12.what the hell are you waitin' for?

[Jay-Z featuring Linkin Park - Numb/Encore]

"Now can I get an Encore...do you want more?"

It has been two painstakingly long weeks since I've been able to regurgitate my thoughts and experiences here. The medical facts and intangible life lessons -- the Crates and the Hippos.

Rotations and this 3rd year of Medical School is only getting busier but I still feel the need to record my musings now at my current premature (and perhaps often immature) stage of life. Whether it will serve as a reservoir of silly innocence...and thus a shield against cynicism and indifference or as something that my future self can laugh at many years from now...seeing how I've changed...I don't know. It can really go either way and I welcome both outcomes -- it will keep me anchored with ample material for reflection. 

Hollaback.

-----

I have been itching to back to this. Regretfully, I've already forgotten many Crates and far too many Hippos that I wanted to mull over. A lot has happened. The highlights?

1. I finished my Psychiatry Rotation a week ago.

2. I am coming off the first week of my Neurology Rotation.

The two fields are closely related yet different enough to justify their separation -- two sides of the same coin. Regardless, it makes sense that our school bundles Psychiatry and Neurology into back to back blocks, where the only difference is which one you rotate through first.

"Can't none of y'all mirror me back."

Psychiatry and Neurology are almost the medical specialty versions of Hippos and Crates. The former relies on intangibles and various subjective assessments. The latter is grounded in more reliable science -- diagnostic imaging, lesions of neurological pathways, and electrical recordings from the brain as well as from muscle. It's a wonderful dichotomy. And I've thoroughly enjoyed seeing where they overlap and where they can take on different stances.

It's the same feeling I had when I first heard Jay-Z's Encore remixed and combined with Linkin Park's Numb -- I was pleasantly mindblown and my perspective on what could and should be integrated was turned ungracefully upside-down. Who would have thought?

Well it's been 2 weeks. What the hell have I been waiting for?

"So far one last time, I need y'all to Roar."

crate -- 

Psychiatry Shelf Exam - Encore

As aforementioned I finished Psychiatry just a little over a week ago and, as will be the ongoing Encore for the remainder of this year, we had a shelf exam to mark its conclusion.

What can I say about it? It was another taxing 100-question assessment of our mastery over Psychiatry concepts and diagnoses. I will say that it was much more forgiving than the OB/GYN shelf I had taken previously -- owing mostly to the much narrower scope of material to review as compared with the various conditions that can affect a pregnant mother.

Something that also made the Psychiatry Shelf relatively less stressful is just how rigid many of the diagnostic criterias were -- the Crates for Psychiatry are built as rigidly as they come. Schizophrenia, for example, requires symptoms for a duration of at least 6 months. Which means, if someone has had hallucinations and disorganized thinking for 5 months and 30 days (let's say a day shy of 6 months) they must be diagnosed with Schizophreniform Disorder instead. More than a few questions on the shelf exam relied on counting days and timelines rather than thoroughly analyzing the clinical symptoms. It made for questions that were thankfully more black and white -- more straightforward than most.

In the end, it's as Jay-Z would say: On to the next one...

"Grand Openin', Grand Closin'"

-----

Neurology Week/Weak One - Numb

From Psychiatry straight to Neurology. I just finished my first week.

As I alluded to, the switch required a transition to more objective assessments. There is still an assessment of mental health and cognitive function. We even perform the Mental Status Exam (MSE) and a Mini-Mental Status Exam (MMSE) when needed. That may be where the similarities end, however.

We follow up those initial mental/cognitive assessments with as full of a Neurological Exam as we can manage. We assess cranial nerve function -- including vision, hearing, and at times the Patient's sense of smell. We continue by assessing the sensory and motor functions of the face and, ideally, the rest of the body -- assessing strength, range of motion, deep tendon reflexes, and the ability to feel temperature as well as touch....just to name a handful of parameters that are tested.

"Then you drop a couple of hits, look how they wave at you."

Eliciting reflexes is particularly enjoyable, when successful of course.

More than anything this past Week, I've realized just how common it is for Patients to feel Weak. There are countless reasons and etiologies that may lead to weakness  -- metabolic, toxic, infectious, neurological, trauma, etc. Almost every medical specialty has some stake in working up a Patient that presents with Weakness. In many cases, our Patients not only feel Weak but also Numb and those two together make for an instant call for Neurology.

By finding out exactly where and to what degree a Patient has lost strength and/or sensation we can gain some insight into what may be dysfunctional. Loss of function in the face, for example, would instantly eliminate spinal cord pathologies as the face is not serviced by the spinal cord -- we'll suspect something in the brain or brainstem. On the other hand, if we notice fasciculations of the leg -- involuntary muscle contractions -- we might then suspect a lesion at the level of the spinal cord. Much more concrete. Much more Crate-like in comparison to the assessments we were performing last month in Psychiatry.

"It ain't to play games witchu, it's to aim atchu."

Some of the tests for the Neurological Exam can feel silly. We ask the Patient to smile and frown and squeeze our fingers as hard as they can. It feels like a game at times, but every single test is purposeful and full of useful clinical information. 

"and I need you to remember one thing..."

I am thoroughly enjoying it. I am also admittedly biased as Neurology or Neurosurgery are my top prospects as far as medical specialties. It's not all pleasantries, however. I mentioned it our job to get as full of a Neurological Exam as possible and the reason for that is because it's not always possible -- especially with our sickest Patients.

"I've become so Numb, I can't feel you there."

hippo --

Nothing to Complain About. - Numb

In only one week I've already seen and experienced a number of heartbreaking cases.

The most severe Neurological Disorders can be completely and utterly debilitating. The biggest Crate from the week has been my greater acquaintance with the symptoms of Weakness and Numbness. The biggest Hippo of the week, however, is an overwhelming sense of humility and being constantly reminded of how lucky many of us are -- courtesy of our Patients who go through so much.

"I've become so Tired, so much more Aware."

I absolutely can not forget an experience from this past week where my Attending delivered a diagnosis of Amyotrophic Lateral Sclerosis (ALS) -- also known as Lou Gehrig's Disease.

It's the same disease that has gripped Stephen Hawking and it is near the top of my list for worst diseases ever. Along with Cancer, Huntington's Disease, and an unfortunate slew of other diseases... ALS has no cure. The supportive and palliative treatments we do have are limited.

It results in progressive paralysis of essentially every muscle in the body. One's sensory capabilities are generally spared as is one's cognitive abilities -- but it is almost a cruel tease in light of everything that is going on.

The Patient burst into tears. Who wouldn't? All I could think about is not being able to hold my loved ones. Of not being able to carry or play with the future children I hope to have some day. Of relying on others for the rest of my existence...the inevitable guilt and frustration I would have from being unable to give back the way I would want. If my mother cried for any reason, I wouldn't even be able to rub her back let alone wipe away the tears I only want to see in times of happiness.

I thought about death. The diaphragm -- the muscle responsible for breathing is also susceptible to ALS' ruthless progression...

"Feeling so faithless, lost under the surface."

That Patient became Weak. I became Numb.

I became Numb to all the petty worries I usually have. The lack of sensation puts many things into perspective. What's most important. What we can do without. What we should be fighting for. I felt terrible for that Patient. But when you see something like that you become Numb to other things as well. You become less tired, less hungry, and endless hours of studying become less tedious.

"and every second I waste is more than I can take."

These are the Hippos. The intangible human fuel that keeps us going.

No time to be Numb when every second matters.

-----

Rounds Abound. - Encore

Why are we so tired? And hungry? And why must we study so much?

For our Patients first and foremost...and then for our never-impressed Attendings.

"Don't know what you're expecting of me."

No matter how much we think we know...somehow Attendings always find the chinks in our armor of baby medical student knowledge. It's an infamous relationship -- with flocks of medical students and interns following the single Attending like ducklings crossing a busy street. 

"Put under the pressure, of walking in your shoes."

But everytime we are shown that our knowledge -- our Crates -- are not where they should be it only shows us where the holes are so that we may patch them up. I've alluded to it in a previous post, but Rounding and being tested by Attendings is an Encore we have to embrace. Just as we have to accept the Encore of shelf exams after every Rotation.

Just as we have to begrudgingly accept 

the Encore of patients who are beyond our help...

...and the resultant hope and renewed resolve that springs

from their strength in the face of tragedy.

"Now can I get an Encore?"

"Thank you, thank you, thank you...you're far too kind."

10.and baby. its amazing im in this maze with you.

[Jay-Z featuring Justin Timberlake - Holy Grail] <--- click for a really good cover of the song.
[Album: Magna Carta... Holy Grail]

"i just can't crack your code."

I just finished my second and final week on the Inpatient Service of my Psychiatry Rotation.

I joked that with the completion of my Inpatient stint that the service just discharged their most bizarre patient (referring to myself of course). Haha. 

They say that Humor is a mature defense mechanism and I realized that the joke itself was my attempt to reconcile just how much my perspective of Psychiatry and Mental Health has changed over the course of two surprisingly short weeks. 'Surprisingly' because I thought the days would drag along like a rusty anchor on concrete.

I'll be the first to admit that I wasn't looking forward to this Rotation with the greatest enthusiasm. I know I showered my first week on Psychiatry with overwhelming praise, which I still stand by, but in hindsight I realize I was so caught up with being pleasantly surprised I never took a step back to mull over how I viewed this medical specialty...and really everything else in life.

If there is one thing I need to work on it's self-awareness. 

If there is anything these first two weeks have taught me...that the Patients I've seen have taught me...it's just how valuable that kind of awareness is. Fortunately, I've also gotten some clues and some inspiration as to how I can work towards it.

"but I still don't know why, why I love it so much."

crate --

:::Insight

Insight is one of the concrete qualities we are trying to assess as part of the aforementioned Mental Status Exam (MSE) that we perform on every Psychiatric patient we see. One part of that Crate we call a Psychiatric Work-Up.

What we are assessing, essentially, is whether the Patient is aware of her/his illness, state of mind, and general well-being. It's very telling. For some of our sickest Patients they have no idea that their delusions of electrified floors or headbands that grant the wearer certain powers are not real and, frankly, quite bizarre. They believe everything is fine. In the absolute worst case some of our Patients mentally exist in an entirely different world that they have fabricated...and we are lucky if we are ever able to 'visit' them there and somehow get in touch with anything tangibly human that resembled their former selves.

Sometimes we break through. We achieve a moment of lucid innocence. There is Insight.

"one day you're here. one you're there. one day you care."

Too often, unfortunately they sink back. In others, we can not get through to them at all.

"you're so unfair."

When Patient's have some Insight, even just a little, their Prognosis and our Hope for them increases exponentially. Perhaps with the appropriate therapy. Perhaps with strong family and social support. Perhaps with proper assessment and modulation of surrounding stimuli. Perhaps with the proper administration and dosing of medication. Just maybe we can help our Patients when things seem most unfair. Just maybe we can help them stabilize so they can return to their lives and their loved ones.

Just maybe.

"sippin' from your cup 'til it runneth over. Holy Grail."

hippo -- 

:::it's not a Fail if you've found the Holy Grail

Cure is a relative term I realize.

In actuality this sentiment can probably apply to all of Medicine. When one can prescribe an antibiotic for a minor skin infection that promptly resolves it is considered a Cure. But when a cancer Patient gains another 3 months to say goodbye to their loved ones...that can also be considered a Cure. It's also possible that a comatose Patient in the ICU with no brain activity and is on every life-sustaining device ever created can be Cured...by turning the ventilator off. A final Cure. As Final as can be.

"you get the air out my lungs whenever you need it."

As I have learned and mentioned, some of our Psychiatric Patients will never or only briefly reach a state of conscious lucidity -- free of any hallucinations, delusions, or other mental traps preventing them from being their true and beautiful selves. But how about the rest?

"and you play this game, in spite, to drive me insane."

For the rest -- for better or worse -- the only Cure we can offer is to prevent as many pervasive thoughts as we can with the tools available to us and to achieve a stable baseline for the Patient. It's all relative. Each Patient in Medicine is unique and Psychiatry is no exception.

~~~~~~

We have had a Patient for the past week with a diagnosis of Catatonic Schizophrenia.

She was relatively young which only served to make the entire situation more tragic and heart-wrenching. She displayed extremely bizarre behavior with abnormal postures and erratic movements of her hands and feet. During a particular interview with her and my Attending she started banging her head on the table and subsequently threw herself to the floor -- all with the same flat facial expression. 

No Emotion. No Insight.

The next day I was caught off guard. Entirely off guard. I sat for another interview with her and my Attending and she was now making eye contact. She sat quietly and answered questions intelligently. She said she felt much better. She apologized for her actions the previous day. She laughed at a light joke my Attending made and I saw her wonderful smile creases for the first time. Was this a Cure?!

"one day you screaming you love me loud."

I spoke to soon..as she then began to rock back and forth in her seat. The eccentric and repetitive movements returned...albeit to a much less dramatic degree. She still retained some Insight, however, and although there were still instances of bizarre movements she had regained the ability to express emotion with her facial expressions and her eyes. Her face had regained some humanity.

"the next day you're so cold."

After that interview my Attending revealed that he had increased the dosage of one of her medications and added another one on top that. My Attending expressed that this may be the best baseline we could achieve for her as medication costs and side effects would likely soon outweigh the benefits.

Was this a Cure?!

For this Patient, yes this was a Cure.

And she was Aware and Thankful for it.

~~~~~

The biblical Holy Grail is an object sought after in story after story. In all of history, Dr. Indiana Jones was probably the closest to finding it (Nerd Alert). But in all seriousness it is that kind of Search for the ultimate treasure -- that ultimate cure -- that parallels what I have seen daily on the Inpatient Psychiatric Unit.

Many Patients will never come back to us from the exotic worlds they have ventured to, but we sometimes can stop the floors from electrocuting them and sometimes we can quiet the voices and conversations that constantly intrude into their minds. And that's about it. They will never be 'normal' according to society's most widely accepted conventions. We do all that we can.

That is far from a Failure though.

It's just their particular Holy Grail.

:::Inside Insight

Seeing and trying to help Patients who have no choice but to exist completely unaware of everything they are, let alone everything that surrounds them -- it's very humbling.

I am lucky.

I don't have fears, and impulses, and voices that are so pathologically potent that I can not function. I am free to take stock of all that I do and all that I say and see if they all match up to the kind of person I would like to be and the kind of life I would like to live.

I have no excuse if I lack Awareness...if I lack the Insight that eludes so many of our Patients.

And since it's a feat and certainly an accomplishment to determine what's going on in one's own head, I've never understood the need for others to assume the content and thought processes that others may have. Gossip is gossip I suppose but when the purpose is to bring down another human being what good does that do for the Patients or for the world at large for that matter?

"you curse my name, in spite, to put me to shame."

I've seen it in the Hospitals and I've certainly seen it in almost every walk of life. For better or worse, I recognize hearsay as a very human activity, but I don't think I could ever see any good reason for the spread of negative words and sentiments.

"have my laundry in the streets, dirty or clean, give it up for fame."

Life is already challenging as it is. And when I see all these Patients that are looking for help and peace of mind it's always a reminder that there are bigger things at stake. I've heard a number of negative comments about others and I've heard a number of negative comments directed at me as well and the only thing I can think about are the Patients who could care less about miscellaneous conversations that may or may not be true.

What a waste of time and effort that could help others.

"fool me twice, that's my bad, i can't even blame her for that."

Regardless, I respect so much those individuals who are very self-aware and have a very profound sense of Insight. I will be the last to ever make that claim, but it won't be for lack of desire or effort. At the very least I have Insight into what drives me -- helping Patients. I have Insight into what I consider valuable -- the Hippos -- the relationships and memories and struggles and intangible human inspirations that are too easily overlooked and forgotten these days. There is no one that can refute these initial Insights I have of myself.

After these past two weeks I've realized we're all just searching for our own Holy Grails.

Those elusive Cures.

Mine is to help others find theirs.

What's yours? 

(Let's find it!)

"why you mad? take the good with the bad."