in for the high jump

sometimes patients can follow you when you rotate to another discipline. sometimes this can be tragic. sometimes it can be funny. and yes sometimes it can be both.
the patient was tired of life. he addressed this problem by taking a massive amount of a large variety of pills and very nearly ended it all. however the internists would hear nothing of it and fought tooth and nail for his life, partly because of the efforts of a certain house doctor who really invested of himself to pull the patient through. every day, while the patient was in icu he visited and tried the best he could to support him. he even started learning the fine art of ventilation by simply observing the daily settings of the ventilator by his seniors. when the patient went to the ward he could be more directly involved. he did all the necessary blood work on the patient, but also consulted both the psychiatrist and the psychologist. he even spent time just trying to encourage the patient.

but in a certain sense it was a bit of a one sided relationship. you see the patient wasn't overly delighted by the fact that the suicide attempt had been thwarted and he went as far as to take it out on the poor house doctor. i suppose it was inevitable. you see the house doctor was the face that the patient associated with the hospital and the doctors and the house doctor was therefore the target for his resentment. but to his credit, the hapless doctor didn't show signs of this getting him down, although inwardly he was struggling a bit. as you can imagine, he was only too glad to rotate from the internal medicine wards on the 4th floor down to the lowly surgical wards on the 2nd floor. unfortunately his fellow house doctors rotated with him. even more unfortunately surgeons are not know for their finely developed sense of understanding and sympathy of emotional issues.

we were standing on the balcony of the doctor's tearoom. the fellow house doctors were having a bit of a go at this poor house doctor about the fact that despite his best efforts the patient ended up hating him the most. the surgical registrars gave their five cents worth about not investing too much time and effort into someone who just didn't care and essentially didn't want to live. the house doctor took it all in his stride and even laughed at the whole situation. yet even then he defended the actions of the patient, talking about decreased personal responsibility due the a defined psychiatric disease. the surgeons, who essentially stand by the dictum that if you can't fix it with a knife then there is nothing wrong with the patient, ragged the poor house doctor even more. the house doctor smiled and answered.

"anyway it doesn't matter anymore. i've been rotated to surgery and it is unlikely the patient will follow me here." with that he turned to gaze forlornly out over the balcony..... just in time to see his patient whizz past in his brief but rapid journey to the concrete floor below. life was still too much for him and he had jumped.

the house doctor rushed down and commenced the resus. in the end he was also the one to call it. the patient had tried to follow him, but had overshot the mark a bit. the words of the surgical registrar which had been shouted to him as he charged out the ward probably didn't help with his overall demeanour:-

"now at last there is something wrong with your patient."

focus

specialists tend to be focused specifically on their field. some might say narrow minded even. way back during my psychiatry block i was made acutely aware of this.

one thing i noticed quite early on in the psychiatry rotation was that, with few exceptions, the consultants weren't interested in teaching us. it seemed to interfere with their tea time and their going-home-ridiculously-early time. so when we were told to go to a particular ward to get a tutorial from one of them i wasn't expecting much. i got exactly what i was expecting.

we walked into the tea room where the consultants were hard at work drinking tea and introduced ourselves. the designated tutorial giver groaned audibly. he then glanced over at his colleagues and rolled his eyes. they chuckled. funnily enough i think they thought they were being subtle. after all we were mere medical students and therefore couldn't easily pick up on the finer points of non-verbal communication like specialist psychiatrists could. i was immediately annoyed, but i chose to hide it.

"you medical students think that when you rotate through psychiatry you don't need to examine patients anymore. where are your stethoscopes?" we all pulled our stethoscopes out of our lab coats and presented them. i considered asking him where his was but decided this was already an unpleasant experience and i wouldn't be popular with my friends if i further antagonised our antagonist. i held my mouth with difficulty. he continued.

"go to the ward on the other side of the hospital and ask to see mr g. examine him fully and report back to me." with that he turned his head back to the tea and seemed to drift off in thought. glad to know our future mental health is in such good hands, i thought.

we entered the ward and soon found mr g. we had all rotated through both surgery and internal medicine so we were quite confident in our examination skills but still we were taken aback by what we saw. with a simple glance it was clear mr g was not well. he lay almost motionless in bed except for the movement of his chest with every laboured breath. we got to work.

during the examination it was clear he was in heart failure and had a massively dilated heart. he also seemed to have pneumonia on the left. his abdomen was tender but we put that down to en engourged liver secondary to the heart failure. his mental faculties were almost non existent but were in keeping with someone who was on the verge of death as we thought him to be. as a side note we noticed he had one glass eye.

as we walked back to the consultant still sitting in the tea room sipping on his so-many-th cup of tea we chatted. we were actually quite worried about the guy. at least we could let the consultant know that he needed some real and urgent medical help at the hands of consultants that actually do have stethoscopes.

"you're back!" he greeted us, "why did you take so long? did you stop at the cafeteria for tea?" tea was clearly an integral part of his life.

"umm, no. we were examining the patient like you told us to."

"ok. present your findings to me." we started with a formal patient presentation the way we had been taught to do in internal medicine and surgery, methodically going through all the systems, one by one. as we spoke and the condition of the patient was painted in increasingly grave hues the consultant seemed to become more and more edgy. at least we were getting through to him, we thought. when we had just explained that the patient was struggling for every breath and his last ounce of strength was being drained from his body even as we spoke, the psychiatrist could no longer contain himself.

"did you at least notice he had a glass eye?" he exclaimed with a bit too much irritation. it seemed his edginess was nothing more than boredom.

"umm, yes. his right eye is a prosthetic eye." we ventured helpfully.

"ok. that is all i wanted you to find. well done." i couldn't help laughing. this guy had probably noticed by chance that the eye was fake when he admitted him some time ago. since then the patient had not been examined at all. also one would like to think that the fact that the guy was just about to die trumps a glass eye, but apparently not.

just because you're paranoid doesn't mean they're not out to get you

i had fun posting about a psych experience. but there were others less enjoyable.

it was during my psych rotation. i was trying to make the most of it and i occasionally almost got it right. one day our intern asked my colleague and i to accompany her on a call to the maximum security ward. we were up for most things and agreed. only after we had agreed did we ask why.
"because i'm too scared to go alone!" was her frank response. bright flashing lights and loud hortatory bells should have been going off in my head but i didn't want to look like a pruss in front of my friend so i became temporarily blind and deaf to them.

the psychiatric hospital was a big sprawling place with each ward discreetly placed far enough from the other wards to try to create a resort sort of effect. maybe in the addams family, i thought. anyway, one of the results was that maximum security was way up on the hill, out of sight of pretty much everything else. i had in fact never seen it before. so when i saw the eight foot concrete walls with barbed wire on the top i was impressed. they clearly were not messing about. we approached slowly, almost in awe of the monster.

when we got to the entrance i was even more impressed. there were two solid iron doors. a camera identified us as something slightly more benign than special forces or the terminator or rambo maybe and the doors swung open. we shuffled into a sort of holding cell. looking at us through what was no doubt bullet-proof glass were two guards. when they had satisfied themselves that we were in fact one doctor and two medical students and not some sort of covert attack team, the inner metal doors swung open and we entered the main compound. nothing in 5 years of medical training or for that matter twenty four years of life could ever have prepared me for what i saw after all those stringent security checks.... nothing.

there was a nondescript road ahead of us with houses on either side. but the road was totally deserted. i imagined a breeze ominously blowing through the grass but in actual fact the grass stood dead still. there was also no eerie music playing which just didn't seem to fit in with the general genre. but the thing that i found most disturbingly normal was the lack of a heavily armed escort. i mean after getting through fort knox-like security surely there should at least be a guy with a truncheon sort of standing around in a lazy way on the other side of the double locked steel doors?

i couldn't help it. i had heard my mind's logic and the final words hung silently in the air. locked steel doors!!! locked steel doors!!! i turned around and observed, now with almost wild panic that there weren't even handles on the doors. where they met the walls and each other was almost seamless perfection. i felt like i couldn't breathe. that breeze would be great right about now, i thought. i tried to take control of my mind, get a grip! i told myself. at least there are no crazies. they must have been locked up before we got here obviously. we are quite safe. the crazies suddenly appeared as if on cue.

at that moment, if sheer terror hadn't totally paralysed all my faculties, i'm sure i would have been able to draw similarities with any number of low-budget zombie movies, because that, in retrospect was how it was. people approached from all sides, walking slowly forward or maybe lurching slowly forward, arms extended and engulfed us with only one word uttered from their lips like a chant, over and over again.

"cigarettes! cigarettes!"

we fought our way through them and finally got to the medical building. we slammed the glass doors behind us as any number of zombies (for that is what my mind had decided they were and no amount of convincing is going to change my mind now thank you very much) threw themselves up against it. i could see the headlines: 'promising young medical student found dead in prominent psychiatric institute. only brain missing.'
then the sister appeared as if from nowhere. if it wasn't midday i would have sworn i saw a bat flutter in just before her human form became apparent. she charged the glass door and as if by magic the patients dissipated and were soon all gone.

she led us through to the examination room where our patient awaited us. it was a man in his thirties with a deep gash in either cheek. i was impressed by the symmetry.

"what happened to him?" i had to ask.

"he fell and cut one cheek. when he saw himself in the mirror, he broke the glass and used a shard to cut the other cheek so both sides would look the same." i wasn't surprised that he was clearly mad. what would one expect? but the fact that any one of those many zombies outside could have access to shards of broken mirror sunk down into my soul and festered like a septic wound. all i could think was we had to somehow get past them all again and this time they were waiting for us. 'remains of medical student found in prominent psychiatric institution. disfigured beyond all recognition'...somehow seemed more appropriate. i needed to get my mind off it.

"why is this patient in here?" i asked. at the time it was no more than an innocent question, i swear!!

"oh, he killed and dismembered his entire family." said the nurse as if she was reciting the day's minimum and maximum temperatures. he what exactly??? my mind screamed. i wanted to ask if that was generally the sort of thing that would get you into maximum security in this institution but i knew that her answer would have implications pertaining to the hordes waiting for us outside. i decided i just didn't want to know.

at about this stage my mind thankfully went blank. i think it was some sort of subconscious defence strategy. whatever it was i'm just grateful. i came to my senses when we were out again and getting back into the intern's car. i stared ahead in silence for some time. finally i spoke.

"mad!! they're all quite mad!!!" i said with conviction. "some of the patients are mad too." i added.

mad as in crazy or just plain nuts

as anyone who knows even the slightest thing about surgeons could guess, psychiatry was not one of my favourite subjects in medical school. but even i could appreciate a bit of humour in my final practical exam in this cursed subject.

i had to get through it no matter how much i disliked the subject. i would have to 'examine' a psych patient and then present him to the examiners. ideally i'd have to come up with a diagnosis slightly better than 'he's mad!' examine basically meant i had to go through a fairly standardised interview. from that interview, using my amazing powers of deduction i would hopefully be able to label exactly what brand of crazy my patient was. the plan seemed water tight at the time.

they told us there would be translators provided if we needed them. (this is something that is actually often needed in our country, bearing in mind we have eleven official languages. i kid you not.) so when i was allocated my patient, the first thing i asked is what language he spoke. it was zulu. i quickly identified a zulu translator, but before i asked her to accompany me i enquired of the patient if he could hold his own in english or afrikaans (as you will see later in this post, this may not have been the best choice of words on my part). the patient, in a somewhat staccato voice assured me he was fluent in english. ok, i thought. and off we went.

the interview was disastrous. it seemed that the patient was simply under the delusion he was fluent in english. to my shame it took me about ten minutes to figure this out. i just thought he was somewhat stupid. turns out he had no idea what i was asking him and was trying to answer to the best of his abilities...in english...which he didn't speak...at all.

finally i rushed through to get the translator. time was limited. this was after all an exam. i was getting tense.

his zulu was fluent and with the translator we were soon in full flight. the only problem was he was answering each of my questions appropriately. he didn't seem mad at all. i started hoping for a bit crazy, but with each ensuing answer he seemed just like your average joe soap (or whatever detergent of your choice).

great i thought. they have thrown me the wild card. they have actually put a totally sane patient into the exam to catch me out. what sort of sick twisted deranged mind does that sort of thing??
i resigned myself to my fate. all i could do was continue to systematically go through the questions.

the next question was about libido. the translator told me he said he had no libido. it was the closest i had to abnormal so i latched on.
"why doesn't he have a libido?" the zulu equivalent was asked and answered. the translator doubled over in laughter at his answer. there was no forthcoming (or any other form of coming it seems) answer in english. i wanted to jump up and scream at her. i had about 5 minutes left before a bunch of psychiatrists were going to determine if i was going to repeat the year or not and the translator was just laughing?? did she think when she took this job that there wouldn't be the occasional strange answer?? and now with what felt like seconds left to me i had to deal with her sudden delicate sense of embarrassment.

"what did he say?" my voice was not raised but i think there was a noticeable quiver.
"he says he doesn't have a penis." bingo, i thought. then my paranoia about the evil examiners got the better of me. i had to quickly check to make sure there was in fact a penis.
"what's this?" i asked in reference to the member that i could clearly see.
"it's not mine."
"whose is it?"
" it belongs to this tsotsi." he said, pointing to his chest. i was so relieved. he was mad. at that point i didn't even care what sort of crazy he was. the moderator was knocking at the door to tell me to present myself to the examiners. the fact that he was crazy was good enough for me. i could wing it.

p.s i passed but not with flying colours. the examiners also specifically asked me if i had physically checked to see if there was a penis or not.