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

Barriers

I learn so much from my patients.  I don't just learn how to conduct a medical interview, how to perform a physical exam, or how to give a case presentation.  No, I learn much more than that.

Yesterday's patient was an 80-year-old man who has been in the hospital for 6 weeks.  Medically, things have gone from bad (weakness and shortness of breath from pulmonary fibrosis complicated by heart failure) to worse (a complicated UTI with methicillin-resistant staph).  Anyone entering his room must wear a gown and gloves to avoid picking up MRSA themselves.  As I donned the protective gear, I wondered how it made him feel to know that the medical personnel feared his infection.  Lifestyle-wise, things have also gone downhill.  During his stay at the hospital, he has been informed that his home is no longer environmentally safe and that he can no longer live alone, as he has for all of his adult life.  He cannot go back to his home, which is the last place he stayed before coming to the hospital 6 weeks ago.  This was clearly upsetting to him, but he tried his best to remain stoic about the situation.  His parents and siblings died at young ages of heart attacks.  His closest relatives were a niece and nephew far out on Long Island.  He was so thin I could see all his bones.

Despite all of these hardships, he showed hardly any emotion about it all.  He clearly liked talking, as he rambled on and on after each question we asked.  He had a sense of humor.  When we asked if he ever married or had children, he said, "No, never.  I offered my hand to many ladies, but they would only give me their foot."  He looked at me and smiled.  Later, "My sister died at 60.  My brother...died at 61.  I guess I was supposed to go at 62, but thank God I'm still here."  I was somewhat surprised, but comforted, to hear this; despite his many difficulties, he was thankful to be alive.  Later, when I was conducting the physical exam, he said out of nowhere, "You're going to make a great doctor."  All I could think about was how young I must have looked to him.  I was caught off-guard.  "I hope so!" I laughed, and then, "Thank you."

By then, I had forgotten about the gown, forgotten about the gloves.  They may have been a barrier to MRSA, but they were not a barrier to connecting with my patient.

I Like My Patients (and my patients trust me)

Some of my classmates take exquisite pleasure in their ability to diagnose an unusual disease etiology on their Tuesday clinical rounds.  "I diagnosed Chlamydia psittici because I thought to ask about her pets."  Others can't wait to brag about the unusual (and often disturbing) medical sights they saw.  "We saw a guy with a necrotic...gangrenous...penis."

I'm a medical student.  Of course this stuff interests me.  Of course I would be excited if I was able to be the one who recognized the one clue that led you to an alternate (correct) diagnosis, of if I was able to see a really rare, gruesome, interesting disease process.  I admit that.  However, I think I'm different from many of my (more vocal) classmates.  For me, the most interesting and rewarding parts of my Tuesday physical exam hospital rounds are my interactions with the patients.

One of medicine's really big pulls, for me, is the patient interaction.  Science is great, but it's even better when it's science and a unique person with a unique personality and a unique history.  It's not just the disease process, it's how the disease affects the individual's life.  An ulcer is an ulcer, but how does the patient experience it?  Deal with it?  Require help for it?  I've always known that patient interaction was a crucial part of the doctoring process, but I was never really sure how good I'd be at it.  I don't want to make any premature judgments, and I certainly don't want to brag, but I think I've found out the answer:

I like my patients, and my patients trust me.  This has been evident multiple times over the course of our physical exam course, when my patients tend to look to me for a smile or understanding even when my partner is doing the interview or exam, but it's been especially evident over the last two weeks.  Two weeks ago, our patient was a young woman with cellulitis complicated by a deep vein thrombosis.  She was in good spirits despite being in the hospital with an immovably swollen, painful, itchy leg.  We performed a full physical exam, as always, to get practice at it.  She asked a few questions along the way, curious about what we were doing.  "We're listening for the size of your liver," I explained, or, "We're comparing the circulation in your legs."  She reminded me of myself, simply curious and interested in the process.

Last week, our patient was a middle-aged woman with every chronic disease in the book -- what we like to call a "typical Bronx patient."  Asthma, diabetes, emphysema, and some sort of upper respiratory infection that had landed her in the hospital for a few days, but she was friendly and cooperative.  In taking a thorough history, my partner asked about her social history, which included drinking habits.  "Ohhh...I drink a lot, we'll just say that."  How much, my partner wanted to know.  "We'll just leave it at that," she chuckled.

But this is a crucial part of the medical history, so I stepped in.  I knew that patients often feel uncomfortable talking about how much they drink or smoke.  I also knew that it can be hard to quantify sometimes, even if the patient isn't uncomfortable.  I tried to help out.  "How many days do you think you drink?  Almost every day?  A few days a week?"  That was all it took.

She looked at me with a smile in her eyes.  "Oh, pretty much most days, almost every day."

"What do you drink?"  Sometimes it's easier to quantify when directly asked about the type of drinks.

"I love my Coors Light.  I get me those big cans -- not the little ones, but the big 24-ounce ones."  She gestured to show me the size of the can.  "Yeah, the big ones.  I like to have 'em nice and cold."

"How many do you usually drink?" I pressed.

"Oh, maybe 3.  Sometimes 2, sometimes 4.  Depends how I'm feelin'."

Usually when you ask about lifestyle habits, like smoking or drinking, you get a vague answer.  Usually patients don't like to go into detail.  They don't lie, but they don't really want to get into the whole story.  I don't think it's because patients aren't trustworthy, or because they're unwilling to tell the truth.  I think it's because we sometimes simply don't ask the right questions.  All it took was a little understanding and creativity to get an answer that was much more full of details and trust than I needed or expected.

I like that.  I like being able to connect with my patients, knowing that I'm able to excel at the part of medicine that pulled me into it in the first place.  When we were done with the interview and exam, and we were about to leave the room, our patient asked us about our status in school.  She was wondering how far along we were, and how much longer we had.  I explained that we were in our second year, and that the first two years were mostly classroom learning whereas the third and fourth years will be spent in the hospital doing rotations, and that patients like her are our teachers.  She loved that.  She laughed and smiled, and thanked us.  Thanked us?  For poking and prodding her when she was already sick in the hospital?  Yes, thanked us.  Need more proof that we connected?  She remembered my name.  "Take it easy, Michelle!"  I did.  The rest of the day, I was elated.

Patient Interaction

The first time, I was nervous.  I desperately hoped that my partner, whom I had happened not to have met during our entire first year and a half at medical school, would be excited and ready to do the physical exam, because I sure wasn’t – I was nervous.  We found our patient.  After introducing ourselves to her, I looked at my partner and suggested, somewhat proud of myself for thinking to do it this way, “Should I start with the history, then?”  I would obtain the medical history, and then he would perform the physical exam.  My plan was perfect.

Unfortunately, my plan was not perfect, and he was just as nervous as I was.  “Well, I could do the history, and then maybe you could do the exam…?”  He asked it as a question, but I already knew my plan had failed miserably.

Come on, Michelle, I thought.  You’re in the Air Force.  You can’t wimp out with something as small as this.  You’ve just got to get through it; it will be fine.  I didn’t want to be difficult, and I didn’t want leave my partner hanging on our very first day together.  I acquiesced.  It felt strange to be examining another human being who probably had no idea how little experience we’d had, but I had expected that.  I was nervous, but I got through it.

The second time, I was less nervous.  I was the one obtaining the medical history that time.  I felt completely comfortable talking to my patient, finding out so many details about something so personal as her own body while also establishing a trustful relationship, an easy rapport.  My partner and I talked through the exam, helping out one another.  Of course it didn’t feel natural, but at least it didn’t feel as scary as the first time.

The third time, I was excited.  By then, I was more familiar with the exam, more trusting of my partner, and more confident in my skills.  An hour before, however, I learned that my partner was sick and would not be able to come that week.  My certainty deflated instantly.  Would I be required to do the entire history and exam on my own?  I felt comfortable interacting with a patient alone, but I certainly did not feel ready to perform the physical exam alone.

The third time, then, I was incredibly nervous, but I was determined to do my best.  To say it was easy would be an egregious misstatement.  The patient was not at all talkative, answering most of my questions, even the open-ended ones, in single words or phrases.  His accent and quiet voice made it even more difficult for me to understand and interact with him.  When I had exhausted my mental stockpile of questions, I moved on to the exam with a new rush of nerves.  He knew that I was a student, but at the same time, I did not wish to appear inept.  I tried my hardest to appear as though I had done this sort of thing many times before.  Since he was a chronic liver failure patient, he had seen his share of medical students.  As I performed the exam, he told me about a time he did not feel comfortable with the student.  It did not seem to him that the student knew the right exam procedures.  I paused.  Was he hinting that he didn’t trust me?  I looked him in the eyes.  He went on, “But you – you’re all right.”  Not wanting to violate his trust, I asked his permission before I proceeded with the rest of the exam, to which he replied, “Of course.”

I’ve only participated in the physical examination of three patients, but I’ve learned so much already.  I’ve realized that it is natural and even expected to be nervous for these powerful new experiences.  I’ve also realized that as nervous as I may become, I can do it.  I can establish relationships with patients, and I can work through my own apprehensions to learn the most important skills we’ve been taught in medical school thus far.  Some exams will be more difficult than others, but that’s why I chose medicine.  I wanted to interact with people – people whose disease processes, medical histories, temperaments, and ultimately lives are all different.   I’ve been nervous, but I’ve also been privileged.  I can’t wait to continue to experience the miracle of interaction throughout the rest of my career.

Feet

First admitted patient.
We talked about her asthma, listened to her wheezing lungs.  They were musical, singing a chord every breath she took.  She told us that she had diabetes as well.  Wishing to be thorough - and hoping to practice as much of the physical exam as we could in our allotted time with her - we attempted the neurological exam.  Attempted, because we didn't have all the necessary instruments.  We did, however, have a tuning fork.  Proprioception was fine in her fingers, but what about her toes?  I moved to the foot of the bed, asking her if I could remove her hospital-issued socks.  Underneath, her feet were dry and cracked.  Her toenails were fragile.  Proprioception was not fine; she couldn't feel the fine vibrations of the tuning fork.  She didn't seem concerned.  She'd probably never had a tuning fork pressed to her toes before.  I helped her put her socks back on and thanked her for helping us learn.

First ER patient.
She came to the hospital, on the busiest day of the year, because of the pain in her ankle.  She and her home-health aide braved the crowded department with the beds triple-stacked and protruding into the already crowded walkways, because she herself could not walk with the pain.  We touched and maneuvered her ankle.  "Ohh!" she cried in pain.  We moved her knee.  "Ohh!"  We manipulated her hip.  "Ohh!" again.  What was the problem?  The ankle, the knee, the hip?  Which one had caused the others' pain?  But her feet were fine.  I tried to find her dorsalis pedis pulse, assuming it would take several tries since I can never seem to find it even on my own feet.  First try, and there it was, bounding and strong.  Her warm feet were more lively, it seemed, than my own.

Second ER patient
She was in the West section, the one where those with the most serious problems are taken.  My preceptor, wanting to make sure I saw interesting cases in my afternoon at the ER, asked another of the attendings if she had anything cool.  "I've got a woman with a cold foot."  We found her and said hello, but she was only minimally conscious and did not even acknowledge us.  Still, a good teaching moment.  We felt her right foot; it was, indeed, cold.  And her ankle.  And her calf - but not her knee.  Left side was not what I would call warm, but it wasn't as cold as the right.  Left was pink; right was white.  No pulses on the right leg, but the femoral pulse was strong.  Was it a DVT?  Something else?  Doppler had been scheduled, but they were unsure if they would admit her or not; they might just send her back to the nursing home.  Before we walked away, I looked again at her feet.  Most of the digits were hammertoes.  I tried to imagine her as a young woman, wearing nothing but high heels every day.  In my mind, she was happy, beautiful, fashionable, not minimally conscious in an ER bed with a cold foot.  I walked away and wondered what would happen to her.

Second admitted patient
What didn't she have?  We talked about her asthma, her quadruple bypass, her liver cirrhosis, her kidney failure, her ascites, her edema, her shortness of breath.  Despite all of these problems, she looked at least twenty years younger than her real age, even though she had already told us about her six great-grandchildren.  She had a moment of sadness when telling us of her frequent hospitalizations, and of how scared she felt when she suddenly couldn't breathe, or when her nose suddenly spilled clots of blood.  I tried to comfort her despite having only minimal experience in this sort of thing.  She cheered up, then commented about how hard it was getting old.  I laughed, and she smiled.  "She's laughin' at me, but it's true!  It's hard gettin' old!" she laughed back.  We began the exam, hearing her labored breathing and the shifting dullness of the abdomen.  She told us she had diabetes, so out came the old tuning fork again.  Off came the socks again.  She looked down and commented on her feet.  "I got no one to take care of my feet.  Can't cut my nails."  It was too hard for her to bend down that far to do it.  "I look at them, and they look like claws to me!" she pronounced with a grin.  I smiled back.  I never knew you could learn so much from feet.

Ireland Broke My Rib

In Ireland, I happened to pick up a bug and come down with a cold.  It was like a typical cold -- fatigue, sore throat, headache, enlarged anterior cervical nodes, runny nose -- except that the cough was worse than normal.  It wasn't a mild-and-will-go-away-in-a-week cough.  It wasn't an annoying-itch-in-your-throat cough.  It was a drowning-in-your-own-secretions cough.  (Gross, I know.  Sorry.)  If I didn't sleep sitting up, I would soon be practically falling out of the bed, curled unintentionally into a coughing fit of a ball because my abdominals were tightened to the point that my chest was nearly touching my stomach.  I've never had this bad of a cough in my life, not even when I had whooping cough.

I felt bad for the guy that had to sit next to me on the plane.  If I could make it 5 minutes without coughing, I considered it a miracle.  I sucked my way through an entire bag of Jakemans Throat and Chest "Soothing Menthol Sweets" (the British version of cough drops, unfortunately with quite a strong anise flavor) in less than a day.  When I got back to the Bronx, I finished off my bag of Robitussin cough drops, then stole some of my roommate's Ricola drops until I could make it to the store to get my own.  I tried NyQuil and DayQuil, to no avail.

Almost a week after getting sick, my right lower ribs began hurting when I coughed.  Sore, annoying, but livable.  Two days later, as I was studying in Manhattan (still coughing), it suddenly got worse.  Much worse.  I coughed, and it felt as if something had popped; my ribs gave me excruciating pain.  I didn't know what to do.  What could it be?  Muscles?  Ribs?  Liver?  Gallbladder?  I had no idea, except that it hurt.  I walked to the Beth Israel ER, where the doctors were incredibly nice to me (I told them I was a med student).  Without doing much more than a simple feel around the area, they diagnosed it as a muscular issue, so they simply prescribed me some extra-strength Motrin and shooed me out the door.

A week later, I had my follow-up appointment.  By then, it still hurt, but it was different.  When I pressed on my rib, it clicked.  Click.  Pop.  Click.  (Ow.)  Diagnosis: cracked rib.  From coughing.  Treatment: nothing.  Let it heal on its own for 6 weeks.  When people hear cracked rib, they become concerned.  When they hear it's from coughing, they laugh.  And then they ask me, the girl who goes through a half-gallon of milk, several cups of yogurt, and ounces and ounces of cheese in a week, if I have a calcium deficiency.  Don't be silly.  But also -- for now -- don't touch my rib.