Tag Archives: crazies

triage

The average triage note:

35 yo  F 10 weeks pregnancy had seizure, similar to szs in past.

68 yo M with cardiac history here with chest pain, started this morning.

25 yo M sore throat.

Yes, boring. But today things took a turn toward crazy:

48 yo M felt the need to direct traffic today to keep the city safe, given orders by the dept of justice to direct traffic on a different corner.

24 yo F needs to get pregnant.

33 yo F has a painful rectum and can’t stop eating.

Really.  How can you not love this job? In other news, today instead of asking my patient if she has diabetes or hypertension in her past medical history I instead asked her if she has diapertension.  Yes, diapertension.



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mr. bossman

I met my patient when he was boarded and collared, on a stretcher in the hallway.  He is a hispanic man who was recently in a car accident who arrived with a relatively complicated facial laceration.  He speaks a tiny bit of English, I speak a tiny bit of Spanish.  He is a nice man, and somehow we  manage to create a rapport.

A while later he’s been moved into a room and I arrive back with the suture kit.  Now there is a dirt covered, young, white man in the room with him.  My patient’s employer introduces himself to me.  This man, no older than me, immediately (and with a lack of social graces) wants to know how long this will take.  I told him that realistically we have two more hours.  But for him, that just wouldn’t do.  Well, sir, your friend was in a car accident.  We’ve determined he doesn’t have any serious injuries but he has a pretty bad cut in a pretty bad place.  We need to do a slit lamp exam to rule out any corneal abrasions and then will need to sew him up.  By the looks of that cut the suturing alone could take over an hour.

Yeah but he still doesn’t understand why it will take two hours.  Two hours at minimun, I reminded him.  “Okay, but see,” (and he lowers his voice) “I’ve got a van outside full of five guys  outside,” (he glances over to my patient), “and there’s no AC.  Can you ask whoever is in charge if he can speed the process along?”

Um, really? You have a van outside with five men in it with no AC? Are they locked in? Aren’t they adults? Might they step outside for some fresh air? Must be a completely legal and humane operation you’ve got going on. And b.t.w., I am in charge of how long this process will take.

At this point another med student walks into the room, he’s checking to see if I need any more materials.  The boss looks at him.  Oh hey doc,  how long you think it’s going to take you to do this?

As I secure knot number two Mr. Bossman decides to confide in me about how he once sewed up his knee with no anasthetic.  Good work, buddy, you must be really tough.

Suture number three I ask my patient if he’s feeling anything.  “Feeling any pain? Need some more pain meds?” Mr. Bossman feels the need to translate for me, “Hey buddy, hurt-o?”

Listening to the conversation next door I advanced another suture through my patient’s lower eye-lid.  Mr. Bossman, who was hovering over my every move, was apparently eaves-dropping on the same conversation.

… and do you take any medications at home?

AT HOME? YES! OF COURSE I TAKE MEDS AT HOME.  AND I LIVE WITH MY STINKIN HUSBAND. TWO OF MY FIVE WORTHLESS KIDS, FIVE GRANDCHILDREN, TWO DOGS, AND ONE CAT.  AND A SON-IN-LAW, EFFING JERK.

… okay, I understand.  But can you tell me what medications you are on?

YOU THINK THAT’S YOUR BUSINESS? I CAN’T BREATH. WHO ARE YOU? YOU ARE A DOCTOR? YOU ARE FIVE YEARS OLD. I WANT TO GO TO A REAL HOSPITAL AND I WANT TO SEE A REAL DOCTOR.

I have a smile on my face because seriously, how can you not get a kick out of this stuff?  By the pattern of her speech I can tell this woman is having no real difficulty breathing and I know the resident in the room next to me is having the same thought process. I am curious to see how this conversation will play out and to see how he will manage to gracefully worm his way out of her room.  I sense my patient’s employer looking at me.  Apparently he thinks we’re good friends now.  “Wow, you must see all kinds of assholes in this place.”

I secure the last knot and  don’t bother to make eye contact. “You have no idea.”

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bad things

A colleague came up to me with a pained look on his face, “Something kind of bad just happened…”

I had NO idea where this was going.  Did you break up with your girlfriend? You missed your patient’s hypokalemia and she started having chest pain? You put a note in the wrong chart? A nurse yelled at you again?

“My stethoscope just fell into the toilet.”

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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 secondarySynapse_diag1 (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.

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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.crazy2 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.

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the psych ward

Today I’m interviewing psych patients in one of the worst inner cities in New Jersey.

When I arrived I walked to the front desk just beyond the front door, hoping to get some directions. White coat on and clip-board in hand I politely asked, “Can you tell me how to get to the elevator?” The large black woman answered my question with a blank faced stare. Ohhhkay so I guess I’ll keep moving. Maybe she’s a patient? I then took literally one step beyond the desk and walked straight into the elevators. Good start.

There were about seven of us waiting for the elevators, including a sweaty, nervous looking, overweight man who couldn’t stand still. When the door dinged open he froze and stared at me. He looked in at the crowded elevator and with the most pained look on his asked me, “uhhh, ummm, is the other elevator working?” It seems that once again my white coat morphed me into an undeserving figure of authority. “Sorry Sir, I have no idea.”

The door shut in his face and I’m on my way to the fifth floor. I was looking at the papers on my clipboard to determine that this is indeed where I was suppose to be headed when half of my papers fall to the floor. A smiling woman looked at me sort of maniacally (is that a word?) and with completely inappropriate affect said, “YOU DROPPED YOUR PAPERS!! YOU DON’T WANT TO LOSE THE PAPERS!!” I bent down to get them and when I looked up again she was still staring (glaring?) and smiling at me. I politely returned her smile and got the hell out of dodge.

Finally I find the room where I’m supposed to meet the doctor only to discover I’m an hour early. The good news? I downloaded wordpress onto my iPhone and am able to share this story. The bad news? I have 30 minutes left of hanging out in the waiting room with all the crazies.

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