I’ve been meaning to post about my psychiatry rotation but it seems the whole rotation has finished and I’ve yet to post. So here’s a few somewhat tardy thoughts.
I was in the university hospital psych ward which is essentially the psychiatric ICU for the state. To enter there are two sets of locked doors which only open one at a time. Patient rooms are bare, with a bed that is attached to the floor and a camera in the corner. IVs and the typical cords, hoses, and accoutrements of a hospital room are out of the question. Public Safety officers are on hand at least several times each day. Patient turnover is high and the requirement for entry is having more than a few screws loose. Or having a high risk of imminent harm to self or others. The types of cases I saw were not something I am likely to see in outpatient practice however it was really fascinating to see patients with textbook descriptions of things such as mania or florid psychosis. We had one patient who was a swallower and had an xray that looked about like this: 
Another patient had decide to stab an ice pick through her temple to the middle of her head. Just because it seemed like the thing to do. Many mental illnesses have concomitant substance abuse or TBI (traumatic brain injury) and our patients were no exception. Becoming familiar with the clinical picture of both intoxication and withdrawal from just about every substance of abuse was critical on this rotation. We also dealt with many serious personality disorders. One severely borderline patient was placed on a hold on our unit after threatening to kill physicians at one of the other hospitals in town. Borderline (FYI) is a personality disorder where the person is on the border between psychotic and neurotic. For example this guy told us a horrendous tale of how his mom had committed suicide and he had found the body. Turns out he fabricated the whole story but yeah, extremely unpleasant. He had several failed suicide attempts and was the one and only person who made me wonder if both his life and the world would be a better place if he succeeded. I’m somewhat ashamed of feeling that way; but these patients can be so wretched that wondering if their life is worth living is a normal reaction for those around them.
Unfortunately for many of the patients there wasn’t a whole lot we could do for them. Their acute illness could be managed but often the social situation to which they would be discharged was incredibly poor. For example we would literally discharge people to the street or if they were lucky, a homeless shelter. With schizophrenia the term ‘downward drift’ is bandied about and refers to schizophenrics gradually becoming less and less functional in society. But really many mental illnesses fit the downward drift model. The social worker and case manager were fantastic but the resources are just not there to help a large portion of the mentally ill in our society.
As an aside, while we try to avoid politics on the blog, I have to just shake my head at the idiocy of the recent fervor about gun control. I mean, sure, let’s have thorough background checks on people who purchase firearms. Very reasonable. But consider that every high profile shooting that I can recall, from Columbine, to Virginia Tech, to Portland and Sandy Hook were by individuals who were mentally disturbed, and at least the latter two were with stolen firearms. I wish politicians would quit grandstanding for the sake of their careers and maybe actually do something to make a difference…such as increasing mental health funding. Many of the state run mental health institutions across the country have shut down during my lifetime due to lack of funding.
Fortunately not all patients were in such poor social standing and we were able to make a difference for some. There were a number of patients who had acutely decompensated and after a short inpatient stay were able to discharge in stable condition to a good situation.
The juxtaposition of the legal and medical systems is still something I don’t quite understand. Patients can be admitted voluntarily but more often are placed on a hold, which means their case is then evaluated by a court investigator. The investigator can drop the hold, put the patient on a 14 day divert (ie. reassess in 14 days), or take the patient to court at which time a judge will decide if they need to be committed. In our state the minimum time for a court commitment is 6 months, but it varies state to state.
A final observation is that the line between life and death is very indistinct for many of these patients either due to psychosis, or suicidal ideation. To sit and calmly discuss with a person the intricate details of their suicide attempt as if we were talking about ordering lunch is completely surreal. The interactions between patients on the unit were almost always positive however, and actually provide a lot of comedic therapy for the staff. It’s much much too absurd to try and describe it here… 
In all psych was a bizarre, intense, fascinating, and sad experience. But one that I’m very glad I had.
Now I’m on to OB which is the final rotation of third year. Day one was interesting as the hospital caught on fire and several floors had to be evacuated. Fortunately the damage was minor and nobody was hurt. It’s always an adventure though!
