12 hours of sleep!!!

My last day of psych consult was yesterday. This week was exhausting. We were swamped with patients, and everyday, we were basically on the run from one consult to another, without time to eat or sit. Of course, I can't really complain. I'm lying in bed at 10:30 on Saturday morning, catching up on email, while Rabbit and Coyote had to be at 5 am rounds this morning for their IM and surgery rotations. I'll be doing that in a month, but for now, wooooohooooo!

Consult was interesting. It is strange to spend your entire day talking to people who are so mentally altered that their medical team requires the consultation of a psychiatry team. There are schizophrenics who can only understand concrete statements, have disorganized thoughts and can rarely remember anything about their lives. There are the "Axis II" personality types: borderlines, narcissists, and histrionics, who are frustratingly hard to talk to due to their blatant sense of entitlement, need for attention, and manipulative behavior. Then there are the "polysubstance use" addicts, all who were at some point abused and dehumanized as children, who live on the streets, and come in the hospital with rotten flesh, assault wounds, alcohol withdrawal, drug-seeking behavior, or, this past week, severe dehydration. There are the old ladies with UTIs, slightly demented and depressed, who lapse in and out of consciousness as their over stressed brains succumb to delirium. Those are the patients we often see on consult. All of them have names and all have remarkable life stories, no matter how quickly we tend to cluster them into a familiar category. I remember each of them distinctly, though I wonder just how long that will last.

This past week, I've had three patients that I really enjoyed getting to know, and one that drove me crazy. Guess which is which:

- Pleasant 50ish yo woman, recent immigrant on prophylactic treatment for exposure to tuberculosis, admitted for appendicitis. Was post-op day 4 when she began to see faces in her windows and hear voices coming from the wall telling her they are going to kill her. Refused to go back to her room and sat in the hallway next to the nurses station, waiting to hitch a ride out of the hospital with her son when he came to visit. Of course, we couldn't let her leave. We suspect she had a rare reaction of psychosis due to the TB drug she's been taking for the past month. We put her on an antipsychotic, discontinued her TB drug, and are hoping she will do better soon. If she does, I and another medical student, who has been helping translate, will likely try to publish a case report on this patient.

- Anxious 40ish yo woman, who's been hospitalized for the last 2 months for a mulitple rare autoimmune, infectious and idiopathic diseases. Her family is far away (she was transported from a smaller hospital that was overwhelmed by her medical conditions) and she feels scared and isolated. We were asked to consult on her for depression, but decided to start by just treating her anxiety. She's gotten a lot better over the last week, especially once she started sleeping a bit more, and they are considering transfering her back to a hospital near her family. Both I and another medical student who was directly in charge of her case have gotten pretty attached to her, and are going to continue following her while she is here.

- Confused, emanciated older man, who always smiled when I walked into the room, had been admitted for dehydration and confusion. Turns out he had not been able to take care of himself in the heat, became dehydrated with renal failure. He showed severe symptoms of depression and possible dementia, but has so far refused treatment with an antidepressant. He has a remote history of incarceration and heroin use, but he has been compliant on methadone treatment for the last 20 years. His medical team do not think he can take care of himself and he will be discharged to a "SNF" (pronouced "sniff"), a Skilled Nursing Facility, when he gets better. He is the first person I've ever seen be excited about this, and he says it will "solve all my problems."

- Unemotional, morbidly obese woman from a rural county, admitted two weeks ago for back surgery. She has been refusing physical therapy and manipulating her staff. When I came to interview her, she interrupted me repeatedly to ask me to adjust her pillows and, at one point, to hold her foot. She's in her 40s but still lives with her parents and sibling - all of whom she absolutely "hates" but talks on the phone with for hours a day. She answer each qustion without a bit of emotion and then goes on, not letting you interrupt her, for a good few minutes telling you in detail every little though she has about it. The staff had to have a meeting, which I attended, about "behavioral intervention" because they fear that she might never leave the hospital, given her current rate of recovery. Her nurse was somewhere between tears and homicidal thoughts. I was glad we could give our diagnosis - narcissistic personality disorder - and sign off.