TSH: Behavioral Unit

Today all five med students (Randy, Kyle, Sital, David, and I) were assigned to sit in on Dr. P's treatment team. (we also worked with her in Admissions our first Friday night here). Dr. P is in charge of the behavioral unit, where the very sick, very ill-behaved patients end up, so we knew we'd be seeing some interesting patients. The first patient we saw, JO, was the same guy David and I saw last Monday who was screaming in the ward. He was a lot calmer when Dr. P spoke to him (though he was a bit incoherent), but after he left we heard him yelling at people on and off for the rest of the morning. Another lady was only sleeping 2-3 hrs every night and could barely lift her head up when Dr. P tried to talk to her. We also saw EC, a patient David saw that same Friday we worked with Dr. P who had attacked another patient; EC said he still sees the devil's face on other people, but when he touches these people, the devil's face fades away. That's good for him, but not for the patients getting poked. One young bipolar guy was going to get released this later this week, and he said he plans to take his lithium faithfully and stay away from alcohol and other drugs "except during holidays." Dr. P shook her head and said if he even drinks one drop of alcohol while he's on lithium, he'll be spending his holidays at TSH. He was disappointed, and it's understandable; young people like to get drunk during the holidays. Another guy had his radio taken away when it made the voices in his head worse, and throughout treatment he kept asking for his radio back. Instead of telling him "no" directly (which probably would have set him off), Dr. P said he'll get the radio back once he moves to Level 5 (he's currently Level 6 and doesn't have as many privileges yet)

The more interesting cases were the women. Two women, the "meanest" of the group, got into a huge "street-fight" the other day; SW spat in CS's eye so CS slapped SW hard. We interviewed them both today to see what was going on. CS was calm, but her hair was unkempt and there was a wild look in her eyes that was a bit unnerving. SW, too, had wide eyes, and she had some major pressured speech as she talked freely about smoking cocaine and living on the streets. One patient Dr. P kept wanting the psych techs to bring in was JF, the same bipolar patient I saw exactly two weeks ago, but she kept refusing to come. She was originally sent to Ward 7, not Dr. P's ward, so I figured that her behavior must have gotten lots worse if she was sent here. On our way out, however, I did see JF across the room, and she saw me too and came over to me. I said, "Ms. F, how are you?" and she immediately burst into tears and threw her arms around me. I wasn't really sure what to do at this point and tried to push her off, and she cried, "You have no idea what they've done!" The techs said, "All right, Ms. F, let's go" and led her away as she began wailing about her husband. Unbelievable. Two weeks ago she was talking about how she knew Adolf Hitler and how she was a strong woman, and now she's hit rock bottom. It was very sad to see.

Tomorrow we'll see some ECT treatments starting at 7 a.m. When I heard that, I immediately drove back to TSH even though we had lecture in FW today. If I have to be in the hospital at 7, no way am I getting up at 5:30 just to drive from home to TSH. Anita said we've become too spoiled; back when we had OB, we had to be at JPS by 5:30 a.m. =P

TSH: No ECTs yet

This morning David and I were assigned to sit in on a treatment team led by Dr. Dee. We heard that Dr. Dee had been in retirement for a while until TSH made him an offer to work that he couldn't refuse ($$$), so now he sees a few patients a week for treatment. He's a little old guy who lets his social worker, nurse, and psychologist run the treatment team; David and I both agreed that the dynamic of this team was more bizarre than most (Dr. R runs her treatment team like a ship). One of the patients was a man that Sital had admitted during our first week here. Back then he was delusional and hearing voices, but now he's happier than we've ever seen him and is looking forward to drug rehab. Talk about a total turnaround! Too bad my patients haven't fared as well; Kyle told me that NF, my manic patient from the first Friday, went home on a weekend furlough but was brought back early b/c she got into a physical fight with her mother and then tried to run away again when she returned to TSH. *sigh*

In the afternoon we talked to Dr. C about ECTs and other topics. Kyle and Sital got to see an ECT this morning while David and I still haven't seen a single ECT. Hopefully we'll get to see one on Wednesday.

The False Accusation

This morning David and I spent another morning with Dr. MW, who told us a little about her background in medicine (and how Texas Tech HSC has almost no psychiatrists on faculty b/c the head of the department was difficult to work with) before we went to K2. There, David received a phone call from Dr. R. I wondered why Dr. R would be looking for David, but when he said, "What?!" we knew it had to be bad. Apparently one of the nurses staying in my dorm saw a male walking out of the ladies' room at 6:00 a.m. this morning and immediately assumed it was a med student (how wrong is that?). Her allegations were ridiculous because David did not have a key to the girls' dorm (I only let him into the dorms once on Wednesday night so he could watch the news since the male dorms don't have a TV), and even more obvious, there is no reason he would be awake 6:00 a.m if we don't start work until 8:00 a.m. Fortunately Dr. R knew David and Kyle well enough to know that they couldn't have been in the dorms early this morning, but she had to check to be sure. Even still, David was very pissed at the nurse who accused him, and Dr. MW advised him to let it go. "Many nurses have borderline personalities," she said, then told us a story of how one of her former nurses practically threw herself at one of the psych techs but later accused him of assault when he returned her advances. So she can make the first move, and not him? Ridiculous.

Other than that, we saw a few patients today who had not been seen when we had treatment team. There was one young guy in the living area who had his arm in a sling; he had a humeral fracture that only could have happened if someone pulled his arm roughly behind his back. The patient suspected of doing it has been sent to the behavioral ward, thank goodness. The last guy we saw was brought here b/c he was picked up by cops for being confrontational, but the only thing wrong with him was a history of alcoholism. That's no reason for him to be admitted to a state psychiatric hospital, so Dr. MW discharged him. Sheesh, talk about jumping the gun.

Texas State Fair!

Today, as promised, Dr. R took five med students (we were joined by a 4th year, Randy, who's working at the child/adolescent ward), several staff members, and about 18 patients to the State Fair. For most of us, this was our first time at the fair; it might as well be mine since I have no memory of going to the fair when I was little. Patients were given about $35 to spend while med students only received $15 ($10 buys twenty tickets and most food costs at least 8 tickets so do the math: we didn't get much). We were split into four separate groups; I went with Dr. R and three patients named John, Renee, and Patel. They were a good, well-behaved bunch except John got tired really easily (he's a big guy) and we had to sit down every so often so he could rest. Renee has bipolar disorder but is doing very well; she expects to be released soon. I don't know what Patel was at TSH for, but she's been at TSH for three months and is just like any other person. John is MR and used to talk only in "yes" or "no," but he sure was smiling a lot and talking more today, so that's good.

Dr. R wanted to ride the Ferris wheel but couldn't leave Renee behind (she's scared of heights), so while the rest of us waited, Patel and I went to ride the gondola (similar to the Conquistador at Six Flags) and then Patel went on a freefall ride alone while I watched (no way am I riding one of those things). The State Fair was known for its fried concoctions like fried ice cream, fried bananas, fried cheesecake, and this year's special, fried lattes. I had no idea how to fry a latte, but I did indulge in some fried cookie dough. It cost me 12 tickets and came in a cute little cardboard model of a 1957 Chevrolet Cruiser (probably why it was so pricey), but that stuff was goooooood. When Patel and I got back to keep Renee company, John and Dr. R went up in the Ferris wheel. After they got off, we went to see a show called Birds of the World. They had various exotic birds fly out and do tricks for us, and the birds were so pretty! Two hawks flew from the top of the Ferris wheel many feet away to land on the trainer's arm, all to demonstrate their speed and grace in the air. Another parrot sang, "Old Mc Donald Had a Farm." I was very excited to see a palm cockatoo, which I first saw an old kids' show back in the day. Dr. R commented later that the closest bird related to the T-rex is the chicken, and I said it was ironic how the T-rex used to eat everything, and now we're eating its descendents. Renee joked, "That's something only a medical student would think of."

After the bird show, we walked over to a Chevy car show, and saw a whole bunch of brand new car models. John liked the trucks and the Hummers; it was fun watching him sit in the driver's seat or else lean against the trucks. Some of those cars were huge, and they cost about $60,000 each. Yeah, can't afford that yet. One thing that excited everyone was the appearance of the Chevy Camaro Bumblebee from Transformers; that car will be available for purchase in late 2008, I think.

By the end of the day (we met up to leave at 3:00 pm) everyone was exhausted but happy. Most of the patients indulged in the food at the fair (Patel had a funnel cake, fruit cup, a Mexican specialty burrito, a hot dog, and a pizza) since it's been ages since they had anything other than hospital food. Others won prizes and bought new items; a pair of sunglasses made one lady very happy. This same lady, however, had jeans hanging so low that when she sat down her entire butt crack was showing; we had to stand around her to keep others from staring. One guy, BB, the same guy who asked Dr. R to "make him happy" two weeks ago, was a bit agitated; he was in Kyle's group and Kyle said BB seemed to be responding to internal stimuli (hearing voices) and at one point took a swing at Randy. Dr. R heard this and said she was assigning him to a lower level (at TSH, level 7 pretty much means isolation whereas level 4 means you can walk around the grounds of the hospital). BB was currently at level 4. Later, when we returned to the hospital, Dr. R told BB that she was making him a level 5, and in his anger he took a swing at another patient, dropping him down to level 6 and he had to receive emergency meds. "Two strikes..." said David.

This was our last day to see Dr. R; she's going to Norway for a 2-week vacation. Randy will be doing the orientation for the new group of TSH students in another week and a half. Wow...I can't believe my psych rotation is almost over!

K2 Treatment Team

Today David and I met with Dr. MW for her treatment team, in which patients would come in and tell her how they're doing and she, in turn, can ask them what she can do for them. Some of the patients were patients that David had admitted, so he was interested to see if there was any improvement. The first one, MG, had come to Admissions on suicidal ideations (and he was exaggerating his tremors so he'd get some benzos), but he's doing better now. Another guy, PS, was totally delusional last week, and he's just the same today. When he saw me, he asked if I was Asian and then started talking about the Red Army and "high tech samarais." It was very hard not to laugh during his rambles b/c he also believes he can communicate with extraterrestrials. As soon as he left, Dr. MW recommended doubling his current medication, LOL, since the current dose is obviously doing nothing to control his mania. It was sad because in most of these cases, the patients were clearly "damaged" with no chance of recovery. What can we do with them then?

On a good note...tomorrow we're taking the patients to the State Fair!

K2: Acute Male Unit

Today David and I were assigned to Dr. MW, mother of Dr. EW, except that she doesn't do anything on Tuesday but look at charts. So...David and I read chart after chart and familiarized ourselves with the patients on K2 (an all-male unit). Some of the cases were very sad. One guy became "damaged" after a failed attempted to hang himself; cerebral anoxia permanently damaged his brain and Dr. MW wondered if he would have been better off if no one had resuscitated him. Another patient (whom Kyle saw the night we were working with Dr. P) is a self-proclaimed lawyer who wrote a letter to Dr. MW stating his rights as a patient at TSH and saying that she's violating his rights by keeping him away from the phone (b/c last year he called the police asking them to arrest her). Actually, several of patients that David admitted made it to K2, so we'll get to see them tomorrow. One patient who is mildly MR (mentally retarded) even got a letter from his mother saying that b/c of his violent tendencies (he tried to strangle her) he is no longer welcome to live with her and will have to find some other place to live if/when he leaves TSH. Very, very sad.

We had lecture at JPS as usual. Marcus was gone, so we assumed he was post-call, but Katie, Mike E's fiancee, said Marcus was "looking at his baby." In other words...Marcus and his wife are at their first sono appt b/c they're expecting!! First Jedd, now Marcus. I can easily see Marcus catching his own baby when its born; just cutting the cord wouldn't be enough for him. Then it'll be eighteen deliveries for him unless he does another OB rotation before the baby is born.

Forensic Psychiatry

David and I were supposed to sit in on an ECT treatment today, but the doctor in charge of doing them had jury duty so we were redirected to shadow Dr. D, the forensic psychiatrist, instead. So what does a forensic psychiatrist do? He treats and evaluates the patients who have committed crimes under the influence of psychiatric disorders, and he reviews their history to decide whether or not they are competent to stand trial. At first we followed him on rounds, and at the behavioral ward, we heard one patient screaming non-stop (as one nurse pointed out, it sounded like an alarm. "AAH! AAH! AAH!"), and when Dr. D went to talk to him, we saw that two or three orderlies were holding the patient down in the recovery position. Needless to say he got some Ativan to calm him down. Later that morning we sat in the treatment room (which was very full b/c there were about 5 nursing students with us) and watched as he evaluated two patients. One, a young guy named MJ, didn't have a GED and couldn't answer questions about a judge, jury, defense attorney, or district attorney without quoting it verbatim from a cheat sheet he carried everywhere with him. When asked about his mood, he said, "Six." (thinking it was 6 out of 10 or something like that) The next patient, DP, was a twenty-seven year old woman known throughout the ward for being aggressive. So far she's spat on other patients, cussed nurses out, slammed doors, and thrown juice at the wall, just to name a few of her actions. The sad thing is, none of these symptoms happened until ten years ago, when a car accident left her in a coma for six weeks. The damage to her brain was so bad that her left pupil was blown; she can't see out of that eye at all. The worst part is that she'll probably never recover and have to be hospitalized for the rest of her life.

We were also supposed to be with the ECT doctor for lecture this afternoon, so after lunch Kyle and Sital joined David and me at Dr. D's office. There, Dr. D explained a little about what forensic psychiatry is all about and gave us some reports from a case he worked on in 1997. The patient in question had murdered his sister, and our job was to discuss amongst ourselves whether or not he could be found not guilty by reason of insanity. Insanity = not knowing that your actions were wrong. The patient definitely had characteristics of a paranoid schizophrenic, but there was no way he didn't know what what he did was wrong. He believed his sister wanted him dead, yet they spent time together shortly before she died. Does a person afraid for his life hang around the person he fears will kill him? On top of that, his sister was shot from behind, not from the front, which rules out killing by self-defense, and after her death, he turned himself in to a mental facility saying stuff like, "I didn't think I'd actually do it." GUILT, anyone? Months later he began saying stuff like how he mistook his sister for the devil with a goat's head, but again, if the "devil" was coming at him, he would have shot from the front, not from behind. At the end of our discussion, we told Dr. D that we felt like this man was not insane, and Dr. D agreed with us. The man in question has been convicted of murder and is serving a 25 year sentence.

TSH: The Borderline and the Quiet Guy

On Thursday I told Dr. R that I brought my violin with me to TSH and asked if she still wanted me to play for the patients. She said that was a great idea and called the social worker in charge of recreational classes to see if I could play for them. David and I asked what the recreational class was for, and she said it was to ensure that the patients could listen to music and sit still without masturbating. Hmm...interesting. At 1:00 pm I brought my violin to the wards, and one guy, Mr. G (I met him last week at treatment, he was bipolar) got all excited when he saw my violin. "Thatasaxaphone?" he asked (he's pretty incoherent) I said no, it's a violin. Everyone was spreading the word that the patients were in for a "real treat" b/c I was going to play my violin for them, and as a result about 10-20 patients showed up for class (more than usual).

I didn't know what to play for them, so I just started taking requests and playing what I could by ear. At one point Mr. G started covering his ears during "Colors of the Wind" and I thought I was playing too high, so I dropped down an octave for his sake. Some patients started requesting old songs that I didn't recognize or couldn't play, but I did the best I could. A few songs I played included Silent Night, Greensleeves, America the Beautiful, The Star Spangled Banner, Lean on Me, Colors of the Wind, Ave Maria, Turkey in the Straw, She'll Be Coming 'Round the Mountain, Unchained Melody, and Yesterday. Quite a selection, ne? Some of the patients sang along, and Mr. G even got up and danced around. It was so much fun!

Later that night I had two patients: a twenty year old, TR, who swallowed a bottle of Tylenol PM a few days ago in a suicide attempt b/c she has been hearing voices for a year telling her to be sexually active with women (which she does NOT want). When Dr. R interviewed her later, she picked up on the fact that TR had a borderline-personality disorder, so I asked a series of questions to see if she was a borderline personality. We needed 5 out of 9 to clinch the diagnosis, and she was 7/9. The next patient was a young guy, VH, who showed aggression toward his mother and nepheew but has been calm and denying everything ever since he was brought here. Needless to say I couldn't get much out of him and he was another psychotic NOS. That meant another long dictation and I couldn't go home until almost an hour after the others left.

TSH: The Bipolar and the Psychotic D/O NOS

Tuesday night: Once again, my patient was one of the sickest of the sick. JF was a 61-year-old author who has developed bipolar I severe mania. Even before I interviewed her she was pissing off other patients by telling them about her conspiracy theories regarding the president and other things, and when I interviewed her, she had many grandiose delusions like how God trusts only her and how she lived in the time of the Nazi occupation and knew that Adolf Hitler had spastic constipation. A nursing assistant sat with me for safety reasons, and we were both taken aback when my patient said I looked like an administrator while she (the NA) looked like a tramp. Dang. After the interview, my patient proceeded to annoy Sital's patient, who had MDD and cried an awful lot. I think she can cry at will just to get attention (which has worked). *sigh* Everyone was relieved when my patient was finally moved to the wards, because she was not making any friends in the waiting room.

Tonight: Today we had a chance to go over our dictations and see how bad (or good) they flowed. Mine was ok, but we all had a chance to correct (revise, refine, whatever) our dictations so that they sounded better. After that, I got the first patient, named AA. She was an interesting yet frustrating case because it was so hard to pinpoint a diagnosis on her. The hospital from where she transferred claimed that she had religious delusions and aggression and had to be sedated, but we saw a withdrawn, quiet woman with flat affect. Her memory was fine and she was very suspicious of some of the questions we were asking her (i.e. are you right handed or left handed? Is there a history of drug abuse in your family) and flat-out refused to answer. This made assessing her all the more difficult. She also kept staring out the window, but whether she saw visual hallucinations or not couldn't be seen. She did not seem overtly psychotic to me, but not quite depressed either. It didn't help that this was her first hospitalization and she had no collateral history from family that would tell us how long she'd had these symptoms. So the diagnosis for now: Psychotic disorder, not otherwise specified. Dictating this one was a real b***h since I had to justify why the patient was NOS, in other words, I had to give reasons why I couldn't rule out MDD, bipolar, or schizophrenia. That took forever.

TSH: The Cluster II Adolescent

Our scheduled "hell week" started out all right since Dr. M will be gone this week (at most we'll get him on Thursday), so we reported to the admissions center at 4:00 p.m. David and I didn't have a chance to grab dinner since the local Chuckwagon (the canteen) was closed, so my dinner consisted of two granola bars. We were supposed to get six admits today, but they didn't arrive b/c their judge didn't sign their OPCs (order of protective custody) that would send them to TSH. Instead, we only got one voluntary admission: an eighteen-year-old with "depression."

This guy told us that he's been feeling suicidal ever since his girlfriend of 1.5 months dumped him, saying that last night he was planning to OD on HTN pills but changed his mind at the last minute. He told us that he's been depressed ever since he was 11 or 12 and that his ex-girlfriend keeps playing "mind games" with him. He also said he'd gotten in trouble in the past and doesn't get along well with authority figures (doesn't like people telling him what to do), and despite being a high school dropout who hasn't gotten his GED, he loves to read and wants to be a doctor and help people "like him." He also had a tendency to rant about his ex and then forget the original question that we asked him. He said he was over her, but a few minutes later he'd say that he can't stop thinking about her. He was hoping that TSH would be able to do something for the negative thoughts in his mind b/c he knows something isn't right and wants to fix it before he does something he really regrets.

This went on for about 90 minutes but it was hard to pinpoint exactly what he had. He had a little bit of every Cluster II personality disorder: borderline (he has a history of falling in love with girls too quickly and they end up hurting him), narcissistic (he bragged about being an avid reader and writer of science fiction stories), histrionic (he wants full attention paid to him and his problems), and antisocial (he's been in trouble with the law and hates authority figures). On top of all that, he smokes MJ and cocaine and has tried almost every drug on the street. Heck, he claimed he "picked up some Vicodin" in Dallas just by saying his arm hurt. Maybe I'm naive when it comes to drugs, but how do you just "pick up" any drug? At any rate, the four of us talked to Dr. EW and we all agreed that he wasn't a good candidate to admit to TSH. He was not suicidal at the moment, and he could benefit from outpatient care.

When we told the kid that we were referring him to a Dallas clinic, he became upset. First he said that he was glad that he wouldn't have to be admitted, but then he said that he felt he would improve more at TSH with doctors around to guide him every minute of the day and tell him what to do. It doesn't work that way, but he didn't believe that. And yet, he doesn't know how to deal with his anger issues. "If I knew that, I wouldn't be here," he said. David put it best when he said later that the kid expected to be spoonfed, as was the case here. He claimed that if we sent him to outpatient therapy, he would forget about it and not go. So...we sent him over to Dr. EW, and they spent over an hour in his office just talking. Sital and I went to eavesdrop for a few seconds and heard him ranting yet again about how he can't stop thinking about his ex. In the end, he was sent home, but Dr. EW said that after some psychotherapy, he and the kid had come to a "mutual understanding" about what the kid had to do to improve his life. Whew. Who knew that one patient would take up 5-6 hrs of our time?