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."

09.i try to channel you in hopes that i could steer you back.

[Nicki Minaj - Dear Old Nicki]

[Album: Pink Friday]

"maybe you died 'cause everybody asked me where you at."

Our Shelf Exams last week marked the End of a Rotation...and as with all ends it also marked a new Beginning. From OB/GYN I have moved on to Psychiatry and the two fields couldn't be more different.

My first impression of Psychiatric practice has me convinced that this specialty represents the purest form of Patient Interaction and exhibits the most intimate Rapport Building in the entire Profession. The Medicine part is at a minimum, at least what we conventionally think of as Medical Practice -- medications, and physical exams, and procedures.

Through conversations and the most careful of observations Psychiatrists must somehow unravel and decode what I consider the most complex entity ever created: the Human Mind.

I admit I have always judged this book by its cover...and not always in the most positive manner. By book I mean the Diagnostic & Statistical Manual of Mental Disorders (DSM). And by the DSM I mean the field of Psychiatry in general. But I also admit that my judgement of Psychiatry stemmed mostly from ignorance and a lack of awareness as to what Psychiatric Physicians and Psychiatric Patients face on, at times, a near constant basis.

Disease is Disease, and Psych is no different.

My first impression of Psych has me convinced that First Judgements 

are only guesses and assumptions at best. 

With that, I think my selection of a Nicki Minaj song is so appropriate for this entry. I don't know a contemporary artist more judged and ridiculed than Dear Old Nicki. Whether we like it or not she is as perfectly imperfect as the rest of us...and admit it: 

You like that Super Bass.

Book covers are meant more for protection anyways right?

"but i needed to grow, and i needed to know.

were there some things inside of me that i needed to show?"

crate -- 

:::The Mental Status Exam

This is the backbone of Psychiatric Evaluation -- the Mental Status Exam (MSE).

It is the Psych equivalent of a conventional Physical Exam that nearly every other specialty performs. Yet instead of shining blinding lights into each eye and hammering on miscellaneous tendons -- both to elicit and assess some sort of reaction -- when performing an MSE one would, alternatively, just have a conversation. Questions are kept at a minimum.

Ideally, a 5 minute conversation starting with "How was your day?" should and could lead to all the answers a Psychiatrist seeks.

The goal doesn't differ though. We are still attempting to elicit and assess some sort of reaction...where any and all reactions are welcome.

But the MSE is a Crate after all, and as such it does have concrete parameters and very tangible aspects. As a mental exercise as well as an informative gesture the following are the broad categories being assessed during an MSE:

Appearance

Speech

Mood

Affect

Thought Process

Thought Content

Perceptions

Sensorium/Cognition

Insight/Judgement

And so the MSE Crate contains quite a lot. Appropriate, as our Patients often have a lot to say whether they realize it or not.

"you told me you'd come when i needed you.

and you said it so sweetly, i believed you."

Whether it takes the aforementioned ideal of 5 minutes or a few hours or even a series of days Psychiatric Evaluations are designed to hone in on our most Human aspects. It's not bleeding, or coughing, or growing tumors that are in focus with the Psychiatrist's lens. That is, unless you are referring to the slow bleed of Depression that decimates those afflicted from the inside out. Or the malignant panic of someone suffering from debilitating Anxiety or Post-Traumatic Stress -- metastasizing towards the depths in us that we hold so close and dear.

Disease is Disease, and Psych is no different.

I have been, unfortunately, quick to Judge otherwise.

~~~~~

Like most things in Medicine, I have found, it is the Patients and Experiences that have taught me best and have left the most lasting impressions. I have spent this past week on the Psychiatric Inpatient Service where we spend all day meeting and talking with our Patients...often 10-12 Patients -- 10-12 different Stories -- in a single day.

Each and every Patient had a cover...a facade. Some by deliberate choice but most had absolutely no say in the matter -- Powerless or Clueless or Both. What I came to realize is that these 'fronts' served the same role as those around books...they are protective. 

Defensive. 

And by no means do they represent what lies inside.

"but you was underground, and i was mainstream.

i live the life now that we would daydream."

"my only wish is you come enjoy it with me."

hippo -- 
:::The My Status Exam

The MSE scratches at the surface, but it is the surface of an iceberg that is larger and more encompassing than any Hippo you'll ever see.

It's a little unnerving to realize that parameters like body posture, word cadence, and thought progression can act as canaries -- indicators -- of thoughts and feelings that lie much deeper within the mineshaft of our consciousness.

I know every Patient is different. That is common sense and emphasized to the maximum in Medicine -- especially now at the advent of the Personalized Medicine movement. Yet, more often than not, we still refer to groups of Patients, mostly for efficiency's sake. You have "the hypertensives" and "the diabetics," for example, (both of which are unfortunately very common) and we have more or less set regimens to deal with such situations.

As the most naive Medical Student in the history of Medical Students I walked into Psychiatry on Day One thinking we could similarly corral Patients into "the schizophrenics" or "the bipolars"...and I couldn't be more wrong.

It worked on OB/GYN where the treatment plans depended less on a person's upbringing and state of mind. Yes, Patient Preference and Compliance are paramount and will of course factor into final decisions. But the intimate details that make each of us unique are not critical to the specific anti-hypertensives used or the dosages of insulin administered. When it comes to Psychiatry, however, our personal stories are not only critical but extremely crucial to a good outcome. This is the Mind after all -- the human aspect that makes us perfectly imperfect...and no two Minds are identical.

"and tell me that you comin' back and you just took a break.

maybe i blamed you for everything that was my mistake."

The Hippos yelled at me in anger this week for my naiveté. I realized that those Hippos -- those human intangibles -- that I so readily defend and spout about can be elevated further than I've ever thought possible.

I have always relished personal stories and emotional well-being but have usually treated those aspects of Patients as a means to build rapport and ensure comfortability -- building a human connection. I have never been so attentive and sensitive to them, however, as a ways and means to diagnose and treat and change the course of a life-or-death situation.

~~~~~

We had a Patient this week who suffered from repeated auditory and visual hallucinations -- often seeing footsteps in the shadows and hearing sounds that were not present. She could not work or function...let alone sleep for that matter...out of fear for the unknown.

Don't judge this book no matter how much you want to I told myself. She was young, dropped out of high school, had an extensive history of substance abuse and was rather unpleasant in conversation. It's tempting to let one's mind wander towards certain assumptions.

"i had to make them changes, i hoped you understood.

you see for every bad, i did a ton of good."

I'm thankful for keeping my perfectly imperfect human judgement in check. Yes the cover of this book -- this Patient -- was not the most attractive...according to society's most widely accepted conventions, but I later learned why. 

Covers really are meant for protection over everything else.

Medical treatments were not effective for this Patient. Repeated Psychiatric admissions in a series of institutions were not effective. Behavioral Therapists and Social Workers were perplexed and at a loss. I had three meetings with the Patient throughout the week and the last one was with my Attending -- who is the best Hippo-ologist I have met thus far.

The Patient, as aforementioned, was not the most pleasant. She was very guarded and soft-spoken. She verbally denied any abuse or substantial trauma -- physical or otherwise. The only clue we could get was an extreme aversion to 'moving shadows' and 'footsteps' and 'sounds trying to get her,' especially at night.

The gut reaction is a diagnosis of Paranoid Schizophrenia, 

but what good does that do for the Patient if she is not getting better?

After meeting with the Patient this 3rd time my Attending turned to me and asked if I ever slept with a nightlight. I replied, yes when I was little. He then asked "Why?" to which I replied I was worried that something would come into my room and eat me. For reals.

He then asked me what I would do if something actually did come into my room when I was younger. I replied I have no idea. My Attending told me that the Patient, too, had no idea what to do. Boom.

Not just a Mental Status. This was a My Status.

She was repeatedly and traumatically abused...to the point that she had no idea. To the point that she denied it and truly believed nothing had happened. There are no Medications or Procedures that are definitive enough for something like this. There is only the personal healing that could come from gradual realization, a core acceptance, and the most wonderfully intimate/intrusive of human connections that Psychiatrists have mastered.

She had come so close to killing herself multiple times. She never knew why until now.

At that point she made eye contact for the first time. She said she felt better.

Mind Blown.

"in hindsight i loved your rawness and i loved your edge.

'cause it was you who talked me down from jumping off the ledge."

~~~~~

It was quite a First Week on the Psychiatry Service. I may have just found the natural habitat of Hippos within the world of Medicine. Intangibles are everything here.

Gut reactions and Judgements may be inevitable as humans but they can not be the end all, be all...I realize. In dramatic fashion I've seen how much each Patient has to say, again, whether they realize it or not.

Disease is Disease, and Psych is no different.

Above all I have seen just how many and how potent the 

Defenses we have erected around ourselves can be. 

We are all Books, ready to be read.

But the Cover is not there to be an indicator of who I am.

It's there to keep me safe.

"but im standing here calling, i cant see you.

but i am holdin' you, holdin' you, holdin' you 

to that."