Borderline

I saw a patient last Friday who I swear was a schizophrenic. She had voices in her head telling her to stab her family and herself, she was depressed, psychomotor retarded, she'd space out as we talk, very blunt affect. I thought she was classic schizoaffective with depression. I looked over her notes and couldn't understand why she was labelled with borderline personality.

Today I interviewed her again with my RMO, and my RMO picked her for borderline straight away. What did I miss?

I had picked up her auditory hallucinations and suicidal ideation thinking I've found the mother-load, and tunnel-visioned myself. As it was pointed out after, that her thought process was clearly not disorganised. Apart from her hallucinations, she had none of the symptoms of a schizophrenic (it helps that she's more talkative and happier today, but it still made me look like an idiot). I rang up her old hospital for a copy of her past admissions, she's had numerous suicide attempts, some of the lethality were questionable. Paracetamol won't kill unless you have taken enough; saying you have Over-Dosed when there's nothing to be found in the blood can't really kill you either. She's also trialled numerous antipsychotics, including clozapine, to no effect.

I realised that she is not psychotic at all. I've been fooled by her alleged list of symptoms. To my comfort, there were other doctors that thought she was schizo as well, which explained all the anti-psychotics that she was put on. She was probably not being factitious, but still, I was annoyed with her fooling me. So I looked up borderline personality disorder to educate myself.

Biggest clue for these patients are repeated suicide attempts (or some form of self harm). 50-70% of them had history of being sexually assaulted. I did read that in her notes, and she started to present to the hospital some short time afterwards. I started to feel really bad for her. She's never had a romantic relationship, chronically depressed, went through ECT, she was a cutter...she eventually reported the sexual assault to authority, the offender (who was family) became alcoholic and died 2 years ago, so she feels exceedingly guilty...the social history is a mess...

And it doesn't help that I can identify quite a few of the symptoms myself.

Don't be a douchebag, take your caffeine

"if you choose to drink decaf, you deserve bad coffee"

Talking to a long 'lost' friend this afternoon, E, she clarified some of my misguided conceptions about coffee. She was lost because E spent a good deal of several months in the snow-covered Canada last year and thus off of my friendar (friend radar). She worked as a travelling coffee barrista much like a Gypsy fortune teller. One can go to a Gypsy to have their fortune told, but if you cross with one, you get cursed with bad Gypsy ju-ju. If you cross with her, you get served with black sludge, literally.

It started with questions about my sanity and my attempts to cover-up the fact that I am actually an emotionally damaged emo kid. But my misconception was that a cup of latte is 50% milk and 50% coffee, and that it shouldn't be foamy like a cappuccino wannabe. But then I found out that there are rarely that much coffee in an actual cup of coffee. You get 2 shots of espresso usually, so around 60mL.

Cappuccino is suppose to be 50/50, so it seems stronger.

Latte has a lot more milk but less foam.

Flat white has only a thin top layer of foam to seal it but rest is milk.

Which brings the question of, if most of my coffee is milk, what different does coffee bean make? Referring to people being fussy about their coffee beans. It doesn't really, unless you drink black coffee and black sludge. That's where fresh press coffee differs from a month-old coffee bean (it sounds more like a description for babies, "can you use some month-old baby beans in my coffee please?").

"What's sludge?" I asked. "Brewed coffee that sits on the burner for too long."

"Oh," I paused "and you can sell that?" She grinned electronically with mathematical symbols, "only when I'm feeling bitchy. Usually to decaf drinkers. If you choose to drink decaf, you deserve bad coffee." She went on to explain how most decaf drinkers act real douchenozzle like.

The word sludge though, reminded me of a case I heard about on the psych ward. The logic is that a man wanted to commit suicide. He heard that if there are bacteria in the blood, it can cause septicaemia which could lead to multi-organ failure and death. He also learned from school that there are bacteria in poo. You put the two together, that is what he did. He injected poo into his blood stream, unfortunately his plan didn't succeed.

Initially it was puzzling for the treating doctor as to why they found E. coli in the blood, and then some curious intern found the 'concoction' in his drawer. Subsequently it was learned that he is usually discharged for this malingering behaviour, so he travels across country, gets admitted to hospitals that his fame has not reached.

When they rang up a hospital inter-state for previous medical record, they said "oh! you guys found the poo-pusher!?"

Portfolio

One of the hurdles we have to jump is to write a portfolio for the school. A thousand-word how-does-that-make-you-feel essay about life in medicine from the perspective of a student. Then we have to talk to our assigned 'mentor' about it for half an hour or so. An assigned mentor is like an arranged marriage with an ugly woman with no sexual desires. You don't like her and she doesn't like you. Nevertheless, after 2 hours of pouring my hearts out on paper, I consider my portfolio a literary achievement. One that is so inspiring, thought-provoking and yet humourous, all in the context of fulfilling a mindless task of a ticking-the-box hurdle. All written in 2 hours.

I met up with my mentor today, and it is obvious that he had a glance through my words. Just a glance. If i put two hours of my time into something, I want someone to at least read it. So here is some extracts:

What have you noticed about work pattern and work practices in medicine? What effect do you think these have on doctors?

I have thus far completed paediatric, obstetrics and gynaecology rotation, rural GP placement and finishing my urban GP practice. I am on psychiatry rotation at the moment. I have spotted that different specialities have very different cultures, practices and thus much different timetable and lifestyle for the doctors. I understand that lifestyle is as much a factor in influencing an individual’s choice in specialty as personal interest, if not valued more sometimes.

Generally the life of a doctor at the hospital compose of ward rounds in the morning, arriving earlier the more junior you are; frantically recording all the instructions and jotting down sparse threads of knowledge that slip off of the Consultant’s tongue. Depending on the specialty and ward, this could be done by early morning, in time for a shot of caffeine, or ongoing till your stomach groans louder than the patient writhing in pain. You divide the rest of your day between carrying out instructions on the ward, visiting clinics and sometimes ED, and wait by the phone for the radiologist to call back. Variations are specific to the specialty, your seniority, and of course, your competency. As a consultant, there are commitments to private patients. A registrar gets peppered with stupid questions from worried interns from another specialty. RMOs get to scare medical students who are following them around like puppies. And interns busy pulling their hair out over their newfound responsibilities and overwhelming work.

Being a medical student amongst all the chaos is the most contradicting experience. On the one hand, nobody expects you to know how to do anything save the most basic history and physical examinations; on the other hand, you better have an answer for the question thrown at you by the consultant with a glare. Everyone expects you to commit as much time on the ward as the patients themselves, leaving no time to study; yet also interrogate why you have not read up on the topics you were quizzed the previous day.

Different specialties require different demands based on the nature of work, and these effects are clearly demonstrated by the doctors who work in the specialty. Paediatricians like psychiatrists are very soft spoken, as if not to spook the patients. Both specialties require endless patience. Added to the playfulness, paediatricians can also make opportunistic diagnosis while cooing a crying baby or calming a child tantrum. Psychiatrists are meticulously observational and insightful; and like obstetricians and gynaecologists, they inspire trust and rapport rapidly with patients.

What kind of work stresses exist in medicine? (what kind of stupid question is that?)

All jobs come with a description of stress, with some more than the others. A physician’s work is especially stressful, for we are always trying to practice beneficence.

At my GP rotation, I found that the sheer amount of patients walking through the door can leave a doctor eating lunch at 3pm. Yet GPs are always trying to spend more time with each patient. So there is a constant time pressure. In paediatrics, stress comes from not only the patients but also the parents, as a paediatrician attempts to treat a family rather than a small sized human. In obstetrics and gynaecology, the most stressful situation is seeing a PPH in action. Never in the field of medicine have I seen so much blood pouring out so quickly with so few warnings. The first time I saw one drained the colour off of the patient’s face, and mine. In psychiatry, the traumatic experiences, social issues, and transference contribute to significant emotional stress.

On top of the specialty stressors, there are always the basic stresses over medical stability of patient, misdiagnosis, and general concern for the outcome of the patient. True to most doctors, but more particularly for a medical student; there is the added stress of studying, or the more troubling, the lack of. This is especially relevant for a third year student. Given the chance and time, I would love to spend as much time on the wards and see as many patients and learn as much as I can, but the looming end-of-year exam means that I have to excuse myself from clinical settings. Sometimes the lack of understanding consequent the biggest stress for me as a student.

Vicious Cycles

Life is fairly consequential. Often the reactions loop back and link up with the actions, forming circles, so life is full of circles. Problem is that some circles turn into vicious cycles that, like maelstrom, suck us down and we cannot escape despite all our efforts.

We saw a young pregnant lady this morning, who had quite a lot on her plate. We saw her for the panic disorder, but the medical problems that she is dealing with took pages and pages to summarise.

Her chronic anxiety lead to avoidance and sensitisation which feed into fear of future panic attacks. Avoidance develop into agrophobia, plus the sensitisation finally becomes panic disorder, which accentuate to chronic anxiety.

When she's anxious, she smokes cigarette, which compromise airway, lead to use of nebuliser (ventolin) that produce symptoms like palpitations that mimic her panic attack, increase her anxiety.

She has gastroparesis which lead to constipation, chronic abdo pain which is accentuated by the panic disorder. She abuses codeine and NSAIDs to control the pain, which reduce bowel movement, lead to more small bowel obstruction, lead to more pain and thus more morphine, slows bowel further, but also lead to addiction and tolerance, so she needs increased dose of morphine use, more constipation, more pain. Downward spiral.

She gets stressed by her panic disorder, so she abuses cannabis (THC), opioid, and was given valium (BZD), developed dependence on all of them, which lead to more stress as she knows she's addicted...

Because of all this on her plate, she has only recently stopped her cigarette and THC a month ago, and possibly still using opioid. She is now 36 weeks, the damage for the fetus has already been done. When the child is born it is likely to have congenital problems, which means more issues for her, who already has 2 children, no job, left school at 15, etc etc. Her parent were young as well, mum was 18 and dad was 16 when they had her.

How will she ever escape?

Madness of King George III

Cardio: Tachycardia and arrhythmia.

GI: Acute abdo pain, vomiting, diarrhoea or sometimes constipation.

Renal: purple urine.

Neuro: seizure, neuropathic pain.

The patient suffers from acute prophyria. To help with memory, I found an old film about it. Following are some memorable lines from the movie Madness of King George:

"Do you think that you are mad?

I don't know

I don't know

Madness isn't such torment

Madness isn't half blind

Madmen can stand

They skip. They dance

And I talk. I talk and talk and talk

I hear the words, so I have to speak them

I have to empty my head of the words

Something has happened

Something is not right."

"Yeah, I've always been myself, even when I was ill.

Only now I seem myself. And that's the important thing.

I have remembered how to seem."

Poor King George suffered the attacks some 100 years before the disease is recognised by the medical profession.

The Fallen

She is only 51, but she looks much much older, in her 80s or 90s. She's frail, skin and bone, sunken eyes and hollow cheeks. She looks like she has one foot in the grave, or just climbed up from 6 feet under. Her fragile frame, gnarly claws, and unsteady gait, reminds me of the de-conditioned black-and-white survivors filed out of WWII concentration camps.

She speaks slowly, but her stares are still sharp and she glares at us for admitting her to the psych ward. She is angry, "I want to go home," she said. "Why am I here?" Her daughter shakes her head and tuts in agreement.

She was a GP not half a decade ago, her license was revoked after she suffered a stroke. The sense of gloom and doom were so great that she became suicidal since her loss. She's given up. She spent the next couple of years contemplating about it, managed to convinced everyone around her that is the way to go, even involving 2 GPs who are now being reviewed for their medical ethical decision. She has literally starved herself of food, of hope, and of life.

She was a medical student once, a breed very much familiar to me. I can imagine her being a perfectionist, particular and highly functional; could handle anything that is thrown her way, and deals with everything herself. Her meaning of life was robbed from her when she had the stroke, she can not tolerate functioning at any level less than the highest.

What really strikes me is that she had given up so quickly and easily. Because I am exactly like that.

The "Stubborn Child Law"

In 1946, The Stubborn Child Law was enacted by Puritans in the Massachusetts Bay Colony - Parents claiming a child was stubborn or rebellious could seek State reprimands, including execution...And I thought Asian parents were bad...

Music logic

I have never been good with words. Other than the obvious suspicion of expressive language disorder, the real annoyance is that I am left with whole heap of theories and points that I find hard to express or formulate into words.

One of them is my theory of music logic.

I believe that just like normal logic, there's a grammar-like rule that helps us understand music, or "complex non-linguistic auditory signals". Our preference of music depends very much on these music logic. We all find some music mollifying and others utter noise, and according to my music logic theory, some music 'makes sense' to us while others do not. Obviously the type of music that makes sense will appear much more soothing and resonate stronger with us.

Music logic allow us to listen to a piece of music, 'agree' to its melody and 'predict' what is coming up. Like when you are in tune with someone's thought process, you can finish their sentence. The harmony between the music and our intrinsic music logic means that we find the piece very favourable to our brains.

I believe that the music logic as I call it can be learned like grammar of a language. So when we are exposed to a new piece or new type of music that we have not previously heard or enjoy, we may resist it at first. But as more exposure and repetition drum it into us, the new logic may stick and starts to 'make sense', consequently become enjoyable.

I have based this thinking on my own experience where, I have only been exposed to classical music as a kid, then old mushy 70s, 80s love songs, and rock in late teen years. Each time it took a while to make the transit, but once 'understood' I enjoyed the genre fully.

I am sure there is a term already coined for this 'music logic', if anyone well-versed with music theory know what it is called, please let me know.

http://www.nytimes.com/2010/06/01/science/01conv.html?ref=science

The Asian version of my name

I've been asked quite a lot recently whether my name is really Shawn.

The latest was yesterday, the first day on my psychiatric ward.

I introduced myself to the Registrar on the ward. She was very friendly and took me aside to give me a brief introduction and what to expect. "A lot of students find psychiatry very daunting at first," she reassured me, "but over time you will learn how to deal with patients, don't worry." After her spiel she proceeded to put my name down on her note pad, just to confirm though, she asked, "what is your name again?"

"Shawn"

"is that your real name?"

"huh?"

"Oh, because most Chinese students and doctors on the ward have Asian versions. Is Shawn your actual name?"

I was tempted to tell her that Shawn is actually my alias for Mon, Wed and Thursdays. I go by a different name at night and also respond to the name Bon Jovi when I've had a few. I am also actually a jaundiced Caucasian. But then I was reminded that we are about 10 meters away from a closed psych ward and that she is a psych registrar. She can have me detained for 24 hours with one signature.

I did not mess with her.

The Son of God

We have just started 2 days of psychiatry, its been crazy so far (Hah! get the slightly inappropriate yet still mildly funny pun?). I have been thrown into the deep end, 5J the closed ward in Margret Tobin Centre, literally the maximum security, ultimate psychotic ward. I met the Son of God today, and he's been preaching to others on the ward. It's only a matter of time before I'm converted, and then I can finally use the excuse, 'it's against my religion to work/study'. I may have to help him write the bible to his new religion, because among his early followers my hand writing may be the only one legible. I cant wait to meet Moses and Joan of Arc, although I don't speak French, I'm sure I can understand her just fine.

There are of course no Joan on the ward atm, but there is a nasty mean lady that shouts, "go back to your country!" everytime I walk pass. It's apparently not professional to play into patient's delusions, so I will have to wait till my last day to tell her that actually, my country has bought the majority of Australia and she will soon be deported to Uzbekistan.

So as I walk around in my shirt w/o a tie, a duress/rape alarm clipped to my belt, and escorted by a macho man-nurse and 2 fat donut-filled security guards, I cant help but feel slightly sorry for the patients. Most of them have a theory and lives in an alternate universe of their own. They are labelled as delusional and psychotic because their realities are different to the one we are used to. Their perceptions of the world deviated from our perceptions, but who is to know that our perception fits perfectly to the actual real world? It's like looking for something with a small torchlight in pitch dark, what we see is limited to the little cone of light. I am sure our torches doesn't illuminate the whole room either. One day, when the absolute Truth is revealed, we will learn that actually, 42 is not the answer.

I will have to find something else to tatoo on my bum.

I exhausted my booze money on a ticket to Slash concert in August in Melbourne :p cant wait. I'm now living on my drugs money. Oh and the first day on Psych ward, I learned how to make hash brownies from the consultant :) Who knew I'd learn something useful on the wards?