Stories from a Student Psychiatrist

I'm a month into my psychiatry rotation. It's a pretty stark contrast to surgery. Morning rounds consist of more than "Pain? Peeing? Farting? Pooing?" There's a lot more talking involved with the patients, and about dramatically different things. Of note, my work week maxes out at about 50 hours, while averaging a little over 40. As opposed to 90 hours work weeks, with some days approaching 34 hours. There's the counseling aspect of psychiatry, e.g. talking to depressed and/or suicidal patients. I'd say that happens on a daily basis. But there's also a decent number of other mental disorders to be aware of. require knowing a subset of behaviors, symptoms, and or signs and being astute enough to pick up on them. It's harder than I would've thought to keep the less common pathologies straight. And the psychopharmacology? Hell no. Too random a collection of side effects and drug/drug interactions.

Some interviews take about an hour. An interview while one call Saturday night took about 90 minutes. Another interview while on call one Friday night took almost two hours. The latter guy was suicidal, having taken ~30 Xanax two days before coming into the ER. As a quick summary of his sad story, he's bipolar and newly homeless. He came to Chicago working for a friend for about 4 weeks. He never got paid, so he quit and ended up on the streets. Without a mailing address, he ran out his meds and his bipolar flared up. He'd had several manic episodes, including binging and spending thousands on his credit cards. He's chronically passively suicidal - i.e. if it were up to him/if he had the balls, he'd already be dead. As a kid, he and his sister were sexually abused by several of her mother's boyfriends, and he still holds homicidal ideation towards some of them.

Another sad patient I talked to just a few days ago is a 21 year old Iraqi veteran. He left high school four months early because wasn't doing enough to help his friends and his country out overseas. After a few months of being deployed, he finds out his wife is cheating on him and that "their child" isn't his. A few months later, he gets knocked off a truck secondary to an explosion and ends up losing consciousness and with several microfractures in his neck. After the army downplays the incident, he is forced back to active duty. While serving with his neck fractures, he gets called out by one of his superiors for his "neck pain." This guy ends up in some sort of verbal altercation with his superior, after which he's sent stateside. After a few weeks, he's discharged with misconduct. The latter phrase is key, "with misconduct," because it means this guy gets no money from the Army and/or government and is ineligible for disability. He's four weeks into a six week hospital stay, after which he has no job or place to go to. Regarding the job, that's not likely for him since he's textbook PTSD. He can't handle large crowds because he has to be able to see where everyone is and what they're dong. He can't handle loud noises because he goes to ground everytime he hears one.

Since I'm on the consultation service at the VA, I don't see too much crazy pathology (no pun intended). Most of that stuff happens up in the psych unit, where two of my classmates got placed. The pathological highlights of my rotation include a schizophrenic and a conversion disorder. The schizo was interesting- he'd been in prison for ~22 years for making threats against every vice president (of the US). He has a secret service agent keeping tabs on him. He talks of a successful money counterfeiting scheme which he's used to finance an armory with cases of rifles, pounds of explosives, and crates of grenades. He was set to be discharged the day we saw him, but Secret Service said no - because Biden was in town that day.

Conversion disorder is basically when psychological stressors manifest themselves as neurological deficits. Long story short, she had a lot of job, money, and personal stress going on. A few weeks ago, this manifested as a left-sided weakness presenting similar to a stroke. On imaging, no deficits were appreciated. On exam, her neurological deficits are inconsistent with a stroke. During her interview, she's noted to have spontaneous left sided movement with minimal assistance from her right side. On asking about her psychosocial stressors, she gets annoyed and doesn't understand why we ask about them. On suggesting a link between stress and her deficits, she invents her own science and educates us about the "Cellular Tear Theory" and "Biomedical Pain Mapping." I must not made it through those lectures in neuroanatomy or neurophysiology. Interestingly, on giving her the timetable for stroke recovery and setting firm expectations, she's recovering pretty close to the timeline laid out.

So yeah, that's what I've been up to the past few weeks at work. Imho, it's not as interesting as surgery, but that's what third year's about. Figuring out what I do and don't like.