Categories
Nonfiction Observations Reflection

Sea Lions.

The sun was beginning its ascent into the sky, though it had yet to peek over the horizon. An occasional harbor seal poked its round head through the surface of the dark water in the marina. The twinkling stars overhead were starting to fade.

Dozens of sea lions were piled on top of the rocky pier. The males, some weighing close to 700 pounds, barked and snarled at each other. A loud splash occasionally cut through the din when, during a quarrel, one of them fell into the water.

My friend and I walked along the platform. The wood planks creaked under our weight as we followed the path back to the shore. We spied a sea otter, curled up and snoozing, at one end of the dock.

My friend stopped walking.

“What?” I asked.

He pointed. My gaze followed his finger through the purple darkness.

Not six feet away from us on the pier was a heap of eight or nine sea lions. The smaller ones were farther away from the main walkway. A blubbery male, teeth showing and head raised, was seated on the platform. He was looking at us.

“What if he attacks us?” my friend whispered.

Some of the other sea lions turned their heads and cast a wary eye upon us. The corpulent male guarding his tribe barked. My friend leaned back into me.

“He won’t attack us. They eat fish,” I reasoned.

“That thing weighs like 700 pounds,” he said. “He could crush us.”

The distance between the fleshy sea lion and the other edge of the platform was about three feet. There was no other way back to the shore.

“Just don’t make eye contact and keep walking,” I said.

He didn’t move. Shrugging, I slipped around my friend, kept my eyes down, and walked past the bulky creatures. My fingers could have patted their heads; their flippers could have smacked me into the water.

When I was about eight feet past the sea lions, I heard hasty footfalls behind me. My friend, unscathed by the animals, appeared by my side.

“That was scary,” he murmured.


“They could have eaten us!” he exclaimed once we were on shore. “They weigh a lot! Did you know that sea lions can run on land faster than humans can? Can you imagine a 700-pound sea lion tackling you? Into the water?”

“But they don’t eat humans. And we weren’t going to fight him for that dock or his clan.”

After a few moments of silence, he said, “You’re brave. You walked by them as if they weren’t there.”


I wondered about this later. My friend is not timid, nor is he nervous. Why did the sea lions rattle him so much?

The construction workers across the street shouted at me.

“Hey baby! Wanna gimme some sugar tonight?”

He was sitting on the stoop when I walked by.

“Konichiwa. An nyoung. Ni hao,” he called. “You speak one of those, right, honey? How do you say ‘I love you’?”

While I was waiting to cross the street, he came up to me and said, “You’re pretty. You’re pretty. You’re really pretty. Asian woman, you’re pretty.”

He waved at me from across the room. “Hey, doc! Do you do sex therapy? I want to learn more about that… from you.”

Of course. I am a woman, he is a man. What have I done in the past when I got attention I didn’t want, when I wanted to disappear?

“Just don’t make eye contact and keep walking.”

Categories
Nonfiction Observations Reflection

Michael.

Everyone noticed him before we boarded the plane. He asked the airline representative at least three times to confirm that he had a seat. He looked like an adult, but the tone of his voice was that of a child.

“Yes, you have a seat, Michael. It’s 7B.”

Grey cargo pants covered his short legs. The sleeves of his striped polo shirt collected below his elbows, making his arms look even shorter and his hands even smaller. His neck hid inside his collar. His fingers were short and thick. His glasses magnified the creases in his eyelids. Because his nose was flat, it made his mouth look wide.

The elderly man in the aisle seat had asked the flight attendant to stow his cane. Wrinkles burrowed into his forehead and surrounded his eyes. They revealed a lifelong habit of frowning. The elderly man heaved a sigh of resignation when Michael took the seat between him and me.

Michael sat down with conviction, then stood up and adjusted the nozzle so more air blew into his face. After sitting down again with resolve, he picked up the seat belt.

“What is this?” he asked, his fingers poking the thick padding. When no one responded, he turned to me and said, “This isn’t a normal seat belt. It’s weird.”

As other passengers filed past us, he greeted every third or fourth person.

“Hi! Hi!” He thrusted his arm forward across the lap of the elderly man. Without realizing what they were doing, many people found themselves shaking his hand.

“Hello! My name is Michael! Who are you going to see? I’m going to see my dad. He bought my plane ticket for me.”

“Oh… that’s nice.”

The elderly man sat back, leaned away from Michael, and sighed.

Michael turned off his cell phone. Turning to me, he saw me send a text message.

“You’re supposed to turn off your phone, like this, see?” He waved his phone at me like it was a baby rattle.

Shortly after the plane took flight, Michael reached his hand in front of my face and pulled down the window shade.

“Too bright,” he said as he looked back at the television.

The flight was about two and half hours long. Twice, Michael announced to the elderly man, “I need to use the bathroom.” The elderly man said nothing, pushed himself out of his seat with his arms, and stood in the aisle with sorrow on his face as Michael ambled his way to the lavatory.

When the pilot announced that we were approaching our destination, Michael reached over, grunted, and pulled the shade up halfway. Through the double-paned window we saw the Pacific ocean, its waves rolling towards the coast in a never-ending parade. A squadron of pelicans glided over the water. Small boats left frothing white wakes atop the blue-green swells.

Michael reached over again and pulled the shade up a little more. We both continued to look out the window.

When the plane arrived at the gate, Michael bolted out of his seat, reached over the elderly man, popped open the overhead bin, and pulled down his backpack.

“I’m going to see my dad!” he announced.

An airport attendant boarded the plane and called Michael’s name. He raised his hand with the enthusiasm of a child who wants to answer a question first.

“I’m Michael!” he said. “Are you going to walk with me off the plane?”

I saw Michael a few minutes later outside the terminal and witnessed his reunion with his father. His father did not share physical characteristics with Michael; Down syndrome is not heritable.

They hugged each other and both smiled with joy. The extra copy of chromosome 21 did not diminish the love father had for son.

“How was your flight?”

“It was great,” Michael said. They began to walk away together, his father’s arm holding Michael close to him.

We judge ourselves by our intentions, but we judge others by their actions.[1. This quote is attributed to several different people, including Andy Andrews, Stephen Covey, and Ian Percy.] For people with overt disabilities or deformities, we are more forgiving of their behaviors because we are more charitable about their intentions.

Why do we not do the same for those people whose deformities or disabilities are not visible?


Categories
Consult-Liaison Education Lessons Medicine Systems

Have You Thanked Your Nurse Today?

As I noted earlier, hospitals permit around-the-clock observation of patients. If you don’t need around-the-clock monitoring, you don’t need to be in the hospital.[1. “But what about ‘social admits’?” you may cry. “They don’t need to be in the hospital, but we admit them anyway.” True. “Social admits” reflect the intersections of social policy, politics, health, economics, and the lack of resources. That topic is beyond the scope of this post.]

Who is doing this around-the-clock monitoring? Nurses.

Therefore, whether you are a patient or a physician, one of the best things you can do is get on the good side of the nurses.

If you are a patient, a nurse watches over you and your care. Nurses make sure that you won’t fall. They make sure they give the right dose of the right medication in the right route to the right person at the right time (which can be easier said than done). Nurses provide education about medicines, tests, and health conditions. They make sure you know what day it is, where you are, and who you are. (Also easier said than done.) They monitor your progress and try to ensure that your health only improves. Nurses can also page the doctor for you or your family. They can find out when you are scheduled to go through a procedure. They can find out what you are waiting for. Nurses advocate for you.

Sometimes it may seem like they’re not “doing” anything. They are. They’re keeping an eye on what is happening with your health.

If you are a physician, you must already recognize the value of nurses. (If you are a medical student or resident and have fantasies that, one day, you will be “running the show”, don’t be a fool: There is no way you could do your work in the hospital without the help of nurses.) Nurses serve as our eyes and ears. They tell us information about patients that patients themselves cannot or will not tell us. They do triage with us when we have multiple patients who are not doing well simultaneously. They tell us if someone is starting to look a lot worse… or a lot better.

While it is true that nurses provide around-the-clock observation of patients in hospitals, it is also true that nurses provide around-the-clock monitoring of doctors in hospitals.

Nurses know when doctors typically meet with patients. They know which doctors are more likely to spend time with patients and answer questions. They know which doctors work in collaboration with nurses and which ones treat them like second-class citizens. They know which doctors return pages promptly. Nurses quickly learn how to alter their approaches with various doctors to get work done.

This is yet another reason why, as a patient, you want to get on the good side of nurses. Nurses manage doctors. Skilled nurses will know how to work with different doctors to help you get what you want (e.g., answers to your questions, a meeting with your family, better pain control).

(Patients, you should also know that nurses also manage you. Nurses tell doctors which patients yell at nurses, which family members are berating them, which patients are trying hard to follow recommendations, and which family members left cookies and treats for them.)

Physicians, thank your nurses for helping you do your job better. Positive reinforcement and good manners go a long way. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you and make your job easier.

Patients, thank your nurses for watching over you. Nurses play an essential role in your care in the hospital. Be kind to them. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you to get you back to health as soon as possible.


Categories
Consult-Liaison Education Medicine Observations Reflection

The Patience of Patients.

When I was a resident one of my attendings said, “You know why patients are called ‘patients’? It’s because they have a lot of patience. For us.”

Patients in hospitals do a lot of waiting. They wait for physicians. They wait for nurses. They wait to use the bathroom. They wait to undergo procedures. They wait for their IVs to stop beeping. They wait for the person next door to stop vomiting up what sounds like all of their internal organs. They wait for the person down the hall to stop screaming. They wait to eat. (Doctors: Reverse those NPO orders as soon as you can! Food is at the base of Maslow’s hierarchy of needs! Food is more important than safety and security of health!) They wait for the nursing assistants to finish taking their blood pressures so they can sleep. They wait for the unit clerk to answer the phone so a nurse can help them get out of bed without the bed alarms screeching throughout the unit.

They wait to feel better. They wait for good news.

No one has any idea how much patients wait in the hospital until you become a patient in the hospital.

Sometimes it’s not even clear what patients are waiting for. Hospital staff arrive and they have no idea why they are there:

  • “Hi, I’m the physical therapist.”
  • “Hi, I’m here to take you down for an ultrasound.”
  • “Hi, I’m the dietician.”
  • “Hi, I’m the consulting psychiatrist.”[1. Hospitalists: If you call a psychiatry consult for your patient, tell your patient. Most people, with or without psychiatric issues, do not appreciate an unexpected visit from a psychiatrist. “I’m not crazy! Get out of my room! No one asked you to come here!”]

Because of the nature of acute care in hospitals, rarely do things run on a consistent, predictable schedule. This lack of punctuality is not intentional; things change. Hospital staff triage patients all the time and, unfortunately, patients and patient care are shuffled around in order of acuity.

Thus, if you’re in a hospital and someone tells you that So-and-So will see you at 2pm, don’t believe it. Yes, So-and-So might actually see you at 2pm, but it takes extraordinary planetary alignment for that to happen. So-and-So might show up at noon… or at 4:30pm.

Yes, doctors wait, too. The waiting doctors do, though, is informed by the knowledge they have about why they’re waiting. Doctors wait for patients to come out of the bathroom. They wait for patients to go for a study or imaging test. They wait for family members to arrive to get more history. They wait for the pathology or study results to clarify diagnosis and treatment. They wait for information that affects what happens next.

Patients often wait without knowing what will happen next.

If you work in a hospital, remember that most patients have an extraordinary amount of patience, given the circumstances. Yes, there is a minuscule minority who have the frustration tolerance and impulse control of toddlers, but that is not a common means of coping in adults. (Physicians tend to call psychiatry when this happens. This is not a common consult.)

Do what you can to orient patients to what is going on. Give them approximate times for your visits and if you are running late, send a message to them to let them know. (Technology could help here: What if we could send text messages to patients through the television? or if the text message could become a voice message on their in-room telephones?) If patients are not around when you come by to see them, leave a note to let them know that you’ll try again later. (Technology could help with this, too.) Tell them why you don’t want them to eat after midnight. Tell them why you want them to work with physical therapy. Tell them the purpose of the bed alarm.

Help them understand what they are waiting for. Don’t take their patience for granted.


Categories
Consult-Liaison Education Medicine Reading

DSM-5: Delirium.

This post is the most recent addition to my DSM-5 e-mail list. I include it here only because I apparently have a fondness for delirium; it was one of my favorite teaching topics when working with medical students. If you’d like to read my other DSM-5 summaries, let me know.


(724 words = 5 min read)

How rarely, particularly outside of hospital settings, do we remember to think of delirium!

DSM-5 lists five criteria for delirium:

A. There is a disturbance in attention and awareness.

Because people who are delirious have problems with focus and sustaining attention, this means you might find yourself asking the same questions over and over. The delirious patient may end up providing the same answer over and over, even though you’re asking a different question.

Furthermore, if patients have severe inattention, they might not be able to have a conversation with you at all.

B. Delirium develops over a short period of time, typically hours to days. There is a change in baseline attention and awareness. It fluctuates throughout the day.

Attention and awareness often worsen at night (sometimes referred to as “sundowning“).

C. There is also another disturbance in cognition, such as in memory, orientation, language, and perception.

Delirious patients might think that a pair of socks is an opossum (illusion), the nurse is trying to sell his blood (misinterpretation/delusion), or that he can hear the conversations that are happening in the cafeteria (hallucinations/delusions).

D. The disturbances in (A.) and (C.) are not better explained by another pre-existing, established, or evolving neurocognitive disorder. (Having a neurocognitive disorder, however, increases the risk of the development of delirium.)

You also can’t diagnose delirium is someone is comatose. Essential to the diagnosis of delirium is that the patient can respond to “verbal stimulation”.

E. There must also be evidence that the delirium is due to a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies.

This means that delirium always has a cause. Your job is to find that cause (or work with someone who can help you find that cause).

There are many specifiers for delirium (which clarify the cause):

(1) substance intoxication delirium
(2) substance withdrawal delirium
(3) medication-induced delirium
(4) delirium due to another medical condition
(5) delirium due to multiple etiologies
(6) acute
(7) persistent (how terrible!)
(8) hyperactive (more frequently recognized, because these are the people who are shouting that they are on a boat and think that the IVs are snakes)
(9) hypoactive (this is often missed because these are the people who seem to be the most “compliant” patients ever)
(10) mixed level of activity

DSM-5 spends a fair amount of time discussing the recording procedures. If you are a consult-liaison psychiatrist, you should look those over.

DSM-5 states that, in hospital settings, delirium usually lasts about one week. Some symptoms, though, persist even after individuals are discharged from the hospital.

Delirium is considered a “great imitator” amongst psychiatrists. People who are delirious can look psychotic, depressed, manic, anxious, or a combination of all four. Delirium also messes with sleep-wake cycles and may manifest more at night because there is less environmental stimulation present.

DSM-5 provides some prevalence numbers:
(1) people in the community: 1-2% (that number ideally should be 0%)
(2) hospitalized people: 6% to 56% (this is not a comforting range)
(3) people who just had surgery: 15% to 53%
(4) people in ICUs: 70% to 87%
(5) people in nursing homes: 60% (yikes!)
(6) people who are at “end of life”: 83%

Thankfully, the majority of people with delirium experience a full recovery, though delirium is a harbinger of death: About 40% of people who are diagnosed with delirium in the hospital are dead within a year. Delirium also increases the likelihood of “institutional placement” and “functional decline”.

In addition to neurocognitive disorders, other risks for delirium include extremes of age, drug use, polypharmacy, a history of falls, and functional impairment.

Delirium is a clinical diagnosis (there is no test for it), though EEGs might show “generalized slowing”.

I have never thought about the differential for delirium, as that is what I always consider first (but that may be due to my past work as a consult-liaison psychiatrist). DSM-5 includes psychotic disorders, acute stress disorder, malingering, factitious disorder, and other neurocognitive disorders in the differential for delirium. Rarely, though, do those conditions have the “waxing and waning” in level of consciousness and attention that is seen in delirium.

I’ll resume sending [DSM-5] posts out after January 1st. May you all recall fond memories from 2013. May 2014 bring you good health, mirth, and ongoing learning.