Adolescent Medicine Block 9: Addiction Clinic

January 21, 2012

My first morning of adolescent medicine began in one of the worst parts of town.  A long brick wall was broken by a video camera bizarrely angled toward the nondescript metal door.  Admittance was only achieved after a long hard pull, followed by an appropriate creek of welcome.  I had arrived at the specialized clinic for young opiate addicts.

Here I would spend about a third of my time observing adolescents participating in a Suboxone treatment program. Truth be told, I have a special interest in drug addicts.  This population so desperately needs coordinated psychological and medical help, and generally addicts are treated terribly by the health care system.   They are not only underserved, but seemingly under-cared for.

I learned from my preceptor that adolescents have an especially difficult time seeking medical help because most adult rehab programs don’t feel comfortable taking care of young people.  Unfortunately, most pediatricians aren’t comfortable with addicts either.  This leaves extremely limited resources for a large at risk population.

My preceptor was extremely calm, and demonstrated how to take a full history about addiction.  This is something I was never taught in my medical interviewing classes.  When did it start? How much were you using? How did you split the dose?  How many bags? Did you ever sell sex for drugs?  Ever share needles? Ever drive while you were high? Did you smoke it, snort it, shoot it? Which veins did you use?  Any skin infections? When was your last use?

“Observing,” as I quickly learned, also meant watching the women give their urine samples.  After performing rectal exams, vaginal exams and other procedures, I thought watching somebody urinate would be no big deal.  However, I felt awkward when I got in the stall for the first time.  How close was I supposed to be?  Did I need to visualize the urethral area?  Look or turn away?  Suddenly I felt a great appreciation for nurses, who usually are involved intimately with bodily functions.  I later asked my preceptor, who explained it was more important to “look and feel for the appropriate color and temperature” than visualize the details.

One patient* came in quite obviously “high.” As I watched her urinate, she laughed insidiously.  “Oh boy, you must be so excited to watch me!” I kept silent and tried to seem “professional.”.  Her urine came back the following week positive for several different drugs, and she never showed up for her next appointment.

A new patient* showed me remnants of a huge abscess, which had destroyed her last good access point.  She told me “I’m here because I can’t get my veins to pop anymore.”  With shriveled surface veins, she felt forced into treatment.

The experience was poignant-not simply invading someone’s privacy for greater good- but learning more about the people behind these addictions. These were hard-working, friendly young people with career aspirations.  Most of them had started going down the path of addiction because doctors or dentists had prescribed Percocet or Vicadin for “legitimate” reasons (broken bones, wisdom teeth, surgery, etc.).   How many times had I helped prepare these prescriptions?  Perhaps too many times.

*Please note all patient identifying information has been intentionally changed or omitted.  While the details are modified, my overall experience remains true.

5 Comments | 4th Year, Psychiatry & Neurology | Permalink
Posted by Liz

Pedi Neuro Block 3: NICU

July 22, 2011

Many of the overnight patients I visit daily during my pediatric neurology rotation are in the NICU (Neonatal Intensive Care Unit).  I begin most mornings with the secret NICU entry code, rolling up my white sleeves and scrubbing my hands.  Then I perform my neurological exam – the mini version for the tiniest patients in the hospital.

Adapting physical exam maneuvers for infants was an acquired skill.  Even though I’m comfortable with examining newborns now, I was hesitant on this rotation.  The first time I tried to elicit a reflex, I barely touched the dime-sized knee cap with my hammer.  I was assigned to babies who weren’t simply newborn babies – they were premature, and they were sick.

As I saw their tiny bodies connected to feeding tubes, IVs and small breathing masks, I thought of the NICU nurses I know (Melissa and Aunt Sharon).  They must be some of the most talented nurses I know to find those piddling veins and perform miniscule procedures.

And NICU nurses are tough because their lives are full of sad stories.  Babies withdraw from drug-intoxication.  Babies stop breathing.  Babies live inside plastic bubbles.  Babies have genetic or metabolic syndromes that have challenging, predictable outcomes.  Or worse, they have mysterious symptoms that doctors can’t place.

My patients* were particularly sad because their parents had done everything right to have a healthy baby.  Parents held one another, grieving the loss of college graduation, football games and all that could have been.  The stress and sadness were apparent.  Later my attending exclaimed the divorce rate of parents with NICU babies is over 90%.  This was staggering, and I couldn’t find data to back it up, although according to one paper I found (“Effects of Child Health on Parents’ Relationship Status” by Reichman et. al. in Demography, August 2004), parents are 10% less likely to be living together after 18 months.

One of my patients was a baby born early who weighed less than 4 pounds.  She suffered an unexpected injury during birth, which had deprived her of oxygen and caused irreversible brain damage. I was in the room when the neurologists explained the devastating news – she had visible brain damage on her MRI.  She would certainly not develop normally, but it was impossible to predict how.

Another baby I saw was missing a part of her brain.  Her parents had discovered this during an ultrasound, and then the baby had a  prenatal brain MRI.  Her parents had to make the difficult decision whether to end the pregnancy.  They chose not to, and now mom told me the most difficult part was “not knowing what to expect.”

Yet a third baby was a twin who had meningitis, a brain infection that affected his brain stem and stopped his breathing.  When I first met him, his arms, legs and face were twitching.  He was having spasms and seizures, and could barely cry.

The pediatric neurologists have a difficult job.  I watched them explain to parents that talking or walking might be unreachable milestones.  Eating and smiling would be huge accomplishments.  And the worst part would be raising a child without expectations.

I came home and proceeded to think about a question that only a medical student would ask herself.  What if I had a sick baby like this?  Would I want to put a feeding tube in her stomach?  Would I want the doctors to save her life?  I feel like the possibility is real, and the endurance of these babies and their parents is an inspirational feat.

*Please note all patient identifying information has been intentionally changed or omitted.  The details are modified, but the overall experience remains true.

7 Comments | 4th Year, OBGYN & Pediatrics, Psychiatry & Neurology | Permalink
Posted by Liz

Pedi Neuro Block 3: Memories

July 11, 2011

Wounding and healing are not opposites. They’re part of the same thing. It is our wounds that enable us to be compassionate with the wounds of others. It is our limitations that make us kind to the limitations of other people. It is our loneliness that helps us to to find other people or to even know they’re alone with an illness. I think I have served people perfectly with parts of myself I used to be ashamed of. 
-Rachel Naomi Remen

This week I started Pediatric Neurology.  This rotation called for an expedition into my desk drawers for my ophthalmoscope, otoscope and tuning fork.  I’ve rarely touched these tools, or performed the full-blown neurological exam since 2nd-year physical diagnosis class.  Little did I realize, this rotation also called for an expedition into my past.

I felt excited.  My husband is a neuroscience Ph.D. student, and I had epilepsy when I was 9-16 years-old.  Therefore, Neurology  - especially Pediatric Neurology – is something near and dear to my heart.  At several points, I thought about becoming a Pediatric Neurologist.

This rotation has a much different pace from my Block 2 sub-internship.  First of all, I have fairly regular work hours 8:30am to 4-5pm. Additionally there are no on-call or weekend shifts.

The Pediatric Neurology team is made up of an attending, a “fellow” in post-residency training, and 3 other medical students like myself.  We are not overwhelmed with patients during the day.  This means there is plenty of time for individual patients and for teaching.

I saw several kids being evaluated for seizures, and these patient encounters were both fulfilling and difficult for me.  I was surprised by resurfacing of my own memories, many of which I had forgotten.  And many of which made me feel surprisingly ashamed.

Perhaps my feelings are best characterized by the first day of the rotation.  The fellow said, “You are going love this rotation… you will see so many cool seizures…”  As soon as I heard the words “cool seizures,” my heart pounded.  Seizures are not cool.  

Yet, I too refer to unusual medical findings as “cool.”  When doctors say “cool,” it means “interesting,” something that makes us think and learn.  ”Cool” is not meant to be a positive remark about disease or the patient experience.  I knew that, but it was hard to hear.

At first I wondered if I had made a mistake choosing Pediatric Neurology.  This rotation felt a little “TOO close to home.”  For example, as I watched a child get an EEG, I was taken back to my own experiences and frustrations.

I remembered sleepless nights, lying motionless in a dark room while watchful eyes waited for me to sleep, and hours later pulling the hard rubbery knots of adhesive out off my head (along with the hair). I remember the disappointment when the EEG was “normal,” like it had all been for nothing.  And both the fear and excitement when one of my seizures was finally caught on EEG!  A painful triumph.

Now, EEGs are much more advanced.  The kids get wired-up and march out the office door with a gauze-turban and small backpack.  The in-patient EEG’s are computerized with constant video monitoring that can be replayed in sync with brain waves.

When I previously thought of Pediatric Neurology, I mainly remembered my deep admiration for the Pediatric Neurologist who eventually helped me find a medication to control my seizures, and my pride of overcoming the disease.  My doctor was a calm physician and compassionate listener who navigated through choices with me.  He led my family and I down the path to control seizures while avoiding undesirable side-effects.

This task is much easier with medications available today.  Just fifteen years later, I learn the medications I was given to control my seizures are now considered sub-optimal treatment for my seizure type.  This demonstrates how quickly medicine is changing!  I selfishly found myself frustrated that the newer medications weren’t available when I needed them.

My teachers on this rotation still reinforce my positive image of Pediatric Neurology – they are calm, caring role models.   Yet, I find myself in an awkward position, as both former patient and “doctor.”  I thought I was in a better place to deal with my past.  My anger and sadness surprise me.  I am challenged to suppress these emotions to focus on my responsibilities with patients.  I thought the personal experience would help me, but I didn’t anticipate it would simultaneously be more difficult.

1 Comment | 4th Year, Psychiatry & Neurology | Permalink
Posted by Liz

Psychiatry Week 4: Psychiatric Soup

February 5, 2011

My 4th week of this rotation was the most memorable.  Instead of my usual life on the hospital consult service, I participated in a variety of other services for the purpose of “exposure.”

The week began with three mornings of rounding on the inpatient psychiatric floor.  I saw patients who were hospitalized solely due to their psychiatric diseases.  There were many schizophrenics, including one memorable woman* who seemed perfectly normal at first, but questioning revealed many delusions, such as the CIA invading her thoughts through her kitchen oven.  Another man* with schizophrenia had been living in a public restroom for weeks before he was admitted.

Some people were not diagnosed with a specific disease.  For example, there was a former nurse* whose son had recently died in her arms of a heart attack.  A few days after the funeral, she was found wandering the streets with no shoes (in January), “looking for her son’s body.”  Her behavior at the hospital continued to be odd.  She became extremely angry when asked about her other children or her dog, and would speak in phrases from several languages she studied in the past.

One morning, as we were rounding, the nurses notified us that there was a “situation.”  A patient* who had been admitted the previous night was “revving up.”  She was pacing the halls, trying to break through the doors of the locked floor and yelling at the staff.  She was bipolar, having a manic episode.

She screamed her patient rights, “It is my right to be treated with respect.  It is my right to know what treatments are being given to me.  It is my right…”  Then she began to talk about how hot she felt, and removed her clothing, exposing her chest and putting her hands into her underwear.

She was angry, acting inappropriately and the nurses were worried she might harm herself of other patients.  The decision was made to give her medication, STAT.  The doctor told me to watch what would happen because I would never forget “mania.”  I followed the resident, a calm woman who made me feel safe.

Four large security guards were called, and she was escorted to the “quiet room.”  She began screaming non-stop, “Do NOT touch me!  I’m looking you in the EYE.  I see what you want.  You all are handsome…”  Initially she agreed to take oral medication, but suddenly she changed her mind and screamed, “Give me the NEEDLE… come on, stick it in me hard.”  She started crying, and rocked back and forth.

I felt sad, realizing the trauma of her life and difficulty of her disease.  Finally, the four security guards held her while she spit and tried to bite them, and the nurse gently injected the medication into her thigh.  Within 20 minutes she was calm, and later she agreed to begin oral medication.

Besides the inpatient psychiatric floor, I also spent one morning witnessing ECT, electroconvulsive therapy.  Contrary to it’s bad reputation, studies have shown it to be extremely effective in people with depression.  I was expecting to see long seizures, but the actual procedure was anticlimactic.  The patient was given muscle blockers and short-acting anesthesia.  The “seizures” lasted less than a minute with nothing visible at all.

Two afternoons I left the familiar walls of the hospital to venture downtown.  First, I went to a suboxone clinic run by an admirable psychiatrist, one of the few accepting Medicare.  Suboxone is a medication for opioid addicts.  Unlike methadone which is given daily, suboxone can be prescribed weekly or monthly.  I enjoyed meeting his patients* who all had stories of recovery intertwined with abusive relationships, legal trouble and mental illness.

Another afternoon, I went to the courthouse to see forensic psychiatry in action.  I went to the holding cells, rustic wire cages in the basement, to interview those who had been arrested.  Afterwards the doctor testified to the judge and court regarding the person’s mental health.  One person* cried as he rolled up his sleeves to show us his track marks.

From these two experiences, I learned a lot about drugs, especially heroin.  It’s cheaper than I thought it was.  It comes in “bags,” 3-4 of which are equal to 1 gram.  Anything more than 1 gram per day is a lot.  When somebody is using drugs, it’s extremely important to quantify what they are using.  I feel prepared to ask these questions now.

Finally I spent the last two days of the week in child psychiatry.  I learned about “PDD” (Pervasive Developmental Delays) the category that encompasses Autism, Aspberger’s and many other developmental disorders.  We consulted on challenging hospital cases involving children and their families who were struggling long-term with the effects of mental difficulties in childhood.

This is an area of psychiatry that is especially stigmatized, and many families feel guilt and frustration as they try to cope with their children.  The most important (which counters a huge societal stigma) is that parenting doesn’t cause or solve these disorders.  And these children need lots of support and medical help.

I am glad for a quick peak at diverse types of psychiatry, a fascinating field that will be with me during the rest of my life in medicine.  After all, the psychiatric soup encompasses all patients at one point or another.  I feel fortunate to have seen so much this week.

*As always, patient information has been carefully changed or omitted to protect privacy.

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Posted by Liz

Psychiatry Week 3: Patient “Prayers”

January 25, 2011

The first time I met Mr. Wilson*, his hands were trembling.  He was in alcohol withdrawal so badly that he couldn’t even stand up on his own.  He sadly recounted how he had travelled to get to the hospital, and when he finally arrived, he wasn’t even able to lift himself to the stretcher because his legs were quaking.

He was different from the other addicts I had met.  He was brilliant, successful and articulate.  He had travelled to my hospital, which was hours away from his home, in order to protect his anonymity.  Nobody knew he was my patient.

Mr. Wilson had been on television, and had a high-powered career that took him to several US cities.  He didn’t start drinking alcohol until his late 20′s.  Mainly because that’s when he began to accept himself as a gay man.

He had incredible insight, and he knew drinking was his own fault and choice.  He was ready for change, and he was taking full responsibility.  He told me about his relationship to family, the book he was writing, and his devout faith in Christ.

“As Christ said, ‘Love the sinner, hate the sin,’” my attending commented when Mr. Wilson told us how much he hated himself for what he had done.

That night, I did as I often do.  I prayed for him.  Not an overt “God, please give him x” kind of prayer, but I just visualized him at the hospital resting, and thought of him speaking during our interaction.  I held him in my mind without any specific desires except general wellness and contentedness.  When I don’t think I have much to offer patients, I know I can at least offer them my “prayers,” and  this comforts me.

Until now I haven’t acknowledged this to many people, especially not my patients.  But I’m sure every caring person must do something of the sort, whether they refer to it as “praying,” or not.  I take a few seconds to think of people during my evening (as a student, I have such a small load, I could take time for everyone) especially those who are sad and challenging.  I do this as I commute home, walk up the stairs or fall asleep at night.  Nobody knows.

I went back to see Mr. Wilson, and he told me how much better he had felt after we talked.  He told me I was the first “psychiatrist” he had ever opened up to.  I told him I was a “student doctor” who had been fortunate to meet him and listen to his story.

After seeing so many addicts who did not seem interested in change, Mr. Wilson was a rare gem.  He was in my care for only a short while, until his tremors subsided enough that he could walk, and his case manager found him a bed at the detox facility.

However, I won’t forget him.  Mr. Wilson was the first patient I ever told about my patient “prayers.”  It wasn’t difficult because he vocalized his prayers for himself.  So, I told him, “You know, I don’t usually tell patients this, but I prayed for you last night, and I’ll pray for you after you’re at the detox center.”

I won’t forget how he smiled warmly with both surprise and gratitude, and I smiled too.  He shared his secret alcoholism with me, and I got the inspiration to mention my secret “prayers.”

*As is typical, all identifying information has been changed or omitted.

3 Comments | 3rd Year, Psychiatry & Neurology | Permalink
Posted by Liz

Psychiatry Week 2: Addiction

January 13, 2011

As I entered his room, I could smell an odor of urine.  He was searching through the pockets of three bulky coats.  Out of one pocket he pulled a plastic bag of coins, and then a pair of eye-glasses.  He rejected these items, and then dove back into the pockets.

I introduced myself: name, rank (student doctor), team (psychiatry consult), reason (because you said you were trying to kill yourself).  Actually, he had told the nurses, “I should have drunk myself to death!”  I began my interview by addressing the reason he was in the hospital: his drinking.

Substance abuse and addiction is part of psychiatry because mental illness and substance abuse often go hand-in-hand.  Already during this rotation I’ve met many patients with addictions to alcohol, heroin and cocaine.  When I speak with patients about substances, I’ve learned to quantify their consumption, and determine whether they are abusing or dependent (alcoholics are the later).

This patient was clearly an alcoholic.  He was in the ICU for withdrawal symptoms, and his alcohol blood level had been more than 4 times the legal limit.  He had barely been conscious, and was struggling through his own vomit to breath when he was brought to the Emergency Room

I learned about his life.  All the while, he never stopped his endless pocket searching.  By the end of my interview, I determined that he did not seem suicidal.  He blamed his drinking on circumstances, accepting no responsibility.  He became more and more agitated, and finally he flung his coats on the bed and began to take off his pants.

“What are you doing?” I asked.

“I’m getting out of here, and as soon as I get out of here, I’m going to find my buddies and get me a drink!”

What could I do?  From a medical perspective, it seemed like we had nothing more to offer him.  The employees at my hospital had intubated him, hydrated him, carefully monitored his electrolytes, prevented aspiration pneumonia, and nursed him back to consciousness… maybe even saved his life.  And all he cared about was one thing: his next drink.

Like so many addicts, he did not want to change.  He wanted me to leave him alone so he could keep drinking.  I certainly did not have the authority to stop him, nor could I help him against his will.

Psychiatry is teaching me a lot about the limits of medicine, both legally and scientifically.  There are three things that give a doctor the authority to commit a patient to an institution against his/her will: if the patient is deemed likely to kill themselves, harm or kill another person, or if he/she is physically unable to take care of him/herself.  These are not well-defined categories.

In some states, relatives can obtain legal authority to force a family member into a rehab or detox program, but if the person is uncooperative, these programs are not a permanent fix.

So, what makes an addict decide to change?   Something internal, perhaps, but there is no good answer.  It’s an internal change caused by a mysterious phenomena.  Oh how I wish I knew.

I need to nurture faith that there is a force inside people, which inspires  healthier lifestyles.  This faith applies whether the patient is a long-term smoker, alcoholic, drug addict, or even an avid caffeine drinker or struggling with obesity.  There are many illnesses that require lifestyle change, something I will never be able to do for patients, and it seems easy to become cynical and give up on patients.

And, it IS tempting to give up!  When this man looked at me and told me he was leaving for another drink… I mean seriously?!

I thought of him searching through his many pockets.  He didn’t seem to know what he was looking for.  Sometimes I, too, feel like I don’t know exactly what I am looking for with these patients.  I’m on an endless search, but I have to believe there might be something in there.

We never know the one day that somebody might be ready to change.  Maybe there is a seed of inspiration, and I provide just a tiny bit of water or light.  Or maybe I do absolutely nothing at all.  But next time I might?

11 Comments | 3rd Year, Death & Diseases, Psychiatry & Neurology | Permalink
Posted by Liz

Psychiatry Week 1: Encephalopathy A Sad Story

January 8, 2011

Psychiatry, a new rotation.  By now, we all know what this means.  New names, new computer system, new location, new jargon and acronyms and new ways of doing things.  It doesn’t seem as difficult or overwhelming this time… oh wait, maybe that’s because my new schedule allows me to sleep 6-8 hours every night!  This is one reason why I love psychiatry already.

I’m on the psychiatry consult team, although I will be exposed to inpatient psychiatry for part of the rotation.  This means that most of my patients are admitted to the hospital with non-psychiatric health problems, but they happen to have psychiatric symptoms or a common condition like depression; their doctors want to tinker with their psychiatric medications, or maybe the doctors need to know whether the patient is deemed “competent,” able to make his/her own decisions or receive a donated organ.

I had a few preconceived notions, but nothing prepared me for my first patient.  Her story was sad.  Middle-aged woman who suddenly had “AMS” (altered mental status) a few months ago.  She had been to several hospitals in the area already, and the outside hospital notes were 3-inches thick.  Multiple CT’s, MRI’s, lumbar punctures, EEG’s, lab tests… all yielded nothing.

She wound up at our hospital to be admitted to the inpatient psychiatry floor, but now was on the medicine floor for severe anemia and AKI (acute kidney injury, although her chart still listed the older term”ARF” acute renal failure).  Nobody knew why.  Her diagnosis was “encephalitis with presumed medical cause of unknown etiology” (brain disease from a medical cause with no further explanation… huh?).

She was sitting, and made appropriate eye-contact as I introduced myself.  However, it soon became apparent that something was different.  She rambled on and on.  I asked a question, and she gave me a long fast-paced answer that was vague, confusing and did not answer my question.  She kept talking fast, and it was difficult for me to stop her or direct the interview.   She was paranoid about having signed a form, and being in the hospital involuntarily.

I tried to do the “MMSE” (mini-mental status exam, a brief tool to objectively score somebody’s cognition) and I could not get through it.  She kept telling me about the forms she had signed.  The interview was going all over the place, and I started feeling nervous.  Could I get the information I needed for my first note?

I had trouble ending my visit.  She kept talking, even when I said I had to go, and finally I felt horrible, but I left while she was still talking.  I looked at my watch… what I had intended to be 15 or 25 minutes had just turned into over an hour, and I was almost LATE to my meeting with the resident!

I rushed down the hall wondering what had just happened to me.  Did this patient have a psychiatric illness?  What on earth could be going on?  More importantly, was I going to do terribly on this rotation because I didn’t know how to handle a psychiatric interview.

You can imagine my relief when I returned in the afternoon with my attending physician to see the patient.  We spent 90 minutes in the room, and he seemed to experience the same difficulty that I did.

Every morning this week when I “rounded” on her, I heard her medical team as they tried to leave the room.  She was worried about this or that, and nobody could stop or comfort her.  They looked relieved to see me, “Look, another doctor is here to see you” …bye!

I am not a doctor, but I looked forward to these visits.  I met her husband (who had known her since first grade) and daughter.  They were devastated by the situation, and wanted answers.  I didn’t have the answers.

There were other patients: a girl who overdosed, heart transplant patients who needed our approval as part of the process, an elderly Chinese man who was so demented he could not use the interpreter phone, and patients with depression, night terrors or anxiety.  However my patient with unexplained AMS (altered mental status) was the major focus on my first week on psychiatry.

I’ll never forget the conversation I had with her family.  Tears running down her daughter’s face as she told me how it took her mom 2-hours to make the bed (it used to take her 5 minutes).  How her mother was a different person.  Before, her mom rarely used to say “I love you,” but now she said it daily.  She wanted to know what would happen “if they never find anything wrong, and what if mom doesn’t get better?”

I was taught never to take anybody’s hope away.  But I felt her despair, and frustration that all the doctors kept running tests without talking about the future.  So, again I explained why I didn’t know, and why all the doctors hoped for improvement.

Eventually our team made a rough plan for her and helped with her discharge.  As we spoke with the patient and her family, I could see they felt overwhelmed.  Who wouldn’t?  A hundred different doctors, nurses, medical students waltzing in and out all day with different questions, recommendations, etc.

I offered to write a bulleted list of the things we had said, to help them remember.  I knew the nurse was supposed to go over everything with them, but it couldn’t hurt.  They all seemed relieved and grateful.  I’ve never seen a doctor take down notes for their patients, but it felt like the right thing to do.

The biggest lesson of the week happened by chance when our deepest conversation took place right before I had a mandatory class meeting.  I should have been rushing out to my first “career night” as her daughter began crying.  I didn’t rush away.  I stayed and listened.  I was late to the meeting, but it was the right choice.

I didn’t imagine that encephalopathy was psychiatry.  Or that my first week of psychiatry would weigh so heavily on my heart.

8 Comments | 3rd Year, Death & Diseases, Psychiatry & Neurology | Permalink
Posted by Liz

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