Monday, August 30, 2010

Creative Conversational Skills Required...


I am at the end of my first 3rd year rotation, Psychiatry. Psychiatry is an opportunistic, albeit interesting specialty. Opportunistic in the sense that it is truly a rotation where a little interest can go a long way in terms of exposure. Now, I did my rotation in the Bronx. Obviously an under-served population. In the hospital I worked at there are 2 locked psych inpatient units and a locked detox unit. You also have the opportunity to work in the "consult" division, in which you spend your days trolling the medical floors responding to requests made for a psychiatric evaluation. I'll explain the different parts.

Locked Psych Unit

Ahh, the truly crazed. At our hospital, the psych unit is not what modern cinema has not made it out to be. This is not "awakenings" at all and only 1 room in the entire unit that has padded walls. The patients admitted to this unit are truly a mixed bag. there are schizophrenics who have been non compliant with medication for many years, the depressed that soon realize their depression, however serious in my naive eyes, is nothing compared to the gentleman next door who cant help but masturbate every waking moment, to the bipolar population with manic phases that intrigue you for hours on end.

The big 5 diagnoses in the Bronx are Schizophrenia, Bipolar, Major Depressive Disorder (MDD), Anti-Social Personality disorder and Borderline Personality disorder.

A quick word about schizo. IT IS NOT MULTIPLE PERSONALITIES.

Clear enough? Let's move on...

The inpatients are a mixed bag of the big three (schizo, bipolar, MDD). The schizophrenics are paranoid, prone to hallucinations, delusional, and if you are real lucky, a bit of all three. They are fine to talk to and most do not pose any violent threat to me or my fellow students, but they have impulse control issues and there have been multiple orthopaedic consults for swollen/sore hands. Some patients will be eager to talk, some will be dismissive, and some will invite you to their wedding. It's all very interesting when you figure out the trigger to their delusions or paranoia and watch them vividly describe their rationale for being admitted to the ward. Reasons vary from "jealous of my potential rap producer career," to "I came to volunteer my services and decided to stay." All in all, a very fun group who if they would just take a shower/medications/change their shirt we would be happy to discharge them and make room for the next patient.

A word on the delusional patient.

Never ever take part in or encourage a delusion. Simply acknowledge to the patient that the delusion exists and you know about it. Taking part only encourages the patient and may reinforce to the patient that the delusion is true. Even if he promises to pay you $60K if you let him off the unit.

The bipolar patients are interesting. The are usually well controlled with their medications but when they decompensate its a crapshoot. At points they will go on and on about the gas chambers to baseball statistics to Al Sharpton's politics to global warming, all seemingly without hesitation. Next week they simply stare out the window and you cannot get the time of day.

The MDD patients are the shortest house guests of the unit. I guess seeing an obese, geriatric, African woman lift up her mu-mu all day gives the incentive to think about all the positive, clothed activities one can do outside the hospital in the sunlight, and not sit alone at home have PTSD like flashbacks about the above mentioned scenario.

Most patients are generally pleasant, some have anger issues and may walk around shouting "Holocaust, Holocaust, Holocaust" for no reason but generally you are in no danger.


Psychiatry's role in detox is to help out the patients who tend to self medicate their bipolar/schizophrenia with alcohol and cocaine. I don't know why we bother interviewing them. They all want their anti-depressants and anti-psychotics which if they had been taking them instead of selling them, they wouldn't need the drugs in the first place. The interesting part in interviewing these patients is their own knowledge of modern pharmacology, its poetic and ironic. They know dosages and brand/generic names, some even know what they can an cannot take due to their hepatitis C, and yet none can simply open the bottle and follow the direction on how to take the medication.

I hate detox. I don't know why, maybe reading about drug addicts and their constant scheming for a fix has jaded my views of them. Addiction medicine is a serious specialty and I sure do applaud those who day after day deal with people experiencing withdrawal. I just feel no sympathy/empathy for the gentleman with a history of 55+ detox admissions and his 8-10 bags of heroin/day and 150 bucks of cocaine/day and four 40oz. of cobra/day. Seriously, that was the exact line I wrote in my consult. When he told me I couldn't help but laugh and shake his hand, for this gentleman had the system figured out. He saves up money from medicaid or whatever, maybe works on an odd job or two, or hustle's, lives on the street to not pay rent and binges after 2 weeks. He then comes to the hospital, gets "three hots and a cot," a shower and leaves in 4 days.

Rinse and Repeat...x55


This was the bulk of my experience. Medical consults are amazing because you get to see the various pathologies the the hospital has to offer without all the rounding. I got to see trauma victims on their 3rd day post accident. Doing a depression screen on a little old lady with no prior medical issues who just experienced a Left leg below knee amputation via NYC taxi cab really strains your interview skills. I mean, no shit she's depressed, do I really need to ask her if she has suicidal thoughts? Visual hallucinations? It's really numbing trying to interview her about her mental health when all you want to do is give her a hug.

A bonus is being in the emergency department. At the hospital there is no official psych ED, just a bunch a beds called the "bullpen." (Seriously, I need you dear readers to find a better name than "bullpen." Go with an hyperbole, perhaps a pun, maybe an alliteration, I know you have a linguistic talent to come up with a term endearing to and labeling the psychiatric patient in the ED.) The ED is fun because you interview psychotic patients in their acute phase, or manics, or drug addicts that simply don't understand that when you smoke PCP, you hallucinate. It's not rocket science, it's common sense.

"You say you saw a spotted dog running around the ceiling, right after you speed-balled? amazing"

The ED is also probably the most dangerous place, seeing that those who are truly decompensating get brought in and placed in a bed not 5 feet from you. They are paranoid, angry and irritable which proves a dangerous combination. I have been hit and swung at, but a keen eye and a proactive doctor/nurse with a dose of haldol, ativan and benadryl usually save the day.

All in all, psychiatry is fun. I was fortunate to deal primarily with consults to the medical/surgical floors and not spend a great deal of time with the same inpatients. Variety is truly the spice of life and in psychiatry, if you play your cards right, you'll have a fun, easy and interesting rotation.

Until next time...

Whoop Whoop,


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