a turd

My attending storms out of the bathroom and looks over at me, “It’s a fucking turd!”

Let’s back up a few minutes.

My patient has been having (if you are squeamish you might as well stop reading now) copious, purulent, pungent discharge coming out of her vagina for two months.  When I say copious, I mean she had to change her pad every two hours.  When I say pungent I mean it was rank.  Imagine a smell that stings your nostrils and sits like a rotting mouse on top of your gag reflex, now multiply that by twelve.    This poor woman has been living with this for 60 days, and so far no one has been able to tell her what’s wrong.

While prepping for the pelvic exam my attending put on his camping head lamp started to tell me a story.  When he was a third year medical student a classmate on his rotation was in line to do the next pelvic exam. Well, his classmate got lucky.  Half way through the exam the emergency room smells fetid and the student started pulling small body parts from the woman’s vagina.  A miscarriage hadn’t completely evulsed.  Pieces of the fetus embedded themselves in the walls surrounding the cervix.

Don’t worry, today there were no body parts.

As we were chatting my patient went to use the restroom.  Then there was commotion.  I need the nurse! I need the doctor! My attending screams from the bathroom, get me a paper towel! Get me a specimen jar! Things quiet down and the nurse, my attending, and the specimen jar emerge from the restroom.

I ask, “Um, what just happened?”

The nurse: “Something was coming out of her vagina.”

My attending: “It was a fucking turd.”

That begs another question, so in my most professional voice I ask, “Uh, how did a fucking turd come out of her vagina?”

My attending: “A g.d. fistula? I don’t know if it really was a fucking turd but holy shit it smelled like one.”

And so we regain our composure, get our patient calmed down and back in the bed, and begin the pelvic exam.  We proceed, head-lamp and all, and see something peeking out from the crevices behind the cervix.  A tampon. It was fermenting.  It had been there for two months, and started abscessing the side of her vaginal wall.

Tampon goes into a new specimen jar.  Both specimen jars are sent to path.  We tell her to schedule a follow up with her gynecologist and the woman is saved.  Hooray!

And no, I still don’t know what came out of her vagina in the bathroom.  It might’ve been a piece of the tampon we found later, it might’ve been a sponge, and yes, it might’ve even been a turd.

drunks

We were seeing a drunk guy who just happened to mention he wanted to kill himself (while blowing a BAL of over 0.3).  When the guy sobered up a bit he promised us he wasn’t being serious.  Begging for us to discharge charge him he cried, “Come on doc, I swear on my LIFE I won’t kill myself.”  Ha.  And we discharged him.

emergency room elective: day 1

Day 1: After tossing and turning all night I drag myself out of bed and make it to my new site on time. It’s my first day of an EM elective and I’m nervous as shit. I get there at 8:40 (I have an incredibly annoying habit of arriving anywhere I need to be way too early). The administrator was supposed to meet me at 9. It’s now 9:45 and the security guards at the front desk are my new BFFs.

Finally I am situated in the ER.  My first patient is a little old lately with her femur snapped in half.  Literally snapped in half. Her thigh was bent in a position in which I have never ever seen a thigh bent before.  So gross but really cool.  

Later on I watch a woman’s gums slough off as I watch my attending feel around the inside of her mouth with his fingers for an abscess.  Lucky for him she didn’t have teeth.  More gross than cool.

Fever.  Cough. Shortness of breath.  Chest pain.  Abdominal pain.  Abdominal pain. Ruptured ectopic (quick! send her to the OR!). Shortness of breath. Headache.  Chest pain.  Detached finger. 

Over and over and over again.  And I love it!  Focused histories, focused exams.  No time to sit around and pontificate.  See something.  Rule out the worst case scenario.  And treat.

f-ed by the snake tip

Yesterday my patient said to me, “I got fucked by the snake tip.  It was waving a flag.” He then shifted his head toward me, looked directly into my eyes, and while grinning said, “Yeah that’s right, you know what I mean.  We got fucked by the snake tip. You know what I’m talking about, I know you do.  Right?” Still staring into my eyes, but now raising his voice and becoming agitated he continued, “Jesus came and I was going to gangsta parties. Like real gangsta.  And I came out alive and I know it’s because I am Jesus. I wasn’t treated like Mary did, but I got fucked by the snake tip.” 

In psychiatry there is something known as a defense mechanism.  Defense mechanisms can be mature, neurotic, or immature, they are ways that people deal with feelings of anxiety, pain, and internal conflict.  One of my personal favorites is suppression.  It’s classified as a mature defense mechanism, and is defined as conscious burrying of troubling thoughts so that you can continue to function.  Just push it out of your head an keep on truckin’. Acting out is an immature defense mechanism. Projection is transference of anger to a more acceptable recipient.  Intellectualization is when one can’t wrap his head around a painful thought or uncomfortable experience so he finds a rational way to process the info.  A classic example always given the text books is that of a man who finds out he has cancer.  This causes him to learn everything he can about the pathophysiology of the disease and instead of telling his son he has cancer he teaches his son about the aberrant cell cycle, P53, and the Rb gene. 

So, what do you do when your patient is searching your eyes, talking about being f-ed by a snake tip, and is making no sense whatsoever? Well, you nod your head, return the stare, remain expressionless, and intellectualize:

Psychosis has many, many causes.  In general the etiology can be considered primary (functional) or secondary (organic). Schizophrenia, for example, is a primary/functional reason for the development of psychosis. A secondary cause can be due to things like a general medical condition or drug intoxication.  When psychosis is primary (like in schizophrenia) the neurochemical abnormalities have to do with an altered dopamine/acetylcholine ratio. There is a relative increase in the neurotransmitter dopamine, and antipsychotics work because they lower dopamine levels  (usually by antagonizing the D2 receptor).  Organic (secondary) psychosis, on the other hand, is often treated by anti-convulsants rather than anti-psychotics.  This is because this type of psychosis is thought to be ictal, that is, it is thought to be induced by seizure activity (ie. increased neuronal firing) within the brain.  Not only are anti-convulsants used alone, they can be used to augment the anti-psychotics because they are also thought to act on dopamine indirectly (through neurotransmitters like glutamate and GABA) which in turn enhances the antagonistic dopaminergic effects…. la la la.  

Sorry but if you’re gonna raise your voice and get all crazy on me my brain is going to move into science mode. Intellectualization at it’s best.

totally normal

According to Lange Q&A Psychiatry (2005), “Disorganized schizophrenia, traditionally known as hebephrenia, is notable for pronounced and severe thought disorder… Such patients may present with a chief complaint as, ‘I came to restore my tranquility so that I can get what’s coming to me upside down’.”

The other day my patient wrote on the wall, “do not fart in a room with or without windows like a one legged man in an ass-kicking contest.”

Hmmm. Hebephrenia?

three little old ladies

The first little old lady I came across today was my lovely 96 year old patient.  Long story short, she doesn’t function well.  She is disoriented and demented and bedridden.  And every day for the past week the worst part of my day is explaining to her husband of 70+ years that she is not going to get better.  

—

The second little old lady I saw today was wandering the halls of the psych floor.  She was teeny-tiny, had white/blue hair, and was wearing dark, movie star-like, cat eye sunglasses.  Indoors.  On the psych floor. I put my head down and avoided eye contact with the rogue patient, an efficient (and totally mature) maneuver when you are determined not to get side tracked. 

 Later in the afternoon I returned to the same psych floor to follow-up on another patient.  This patient, mind you, hates me.  Mostly because we decided to involuntarily commit him to the inpatient unit. He is large and he is aggressive and when I enter his room I position myself between him and the door.  I go into his room alone as little as possible.  

So this afternoon I entered his room and who do I see sitting there but the same little old crazy lady  I saw lost in the hallways earlier.  Um, what is going on here.  She was relaxing in a chair across from him carrying on a pleasant, jovial conversation.  Huh. This man is not nice, and this woman does not belong here.  But before I had to do something awkward, like intervene, the emblem on her shirt caught my eye.  She was wearing a hospital uniform shirt, a patient-monitor*-uniform shirt.  

My little old lost crazy lady is not so lost after all.  She is my patient’s one-to-one patient-monitor.  And she has blue hair.  And wears sunglasses.  Indoors.  On the psych floor.  

*when a patient is considered a danger to himself or others we are obligated to assign a one-to-one monitor.  This monitor sits in the room with the patient all day and all night.  The monitor doesn’t usually speak to the patient unless the patient speaks to him/her.  He/she becomes a fixture in the room and ensures that the patient isn’t pulling out his IVs or doing anything else alarming or stupid.

—

One of the last little old ladies I saw this evening was admitted for delerium/suicidal ideation.  

Little old lady: Here is my list… of medications.  Oh… and I should warn you… I have a lot… of trouble… hearing.

My resident: WHAT? 

She didn’t get the joke.

life with the crazies

When your patient has his privates hanging out and asks you to come and sit on his lap, you learn about focal neurological deficits that result in hypersexuality.  When your patient insists, while in the hospital bed, that he is in a prison in Las Vegas in 1987 and whose urine is positive for nitrates and leukocyte esterase, you learn about delirium secondary to a general medical condition– or in this case– manifestations of a urinary tract infection in the eldery. When your 55 year old patient comes in unresponsive but has positive urine drug screen and a history of substance abuse you are the one that fills out the involuntary commitment papers because you have a hunch this wasn’t an accidental overdose.  When your patient starts freaking out at the nurses station, screaming and yelling and thrashing, you hide behind the physically stronger while your attending calculatedly and calmly contains the patient until security arrives. After your patient strangles two of his one-to-one monitors within a span of about three hours, your attending tells you stories of serial killers with severe psychosis that will haunt your dreams for the next three weeks.  How can you not love this stuff?

According to med-school-clerkship-lore, psychiatry is one of the most enjoyable clerkships you will encounter.  The hours are fantastic, they are so good that they allow you to sleep like all the other normal human beings.  Call nights are minimal, the staff in general are nice and seem to care about your quality of life.  And the best part is, you sit around all day and– with the most compassion possible of course– you laugh at (or fine, learn from) the crazies. Psych has been at the bottom of my list for years and as much as I hate to admit it, right now it’s inching it’s way back into view.

quick recap

One month and a hundred or so kids, ear infections, and viral exanthems have gone by since my last post.  Not really sure when or how that happened.  

Quick recap on my first clerkship: peds is over, and surprisingly I enjoyed it.  

I do not see myself as a pediatrician. The part of the clerkship that I loved was being in the hospital, being around sick babies, sick kids, and sick teenagers.  I loved trying to figure out what the clinical signs and lab values were telling us. And then I loved figuring out how we were going to handle it.  I love puzzles.  And when puzzles involve sick children they contain a bit of adrenaline, desperation, and are extremely emotionally charged.

The problem is, I do not have the patience to trick a kid into saying AHHH by pretending my pen light is a magic lollipop.  Yes, it’s true that when a kid poops in his pants it’s entirely more bearable than when an adult poops in his pants, but the way I see it is children can either be ridiculously annoying or heartbreaking cute.  And unless they are related are me they tend to fall into the prior catergory.  

Peds is most likely off the list.

blunder

Today in the sports medicine clinic we had a dancer-patient.  As the resident was presenting the case to the attending, the attending interrupted, “YES, but I’d really like to know, what KIND of dance does she do?” The resident had a brain fart and looked at me for some help.  

Finally! A question I can answer! “Bazz and Jallet,” I blurted.

Without skipping a beat the resident continued, “Right, she’s been doing Bazz and Jallet for four years now.  She practices two hours a day, six days a week…”

the beginning of the end

Today was the first day of my pediatrics rotation.  It involved lectures and tours and lectures and lectures.  I have yet to even see a child, and surprise surprise I have a runny nose, sore throat, and headache.

My roommate arrived to her first day of surgery 25 minutes late, got stuck on a team with someone with whom she once had a random and awkward make-out, and got assigned to the senior resident who likes to do pre-pre-rounds and be terribly mean.  She will be arriving at the hospital at 4:30am every day for the next 8 weeks.

It’s going to be an interesting year.