Enter Psychiatry

Enter Psychiatry, the cushest rotation of my life. Psychiatry was in effect a 7-8 a to noon kind of bit. At our hospital there are no psychiatric residents, just attending. Two attendings work at a time. One attending is the Psychiatry Consult MD, meaning they are the triage doc. They determine if there’s a need to follow a patient for a while , admit them to the psych floor or wonder why the heck we were consult.

So consult service was neat. Days started off one hour before the attending showed up. This was usually 7/8a. We’d head to 6 East, the psych wing and find all the pieces of paper saying “Psych MD consult and some little scribble of why they were consulted” We’d then update our PSYCH MD list and divvy up the patients. There was three of us, so we split it three ways, giving new patients priority. Then we’d head out. Our plan of action went like this:

1. Find patient’s chart – this is probably the most involved task… any number of people can have the chart – other teams, case management, xray/procedures, chart gnomes, wizards
2. Collect billing sheet for psychatrist
3. Find out why we were consulted. This may or may not be readily apparent. If we’re lucky , it’ll say Consult Psych MD: r/o depression/suicide. But it’s never that simple, otherwise life wouldn’t be as exciting. Sometimes, there is no order for PSYCH MD. Sometimes there’s no clear reason on the chart. Then you proceed to step 3
4. Find nurse. Finding a nurse is really important on pyshc, moreso than other rotations . The nurse sees the patient the most and they can appreciate changes in patient’s mental status and hopefully.. the nature of the consulted. It also is a great way to meet cute nurses, I mean.. expand your social.. I mean… be really nice to nurses.
5. Find patient - another task.. sometimes you find the room AND BAM.. patient is MIA… could be smoking, could be getting something done or imaged, or one day I had a patient up and vanish (based on previous records, she’s done that before)
6. Talk to patient – psych histories are conversational. You want to assess the immediacy of need, the history and boil it down to : what can we do to help this person
7. Sit down rounds – students report to attending and we build a priority list of patients to see
8. On psych, some attendings want to see all patients on the list while others want to see teaching cases. So we round afterwards based on that
9. Round, learn, peace out for lunch
10. Occasionally we had things in the afternoon like lecture or conference but the latest we went was 2/3p
That was consult service. I saw all kinds of patients: personality disorders, substance abuse, plenty of suicide attempts, PTSD and my favorite, schizophrenics. I’ll tell you about two that I picked up on one day that were just special.

The paranoid schizophrenic
Pleasant AAM who’s sitting in his bed in the EC. He has a sitter which means he had some sort of suicidal ideation/plan. First thing I notice when I walk in is a sheet of paper covered with writing and symbols. This becomes my talking point. I introduce myself and sit next to this pleasant gentleman. I ask if I can look at the paper. The paper is filled with terms regarding chromosomes, genetics, cloning, formulas. My patient proceeds to explain that the government stole his secret for chromosomal liver transplants. [ I think to myself, oh this is going to be good. Not so much the oh you’re a nutcase good but I find a schizophrenics train of thought and delusions interesting. They have a thought disorder, their ability to relate their reality to you and their perception of reality are disordered, disjointed] My patient explains that he is a veteran and had been working on these formulas and really it boils down to him not taking his meds and having stressors in his life that made him want to hurt himself. I really ached after seeing him. It’s strange how some patients just jar you and feel for them.

The disorganized schizophrenics
Agitated Caucasian male that presented to the EC because he was found passed out on the street secondary to alcohol consumption with possible lobar penuomia. This gentleman was just.. well… a disorganized schizophrenic who had been living on the street for 10 years. He was disheveled, thousand yard stare, monotonous voice, wanting to go back to the streets. Our conversations usually started off normal. We talked about his pneumonia at one point:

… Me: so it looks like you have a pneumonia here
Patient: acknowledges what I say but then looks outside , starts rambling. Then he goes on to say: “this is the climate for walking pneumonia”
Me: [wtf?] Um, I suppose you’re right sir
Patient: grumbles/rambles … new word for that “grambles”
Me: looks over at IVs, sees Levaquin running. But it looks like you’ve got a more serious pneumonia that just walking pneumonia, that antibiotic over there covers things like lobar pneumonia [point for me… what what..]
Patient [unimpressed, continues grambling]

So I take in the rest of the room, seems like he has all kinds of random jars of liquids and trinkets from his travels. He has one worn backpack. So really our encounters consisted of conversations that started off okay with him mostly questioning things and then proceeding into a series of grambles. The day our attending met him, with our team in to (three students, one doc) our patient proceeded to go on a gramblage- grambling rampage. When asked if he’d like to spend time on our psych floor aka “the pavilion” (which is a hilarious name as it implies the psych unit is some kind of robe wearing spa that only the elite patients go to), our patient thinks it over. His thought process proceeds as follows

Well, I understand that you are offering me to go the pavilion
I’ve been there before
I’d like to walk around the hospital some more
Move floor to floor
You see, I need access to a library
Insert some reference to aliens/UFOs
I need to get a library card
Grambles about oil spill
I can research genetically engineered fish that can clean up the oil spill
[at this point, the attending motions for me to open the door and that the interview is done, saying to open the effin door]

We all proceed to file out, close the door and bust out laughing. It was ridiculous. The whole time we were all holding back, maintaining professionalism listening to our patient move from coke to central park to libraries to fish to aliens to cleaning up oil spills. For me, laughter is a coping mechanism that I’ve employed throughout life, especially now in medicine. There’s so much we see and do that we need an avenue to channel that experience, that stress. Some people take it seriously.. others like myself .. laugh..

So to wrap up psychiatry, I ended on three weeks of inpatient psychiatry. These were the “unit” patients. I’d see maybe 1-2 new patients in the morning, obtain a good history and see my continuity patients. Again, we’re the residents basically at our hospital. Our attending would let us lead team rounds. So nurses, social workers, our attending would all sit in a circle and run through the list talking about medication effects and mental state of our patients. Psych inpatient is very cool in this regards because the longer you were on the more it became “well, he’s still psychotic but I do believe he’s much more socially appropriate today.”