Category: Nonfiction

Categories
Consult-Liaison Nonfiction

Delirium Adventures with ChatGPT.

I still think one of the most valuable skills psychiatrists have is to help distinguish psychiatric illness from “delirium”, which, for the purposes of this post, we can call “acute brain failure”. Other organs can abruptly stop working for a variety of reasons. Hepatitis infections can cause acute liver failure; dehydration can lead to acute kidney failure; we’re all familiar with acute heart failure, too.

Delirium is a symptom of an underlying medical condition. It’s like a fever or a cough: Many conditions can cause fevers or coughs, so you have to seek out the “real” reason. When people develop delirium, their thinking, behavior, and levels of consciousness change abruptly. People can get confused about who or where they are; they might start seeing things or hearing things that aren’t there; sometimes they seem to “space out” for periods of time. These are all vast departures from their usual ways of thinking. (The abruptness here is key; people with dementia may have similar symptoms, but those typically develop over months to years.)

(Fellow psychiatrists and hospital internists recognize that delirium isn’t always that dramatic. Sometimes people are lying quietly in bed, hallucinating and feeling confused, but never behave in a way that would suggest otherwise.)

Because I spent a few years working in medical and surgical units (where the risk of delirium is higher than in the community), it is still my habit to consider delirium when I am meeting with people. Given the disease burdens that people experiencing homelessness and poverty face, this is prudent. (Fellow health care workers might also more likely to believe a psychiatrist when we report that someone might be delirious, rather than psychiatrically ill.)

I wondered if there is any evidence to support that psychiatrists are more likely to detect delirium compared to other health care professionals. Enter ChatGPT.

ChatGPT cited two papers that reported that, yes, psychiatrists are more likely to detect delirium, though shared only the journal and the year, along with a summary of results. I asked for a list of authors for one, thinking that might help narrow down the search. It did not. So then I asked for the title of the two papers.

I could not find either title on Pubmed. This was curious. And concerning.

I then asked ChatGPT to share with me the Pubmed ID (a number assigned to each article) for each paper. Here’s what happened:

ChatGPT said that the first paper, “Detection of Delirium in the Hospital Setting: A Systematic Review and Meta-Analysis of Formal Screening Tools”, was published in the Journal of the American Geriatrics Society in 2018. ChatGPT said that the ID was 26944168. In PubMed, this leads to an article called “Probable high prevalence of limb-girdle muscular dystrophy type 2D in Taiwan”.

The second paper reportedly had the title of “Detection of delirium in older hospitalized patients: a comparison of the 3D-CAM and CAM-S assessments with physicians’ diagnoses”. (CAM stands for Confusion Assessment Method, which is a real, validated tool to help measure delirium.) ChatGPT said that the ID was 29691866. In PubMed, this leads to an article called “Gold lotion from citrus peel extract ameliorates imiquimod-induced psoriasis-like dermatitis in murine”. (I did learn that “gold lotion” is “a natural mixed product made from the peels of six citrus fruits, has recently been identified as possessing anti-oxidative, anti-inflammatory, and immunomodulatory effects.”)

It makes me wonder how ChatGPT generated these articles and their titles, where it created the summaries from, and where it found the PubMed ID numbers.

Indeed, ChatGPT is artificial, but not so intelligent. And it will take me a bit more time to find the answer to my question.

Categories
COVID-19 Medicine Nonfiction Public health psychiatry Reading

Things That Made Me Smarter This Week.

Some media recommendations for your consideration:

Three Years Into Covid, We Still Don’t Know How to Talk About It. This article is one of the few that resonated (more) with my experience of the Covid-19 pandemic. Despite my professional training and expertise as a psychiatrist, I still can’t find the “right” words to describe what happened to me, the people around me, and the world. Without adequate words to create a coherent narrative of my experience, I still don’t fully understand what happened. (I hope that I will not give up trying.)

Freedom House Ambulance: The FIRST Responders. Did you know that the first modern ambulance service in the United States was developed in a Black neighborhood in Pittsburgh? The Freedom House Ambulance served as a model for the rest of the world.

This Book Changed My Relationship to Pain (title of the podcast, not my comment). Dr. Zoffness explains the bio-psycho-social nature of pain in an engaging way with plain language. (I am one of the many people she describes in the podcast who developed chronic pain during the pandemic; I have known since its arrival, both as a professional and as a human being, that there is significant a psychological component.) Pain is not all in your head AND the state of our minds affects how we experience pain.

Mathematician Explains Infinity in 5 Levels of Difficulty. I have always found math interesting. What I particularly enjoyed in this video is the skill Dr. Riehl shows in teaching the concept of infinity to different audiences. This is something I aspire to (and have mused about doing something like this for myself for psychiatry, à la the “Feynman Technique“). I also appreciated the similarities between the explanations she provided at level one and level five.

Salve Lucrum: The Existential Threat of Greed in US Health Care. When I read things like this, I see yet another pathway that someone can unwillingly tread upon that will result in homelessness. (Some people think they are immune to homelessness; that’s just not true.) “… unchecked greed concentrates wealth, wealth concentrates political power, and political power blocks constraints on greed”, and “[g]reed harms the cultures of compassion and professionalism that are bedrock to healing care.”

Categories
COVID-19 Homelessness Nonfiction Observations Policy Public health psychiatry Seattle

Gifts of Our Lives.

Photo by Leeloo Thefirst

(I know it’s the holiday season and I promise I’m not actually a grinch, but here’s your warning: This is going to be kind of a bummer of a post.)

Some recent scenes for your consideration:

  • The sliding wooden gate did nothing to dampen the sounds of traffic on the boulevard. Inside the wooden gate was a parking lot that was now occupied by around 40 small sheds, each painted a different color. At one end was an open-air shared kitchen and a set of small bathrooms. It was snowing, the kind of wet, clumpy snow that doesn’t stick, but instead seeps immediately into clothes, hats, and sleeping bags. Though people in this “village” are still technically homeless, they were at least protected from this unusual Seattle weather. Within a few minutes of my arrival, a skinny kid, maybe eight or nine years old, wearing a sweater, shorts, and sandals, ambled outside alone to look up at the sky. Later, another skinny kid, maybe thirteen or fourteen, came out, his hands shoved into the pockets of his sweatpants and his eyes fixed on the ground. I wondered what their ACEs scores were and hoped that, as adults, they would escape and remain out of homelessness.
  • As I threaded my way through the city and the morning chill, I kept a mental tally: One man wearing a tank top and making grand gestures at the sky; another shirtless man pacing in tight circles; one woman wearing a soiled hoodie, with either black ink or a black substance smeared across the bottom half of her face, picking up trash from water pooled in the gutter; a man hobbling with a cane and screaming a melody; a man emerging from a collapsed tent to fold up a crinkled black tarp; a woman with bare legs and swaths of bright green caked on her eyelids who, in slurred speech, offered me a wristwatch dangling from her fingers.
  • “We have burned down the house of mental health in this city, and the people you see on the street are the survivors who staggered from the ashes,” writes Anthony Almojera, an N.Y.C. Paramedic [who has] Never Witnessed a Mental Health Crisis Like This One, who also comments that “there’s a serious post-pandemic mental health crisis.”

Maybe my expectations about the pandemic response were too high. A pandemic is an act of God; what could mankind possibly do that can deter the power of God?

And yet.

There were things we could have done to protect mental health during a pandemic. I am not the only one who was (and remains) worried about the psychological consequences of this pandemic in the years to come. There remains insufficient mental health policy or policy implementation, insufficient resources, and insufficient political will, among other implementation failures of public mental health.

I do believe that hope is a discipline. It’s hard to practice every day. But this is why I still question whether my expectations were too high. God spared us—you, dear reader, and me—during this pandemic. For what reason? What can and should we do with the gifts of our lives?

Categories
Nonfiction Seattle

Blue of the Sky.

Photo by Johann Piber

The bus stop is at 145th Street and Aurora Avenue. There was a city bus there; if I run the two blocks fast enough, I thought, maybe I can catch it.

Then I noticed the two law enforcement vehicles, sturdy vans with red and blue lights flashing from the windows. One was parked directly in front of the bus; the other was in the driveway of a nearby storefront.

The bus remained at the stop as a third law enforcement vehicle made an assertive U-turn in the middle of the street to join the other two.

I stopped walking. I took a few steps forward, then stopped again.

“No, this doesn’t seem right… I can catch the bus at the next stop,” I muttered out loud.

It was a few minutes after 11am on Tuesday, November 8th, in the year of our Lord 2022.

There is essentially no sidewalk on the west side of Aurora Avenue. I reached the bus stop at 135th Street on Aurora; no bus was coming. I kept walking, squeezing myself between the parked cars and the businesses along the street. I had faith that a sidewalk would soon appear.

I heard the rumbling first. A bulky black box with thick treads on its large wheels approached. A man wearing a helmet and sunglasses inside the armored vehicle glanced out the open window. The red and blue lights in the front and on top of the vehicle were not on. The white “SWAT” lettering on its side gleamed in the late morning sunlight.

A few minutes later, a second armored SWAT vehicle rumbled past.

“What is happening?” I asked.

A photo of the 14-year-old was distributed to all Seattle police and an officer located the two teens on a Metro bus at North 145th Street and Aurora Avenue North at 11:02 a.m., the charges say.

Seattle Times: What prosecutors say happened at Ingraham High before the fatal shooting

I had to cut through a car dealership on Aurora because there still wasn’t a sidewalk. Despite the sun floating in the blue of the sky, I put the black beanie back on my head. Underneath my black wool winter coat was a black puffer jacket; a grey scarf was knotted around my neck. I continued to look for a sidewalk. I was apparently unwilling to cross the street.

The young women already knew that there is no sidewalk on Aurora, so they stood in the street. Their hands, adorned with colorful fingernails, tossed their shiny, long hair over their shoulders. Their shorts and skirts stopped just past the curvature of their hips, exposing the bare skin of their legs to the gaze of drivers and the cold morning air. The cropped jackets covered their arms, but not their cleavage. Their eyelashes looked like small, dark butterflies on their cheeks. Shades of red, pink, and purple were on their lips.

They weren’t yet waving at cars passing by.

One of them waved at me as I approached and called, “Hey!”

We made eye contact; she grinned. “What do you call those big cats that live in the hills?”

I reflexively smiled back at her, though did not stop walking. “Mountain lions?” I guessed.

Her rosy lips bloomed into a satisfied smile. She nodded, pointed at me, and said, “I like that.”

I shrugged and kept walking. I wished she and her peers weren’t standing out there. I wondered what their circumstances were. I prayed for their health and safety. I thought about why she asked me this peculiar question. (I only learned about REST, real escape from sex trafficking, after this conversation.)

I continued to look for a sidewalk.

About a week later, I boarded the light rail at the most northern stop. It was another sunny and cold day.

Many young people were on the train. Some of them had signs. I couldn’t read all of them; I spied one that was upside down that included the word “GUNS”.

They poured out of the train at Pioneer Square. Many of them had traveled over 130 blocks to join other students at Seattle City Hall to

[call] for better mental health support, more restrictions on gun access and more training for security staff in the wake of a shooting Tuesday at Ingraham High that left one student dead.

Seattle Times: At rally, Seattle students demand more mental health resources, gun safety measures

I looked up, shielded my eyes from the sun, and squinted at the blue of the sky, white of the snow, and grey of the mountains.

Categories
Consult-Liaison Nonfiction Public health psychiatry Seattle

Constraining Choice Sets.

The rains have finally returned to Seattle, though the wildfires continue to burn:

Wildfires from Google Maps as of the morning of 2022 Oct 24.

That map does not include the entirety of Washington State (there are more fires outside the boundaries of that image), or the fires burning in neighboring Idaho and Oregon.

While we did not experience the blood red skies that San Francisco experienced from the wildfires of the summer of 2020, the air was looked and smelled thick. Each whiff contained fragrant notes of Douglas Fir and perhaps Western Red Cedar, all overwhelmed by charred carbon. Landmarks disappeared into a gritty haze of grey. The evenings featured a crimson sun sinking into ashy layers of peach, pink, and coral.

By October 19th, Seattle had the worst air quality on the planet:

Conditions did not improve the next day. The Space Needle has a webcam (more precisely a “panocam”, as it provides a 360-degree view). Go take a look at it now; this is the grey pall that we embrace for much of the year. Despite this pewter drape, one can still see the surrounding buildings, lakes, and trees. Compare this to the view on October 20th:

(“Is the Mountain Out?” refers to glorious Mt. Rainier, the 14,410-foot tall stratovolcano that looms over the region.)

The rain finally arrived on October 21 and displaced the smoke:

Unfortunately, it did not extinguish the wildfires. Our neighbors to the east have yet to escape the smoke.

In addition to headaches, congestion, and watery eyes, people also experience psychological effects due to wildfires. I came across this paper in Nature Human Behavior from July 2022 that reports on one aspect of this: Exposures and behavioural responses to wildfire smoke (no paywall as of this writing). While the paper doesn’t quite answer the question I want to answer, it did report:

… during large wildfire smoke events, individuals in wealthy locations increasingly search for information about air quality and health protection, stay at home more and are unhappier. Residents of lower-income neighbourhoods exhibit similar patterns in searches for air quality information but not for health protection, spend less time at home and have more muted sentiment responses.

(For those who consider how your digital data gets used, the data for this paper came from Twitter, Google searches, and a real-time air quality monitor called PurpleAir, along with geographic income data.)

As we also have seen during the pandemic, people with lower incomes have less choices, even if they have access to similar information (emphasis mine):

Why do wealthier locations respond differently to smoke exposure? The measured differences do not appear to reflect differences in exposure information or in overall internet activity, given the consistent response of air-quality-related searches across income groups. Rather, the responses are consistent with lower incomes constraining choice sets and behaviours, including less flexibility in working from home, fewer resources with which to consider purchasing protective technology and (regarding the sentiment results) having other more pressing matters to worry about.

The Seattle Times published an article on October 20th that highlighted “constraining choice sets”. The King County Regional Homelessness Authority opened a “smoke shelter“, though few people used it. Why?

“The long-term effects of breathing in smoke is not going to be like the most highest of priority,” said an outreach worker. This is consistent with the findings from the article: While people living outside may have access to the internet, they likely are not seeking air quality monitors or information about filtration, as they do not have their own windows to close or own spaces to filter.

One of the conclusions of the article about wildfires could very well be applied to the pandemic: a “policy approach of promoting private provision of protection could be biased against disadvantaged groups”. I also suspect that the unhappiness the wealthier respondents reported as a result of wildfire smoke is not dissimilar from the ongoing unhappiness we all are seeing as a result of the pandemic and its social consequences. (It is likely that people who are poor are also experiencing unhappiness; they simply may not have the time, energy, or resources to feel it.)