I know i have been neglecting my blog posts, and truthfully there is no good reason or excuse. Updating my blog is my method of decompressing from my days on clinical rotations, since i dont live in a cave, i am not antisocial and generally enjoy talking. So normally when i come home from a long day my roommate and i cook dinner and debrief from our day. We are both on clinical rotations, at different institutions and we enjoy sharing cases with one another, 'pimping' each other on topics discussed during the day and having time to gossip and swap stories/ drama from the other hospital. usually by the time i have completed this evening ritual there is nothing left for me to say, and i dont have anything to share with the world through my blog. In recent days, people have approached me asking to update. In my amends to them, i decided to be more proactive with the updates, since most are not present at my dinner table and miss out on the debrief firsthand, i will try and give the highlights. From now on my blog with the 'sports center' of my day.
I have not posted anything from my time in the psych hospital, where i spent my 4wks of February. Oddly enough it was the most exciting event filled rotation i have been on to date, so you would have thought there would be much to talk about it....but by the end of the day, when i got home i was happy to be home and away from the crazy patients i dealt with on a regular basis.
Background: the hospital i worked at is a state psychiatric hospital, that mostly has involuntary commitments with some voluntary. I had the pleasure of working on the male aggressive unit, with the convicted rapists, murderers, felons of other types, and basically the worst males in the hospital. We had a full unit of 40 patients, some of which had been there for the last 15 years. Most were not going to be getting out anytime soon either...the diagnosis ranged, but all had a major psychotic disturbance, schizophrenia or schizo affective disorder with concomitant personality disorders, overlying substance use disorders, and a variety of the normal and common medical conditions.
responsibilities: During the course of the month, i also had the pleasure of working with another student which always made the day more fun! We divided the patients in half and each managed and took responsibility for 20patients. For these patients we had to write monthly progress notes, interview and conduct assessments, write update notes for any incidents that occurred, reasons for medication changes, prepare court briefings for the attending to testify at hearings (for the involuntary court commitments of the patients), obtain consent for psychotropic medications and write orders and monitor medications adjustments.
daily schedule;
Arrive to the hospital and enter key code to obtain my keys, walk to the unit and unlock/lock the door, meet in the Dr office for morning report from the head nurse (no nurse ratchet here!). This is when we would get all the updates on who didnt take there meds, got into a fight, had an outbreak or difficulty overnight, or wet the bed. (we had a lot of people with psychogenic polydipsia, meaning their brain told them they were thirsty all the time, and these guys would have the water shut off to their rooms, but would drink from the toilet at night or sneak drinks during the day and wet the bed at night, we had to monitor their sodium level and watch for seizures). after report we would give a list of patients to the techs so they could bring them to the team meeting room. We could then ask questions and talk to the patients in a more controlled environment. Some days we had team meetings, with case workers, social workers, the patient, the social worker, recovery specialist, psychiatrist, med students, head nurse. (this would drive me CRAZY!!! seriously, hide the knives, because team meetings made me want to hurt people...)
I really enjoyed talking with the patients, mostly because i could ask them any question i wanted, and would get a response. Normally in the clinic you can ask patients a variety of questions, but here any question is fair game.....I would like to provide you with the highlights from the month...
"what super powers do you have?"
"are the voices fighting today?"
"are the voices male or female? what are they saying?"
"how much money did you win in the lotto?"
"did the zombie come and visit you last night?"
"why did you hit_____ in the face?"
"why did you take your clothes off and run down the hall?"
"what type of experiments are the Russians performing?"
"so you say there is a serial killer loose in the unit, and is hiding bodies in bags in the cafeteria..."
"why do you think we are trying to kill you with Zocor?"
"why do you tie a string around your penis? how come you put rub the semen on your face?"
"what are the names of your 53 kids?"
basically, i could ask a single question, and from there just try and follow the thoughts, usually it was pretty interesting to see what they would say. I enjoyed assessing the delusions, but at the same time its also amazing to watch some of the patients start to get better, as the medications are adjusted, you can actually see a difference in the mood, affect, tone and their delusions. One of my patients on discharge said to me, "Dr stephanie, i dont have delusions anymore!" but he had severe tardive dyskinesia (abnormal movements of the jaw, tongue and spoke with a lisp). Watching a few of my patients leave the hospital is bitter sweet. If on their medication they are pleasant and not threatening, but i have read their charts and i know why they came into the hospital in the first place, so its only a matter of time before they stop taking their medications and have another relapse and develop their psychotic symptoms all over again.
The single largest problem with the psychiatric population is compliance (or adherence) to the medication regimen. The patients do not like taking their meds and then they start to decompensate and definitely will not start taking their meds on their own...basically the only solution is to create more depot injections of psychotropics that last for weeks to months at a time, and have them come in to have shots of their meds, or if they can develop some form of an implantable that would release slowly overtime.....clearly there is room for progress. Historically the mentally ill have been forgotten, and i am guessing with the current trend in health care costs, the chronically mentally ill will continue to be forgotten.
Another interesting case i had, we decided to stop the depakote on one of my bipolar patients, and within 3 days of not taking his medications had slipped into a manic state, where he would rap and preach about black power and white hatred, and started to form a gang with the other black patients to gang up on the doctors and nurses. He also filed "habius corpus" for being held against his will, called the local newstation to report that he had been mistreated by the staff. Basically went a little nuts, even his appearance changed. It was remarkable to see the change in his demeanor in just a few days with no medication, esp because he was not on a large dose. He refused to take medications at this point and we had to forcibly give some injections, after which he started to cooperate and take his medications by mouth. Most of the patients didnt like to take their meds, and would hide them in their cheeks, spit them out, require them to be smashed and put into apple sauce or pudding or they were placed on Intramuscular injections of their medications. because these patients were court ordered to be here, we had the right to force them to take their medications.
Going to court was the other highlight of the rotation, and preparing my attending for the cross examination was fun! since we (as the students) knew the most about our patients, we had to brief him on the patients that were being presented at the hearing. Supply him with dates of incidents, medication changes, and basically supply the judge with the specific reasons why they should not be discharged at this time, and why they require continued hospitalization. The defense attorney did his job well, and gave some great cross examinations were i began to think theses patients my have a shot of getting out...until the judge would allow the patient to speak on his own behalf...then they would place the nail in their own coffin. Here is my favorite testimony....
'I am in my right mind, i am fully aware of my situation. The Russians are experimenting on me with methamphetamine, and have possessed the bodies of my family members in order to gain access to my mind and uncover the secrets that i posses. If you continue to keep me here the Russians will kill me because they are no longer to experiment while the doctor has my cholesterol so low.'
yep i know....crazy. truly crazy. those are the only words.
then there were the days, were i actually feared for my own personal safety, the day one of the convicted rapist decided to remove his clothes at the nurse station, state very loudly that he needs physical sex, points at me and yells, "you stupid bitch, you stole my money" This is a guy who already has been restricted to the unit for days and days for fighting and sometimes spends the majority of his day in time out or seclusion for inappropriately touching the female staff, attempted to rape one of the female nurses who subsequently had been let go. This is a patient that is definitely not to be trusted, and has the potential to snap. he has anti personality disorder and doesnt care about his actions and has no sense of consequence. while at the same time has more rights as a psych patient than i do as a medical student because they are protected under Florida statue (similar to children and the elderly) so if we get hit or assaulted in any way we are not allowed by law to fight back. This is completely unfair! We are trying to transfer the patient to a forensic unit where he is in a prison setting and the guards have guns. All we have are some big black guys, and the ability to tell him in a stern voice to please stop and go back to your room. Which if you have ever tried talking to a man in an active psychotic state, who is angry...talking is not going to do a damn thing...we need meds and we need them in dart guns.
Haldol 10mg Ativan 2mg darts! that is what we need....if they can combine those into one injection and then be able to put them in a dart gun that will inject upon penetration!! ahhh the future!!
Well i guess that basically sums up the month i had in psych....everyday was an adventure, there was never a dull moment, and there are plenty of stories....i think my unit was more exciting than jack nicholson in one flew over the cookoos nest, but hey i probably have a small bias.....
next up.....a month of veterinary medicine!!! yep you guessed it i start a 1month rotation at the children's hospital......yay kids!! (apply sarcasm here)
Posts
