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.



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?"
"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.