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.

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.  

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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.

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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.

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.