The 1st step may not be the noblest...

... but it should prompt you to take more.

Today, walking out of pediatrics to head home for the day, I saw a Hispanic lady in the waiting area outside the ward weeping into a towel. I had seen her earlier on the floor; she was presumbly the parent of one of the kids on the ward (not one of my patients). She had expressed to the nurses in her broken English that she was stepping out to get some air, and her demeanor then had been cheerful and pleasant. Imagine my dumbfounded surprise when I saw her crying.

I wish I had done more than just ask "Are you OK?" and accepted her hasty nod yes. Not that I believed her, but because at the moment, I was scared and felt inadequate and didn't know if I could help her. But that last bit is a sympathetic lie to myself - of course I could have done something to help her, and I should have. Even walking out, I knew that at any moment I could turn back, call the translator, and try to assuage what worries she probably had about her child. I would not have been overstepping my boundaries, or if I truly felt that I was, I could have called her physician to talk to her. But the fear of doing something unfamiliar stopped me, so there I was, sitting in my car, justifying my inaction on the grounds that she would feel better soon, maybe she just needed to cry, the translator might be out... name an excuse, and I thought of it. And then I drove home.

Not long ago, Lydia and I discussed how the 21st century, despite all its progress, is an era that has cultivated fear. I'm not referring so much to 9/11 and the subsequent actions of the Bush administration (although that certainly changed my experience of America more than I would like), but to the caution that was drilled into us even as young children. We are the generation of throwing away unwrapped Halloween candy, of never picking up hitchhikers, of not looking the homeless in the eye. So is it any surprise that as adults, our mindset is insular, hesitant even when our sense tells us we won't die if we help a random stranger who does not dress like us or talk like us? The world is our oyster, but we crack it open with only a select few.

I had thought about all this before, yet I still hesitated today. I am certainly not proud of that.

I guess if one good thing came out of that experience, it's that I will absolutely loathe myself if I allow it to happen again. The next time I see a scared patient or family member, I will get involved, even if it means I feel stupid doing so. Even if the fear is not gone. After all, what is the worst that can happen?

A friend posted this on facebook, and I thought it was a charming little article. I remember feeling the same way during my psych rotation: Can I crack a joke? Are the paranoid schizophrenics going to go crazy if I smile at them? Will the demented people take what I say the wrong way and tell my attending I harassed them? In the end, it's a matter of discretion, but it's nice to know that there ARE times to loosen up, and be able to address your patients - even the ones who are supposedly "not all there" - with some semblance of humanity. After all, whoever said that WE were the ones who should control the show?
****

In Psychiatry, Can a Punch Line Be a Lifeline?

By BENJAMIN BRODY, M.D

“Has anything changed since the treatments began?” I ask the patient, as he lies down on a stretcher in the ECT suite. The anesthesiologist places an IV line in his arm and checks his vital signs. My attending psychiatrist adjusts the machine that delivers the electric stimulus. I’m a psychiatry intern, and this is my electroconvulsive therapy rotation. I’m here to watch and learn.

“My cellphone always has a great charge,” the patient deadpans.

If this were a friend or colleague, I would laugh easily. But this is a patient I barely know. He has bipolar disorder, a previous suicide attempt and a history of bizarre, impulsive behavior. In that context, his joke just feels inappropriate and overly familiar.

I’m taken aback. Is it O.K. to laugh, I wonder? An intern, with years of experience being inexperienced, I quickly glance around to take stock of the room.

The nursing assistant laughs and the anesthesiologist grins broadly. The attending psychiatrist remains stone-faced, and says, “Clearly he’s improving.” As the anesthesiologist injects a sedative, a telephone rings. Everyone’s hands are occupied; the ringing continues. Just as the patient starts to drift off, he looks over at me and says: “Can you get that? It might be the governor calling to stay my execution.”

A moment later, he’s out. The attending hands me the leads, and I feel slightly uncomfortable as I bring them to the patient’s head. The nurses are still laughing as he begins to convulse.

When I was an intern on the medical service, I often joked with my patients. It’s how I naturally relate, and carefully joking with a frightened patient is a powerful way to establish rapport.

But when I left the internal medicine floors for psychiatry, the humor stopped. On the advice of the attending doctors, I tried to be more concrete and matter of fact with psychotic patients, more empathetic with depressed patients and more authoritarian while working in a volatile emergency room. Not since adolescence had I spent so much time worrying about how I come across.

I had a vague sense that prompting a patient to laugh could sometimes be therapeutic. But when is it safe — let alone useful — to joke with a psychiatric patient? At least in the hospital, the patients seemed to have enough trouble relating to me without having to decode the nuance of humor. It seemed too risky, too ripe for misunderstanding.

Still, there were patients who insisted on joking with me.

Leading a community meeting on the inpatient unit, I asked the patients and staff members to introduce themselves and say something about who they are. “I’m a social work intern!” a staff member said brightly, followed by a patient, who declared, “I’m a chronic bipolar patient.”

This wasn’t what I had in mind; I’d imagined some type of biographical detail, not a recitation of titles and diagnostic labels. I grew uneasy as the patients started describing their personal pathology to the group.

Just as I was getting uncomfortable, one of the patients acknowledged the tension. “I’m a nursing student,” he said, with mock authority. The next patient, someone who had trouble relating to others and often missed social cues, said, “I’m the nursing manager.”

The entire group, myself included, erupted with laughter. The moment was a striking contrast to the unit’s usual sober atmosphere. Not for the first time, I wondered whether it might ever be appropriate for me to lighten up and initiate a joke.

At the end of my internship, I got my answer. I was on call at 1 a.m. on a Thursday, admitting my last patient of the evening. She was a woman in her 60s, brought in by the police for disruptive behavior in her apartment building. After being involuntarily admitted, she hid in her room and refused to talk to the nurses.

When I tried to interview her, she buried her head under a pillow, exclaiming, “I refuse all psychiatric care!” But beneath her refusal, I noticed something playful in her tone.

“That’s O.K.,” I said. “We’re good at treating people who refuse psychiatric care.”

That got a little laugh.

“Can you tell me how you got here?” No response.

Maybe I should try something more concrete? Given her age and the story I got from the senior resident in the E.R., it dawned on me that she might be cognitively impaired. “Who’s running for president right now?” I asked.

That got a response. Three people, she replied, using an epithet I can’t repeat here.

What are their names? I shot back, using the same epithet.

“Clinton, Obama and McCain,” she said. She was looking at me now.

“O.K., so what’s a nice lady like you doing in a place like this?” I asked.

Suddenly, I was in. She started telling me about her paranoid delusions about her landlord and neighbors. I sat down and started writing.

“Tell me more,” I said.

I'm just curious...

Why isn't Condeleeza Rice being re-considered for the position of Secretary of State? I thought she was doing a pretty good job, and the world leaders are used to working with her already. Is that not allowed to serve 2 terms in a row under different administrations as SOS? Has she stated that she is not interested??

"the slow fade of love"

Hmmm.... is Rilo Kiley ever going to play near me? At a time I can actually go to? Because if so, I'm THERE.

"If livin' is the problem, well that's just baffling."

strange sad song

Tell me one more time
Why you went away
It makes a little sense
In the light of day
When evening comes around
All my senses fly away

Pediatrics

I really like the way my current peds rotation assigns responsibilities to the med student. As I've mentioned earlier, I really think med students could do a lot more, and their personalities are generally those that like to rise to the occasion. Thus, there is no better way to teach and cultivate a med student than to have them perform tasks that are just a little bit above their comfort level (with supervision, of course).

Anyways, I'm on call tonight (in fact, I'm on call all week), but I'm FIRST call. So if a patient needs something, or if they're getting admitted, the nurses call ME first. Totally sweet! I really feel like I'm learning a lot better this way. I wish all rotations were like this. I like peds just fine so far, but I don't think there's anything intrinsic about the field that calls to me. But the way this rotation is being run, peds is going to be much higher up on my list of possibles than if it were being run the way, say, L&D was run.

I'm very excited about these next 6 weeks :-)

life is good

I'm sitting outside at my parent's house, enjoying the fall colors and breeze, and getting in some of my Vitamin D. Yes, I am doing some USMLE World questions, but Pandora is on playing some kick-ass songs, and the neighborhood is content and calm. Life is good.

Now for some music videos from one of my favorite bands from the 90s.