Loveless Cafe barn.

In Memphis, we attended one of the Top 10 Rooftop Parties in the country at the Peabody Hotel. 

In Louisiana, outside of Baton Rouge, we were able to see the beauty of the Rosedown Plantation. 

Later, we joined in a crawfish boil at the house of the brother of a friend of the roommate of the former babysitter of Thomas (one of our road trip companions).  Talk about southern hospitality! 

In New Orleans, there was a band on practically every corner. 

We were also invited to participate in a second line, the parade held to celebrate the life of someone who's died. 

The culmination of our New Orleans experience was Bourbon Street, busy even on a Sunday night. 

In Savannah, we ate every southern dish you can name (and a few more) at this former boarding house. 

We were able to soak in some sun and play in the bathwater-warm Atlantic at Folly Beach, outside of Charleston. 

When we camped on Ocracoke Island (part of the outer banks islands of North Carolina), we were just on the other side of the dunes from the ocean. 

On our way back home, we stopped briefly at Kitty Hawk, where the first powered flights took place.  The first flight took off from this large rock and came back down at the small rock in the distance.

It was a delightful trip, a great break before beginning our real lives as third-year medical students.

Real Life

Over the next few days I will be trying to recap the amazing 15 days of our 3,929-mile road trip down South.  Maybe a picture or two will highlight each of the many cities (and non-cities) we saw throughout the trip.  Tonight, however, my mind is on one thing:

I am now officially a third-year medical student.  I am a clinical clerk.  I am no longer a regular student, someone who sits and listens and learns.  I am now a member of a team responsible for the care of real patients.  Tomorrow, I report for my first day at Bronx Psychiatric Center, where there will be anyone from the severely depressed to the severely psychotic.  Yes, it's nerve-wracking, but I can't wait to learn.

Rambling

Done with the boards!  (And thank goodness for that...)  So now what do we do with our lives, now that we're not studying all day long?

ROAD TRIP!  Watch out, South...

...here we come!

On Days Like This

I can't believe I'm stuck indoors.  One thing's for sure, though...

...in two days, I will be FREE!