Friday, March 15, 2013

Guns Scare Me

A few weeks ago, I was called to the ER to see a man who had threatened to kill another man in a drunken rage. When I spoke to the ER doctor over the phone about the case before actually seeing the patient, my first question was, does he have any weapons on him? And if you haven't asked, could you go ask? He had a 3 inch knife on him (legal to carry in the hospital if it can't be opened with just one hand), but no guns. 

Then, a few nights ago, I was called to evaluate another man in the ER. Halfway through the conversation, he started talking about a shooting at another hospital. I am not sure how he got onto the topic or what his point was (something about saving extra medicine at home in case of an emergency), but I became anxious. He sat with a large black bag on his lap, and I knew he had some other belongings out in the waiting room. What if he had a gun in that bag?  I could not focus on what he was saying anymore. My rational mind told me that this man was at quite low risk for acting violently in the next few minutes. He had no history of violence, he was quite cooperative and friendly while I interviewed him, and he was not intoxicated. But I couldn't focus. What if something happened and I had ignored my feelings? My heart was racing. My patient's lips were moving, but all I could hear were thoughts in my own mind. I knew I needed to take a break before going any further. I abruptly stood up and excused myself from the room. I had to get out of there. 

I ducked into the social worker's office across the hall and confessed to her why I had stopped the interview. I felt really silly. This person probably didn't have a gun, but my imagination, with recent current events for material, was running wild with possibilities.

I called the grounds security police to accompany me back into the room. I thought there might be a "safe" way to ask this question, but there really isn't. The police man looked at me, then looked back at my patient and literally said, "Sir, do you have any weapons on you?" I had been scared to ask that question on my own. 

Like the patient I mentioned first, this man also had a small blade on him, but no guns. He was embarrassed; he thought that I had seen the knife he kept on his belt and then called the police in because of that. He quickly unbuckled his belt, on which the knife pouch was threaded, and reached behind his jacket to pull it through the loops. This motion made the policeman say, "Hey! Hey, what are you doing?" My patient immediately put his hands up in the air. "I'm sorry," he said. Now it was awkward, and we were all on edge for apparently no reason. I thanked the officer for his help, and then I was back with my patient, finally talking about what brought him to the ER in the first place. 

Recently, I have felt extemely vulnerable when meeting patients for the first time in the emergency room. People come in from a number of different situations from the community. They are not initially screened for weapons, and though a sign at the hospital entrance prohibits weapons, I'm not sure what deterring power it has. 

There has been extensive press about mentally ill people and guns in the context of horrific recent shootings. There has been a push to prevent mentally ill people from getting their hands on guns. In California, the law prohibits anyone who has been placed on a 5150 hold from owning or buying a gun for 5 years. However, enforcement is problematic, and as we have seen recently, people get access to guns from family members and friends. 

To work under the knowledge that people can be carrying weapons freely and/or illegally is unsettling to say the least. At times, I am finding it makes it difficult to focus on my job and to treat people openly and without fear. The more I learn about people, the more I realize we can't control people. But we can control  the weapons that are acquired by citizens and what ammunition is out there. Let me get back to my job. Let school teachers get back to their jobs. Let movie and mall goers enjoy themselves with peace of mind.  Gun control is what our administration should focus on. Obviously there are a lot of nuances here, but in the clinical setting, my recent personal reactions have been quite strong and clear, however rational or irrational they may be.


Wednesday, February 20, 2013

Not-so-great expectations

I am really tired from over four months of inpatient work. The time requirements of being an intern have meant that I have had little time to maintain aspects of my life that used to define me. When friends or family ask to hear what I've been up to, the answer is work. When applicants to the psychiatry program ask me what my hobbies are, I tell them what I used to do. Though I know this is a very unique and all-consuming time in my training, it is still disturbing for my identity to be reduced to my job and to often be isolated from the healthy majority of people.

On one hand, I love being a doctor. I love working with people and often helping them. I love learning and becoming skillful in different areas. But for all of this, I also resent what I have to sacrifice in order to do these things. My own ability to cope with stress, with sick patients, with anxious families, with abrupt co-workers, is reduced in my state of physical tired-ness and shallow emotional reserve. At my best, I can take things in stride, give myself and others a break, and go home and get a good night's sleep. At my worst, I've taken out my frustrations on family, friends, co-workers, and even subtly on my patients.

One of my mentors told me that the key to maintaining reserve is to offer oneself unconditionally without being invested in the outcome. In other words, give freely, with no expectations of anything in return. So I shouldn't expect patients to agree with a plan I have thoughtfully put together. So I shouldn't expect patients to thank me for going out of my way to make appointments for them. So I shouldn't expect patients to miraculously change their lives because I treated them. Sounds obvious (and I sound narcissistic) writing this, but sometimes, I get the idea that when I spend time and energy on something, that I should get something back in return! Credit, gratitude, a break, kind words...and it just doesn't work that way. It's a weird dynamic between being taught that we are "worth" this and "deserve" that and "our time is valuable"--but do these ideas fall into the categories of self-respect, self-preservation, self-defense or self-righteousness? It's not always clear. By freely giving (and also by asking for what we need in earnest), we can tap into an endless supply of love and energy to share with people.

Thursday, February 14, 2013

Basic Mental Health Law

Last month, I went to court. The proceeding was held in a conference room on my hospital unit. In front of a county judge, I stated that my patient should continue to be hospitalized against his will because of his high suicide risk. The evidence to hold him included: a recent suicide attempt, past suicide attempts, recent end-of-life gestures including saying goodbye to his son, and constant thoughts of killing himself. 

The patient, who wished to leave the hospital, sat across from me. An appointed lawyer, a mental health specialist, spoke on his behalf. She appealed for his discharge, stating that he would continue outpatient psychiatric care and that he was making future-oriented decisions such as establishing his social security benefits. 

Mental health law is different in each state, but in California, the rights of mentally ill patients are currently protected under the Lanterman-Petris-Short Act (LPS), which was signed by Governor Ronald Reagan in 1967. Some of the wording includes, "to end inappropriate, indefinite, and involuntary commitment of mentally disordered persons..., to provide prompt evaluation and treatment of persons with serious mental disorders..., and to protect mentally disordered persons and developmentally disabled persons from criminal acts..."

Under LPS law, patients must meet one of three criteria to be held against their will: danger to self (DTS), danger to others (DTO), or grave disability (GD), which is one's inability to provide a plan to get food, clothing, shelter.  Importantly, the criteria must be true because of a mental illness, and not a medical illness (like dementia or brain tumor) or criminal pursuit. 

Out in the community, police or designated mental health workers can place what is called a 5150 and bring a person to a hospital for evaluation. A 5150 is valid for 72 hours and cannot be contested by the patient, though it can be discontinued earlier than 72 hours a doctor. At the end of 72 hours, if a person still meets DTS, DTO, or GD criteria, a doctor can apply for a second certification that allows a patient to be held for an additional 14 days. This is called a 5250, and this CAN be appealed by patients. They have the right to see a judge within three days. 

While it may seem that LPS law imposes on more rights than not, the law ensures prompt evaluation by a doctor and continual necessity for justifying hospitalization, which is in contrast to the old days when mentally ill patients were held indefinitely against their will and subjected to treatments without consent. In addition,  mentally ill patients have other protections against forced treatment. Under LPS law, even if patients are held, they cannot be given routine medications against their will (this requires another court proceding). To administer any medications on a psychiatric ward that affect a person's brain, the patient must given documented consent. Interestingly, these same medications, if prescribed in a general medical clinic or on a surgical ward, would NOT require consent. 

To finish my story, the judge denied my patient's appeal, and his hospitalization was continued against his will. While I do think we were protecting him from self-harm and buying time to help his depression, it made my relationship with my patient adversarial. It felt contradictory to testify against him one afternoon and then invite his trust the next morning in our daily sessions. It was quite uncomfortable and challenging to rebuild that alliance with patient in the following week. It also infused questions into my mind if we are doing the right thing by holding the patient and reminded me of the seriousness of taking away someone's civil rights. 

Thursday, January 31, 2013

The Making of a Mind

Hello again, world! I haven't posted in about three years to the date. According to that post, I was considering many different medical specialities. Looking back, I didn't mention psychiatry! And now I am more than half way through my psychiatry internship (first year of residency) at Stanford.

Psychiatry is a medical speciality that treats illness of the mind and brain. Patients might have symptoms in the areas of mood and emotions, behavior, thinking processes, perception, sleep, or language. 

Understanding psychiatry means understanding the layers we all have. As new creatures, we start out with brains that are wired a certain way. We have certain genes, which gives us certain anatomical wiring and neurotransmitters, which, in turn,  makes us more or less likely to be depressed or anxious or even have hallucinations. Now take this pre-made device out of the womb and expose it to the world. The young brain is incredibly dynamic and reactive to its surroundings, and it grows and adapts. This learning results in behavior. We get older and our brain stops changing so quickly, but it continues to change throughout out our lives.  If we are lucky, we start out with a good piece of equipment, are nurtured, loved, encouraged, face just the right amount of hardship to produce growth, but not be traumatized, avoid toxic substances, and attend a stimulating school, and so on. This whole picture, with all the layering, refers to someone's mental health. 

Another way to think about it: just as some of us have bad knees, are prone to colds, or have poor eyesight, some of us started out with wiring that is slightly different. Then, just as too much running on pavement might lead to stress fracture for some people, so might psychological trauma or stress lead to depression, PTSD, or substance use.  We can often get through a cold or a sore knee on our own, and similarly, we can often get through some depression, anxiety, and even substance use on our own.  But sometimes we need a doctor. 

Another angle that I sometimes use to think about mental illness is whether or not someone can be "talked" out of an unwell state. By that I mean, will someone respond to therapy, which would indicate that he or she is able to harness and train his/her mind. This requires a certain amount of insight and ability to step outside of one's mind and examine oneself objectively. On the other hand, some patients have illnesses that may improve a little bit with therapy, but ultimately require medical intervention, and maybe even hospitalization, for treatment. These people might have severe depression, schizophrenia, or dementia. Of course this model is oversimplified, but I think it is helpful way of thinking about the components of mental illness and how they interact and overlay.

Doctors of mental illness come in two varieties: psychologists and psychiatrists. In traditional comparisons, psychologists address behavioral or learned aspects of mental health, while psychiatrists use a medical model of disease to diagnose and treat mental illness. Psychologists use various types of therapy as their main tool.  Psychiatrists receive broader training that covers some general medicine and neurology as well, but receive less depth of training in therapy and behavioral science than psychologists. The toolbox of a psychiatrist includes therapy, medications, and even procedures such as electroconvulsive therapy and magnetic stimulation. 

The psychiatrist is also trained to help other doctors determine whether a patient has a primary psychiatric disorder or whether an underlying medical condition might be responsible for psychiatric symptoms. In particular, many neurologic disorders are accompanied by or mimicked by psychiatric disorders. Patients with parkinson's disease may have hallucinations. Patients with multiple sclerosis may experience depression and decreased cognitive function. Personality change might be the first symptom of a brain tumor. Also, patients might have neurologic symptoms such as twitches or seizures that are actually psychiatric in nature. Chronic pain is another entity that can be approached from a psychiatric perspective.

So there are a few ways to understand psychiatry and a few reasons why I think it's a great field. My final thought for the night is that I love that the marker of success in psychiatry is improvement in a patient's ability to do the things that make us human-- like feel, think, and love-- and to participate in meaningful activities such as work and family life.

Saturday, February 6, 2010

Resuscitating Health Care

I am a second year student at UCSF Medical School. Health care policy and reform fits into the fringe of our basic science curriculum, which focuses on clinical diagnosis and patient care. My classmates and I are about to graduate from the basic science part of our curriculum and move into the clinical years of our education.

As we progressed through various organ systems over the past year and a half, I imagined myself in various roles as a physician; could I see myself practicing as a gastroenterologist? Neurologist? Cancer surgeon? Infectious disease specialist?

Our current course is called, “Lifecycle,” and has covered principles of reproduction, embryology, pediatrics, childhood development, and geriatrics. I have again been moved to think about myself in various practice settings. In recent exercises, about a dozen classmates and I have discussed neonatal emergencies and even simulated the resuscitation of a high-risk infant. We discussed the trajectory of a fetus born with a hole in the septae of the heart and instances in which the fetus is deprived of oxygen and sustains brain damage early in life or even in utero.

We discussed the ethical implications of the cases. Less than 25% of neonates born at 24 weeks survive without brain damage. Hospitals vary in their willingness to resuscitate neonates born between weeks 23-26 of gestation. Who makes the decision about resuscitation? Who represents the fetus? What happens if the parents disagree among themselves or with the doctor?

I threw in the question, how much does it cost? No one really talks about that. According to our discussion leader, one of the chief residents in pediatrics at UCSF, a day in the neonatal ICU can easily run between $20,000 and $30,000. As I understood it, sick babies can walk out of the hospital with million dollar bills, with no improved prognosis, and with the likelihood of returning for more costly care in the early years of life.

We talk about the ethics of neonatal resuscitation and who gets to make tough decisions, but what about the ethics of cost? The burden of cost on the hospital and society is not trivial. Most families wouldn’t have the resources to cover such a hospital bill, so either a government program or private insurance would end up paying.

The government, as we know, is broke. And health care spending is helping break it. National health spending totaled 17.3% of the national economy last year. Health spending share of the GDP increased 1.1% last year, which was the greatest increase since 1960. It is estimated that by 2019, health care spending will make up a full fifth of the national economy.

Could resuscitating preterm babies be responsible for underfunded education? Deteriorating infrastructure? Cuts in other social programs? If the parents of the child could pay the bill in full, then by all means, they can decide how to spend their money. But it the government is paying, shouldn’t there be some ethical consideration of the other beneficiaries (stake-holders?) of its service?

Tuesday, July 7, 2009

Independence Day...Sierra Style

For the second year in a row, I spent the night of July 4th under the stars and well away from any airport security lines, barbeques, or fireworks. With my friend Justin, I climbed Stately Pleasure Dome, Lembert Dome, Cathedral Peak and Matthes Crest, which are all near Tuolumne Meadows in Yosemite National Park.

At this time last year, I had just joined the local rock climbing gym, Mission Cliffs. I started going a few times a week. At the end of July, 2008, I went with Justin and his friend Zennard to Yosemite. Still too novice to climb with them, I hiked to Echo Lake while they climbed Cathedral Peak.

This year, I was ready to climb. Our trip started with a traffic jam leaving San Francisco on Thursday evening, but after we crossed the Bay Bridge, traffic had thinned, and we made good time to our camping spot that evening.

We woke up early on Friday and drove into the park. By 9 am, we arrived at Tenaya Lake. We walked up some low angle slabs to the beginning of Hermaphrodite Flake on Stately Pleasure Dome. I led the route--my first trad lead! The highlight was shimmying up the chimney that formed behind the namesake flake on the second pitch.

I also led the first pitch of the route above it called Boltway. The second pitch had a 5.8 slab move right of the belay ledge, so I turned the lead reins over to Justin. We topped out around noon and rapped/walked off the side of the dome.

After a nap on the beach of Tenaya Lake, we dumped our stuff at our campsite (Tuolumne Campground) and headed back out to Lembert Dome. We climbed Northwest Books, which started with a fun mantle move followed by an awkward lieback. Three people flew by us free-soloing the whole thing. Oh well, so much for being hardcore! The second pitch began with a two parallel cracks in a corner and mellowed out at the end. We topped out by climbing up some 3rd class slabs and then walked off the northwest side of the dome.

That evening, we organized our packs for the main event of the weekend--Cathedral Peak (10,940 depending on who you ask) and Matthes Crest. At 5 am on Saturday, we got up and drove to the Cathedral Lakes Trailhead. I'm guessing our packs weighed close to 40 pounds, loaded with our camping gear, two ropes, and a full rack of climbing gear.

We followed Budd Creek and reached a patch of pine trees below Cathedral Peak around 9 am. We dropped our big packs, took our climbing gear, and scrambled up a steep slope covered with scree and small boulders. We could see a few other parties on the upper pitches, but nobody was at the base. We began climbing almost immediately. Justin led the first pitch. He ran the rope out, and then we simul-climbed for about 15 feet until he reached the top of what was marked the second pitch on our supertopo map.

From there, we climbed variation routes to the summit, making four more pitches out of it. The highlights were a chimney, a splitter hand crack and another outward flaring crack that were all lots of fun. The summit was about nine square feet in area. We took pics and then downclimbed around the back of the spire to 4th and then 3rd class rock. The path wrapped back around to the east face, and we descended on a trail from there. With the help of Justin's GPS, we walked straight back to our stashed backpacks.

We started off the slopes of Cathedral and headed southeast towards Echo Peaks. Snowfields were still melting, and we crossed meadows that were oozing with water. We walked south up into a saddle, which Justin aptly named Echo Flats. We followed the shoulder of Echo Peaks first to the south and then southeast until Matthes Crest came into view. The imposing razorback of granite towered over the backcountry bowl. I doubted my abilities for a minute.

At this point, I felt like I was crashing. I had a bad headache from being in the sun all day, my throat was sore for some reason, and I was really sugar-low. It was after 6 pm; we had been on the move for over 12 hours. I made it clear that I needed to stop. Every step was jarring to my entire body and exacerbated my headache. Call me weak, but I needed food, drink, and rest. I proposed that we stop and hike to the climb from this point in the morning. Justin sensed the urgency (desperation?) in my voice, and agreed.

We stopped, pitched our tent, and ate chili and rice for dinner. I was laying down by 7:30. I faded in and out of sleep and tried some restorative yoga moves. My headache lingered on. I got up after a few hours. The moon was rising over Matthes, and the evening alpinglow on the mountains was spectacular. We heard two people walking by who had presumably come off the crest. Justin ran after them and got some route beta. We had been concerned about a snowfield that appeared to be at the base of the last descent rappels, but we learned that there was room to pass around it.

We packed out bags for the next day. A climbing rope and a tag line, a full rack of gear, some food, and two liters of water each. We planned to go on belay to gain the ridge and then simul-climb over to the south summit. I set our alarm for 5 am and went back to sleep.

The sky was just turning pink with morning light when we woke up. We boiled some water for oatmeal, took down the tent, stashed our big packs under some rocks and headed crosscountry towards to the south end of the crest.

It took us about an hour to get over there. The last 15 minutes, we scrambled up steep slabs to a notch marking the south end of the crest. The sun was not yet on us, and the wind was blowing. My teeth were chattering as we started climbing around 7:30. Two pitches, and we were on the top of the ridge. The climbing was incredibly fun. Knobs, cracks, corners, all combined in a haphazard, choose-your-own-adventure fashion.

Once we gained the ridge, we each wrapped about 50 feet of rope around us from our respective ends so that only 100 or so feet of rope remained between us. Justin began advancing along the ridge and placed pieces of protection when possible. When the rope was taut, I began climbing and removing protection as I came to it. We continued in this manner for a few hundred horizontal feet before we came upon a sketchy downclimb. Instead of proceeding forward, we went down a south facing ramp, which dumped us out on another north-facing ramp. There, we had to traverse north and pull a roof move to gain the ridge again. We were definitely off route, but it was fun! Except for the part where I fumbled and dropped my belay device off the side of the cliff...not good for morale.

The exposure was as mind-blowing as the guide book said it would be. In fact, I only took brief moments to absorb the spectacular surroundings; I focused mainly on my feet and the rock. Another party passed us. We continued to simul-climb the undulating granite until we came to the South Summit.

We took a breather and then planned our descent. There were slings and a rap ring on the South Summit, so we decided to rap off the east side into the notch below. We had two ropes, which we joined together to make one long rope and hoped for a single rappel. We managed to not get the rope caught in the maze of flakes and cracks in the rock. Once in the notch, we crossed back over to the west side of the crest and scrambled down to a pine tree with slings around the base. We rappelled from there to one final rappel station. Since I had lost my belay device, Justin went first and then tied his belay device to the rope, which I then pulled up to get the device. I then lowered the rope and rappelled down.

There was a snow field below us, but we were able to scramble to the north of it. We scrambled down the last scree field of the trip, and then booked across the bowl to where we had camped the night before. A brief rest, a bite to eat, some water, and then some repacking of our big packs, and we were all loaded up again for the walk out. We had to climb a few hundred feet to get back around the shoulder of Echo Peak, and then it was a smooth three miles back to the trailhead...downhill all the way... The mosquitos were enough motivation to keep the pace up. We reached the car at 7:45 pm. The smoke from the fires had gotten a lot thicker; the smell of smoke was obvious and the air scratched my throat.

We turned on Doc Watson and hummed to some Banjo music as we drove out of the park. No traffic to speak of. Most everything was closed as we drove home. We made one quick gas stop in Oakdale, and made it back to San Francisco in about 5 hours.

Tuesday, May 6, 2008

Exit Stage Left

On March 31, I left Sierra Leone after ten intense weeks of living with Dr. Barrie and working on two health care projects. I hoped that my final day in Sierra Leone would be both stress- and sweat- free, but Freetown was relentless until the moment I boarded the plane.

My flight out of Lungi airport, located across the bay from Freetown, was scheduled for midnight. Just before 7:30 p.m., I finished washing up and zippered my bag. The last light was disappearing over the hills, and Dr. Barrie and his family were praying by candlelight in the common room. I stood by discreetly for a few minutes and then paced on the balcony a times. Ten minutes passed, and the traffic outside looked menacing. They looked deep in prayer, but I wanted to say goodbye. Finally, their prayers ended. I hugged everyone—Dr. Barrie’s wife, mother, mother-in-law, grandmother-in-law, son, daughter, cousins, and sister-in-law. Many aspects of Sierra Leone would be easy to part with, but I was truly sad to leave these people.

Dan, Dr. Barrie, and I hopped into our vehicle for the short ride to the ferry terminal, but we could not even pull out onto Mountain Cut. The traffic was gridlocked, and the last ferry was scheduled to depart in twenty minutes. We got out of the car, each of us carrying one of my bags, and started walking. With sudden inspiration, Dr. Barrie hailed a passing motorbike. Dan did the same, and soon, with heavy bags on our backs and across our laps, we were weaving in and out of traffic and riding down the center line between immobilized vehicles.

By this time, I had completely sweated through the clothes I would be wearing for the next forty-eight hours. Otherwise, traffic had finally opened up and we were zooming towards the ferry terminal. Our three motorbikes arrived one after the other, and we all laughed in relief. But three men shouted that we would miss the ferry if we didn’t run.

We left Dr. Barrie behind and ran through the terminal and out the other side. The ferry was backed up to a concrete loading ramp leading into the water. The boat was inching away from the ramp, and the boat’s loading stand was lifting. Dan ran ahead to get on the boat, and I struggled with my bags. I watched Dan jump three feet up to the platform and thought I’d never make it. I got up to the base of the ferry and was looking up in defeat when three young men from above grabbed me, bags and all, and lifted me effortlessly onto the boat. They let me catch my breath before demanding a small token for their deed. Then they disappeared into the crowd on the lower level of ferry.

The ferry was completely full of people and their goods and belongings. We sat down on the only empty bench, but soon found out why it was empty. A crazy man stood by and shouted about ice cream for the entire ferry ride. We finally arrived on the other side of the bay, and I caught a local taxi for the last ten kilometers to the airport. For a little extra, I got the front seat in the car. Four other people piled in the back, and we were on our way.

At the airport, generators were running, check-in was smooth, and my flight left on time. I wrote my own baggage ticket, making sure that the letters S-F-O were crystal clear. A man took a picture of my passport with a digital camera. After a completely manual security check, I walked out onto the tarmac in the humid darkness. I was sweaty and exhausted. Culture shock began when I stepped inside the airplane: air conditioning, magazines, light. We were all disinfected with a light aerosol spray, in accordance with WHO regulations. And with that, we were hurling down the runway. I slept all the way to Heathrow, and it was the best I had slept in three months.