Mashup

The top 25 songs of 2009 mashed together to form another awesome pop hit! And it's totally dance-worthy! Get up and move that booty.

The thin red line

He wouldn't talk to my attending or chief resident, forcibly pushing them out of his room that morning, threatening to go combat style on them. "I've seen things you've never even imagined! I've done things you wouldn't think possible! I will hurt you!" he yelled at their retreating backs.

I was told to try again in the afternoon; maybe he would be a little nicer after he got more rest and some food in his belly. "But interview him out in the group space...he's here for homicidal ideation, after all," my attending warned me.

So around 1pm, I headed over to that patient's room and knocked on the door.

ME
Excuse me, Red?

PATIENT
Who the hell are you?

ME
I'm Michelle, the med student on your care team.

PATIENT
Student? Stop right there. I ain't having nothing to do with no students. I'm not some guinea pig for you all to experiment on.

ME
No sir, I'm not doing any experimenting - I just wanted to talk with you and see why you're in the hospital.

I smiled, trying to convince him that I was harmless. But he wasn't having any of it and he got up from his bed and started moving towards the door, presumably to close the door in my face. I started to back away, because even though he wasn't an especially large man, he was still cut a pretty threatening figure.

ME
Sir, truly - I'm just here to try to help you.

PATIENT
Help me? You don't know the first thing about helping me! You think you know anything about war? I've got some serious PTSD shit, and you think you can help me?!

Clearly, I had said the wrong thing. And he was angry now, yelling and swearing as he stormed out of his room into the common area. I apologized as I followed behind him. No, I didn't know what it was like to be in the army...but I did just have a lecture on PTSD by our residency director who used to work at the VA. Dr. Anzia? Perhaps he knew her?

He turned around to look at me and solemnly replied, "She's the greatest doctor that ever lived."

I nodded. He was calmer now, so I didn't want to say anything that might disrupt the milieu. He sank into the lab chair next to the nurses station. "You wanna know why I'm here? I'm here because in two days, it'll be the anniversary of something terrible. It'll be the anniversary of why I'm so dang messed up in the head. There was a helicopter accident. And everyone but me and three guys made it out. We lost everyone."

He started tearing up and his voice dropped to a whisper. All this had happened so many years ago, but it seemed like every little thing would set him off and send him back into those nightmares of war.

This time, he was walking along Michigan Avenue when he passed by a Vietnamese family. Seeing those children's faces immediately sent him back in time and he was reliving the terror. He thought he was back there, as he ducked behind planters on the street, jumping over railings, screaming at the top of his lungs, and generally just acting like a crazy person.

But he wasn't crazy; he just suffered from severe PTSD that had never been really treated. He was openly crying now, and feeling foolish standing in front of him, a towering giant in my 3-inch heels, I dropped to squat next to him. I thanked him for telling me his story, knowing how hard it probably was for him to relive it again.

We went through the rest of his psych and medical history quickly - finding out what pain regimen he needed for his terminal prostate cancer, what drugs had worked for his depression in the past, and lastly, what combo of drugs would work best for his PTSD. We finished talking about who he was seeing for therapy, and then after thanking him again for opening up to me and telling me his story, I went off to the med student room to write up my note.

I was proud of myself. I had taken this hostile patient and gotten some very pertinent information out of him. We had him on an antidepressant that he had failed twice before in the past, so we needed to change that. We had him on some Ativan but at such a low dose, it wasn't going to do anything for him. And he had bone metastases from his prostate cancer. Our current order - Tylenol for pain - clearly wasn't going to cut it for him. I sent a page to my chief resident, who texted me back with "strong work!" and I smiled. Maybe I am meant to go into psychiatry.

As I sat there typing up my note, happy as a clam, a nurse I had never worked with before knocked on my door. "Michelle, may I see you for a moment?"

My fellow teammate, whom I had excitedly told about my patient encounter, smiled at me. Clearly, she was going to praise me for having such a great bedside manner. He patted me on the back as I made my way out of the room.

NURSE
I saw you earlier talking to Red.

ME
[trying to be humble, but really, busting at the seams at what a great job I had done]
Yes. Are you his nurse? I looked on the board - I thought his nurse was Eva.

NURSE
No I'm not his nurse. But I needed to let you know that what you did out there in the middle of the room with Red was completely absurd!

ME
[shocked and honestly taken aback]
W-w-what?

NURSE
You were a pawn in his grand scheme! And you just ate it up, didn't you? Oh you young young thing. Red has been in and out of hospitals. I've been here for a long time and I can recognize that he's just here to get narcotics.

I sputtered, not quite knowing what to say. What had I done wrong? I know I'm pretty gullible, but my interaction with Red seemed genuine. He was crying, for chrissake! I hadn't taken him into an interview room, but that was on direct orders from my attending.

ME
Are you referring to how I was sitting next to the patient? I know that probably wasn't the safest thing, because he clearly could have punched me if he wanted to, but he was crying, and I really didn't think he was a threat --

NURSE
No! But that's another thing! He's a Vietnam vet! And you! You are this young Asian female, basically prostrating in front of him. Worshipping him! He was clearly enjoying this. You were right in the palm of his hand! Like a slave or concubine! I'm not saying that you are...but really. You were so subservient...ending the interview with a "Sir, is there anything I can get you before I go?"

I was shocked now. I would have understood if she were concerned about my safety. I would have understood if she had witnessed me crossing boundaries. But everything I had done seemed right in the realm of medical care. And honestly, I was a little offended. She had just compared me to a concubine! If that wasn't crossing a line, I don't know what is.

But I'm a med student, and we are the bottom-feeders in this hierarchy. So I gritted my teeth and smiled at her.

ME
Thanks Lee for the advice. I can see that you were worried about my safety, and I appreciate that.

NURSE
Now, no hard feelings between us okay? I'm just looking out for you. You're so young, you know. So young. If you have any more questions about anything, don't hesitate to ask me!

ME
Oh, I won't.

I smiled fake-sweetness at her and then went back to the med student room. My teammate whooped when I walked in the door, "Yeaaaaaaah!!! Did she just give you an honors guarantee??" I shook my head ruefully and told him what had just happened. He was shocked as well, "You know what? She wasn't there for the interview. She doesn't know what was going on. She's not even the nurse on our side! What the heck. She has no right to talk to you like that! And I can't believe she kept telling you that you were so young. Ugh. You should have been like, well, you're SO old! The old hag!" We laughed. I thanked him for making me feel better about myself, and then turned around to finish my note.

I still don't quite know what to make of it all. Looking back now, I realize I must have done something that set of the nurse's Danger radar. But what was it? Maybe I was squatting too close to the patient - he had been whispering after all. Maybe I should have excused myself to get another chair. And when he was crying, maybe I shouldn't have paused and patted him on the arm when he got choked up telling his story. There is a no-contact rule in psychiatry after all.

But at the end of the day, I have to remember that one of our psych lecturers told us we have to trust our gut. And my gut was telling me that this patient had been through a lot. He was angry, but for good reason. My gut told me that what this man needed at that moment was an ally. Someone who believed him and didn't think he was merely drug seeking. Someone who would listen to his story and emphatize. Sure, there are things I could have done to have made the situation better. But looking back, I doubt I would have changed anything. Regardless of what the nurse thinks she saw, I know that I was being professional but caring at the same time.

I might not be the best psych med student, but hey, at least I'm not jaded yet.

Tidings of comfort and joy

ME
Boo!

MARTIN
Ahhhhh! Hi. I bought your Christmas gift.

ME
What?! Already?! What did you get me?!?!?! AHHHHHHHHHH - I HATE SURPRISES!!! AHHHHHHHH!!

MARTIN
I just wanted you to know so I can make you suffer x 2 weeks. Hahahaha!

ME
AGH. You are so TERRIBLE to me.

MARTIN
Hahahahaha!!

ME
I think you should tell me. Or at least give me a hint! One every day! Yeah yeah! BEST IDEA EVER!!!!!

MARTIN
Okay. Today's hint = I bought you something.

ME
Nooooooooooooooooooooooo!! Dude, that sucks!!

MARTIN
A hint a day! That's your hint. Otherwise you'd never know.

ME
Hmph. I wish I never knew.

Gansta's paradise

It's a Harry Potter/Dangerous Minds mashup!! Hermione Granger teaching a bunch of inner-city kids? Genius.



Seriously, I haven't seen a parody this good since SNL's early days.

Is it bad that I wish they would make this movie purely so that I could watch it? This is box-office GOLD.

It's like you're a drug

ME
Ugh, I had McDonalds for dinner. Fries and a fudge sundae. And now I feel gross and disgusted with myself.

MIKE
Sounds like someone needs to go to some MA meetings (McDonald's Anonymous)...wah wah.

ME
Hahaha, I totally do!! I'm addicted to their fries and I think about them ALL the time. It's starting to disrupt my life. Hahaha, I'm laughing, but I'm serious.

MIKE
There you go. But you should determine whether it's abuse or dependence

ME
Oh it's dependence. I will do illegal things to obtain it. For instance, I will leave work early because I need to get some fries. Truancy! If that's not dependence, I don't know what is.

MIKE
Did you use to order a small fry, but now you have to order a large to feel just as happy?

ME
Yes! Now I have to order TWO larges. One to have later, because I worry about not having it when I really need it!! Like at 2 in the morning! McDonald's isn't open then!

MIKE
I think you hit at least 3 criteria within 12 months....Michelle, I'm afraid you've met DSM IV criteria for McDonald's Dependence

ME
Sigh. I've denied it for so long, but you're right. I need help.

MIKE
Diagnosis 304.90 - don't panic, you're not alone. Millions of Americans just like yourself suffer from this very same disease. But you can be cured. MA can help.

ME
Hahahah, this is such sad nerd humor.

MIKE
Michelle, McDD is no laughing matter.

Cute is what we aim for

This is the cutest thing I've ever seen. Seriously, if you don't smile upon seeing this video, you might be dead inside. Just saying.

There must be more

I was raised in a Presbyterian household. My grandfather was a prominent pastor in Taiwan and my family was always very involved in church and church-related activities when I was growing up. However, once I left for college, without my family around, I stopped attending sermons religiously. I still went every now and then, but it seemed like schoolwork and studying for exams started to take more and more precedence to the point where I was only going for Easter and Christmas. And as shocking as it might be to my father, I sometimes ate without saying grace. I had unfortunately become what the evangelicals would call a wayward Christian.

But I never lost faith. And I never forgot what I was taught – the doctrines, the stories, the miracles.

So once I started third year on the internal medicine floors, I figured I would be able to talk with patients about faith if they needed it. I figured I could say prayers and I knew most of the words to the hymns and songs. Bring it on.

Yet I was never asked to be part of my patients' faith-based healing. When I walked in the door, all my patients wanted were the concrete details. What were the LFTs like today? Were they low enough that the patient could leave? Did the cultures come back yet? Had someone determined the cause of the fevers?

I figured it was because I was lucky. None of my patients were terribly sick. All of them were going to walk out of the hospital. There was no need for prayers from me, really. They weren’t about to go off to that kingdom in the sky. All they needed from me was to know when they could go home. In fact, I think if I were to suddenly ask about faith or spirituality, I would probably scare my patients into thinking that they were about to meet their maker.

Then last week when I was on psych consults, it seemed like we were talking about religion and spirituality with everyone. We had one patient who wanted to leave AMA even though he had osteomyelitis of his sternum. He had refused blood draws and IV antibiotics, convinced that God - who had brought him back from a coma after a terrible car accident - would save him yet again, without our intervention. He wouldn’t cooperate with us, muttering prayers under his breath and tuning us out. We had been consulted to see if he would be eligible for involuntary hospitalization. He was a religious fanatic, to be sure, but perhaps he was delusional as well?

We were also consulted for another patient who was truly on his deathbed, when he told his nurse that he wanted to withdraw care. He was tired of living in the ICU, living on machines, unable to speak to his wife, unable to see his kids. The surgeons had called in the chaplains, and at a family meeting, I was struck by how the trauma surgeon kept referring to how it wasn’t time yet for the patient. That he had to have faith that he would get better. That there was a reason that all this was happening to him. There was a light at the end of the tunnel, and that light had nothing to do with taking him up to heaven.

It seemed like the doctors were using or disregarding spirituality and religion as they saw fit. The patient with osteomyelitis was diagnosed as a delusional schizophrenic. Sure, he was claiming to be a religious man, but my attending believed it was more a delusion than anything. And so we used that to involuntarily hospitalize him. He was a danger to himself and he needed to be kept in the hospital where we could monitor his infection, even if he wouldn’t let us give him meds. On the other hand, the ICU patient was someone who had lost his faith. And so we used that to say that he didn’t have capacity. He was too depressed to be thinking clearly. They had both wanted to withdraw care, but for completely different religious reasons.

One patient had too much religion and so we deemed him to have no capacity. Another patient had none, yet we also deemed him to have no capacity.

We deal with religion but not in the way I thought we would. So, I’m still trying to figure out how spirituality fits into modern medicine. How does hoping for miracles fit into something based on the scientific method? Where does the abstract fit in with something so definite?

I’ve always thought that it was a way of coping. Sometimes for the patient, sometimes for the family. And now I’ve come to realize that sometimes it’s just for me. In a field that is so concrete, I need to be able to hope that things can work out, even when all the numbers and all the images - everything - tells me that it can’t. I need to believe that miracles can happen so that I can get up every morning and keep going.

Taking chances

Life is calling. How far will you go?

I'll go to the edge and back. And I hope it's with you.

Let it snow

ME
When are you getting back in?

LISA
Late Sunday sometime.

ME
Btw, it's snowing in Chicago right now!

LISA
Oh crap! Seriously? A lot? I have to drive!

ME
Erm. To be honest, I closed my blinds because it was making my room too cold...but according to my gmail theme, it's snowing, cause there's snow on my inbox and chat boxes.

LISA
HAHAAH, I thought you had a weather app or something, but no, you're relying on your google theme?

ME
[embarassed]
It's actually kinda sorta pretty accurate.

LISA
HAHAHA

Back against the wall

He was a well-dressed man in his fifties. He had a history of bipolar disorder, avoidant personality disorder, and childhood seizures. He had been hospitalized 25 years ago for having suicidal thoughts and depression. When he was discharged, he was assigned a psychiatrist who would see him on a regular basis. He was doing well. But, when that psychiatrist moved away eight years ago, she tried to set him up with someone else in the practice. Yet given his avoidant personality, he just kinda got lost to follow-up.

So it had been eight years since he'd seen anyone for his mental health issues. And then today, he decided to call up the clinic and ask for an appointment.

Oh sorry sir, but the next available appointment isn't for 2 weeks. Will that be okay?

He paused, counting the number of days til he could be seen in his head. Sure, he replied hesitantly. Go ahead and schedule me.

And what shall I say this is for? asked the receptionist.

Oh, well, I made a pretty major mistake at work a couple of weeks ago, and I've been feeling really kinda anxious and guilty about it. And I think maybe my depression is getting a little out of hand again. He was being forthcoming and honest about his feelings. So the receptionist wished him a good day and hung up.

He walked into the ER three hours later. Why was he here? He couldn't really say why. So the ER triage nurses flagged him as a psych patient, and the psych team went to go see him. Was he depressed? No, not really, he said. He had made a mistake at work a couple of weeks ago, and his boss yelled at him, but no one was hurt and everything turned out okay. Since then he had had some suicidal thoughts. But they were fleeting - nothing serious, he claimed. He had thought about jumping out his window, but he couldn't do it. He knew it was wrong, he said.

And now sir? Do you have any thoughts of hurting yourself now?

No, he replied. Not at all.

The patient had called up his sister and brother (who lived just a couple of towns over), and they were waiting for him in the waiting room currently. His dad was awfully sick, so he felt depressed about his dad's worsening health. But that was it.

Any firearms in the house?

No, sir.

The psych resident on call wasn't sure what to do.

He felt uneasy just letting the patient go, but the patient wasn't having any suicidal thoughts now. And his family was here and supportive. And the holiday weekend was coming up. Did he really want to hospitalize this patient, when it seemed like all he really needed was an outpatient psychiatrist? Really, there were far more patients he'd seen who needed to be hospitalized and weren't, so maybe this wasn't the best use of resources.

Sir, I think I'm going to let you go with your family on the condition that you see someone in clinic soon --

Oh, I have an appointment for next Wednesday! the patient interjected.

-- oh that's great! Okay, and I want you to realize that there are a lot of people out there who care about you, so if you ever feel like you might be thinking of hurting yourself, I want you to call 911 right away. Or come into the ER again, okay?

The patient promised.

Thanksgiving came and went.

And then Wednesday came and went.

The patient didn't show up to his appointment. The attending's secretary left a message on his landline - Hi sir! You were scheduled to be seen today in the Mental Health Clinic - please call back so that you can reschedule!

The attending got a call back later that afternoon. It was the patient's sister.

Tearfully, she informed the psychiatrist that her brother had killed himself two days ago - jumped out his window to his death 57 floors below. No one had seen it coming or thought he would do it. Her other brother had had lunch with him the day before he jumped, and he had seemed okay. Fine, even. And before he had jumped, he had called 911. But by the time help had come - no more than 4 minutes later - he had deadbolted the door, refusing to let anyone in to help him. They set about trying to tear down the door, trying to find someone with a master set of keys. But thirty seconds before they were in, he had jumped.

---

Our lecturer finished her story. And we, the students, sat there in shock, realizing that many of us would have done what the resident did. He didn't fill any criteria for major depressive disorder, he wasn't endorsing any suicidal ideation, and he had a great supportive family. We would have sent him home, too. Yes, there was that vague I don't know why I came into the ER bit and the whole prior psych history, but he seemed stable. He had seemed like he knew that he needed some help and had set the ball rolling with the psych appointments and calls to his family. True, we weren't there, so we couldn't pick up on minor body cues and such, but it seemed like the resident had made the right call. After all, who wants to be stuck in the hospital during the holidays?

Our lecturer was telling us the key clinical pearls from the story - that safety trumps any DSM-IV diagnostic criteria. That if you have a weird nagging feeling about something, you're probably right.

In every field, there's a fatal end point. Heart attacks for cardio, strokes for neuro. In psych, it's suicide. We might not have lipid panels or MRIs to go on, but we have our gut and our intuition. And that's what we have to trust.