Grip

I've finished my fourth week in Psychiatry and I can't say I've studied much. I haven't been able to revise and I'm still convincing myself that I'm exhausted from the previous exams. Given the assessments are a month away, I would be nuts to believe this thought process is productive in any way.

Speaking of nuts, Psychiatry has been quite interesting. The first three weeks was in the Drug & Alcohol service, where most of the patient population represents a unique and unfortunate minority. This week was my first time in the "subspecialty" known as Consultation-Liaison Psychiatry (C-L).

C-L is a team of doctors and nurses who see in-patients within the hospital system after a medical or surgical team has requested a consultation.

When I arrived on Monday, I was expecting quite a large team and it turned out there was a Specialist, Registrar and Clinical Nurse Specialist. An overseas student interested in Psychiatry showed up as well, but she got bored before the clock hit midday and I was happy to be on my own with the team. Dr. FN was the specialist, though he was a Pain Physician as well as a Psychiatrist. Like most medical students, I too am intimidated by meeting new specialists. To my surprise, it didn't take long for me to feel comfortable in the team.

Dr. FN's manner was absolutely amazing. A man who never addresses a patient by their first name unless prompted to do so, a doctor who asks if it's okay to sit next to a patient and a specialist who could not be more polite. I watched in awe as his questions were comfortably received by patients and his very presence had a soothing quality. He explained concepts to patients and asked them very personal questions, but apologised in advance if he felt the question was sensitive. He, like Dr. JP in my O&G term, restored my faith in the medical profession.

Seeing in-patients with new-onset psychiatric symptoms, or patients with chronic psychiatric illness was quite a change from the Drug & Alcohol department and the spectrum of illness was quite different. The first thing I picked up quite quickly was how ridiculously ignorant the medical and surgical teams were when it came to mental state, except for the Geriatric teams.

One patient, Mr. AK, is a 29-year-old gentlemen with known treatment resistant Schizophrenia who presented to the emergency department with constipation, which later the Acute Surgical Unit (ASU) labelled as a small bowel obstruction (SBO), probably due to the effects of clozapine. One of the important management aspects of SBO treatment is to ensure that the patient no longer eats or drinks (ie Nil By Mouth - NBM). Therein lied the problem - how was this gentleman to receive his clozapine if he could not take his tablets? And unfortunately this drug is not available in any other form. They decided to start him on olanzapine, another medication but definitely of lower potency. Anyone who's done any form of Psychiatry knows if a patient is on clozapine, that this patient has already been on several medication regimes previously, which have failed. However, let's not forget about his SBO and all the excruciating pain that accompanies it. So the surgeons didn't know what in the hell to do, especially since their knowledge of pain-relief medication is limited.

They requested a consultation from the Acute Pain Service (APS), which was a team composed of an Anaesthesiologist, Neurosurgeon and a number of other doctors. After they saw Mr. AK, and given his particular history, they decided that opiates were not the best option. So they decided to give him Ketamine.

I told this story about a dozen times to my colleagues and the commonest response I got was: Ketamine makes a normal person psychotic!

So one can imagine what it did to a patient with treatment resistant Schizophrenia. He developed florid psychotic symptoms and before the surgical team realised what the hell was happening, the C-L team responded, calming poor Mr. AK down with a cocktail of anti-psychotics and sedatives.

Before we knew it, we realised that his psychosis was under control with an aggressive combination of medications... I'm tempted to call some of them tranquilisers.

2 weeks later, his bowel obstruction didn't resolve and the surgeons had no choice but to start him on total parenteral nutrition (TPN), which is nutritional replacement. It pretty much means that someone needs to be fed their three meals and a few snacks a day through a line that's been inserted into a large vein very close to the heart.

We were doing rounds in the hospital with our inpatient list in C-L and we ran into the Anaesthetics Registrar part of the Acute Pain Service, who told us that Mr. AK ended up in the Intensive Care Unit due to an infected central line.

So this guy came to emergency with constipation. The doctors that accepted his care as their responsibility decided to keep him nil by mouth and by doing so ended up exacerbating his schizophrenia and eventually leading to his admission to ICU for a fucking cause that was none but our own.

It's so tragic how we can fuck up someone's situation so quickly, amplifying their pain, their agony. When I tried to express these thoughts to my colleagues, the answer I got was "that's why you have consent forms" - fuckers.

Stay out of hospital. There is a reasonable chance you can get worse well before you get better.

How do we live with ourselves? How do we go home at night?