I'm very impressed with the organization of the pediatrics clerkship, so far. The logistics of this clerkship are especially difficult because students do a mix of inpatient and outpatient work, with some maternity wards thrown in. To make matters more complicated, students spend varying amounts of time on each part of the rotation, so everyone's schedule is different. I have two weeks of Urgent Care, a week on inpatient, and three weeks outpatient with a pediatrician in private practice.
Waiting for all the students at orientation this morning were binders with all sorts of useful information: each student's schedule, required assignments, forms to fill out throughout the rotation, grading policies, some selected journal articles and other required reading, etc... These binders looked professional, with color-coded tabs and everything. This may seem inconsequential, but presenting all of this information clearly and organizing it well makes a huge difference in terms of reducing stress and confusion.
Aside from going through the binder section by section, we also had three teaching sessions: infant and child development, pediatric fluids/electrolytes, and pediatric nutrition. All three of these sessions were interesting, engaging, and very relevant for this rotation.
I left the pediatrics orientation feeling like I know what is expected of me in these next 6 weeks and well prepared to meet those expectations.
Monday, January 30, 2012
Sunday, January 29, 2012
Starting my pediatrics rotation early
I ostensibly start my pediatrics rotation on Monday, but in reality I began this weekend while visiting my brand-new-to-this-world nephew, all of a week old. He's quite adorable.
As I fended off my family members for the privilege of holding him, I couldn't help but give him a quick once-over. Symmetric eye movements, responds to auditory stimuli, soft non-bulging anterior and posterior fontanelles, good muscle strength and tone, no skin markings, etc.... I cursed myself for leaving my stethoscope at home (joking, mostly).
It felt good to have a baby in my arms, especially one that happens to be my nephew. I'm actually looking forward to my pediatrics clerkship. Considering how much I enjoyed my pediatric neurology rotation, it'll be interesting to see what I think about general pediatrics and whether this experience makes me want to incorporate pediatrics into my future career.
As I fended off my family members for the privilege of holding him, I couldn't help but give him a quick once-over. Symmetric eye movements, responds to auditory stimuli, soft non-bulging anterior and posterior fontanelles, good muscle strength and tone, no skin markings, etc.... I cursed myself for leaving my stethoscope at home (joking, mostly).
It felt good to have a baby in my arms, especially one that happens to be my nephew. I'm actually looking forward to my pediatrics clerkship. Considering how much I enjoyed my pediatric neurology rotation, it'll be interesting to see what I think about general pediatrics and whether this experience makes me want to incorporate pediatrics into my future career.
Friday, January 27, 2012
Recidivism in psychiatric patients
It has been a running joke with one of my residents, my optimism when it comes to the chances that my patients will actually make meaningful changes in their lives. Out of curiosity, and as a sort of exercise, we sat down together and reviewed the charts of my patients from earlier in the month. My meth addict patient? Missed his follow-up appointments. My alcoholic patients? They all missed their appointments. My borderline patient with anger issues and family problems? "Oh, look," my resident chuckled, "He made his optometry appointment but missed his psychiatrist and family therapy appointments! That's interesting..."
She wasn't so much rubbing it in my face as making her point that, as a psychiatrist, you can't expect your patients to change any more than they are ready to change. It's easy to get discouraged and jaded, she said, the more of yourself you invest in their recovery. Her eyes widened for a flash, a microexpression. I think she got worried that I might judge her as jaded and cynical. But I understood what she meant. It was natural for me to want to single-handedly fix my patients' self-destructive behaviors, but the game was already lost the moment my motivation exceeded my patients' motivation for change.
She wasn't so much rubbing it in my face as making her point that, as a psychiatrist, you can't expect your patients to change any more than they are ready to change. It's easy to get discouraged and jaded, she said, the more of yourself you invest in their recovery. Her eyes widened for a flash, a microexpression. I think she got worried that I might judge her as jaded and cynical. But I understood what she meant. It was natural for me to want to single-handedly fix my patients' self-destructive behaviors, but the game was already lost the moment my motivation exceeded my patients' motivation for change.
Sunday, January 15, 2012
Time for lunch
To my surprise, psychiatrists take an hour out of their day to eat lunch. Even psychiatry residents do this. Fairly regularly, too. On my first day of the clerkship, the residents and medical students all walked a few blocks to a local deli. We actually ate at the restaurant instead of taking the sandwiches back to the hospital and working through lunch or eating at a noon conference. The thought crossed my mind that this luxury might just be an anomaly.
But it continued. One day last week, I had to write two notes and talk with a patient, so I decided to work on the notes through lunch. My resident was apologetic: "I'm so sorry you're not taking a lunch break!"
Working so hard through the third year of medical school, I've almost forgotten how relaxing and refreshing a lunch break can be. It's social; it's fun; it's what normal people do out in the real world.
But it continued. One day last week, I had to write two notes and talk with a patient, so I decided to work on the notes through lunch. My resident was apologetic: "I'm so sorry you're not taking a lunch break!"
Working so hard through the third year of medical school, I've almost forgotten how relaxing and refreshing a lunch break can be. It's social; it's fun; it's what normal people do out in the real world.
Friday, January 13, 2012
The psychiatry schedule
My psychiatry rotation at the VA is by far the most relaxed schedule I've had in my third year. I get in before 8am so I have enough time to read notes on my patients from the day before. No pre-rounds and no rounds. We have a brief meeting with the social workers at 8am, then table rounds with nurses afterward.
After rounds, the daily schedule is remarkably unstructured. Sometimes we have a new patient and do the intake interview together as a group. Usually, though, we medical students are left to our own devices. I use the time to go talk with my patients, take care of patient-related tasks, and write notes. I actually have a lot of fun writing psychiatry notes, probably because we're expected to be verbose and because the subjective portion of the note is simply recounting a conversation, most of which are rather interesting.
Writing notes usually takes me until early to mid afternoon, depending on whether we admitted a new patient or not. Both my attending and residents have repeated that we should go home when we're finished with our clinical duties, but both my classmates and I tend to stick around until 5-6pm, studying Psychiatry Case Files together, until the residents call it a night.
Part of the reason I finish so early is because I'm only carrying two patients. This is due to unfortunate timing of construction that necessitated closing one of the two psychiatry floors, truncating the bed count from 36 down to 22. That means fewer patients for everybody.
We don't work weekends. On top of that, there are two national holidays (New Year's and MLK Day) during this rotation, which the VA hospital patriotically observes by closing. All of this means that my psychiatry experience is more limited than I would have liked.
After rounds, the daily schedule is remarkably unstructured. Sometimes we have a new patient and do the intake interview together as a group. Usually, though, we medical students are left to our own devices. I use the time to go talk with my patients, take care of patient-related tasks, and write notes. I actually have a lot of fun writing psychiatry notes, probably because we're expected to be verbose and because the subjective portion of the note is simply recounting a conversation, most of which are rather interesting.
Writing notes usually takes me until early to mid afternoon, depending on whether we admitted a new patient or not. Both my attending and residents have repeated that we should go home when we're finished with our clinical duties, but both my classmates and I tend to stick around until 5-6pm, studying Psychiatry Case Files together, until the residents call it a night.
Part of the reason I finish so early is because I'm only carrying two patients. This is due to unfortunate timing of construction that necessitated closing one of the two psychiatry floors, truncating the bed count from 36 down to 22. That means fewer patients for everybody.
We don't work weekends. On top of that, there are two national holidays (New Year's and MLK Day) during this rotation, which the VA hospital patriotically observes by closing. All of this means that my psychiatry experience is more limited than I would have liked.
Thursday, January 12, 2012
Security on the psychiatry ward
I was leaving the psychiatry ward earlier today when I turned around and saw an older gentleman wearing a veteran's cap and street clothes, wanting to exit through the locked doors with me. I only had an instant to react: "Are you supposed to be leaving this floor?" He looked up at me with some surprise: "Oh, yes." Should I believe him? Before I decided to not let him through, a nurse who overheard this exchange yelled down the hall that it was okay for him to leave. He turned out to be the janitor leaving after his shift. I felt embarrassed and apologized, but the veteran took it in stride and said he was glad I'm being careful. The nurse also told me later that day that I did the right thing. There are few better ways to fail the psychiatry clerkship than letting a psychiatric patient escape!
Tuesday, January 10, 2012
Stepping into a teaching role
The other day I was working with my preceptor at the University emergency department when a maroon-vested undergraduate volunteer took to following me around. I happily answered several of his questions then referred him to this blog.
Later that evening, we were both watching a resident sew up a laceration. Even though the resident had already taken the patient's history, I asked the patient simple questions like how and when, as much for my own curiosity as for distracting her from the discomfort.
As I stood there watching the resident put in one simple interrupted stitch and then another, I realized that this kid standing next to me had little or no context and probably had absolutely no idea what was going on. So I decided to teach.
"The reason why I asked how it happened is because it could give me a clue as to how dirty that wound is and what possible organisms could be in there."
"I asked her when it happened because we don't typically close wounds on the extremities if they happened more than 8 hours ago. It could cause an anaerobic bacterial infection."
These are things that I take for granted now but that he likely didn't know.
The resident heard me teaching the volunteer and asked me if I wanted to finish up. Sure! As I put in the last three sutures, I verbalized everything: grip the needle in the middle of the curve using the tip of the needle drivers for better control, needle perpendicular to the skin, roll my wrist because the needle is curved, take an even bite on either side of the wound, don't tie the knot too tightly to avoid strangulating the skin, etc...
It felt good to be on the other end of information exchange for once. Teaching felt natural.
Later that evening, we were both watching a resident sew up a laceration. Even though the resident had already taken the patient's history, I asked the patient simple questions like how and when, as much for my own curiosity as for distracting her from the discomfort.
As I stood there watching the resident put in one simple interrupted stitch and then another, I realized that this kid standing next to me had little or no context and probably had absolutely no idea what was going on. So I decided to teach.
"The reason why I asked how it happened is because it could give me a clue as to how dirty that wound is and what possible organisms could be in there."
"I asked her when it happened because we don't typically close wounds on the extremities if they happened more than 8 hours ago. It could cause an anaerobic bacterial infection."
These are things that I take for granted now but that he likely didn't know.
The resident heard me teaching the volunteer and asked me if I wanted to finish up. Sure! As I put in the last three sutures, I verbalized everything: grip the needle in the middle of the curve using the tip of the needle drivers for better control, needle perpendicular to the skin, roll my wrist because the needle is curved, take an even bite on either side of the wound, don't tie the knot too tightly to avoid strangulating the skin, etc...
It felt good to be on the other end of information exchange for once. Teaching felt natural.
Sunday, January 8, 2012
Electroconvulsive therapy
I was introduced to electroconvulsive therapy (ECT) on just the second day of my psychiatry rotation. ECT was first developed in 1938. Although no one really knows how it works, the idea is that by inducing a controlled tonic-clonic seizure with electrical current, we can "reset" the brain's pathological function, whether that's by interrupting connections between different brain regions or altering the balance of neurotransmitters. It's a lot of hand-waving.
Regardless, ECT works; in fact, it works much better than any pharmacotherapy, including selective serotonin reuptake inhibitors (SSRIs), with a 95% effectiveness. When used in depression, ECT has a recurrence rate of 50%, which is comparable to SSRIs. 100,000 people in the U.S. and 1,000,000 worldwide undergo ECT yearly, mostly for depression with psychotic features but also for schizophrenia; my attending thinks that ECT is underused.
With that background, I met my patient: an older veteran suffering from such severe recurrent depression with psychotic features that it led him to attempt suicide. He had already undergone four ECT sessions. On the morning of his fifth session, he was so nervous that he was visibly shaking. A friend held both of his hands and prayed briefly with him before we led the veteran through two locked doors and into the elevators down to the minor procedure suite. He walked bravely, as calmly as he could manage, because he knew that this treatment was necessary.
Once he was lying on the procedure table, we placed blood pressure cuffs around both his ankles and inflated them so they would act as tourniquets to block the drugs from reaching his feet. The anesthesiologist sedated him, paralyzed him, placed a tongue guard in his mouth, and began breathing for him with a bag valve mask. Then, my attending poured gel onto two 1.5-inch diameter metal plates and secured those plates on the patient's temples with a rubber strap. The metal plates were connected to the machine that delivers a prescribed electric shock. A baseline electroencephalogram (EEG) was obtained, then the shock was delivered by simply pushing a button.
Suddenly, his toes curled and the arches of his feet flexed continually for the duration of the 8-second stimulus. I looked up at his face and was surprised to see a contorted grimace: clenched jaw and eyes shut tight. A few seconds after the stimulus ended, his feet began contracting and relaxing indicating that he was in the middle of the tonic-clonic seizure that is the goal of ECT. The foot twitching lasted about 20 seconds. The spike-wave squiggly lines coming out of the electroencephalography machine, indicating a seizure, flattened to baseline after 50 seconds indicating that the central seizure had stopped. Then the anesthesiologist woke him up. It was over.
From start to finish, the whole thing took less than a half-hour. This patient's ECT bore no resemblance to the dramatic convulsions and screaming that most people associate with ECT, thanks to Jack Nicholson's unnerving performance in One Flew Over the Cuckoo's Nest.
The addition of anesthesia to ECT protocol in the late 1960's (notably before this movie was released in 1975) has made ECT a much more humane experience. Paralytic drugs prevent the thrashing around, and some anesthetic agents can cause retrograde memory loss so the patient doesn't even remember the procedure. ECT itself can also cause retrograde memory loss as a side effect.
My patient remembered the anxiety leading up to his ECT treatment but not much else about it. We interviewed him briefly a few hours after his ECT session, and I was shocked (pun intended) by the transformation. He was freshly showered and was wearing a freshly ironed shirt that his friend brought from home; he was much more expressive and interactive, he wasn't hearing voices, he didn't have suicidal thoughts, and he said that he was actually feeling good. Despite the dramatic nature of ECT and its negative portrayal in the arts and media, it's hard to ignore such striking success.
Regardless, ECT works; in fact, it works much better than any pharmacotherapy, including selective serotonin reuptake inhibitors (SSRIs), with a 95% effectiveness. When used in depression, ECT has a recurrence rate of 50%, which is comparable to SSRIs. 100,000 people in the U.S. and 1,000,000 worldwide undergo ECT yearly, mostly for depression with psychotic features but also for schizophrenia; my attending thinks that ECT is underused.
With that background, I met my patient: an older veteran suffering from such severe recurrent depression with psychotic features that it led him to attempt suicide. He had already undergone four ECT sessions. On the morning of his fifth session, he was so nervous that he was visibly shaking. A friend held both of his hands and prayed briefly with him before we led the veteran through two locked doors and into the elevators down to the minor procedure suite. He walked bravely, as calmly as he could manage, because he knew that this treatment was necessary.
Image taken from the blog of actress Carrie Fischer, who has shared her experiences with ECT for bipolar disorder. (http://carriefisher.com)
Once he was lying on the procedure table, we placed blood pressure cuffs around both his ankles and inflated them so they would act as tourniquets to block the drugs from reaching his feet. The anesthesiologist sedated him, paralyzed him, placed a tongue guard in his mouth, and began breathing for him with a bag valve mask. Then, my attending poured gel onto two 1.5-inch diameter metal plates and secured those plates on the patient's temples with a rubber strap. The metal plates were connected to the machine that delivers a prescribed electric shock. A baseline electroencephalogram (EEG) was obtained, then the shock was delivered by simply pushing a button.
Suddenly, his toes curled and the arches of his feet flexed continually for the duration of the 8-second stimulus. I looked up at his face and was surprised to see a contorted grimace: clenched jaw and eyes shut tight. A few seconds after the stimulus ended, his feet began contracting and relaxing indicating that he was in the middle of the tonic-clonic seizure that is the goal of ECT. The foot twitching lasted about 20 seconds. The spike-wave squiggly lines coming out of the electroencephalography machine, indicating a seizure, flattened to baseline after 50 seconds indicating that the central seizure had stopped. Then the anesthesiologist woke him up. It was over.
From start to finish, the whole thing took less than a half-hour. This patient's ECT bore no resemblance to the dramatic convulsions and screaming that most people associate with ECT, thanks to Jack Nicholson's unnerving performance in One Flew Over the Cuckoo's Nest.
The addition of anesthesia to ECT protocol in the late 1960's (notably before this movie was released in 1975) has made ECT a much more humane experience. Paralytic drugs prevent the thrashing around, and some anesthetic agents can cause retrograde memory loss so the patient doesn't even remember the procedure. ECT itself can also cause retrograde memory loss as a side effect.
My patient remembered the anxiety leading up to his ECT treatment but not much else about it. We interviewed him briefly a few hours after his ECT session, and I was shocked (pun intended) by the transformation. He was freshly showered and was wearing a freshly ironed shirt that his friend brought from home; he was much more expressive and interactive, he wasn't hearing voices, he didn't have suicidal thoughts, and he said that he was actually feeling good. Despite the dramatic nature of ECT and its negative portrayal in the arts and media, it's hard to ignore such striking success.
Wednesday, January 4, 2012
Introduction to my psychiatry work environment
I am doing my psychiatry rotation at the Denver VA Medical Center, which has a 36-bed inpatient psychiatry unit. The psychiatry patients are cared for by three separate teams, two of which take medical students. My team is composed of one attending psychiatrist, two psychiatry residents, and one classmate.
The psychiatry ward is locked down, as one might imagine. You have to pass through two locked doors and walk by a security station to get into and out of the psychiatry ward. Plus, the security badges that unlock the doors only do so for a quick half-second before locking again, making escape by someone unfamiliar with this timing that much more difficult.
Once on the floor, there's a ten-foot stretch of hallway before reaching a taped red line on the white linoleum. Patients aren't allowed to walk beyond that line unchaperoned. Similar red lines are in front of doorways and serve to keep patients out of restricted areas. It's remarkable how well the red line works and how rule-driven these veterans are, in general.
Everything is designed so that it can't be used as a weapon. Drinking fountains have no spigot head, sinks have no faucet, chairs have no legs and are so heavy that they can't be picked but instead have to be scooted around the room. Doorknobs are not knobs, rather semicircles practically flush with the door with indentations for grips.
A wide array of patients stared at my attending, two classmates, and me as we walked down the hallway during our orientation. Some were poorly groomed; others were clean-cut. Some were wearing government-issued pajamas, a bath robe, and hospital socks; others wore street clothes and were actually sharply dressed for the setting.
An unfamiliar face in the psychiatry ward is the object of curiosity. Several patients stared at us three medical students with an unsettling vacant gaze that all of them seemed to share. One "happily demented" veteran, hunched over and pushing a walker, a smile on his face, approached us just to strike up a friendly conversation.
Another veteran, younger, balder, and unhealthily skinny, sidled behind the group and when he was noticed blurted out in one breath, "What do you know about perpetual consciousness? It's like a circle running around and around and around in your mind not stopping, which is ironic because," and he moved his finger in a circle by his head, then whispered, "it makes you look crazy." I felt uncomfortable. How do you respond to something like that? My classmates felt equally awkward. One of them decided to reply in the only way he knew how: "Hi, my name is John," offering a handshake.
This interaction made me understand that my biggest challenge for the upcoming psychiatry rotation will be to set aside my feelings of discomfort, and other negative emotions elicited by my patients' unusual affect and behavior, to make sure that they don't get in the way of my ability to understand and empathize with my patients. Easier said than done.
The psychiatry ward is locked down, as one might imagine. You have to pass through two locked doors and walk by a security station to get into and out of the psychiatry ward. Plus, the security badges that unlock the doors only do so for a quick half-second before locking again, making escape by someone unfamiliar with this timing that much more difficult.
Once on the floor, there's a ten-foot stretch of hallway before reaching a taped red line on the white linoleum. Patients aren't allowed to walk beyond that line unchaperoned. Similar red lines are in front of doorways and serve to keep patients out of restricted areas. It's remarkable how well the red line works and how rule-driven these veterans are, in general.
Everything is designed so that it can't be used as a weapon. Drinking fountains have no spigot head, sinks have no faucet, chairs have no legs and are so heavy that they can't be picked but instead have to be scooted around the room. Doorknobs are not knobs, rather semicircles practically flush with the door with indentations for grips.
A wide array of patients stared at my attending, two classmates, and me as we walked down the hallway during our orientation. Some were poorly groomed; others were clean-cut. Some were wearing government-issued pajamas, a bath robe, and hospital socks; others wore street clothes and were actually sharply dressed for the setting.
An unfamiliar face in the psychiatry ward is the object of curiosity. Several patients stared at us three medical students with an unsettling vacant gaze that all of them seemed to share. One "happily demented" veteran, hunched over and pushing a walker, a smile on his face, approached us just to strike up a friendly conversation.
Another veteran, younger, balder, and unhealthily skinny, sidled behind the group and when he was noticed blurted out in one breath, "What do you know about perpetual consciousness? It's like a circle running around and around and around in your mind not stopping, which is ironic because," and he moved his finger in a circle by his head, then whispered, "it makes you look crazy." I felt uncomfortable. How do you respond to something like that? My classmates felt equally awkward. One of them decided to reply in the only way he knew how: "Hi, my name is John," offering a handshake.
This interaction made me understand that my biggest challenge for the upcoming psychiatry rotation will be to set aside my feelings of discomfort, and other negative emotions elicited by my patients' unusual affect and behavior, to make sure that they don't get in the way of my ability to understand and empathize with my patients. Easier said than done.
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