Super-ego steroids: debunking some myths about psychiatric illness

Psychiatry has always been one of those rotations that I had dreaded because of the heavy subject matter. At the same time, I have looked forward to going through this because I was hoping to finally be able to reduce some of my own prejudice and stigma around mental illness (we all have some of it, let's be honest). I had come into this rotation with certain ideas based on my own anecdotal encounters with family members who suffered from mental illness, as well as my own experience with caring for my mental health in this rigorous program. I would like to share with you some of the thoughts, feelings, and lessons that I have experienced over the last three weeks.

1. Psychosis is anxiety on steroids
Psychosis is effectively a loss of one's connection to external reality; it can manifest with features such as paranoia, hallucinations, etc. Contrary to what I had previously believed, psychosis is a response in some people to overwhelming anxiety. When emotions become too overwhelming for a person to handle sometimes their brain will create these psychoses as a way of alleviating that anxiety. We have all experienced anxiety and seeing psychosis as an extension of that for me has helped me better relate to these patients.

2. Psychosis is on a spectrum
Again from anecdotal experience with people I know, as well as input from the media, I had always thought that psychosis was like an "all or nothing principle" and that one day people "snap". One of the greatest revelations I have had in this rotation is that psychosis is on a spectrum and many people who are psychotic have good insight into their condition. I have had numerous patients tell me that despite taking their medication they are still hearing voices in their head that tell them to hurt themselves and others. They know these voices aren't real and are in their head. They try very hard to ignore them but sometimes it can be very difficult. They have calmly and eloquently explained this to me, stating that they think they need a higher dose of their medication which is supposed to stop these voices.

3. Personality is fluid
Prior to psychiatry, I had always confused temperment with personality. Temperment is more of an animalistic state of being, i.e. are you a calm person vs someone who is more volatile at baseline. Personality is a combination of a person's temperment, opinions, personal characteristics and emotional responses. Growing up as a somewhat anxious person I had always felt that there was no hope in changing something that was so ingrained in me. However, through various psychotherapies we can change our emotional responses and various facets of our personality. These changes are a slow and require a lot of work. But the way a small simple stream of water can erode a boulder, we all have the ability to change ourselves. Even looking back on the last three years I have noticed changes in my personality - I have become more positive, more patient, and more spontaneous based on the experiences I've had and my own personal commitment to self growth.

4. I have much admiration and respect for the patients I have met in the ER
I know that seems like an odd thing to say - that I admire patients coming to the ER for psychiatric care but I promise it will make sense so please hear me out. These people have often been through so many traumas and overcome so much in life, I can't even begin to imagine what they must have gone through. Many of them have such strength in the face of adversity. They come to the ER because they have insight into how they are feeling and have recognized that they have exceeded their capacity to cope on their own. I think we can all remember a time where we were overwhelmed and were maybe too afraid to ask for help. It takes tremendous strength to reach out to others for help, and even more to open up about pain and suffering to a stranger.

5. People with psychiatric issues are good people who need help
The majority of people I have met were contributing members of society, highly intelligent and caring people that grew up in environments where they were never able to learn proper coping mechanisms to deal with the difficult situations that they were living. I will never forget one man whom I met in the emergency room. He had presented for suicidal thoughts after many months of loss; first his job, then his family under tragic circumstances. When I came to see him, he was sitting and listening to another patient who was crying in a corner. At the start of our interview, I had asked what they were talking about and he said the following: " We are all kind of in the same boat here in the ER, but that doesn't mean we can't be there for each other. I had nothing else to do and if I could sit and listen to someone and have them truly feel heard why shouldn't I? Is that not what being human is all about?" My inner clinical instincts recognize that this is partially a coping mechanism on his part. That aside, throughout the interview this patient strongly valued being kind to your fellow man - something we can use more of in world of violence and unsightly comb-overs.

Over the past three weeks, I have seen more random acts of kindness in the psychiatry emergency than I have for months walking around the streets. I hope that reading this blog has helped you to have a greater appreciation for the people behind the labels of psychiatric illness.

Medical Miracles

As much as some people believe that doctors are god, we are not. We are fallible like any other human. We are not all knowing, not all seeing, nor all powerful beings. We rely on our extensive knowledge base (with the ability to look up what we don't know), our physical exam findings, lab and imaging results, and how well the patient responds to different treatments. We often objectively manage patients in situations of uncertainty by covering our bases. This translates into throwing multiple medications at our patients and hoping that one of them was the right one to treat the underlying disease. It's not an ideal way to practice medicine but sometimes it's the best we can do. However, I now know what it feels like to be in the position of my patients' families having personally been faced with this difficult situation.

I will never forget the moment in class on Dec 22 when I received a message from my family that within 24 hours a family member went from being in their usual state of health to being confused to being admitted to the ICU, unresponsive and intubated. Despite extensive blood work, cultures, imaging, and even a lumbar puncture doctors STILL had no idea what was going on and a discussion about DNR (do not resuscitate) had been initiated . What could have possibly happened? How is that no one could figure out the etiology of such a severe and rapid deterioration in an otherwise healthy person? Sometimes our tests fail us. Sometimes everything comes back normal and it can be difficult to reconcile these normal test results with the seemingly dying patient in front of you.

I was shortly thereafter excused for the holidays and it is my philosophy that one must keep on living. Subsequently, I tried to disconnect for some much needed rest and family time. On Christmas Eve, as a gesture of good will, I decided to accompany the in-laws to Christmas Mass. Having grown up in a secular Jewish household, I had never been to mass and was curious. As we sat in the pews, nestled between strangers, I receive a message that my loved one was no longer intubated, but still unresponsive. Dammit, what if this is permanent. Despite being present for the service, I found myself distracted by the children fidgeting and crying nearby, and even more distracted by the thoughts in my head. "We will now take a moment of silence for prayer to heal those who are ill" said the priest. The room fell silent, the only sound the occasional creaking of pews as everyone bowed their heads in prayer. Praying was never something I did regularly but when in Rome; what did I have to lose? I closed my eyes, and like a nervous teenager about to ask someone to prom, said: "Um so I'm not sure if anyone is listening but uh well there is someone I would like you to help...obviously you know who. But...yeah, I would really appreciate it and it would mean a lot to my family. Thanks for listening." It was far from eloquent but I felt comforted nonetheless that there was a chance that I had been heard.

The rest of my evening was uneventful. I awoke Christmas morning to open presents and enjoy the festivities. After breakfast I checked my phone and I had received another message that my loved one was sitting up eating breakfast, completely back to normal. No one knows what exactly was the cause, nor what was the cure. With that comes the unsettling worry of could this happen again, but for now all is well. Whether it was due to divine intervention or stellar medical management or some combination of both, I think we have had a true Christmas miracle.

My First Delivery

"PUSH!" I hear from outside the room.

I run over to the board only to see it's my patient and she's at 10cm.

I open the door to the room to find my patient already pushing, all the tools needed meticulously splayed out on the green blanketed table.

"We have a gown for you, here. It's your turn."

I gown up quickly, put on my white sterile gloves,  and gently make my way over to the patient.

She has her feet in the stirrups, legs fallen to the side and a bright light shining on the exposed area. No baby yet.

She begins to scrunch her face and I see the numbers on the nearby monitor rising. A contraction.

"PUUUUUUUUUSHH!" Yells the nurse. We all count "1, 2, 3, 4"... all the way to ten, repeat it another two times and as the contraction eases of the patient has a chance to relax. Her husband clutches her hand excitedly as the moment of getting to meet their first child draws ever closer.

Another contraction. As she pushes again I can see some tiny tufts of hair for a brief moment and then they are gone. With every contraction that goes by, I see a little more hair and a little more of the baby's head, until finally  the head no longer disappears back into the vaginal canal and stays permanently visible in between contractions. I hold one hand against my patient to help support her delicate tissues and the fingers on the other hand along the baby's head. For every contraction, with the guidance of my staff, I applied gentle pressure to help control the speed at which the baby was coming out. With one big push the whole head is out. I quickly feel around the neck for a loop of umbilical cord. Thankfully there is none. As she pushes again the baby rotates sideways as they always do and with one final push the baby comes rushing out into my hands. With the support of my staff we ease this new baby onto my  patient who is now a first time mom.

"Congratulations! It's a girl"

She begins to cry and her husband eagerly cuts the umbilical cord after we have clamped it. The baby finally begins to cry forcefully and goes from a shade of worrisome blue to rosy pink; a new little human starting it's first day in our great big world.

Finding life in death

"We are ready to turn off the machines, we know he won't come back, we don't want to prolong this anymore"

Every inch of me wanted to run. Run far away from that room. And yet, as if possessed by another being I calmly asked "Do you want me to stay or would you like this in privacy"

"Stay" they all said simultaneously.

The nurse came in and turned off all the monitors, all the IV drips, everything but the respirator. The family stood at the bedside each member holding a one hand of their dying relative and holding each other's hands forming a complete circle. They stood this way for several minutes, but it might as well have been an hour. Time froze. I looked out the window at the nursing station - the monitor was flat lined. The respiratory therapist came in to turn off the ventilator that kept his chest rising and falling.

I had spent all morning helping to order labs, check vitals, adjust the respiration rate, every little thing I could do to give this person a fighting chance. I couldn't understand how yesterday they'd been completely well, and now today leaving this world.

As soon as the button was pushed, the staff left and the room fell silent. No one moved, we all stared. The chest was still. He was gone. All eyes slowly turned towards me.

"Is he gone?"

"Yes," I replied softly. "He's gone"

The family erupted in tears. The nurse came in with tissues for everyone and she started crying. I held hands, shuffled tissues around, listened to stories and thoughts and feelings. I turned to offer one woman a tissue and she replied: "Oh no I'm trying to stop crying," she smiled through sobs.

I took back the boxes and flipped them upside down so the tissue was no longer accessible.

"Ok, there!" I said smiling.

Everyone laughed. A true genuine lighthearted laugh. Exactly the kind of light humor we all needed in that moment. I then felt a tap on my shoulder.

"Tissue?" a family member handed me a box. I didn't even know I was crying.

I'd never seen someone die before. I always expected death to be dramatic, creepy, eerie. And yet everything felt so natural and calm. As the family slowly trickled out I was alone with the body. I took his hand. I was stunned by the fact that it was still warm, in contrast to my cold shaky hands. I squeezed it tight and whispered "Do know you were very loved? I never met you but I had the privilege of saying goodbye. I hope you are happy wherever you are now."

After everyone left I snuck into a transport elevator and cried for 10 minutes, wiped my eyes, and went back to my clerical work with my face red and eyes puffy. Everyone knew I had been crying, I could feel the stares and tried to ignore them. After bidding the evening staff goodbye I headed home. As I meandered towards my front steps lost in thought I stumbled over a notch in the sidewalk. I look down and see a mighty stalk with flowers growing out of it. With all the crazy weather we'd been having and the Autumn frost, these purple flowers bloomed from a crack in the sidewalk. A new life in the midst of death. 

Room 31

*Please note that the age, diagnoses, genders, and all possible identifiers have been altered for patient protection. Any resemblance to real life is purely coincidental*

Sweat is dripping down my forehead as I dash through the ER, chart in hand. I have no idea who this person is, I was just told to grab the chart for room 31 on my list. A last name and a number. That's it. The last patient we have to see during rounds this morning. The one thing between me and breakfast.  I can hear the many pages flapping as I run, barely masking the sound of my belly growling for food. I've got the vitals, I've got the labs, I hope I left enough space for the physical exam section. This should be quick - in and out, admit to the floor. I gently slide open the door and sneak into the room.

My staff is sitting by the bed. Why isn't he examining the patient? I glance down at my list and it says "51 year-old male; perforated appendix". Well I've seen plenty of those.

"We will do everything we can to make him comfortable. I just watched someone I love go through this and if I were them I would have done the same thing. Surgery just isn't worth it", my staff says gently.

What does he mean it isn't worth it? This guy is young. Surgery is what you do for young people with appendicitis, especially perforated appendicitis.

"I just don't think in your condition surgery is right for you. You want to enjoy a certain quality of life and keep your dignity. I think surgery would take that away from you."

What the hell is he talking about?? I discretely open the chart and start flipping through pages. "Metastatic brain cancer". Oh my god. No no no no. I've just walked in on THAT talk. I've never seen one of these talks before. No no no this was supposed to be a simple appendicitis case. Get consent for surgery, fix the problem, send them on their way. Breathe. Just breathe. I try to calm down and look back at what's going on.

"So how much time do I have now? Before I was told months. I  had plans," the patient says with tears welling up in his eyes.

"We can't predict these things...but I wouldn't say more than a few weeks. We'd like you to sign something that says we won't take any heroic measures if you stop breathing or your heart stops. We think it's best."

The surrounding family members start crying as he shakily signs the paper. I robotically dart out and come back with Kleenex. My staff continues to sit and tells the patient that it was very nice to meet him and we will make all the arrangements with palliative care. They shake hands and the staff gets up to leave. The resident, who I never even noticed enter the room, was standing behind me. He abruptly walks out. I quickly answer a few of the family's questions about when the patient will be brought upstairs etc etc and then go to meet up with the rest of my team.

I  approach my resident: "Um excuse me... so just to be clear I don't think I got the entire impression and plan-"

He sighs and shakes his head, grabbing the chart out of my hands. He quickly fills in the remaining information. "This patient is going to palliative care. Nothing left for us to do. You need to be quicker and catch what we say", he says snapping his fingers. He hands me back the chart and walks away. What the hell just happened.

The Life of an Internist

Having had a few weeks on the floor, I can only truly see now how much I have left to learn. Coming up with a complete list of possible diagnoses, examining patients, and writing up all the appropriate documentation takes me hours, whereas my staff seem to do it effortlessly. It will come with time they told me but it almost seems impossible at this stage to imagine myself working as effectively as they do. I'm trying to take it one day at a time but it's hard not to regularly feel a little bit incompetent.

So far internal is exactly as I've expected it to be and nothing like I've expected it to be. I've been blessed with amazing staff who really value team work, wellness, and maintaining a good rapport. The patients, like in any setting, a mixed bag. The type of work - namely daily physical exams, charting, calling specialists for consults is exactly what I expected. What I didn't expect is the complexity of the cases managed on our floor and so much exposure to dying patients.

On a regular basis we do sit around a table, and as a team brainstorm diagnoses and possible issues, and occasionally jot down teaching points on the white board (House style). It is wild how differently patients can present for a given disease compared to how we learned about them in our textbooks and lectures. The cases we sometimes have are particularly complicated because they've already been worked up by family doctors and specialists to no avail. Now they end up in our care, much further down the line in their disease process and it is up to us to continue investigating and help manage the many health and social issues patients may experience.

That was something I found equally surprising; the number of older patients that come in because of an incident (such as a fall or an acute pneumonia or even caregiver burnout) that has left them in a state of health where they can no longer return home to their primary residence. They are then stuck in a difficult position of being in the hospital (when there may no longer need medical management) awaiting placement in a rehab facility or group care home. It's a phenomenon I expect to become increasingly prevalent with the aging population. It's difficult to manage on a systems level because there simply aren't enough resources and beds out there for our patients. We can't send patients in this condition home because it isn't safe, but then we also have people stuck in the ER who need to be admitted for care but can't because there are no available beds. This also leads to congestion in the ER, increased wait times for a bed, and undue stress on both the healthcare workers and patients alike.

I was also stunned to see how complex the doctor-patient relationship can be and how it can evolve as the disease process evolves, and as the patient nears discharge. I had a patient who started off very cooperative and pleasant. We had a good trusting doctor-patient relationship, however, as we got ever closer to discharge, most likely out of fear, this patient began to be more belligerent, angry, and even started sharing with me racist sentiments about other colleagues. Soon I became one of the few people this patient would be compliant with and it was very difficult for me to balance continuing to nurture this relationship while standing up for my colleagues and team members as they were the subject of discriminatory discourse.

Lastly, I did not expect to have as many palliative patients on our floor as there are. I have seen about 3-4 deaths in the first few weeks. You come in one morning and you see their room being cleaned and you just know. What I find hard compared to previous hospital exposure is it's not just one short encounter with these patients. You are seeing them, deteriorating slowly every day, sometimes for weeks. I find it harder to not feel as emotionally connected, I mean I see these patients more often than my own family. Names in the obituary column of the newspaper that were once strangers are now names that I can put to a face, whose journey I know all too well. For the first time in a long time, I find myself lying awake at night thinking about some of the stressors of work and the difficult patient encounters I had that day. I think it will take a bit of time to adjust and be able to sleep more peacefully. But for now, thank goodness for friends and exercises - my two pillars of support. 

And So It Begins

Tomorrow. Tomorrow I am officially in 3rd year. I will have responsibility for patients. I know I will be supervised, but still, they will be MY patients. I'm both excited and terrified. The learning curve is going to be steep and although I know I am prepared for what lies ahead of me it's hard to feel like I am actually prepared. As of tomorrow, I will be working about 12 hours a day in hospital as part of a team. I can't remember the last time I truly felt like I was part of something greater that really made a difference in peoples' lives. I look forward to experiencing everything that this new life will have to offer, both the beautiful and painful moments.

To my friends and family reading this, you knew this time would come. No matter how busy I get, you still hold an incredibly important place in my life. I wouldn't be here without your love and support. I'm going to need that love and support more than ever. You know I've never been the most confident person but having you all in my life has helped me find muster up enough confidence to move forward. You have helped me regain my footing when I feel like I have slipped and am falling uncontrollably. I am so sorry that I will have to miss important life moments of yours. Parties, weddings, etc. I'm sorry I won't necessarily have the same amount of time to give to you as before. Please understand that I do not value any less our relationship and that if you really need me, I will find a way to be there and make time for you. It may be at some weird hours but I will find a way.

To my colleagues, now we are going to need each other more than ever. We will all be in the trenches together; fighting for our patients, fighting against the negative aspects of the culture in medicine, and growing into the professionals we all want to be someday. I look forward to getting to know so many of you in a greater capacity and learn from you. We are all in this together.

The house is almost clean, the laundry is almost done, all food for the week is almost ready. I stare at my freshly washed white coat, still pristine, white with inexperience. Never in my life have I more looked forward to wearing out a piece of clothing.