Conversations from Psychiatry

I have only a short post for you, since I only attended parts of my already short Psychiatry rotation.Other than that, do let me know what you all have been up to, how are your rotations going, and for my co-interns, how bad is the exam fever?
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An ongoing discussion about various ways in which funds can be used by the department.

J: Sir, we can get carrom boards in the wards for indoor patients, some entertainment for them. Both the side rooms are empty only most of the time. We can keep it there.
Y: Yes, that's a good idea, but who will take responsibility for taking care of the carrom boards, that is the question.
P: Oh yes, always good to entertain the patients. Tell me, is the TV in our ward working?
J: Yes sir, the one in the male ward is working, the one in the female ward isn't.
P: Okay, don't you people want to install a treadmill in the ward? Let's get a treadmill. All you junior doctors can work out on it, patients can work out on it, good for everyone.
J: <Says nothing>
J: (trying again) We should get some games for the patients to play and pass time. We can get something like playing cards.
P: Yes, let's get them Tarot cards.
Me: <mouth hanging open>
J: Sir, the psychotic patients will make predictions with the Tarot cards and become even more psychotic.
P: Yes, that should be great.
J: (looks at where I am sitting) All you interns, please go sit in the next room.

{J=Junior Doc
Y=Unknown in pyramid
P=Senior doc
Me=Bottom of pyramid}
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Intern: (Shouting in the ward for a patient) ABC, ABC... ABC kaun hai?
X: Haan ji, yahaan hoon.
Intern: Aapka khoon nikalna hai, chalo so jao.
<proceeds to collect blood>
Intern: <handing over a bulb> Issme Urine collect karke table pe rakh dena.
X: Theek hai Doctor sahab.

<Intern goes and starts studying>

<After some time>

Sister: INTERN, INTERN!!!

<Everyone gets scared and looks at each other>

Intern: <bravely gets up and goes out> Yes, sister. Kya hua?
Sister: <gives murderous look>Why did you collect the patient's relative's blood? And Urine also!!!
Intern: But, but, I was calling for the patient, and he came!
Sister: But, don't you know admitted patients are in hospital clothes?
Intern: But...
Sister: But what?
Intern: <shuts up and goes to collect the patient's blood now>

{Yeah, this story wasn't even related to psychiatry. But it happened during my Psyche rotation. You will have to just grin and bear it.}
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I have had this love-hate relationship with Psychiatry since I joined MBBS. As a subject, it has always fascinated and intrigued me to no end. All the oppurtunities the field brings, to people-watch, and psychoanalyze, and counsel (which very ironically I think I would be good at, believe me or not!) had me in this excited state for a couple of years, and I seriously thought that this is what I would get into. But then, my family explicitly forbade me to even consider this an option, and gradually I realised the field is very sidelined in India, with most people looking down upon Psychiatrists as well as their patients.

But then, I was faced with an even bigger problem. I could not find a single Psychiatrist who would command some respect, in the professional sense, and in the way they conducted themselves. I found no one I could look up to. And I looked. But all of them seemed to have issues. When they came and conducted lectures for us, the lectures were huge embarrassments. None of them seemed to treat their own profession with respect and/or like a science. Disheartened, I gave up.

I know, I'm probably sounding like a demented snob right now. But I have nothing else to blabber about so bear with me. I eventually decided Psychiatry would not be a good career choice for me.

But then, during this rotation, I think I may have finally come across a sane Psychiatrist who commands some respect. Not too sure though. Let's see.

Catching up. And deaf culture.

I know.

Long time, no see.

I was just going through a hide - underground phase. Didn't feel like writing much. Now I'm back. And I'm rusty.

Anywho. Internship's been going on pretty much as usual and as expected. But most times I really enjoy the contact with various kinds of people it brings for me.

Now just during my last 15 day Ophthalmology posting, all I did was check the visual acuity of the patients in the OPDs. Very boring, you might think? Yeah. I guess. But you know, not really.

It's just fun coming across so many people and all their idiosyncrasies and wondering about their back stories.

And I just love it when a patient comes and wishes me "Good morning Doctor" with a really excited smile. It makes my day.

So, ophthal brought me tons of kids who thought reading out the visual acuity chart correctly was like passing in a school test, old ladies who forced their life stories upon me instead of getting tested, the relatives who tried to prompt to the patients whenever they wouldn't read correctly, the little kid who tried to cheat by peeking through her good eye every single time I asked her to read anything, the proud uncles who were too embarrassed to admit they couldn't see, and the pros who were so used to the testing they just told me up to which line they could read. And of course, the occasional lecherous old men. But yeah.

I pretty much enjoyed the experience. 

But there's one story I'm unlikely to forget. A 17 year old kid came in one day along with his father. He was thin, lanky, and otherwise looked non-descript. Once he took his seat his father informed me that he was deaf. I was mildly surprised, but didn't react. Instead I was pretty much in awe.

*More info required here* So, of late, I have taken to watching a new series called 'Switched at birth'. One of the two protagonists on the show is deaf, and the show also has a lot of other hearing-impaired characters. The show has vastly improved my knowledge and education regarding the community of deaf/hearing-impaired people, acquainted me with the kind of lives they live, and helped me develop an immense respect and greater awareness about them. It also introduced me to what is known as deaf culture, as well as to the ongoing debate in the community regarding cochlear implants.

I have never ever met a deaf /hearing-impaired person earlier in my life. So when I came across this kid, I looked at him in wonder. I know that some deaf people talk aloud, and some don't. He was one who didn't talk aloud. His dad pretty much talked for him. I also noticed that neither of them used sign language, quite unlike what I saw on the show. Neither did the kid seem to know lip-reading. But then again, this was India. So then their problems and the way they live over here and how they deal with it would be totally different. I probably still need a lot more education in this area.

Anyhow, so, back to the story. The kid sat there, a bit confused about how to proceed. I immediately got up, and started pointing out to the boxes I wanted him to read, and he immediately responded by gesturing the answers with his fingers. He looked sad when he couldn't read beyond two lines with one eye, and nothing with the other. That meant even his vision was poor.

When I glanced at his papers, his history said that he had been diagnosed with a cancer in his lymph nodes a couple of years back and was still undergoing treatment for the same. And now, from the looks of it, even his vision was receding. he didn't wear spectacles, so it had to be a recent development.

After knowing all this, I couldn't  bear to ask his father anything else. About whether he was hearing impaired since birth, since when and why was his vision receding, and how was he dealing with the cancer. How can one person have to deal with so many problems and that too so early on in their lives?

It scared the shit out of me. So I acted like a coward. I was too scared to find out what his life was like. I didn't want to know. I wouldn't have been able to bear it. So I didn't ask. I just politely sent him his way.

Hopefully I will learn better. But I have thought about him often after that.Which has obviously led to this post.

Then just a few days after that incident, I came across this quote put up in a frame inside my ENT department:

"I am just as deaf as I am blind. The problems of deafness are deeper and more complex, if not more important than those of blindness. Deafness is a much worse misfortune. For it means the loss of the most vital stimulus-- the sound of the voice that brings language, sets thoughts astir, and keeps us in the intellectual company of man.

Blindness separates us from things but deafness separates us from people."

- Hellen Keller.

While I had heard of Hellen Keller before this, I didn't really know her story very well. Researching that thought-provoking quote led me to read more about her. I am so glad that happened. Her story was one of the few truly inspiring ones I have read.

It also made me realize that the Hindi movie 'Black' must be inspired by her story. I just wish it hadn't starred Amitabh Bachchan (Yeah, I don't like him too much). Just watch this trailer and you'll see how similar the two movies must be if you've seen Black. Now I am going to watch the original movie.

Anyhow, so I am going to correct my lack of knowledge about hearing disabled people. Hopefully my post will make you want to do the same.

I guess I'll leave you now with all this food for thought. End of post.

Good night and good bye.

"Always use your own clinical judgement..."

Here's a story of how I learnt a good lesson in the practice of medicine recently.

There was this patient who'd been coming to my hospital's Casualty OPD since the day I joined. He'd turn up every couple of days, at different times of the day, complaining of pain in his right knee joint.

He would walk in with this bandage tied around his knee and complain of unbearable pain. And then ask for painkillers. My senior told me he's been coming like this for quite some time, has been evaluated by many Doctors, who all say there's nothing wrong with his knee. He'd probably gotten addicted to the pain killers, or that's what everyone thought was the case. He would never go to the regular morning OPD, he just came to the Casualty OPD everyday.

So over the next month, I watched him come in multiple times. Sometimes we just gave him the drugs, sometimes we told him there's nothing wrong with him and shooed him off, sometimes we gave him placebos. But always, he would be back for more pills.

Of course, there's no such protocol followed like counseling such a patient or giving him a psychiatry reference. No one thinks it is necessary or advisable to do such things. Hell, no one even gets such ideas.

Pretty soon all the interns, all the Doctors, and all the staff started recognizing him well. Most refused to give him any treatment whenever he turned up.

One time I saw a Doctor tell him that he should wait outside quietly, come in only when he saw that particular Doctor (himself) over there, only during his shift, and then he would get the pills he needed. The Doctor then proceeded to prescribe Diazepam to him. Was that some kind of weaning tactic? I don't know. I didn't ask. We don't generally question our supervisors about their prescriptions, or about anything for that matter.

Then, after a month or so of this, he now came in during one of my night shifts and started complaining of pain in his left knee joint. Of course no one batted an eyelid or probably even noticed the difference. He came in  with three people carrying him, complaining of severe pain.

I told the on-call Medical Officer that he's been coming with similar histories all month long, since he (the MO) didn't seem to recognize him. Even the nurse recognized him, and the tons of prescriptions he had with him showed the same thing. The MO still listened to him, elicited his history. The patient mentioned that he had had a fall 4 days back, and since then developed severe pain in his left knee. This ticked something off in my mind since I clearly remembered him with a bandage over his right knee in the past.

The MO then examined him, and noticed there was a slight swelling over the knee joint. That, combined with the history, was enough to convince him. He sent him for an X-ray, and called the orthopaedician on-call to have a look. It was 12.30 am at that time.

The Orthopaedician on-call came in, took one look at the patient, got livid and started shouting at him. The patient it seems, had been coming in two-three times per day, everyday, for the last three days, complaining of pain in his left knee. But every one knew that he was a so-called addict so they just ignored him, or just gave him pain-killers and sent him off. The orthopaedician was furious that he had been called at midnight once again for that patient.

In the meanwhile, his X-Ray came. It showed a fracture lower end femur, with increased joint space, probably due to ligament tears. This man had been walking around with a fracture for four days now and no one had thought about evaluating him. In his defense, the Orthopaedician said that the patient had not given any history of trauma or fall before that particular day, so he had not thought about getting an X-ray.

Even after his diagnosis, the patient didn't want to get treated as he didn't have any money. He kept asking for some pills so it would be alright. When we asked him about addictions while taking his history, he confessed that his only 'addiction' was that he needed to take pills at night to sleep.

Finally, the patient was advised to temporarily get a cast, and arrange for more money for further surgical management, or go to a bigger hospital where a Trust Fund could be used to pay for his treatment. After he left, the MO on-call told me: "You see now what a good thing it was that I sent for that patient's X-ray? You should always use your own clinical judgement rather than listen to what others tell you. That's called practising good medicine. I saw that he had a swelling over his knee, so I sent him for an X-ray."

And that was one of the best lessons I have learnt in a long, long time.