A Day in Psychiatry

Psychiatry was a roller coaster ride for me. It went up, down, side-to-side and it was enjoyable for a while. I was on this ride for eight weeks and I'm starting to ask myself "Was this real? Or was it just a ride?" Seeing patients with such disabling, dignity-stripping illness crippled me and I had trouble composing myself on a day to day basis. I looked for ways out - I wanted to leave early, take days off and try what I could to avoid the ward.

But Dr. BB, my supervising Psychiatrist, was adamant that I stay for all activities and help him in any way I could. I really enjoyed working with him and watching him speak to patients. There was something about his mannerism and passivity that was therapeutic even if I wasn't the one sharing my worries and stressors. He emphasised principles that few consultants paid attention to, such as introducing oneself as one the caring doctors and asking "do you have any questions for me?" It was these qualities that enraged me when he asked me to attend the ward on the Friday after the exam was over... but it was also the same qualities that propelled me to come in. 

One afternoon, I was milliseconds away from a total public breakdown. On morning handover, we listened to the supervising night nurse explain the inpatients' behaviours over the last twelve hours or so. The tone was very "us against them" and even more "I've heard all this before. What's for breakfast?" Dr. BB asked me to attend the Electro-Convulsive Therapy (ECT) session that morning. He said he would join us (the students) later and Dr. ZN, one of the unaccredited Psychiatry registrars, was in charge of the session.

J, G & I headed over to the outpatient's clinic, where they had a room with an old bed beside an even older set of anaesthetic monitors leaning on antique exercise equipment that was gathering dust since the hospital declared them unsafe for patients. The very atmosphere made it clear the hospital wanted to forget patients undergoing ECT as much as they did the lawsuits that were a consequence of faulty exercise equipment. 

Dr. ZN was an overseas doctor who passed the admitting exams in Australia. I had already spent a couple of weeks with him in C-L Psychiatry earlier in the term and he seemed nice enough. However, it became quite clear the admitting exams did not test empathy or basic common sense. 

Ashley, the first patient on the list, was wheeled in. The anaesthetic team was there, waiting for him. He was a young man with schizophrenia with such profound negative symptoms that the Psychiatrist believed he would benefit from ECT. Dr. ZN was with us by the corner of the old bed explaining the differences in parameters with the ECT settings, why one might be better than the other and the idea behind it. This all happened so quickly that before we knew it, Ashley's face was but a few centimetres away from our backsides. We didn't even notice before the anaesthetic nurse said "watch your step" as he plugged the ECG leads in. It was then we realised we were literally rubbing shoulders with each other and that we should probably give the poor man space. 

Dr. ZN couldn't care less. He proceeded to explain the voltage, amperes and hertz he was selecting as poor Ashley's head was beside Dr. ZN's waist. I could feel the rage building up inside me. The disgust really started when he pulled out a couple of alcohol wipes and proceeded to hold Ashley's head and wipe it down as if he were cleaning a mud stain from the top of a leather boot. I was surprised Ashley stood still. He didn't explain what he was doing, why he was doing it and Ashley didn't even know his name. 

As Ashley was wheeled out after his medically-induced seizure, Dr. ZN continued to explain his waveform and why it was a 'good shock'. 

Elaine was our second and last patient for the morning. She was wheeled in by one of the mental health nurses as she cried her eyes out, begging all of us not to proceed. Unfortunately it wasn't up to her, as Dr. BB presented her situation to the medical tribunal, who agreed with involuntary ECT for her melancholic depression to, I guess, shock her back to reality. 

My blood pressure really started soaring when Dr. ZN continued to explain the waveforms, "alpha waves bla bla bla. Beta waves bla bla bla" while Elaine was crying her eyes out. Her depression started after her husband had a disabling stroke and she was left with all the responsibilities around the house. So she was forced to retire and proceeded to be his full time carer for a solid two months until she literally felt inadequate, incompetent and hopeless. Eventually, her feelings of inadequacy lead her to lose touch with reality. 

I was praying someone would shut Dr. ZN up before I broke his neck, because at that point I didn't know what was holding me back. Finally, the mental health nurse approached him and said "excuse me... I hate to be a pain in the ass but your patient is really unwell. Maybe you should go over there?" he smiled sarcastically and reluctantly agreed. 

Then G, one of my colleagues, proceeded to explain how he met Elaine and thought the point where she was struggling in bed while they were sedating her was a good time to explain her history. I felt J was also quite disturbed by what happened and we both shot G a look, and he didn't understand. 

Could you shut the fuck up? 

"What? I'm trying to explain her case to you!"

It's really not a good time.

"Yeah, G, seriously. Just shut up."

G, baffled, walked away from us and sat down to read Elaine's notes. 

At that point I needed to leave the room. I was holding my tears back and then Dr. ZN looked at me from across the room and said, "You look a little detached!" with a big smile on his face. That was when I walked out of the room. 

I locked myself in the bathroom and I was either going to break the mirror, cry, pass out or wash my face. So I did the most appropriate of those choices. After drying my face with some paper towels, I walked outside to find Dr. BB. He saw me and it wouldn't take a Psychiatrist very long to work out how I felt - my face usually does express my feelings quite well. 

He tried to pull me aside but I said I wasn't comfortable talking about anything there and then. He agreed, and said that we'd see a few patients and then we'd have a short meeting. 

J & I went with Dr. BB to the emergency department where we had a call from one of the doctors working in Psychiatry (a Career Medical Officer - someone who doesn't specialise but works their career in one speciality) to review a patient he was asked to see. He described Rowena as having anti-social personality traits and he wasn't keen on admitting her to hospital. After a few minutes of chatting to her, it was clear she had grandiose delusions, pressured speech and flight of ideas. Yes, Rowena might have had anti-social traits, but more importantly, she was really unwell.

Dr. BB asked the CMO to sedate the patient and admit her involuntarily into the mental health ward. When we went back to the ward to see more patients, Rowena was brought in by security personnel with no sedation, trying to wrestle herself free. We were both baffled. Why wasn't sedation given? Patients in mania are usually quite distressed and for the sake of harm-minimisation, this lady needed medications to calm her down.

It was a hectic morning and it felt as though it couldn't get any worse. Luckily, it didn't.

I ended up with Dr. BB in his academic office to present a case to him and to get feedback from him regarding my rotation. One could always present cases better, but I felt relieved that he passed me - he's a hard examiner... even if it was a practice run.

He then asked me what happened in the morning. I got worked up and angry about how patients were treated by Dr. ZN. It felt like I was throwing the words at him. By the end of it, Dr. BB was shaking his head in disgust.

I always tell junior staff to introduce themselves, be polite and respectful. They just don't seem to want to. There's not much else I can do other than to tell them. 


"But you're a consultant. Why don't they listen to you?"

I don't know. It's more prevalent among our overseas colleagues. 


"Perhaps it's because your feedback doesn't hold the gravity with them as it does with us"

Could be. 


There was a short moment of pause before we exchanged a smile.

"How do you cope with the things you see everyday?"

Mostly by speaking to other consultants and with weekly debriefs with the head of department. It's very important to share your encounters and thoughts on clinical situations with senior colleagues. 


"I'm having a lot of trouble seeing the patients in Psychiatry so far."

*Pause*

I really think that if you don't share what you see, you will lose touch with reality.

It felt like a bomb hit the building. "So what? People become psychotic?"

I do think so. You surround yourself with patients who have delusions, hallucinations; symptoms and signs that convey their reality is distorted. Eventually, anyone would find it difficult to separate all the stories from reality. It's very difficult to stay objective, particularly in Psychiatry.

We spoke a little longer to debrief but I could've stayed in there for an hour. But the bottom line was drawn well before I walked out of the room.

There is always a chance our reality will become distorted.

So I may very well still be riding on a roller coaster... and that may be real.