Moving day

It’s the month of moving. Across town for me, across country for Geoff. Thank you to our friends who helped! We love our new place!

Platinum weekend

In residency, a Golden weekend refers to having Saturday and Sunday off. This is in contrast to a Black weekend where you don’t get a day off at all. But since Geoff and I will have completely different schedules soon, we decided to refer to any weekend that we both have totally off as Platinum! This weekend we enjoyed local farmers market and cinco de mayo festivities, visit from dad, wine tasting, wedding venue site seeing, brunches and lunches with friends.

“…the purpose i…

“…the purpose is to help the person keep exploring his own experience and wisdom. Reflective listening involves certain trust that people are experts on themselves, want to be healthy, and can reach their own conclusions. “

If you have talked to me in the last few weeks you know I am obsessed with Motivational Interviewing right now. Last year Rollnick and Miller released the third edition on a therapy concept they coined thirty years ago. Now much evolved, “MI” is highly relevant to primary care, psychiatry, and many other areas, and I’m eating this book up! Though many of us learned the concepts in medical school, this detail is coming at the perfect time. “…From your side there is often no shortage of threats to calm and thoughtful practice, including time pressure and multiple tasks that compete for your attention.”  It’s easy to feel unsettled jumping from rotation to rotation, hospital to hospital, clinic to clinic, specialty to specialty.  This book talks about the doctor as guide rather than director, “people are the undisputed experts of themselves.” Sounds simple, but I have found there is a compelling tendency to hurry up and hand out advice to my patients, and then feel defeated if the patient doesn’t follow it.  This book talks about “dancing rather than wrestling” with patients.

“I don’t want t…

“I don’t want to do what I was thinking about doing last week.”

These were the words of my patient who I admitted to the Psychiatric Intensive Care Unit today, as he explained how desperate he had come to feel in recent weeks.  It struck me how ego dystonic feeling suicidal was to him. He had tried for months to pull himself out of his depression, turning to his children, friends, grief groups, and his pets for support. He was suffering so terribly after his wife of 30 years suddenly died 7 months ago. He even contemplated relapsing on alcohol after 27 yrs sober.  “I found myself parked outside the bar before it opened at 6am. I only had $20 in my pocket, but another $40 in the glove box. But when I opened the glove box the AA manual fell out. I drove home.” Addiction is a mysterious thing. Targeted at brain areas below the frontal lobes, and for the most part, at the really primitive parts, the brainstem. I found several moving pieces to his story today. In particular after working at the Addiction Recovery center for a week and just beginning to grasp what an uphill battle the field faces,  to see him steadfast and principled even over the impulse, even in a time of greatest darkness and despair. 

Yes! Geoff!

Today was my first day wearing a new “doctor hat” at ARTS or Addiction Recovery Treatment Services. I won’t dwell on the challenge of my transition from the ICU to ARTS, but suffice it to say leaving the Medical Intensive Care Unit less than 24 hours ago where most of my patients were unfortunately intubated, very sick, or dying, was tough. I’m very grateful to Geoff for helping me work through the growing pains recently. On a delightful note, here is picture of how I learned of the news that Geoff had matched here. There was no cell phone service in the ICU and Geoff knew that so he txt paged me at work (yes I wear a pager everyday, no it’s not 1995). I was presenting a patient on rounds when I received it, but didn’t read the juicy part until I escaped out of the spotlight and into a private stall. With just this one word I nearly screamed and definitely cried.

Working Nights

I’m really enjoying working nights! My job on night shift (6pm-6am) is quite different from my role during the day. Now I’m one of he first doctors to evaluate patients being admitted to the hospital. Instead of following up on numerous tests and labs and notes, I get to spend time digging into patient concerns. I love the thorough discussions I’m having with my patients when they arrive in the emergency department, answering their questions, talking with family. It’s so fun to try to piece together their story, labs, imaging, and come up with a hypothesis of what’s going on and plan for what to do next. It’s also fun because I’m working at a small community hospital, the VA Hospital in Rancho Cordova, so you basically know everyone working there night after night. It has a small town feel. We have fun. Unlike during the day, there are only two residents for the entire hospital. Me and an upper level. We take care of all four general medicine patients plus the ICU patients while the day team is off. Then when the day interns arrive (see picture) I tell them about who I admitted overnight and what happened to their patients while they were gone. These are some of my favorite interns, it’s a coincidence we are all on service together (Amy Family Medicine/Psychiatry, Jeremy Internal Medicine/Psychiatry). See you guys tonight! I look forward to sign-out to see how the patients I admitted the night before are doing.

Too mentally ill for medicine, to medically ill for psych

Unfortunately this story is not unique: you are a patient with severe mental illness X and severe medical illness Y, and you are caught in limbo with no appropriate place in our medical system to treat you. You are too physically sick for psychiatric hospitalization, too mentally ill for appropriate medicine service. Let’s say you have Lymphoma and you have Schizophrenia. Say that your cancer is so advanced that you are very weak, too weak to eat, and too nauseous from your treatments to drink. So you need nutrition through your vein temporarily, but because you have stopped taking your Schizophrenia medications, maybe you ran out, changed housing, lost supports, maybe the medications stopped working and it there wasn’t anything you could have done to prevent it, regardless you are now very psychotic. Maybe you are aggressive and violent, maybe catatonic, maybe paranoid and delusional. Unfortunately you are so acutely mentally ill you cannot take care of yourself as you could before. You need a short stay with mental health professionals to get you back on your feet and maybe even with a better long term plan so you stay feeling mentally well. Unfortunately, because you can’t eat or drink you require intravenous fluids (or IVF), but you are not a candidate for psychiatric hospitalization. Because intravenous lines are not allowed where people receive intensive psychiatric care for a number of reasons. Probably simplest to appreciate is that there are often patients who are suicidal there and for there safety should not be around materials they might hurt themselves with. But that’s really simplifying the problem. Even if I could solve your immediate IVF problem, I could come up with a million other problems that prevent people from being “medically cleared”, that is when a patient’s medical issues become “stable enough” that they can be treated safely in a psychiatric intensive environment.

I had another patient like this tonight. A very sad case because he is so medically sick he is near death, but due to symptoms of his mental illness, he was not accepted to Hospice even though that’s where he wanted to go when he was thinking clearly.  The reason why he was not accepted to Hospice is because his mental illness has decompensated and he is exhibiting signs of psychosis. He is too medically sick to care for himself alone in order to pass away at home so he needs hospice, but he is too mentally sick for the hospice service. So instead I admitted him to our hospital tonight. He is very very sick, and is likely receiving medical interventions that he may not have wanted if he could tell us. This particular situation brings up ethical considerations such as autonomy and nonmaleficence, and contextually features such as the fact that this patient has no family to speak on his behalf, but at its practical center is the problem that our medical system has not figured out a consistent way to provide care to these patients. And by ‘care’ I mean a physical space with medical practitioners to provide individualized treatment- whether it is treatment to cure or treatment to help die peacefully. Patients too mentally ill for medicine, to physically sick for mental health are a challenge for all doctors to consider, and a scenario I find particularly disappointing as a practitioner of medicine and psychiatry because it doesn’t have to be this way. 

What a difference a month makes.

Today was my last day on the Jail Psychiatric Service. I’m not exactly sure what changed or precisely when it happened, but I actually feel saddened to leave the Jail and my patients there. One of my greatest triumphs of the month is that I helped two of my very sickest patients who have been on the unit the longest to improve and I actually discharged them today. I’m really proud of that. Writing the discharge summaries of their stay on our unit helped me to see how well I knew them and how far they had come. And I played a role in that, and it felt great. I also gained some major confidence over these four weeks; I had to, actually. About two weeks ago, our team shrunk from five to two members. Only me and the attending remained. Instead of carrying 3-5 patients, I was carrying 9-10. Whereas I was originally scared to be alone, in the end I enjoyed the freedom of interviewing, diagnosing, and recommending treatment for my patients independently. To the point that when my attending left for Holiday and a new attending came on, I hardly needed direction in recommending a treatment plan. Not to say I wasn’t open for advice along the way, of course, but I wasn’t floundering getting started anymore. So cool!
Monday I start on the Gynecology Service, at UC Davis. A serious medical paradigm shift. I’m dreading it. I feel comfortable in my current (I guess technically now previous) role. Who wants to start learning from scratch again. If JPS is Earth, Gynecology is Pluto. This weekend I’m looking forward to spending time with my Family/Psych combined intern bestie Amy. She’s one of the few people who will understand how I feel even without even having to explain it.

The day I blogged about JPS originally, I took a picture of the Jail before heading into work. This is the picture I took of myself that same morning. Today looking at this picture I feel proud and confident that I can provide some relief to the patients there. I had that ability even then, I just didn’t know it yet.

Another wonderful weekend with Geoff

We’ve switched roles and now Geoff is working 12 hr days 6 days weekly since arriving in CA. Fortunately we’ve been able to make the most of his 36hrs of consecutive free time. This weekend we went to see Jordyn Hilliker perform in a terrific Nutcracker, met old friends at Kristina Kearney’s Holiday party, enjoyed relaxed Christmas shopping in my neighborhood, brunched outdoors on a beautiful December day, baked and decorated at Jea-Hyoun’s house, and hung stockings (thanks mom!). Great days.

Jail Psychiatry Services

Chilled air, cold drafts, icy cell walls. Dim lighting, absence of natural light. Banging, buzzers, yelling, howling. Uniforms, guns, bars, locks, cameras. Obedience, fear.

The first week at the Sacramento County Jail elicited strong reactions for me that are challenging to deconstruct beyond gut reactions and observation. I’ve only just now after five days began to contemplate the experience beyond the immediate environment.

Even working at the Jail can feel like a subtle loss in freedom. As soon as you walk inside off the street it begins: empty pockets for metal detector, wait in line to prove my identification, receive a daily pass and adorn it, wait for escort, escort to lockers where all personal belongings are stored until the work day is done (no access to phone etc), stop for camera to grant access to locked and guarded door 1, then stand for camera at locked and guarded door 2, then wait for the deputy to unlock door 3.

The Psychiatric unit itself little resembles a medical unit. Where as most medicine values sterility, frequent orientation to the sun’s natural cycle, and health promoting spaces complete with noise monitors and decorative art. The lack of bright light makes the JPS unit appear permanently dusk. You can feel the cold draft through the food port in the cell door. Debris stained floors and walls appearing decades older than the late 90s when it was built. Instead of smiling to passers by in the hallway as I would the hospital, I avoid eye contact with deputies and prisoners. Instead of looking my patients in the eye, the protocol is to sit on children’s chairs that puts me eye level with their food port (that is 28″ from the ground).

Amid all this my challenge is to provide an ounce of healing.