Wednesday

A Typical Wednesday on the Hospital's Psychiatry Consult/Liaison Service.

This Substack’s follower count doubled in the last week (granted, it started in the double digits). Welcome newcomers. I write about things I find interesting, which include mental health adjacent topics, and everything else. Check out the About page. Obligatory introduction: No one in this piece represents an actual person; facts have been altered to keep anonymity. This is a blog for fun, not a source of medical advice. You should not take medical advice from people on the internet who say they are doctors.

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6 am: My alarm goes off. The alarm isn't necessary because my biological alarm clock - a 2-year-old trained with classical Pavlov conditioning - will begin banging on her door at this time when her green light alarm turns on at 6 am. Consistent 6 am door banging is rough, but it is much better than inconsistent 4 am / 5 am door banging. My wife gets the two-year-old. I hit snooze for 10 minutes, then awaken in a panic. I'm in charge of the 2-year-old starting at 6:30 am, so my wife has a chance at some alone time in the morning before I leave for work. I stumble to the shower in a daze, asking myself the existential question all of us have asked at some point in our lives: Do I have sleep apnea?

6:33 am: Clearly not running behind, I try to take over care of my two-year-old, but she just wants to see Mom.

Can Dad get your milk? ‘No, just mom’.

Can Dad cut your strawberries? ‘No, just mom’.

Do you want to come with me to take the dog out? ‘No, just dad go outside’ she replies matter-of-factly.

My morning ritual of trying to take over is over. As I start to take the dog out, a two-year-old yells out from across the apartment, ‘No Dad, me too’. We take the dog out together.

7am: Leave for work. I stop by the doctor’s lounge, where there is free coffee and light breakfast items. The coffee machine has fresh beans, a touch screen, and soft gospel music coming out of it. But after visiting these holy grounds daily for a month, I have realized that the beans are always at the same level. This is instant coffee in disingenuously disguised in the garb of freshly ground coffee. Oh well. I hit start, and the gospel music is replaced by the soft whirring of mechanical machinery.

On my way out, I grab a Big Texas Cinnamon Roll as it is the highest calorie per bite option. I think about diabetes, then avoid (most days) getting the orange juice from the drink machine. It tastes clearly of high fructose, and there are only Styrofoam cups to drink from. A friend once commented on the irony of asking patients if they want to kill themselves on morning rounds in the behavioral health unit as they eat hospital breakfast out of Styrofoam containers. I think about that comment a lot.

7:30 am - 8:30 am: I read the computer to remind myself of the patients, catch up on anything that happened overnight, etc. This is one of the secret skills that all doctors are never taught but rarely mentioned because it doesn’t make good TV drama: How to quickly sift through mountains of copypasta notes and janky flowcharts to find the relevant information you need. I never got to experience the days of handwritten notes, but I can't help but feel nostalgia for those days. I remind myself the grass is always greener on the other side.

8:30 am to 12 pm: See patients mostly. Answer pages. Achieve my 10k steps for the day.

Patient A is a 53-year-old male with a history of alcohol abuse (now called Alcohol Use Disorder as we run along the euphemism treadmill). He was diagnosed with Korsafok Syndrome last week. Our conversation is pleasant. He introduces himself to me and informs me that he is recovering well, his interactions with the hospital staff have been ‘stellar’, he has enjoyed watching NCIS on the TV, and his sister has been visiting. To the medical student rounding with me, this seems like a success story. But, Korsakoff Syndrome is characterized by amnesia, deficits in memory, and confabulation (subconsciously lying and truly believing it to fill in the gaps in memory). Patient A has no idea why he is here. He doesn’t recall arguing with his wife over his alcohol use for years. He is mistaken that his sister has been visiting, as she died five years ago, and the patient hasn’t had a single visitor while in the hospital. He is pending placement as he cannot care for himself anymore. He doesn’t remember meeting me despite it being our 6th time meeting. At the end of the conversation, I ask him why he is in the hospital. ‘I'm not sure, to be honest, doc’. I encourage him to read the letter at his bedside: Dear Patient A, you are suffering from a memory disorder. You are safe, and the hospital staff are caring for you while you recover…’. The prognosis is poor, and people tend not to recover their lost capacities. He thanks me, though I'm not doing much beyond being friendly at this point.

Patient B is an 89-year-old whom we were consulted for with concerns of late-onset schizophrenia. Last night, she was confused, reported seeing dogs in her room, and agitatedly attempted to leave the hospital last night despite being in the midst of IV antibiotic treatment for pneumonia. She threatened to sue the hospital when they wouldn’t let her leave. It is obvious to me before I see the patient, but apparently not to my colleagues on the medicine floor, that this is not how schizophrenia works; there are no ‘surprise you have schizophrenia for 2 hours at age 89’ cases, just as there are no surprise triangles with four sides. Like many of the patients we are consulted on in the hospital, she has delirium - a short-lived episode of confusion. It’s remarkable that the brain can reliably create a coherent picture from the enormous electrical storm going on during normal waking periods; consequently, it’s not surprising that in the setting of medical illness (i.e. systemic inflammation, dehydration), poor sensory input (dim rooms and lack of hearing aids leading to more informational ‘noise’), and being bombarded with consciousness-altering medications (opioids, anti-cholinergic burden) that the mind gets confused sometimes. Remember, brains don’t see the world; they construct it. I meet with Patient B. She is kind. She doesn't recall last night’s events. She is hard of hearing, and I have to yell at her for her to hear me. She smiles at my yelling, but I’m not convinced she actually hears the words I am saying. She thanks me for being so caring last night and not letting her leave as she was not in the right state of mind. I nod along, knowing that I was asleep at home when all this unfolded. My mind begins to drift as she tells me about her grandkids, who apparently are bringing her hearing aids. The asymmetry of the importance of this encounter becomes apparent, and I politely excuse myself over the course of five minutes. I leave generic delirium recommendations for the primary team to help minimize and prevent delirium episodes - though I put in boldface letters: PLEASE ENSURE THE PATIENT HAS HER HEARING AIDS.

Patient C is a 68-year-old female with stomach cancer. She has been in the hospital for 67 days. She is frail and has no home to go to, as medical bills have robbed her of any financial stability she once had. She gets nutrition through a tube that has been siphoned into her stomach because she was not eating enough on her own. She has one cousin in the area, who drops off cases of Mountain Dew for her every few weeks; this cousin is her legal guardian and won’t let her discharge to a skilled nursing facility because she believes the patient ‘is a fighter’. Hospital bean counters are frustrated at her lengthy stay as it is losing the hospital money. Her daily staff are frustrated at her demanding personality. We were consulted because of concerns that depression is interfering with her recovery. Meeting with her, she is anxious about what the future holds for her, but otherwise satisfied watching reruns of NCIS on the TV every day. Does everyone but me watch NCIS? Her needs are taken care of; why would she want to leave? She declines that our team meets with her again as she doesn’t like to talk about her emotions. Everyone could use a therapist and emotional support through medical illnesses, but there is one of me, and one thousand patients in the hospital. Therapy can’t be forced, nor is it really realistic within the time constraints of our service. I feel myself being frustrated at the long line of patients I still need to see today, and having spent time here where the benefit is marginal. Ironically, the patient is the most content of everyone involved. We sign off.

Patient D is a 38-year-old male who just had a nail removed from his skull after he ‘accidentally’ shot himself in the head. He denies suicidal intent and is oddly charismatic during our conversations. His wife shares a different story of near-constant suicidal threats, locking himself in the shed the day of the incident declaring his time on earth was over. A lot of psychiatry is he-said-she-said, and this is no exception. Patient’s D story changes over the course of his hospital stay, though, and he has a past history of suicide attempts. He will transfer to the behavioral health unit tomorrow.

Patient E is a 22-year-old male with a diagnosis of schizophrenia. Unlike our 89-year-old, he has been in and out of the psychiatric hospital for years and is familiar to our service. Unfortunately, he also has type 1 diabetes, which requires him to monitor his blood sugar and self-administer insulin. Managing type one diabetes is difficult alone; doing it while also navigating a psychotic disorder, leaving you in poor contact with reality, is a nightmare. When I meet with him, he is paranoid, convinced that certain insulin bottles have been tampered with by the government in order to have microchips placed into its citizens. He shows me various links about Voice to Skull technology. He explains to me that the voices are real, and he is being targeted. I don’t deny that they are real (they are as real to him as any of my perceptions are to me). Instead, I show him his deadly glucose levels with red exclamation points next to them in his chart and reassure him the insulin the hospital uses is safe and will help him feel better. He remembers me from our past encounters, and our rapport pays off. He agrees to take insulin while in the hospital (and also the antipsychotic medications that he had self-discontinued last month). Everyone on our service has met patient E, which is not reassuring from a prognosis standpoint. But he holds a special place in our department’s culture as we all root for his success. He is going to the behavioral health unit tomorrow as well.

<BEEP BEEP BEEP>

My pager goes off - “This is Dr. Frantic. I have Patient F here. I need a capacity evaluation STAT. I need an overall capacity. I don't know if this person has the capacity to lift a spoon to his F****** mouth. He’s cursing at the nurses and throwing his food on the ground. You need to see him”

One of the things you learn while being on a consult team is that the person calling you sometimes has no idea what they want. They just know they need help. Part of my job is not just seeing the patient that the other doctor asks me to but exploring what exactly our assistance is needed for and exactly how I can be helpful. In this case, we have what I’ve come to refer to as a countertransference consult¹. After discussion with Dr. Frantic, we determine that Patient F can indeed throw his breakfast tray on the floor if he chooses to, and that the best way to approach Patient F would be with curiosity instead of consulting psychiatry. Capacity consults are a valid entity, but they are for specific questions like ‘does this person understand everything about and is able to rationalize through their decision to refuse a life-saving amputation?’ and not ‘This patient is rude, it makes me mad, maybe psychiatry can fix them’.

Patient G is a 45-year-old female with a rare medication side effect called Serotonin Syndrome. Most of the times I talk about Serotonin Syndrome, it is reassuring patients that they shouldn’t worry about the harrowing things they read on WebMD, that their medication dose is safe, and that this rare side effect mostly only happens when you overdose medications, which, results in too much serotonin release². Today, my conversation is different. Patient G had a medication list longer than my weekly grocery list, with medications from over 6 different providers, all probably just focused on their own medications, and it smelled of polypharmacy and unrealistic expectations from that polypharmacy. I am reminded of the human bias to add instead of subtract while problem-solving.

12 pm - 1 pm: Heat up lunch in the microwave next to my desk while I keep working. Things keep popping up, and I forget to eat. The next wave of consults comes in as all the other doctors are also at their computers now, placing consults that all sound eerily similar to today’s list:

• 'Psychiatry, this patient is big sad. They are dying. Please advise.’

• ‘We have a new onset psychosis in this 67-year-old here for urinary tract infection. Can you see them?’

• ‘This patient said he’d rather be dead than use reduce his pain medicine. And we reduced his pain medicine. Now what should we do?’

1 pm - 4 pm: I wrap up morning things, see the more time-sensitive consults, and tell the others that we will see them in the morning because our service closes at 4:30 pm.

4 pm: An urgent consult comes in. CAPACITY TO REFUSE AMPUTATION. I die inside, knowing I will not be home on time now.

4 pm to 5:30 pm: I spend 30 minutes reading the chart to gather an understanding of why they are being considered for amputation, what the team has spoken to the patient about, and why they are concerned that she may not be acting rationally. She has ischemic changes to her lower extremities from a combination of smoking cigarettes and diabetes. This is not her first limb amputation; it was already amputated to below the knee a few months ago. After which, the patient continued to smoke cigarettes.

I meet the patient, and she tells me that she knows she needs the amputation but has a hard time committing. “How does one say goodbye to a limb?” A fair question, but based on the previously performed amputation, I feel as if she has more insight into the question than I do. She is ambivalent during our conversation. She can’t, despite my best efforts show me she appreciates the severity of limb damage, despite the smell being apparent in the room. I speak with her family outside the room, and they all say she says she wants the surgery and then backs out. When the conversation is over, the patient asks me ‘I need the surgery, don’t I?’

Is 30 minutes enough time with a patient to know if you should take their leg? When necrotic tissue is spreading by the hour, apparently it is. And this patient is going to be losing hers. I spend 30 minutes documenting my 'formal psychiatric opinion'. I've been trained to chart like it's going to be read in a deposition, and I imagine if I get sued it will be over someone losing a leg, not starting someone on Prozac. I still feel I need to review my documentation, so sign a brief note and go home.

6 pm: I get home late. I feel guilty. A two-year-old runs to me at the door while Rafi is playing. It's a different world. The next two hours are spent on their dinner, bath, and bedtime routine.

8 pm to 8:30 pm: I finish that urgent consult’s note. My brief 'Patient does not have the capacity for this decision, full note to follow' should not be left for too long without its fully formed brother. It’s defeating to be doing work at home at this hour when the work day ended four hours ago.

8:30 pm to 9 pm: I think about how it would be nice to write down what a typical day on service is like while I get myself ready for bed. But doing so would require substantial energy, of which I have little.

9 pm - x: Distract myself with dopamine hits from my ‘cultured’ #psychtwitter feed, read one of the 4 books I’m simultaneously trying to read, etc. I push into the night, not wanting to sleep, only for 6 am to arrive and I hit snooze again....

1. I recognize that this would not be countertransference in the truest form of the psychodynamic term… but I still incorrectly call it this in my head. Probably a ‘frustration consult’ would be a more apt name

2. I’m simplifying here. Don’t shoot me.