MRSA Update

More reasons to get immunized.

Apparently, in a recent CDC update in Annals of EM, there were more cases of necrotizing pneumonia associated with flu-like illnesses--10 in 2 months, with 6 deaths.

The deaths were notable for the speed of worsening and the age, worse in younger people rather than older.

Still rare, MRSA pneumonia may be more virulent as it is apparently able to kill the very cells (PMNs) that the body uses to neutralize it. Some of these cases were associated with a preceding MRSA skin infection.

0 for 3

I'm something of a black cloud.

3 times I've participated in resuscitations, 3 times the patients have shuffled off. It's been a watershed for me, the stepping forward, getting on the step ladder, and performing compressions. 90 percent of my thought is, 100 per minute, allow for full recoil, 100 per minute...10 percent is a sponge for death.

In the first resuscitation, we preserved dignity with our demeanor on his passing. Dignity in death, I now think, is not a function of tubes, or wires, or excreta, or the state of the body. It seems rather to be a state of the event. I've talked about the first loss before, a middle-aged man stabbed in the chest after bumming a ride. Twenty minutes out from the event, he arrived with a penetrating left chest wound; we opened the chest, plumbing for the heart, in the trauma bay. Heroic efforts would likely only have been successful if we had seen him get stabbed and immediately rushed him to help. Nevertheless, all that could be done, was.

I remember, after time had been called, the silence. The team set this. The team decided there was not space for idle chatter. I laid a hand on his knee before leaving, some attempt at communion. We didn't say a word following for what seemed like minutes. When we did talk, the chief's thought was to examine what we could've done better. He didn't speak of anything else for a good hour, and spent time just staring off even if others were talking.

There was a tacit understanding that the work we did was in the service of the patient and those to come which lent the event the dignity of respect. I hope it would've been seen that way by observers.

The third time, the dignity of passing was set by the observers. Death came sprinting down the long hallway of the ED in a wheelchair, nurses trailing behind, mouth open. She spewed up, yellow and frothy during CPR as we worked, knowing the futility. She had aspirated; her thin limbs spoke to her age, to long illness. Dry, papery skin and bones barely concealed underneath a patina of muscle. The success of CPR for non-responsive cancer patients is next to nil.

As I got down from the CPR step-ladder, her husband and son looked on. Both were seated, almost as if at a visitation; both were quietly crying. Not screaming. Not wailing. Not blaming. I can only guess what they were thinking, but their faces and attitudes bestowed upon their loved one all the dignity of her life until then. The resuscitation--messy, smelly, primal, and filled with the excreta of decay--was but a passing blemish. They were witnesses to her passing. The son and father accepted the gentle apologies and sympathies of the staff as they passed, and remained sitting as I left.

Dignity is in the spirit, in the mind, as well as in the body. Right thought and intention can overcome the bald shock of the body in death.

CA-MRSA, Bogeyman Extraordinaire

There's been a ton of news recently with regards to community-acquired MRSA--school closings, cancellation of sports events, deaths, rioting in the streets, mass panic. See this NY Times article.

The CDC has adroitly headlined recommendations on their website. One wonders how many hits they've gotten recently.

Wouldn't want to catch MRSA. It can kill you, you know. Keep your kids home from school. Keep them out of sports.

MRSA is now the most common cause of skin infections seen in the ED. It's a common question for med students--how would you treat CA-MRSA versus hospital-acquired MRSA, which is still much more common? The answer is a drug switch: Bactrim or clindamycin instead of vancomycin. Patients in contact isolation for MRSA are common. One of my first patients was a woman who likely turned septic and developed MRSA tracheobronchitis. Not so easy to treat; she was in the ICU for weeks. I've seen her since for a hysterectomy, and she seemed well. She had MRSA from her chronically open and weeping leg wounds. She was immobile.

Superbugs are scary, I admit. Clostridium dificile is scarier to me than MRSA because sepsis and invasive disease can just as easily be caused by bugs that are susceptible, and kill you anyway. So, MRSA is more difficult to treat--but the main problem with early invasive disease is recognizing it and treating it supportively until the correct antibiotic can be chosen. I therefore rate it as about the same on the scariness scale as susceptible staph infections, invasive strep infections like toxic shock syndrome, or meningitis--the kind that kills teenagers. Very scary. But not very common.

A recent JAMA article (not permalinked, may expire) placed the incidence of invasive CA-MRSA infections at 3 to 5 per 100,000 by examining 7 LARGE areas--for example, the whole state of Connecticut. Compare that to the incidence (i.e., only new cases) of diabetes, now at over 7 per 1000, or 200 times more common than invasive CA-MRSA infections. And diabetes is less scary but, over the long run, still loaded with significant morbidity and mortality. It is the leading cause of limb amputations in the US.

What about mortality? The mortality rate from what I can tell for CA-MRSA is 0.5 per 100,000 in the JAMA study above. Heart disease mortality, by contrast, was from 239 to over 430 per 100,000 depending on demographics in the year 2000.

It may well be that resistant infections turn out to be the defining adversary of our generation in health care. For now, though, I wonder if they don't just make good news. Even the CDC, who quotes the rising rates for MRSA infections overall, doesn't advocate the closing of schools. Even if you could eradicate MRSA from all surfaces, I have a feeling it just might be back as soon as the kids return.

So--Purell kills MRSA--wash your hands. And keep living. Because, like it or not, this bug--which lives on everyone's skin, for crying out loud--isn't leaving.

Belly pain, the black box of medicine

Up to 8% of all emergency room visits are for abdominal pain. Up to 50% of those will leave without a clear diagnosis.

Said one ED attending to another, 'what if we just had a belly pain team? Then that team could see all the belly pain patients on one shift, and you could rotate through it'.

Came the reply, 'if you wanted to kill yourself, that'd be a great idea'.

Frustration. Risk. Hallmarks of a belly pain patient. I remember opening the abdomen during anatomy. It was a mess. A mess contributed to by a cadaver that had megacolon (you can guess what that caused, I suppose), but a mess in any case. There are pouches (of Douglas, of Morrison), ligaments (of Treitz), ascensions (of the colon), flexures, anastomoses (my favorite, the superior and inferior pancreaticoduodenal), gutters, and lumens. There are systemic arteries and veins, and then the portal venous system that returns to the liver for metabolism from the digestive tract. There are spots for hemorrhage and infection inside the peritoneum (the lining of the gut) and behind the peritoneum. There's an omentum that hangs over it all like a beaded curtain.

So one can understand why the abdomen can be frustrating. There are also extra-abdominal causes of 'abdominal' pain, some of them catastrophic. In an elderly diabetic lady with indigestion and belly pain, an EKG is a sensible order to rule out a heart attack. Pulmonary embolism and pneumonia can both present with belly pain of one sort or another.

Obscure causes such as an abdominal migraine (the gut has more serotonin receptors than the brain) usually seen in children and errors in hemoglobin metabolism can cause belly pain. And, of course, the appendix.

Ah, the appendix. Still the most commonly missed diagnosis in the ED. So the question for a new belly pain patient could be phrased, 'why isn't this appendicitis?' It can flip up, as high as right below the rib cage, especially in pregnant women. It can migrate down and hide behind the bladder.

So here's to the 8% of my future life spent looking for the appendix.

Glow-In-The-Dark Pee

R the nurse was walking down the hall with an open urine cup, looking at it and smelling it. That doesn't happen too often. It looked like it was glowing; Mountain Dew straight out.

"You should put that under a Woods lamp (a black light)", I said. So we did, and gosh darn if it didn't glow like a kid's glowstick at Disneyland.

So what's the guy's story? He was an ingestion, unclear history, suicide attempt for two days...perhaps he decided to add antifreeze to his list. Antifreeze has a compound called fluorescein added for this exact reason, because antifreeze kills kidneys, tastes sweet, and tends to get ingested by kids and dogs. And alcoholics.
His blood alcohol level came back at an impressive 0.390, which is a personal best for me; this, actually, was really good news. Antifreeze is fun for two reasons--one for the fluorescent pee, two because the old school antidote is a lot of alcohol. The two are metabolized by the same pathway, but alcohol is a better substrate, so if you drink enough, you can prevent the antifreeze from being changed into it's toxic metabolite.

As with anything that's 'interesting', the guy's antifreeze level came back very low. Possible we just missed it and he had peed it all out. But, a Google search also turned up a wide variety of things that turn your pee fluorescent. In fact, there was an article in a pediatric journal that discussed a random sample of 30 pediatric urine tests, 21 of which were fluorescent underneath a Woods lamp. None of those patients had antifreeze poisoning.

Turns out niacin and other B vitamins turn your pee fluorescent, among other things, including certain other medications. I also wonder about food coloring, especially in children (perhaps why 21 of 30 randomly selected had fluorescent pee--have you seen what they eat?)

So the next time your friend drinks a pint of antifreeze, take him or her under a black light and hand them a fifth of tequila. And, again I'm reminded, even the classic cases, aren't.

Jaded

The slow progress from naive to bitter I expected, but the first patient who burned me I didn't see coming.

26-yo female came in with lower pelvic pain and bleeding that she truthfully attributed to endometritis, and had a long history of work-up for the same. I don't know about the literature, but I've seen a couple patients have significant pain from this condition, where implants of uterine lining in the pelvic cavity cause pain secondary to bleeding; though outside the uterus, they are hormonally responsive. It's not fun, partially because the pain and scarring isn't life threatening, so patients tend to feel their complaint is minimized.

The nurse, Robert, recognized her immediately and warned me that she was a 'frequent flier', and had been to the ED numerous times in the past six months. Her first request for pain medication was for Dilaudid, which I've seen used multiple times in my first ED but not at my second. It's considered overly strong. Too fast acting, too likely to cause respiratory depression. I'm sure the high is killer. I'm also sure that the pain relief is both quick and dramatic.

Most patients who are opiate-naive don't have a favorite yet; they may remember what they had last time, but they often mangle the name or just don't remember. The nurse was suspicious from the beginning that she was exaggerating her complaint to get more substantial pain relief.

The work-up, as expected, was negative for any of the more dangerous causes of bleeding and lower pelvic pain like an ectopic pregnancy or a ruptured ovarian cyst. I went to check on her, and sat down at the bedside. She was shaking, sitting curled up. She said she was frustrated by the pain she was still having and didn't feel like she was under control; we had offered a Percocet script to take with her and a dose of Toradol (similar to ibuprofen) before leaving, but that wasn't sufficient. She said she'd call for a ride if we could help her control her pain.

I walked back to the attending doc, who said he'd be willing to do that after she called for a ride. So I went back and told her and she said she'd call and picked up her phone. I went back and told the doc.

"Did she call?" he said.
"She was going to", I said.
"She can't have anything until she calls and her ride is on the way", he said. Then he looked at me. "Here's what's going to happen. She'll say she's getting a ride, get the shot, and take off. Then she'll drive herself into an abutment with narcotics in her system".

I didn't believe it. I thought she was genuine. Then I went back and talked to her again, and she said, 'Oh, did you want me to call? I wasn't clear'. The context made it suspicious. Maybe she was just gaming me into getting her high. The tricky part was that she did have genuine pathology; no one was arguing that. The argument was that she was way too into a shot of Dilaudid. By the time she finished her plea, called, and then 'couldn't get a ride', she would've had good relief from her oral pain meds.

So that plea, where she was shaking and frustrated and talked about how her pain had gotten worse after the pelvic exam, all calculated? Who knows? Perhaps all genuine but just accentuated. These are the drug seekers I have to get used to, the ones who are really sick. The most egregious are sickle cell patients, classically. They get so zonked out that they'll be close to respiratory arrest and still requesting meds. No one, however, will argue that a sickle cell crisis is faked. You try having your hemoglobin precipitate out in your peripheral arterial system.

The IV component can't be underestimated, either. Benadryl would never be considered a drug of abuse, but in the form of an IV push (given in one dose) it produces a high just because of the route.

I guess I'm a bit more cranky and jaded than before my shift started. I still believe pain must be treated, but, just as with every other complaint, the world is grey--or, in the case of the ED, a bit green.

What do this shack and a little girl have to do with an EKG?

So there's a foundation, Hearts for Kids, that helps kids in Africa get heart transplants. That's awesome. This picture, from their website, is where their patients live.

I don't know anything about them, I just found them with Google while I was searching for rheumatic fever. If you do a Google image search for the same, you'll see a lot of black and white pictures from the pre-antibiotic era of people who died from RF, including Mozart. Then I saw this picture. Not black and white. Full color. Hmmm.

RF is still on our diagnosis list of kids with fever and migratory rash; it can attack the heart most famously, or cause people to have similar symptoms to Huntington's disease, also known as Syddenham's chorea. During a grand rounds last week, a distinguished class of residents at a top program didn't recognize a video of it. That video was taken in Africa. To learn about it, I've had to use the Internet, textbooks, and slides, because I've never seen a case, and likely never will until I travel overseas.

According to an NEJM article, rheumatic fever in the US has decreased precipitously. From being a more common topic than stroke in the era from 1967 to 1976, it is now rare, and a search of all medical journals in the US yields only eight articles between 1997 and 2006. But in places like that in the picture above--that is, the 80% of the world without access to prompt antibiosis for strep throat--there are 470,000 new cases of ARF each year.

What got me on this topic? EKGs, actually. Wolff-Parkinson-White syndrome is a sub-set of supraventricular tachycardias, or fast heart rhythms. It is a characteristic, classic finding on an EKG; there is a bit of an early rise in the QRS complex called the delta wave, and it represents a track of heart muscle that goes around the normal pathway of conduction. It typically does not cause problems (story to the patient) but can proceed to ventricular fibrillation (story to students) if you block the normal pathway.



Our hearts have a built in delay to allow for filling of the ventricles. Because the WPW pathway bypasses that system, if it becomes ascendant, it conducts directly from the atria to the ventricles at a rate of anywhere from 150-300 beats per minute. That is sometimes called 'badness'. If the patient is unstable, the best treatment is to shock them (electrical cardioversion). If they are stable but fast, a variety of drugs can be used; I learned that adenosine, which is usually used even in the field by paramedics for narrow-complex tachycardias should not be used for WPW, but some texts seem to suggest it is acceptable. I'll have to read more to figure out the differences.

WPW was first described by a few physicians, as often happens, but Paul Dudley White, who worked at Harvard at the turn of the century, described it in 1908. It is interesting to note why he became a physician, and to wonder why he decided to focus on the heart. He, like countless others at the turn of the century, before the advent of penicillin, lost a sister to acute rheumatic fever at the age of 12.

Tired

My speech doesn't slur so much as pause, catch. I'm still processing the last thought as I ask for the next.

Slow, and careful. Musn't miss.

Light is a soft glow at the edge of vision. Sounds encroach. Monitors pace thought, insistent, racing.

Moments magnify. As if the previous one isn't gone yet, new one already here.

My stray thoughts are of sheets, and food. Heavy, sweet food.

Standing in the middle of this river, current stronger than it appears. How tempting to float rather than wade.

To be the responsible one at 4 am.

And, finally, the morning air.

Genius Parade, part 1

At first he just laid on the backboard, stabilized. Two giant styrofoam logs on either side of his head helped keep him from moving.

Perhaps we should've left him there. He refused to tell his story. How did you get that 3 cm gash on the back of your head? Did someone jump you? No answers.

Try a bit of cajoling, which, of course, he doesn't respond to, being a young, drunk male. Where are you? What's your name? No response.

Normally, I suppose petulance works well to control your situation, but in an ER it's more likely to get you intubated, which I told him. He winked at me. Like, you understand, don't you? I can't tell the police what was happening.

Despite myself, my response at that point showed how old I really am. No, I don't understand you, genius. What the hell are you thinking exactly?

Restraints came next, eventually, as he got less and less cooperative and started to insult nurses, doctors, guards.

After we spun his head (CT) and found nothing, it was time to fix the laceration. It was a Y-shaped laceration with relatively clean lines that I could re-approximate well. Having done a few scalp repairs, I was hoping to try for a good result with a stitch at the Y that re-approximated the three angles loosely; Y-shaped lacs are notorious for losing blood flow at the middle of the Y since there is often a tearing force involved.

So that's where my head was. How can I technically approach this problem to get the best result for the patient, with regards to infection prevention and cosmesis?

His head wasn't at the same point. Just to get him turned over we had two security guards holding the limbs out of restraints. As soon as I started to irrigate, he started moving his head around, shaking it. To truly irrigate a wound the minimum amount is probably on the order of a 1/2 liter or so of tap water or saline. That didn't happen.

And my plans of stitching didn't happen, either. Once the wound was tolerably prepared, I asked him if he'd allow me to fix it, and he said, 'you do what you have to do, but as soon as you start, I'm going to go like this'--and he shook his head violently back and forth.

Now I'm less worried about him than us. There were four people in the room trying their best to help this genius, and the time it would take to suture him wasn't feasible. So he got staples. Less than 30 seconds, and his wound was closed. There was a touch of satisfaction that I would be lying to deny in stapling his head. 30 seconds was about all we had as someone had to hold his head down, and his free arm.

During the time we were screwing around trying to take care of genius no. 1, there were probably about 15 other patients that came into the ED and needed help, including a couple cardiac arrhythmias, a woman on the edge of sepsis, little kids that were really sick in the middle of the night.

Re-reading this post, I can see my writing is a bit choppy and odd. Probably because I'm still suffering from counter-transference--that is, strong feelings that arise in a provider in response to a patient that should, ideally, be put to the side. Not always so easy to do.

Perhaps I'm younger than I think, and still too close to the time in my life when I made my own stupid decisions. He certainly made it difficult to help him. Perhaps I'm not the most patient person by nature. Or, perhaps I was starting to be aware of everything going on in the ED that needed attention.

I'm still sorting this one through. What are the consequences of helping everyone? Can you make a judgment on how deserving someone is of help? If so, how?

In the meantime, I'll try to be less of an idiot, if only for the sake of others.

'stop if you see brain'

Probably you saw the photo before you started reading. Probably the correct response, if there is one, is 'dear Lord', or an expression of your choice to that effect.

That's about right. That's what I say to myself too. A couple shifts ago I spent five hours on scalp lacerations, including history, eval, and then repair.

The first one was a bit silly; poor anxious girl had banged her head on the visor of her car after running into a post at 5 miles an hour and was more upset about what dad was going to say than the lac in her forehead. Aside from poor anesthesia, probably secondary to her anxiety, it was a quick repair.

The second was a stoic swiss farmer who had fallen off an ATV and hit god knows what; he had four inches of a jagged tear. The ED was busy. I went in to clean and evaluate it.

"Any pain here?" I asked, tapping on his exposed skull. His exposed skull. When I went in, the attending said, go ahead and clean it out well. Stop if you see a fracture or exposed brain. Always good advice, stopping when you see exposed brain.

The ED was still busy. Attending came in, looked, and said, 'OK, well I'd close with a couple sub-Q for approximation and then staple it. Let me know when you're done.' Twenty-three staples and five sub-Q dissolveable stitches later, it was a nice Frankenstein scar down the right side of his forehead. But it wasn't bleeding. And the bits of hay and dirt were gone.

Despite myself, it was an amazingly satisfying complaint. The guy needed help, but there was no way he was going to surgery. The perfect wound care challenge for the ED. And now, when I walk into a room with a lac and they say, 'have you done this before?', I have a lot more confidence in saying, 'yup'.

Wow. I can actually deliver care, instead of just going in and talking to someone. Gotta love this job. A small part of me still whistles internally as one would witnessing any dramatic incident from afar; the part that drives me at work steps up and sees what needs to be done. So much still beyond my experience, obviously. But there's getting to be more and more I can handle.

BTW, please don't ride your ATV without a helmet. Thanks. Remember how lucky the patient in this story was. His CT was normal.

Exam Under Anesthesia

Ah, ethics.

The OB rotation includes the requirement that medical students participate in 'exams under anesthesia', which are completed in almost all surgical specialties. Orthopedics is another rotation where you can learn a lot from these situations.

In OB, though, I'm not so sure it's so straightforward. Technically, we're performing an extra, and theoretically unnecessary pelvic exam. That's a bit different than an extra knee exam. And this with the patient unresponsive.

ACOG, the governing body of OB, says that exams under anesthesia are allowable with specific consent. But, like all things that involve consent, they are put on the form but not typically discussed in length. How many people would consent if you said, 'is it OK if the med student performs and extra exam on you while you're out?' Probably, some would, or even most, since many are open to helping education.

I completed these because, even though it felt weird, I would've had to cause a big stink to not do it. But ethically, we've been taught that we should avoid even the appearance of impropriety. Does this count? Is this something that is emotionally important enough to specifically discuss in consent? Or am I just uncomfortable? Probably I'm just uncomfortable.

There are a lot of times when we inconvenience patients for educational purposes. I think the way to deal with that is to recognize the debt you owe to all patients for those that helped you learn, and repay that debt with quality care.

But those exams still make me uncomfortable.

"Who are we to play God?"

I'm down to a post a month. Sorry. Things should pick up soon. Currently I'm taking a break from multiple choice questions contrasting various treatments for a rectocele, which, by the way, is caused by a loosening of the levator ani fascia, and results in the rectum encroaching into the vagina.

I have my doubts about my future career proceeding in uro-gynecology. Not that there's anything wrong with fixing such problems. Anyway.

OB has been hard to write about. But I figured it out reading an article in the NY Times about gender selection. The director of a prominent fertility center in the above article perhaps questioned a doctor's right to play God, but, interestingly enough, he was in support of allowing a patient to choose the gender of their child. He essentially said, if the patient wants to have a girl, who are we to play God and prevent them from making that choice? Clever, to turn the argument on it's head that way.


Aside from chuckling at the inversion of logic evident in such a turn of phrase, it got me thinking that doctors constantly play God, so to speak. Fertility is an obvious example. But every operation or intervention is essentially an attempt to monkey with the divine design of nature. Are we not playing god when we insert three or four instruments into someone's belly to extract a hemorrhagic ovarian cyst? Certainly we are not trusting to nature to sort things out. Certainly there is some element of intervention there.


And we would not have it any other way. The hubris necessary to even think of taking a person caught in a car accident, opening their stomach, and ripping out their bleeding spleen in a matter of minutes is a bit mind-boggling. Thank goodness we do it. If we weren't a bit hubristic we'd be paralyzed by indecision.


But what's the real difference between that and fertility other than speed? The person in the car accident may have made any number of questionable choices, just as some say fertility seekers and the doctors who treat them are on shaky moral ground. The trauma victim may have been a 21-yo, intoxicated, unbelted, ejected driver found on the scene of a multi-car accident unresponsive. In the absence of any recorded spontaneous resuscitation and splenic rupture repair in the field, I'd have to say, we're 'playing God' and altering the natural consequences of his choices.


So to say that fertility docs are somehow monkeying with God's natural order more than doctors in general is a bit false.


I don't actually support choosing a gender, and I think most couples who want the most expensive fertility interventions should actually adopt, since they often aren't using their own genetic material anyway. But that's my personal opinion, not my professional one. Let's face it, we're playing God all the time. Perhaps the real hubris comes when a doctor says, 'you may play God', and, faced with someone else, 'you may not'. Perhaps the very argument should be discarded altogether.

This one isn't sorted out yet, more later. Back to Burch slings and cystoceles.

NY Times Takes on Pharma

The New York Times has recently had two fascinating and, I think, accurate articles highlighting the relationship between doctors, health care, and pharmaceutical companies, in anemia treatment, and in antipsychotic use in children.

I posted once about problems with the use of antipsychotics, but this is a whole different issue. This is a major problem. It looks like doctor's groups in NY that were prescribing variants of EPO, which boosts red cell production and is thought to be useful in conditions like chronic kidney disease and chemotherapy, were receiving rebates from the pharmaceutical companies based on how much they gave patients to the tune of millions. Millions. Sounds a bit fishy. Getting rebates based on the drugs you give people.

Then, there's a second article about psychiatrists receiving payment from drug companies in Minnesota, which publishes such statistics unlike most states. It said the most money received by a doctor was over $600,000 in a year.

Now, I'm usually one to point out that doctors don't make as much money as CEOs, or business folks, or lawyers; in a recent book, Better, Atul Gawande pointed out that the return per year of schooling for doctors was on the order of 16%, as compared to almost 30% for business school. Still, we're not about to end up in the poor house as a profession. We should know better.

There's good evidence that these trips and gifts and, well, cold cash in bank accounts, influence prescribing practices. It seems obvious with enormous rebates, but it's true even of the pens and note pads. Ask your doctor about it. Go ahead. And check out a site that some doctors have started in protest, called No Free Lunch. It has just started a directory of providers who have pledged not to accept gifts from pharmaceutical companies.

Yes, we need drugs. Sure. But we don't need to be paid by the companies that make them. Sheesh. And we all supposedly took ethics in med school. I suppose it's easier for me; drug reps aren't allowed to visit UW physicians. I've never seen one.

Merlin Deficiency

Neurofibromatosis has two types; medical students are taught to think of it whenever they see cafe au lait spots, literally 'coffee with milk' according to those crazy French people who, as Steve Martin says, 'have a different word for everything'.

A couple interesting things. We associate these with all sorts of syndromes in children, but it turns out that something like 1% of caucasians and up to 27% of african-americans have 1 to 2 spots (as found and presented well by a classmate). Like unequal pupils, most of the time this doesn't mean disease.

Still, neurofibromatosis sydnromes are associated; these people deal with a variety of tumor types that grow out of Schwann cells, normally responsible for covering peripheral nerves in myelin, a sort of insulation that speeds transmission and makes life possible. Depending on the type these can be on the skin or, commonly, in the eye or ear.

But the real reason to post is that the alternative name for the gene in type 2 is 'merlin'. As in, the wizard. So, it's correct to say that the little girl receiving chemo down the hall right now for a resistant optic glioma has a shortage of magic in her life; specifically, a shortage of tall, long-bearded wizardry.

Gorgeous

The iris is ignored. Unless there is an iridectomy, and irregularity, ophthalmology goes right past the iris after checking for sufficient anterior chamber depth. But I think it's gorgeous. These pictures on the web discuss the beauty of their subjects, but they miss the patent fact that the iris is a thing of beauty in ninety year old veterans, too.

Look at that thing. The texture is wonderful. Irises like Saharan sand-dunes, like kelp in the Pacific. And when you look at it, it moves, contracts, bunches up and then relaxes. Sure, lens, retina, fovea, hemorrhages, optic nerve, blah, blah, blah. But let's not forget the beauty inherent in our patients in or mad rush for pathology.

Wear Your Seatbelts

A classmate recently had a roll-over accident and sent out a mass e-mail reminding people to wear their seatbelts with pictures of his car.

I prefer to remember a couple of patients. It would start with a funny feeling, and then the pager would go off; a text page. Level 1, 24-yo unbelted ejected driver high-speed MVA, GCS 3. Then some vitals, unstable. His arrival is busy, scrubs, x-ray lead, and gowns blur around him, while I remember his head, bright red from across the room. His scalp is bleeding. His nose is bleeding. His ears are bleeding. He bleeds around his intubation. The blood pools in the antihelical fossa of his ear as it drains out of the canal. Blood, blood, blood. We take a stapler to the scalp, which is the trauma way of treating a minor injury. One can only imagine what his brain looks like. I clean the blood from his nose for a while, then stop. There are bigger problems.

Or, in rehab, another young man, recovering from an unbelted ejection from his car. He had been on his way home from picking up his brother upon return from Iraq. It's not hard to imagine, and indeed forgive, the idea of stopping for a few beers. Now, months after his injury, he can't speak, walk, or remember three objects you tell him to remember for more than five minutes.

So yes, wear your seatbelt. Put your children in their car seats. All the king's horses, all the king's men.

Can't Escape the Psych

'I don't know. I can't localize his lesion; he's had three episodes of left-sided weakness, he says it came on suddenly followed by headache, and he had pins and needles on both sides. So, if we were to go with one lesion, motor only, let's say, that could be his right internal capsule...but to have three episodes that resolve completely and last for days?'

Dr. S strokes his beard, says a non-commital 'yes', which means, 'I'm thinking of how to tell you what I think', and says, 'I don't think he's had a stroke. At this point, I'm hesitant to call it conversion disorder...there's always a kernel of truth to these. And, just because this isn't, quote-unquote, real, doesn't mean he can't have a real stroke'.

'What about the one-sided migraines that affect 0.00005% of the population?'

'Well, it doesn't fit the onset...and before you really go and lay your nickel down and say, 'I think it's migraine', we would need to rule everything else out...'

Conversion. As in conversion from the brain to the body, crossing the border, if there is one. Conversion disorder occurs most in young women with other psychiatric diagnoses. As in, 27-yo female w/hx of OCD presents with acute onset of bilateral pins and needles in hands along with right-handed weakness, worse in her fingers than wrist. Oh, BTW, she just had a huge fight with her boyfriend and he's moving out. There's no explanation for her neurological complaint. None. You can't put it anywhere in the CNS. So the patient 'converts' their emotional stress into a syndrome that fits their own idea of illness, and makes it real. The opposite of self-help.

Or, factitious disorder. The patient fakes it, but in order to take on the role of the patient, be cared about, get tests, perhaps in an attempt to compensate for some loneliness curled around their heart. We look at their hearts, often, with sound waves, with dye. We don't see the loneliness.

At extremes, people may contaminate their own surgical wounds, give themselves thyroid hormone. An historical precursor was named after a German baron, Munchausen, who told amazing tall tales upon returning from a war with the Turks.

That's him. But the idea that these patients are making up their lesions is somewhat more sinister than his tall tales of riding on a cannonball, or pulling himself out of quicksand by his beard. I've blogged about one before, the patient below who would put her head in the pillow to drop her O2 saturation. Perhaps not faking, but on a spectrum from the professional patient to Munchausen's.

Or, most distasteful, described in my lifetime, Munchausen's by proxy, in which a parent, usually a mother, makes their child sick deliberately in order to receive care for themselves. Perhaps I won't say any more about that.

These people are included with malingering in some articles, people who are faking pain, for example, in order to obtain narcotics. But I don't see them in the same spectrum. Imagine being so lonely that the attention of a stress test relieves some need; that the clustering of your family in a tiny room, with the gentle beeps of IV monitors to guide you, starts to feel more familiar and comfortable than home, or what passes for it. That seems worse than wanting narcs bad enough to complain about abdominal pain, a lot.

My world tilts a bit more towards the bizarre; or, more likely, I see a bit more of what's real. I still can't let go if the idea that he has the migraines that cause paralysis, and that's he's in that 0.00005%.

Anisocoria and PFO

25% of us walk around with a hole in our heart. When we're little, the foramen ovale allows blood flow from right to left without having to go through the lungs, which don't work right. But in up to 1 in 4 of us, it doesn't close, and we're never the wiser.

20% of us walk around with unequal pupils, anisocoria, which is a finding on neuro exam.

Just something to think about. Not all that looks broken, is.

Trach, PEG, SNF

"So, someone like this, who is already on the borderline of having her husband take care of her at home, with a major cerebrovascular incident, it's unlikely she'll be back...it looks like she's headed for", count them off on fingers, "trach, PEG, and SNF".

As in a tracheostomy, because she can't breathe, a PEG tube, which allows us to dump food directly into her stomach, and a SNF, or skilled nursing facility, which some used to call nursing homes.

She can blink, but can't tell her right from her left. She easily coughs with the whole-body-but-silent cough of necrotizing pneumonia on a ventilator; the sound doesn't come out, but all the lines on the ventilator go crazy. When she came in she couldn't even move; she was in a seizure that wouldn't let her move that lasted forever and a day. Status epilepticus.

She has infarct upon infarct upon infarct in her brain, three, layered, all of which could result in her waxing and waning weakness on one side; one way it is described is as an anamnestic respose, literally an 'unforgetting' that the brain engages in when put under stress. Old strokes become new again.

I keep wondering where mercy lies. The triad, the trach PEG SNF triad, an epithet, a plan, an epitath--would I want to be kept alive? Are these still people who can live meaningful lives? The same question comes up again and again for the 30-yo in an earlier post, off ventilator, on ventilator. He's strong, responsive, too. He can open his eyes sometimes, squeeze fingers, communicate. He was trached and PEGed today also.

The choice to withdraw care is somewhat like the choice to have an abortion. People who haven't stood in that circumstance can't know what it's like, and that includes me. If it were my parent, or aunt, or uncle, or spouse, I might want to keep them alive as long as humanely possible and longer. If it were me, I might be more cognitively aware than I thought. Would I feel trapped and ready to go, or would I cherish every flicker of light I could see through the skylight of the intensive care unit?

I guess we'll have to wait and see. My only advice from three weeks of seeing people vanish into their own bodies is that judgement on any decision about end of life care is not something to be taken lightly. Someday, we all might be trached, and PEGed, and SNFed.

Humor

Ponder This: The difference between a neurotic and a psychotic is that, while a psychotic thinks that 2 + 2 = 5, a neurotic knows the answer is 4, but it worries him.

That's Me

His CT scan looks worse than this one. And it's on the other side. The 'hypodense' areas on scan are dead or dying brain, the fluid build-up from a massive stroke.

Down the middle you can see the ventricles on the left side of the image, which is the right side of the head. Not only are his ventricles effaced on one side as here, but the midline is being pushed into the other side of his skull--or, at least, it was, until the neurosurgeons took the skull off. That's the treatment of choice. Brain swelling from a massive stroke, young, 'juicy' brain (said with a straight face, it's not derogatory), and a young guy has 80 plus-percent mortality with medical treatment alone, cut to between 47 and 53 percent with the removal of the skull piece.

His family has camped out in the elevator lobby between two units; there are constantly ten to fifteen people there, men women and children, with air mattresses, portable DVD players.

On day 4 after surgery, a repeat CT is, unfortunately, even worse; in addition to the right-sided lesion, there are new, bilateral, occipital lesions. He's now likely blind; the area at the back of the skull processes vision.

The walls are plastered with pictures of the patient and his wife, who is seven months pregnant, on an ATV, dressed up at their wedding. Their three year-old daughter with straw-colored hair, who, when I first see the patient, is standing next to the bed, looking up at the parade of coats; she can't even see her dad from the floor, the bed is too high.

He had a headache. He went to the chiropractor. His headache got worse. Then he lost consciousness. That's it. Done.

Should he come back? His vitals have leveled off, temp is stable, BP is controllable, ICP (the pressures in his head) are low, which is a good indication that the swelling is down. But his brain is jelly. Or, at least, half of it. Paralysis, loss of sensation, slurred speech, blindness. Neglect. Not of his children; of half of his reality. Since it's in the half of his brain that's likely non-dominant for language, he won't be able to put his world together. If you show him his left arm, he won't know that it's his own arm. But he won't be able to move it anyway. Does that mean they cancel out?

There's a steel of spirit needed to even enter the room that becomes second-nature to clinicians for defensive reasons. If you allowed these cases to get all the way into your head right away, you'd just cry in the broad, antiseptic hallway and then leave for the day, desperate to return to fresh air, movement, life. Within that context there is a feeling of helplessness, a knowledge that we've built to acquire that tells us how long the road to recovery will be, and how incomplete his return will be. He has truly put one foot in the grave, and I'm not sure if he can come back.

The family wants him back. Of course. But do they want him back? I don't know, I've never been the caretaker for a massive stroke victim. The question is worth asking. Death is not always the worst option, is it?

Every morning, we go in and push on the beds of his fingernails to see if he withdraws to pain, pull open his eyelids and shine lights in, rock his head back and forth gently to check for eye movement, try and decide if his periodic writhing movements are purposeful or stereotyped and primitive. Primitive because they come from a part of the brain that predates the concept of history. That breathes for us, sets heart beat, controls the myriad of daily control tasks, provides basal input into the motor system so we don't have to coordinate the thousands of muscle motor units involved in every single action.

He's me. Thirty. Kids. Healthy. He wasn't being risky, wasn't skydiving, wasn't drinking. Just got a headache.

The leading cause of death I have to worry about is still trauma, and yet I manage to ride my bike to work every day. But sometimes patients get to me not just because they are suffering, sick, and beautiful, but because it's so easy to put myself in their shoes--or, more accurately, in their compression stockings and compression devices, balloons that inflate rhythmically from the bottom up around each leg to ward off clots.

Grief wells up like air underwater which I cannot breathe.

Free Little Bird

One last psych post.

HL sat up in bed when we talked to her with glasses on, a tiny whisp of a woman, reading. The muscles in her neck were prominent, and her collarbones were more visible than normal as they joined the sternum, prominent above the collar of a baggy grey sweatshirt.

There's a Lisa Loeb song for kids that came into my head as soon as I saw her.

I'm as free a little bird as I can be...Gonna build my nest in a big oak tree, where no one can never bother me...

She had tried to end it all. Why? Well...her husband, who she had married only a year or two ago, had said he wanted a divorce for no reason and was apparently having an affair, but they were still living together, and he apparently changed his mind daily as to whether he wanted to actually finalize the divorce or not. They slept in seperate beds. She had a long history of sexual abuse. She had a history of anorexia nervosa; and she had OCD. She counted. She would look up and count to distract herself from troubles. She was a recovering alcoholic, and had fallen off the wagon. Hard.

I suppose I would too.

Normal conversation for B6/5, actually. But the most interesting part came when we talked about her drinking. She had started a new job and not told anyone she had an alcohol use 'issue', then gone out one night and, well...she said one drink led to another and to another.

"Did you have a feeling associated with this relapse?"

"Freedom", she said, clearly, after thinking for a fraction, and pushed her glasses back into place with a tremulous hand. And, despite my feeling about alcoholism and what it does to people and families, I thought to myself, go on, build that nest. Better you climb into the oak tree where no one can bother you than go back to a house where your nutso hubby emotionally tortures you with the daily possibility of divorce. And this for a person who by temperment and disorder has a need to control her reality to a degree that natural drives are the enemy to be kept at bay by castle walls of restrictive behavior and rituals. Imagine that. And for that relapse, that evening, she felt free. It almost killed her.

I'm struck at how strong and fragile we are at the same time. Not least of all this one, who, despite it all, was an executuive for marketing at a major national brand. Free as she can be, drinking deep red wine, one tall glass after the other.

The Onion must have known it was my last day.

Or they wouldn't have printed this awesome meth article,

Meth Addicts Demand Government Address Nation's Growing Spider Menace

Which is both hilarious and sadly accurate. Enjoy, while I enjoy a brewski having finished a month in the bin with the looneys, who I will miss and who I hope will continue to improve through thoroughly effective psychotherapeutic and pharmaceutical intervention.

Talk at ya soon, A

Newbies

Through the central square of the hospital, three walked, in clean, short, white coats. Their newness was a beacon; the shining, spotless coats, clean-shaven faces (just so happened they were all guys).

The only people who have spotless white coats in the hospital are the new medical students and the attendings. The attendings have spotless coats because someone washes and irons them for them in some mysterious way I'm sure I won't find out until the day after the end of residency. But you can tell, given the creases in the sleeves that every attending has, they don't all get up themselves and iron their coats at four in the morning. If that were the case, some of them would be bound to skip it.

And the new medical students, their coat is probably still fresh from the ceremony that starts medical school. They don't have the ripped pockets from stuffing them full of extra books in a vain attempt to ward off ignorance. Or, for that matter, stuffing lunch into them, or even a drink. I saw one experienced resident fit a full cup of water with no lid on it into his pocket to pass through the ICU, then take it out again on the other side. Only one of the reasons he was a mentor.

No coffee spilled from late nights, no staining chlorhexadine scrub from washing hands after going to see a patient with C. diff (actually, soap and water is probably good enough, but tell me that my first week of medicine). No gunk from the chest tube removed a bit too briskly.

What's amazing is how close I still am to those spotless students. We acclimate quickly, and after only a semester I and all my colleagues have strong, strong opinions on diagnosis, treatment, current issues. We aren't always right, but increasingly, we are. And to think, six short months ago, I felt as though I hadn't a clue. Don't get me wrong, I'm still not competent, but getting there.

The coat must also be some metaphor for training. It's no coincidence that it's spotless only at beginning and end. The training drags you through the mud of humanity and your own self for years to re-forge you on the other side. And we ask for it.

So those new students inspire feelings of relief that I'm finally learning the 'real' stuff of medicine, 'living the dream', and not just watching it on PowerPoint. But their spotlessness reminds me how far I have to go, how I'm still deep in it. And, truth be told, the clean coat of the attending is a different clean; a clean of someone who has learned to live in the midst of medicine. A clean I'm not ready for yet. For now, I'll stick to the proud, battered coat I have, with the ripped sleeve, torn pockets from overstuffing and running into corners rushing to finish my scutwork before rounds, and stains from Lord knows what. Until I earn the longer coat.

spirit salt

Says the wise patient of the week,

"If you remain righteous in your salt, your mouth tastes salty. That helps you realize that the spirit is eternal and the body is not; you're supposed to thirst for righteousness, and there is a secret ancient ritual you can do to fill your thirst without drinking water".

"Do you hear voices telling you these things?"

"My mouth speaks to me and tells me all these wonderful things".

The nurses are against giving her extra salt at mealtimes. She is improved from admission, when she wore an improvised hijab complete with veil fashioned from a towel, and covered her hands in old socks to avoid exposing her skin. Do we suppose she was tachycardic at vitals check because of a medication side effect? Or, perhaps, water deprivation? Hmmmm.

Yes, it's been a quiet week here on B6/5; where all the men are alcoholic, the women are psychotically depressed, and the children, clever ones, are on another unit. I have one week left, and it can't pass quickly enough. I drift from one steel white door to another, asking in a strangely depersonalized tone about the voices that continue, the suicidal ideations that are either decreased or increased or the same, all my questions asked to the accompaniment of wails.

Not screams, wails. Thin, high, reedy wails that may be factitious, since the origin was able to speak clearly when asked for the address of her parents in Mexico that she wanted to obtain a special dispensation for, but then lapsed instantly back into catatonic, rocking stupor.

Down the hall, our tune-up on JL didn't work for more than a week; discharged my second week after family meetings and adjustments in her intrasynaptic serotonin levels, she went home to her parents' house (she's 53) and curled up in a ball for a week, until she decided she had enough energy to consider walking in front of a semi again. She's back, and pounding her fist into her hand wondering why she's so f---ed up. To myself, I wonder the same thing. In good medical student fashion, I handle the situation by running off to the computer so I can look up the manifestions of serotonin syndrome. For your information, I find that it is a clinical diagnosis marked by flushing, autonomic instability with possible raging hypertension, hyperthermia, and hyperreflexia.

JL is super hyperreflexic on exam, and flushed, and agitated. And she feels warm. I'm stoked. The attending is not. He figures it's just situational anxiety. And another attempt at 'making a difference' is shot. Just like they shot down my idea to screen for PSC in T, who has an isolated high GGT without a drinking history and a family history of ulcerative colitis, which is linked to PSC. Never mind none of his other liver enzymes are elevated.

That's all right, I've had my triumphs. The ear drops I perscribed for MH's ear wax were a hit, resolving her ceruminous trauma within hours. See, I think. It is possible to make a difference.

That's the main problem. JL's failed tune-up is proof that change is not often to be found on the unit. The best we can often hope for is a tweak of the meds, a passing of the acute hurricane of psychosis or suicidal ideation, and a discharge into an uncertain world which is no kinder than when last we saw it.

See how I say 'we'. I'm stuck in here, in the bin, with them. I identified symptoms of hyperarousal a few nights ago. I am paralytically anhedonic when faced with the prospect of dictating even more scintillating discharge summaries. Family meetings make me hypersomnolent. Dear Lord, save me from any more countertransferance, transferance, empathy, identification--anything that points out to me more clearly the thin thread of sanity that, for some unknown reason, has held firm for the first 32 years of my life and kept me from the abyss of command hallucinations telling me to throw bananas at passing horses on State Street in order to save Western Kazakhstan from nuclear annihilation. And, you know, I have a personal connection to the Lord. Mostly, because I put extra salt on my Pop Tarts.

'Night.

Other Med Student Blogs

Check out these other blogs from Medical Students. They're all, like, babies, and don't have kids or anything so the content, well, I can't vouch for it (ha ha). I shouldn't link-post, but these are cool.

Who's Really Gorked Out? Part 2

The best part of psychiatry is the meds. They do some cool stuff. According to our patients, they make your life better, fix your mood, take away your pain.

'I've been feeling this way all my life, I just want you to fix me'.

'That's what meds do, they glue you back together'.

'Why won't you give me my pills that take the voices away?'

On the other hand, according to this article in the NYT, psych drugs kill people. By making them fat.

So who to believe? The drug-pushing, soul-less ad folks at the drug companies, or the liberal hippies who want to treat colon cancer with Lemon Grass herbal tea?

Well, neither. I first read the article, which is about olanzapine (Zyprexa), a new anti-psychotic. My reaction was typical for a medical student, new as I am to my profession, in that I dismissed the worries. 'Oh', I thought to myself, 'of course, worry about the weight gain in the context of a crushing psychiatric illness'. But then I talked to my resident. His response was actually measured. Yes, in general, treatment is necessary, as it was in the case of this patient, who had severe bipolar illness with psychotic features, or perhaps a misdiagnosed thought disorder such as schizophrenia. But, he pointed out, olanzapine was probably a bad choice for long-term therapy, as it does lead to the weight gain mentioned. Which is why we don't use it at the UW.

So, in the end, the article has merit. A better choice would have been a different antipsychotic, leaving the Zyprexa for short-term use in people predisposed to side-effects like drug-induced Parkinsonian symptoms (like young, African-American patients who need help for a week or so). The key is to avoid over-reacting and shooting off one's mouth. Patients will come in with all sorts of concerns about medications. We can't listen only to the drug companies OR the 'I cured my liver cancer with aromatherapy' people. The best path is the middle one.

Chief Complaint

"I am suicidal and I would like to review my cholesterol."

We use the chief complaint to describe what a patient is coming in for; it should be in the patient's own words. The above was an actual CC in a chart for a family practice visit.

You have 15 minutes to work with the patient. Go!

I think family practice docs don't ever get enough credit. They have to deal with such a wide scope of problems that it's unbelievable. Perhaps even more amazing about the visit above is that the doc addressed both concerns. His assessment at the end of the note went something like, 'we agreed that she was not in imminent danger of harming herself; the patient was given hotline numbers if the situation worsened. Her most recent triglyceride value was 488; we discussed staying away from fatty and fried foods in addition to her normal medication regimen.'

Who's Really Gorked Out? Part 1

"Psychiatry consult service."
"We have a patient who sticks her tuckus in the air and her head in the pillow until her O2 sats drop into the 70's, and when she's not doing that she's abusing the nurses verbally, and when she's not doing that she's pretending to be asleep so you can't talk to her. What do we do? Does she have a personality disorder? How do we manage her?"
"OK, (sigh), we'll come take a look."

Anything else to know? (BTW, O2 sats are a common vital sign measured; normal is above 90%, and it is a measurement of the percent of binding sites for O2 in a person's blood that are filled. Below 60% is really bad news, but any drop below 90% is at least worth noting).

The patient is 38 and has been on dialysis for 20 years. TWENTY! Five or ten is pushing it. One failed transplant. Homeless often, polysubstance abuse. When she was admitted, there is a measured blood pressure of 277/119. We thought it might be a dictation anomaly, and that the real value was 217/119; either way, some serious hypertension. At that level, bad things happen.

Does she have a personality disorder? We investigate. We go in to talk to her, the two med students. As soon as I get to her room and see her chart, I have flashbacks to Medicine. The forty-plus medication list. The isolation gowns because she's had MRSA (resistant Staph, a bacteria that is harder to treat than normal), the monitors in her room that surround a tiny black woman curled up and snoring in her bed. For the next ten minutes we enter a cycle of waking her up, at which point she barks out a 'what?', we ask a question, and before we're done, she's snoring again. At one point she even gets out a 'well, go on and ask your question, doctor', with emphasis. She's been in and out of the hospital for twenty years and I wonder if she's purposefully emphasizing what we are not.

Back to the staff. Apparently she 'plays possum' and doesn't want to answer questions, but then sometimes wakes up and is abusive. Hence the personality disorder consult.

Except...what if she isn't playing possum? A personality disorder that would make you argumentative and abusive would fit in a cluster that includes antisocial, narcissistic, borderline, and histrionic. But you have to know the person for a long time, have seen this disturbance repeat and be durable. Personalities are the bedrock on which we constuct our glass houses, unchanging.

Is there anything else that could be leading to this behavior? Any other answer amidst the forest of IV poles, the disposable gowns, the surgeries, the failed organs, the unbelievable pressure in her vessels that traverse every tissue in her body, no matter how fragile?

We all agree she's gorked out, rather than playing possum. Even if you threaten (not that we would carry it out) to use some injection or antidote to her pain medication, she doesn't rouse. Still, is she just too seasoned to fall for our gambit?

Patients like this are the true test. They are difficult, they are unlikely to be 'fixed' or 'cured' and they may well be much more wily than, well, med students for sure. They often raise questions in me about the limitations of medicine and the patterns we can fall into, especially with these so-called 'professional' patients. Our attending was under the impression that she likely had some form of hypertensive encephalopathy--that is, the main problem was brain damage from her hypertensive episode, not a game of possum. But there's no way to know. So we tinkered with her meds, suggested a few changes--discontinue the Cymbalta, which can contribute to hypertension, consider reducing her narcotics (a fentanyl patch as well as Dilaudid, if I remember right); then, wait, and see.

A Hairball of Souls

The voices in her head are like 'a hairball of souls', she said as the intertwined her fingers and rolled her hands around, creating a picture of some tumultuous, chaotic interface between herself and realities both real and dreamed.

Her psychosis is distinct from the manic patient; it doesn't fit, doesn't match. Blauer, in first describing schizophreia, described psychosis as a loss of self. She speaks of the voices and the experiences as though looking through soundproof glass at herself, at once acutely aware and immersed in the gumbo of her thoughts, but also different. "Mood incongruent", I write in the note.

Of course the word choice of 'soul' is significant. Satan and God and the bible play a strong role in her life; more than many of us who may say "I'm a spiritual person", she means it that Satan has recently chased her through the streets in the middle of a frigid night with a cohort of demons. Were they close to her? Was it just a sense of dread, or did she turn and look over her shoulder and see them coming on? The whole time, she recounts the story with the tone of an unimpressed, nonchalant twenty-something relaying a recent visit to Starbucks with her friends.

She wants to get on with her life, even says the second morning here that 'it's probably not a good idea to live according to the voices in your head', and the whole time she has an odd mix of psychosis and insight into her condition; the voices are at times external, at times her own voice acting out a part.

After a week and a half, dignity begins to appear for me in madness. The people on the ward are sick, but at the same time, just as an elderly veteran might suffer in dignified stoicism with advanced peripheral vascular disease or heart failure, these patients have their own sources of strength that they call on in the midst of the chaotic milieu of unusual inner dialogues (see, it's happening--I never would've used the word milieu on a Surgery rotation. Pretty soon I'll have to get sweater vests and jackets with elbow patches).

In Case of Emergency

L was brought to the ward on a Monday by his family speaking of patterns in the frenetic voice of madness, sleepless for three days. In the intake, he reached for the antenna of the boom box next to him and bent it into a triangle. He grabbed the paper off of the table, ripped it in two, handed it to me, and pronounced, 'now you understand, and I can go'.

Mania. Totally nuts to actually see. Forget Mr. Jones, if anyone remembers it, with Richard Gere displaying his mania by handsomely playing Beethoven on a store piano. L feels unhinged, from another planet. At one point he grabs the lanyard around my neck and says, "I could take this and you would be upset", bizarrely obvious and direct, as if normal conventions of personal space and society don't exist. He's tortured by 'patterns' he sees in the everyday. Triangles, numbers. Pyramid schemes and the DaVinci code.

5 of Haldol and 2 of loraz and he sleeps. He wants sleep. When he came in, he said the only thing he wanted was sleep.

He needed the same cocktail twice over the next two days, a former lead blocker in high school prowling around the ward, not aggressive, but invasively curious; he ripped the IV pole off his bed and bent it on the wall trying to find out what was behind it after he found a 'hollow spot' over by the window. When I came in to see him the next morning, his room is bare of everything except a mattress, bottles of water, Kleenex and socks strewn across the floor as he sleeps.

"Can I ask you something?"
"Sure."
"I heard a hissing in my room, could that be, like, gas or something that you're filling my room up with?"
"Um, no. We don't do that. It was probably your heater."
"Because what are these for", he asks, pointing to the emergency shutoff valves for the O2 and vacuum tubes to the rooms. And just like that he pulls the cover off, the 'remove in case of emergency' cover, before I can fully articulate that it would be a bad idea.

He's just curious. He didn't want to cause trouble. But I see in that episode a bit of the difference between me and mania. I would never pull an emergency cover off; I'm conditioned and inhibited by years of having teachers tell me not to pull fire alarms. But he doesn't care, doesn't think, is just acting on his impulses. Same reason he grabbed me by the lanyard. When he's in that state, though, my own brain notices at a deep level that is unsettling in a way I've never experienced before with patients. I find myself instinctively positioning myself between him and the door of his room so I'll never be pinned in a corner, avoiding taking sharp objects into the room, watching him carefully.

One manic episode and anyone can be diagnosed with BPAD, or bipolar affective disorder. Features include those L is exhibiting, such as 'pressured' speech, loss of association, where it is unclear how he is switching topics. Lack of need for sleep, inflated self-image, easy distractability, hedonism, or increased activity can all be features, as well as duration of 1 week or severe enough to require hospitalization. L's distractability is incredible. He'll get up and leave a discussion to 'take a nap', go to the door, and change his mind to watch the news on across the hall, then see the janitor, and instead ask whether that janitor is new and go talk to them.

I'm on the ward for a month. L came in my first day. Some fun. More to come.