14.it's not much of a life you're livin'.

[Rihanna featuring Mikky Ekko - Stay]
[Album: Unapologetic]

"round and a round and a round we go."

Finished Week 3 out of 4 on Neurology -- this one spent on the Neuro ICU floor.

Edit: I started this post at the end of Week 3. I now finish this after the final week and immediately after the Neurology Shelf Exam. Entry shall be adjusted accordingly. sho nuff.

The Intensive Care Unit is as Medicine as Medicine can get.

Although the unit I was in this past week had a Neuro focus it allowed me a quick glimpse at what a general Medical ICU might entail. Despite the Neurological emphasis, every single organ system was still reviewed and examined. Cardiovascular. Respiratory. Renal. Gastrointestinal. Genitourinary. Younameit. The Medicine I saw this week was so thorough and all-inclusive -- at times I forgot I was in my Neurology Rotation. Conversations concerning other body systems, more often than not, took center-stage as the Residents and Attendings scrutinized every detail to ensure the most fragile of Patients did not deteriorate any further.

"I threw my hands in the air, said, 'show me something.'"

I've often wondered what Intensive or Critical Care Medicine would be like. I braced myself at the beginning of the week because I wasn't sure what to expect. It turns out, possibly, that this past week is the most I've ever learned within a one week span as a 3rd year medical student.

In my head, and in general, hospital specialties tend to be roughly divided between the Medical Specialties and the Surgical Specialties. If nothing else, this past week has me convinced that the kind of thinking and consideration that go on in the ICU warrants a third designation...or perhaps a hybrid of both.

In Medicine one talks and forms differentials for hours.

In Surgery one stands and manipulates instruments for hours.

In the ICU one does both. At the same time.

It's Inspirational and Intimidating and Intriguing. All at the same time.

Maybe the "I" stands for all of those instead of 'Intensive'?

crate -- 

--I.C.U.

If Medicine is analyzing every symptom, every Crate, to diagnose what's wrong...then ICU Medicine is analyzing every last splinter of each Crate AND all the nails that hold it together...just to keep Patients alive.

The first couple of days my brain was pretty much swimming. Most of the words spoken between the Residents and Attendings went right over my drowning head. I feel that we have been trained and conditioned so well to look at the body just one system at a time, with limited thought as to how complex the interplay can potentially be within the human body as a whole. That's not a surprise, however, since as aspiring Physicians we know we have to put all the different Crates we are learning together like puzzle pieces into a final mosaic -- a final diagnosis that we can act upon. The surprise, instead, is that ICU Patients have multiple body systems failing. Too often, every single organ system is failing. As a result, there is no single Medication or Procedure that can fix ICU Patients. That kind of luxury does not exist.

"It's not just something you Take...it's Given."

And here is where I left off before embarking on a frantic week-long study binge for the Neurology Shelf Exam earlier this morning. Admittedly, the Neuro ICU experience is not as fresh as the day I originally started this entry. Regardless, it's still an experience that is hard to forget. And you know what? That is one thing that, in particular, sticks and hits home harder than Miguel Cabrera of the Detroit Tigers (holla). Nothing about the Patient can be forgotten in the ICU, lest you overlook or counteract a vital fact or exam finding. Allergies? Recent anticoagulation medications? Renal excretion and toxicity? Increased PEEP ventilator pressure leading to decreased venous return?

It's a veritable rodeo in there.

"Oh now, tell me now, tell me now, tell me now, you know."

Micromanagement in its most excruciatingly pure form. That is the Crate that is the ICU. Every microliter or microgram of anything that enters or leaves the body is recorded and accounted for. Every organ system is monitored as intensively as NASA in Houston does for every spacewalk (possibly a slight exaggeration here, but you get the picture). As a result the Attendings on this service are like hawks, with oversight that would put the visual acuity of eagles to shame. I was very impressed with the decisiveness and breadth of knowledge that the Attendings, Fellows, and Residents had while caring for the sickest of Patients. In a way, you see...or try to see everything in the ICU. I was blown away.

"It takes me all the way."

hippo --

--I. See. You.

So many labs. So many disease processes. So many medications, procedures, and intertwining differentials to carefully and methodically tease apart. It's a wonder there is any room left for Hippos with all these Crates.

But they always persevere in Medicine. Duh.

I technically experienced a death during my week at the ICU. I regret not having the privilege of meeting the Patient while they were lucid and conscious, but perhaps its for the best -- as the personal connection may have just destroyed me.

I learned, initially, about the Patient's story from medical histories and Physician's notes. I did my best to learn everything I could about him because I secretly and fervently hoped that, even with the slimmest of chances, I might find something that the busy Physicians had overlooked and could use to reverse the Patient's, then, comatose state. I found nothing.

"All along it was a fever."

It started with the mildest of symptoms... a low-grade fever and a throbbing headache that persisted and could not be attenuated by over the counter medications. The Patient was found to have a Subarachnoid Hemorrhage that prompted an immediate trip to an ER and then an OR. I found nothing.

"A cold sweat, hot-headed believer."

I still kept on looking. Believing. Digging through years old medical records and CT scans. Even though I found nothing I thought it for the best that I knew this Patient inside and out, so that I could relate his story and predicament with every new Attending and Resident I came across. I wanted to know him because that's what you do in the ICU -- you look at everything and you don't forget.

None of us believed he had any family. No visits. No contacts. I found nothing.

The day he passed away, however, was probably the day I got to know him best. His wife came. Yes, he had a wife -- and one that without a doubt loved him dearly. She allowed us to remove his endotracheal tube and free him of the necessary monstrosity that is the mechanical ventilator. His sister came. His aunts and uncles came. Two of his daughters came. His grandchildren came and almost unleashed the safety valve on my tear glands when they saw their grandfather like they had never seen him before.

No medical records, lab value, or diagnostic image could have allowed me to see him as a person more clearly than the day he passed away -- when family member after family member filed through to say their goodbyes and have their final conversations.

ICU. I See You.

I get it now.

"He said, 'if you dare...come a little closer.'"

--Shelf Exam. Self Exam.

I thought about him today. I had a question that matched, pretty closely, my Patient's initial presentation to the hospital. I'd like to think I got that question correct -- because I saw it in the ICU. Because I saw him.

3rd year clinical clerkships are a unique experience. In many ways it's the same rinse and repeat story we, as medical students, are all too familiar with. Another month? Another rotation -- punctuated at the end by another Shelf Exam. Been there. Done that.

But I am seeing it all around me. A slow transformation. Yes, it is extremely repetitive. Sometimes it can be, admittedly, extremely boring. At all times it is most definitely tiring and taxing in more ways than one. But I am seeing hints, here and there, of what I looked up to in my Pediatrician and in other clinical mentors I've encountered in my short life.

The way my colleagues carry themselves. The style and content of the conversations we now have. They are almost entirely different from the ones we had two years ago. And although we are far, far from being full-fledged Physicians...the only way I can describe this new style and culture...it's all very 'Doctor-ly'.

"Funny you're the broken one, but I'm the only one that needed saving."

My ICU Patient was sick. And although he never opened his eyes or said a word he inadvertently showed and told me more than I could have ever imagined. He may have been physically ill but he was the one that helped me feel better and more rejuvenated.

There's probably a reason Medical Education is the way it is...and has been for well over 100 years. It is tiring, and boring, and frustrating, and on the surface it can be a waste of time. But experiences like this are hard to come by and are too valuable to miss. 

How else can we gain this insight? 

How else can we become Physicians?

"'Cause when you never see the light, it's hard to know which one of us is caving."

And for all the Practical individuals out there...all these intangibles...this anecdote and this 3rd year experience. Well, again, I'd like to think I got at least one more question correct on today's Shelf Exam. So yes, there is a technical gain in all of this. A little surprise Crate if you will.

If you ask me, however, every Shelf Exam deserves a Self Exam.

I saw a lot in the ICU.

Ultimately, I saw myself in the ICU.

No doubt I called my Mother and Father that day after being "busy" for the past 2 weeks.

"Makes me feel like I can't live without you."

I only wish I could have had a conversation with him.

I want you to Stay.

13.if i told you that a flower bloomed in a dark room, would you trust it?

[Kendrick Lamar featuring Drake - Poetic Justice]
[Album: good kid, m.A.A.d city]

"But I can never write my wrongs unless I write them down for real."

"P.S."

Just finished Week 2 of my Neurology Rotation -- well into the swing of things, more or less.

As much as I like to fly off into the comfy fluff of unspoken emotions and heart -warming/-breaking stories I realize one can't be so airy as to lose sight of and acquaintance with ever-so-reassuring solid ground. I hope to veer slightly back towards practicality and reality. This is not to say that the wonderful Hippos I try to find along the way are irrelevant, but that they do somewhat lose value when concrete events are ignored.

I could reflect on the death of a patient forever -- which I thankfully, have not personally experienced yet. I could tease apart and attempt to decipher the whirlwind of emotions and the facial expressions of everyone around me that say so much without a single verbal utterance. But when it comes down to it, I would rather have been skilled or tactful enough to have saved that life. That requires Crates. 

"You live life on an everyday basis."

I suppose what I'm trying to say is that the intangibles are important and necessary in my humblest opinion. Yet despite their vital nature it does represent a type of wishful thinking that has difficulty manifesting in our reality of disease and various injustices. I've been getting carried away with the Hippos, admittedly because of my deep bias favoring them.

Like Anakin Skywalker's destiny it's time to bring balance to the Force. 

(Nerd Reference: Star Wars)

It's appropriate, as this past week has been full of slightly sobering realities. The Crates we have learned up to this point have been purely academic -- symptoms, medications, statistics, etc. Now that we are in the hospitals and out on the wards there are other Crates to pay attention to lest we miss them altogether. Politics exist and the teamwork required of modern medical practice is, more often not, plagued by the double-edge of social tension and clashing identities.

It's time to deflate a little. Air can be thin when too far up.

"I mean I write poems in these songs, dedicated to you when...

you're in the mood for Empathy, there's blood in my pen."

crate --

:::Consults and Progress Notes

The most obvious Crates are all the symptoms, lab tests, and other clinical signs that we attempt to memorize and recognize within our Patients -- all in an effort to alleviate or avert illness.

All well and good. But from the surgically inclined specialty of OB/GYN to the uniquely subjective nature of Psychiatry I have finally spent considerable time in the relatively conventional inpatient world of Neurology. With that comes the monolithic reality of job duties and paperwork.

Physicians do not simply live in a House M.D.-like world where they can sit in rooms of glass and metal contemplating diagnoses all day errday. Yes, differentials and discussions are made but documentation is key and central to the practical reality of Physicians and other healthcare professionals. Like other professions it's not as glamorous as media and pop culture make it seem.

"They say conversation rule a nation, I can tell."

In fact, what I've realized and experienced thus far has me convinced that more and more of a Physician's time is spent pouring over laboratory results, diagnostic images, and notes from others rather than actual face time with the Patients themselves. This is before the Physicians go ahead and write their own daily Progress Note. The process takes forever. And it's repeated all day errday.

The added responsibility of Consultation adds another dimension. The various specialties that make up modern Medicine not only have an obligation to the Patients within their service but also lend their knowledge and insight to Physicians in other fields when needed. That package deal comes with even more note sifting and literature searches -- so much so that Physicians can effectively be described as data miners if one wants to get technical.

"Everytime I write these words, they become a Taboo."

It's a lot of work, but there's no way around it as far as I can tell. Documentation is everything these days, with multiple Physicians in multiple specialties from multiple facilities working on the same Patient. I am not even going to delve heavily into the legal implications that can result from shoddy records and Physician dictations that are any less than pristine and meticulous.

It's a lot of work. Welcome back to Earth.

"Read slow and you'll find, gold mines in these lines.

Sincerely, yours truly...

...and right before you go blind"

"P.S."

hippo --

:::Teamwork and Division of Labor

It's a lot of work. It's also, as aforementioned, not anywhere close to the satisfying drama of Dr. Meredith Grey's life or the comedic antics of Zach Braff and Donald Faison on Scrubs.

Modern Medicine is a team sport. A good thing. Though where before it may have been a pleasing innovation in the healthcare field, it is nowadays, seemingly, a core requirement -- Physicians can no longer operate solo like the practitioners of old.

"And they say communication save relations, I can tell."

Above everything we are and always will be Human. We are social creatures for all the double edges that it comes with. Patients have the ability to annoy us. Our fellow colleagues can annoy us. Sometimes we have bad days -- we lose our keys, we argue with significant others, we get pimples on the most visible and prominent parts of our face. Life happens. Human life happens.

On more than one occasion this past week I have heard my Residents vent about life, about inefficiencies within the system, about other Residents or healthcare professionals not picking up the slack. They are not complainers by any extreme means, nor are they particularly diva-ish drama queens. More often than not I agreed with them...or at least saw where they were coming from and could not blame them for what they say and feel.

"A fatal attraction is common.

And what we have in common is pain."

These are far from the facts and figures I've originally described as the Crates we are here to learn concerning Medicine. It's far, even, from the Consults and Progress Notes -- those tangibles -- that I've described above. These are the raw Hippos that I can only now see and appreciate as a 3rd year medical student on the wards...the need to interpret social situations and balance the tight rope of one's personal viewpoints alongside the 9 billion others that exist in this world.

Sometimes we have to put aside differences to keep everything smooth. To ensure that Patients receive quality care. Sometimes we have to take a time out and let our closest companions know what is going through our minds before we supernova explode -- even though we know nothing will change. Sometimes we need to suck it up and grow up so that we can let others know how and what we feel....so we can finally finish that darn Progress Note and hopefully see that next Consultation.

Maybe at that point I could get lunch...maybe? Want to join?

"Every second, every minute, man I swear that she can get it."

Even with all this seemingly 'harsh' reality it still stands that nothing can overshadow this profession in my mind. In fact, it may be all this conflict and hidden turmoil that partially attracts me even more towards this calling. Physicians, after all, take an oath to take care of People. Human Beings.

And who better to take care of them than us Humans with our wonderful inefficiencies? 

Yes, I want to take care of my fellow men and women. But in doing so I don't want to give up my Humanity. That package deal comes with complaints, and he-said/she-saids, and late-night delirious laughter. It comes with others. And I would hate to be alone. Who will laugh at my not-funny jokes?

So I'll take it.

It's nice to feel solid ground from time to time.

"Poetic Justice, put it in a song."

When you figure out you need someone.

When you figure out it's alright here in the City.

And you don't run from where we come from.

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."

11.the only place where thugz get in free -- and you gotta be a G...

[Tupac Shakur - Thugz Mansion]
[Album: Better Dayz]

...at thugz mansion...

"Nothin' but Peace, Love, Street Passion.

Every Ghetto needs a Thug Mansion."

This is week 3 out of 4 on my Psychiatry Clerkship.

As aforementioned, I finished my rotation through the Inpatient Service and spent the past week at my hospital's Psychiatric Crisis Center. It's an Outpatient Emergency Room, of sorts, for Psychiatric and Mental Health emergencies -- in other words it's a wildly different experience.

What Hippos and Crates are in store?

It's for the severe nervous breakdowns, the imminent suicides and homicides, the unrelenting voices and visions that can push any person to the very literal and figurative edge. I'm glad that centers like the one I've been at are in existence, it's not only the body that may require time-sensitive treatment but the mind, also, can oftentimes need the same urgency and medical expertise.

I've found that it's not that simple. Especially for My City and the Patient Population we have here. Detroit is not the healthiest city out there. Or the richest. Nor is it on any top ten list of desirable places to live. But, it's My City.

"Every Corner, Every City. There's a place where life's a little easy."

Many of our Patients are uninsured, or on Medicaid, or on Disability. As it turns out one of the most straightforward ways to obtain some kind of government-provided benefits/income is to receive a Psychiatric Diagnosis of Major Illness. Schizophrenia. Bipolar. Major Depression. Whathaveyou.

As such, the biggest thing I've realized on this Outpatient Service is the difficulty of distinguishing between those who are actually sick and those who are looking for some secondary gain -- the Malingerers.

"Ain't no heaven for a thug, n*gga.

That's why we go to Thugz Mansion."

No matter how hard it is to separate the 'boy who cried wolf' from those who are already being ravaged by a pack of carnivores, it is our duty to stay resolute. There is no where else for these people to go.

Thug. Lowlife. Homeless.

The only labels we use are Patient.

Even though we operate out of an ancient structure next to a

Burger King and a Liquor Store...

I'm sure to those who are in need, it looks like a Mansion.

It's hard, but we have to keep believing that's the case.

"No one knows my struggle. They only see the trouble."

crate -- 

:::Malingering.

I've already alluded to it, but for formality's sake here is the Crate -- the definition for this official Psychiatric term:

"Malingering involves the feigning of physical or psychological symptoms

in order to achieve personal gain."

Some common reasons to fake sickness are to avoid the police, receive free room and board, obtain narcotic medications, and to receive monetary compensation. In my short time at the Crisis Center I've already experienced Patients attempting to Malinger for all of these secondary gains.

"Tired of gettin' shot at. Tired of gettin' chased by the police and arrested.

N*ggaz need a spot where we can kick it. A place where we belong."

As I've also mentioned before, this Outpatient service differs markedly from Inpatient. We don't have appointments, nor do we keep Patients any longer than their unpredictable visits. We don't have the luxury of getting to know Patients over consecutive days or the opportunity to observe Patients at almost every hour of the day. There have definitely been Malingerers on the Inpatient Service but those can usually be eventually sniffed out and documented. This is not the case with Outpatient Crises.

"Is there a spot for us to roll? If you find it...

I'll be right behind ya, show me and I'll go."

Thankfully. Almost artistically. My Attending Physician at the Crisis Center has been able to methodically pick and prod at each Patient to see if their symptoms are actual or theatrical. He would somehow catch Malingerers off-guard -- tongue-tied and noticeably nervous. Sometimes they'd break character or stories would conflict...somehow my Attending, more often than not, just knew. 

When I asked him how long he has worked there he asked me my age. (Warning: about to date myself). I told him 27 and he smiled and replied, "much longer than you've been alive my friend."

The second sub-Crate I learned this week is that Experience can be the most valuable teacher of all. It made me feel more than a tinge of impatience as I knew there is no way to speed up time -- to reach his level of acuity tomorrow (or any day soon).

But it provided Hope. There was a way to defend ourselves and the Patients who truly need help from the Malingerers. Although there is no fool proof way to prevent it....although there may be a number of false positive diagnoses out there...in the end it's not necessarily our role to keep score.

According to my Attending, physicians must wear many hats.

This past week it's been the Crisis Hat.

And the doors are open to anyone. No appointment needed.

"We still visualize places, that we can roll in peace."

hippo -- 

:::When the Wolf is Real.

I feel as if I've painted a very negative picture of the Crisis Center and of my week's experience, but that is not the case. Even when there are obvious Malingerers, it's still an invaluable learning moment... and I try to remind myself to find kernels of knowledge in every surprise popcorn moment.

"So much pressure in this life of mine, I cry at times."

It has been rewarding too. We have helped Patients with serious issues who have no where else to turn. We have helped a new mother with Post-Partum Depression obtain state insurance so that she can continue going to work as well as school for her incredibly adorable newborn daughter. We have been there to convince a laid-off factory worker that life is still worthwhile...eventually admitting him to the Inpatient Service where we look forward to catching up with him tomorrow. We have provided a compassionate ear...listening to a stressed out teenager who has put up with and borne more than someone three times her age -- scheduling weekly therapy sessions for her where before she had to keep everything buried unhealthily deep.

"I once contemplated suicide, and woulda tried.

But when I held that 9, all I could see was my momma's eyes."

More than anything, the most gratifying moments have been the occasions where we remind Patients why there is Hope, and Beauty, and that just maybe their Dreams are still viable no matter how bleak it may seem. It feels best because it's almost as if we help Patients help themselves. No medications required. Only the kind of human interaction that we crave and were designed for. Patience. Empathy. Encouragement. Understanding. 

"Not knowin' it's hard to carry on when no one Loves you."

We aren't robots or statistics or labels.

We're just and always will be Human. Duh.

:::Save me a place, in Thugz Mansion.

"They'd rather see us locked in chains, please explain.

Why they can't stand us? Is there a way for me to change?"

As I mentioned this is Detroit, MI.

I think people forget that Life still happens here.

"Or am I just a victim of things I did to maintain?"

More than anything, the accompanying Hippo of my first week on the Crisis Center service is a reinforcement of a previous sentiment: to be cautious and mindful of Judgements.

"How can I be peaceful? I'm comin' from the bottom."

Only this time it's more than that. This past week has also been a reminder that as healthcare professionals, whether we like it or not, our task is often to provide the benefit of the doubt. 

How can I be so sure?

I've seen the most charismatic and young female Patients, tears and all. 

Malingering. (No Benzodiazepines for you.)

I've also seen the most intimidating 6'5" gentleman. Covered with tattoos.

Vietnam Veteran.

Major Depressive Disorder and Post-Traumatic Stress Disorder. Crisis.

"Watch my daddy scream peace while the other man shot him.

I need a house that's full of love when I need to escape."

Sometimes we have to wear the Love Hat.

But, it's our duty to always wear our Patient's Hat. Everytime.

"Trouble sparks, they tell me Home is where the Heart is.

Dear Departed."

We are here to heal. I'd like to think I'm echo-ing the same sentiment as all my colleagues-to-be and of those ancient healers that have come before: I'd rather let a million Malingerers have their way...take advantage of me and the healthcare system...then let that one Patient slip through because I doubted their symptoms and the seriousness of their life's situation.

"Picture me inside the misery of Poverty.

No man alive has ever witnessed Struggles, I've survived."

Every Life is Precious.

And there's always enough room in Thugz Mansion.

No Appointments Needed.

"And in my mind's eye I see a place, the playas go in fast.

I got a spot for us all, so we can ball, at Thugz Mansion."