Wednesday, April 13, 2005
Psychosis and me
It was the best of times, it was the worst of times.
It was a month on the psychiatry service at the busy county hospital.
It's been a whole boat-load of fun so far. Let me tell you about it.
During our psychiatry rotation, we do 2 weeks on an inpatient unit and 2 weeks in the psych ER. I started with the psychiatric ER because I thought it sounded more fun than the inpatient side. Also, there was a rumor that the inpatient unit usually gets out early every day, so I thought it would be cool to have the time to study for the shelf in the last 2 weeks. So far, it has worked out pretty well for me.
The first 2 weeks, as I noted above, was spent in the psychiatric ER. This time is spent triaging patients that either present to the ER or are brought in by the police. Those that come on their own are called "voluntary" (obviously), while those that come in by the police are in on warrant. A warrant can be of two types: magistrate's warrant or detention warrant. The difference is that a Magistrate's warrant is initiated by a family member, roomate, etc when they are concerned for their family member or friend and a detention warrant is served by a peace officer when he or she feels that a person is a danger to himself or to other people.
So a person comes in voluntarily or is brought in by the police and is evaluated by a physician (or student). It is then determined what the best course of treatment would be for said patient, whether it be admission, discharge, referral to counselling, or drug rehab. The unfortunate thing is, many patients are shelter-seeking or drug-seeking and are very medicine-savvy, so the challenge is to determine when a patient is truly a danger to himself or others or whether they are in-fact malingering. Fortunately, many of the return patients are known to the department as recidivists, so are appropriately turned away when they come to the psych ER looking for 3 hots and a cot.
It is very interesting talking to patients when they have not previously been worked up and trying to come up with a good differential and provisional diagnosis. The problem with psychiatry is that many times one cannot make a definitive diagnosis because it is very difficult to gather all the required information from the patient and all involved relevant family members. As a result, many patients are dispositioned with a provisional diagnosis, such as Depression not otherwise specified (NOS), psychosis NOS, or mood disorder NOS. The two most common diagnoses in the actual psych ER (not the clinic or walk-in part of the psych ER) in my experience are psychosis NOS or substance-induced psychotic disorder.
Overall, this was a very exciting two weeks for me - I had a lot of autonomy since the student is truly the major caretaker for all the patients, and the attendings and residents have more of the role of consultant and advisors. By the end of the 2 weeks, I felt fairly comfortable in the psych ER, although there were always times I worried for my life. There are many crazy people here.
The second 2 weeks of the rotation are spent in the inpatient unit here at the county hospital. It serves people admitted from the psych ER - mostly those that are indigent and have no insurance. If they have insurance, most of them go to other facilities. This is very unfortunate, because I feel that the experience I am having is somewhat skewed because of the patient population I am serving. These people are medically underserved and therefore often have chronic medical problems that are uncontrolled on top of their psychiatric problems (or possibly causing their psychiatric problem).
The typical day on the inpatient unit is arriving between 7 and 730am, seeing the new patients that were admitted overnight and also re-evaluating the patients we already were seeing the days before. Then, we have all the patients come into the group with us (staff physician, residents, medical students and a social worker) and discuss their progress from the day before. Sometimes, there is some therapy that occurs at this time, usually minimal, and then we move on to the next patient. The cycle repeats itself until all the patients are seen in a day. If the patient is aggravated or dangerous, we see them on the unit where there are other people around to help if a situation arises.
This part of the rotation has been pretty boring to me thus far. I am not much for sitting around and talking to people in a group (mostly listening to people, since the attending does most of the talking). I haven't really cared for this part so much.
A couple things I have noticed since starting this rotation: 1) My problems are VERY VERY insignificant compared to these people's. This makes me feel much better about myself. 2) I have noticed in both myself and my classmates that are on the rotation with me, more psychiatric problems. I don't know if this is because I am more attuned to these clues or if being around the crazies induces craziness in others. Something like a shared psychosis (folie a deux - a truly excellent X-Files episode if you haven't seen it). I've always wondered if insanity could be communicable.
I know it isn't - but it is still a interesting thing to think about.
For instance, I have noticed more hypo-manic or manic symptoms in myself since starting this rotation. As I said before, I'm not sure that this isn't because I'm more savvy and recognize the symptoms more readily or whether there is, in fact, an increase in the symptoms. I think I'm usually a pretty "up" guy, but I don't think I'm usually as "up" as I have been the past couple of weeks. Weird association...
What do you think? Anyone else have a similar experience? ¶ 8:48 AM
It was a month on the psychiatry service at the busy county hospital.
It's been a whole boat-load of fun so far. Let me tell you about it.
During our psychiatry rotation, we do 2 weeks on an inpatient unit and 2 weeks in the psych ER. I started with the psychiatric ER because I thought it sounded more fun than the inpatient side. Also, there was a rumor that the inpatient unit usually gets out early every day, so I thought it would be cool to have the time to study for the shelf in the last 2 weeks. So far, it has worked out pretty well for me.
The first 2 weeks, as I noted above, was spent in the psychiatric ER. This time is spent triaging patients that either present to the ER or are brought in by the police. Those that come on their own are called "voluntary" (obviously), while those that come in by the police are in on warrant. A warrant can be of two types: magistrate's warrant or detention warrant. The difference is that a Magistrate's warrant is initiated by a family member, roomate, etc when they are concerned for their family member or friend and a detention warrant is served by a peace officer when he or she feels that a person is a danger to himself or to other people.
So a person comes in voluntarily or is brought in by the police and is evaluated by a physician (or student). It is then determined what the best course of treatment would be for said patient, whether it be admission, discharge, referral to counselling, or drug rehab. The unfortunate thing is, many patients are shelter-seeking or drug-seeking and are very medicine-savvy, so the challenge is to determine when a patient is truly a danger to himself or others or whether they are in-fact malingering. Fortunately, many of the return patients are known to the department as recidivists, so are appropriately turned away when they come to the psych ER looking for 3 hots and a cot.
It is very interesting talking to patients when they have not previously been worked up and trying to come up with a good differential and provisional diagnosis. The problem with psychiatry is that many times one cannot make a definitive diagnosis because it is very difficult to gather all the required information from the patient and all involved relevant family members. As a result, many patients are dispositioned with a provisional diagnosis, such as Depression not otherwise specified (NOS), psychosis NOS, or mood disorder NOS. The two most common diagnoses in the actual psych ER (not the clinic or walk-in part of the psych ER) in my experience are psychosis NOS or substance-induced psychotic disorder.
Overall, this was a very exciting two weeks for me - I had a lot of autonomy since the student is truly the major caretaker for all the patients, and the attendings and residents have more of the role of consultant and advisors. By the end of the 2 weeks, I felt fairly comfortable in the psych ER, although there were always times I worried for my life. There are many crazy people here.
The second 2 weeks of the rotation are spent in the inpatient unit here at the county hospital. It serves people admitted from the psych ER - mostly those that are indigent and have no insurance. If they have insurance, most of them go to other facilities. This is very unfortunate, because I feel that the experience I am having is somewhat skewed because of the patient population I am serving. These people are medically underserved and therefore often have chronic medical problems that are uncontrolled on top of their psychiatric problems (or possibly causing their psychiatric problem).
The typical day on the inpatient unit is arriving between 7 and 730am, seeing the new patients that were admitted overnight and also re-evaluating the patients we already were seeing the days before. Then, we have all the patients come into the group with us (staff physician, residents, medical students and a social worker) and discuss their progress from the day before. Sometimes, there is some therapy that occurs at this time, usually minimal, and then we move on to the next patient. The cycle repeats itself until all the patients are seen in a day. If the patient is aggravated or dangerous, we see them on the unit where there are other people around to help if a situation arises.
This part of the rotation has been pretty boring to me thus far. I am not much for sitting around and talking to people in a group (mostly listening to people, since the attending does most of the talking). I haven't really cared for this part so much.
A couple things I have noticed since starting this rotation: 1) My problems are VERY VERY insignificant compared to these people's. This makes me feel much better about myself. 2) I have noticed in both myself and my classmates that are on the rotation with me, more psychiatric problems. I don't know if this is because I am more attuned to these clues or if being around the crazies induces craziness in others. Something like a shared psychosis (folie a deux - a truly excellent X-Files episode if you haven't seen it). I've always wondered if insanity could be communicable.
I know it isn't - but it is still a interesting thing to think about.
For instance, I have noticed more hypo-manic or manic symptoms in myself since starting this rotation. As I said before, I'm not sure that this isn't because I'm more savvy and recognize the symptoms more readily or whether there is, in fact, an increase in the symptoms. I think I'm usually a pretty "up" guy, but I don't think I'm usually as "up" as I have been the past couple of weeks. Weird association...
What do you think? Anyone else have a similar experience? ¶ 8:48 AM
