Thursday, August 10, 2006

they stuck me in an institution, said it was the only solution

every week, we have 90 day conferences with patients on their progress. mostly, their only statements on record are some form of "get me the hell out of here".

ms. x is different. she has been at the psych hospital for a few years, and wants nothing more than to stay there. she is a schizophrenic, paranoid type, but because of her meds is completely lucid and engaging. she is different from most of the other patients: college-educated, articulate, the product of an average middle american family and a "great childhood". she has a work assignment, is an ideal employee and looks forward to being visited by her family.

the problem is, they have little reason to keep her at the hospital because she is doing so well. so the hospital and ms. x have a little game: they see she's doing well and talk about sending her to the step-down board and care, and she starts acting loopy. she's smart enough to know what she needs to do to stay there and does it.

at her last conference, she laid it all out for us on why she wanted to stay. ms. x is about the same age as my parents (mid fifties), and i can really see the 1960s ideals in her. she was always expected to have the same life as her parents: get married, have kids, have the house, etc. but she didn't want that life and acted out. she was homeless for periods and took drugs. she committed crimes, got arrested and sent to the hospital because of her mental illness. now that she's here, she has everything she needs. she gets the structure of having all her needs met, having a job that gives her peace and a sense of accomplishment, and feels that she is in a safe place. the outside world, including the step-down place, doesn't have those guarantees. she cannot imagine going back to it now.

my attending argues that she has such great potential and would have a much better life outside, but i disagree. she dropped out of society for a reason, and by her own admission, there is nothing out there that would be better than where she is now. our rewarding lives out here mean nothing to her, and trying to sell her on it is a waste of time. but the law is the law, so she very well might find herself essentially kicked out. i reckon she'll do something to get back in, maybe for good. i'm hoping that won't be the case, as some of the people in the conference were able to guide her into saying what she needed to say in order to keep her "mentally disordered offender" status and stay there for at least the next 3 months. but will there always be someone willing to help her stay there?

as hard as it is to believe, there are people who are better off in institutions. i don't want to get into a rant about california kicking patients out of state run mental hospitals starting in the 1970s and decreasing funding to both those hospitals or the community-based programs that were supposed to take their place for the ousted patients (maybe next time). the point is, we can't always put our values on our patients. we also can't assume that they will do the same in society as they do in the hospital. some people may fit the state's criteria for being released and self-sufficient, but if they don't feel ready themselves, they are destined to come back. they will do whatever they can to get back in there. and you can imagine what types of crimes would keep you in a state hospital for life.

Tuesday, July 25, 2006

my DSM-IV code right now is 300.00, generalized anxiety disorder NOS

it was actually the second day of my psych rotation, but yesterday all we did was get our badges and watch a HIPAA video. i'm on the women's unit, which is both good and bad, being that women scare me in general and i have no experience with violent mentally ill women.

this morning we walked over to the unit, and had to go through a guard's station and about 10,000 locked doors. some of them you look yourself, and some lock automatically, but i can't remember which is which, so tomorrow will be interesting. as soon as we walked into the unit, the patients were lined up to go to breakfast. "oh, we got some white girls!" said one of the patients as we walked in, and everyone laughed, myself included. it was the pseudo clarice starling moment i had been waiting for.

as in all of mental health, everyone smokes, even the staff. i quit smoking in april and if anything, this reaffirms my decision because i realize how nasty smoke smells on people and everything else. even the air is hard to get used to, but the heat might have something to do with that.

the patients are for the most part non-threatening and just about everyone is quite respectful. most of them are trying to get to a step-down unit, so they know they have to behave. we saw about 6 of them today and they all had schizophrenia, which is my reading assignment for the night. since this is a forensic unit, all of them have been deemed NGI (not guilty by reason of insanity), incompetent to stand trial or need to be here for their parole. there's a good mix of crimes, and not all are here for manslaughter, which makes me feel better.

at first i was scared to turn my back to them, thinking that if i did, i'd get shanked. but then i noticed how the staff are not all paranoid, and i got way more relaxed, although i still got nervous when we were out in the yard and they were hovering around us. my classmate was really on edge, having never been exposed to psych patients before. i hope she gets through this month ok.

in reading their charts, i've seen some themes in mental health care within the prison system that i'm going to research a bit and write more about this month. i have to watch what i say very carefully (hence this dry ass post), but i expect to learn tons about how we treat our mentally ill criminals and how they are eventually rehabilitated.

our psych attending is young (um, like 3 years older than me) and is an alumnus of our school. he loves psych mainly because "people do get better". the money and chill lifestyle don't hurt either. will i lose the bet with my dean, who said i was destined for psych? i still feel like i like everything else, that going into psych is a waste of most of my education. i just can't stand the thought of going into the wrong field and things sucking for the next 30 years.

Tuesday, July 18, 2006

fourthmeal- the crispy, crunchy, cheesy and chewy road to diabetes

i'm in my last week on the endocrine service, and having seen my fair share of patients about to lose pieces of their lower extremities, i've been thinking a lot about all the little ways we seduce ourselves into insulin resistance and the big DM.

one of the most interesting recent ad campaigns lately is the taco bell fourthmeal concept, which comes complete with a sexy, sims-esque website where one can run amok for hours "rochambelling" other nacho cheese lovers or making special soft drink mixes a la the mr. pibb and orange soda suicides of 7th grade.

i can see why taco bell would want us to eat another meal and wants us to eat it with them. but do you think they did any legal research into corporate responsibility before they started their ad campaign? my best friend the lovely litigator says that even though there aren't any specific laws they could be sued under, it's still really irresponsible to market a new meal when it's obvious we all eat to fucking much already.

some scary data on diabetes, courtesy of the american diabetes association:

Total: 20.8 million children and adults -- 7.0% of the population -- have diabetes.

Diagnosed: 14.6 million people

Undiagnosed: 6.2 million people

Pre-diabetes: 41 million people

1.5 million new cases of diabetes were diagnosed in people aged 20 years or older in 2005.

these numbers don't include those with insulin resistance or impaired glucose tolerance (known as pre-diabetes on the street), conditions which are not considered diabetes themselves, but have a high rate of progression into diabetes.

now i dig taco bell (although i dig del taco even more), but it's such transparent manipulation that it turns my stomach.

the new hummer ads with the slighted soccer mom and the emasculated tofu-lover makes me feel the same way. they aren't online but i'm sure you'll see them soon enough if you haven't- the tofu guy bit played like 2 minutes ago while i was writing this and watching the "spice capades" episode of good food. we all know that ads like these are meant to provoke, and playing on the obvious insecurities of your likely customers is cheeky enough to work like gangbusters. of course i should buy a huge laughingstock of a car because i feel all small and shamed! it's like i never left de mille junior high after all! thanks to my big new fuck-off hummer i'm in my happy place again...

ok, back to fourthmeal. so we're eating all the time thanks to that hideous word snack, plus we're eating crap from places like taco bell (and del taco). but that's not enough! we need another meal, late at night, when we are likely to be drunk and in that state where we don't give a shit who we sleep with, much less how many calories we consume. no longer do we have to feel bad about eating so late, it's legitimized because the taco bell people told us so, right on the drive-thru menu board.

why not a fifthmeal? or eighthmeal? shit, why not just throw an NG tube of taco bell nacho cheese in and have perpetualmeal?

we know that eating too much and too many of the wrong foods can lead to diabetic conditions. so why are we still bombarded with shit like fourthmeal? why are people still eating hotpockets?

there is more media about healthier lifestyles, but so much of it is hollow, like the "Mediterranean diet" brochure i got in the mail from kaiser with my cholesterol results (don't ask, it involves family history and ikea meatballs). the letter said, "read this brochure and get your blood tested again in 6 months". no follow up with the doctor, no call, nothing. it's a start, but any effective lifestyle changes require better monitoring than a letter. kaiser wants to tout their preventative care while still providing the socialist masturbation they call managed care, which precludes any attempt at the necessary communication for said lifestyle changes. if the biggest private health provider can't be bothered to get on the lifestyle changes bandwagon and mean it, we're all potentially on the highway to metformin hell. and for every step forward that we make to educate the public and help stop diabetes before it starts, things like fourthmeal (it's ok! eat another meal, because you're hungry! very hungry!) add up to pushing us back.

we have to become resistant to suggestions that we eat more often, eat with our emotions and eat more cheesy bacon with bacon and cheese, and cheesy bacon-blasted ranch dressing. so many people still don't really believe that obesity and diabetes are linked, and that untreated diabetes leads to renal failure, blindness and getting your fucking feet cut off. health professionals need to take a tougher stance, and say something to every patient, every time, even if they don't have any of the signs yet. at first when i saw my attendings talking to patient's families about their own diabetes risks and flat-out saying things like "you're overweight, you need to lose weight and eat better because what is happening to your family member could happen to you", i was floored. but we have to try, make people uncomfortable, make them look at their father's leg stump, make them think. ultimately, it's us or taco bell.

Friday, June 23, 2006

an M3 in 3 days

i got an extra white coat. some black pens. had all my doctor-y clothes dry cleaned. the car is getting a very expensive tune-up. i read first aid for the wards and how to be a truly excellent junior medical student. i'm taking ACLS this weekend. all of this to be totally prepared for rotations.

but really i'm not prepared at all. i feel woefully inadequate for what i'm about to start. i am about as anxious as i was in the days before i started med school, although i haven't gotten a rash. yet.

it helps to relax at home, doing little but watching tv and catching up on world news. i felt like a loser for not going out all day at first, but after spending the last two years feeling like a different person and wondering when i'll get myself back, i know that part of me is gone forever. that's not just a function of being in med school, it's just being a grown-up.

i know where i will be on monday. i called yesterday and i will be on the endocrine service. i'm technically supposed to be doing general internal medicine, but that's how things go sometimes. the upside is that the attendings for this service consistently get positive comments in evals and everyone emphasizes how much they enjoy teaching students in a non-stressful environment.

i just might survive. wish me luck.

Monday, June 19, 2006

i am alive

you wouldn't believe the number of times i've said "hmm, need to update the jerk" and didn't. i even had a couple of drafts that i wrote that didn't feel right.

as you can guess, i'm done with 2nd year. i've taken my boards and await to take the USMLE on wednesday. then i start my medicine rotation at...well, i'm not sure really. (ok, this will give away my identity to people who read my other journal, which i have been updating as usual. but, like anyone cares, right?) due to the preceptor's illness, my previous medicine rotation was cancelled. i'm supposed to find out today where i will be next monday. it could be anywhere, even michigan, although that's a stretch.

2nd year went well academically, but personally tested the limits of my sanity and emotional stability. i didn't get divorced or anything, but a death in my husband's family brought confirmation that there is indeed a fatal genetic disease hanging around. i don't want to elaborate, but it's one of those diseases where you think "jesus, i'm glad that's not in my family" when you learn about it, and since it's on every board exam, so i'm bound to get a nice punch in the gut on wednesday when i'm trying to concentrate.

in the last few months, we have learned a lot about insurance policies and terminal illness. patients with the disease have a suicide rate 7 times higher than the normal population, and face the reality of never being insurable again after testing positive. needless to say, i am terrified at the possibility of losing my husband after he suffers from horrible symptoms for years or commits suicide, not being able to have children and the absolute uncertainty of our lives forever.

yes, they could find a cure. the problem is theoretically an easy one to solve, and there is a lot of research money thrown at this disease. but they are still in the easy (like, mouse and drosophila) stages of the most promising research, and i'm afraid by the time they figure out something he will be too sick for it to make a difference. godspeed, researchers- please find the way to help people with this gene.

i wish i could say more, but the fact that this is out there in the internets stops me, as does the pain that comes with thinking (and writing) about it. i just had to put something up here though.

Sunday, September 25, 2005

kitty love

just now, i led our cat, sarin, into the bedroom to greet the husband. she has a little ritual with him on weekdays, where she waits outside of the bathroom door for him to finish showering. when he comes out, she will start chattering incessantly until he starts for the kitchen to feed her. on weekends he sleeps in more often so i end up feeding her. i can tell she's ok with this, but isn't stoked about it as much as she about him feeding her.

when we got into the bedroom, she went over to his side of the bed, where he had left his clothes from yesterday in a pile. he did some yardwork yesterday, and said he forgot to put on deodorant. this = dirty hippie stink all over the shirt. sarin went nuts, treating the shirt like it was sprayed with catnip. she sniffed and chewed the armpits, then flopped down and did the hind legs rabbit routine on it, just in time for him to come in and watch.

this is a recurring theme with sarin. every time there's been a man in the house with her she's taken to them like a giddy schoolgirl. she'll follow them everywhere, hop up on their laps often and sleep on their side of the bed. she makes nests for herself with clothes that smell like them. i will admit i am somewhat jealous because she likes girls ok, but nothing like how she responds to males. i've had her since she was 8 weeks old, and have been the only constant person throughout her whole life. when i come home she might greet me if i happen to go into the room she's in, but when the mister comes home? she runs into the room and starts up with meowing and the face rubbing on his pant legs. it's not me, it's that i'm a girl and she can smell that on me. i have nothing to offer her.

so it makes me wonder how strong is a signal between two species? i always thought they'd at least be different enough so that you wouldn't have tons of useless attempts of interspecies mating going on in the wild.

(as a side note, there are real hybrid animals, but it's between two species that are pretty damn close evolutionarily speaking. still though, a wolphin!?)

wouldn't you know? they've done studies on this type of thing:

"Recent evidence suggests that vomeronasal sensory neurons may be narrowly tuned to specific molecules (Leinders-Zufall et al., 2000), unlike the main olfactory system, so why would one species respond to another's pheromones? Foreign pheromones would be unlikely to carry mutually beneficial information for another species, but they may have common chemical components. Hamsters probably also share a similar repertoire of functional VR genes with other rodents, as is the case for mice and rats (Dulac and Torello, 2003). Common chemicals would activate common receptors but could be components of different blends, each blend a pheromone only for one of the species. It is also possible that the VNO may have receptors (specialist or generalist) for nonpheromone substances. For example, snakes use the VNO to detect predators and prey (Halpern and Martinez-Marcos, 2003)."

now, this study used hamsters, but it gets my point through. if there are common molecular components to the pheromones of cats and humans, sarin's response could be due to some part of the human male sweat that reminds her of boy kitty scent. it's a response i've seen in her reaction to three different men. it's been the strongest in the husband, but when my brother and i lived together with her, she did exhibit the same behavior with him, and still does when he comes to visit.

i don't know if it's purely sexual, or related a deference to males in general. it's hard to swallow that last part if you know sarin, because she's really not the type to play submissive to anyone. at the very least, it highlights how her interactions with our family may not be merely based upon the promise of some more wet food, but as a necessary social interaction. and they say cats prefer to be alone!

since we're talking about kitties-we are in preparations for getting another cat. it's gonna be a boy kitten, and we should receive him as soon as he's weaned, which will probably be another couple of weeks. i think she'll like him. but he's very cute, very laid back and kinda chubb for a 4 week old baby. i'll post pictures when he gets here.

Sunday, September 18, 2005

Welcome to MS2: no more fucking around, we've got lives to save!

this year started off with a bang, namely the party the boy threw for me when i got back. it was great to see all the people i'd missed while being braised in my own sweat over in bethesda. our research finished nicely, having seen something like 26 patients. with every patient taking half a day, that's pretty damn productive. if all goes well and the gods are happy with the immolation, we'll get a couple papers published.

it's become very clear from the start of MS2 that there will be no more of what one of our professors calls "academic bulimia". it's not like we didn't realize before that we needed to know this stuff for a reason other than to pass an exam, but it seemed so far away then. now it's less than a year away. the exam questions have become more clinical in nature and the lecturers now assume we remember the anatomy behind the stuff they're teaching. needless to say, i've been breaking out the old shit a lot.

currently we're in the cardiovascular system. i've never been the heart's biggest fan, given that it's a lame-ass pump (with 14% efficiency i might add), but nonetheless, it's pretty important since so many people have bad ones. here's some numbers for the US, from some guy named Ben Best, who seems to like death + statistics as much as i do:

in the US:

(1) Diseases of the heart heart attack (mainly) 28.5%
(2) Malignant neoplasms cancer 22.8%
(3) Cerebrovascular disease stroke 6.7%

In other places:

(1) Ischemic Heart Disease 12.4%
(2) Cerebrovascular Disease 9.2%
(3) Lower Respiratory Infections 6.9%

and it's only gonna get worse for my generation of physicians:












-From 1979 to 2002 the number of Americans discharged
from short-stay hospitals with CHD as the first listed
diagnosis increased 22 percent. (CDC/NCHS)
-From 1990-–1999, the median duration of hospital stay
related to acute myocardial infarction dropped from 8.3 days
to 4.3 days, according to an analysis of the NRMI. Findings
were similar for both patients receiving primary PTCA and
those receiving thrombolytic therapy. (J Am Coll Cardiol
2000;2056:63)
-Based on the NHLBI'’s Framingham Heart Study (FHS) in
its 44-year follow-up of participants and the 20-year followup
of their offspring (Hurst W. The Heart, Arteries and
Veins. 10th ed. New York, NY: McGraw-Hill; 2002)
-The average annual rates of first major cardiovascular
events rise from 7 per 1,000 men at ages 35-44 to 68 per
1,000 at ages 85-94. For women, comparable rates occur
10 years later in life. The gap narrows with advancing age.
Under age 75, a higher proportion of CVD events due to
coronary heart disease (CHD) occur in men than in women,
and a higher proportion of events due to congestive heart
failure (CHF) occur in women than in men.
-The aging of the population will undoubtedly result in an
increased incidence of chronic diseases, including coronary
artery disease, heart failure and stroke. (Circulation
2002;106:1602:–5)
-The U.S. Census estimates that there will be 40 million
Americans age 65 and older in 2010.

Source: American Heart Association Website

so yeah, this heart stuff is pretty important no matter how damn boring it is.

as i was looking all this stuff up, i found out that september is not only National Cholesterol Education Month, but also National Osteopathic Medicine Month.

spread the word, get your cholesterol checked. mine is total: 176, LDL: 115, HDL: 51 and triglycerides: 48.

yes, thank you, i will have another steak.

and get some osteopathic manipulative medicine done, because frankly, your back is killing you, isn't it?

as an aside, if you want to be thuroughly informed and entertained, the rest of Ben Best's website is completely awesome. beware of driving in Portugal or South Korea, and of being poisoned in Russia. he also write stuff on nutrition, calorie restriction and how it makes you live longer, and cryonics for when you've fucked it all up and want another spin on this mortal coil.