Wednesday, October 28, 2009


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Sunday, October 25, 2009

Neuro Psych

So I haven't posted in a while, but not because I haven't had anything to say. I have spent the last 4 weeks doing inpatient psychiatry at our inner-city hospital. Daily, schizophrenic patients abstaining from their medications would report to the ER or were brought by the police after being found cursing in the street or doing other disorganized behavior. We had a gentleman with multiple personalities, numerous heroin addicts, an anti-social personality, a borderline personality, multiple suicide attempts or gestures, and of course generic psychosis and delirium. I live a very sheltered life, it turns out. I never really realized how well off I am, despite living on a pittance from student loans, until I saw the effects that devastating mental illness had on these folks. You never really think twice about being able to evaluate the world realistically and act accordingly until you meet people who can't. It was disheartening, really, to help bring a schizophrenic patient down from his floridly psychotic state to a less psychotic, but still rather disorganized condition, discharging him, and knowing that in 2 months or less, he would have stopped taking his medication, or not followed up or been lost to follow up, and likely be gracing our ER again.

The downward drift hypothesis of schizophrenia certainly holds true in the city here. This hypothesis posits that schizophrenia is more common among lower income echelons of society, either because of their low income status, or more often because their schizophrenia causes them to lose employement and become a marginalized member of society. Most of our patients drifted from group home to group home, and living intermittently on the street until they were sick enough the police found them and brought them to the hospital. Dante outlined concentric circles in Hell, and presumably there are analagous realms in Heaven, the more exalted of which are occupied by Social Workers. The social workers on 4 West Psychiatry Service found these people homes and case workers who would follow them and ensure, to some degree, that they recieved and took their medication. Their tireless efforts ensure that, at least on discharge, our patients at least had a roof and food.

Depressing as the schizophrenic patients were, the heroin addicts were worse. They would come to the ER either having OD'ed, run out of dope and detoxing, or allegedly wanting to go to rehab, which usually happened mostly on cold nights. If they only wanted a roof, they left AMA (against medical advice) when the weather warmed up, or when their cravings got bad enough, usually after 36 hours or so. The really sad cases were those who wanted, or at least convincingly acted as though they wanted (drug addicts will make you cynical very quickly) to get clean, but would then leave as soon as the craving for heroin overpowered their higher cortical funtion. The ol' limbic system is pretty powerful compared with the puny little cerebral cortex. One trio went so far as to stage a little drug reunion in the parking lot after leaving AMA. Sadly, two of them were at a point when they really could have changed, gotten clean, and moved on in their lives, but instead chose to piss away what little meaningful trappings of life they had left.

I can never practice Psychiatry because there is so much of the patient's social environment that factors into their illness but that lies outside the realm of any intervention I can make. It is arguable that this is true in all medical specialties, but I contend that it is to a lesser extent. So much of psychiatric illness stems from problems in childhood, abuse, poor education, low income, poor housing, poor mobility, poor literacy, poor parenting, that a psychiatrist can only do so much to ameliorate. Combine the underlying socio-economic problem with a pharmacological arsenal that is rather limited, and psychiatric illness becomes a daunting and frustrating thing to manage.

I never fully understood the logic behind giving a patient SSRI #1 v. SSRI #2 , and then why schizophrenic patient Joe took antipsychotic X which we then switched to Y , thinking of perhaps combining with Z and W as well. Perhaps that's my fault as a medical student, but as I have alluded to in other posts, psych meds are difficult to understand because of the combinations of receptors that they interact with, as well as the fact that the underlying disease is very poorly understood from a molecular biological standpoint. Take my patient "Joan", who took: Seroquel (quetiapine, an anti-psychotic with anti-dopamine and anti-serotonin properties), Modafinil (an atypical stimulant type medication whose mechanism is unknown), Celexa (a selective serotonin re-uptake inhibitor (SSRI)), and a few other non-psych meds. It would be extremely challenging, based on the known mechanisms of those drugs, to predict how they will interact with one another, let alone the underlying psychiatric illness, which in this case was a personality disorder more than depression, and thus more likely to be refractory to medication in the first place! (take that, grammar snobs! 'twas a run-on sentence!)

I bid adieu to neurology/psychiatry and will now enter the cut-throat world of surgery (no pun intended). I have the following rotations: pediatrics, pediatric urology, general adult, and orthopedics. At least I will be back in children's hospital which is much nicer than the adult hospital next door. As I know that there are surgeons who read this blog, I will be diplomatic in my analysis of this rotation. I fully expect to be the low man on the totem pole, in this case the little raccoon-man who is parked 2 feet underground holding up the rest of the totem pole so that admiring tourists can gush about the woodwork.

Our Tiny Toddler

Gunner is getting so good at walking. We had such a beautiful Fall day one day last week, so I took him on a little walk outside. He loved it! He walked a block in about an hour. He liked all the leaves on the ground, and he was absolutely fascinated by each set of stairs we passed. He's a pretty good climber, too. He doesn't know how to get back down safely yet, so I spent my time heaving him off the landings and redirecting him back down the sidewalk.

This is a video of my view as I walk behind him. He's a pretty stinkin' cute tiny toddler!

The title of the video is a reference to our friend's little boy who couldn't remember Gunner's name, so he called him Baby Jones. In their family, we are now called Spiff, Windy and Baby Jones.

Friday, October 23, 2009

Gunner's 1st Birthday

Last week, we celebrated Gunner's first birthday. I can hardly believe that he is one already, but watching him talk and talk (babble is more accurate) and walk around the house leaves me with one conclusion... Yep, we have a toddler! And I have to deal with the initial shock of that realization, and the terror that grips my heart when I realize that I have no idea what to do with a toddler, especially a toddler boy. It is seriously a different beast, and it happened almost overnight. Since he started walking and "talking", he has decided that life is just too fun to ever ever slow down for a nap. And those teeth and the shots from the 12-month doctor's visit just clinched things for him, and not only does he think that napping is now optional, he also thinks that morning starts at 5:15 in the morning.

Yes, I did write 5:15!!! In the morning!!!

And remember, naps are now optional. Which means that he usually chooses to opt out.


Anyway, about the birthday festivities. We had a great time. First, my sister was in town, and so we held a little "party" before she left. Lucky Gunner got to dig in to this cake 5 days before the big day.
I must admit that I was pretty excited about the cupcake eating/smashing experience. He loved it, and he was the perfect little performer. When he figured out that he had a yummy, sweet cupcake in front of him, and it was all for him, and he had permission to actually eat it, boy did he dig in. He started by sucking all of the frosting off the top, and then proceeded to devour the entire thing, other than what he smashed onto his hands, belly, face, hair and ears.

We continued his birthday celebrations over the weekend when some friends came into town from Minnesota. We went downtown and visited some parks and the Old Courthouse. We went to the zoo, and we ate a yummy BBQ dinner. Then lucky Gunner got to dig in to this cake:
This time, he wanted to eat the whole thing (all twelve cupcakes in the stack), and when Spiff took the cake back to the table after blowing out the candles, Gunner lost it. There was too much excitement and not enough cake for him, and he cried uncontrollably for a good two minutes before he realized that there was in fact another yummy cupcake sitting on his tray, all for him. He devoured that one, too.

He also got spoiled with lots of fun presents from his aunties, grandparents, friends, and us, of course. And I have loved having some new toys around this week. He is in heaven, carting his new soccer ball, cars, fishies, books, and stacking cups around the house. That's just all part of the fun that is this new life called Toddlerhood.

Wednesday, October 14, 2009

On Being Alone

I have an adorable little two-year-old niece who, like me, has two beautiful older sisters. I think she is a very insightful little girl because she feels lucky to have sisters. As I was visiting with her family not long ago, she walked past me, and in her sweet sing-song voice said, "I go play with my sisters!" As she rounded the corner to the play room, she sung out to them, "Hello, Sisters!"

I adore my own sisters, and I miss them every single day. One of them came to visit me last weekend. We had a great time together, and I'm so glad she came. But then, as I drove up to my house after dropping her off at the airport, I felt my heart sort of sink into my stomach with the thought, "I'm alone again."

I don't mean to sound depressing, or in any way ungrateful for my circumstances. Of course, I have Spiff, and I am so grateful that he loves me and comes home to me every day after his long, hard days of school/work. And of course, I have my little Gunner, who is with me almost all of the time. I have a constant companion who loves me so completely that I hardly dare ask why. So I'm not really alone. But I feel like it sometimes when I find myself facing daily life and my mountains of chores.

I bring up being alone because having my sister here was so refreshing. It was so very glorious to have some company. We ran errands together. I carried the bags, and she carried the baby. We cooked dinner together. She chopped, I stirred, and the food was finished and on the table in half the time. We talked, and she gave me an outlet for my insatiable need for conversation. We watched movies, hung out, and laughed until we cried, all in a way that only sisters can.

So when she left, I admit that I felt sad and a bit incapable of facing those mountains of chores...alone. Now imagine the big sigh, and me trudging up my large front stairs, head down, with the sad Snoopy song playing in the background.

And then a friend called me up and came over for a visit. We hung out together with our kids, talked, and ate lunch together. She probably didn't see it as an act of service, but it meant the world to me. For a few hours, she took my mind off of the fact that I'm not going to see my sister for months. She kept me company, I hope she knows how much I appreciate her friendship.

I feel like I am a fairly independent person. I enjoy running alone. I do most of my errands and shopping alone. I can eat alone at a restaurant. I have even gone to movies by myself. I enjoy having alone time. (Doesn't some time alone, without a baby crawling all over you, sound just divine?) I think that independence is an important quality to have. But I can't help feeling that sometimes, things are just better with some company.

I have great friends here, and I hope they don't mind me leaning on them when I feel lonely. They make it possible for me to be okay about being so far away from my sisters. They make it bearable to say "Hello, Sisters!" from thousands of miles away. They make it bearable to face the mountains of chores "alone".

Tuesday, October 06, 2009

Only 25 weeks to go!

I was finally able to schedule my anesthaesia electives for the spring, and they're in only 25 weeks! All I have to do is make it through 3 more weeks of psych without tearing my hair out (trichotillomania), 8 weeks of surgery, 12 weeks of eternal medicine, and then the promised land! For the mathematically inclined, I have a two week christmas vacation during which I will sleep.

Psych/neuro has been the nadir of 3rd year thus far, which they will hopefully remain as I would like to enjoy the rest of the year. I don't enjoy the pigeonholing arbitrary nature of psych. Everything has to fit into a neat little DSM IV rubric. If your patient has been depressed for only 3 weeks and 3 days, they aren't technically depressed yet ( or somesuch crap, I don't care to look up the criteria right now), but it doesn't matter any way because they still get an SSRI. What if your patient is 86% of her ideal body weight, but is still binging and purging? Well then she's not anorexic, she's bulimic! (binging and purging are found in both anorexia and bulimia, percentile body weight is actually used to distinguish the two.) But if she loses 500 grams, then she's anorexic! These categorizations are totally arbitrary and more or less pointless because they don't really affect therapeutic decision making.

Psychopharmacology also sucks. The names of the drugs are all confusing, and the trade names sound like the generic versions of other drugs. That, and they're all very dirty drugs which act on multiple receptors and have about a dozen effects and two dozen side effects. These drugs are not like blood pressure meds, for example, which have well understood mechanisms and a relatively straightforward effects. Additionally, there doesn't seem to be any rhyme or reason as to why one patient gets SSRI X while another gets SSRI Y. 2.5 weeks left until I prostrate myself on the shelf exam and hope to heaven I pass.


Friday, October 02, 2009

Attack of the Tooth Fairy

One Tooth, Two Tooth, Three Tooth, Four;
Today we found a third tooth, and then One More!

We discovered his third tooth today, and then just before we put Gunner to bed tonight, I thought that his gums were looking awfully swollen. Plus, he has been a complete bear for several days. We were sure that the fourth tooth was going to be following that third soon, but I didn't expect to find that it had also broken through today! No wonder he has been having a rough time lately. Two new teeth in one day!

Three Teeth

Gunner has his third tooth! Today he added his upper left to his collection of two bottom teeth. We're so very excited!

Thursday, October 01, 2009

Parking Troubles

I got a parking ticket today for forgetting that it was street-sweeping day (darn first day of the month snuck up on me). And then a parking meter ate my quarter!

Is that bad luck? Or did I anger the Parking Gods?