7 am finds me racing through the hallways to the psych ward because I underestimated the amount of traffic on the road at 6:30. Note to self, must leave house earlier.

I have a sheaf of papers, the photocopies of my two patients’ charts, plus my notes. I find the two charts, flip through to the nurses’ notes. “2 am: Patient was asleep. 4 am: Patient was asleep.” Ok. I go out of the glassed-in nurses station to look for my patients’ rooms, which are dark. I don’t yet have the nerve to wake patients up at 7:05 for fear of what the attending will do to me if I don’t, so I let them be and go back inside. And stand around for half an hour. Then I manage to catch the resident (a very nice lady) who is in charge of my two patients. I follow her into their rooms and listen while she asks how they slept, whether they’re hearing voices or seeing things, whether they’re thinking of harming themselves or someone else, and what they think of the scheduled visit with their families later on in the day. These two are relatively uninteresting. They’ve calmed down from the episodes that led to their hospitalization (I almost said imprisonment – is that a Freudian slip?), one a psychotic episode, the other a suicide attempt.

Back in the nurses’ station, I get out two sheets of notepaper, and write progress notes, mostly by frankly copying from previous notes in the chart, and from the example sheet we were given. Finally, time for rounds. I rush over to the conference room. The attending in charge today is relatively nice. She has the residents present all the patients, since this is our first day. The two guys ask several questions, and one gets assigned to look up and present the relationship between schizoid and schizotypal personalities, and schizophrenia. Since I don’t ask any questions the doctors don’t know the answer to, I don’t get any assignments.

Most of the time is spent discussing a new patient, a young man threatening to mutilate himself, brought in by the police. After discussing his case, we all troop around to his room. He sits up and answers the attending’s questions in a pretty flat voice, flat expression, looking mostly at his feet, a little at the attending, very little at us. He does laugh at a few jokes. He describes his life as empty and meaningless, and explains that his violent attacks on himself have been a means of getting attention from his parents. I admire the way the attending elicited his story, summing up his slow, awkward phrases, not mocking his psychotic perceptions of extraordinary knowledge, helping him understand his own behavior. But I really feel like a conversation about God would be the most useful thing for him. He doesn’t sound very intelligent, not too good at carrying on a coherent conversation, so maybe it wouldn’t be possible to talk to him like that. But I doubt that the attending’s plans for various antipsychotics and antidepressants will solve his real problem. She’ll probably also try to arrange family counseling, which will be more helpful. Of course this is only my first day; for what this is worth.

Then the attending visits a few other interesting patients with just the resident and med student belonging to them. I’ve already finished the notes on my patients, so I stand around the station for half an hour, then read the pharmacology book for half an hour, while the other students call other hospitals for old records, call family members to explain patients’ falls, etc. Then we all leave, seriatim, for lecture, on another campus.

I get my first page! The resident wants to know, with some asperity, what we’re planning to do about the two new patients. I’m very glad to be able to explain that one of us has already enthusiastically started the history and physical on one of them, and the rest of us have a very good excuse: lecture. Fortunately, she doesn’t insist on us coming back at five to take care of the other admission.

Well, that’s the end of the interesting part. The rest is just lecture. One hour of neurology review. A lunch meeting of residents reviewing for their boards, with quiz questions on the overhead. I don’t realize in time that this is mostly for residents, so I shout out answers too – mostly right. Competing with residents feels good. πŸ™‚ Then a lecture on dementia vs. delirium, during which I fall asleep. Then a video of a very weird patient, to illustrate making observations on the patient’s mental status. Look at her clothes, her makeup, the way she did her hair. Notice how friendly she seems, but not concentrating enough to answer the questions the interviewer is trying to ask. She has an agenda of her own – pouring out a long and dramatic history, involving multiple husbands, rare medical illnesses, villainous surgeons sabotaging the drainpipes, personal messages from Jesus, multiple robberies, etc etc.

Which brings me to my biggest problem so far: Everyone here assumes that if a patient says they’ve heard from Jesus, or they’ve seen a demon, or they’re hearing from demons, they must be insane, and in need of antipsychotic meds. Whereas I would much more readily assume that the patient is indeed hearing from demons (perhaps masquerading as Jesus or an angel), and is in need of an exorcism. I don’t s’pose I should try to explain that to the attending? I’m not anxious to become the subject of a “pink slip” – involuntary admission. πŸ˜‰ But seriously. Voices telling the patient they’re worthless, they should kill themselves, or someone else – that sounds like a real demon to me. And even self-mutilatory behavior; the Gadarene in the Bible was always cutting on himself. And then those demons went and threw the pigs over the cliff, which sounds like they could have been a danger to other people, too. The problem is, I don’t imagine myself capable of actually casting out demons, and I’m not sure how to go about getting hold of a pastor who would be. Actually a more common case is the patient believes themselves to be Jesus. I hate how everyone else snickers when this is related. I don’t think it’s funny. I don’t think it’s funny that most of the psychotic patients here seem to have created some perversion or inversion of Christianity in their own private worlds. Maybe they need an exorcism too.

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