Thursday, October 18, 2012

Subinternship Day Before the Last Day...

Wow, had a crazy day today.  The morning was okay, but this afternoon had a really crazy patient...

So...patient is on 120 mg of adderall - an amphetamine derivative.  He's a graduate from a medical school, had to leave his advanced fellowship because of "personality clashes" with a faculty member, has a history of ADHD supposedly.  This kid... (I say kid despite the fact this person is older than me) ... is talking a mile a minute.  He's got a pale color.  He looks like he's got some amount of sweating.  He's talking rapidly, looking  around the room, shaking his legs back and forth, fidgeting with his hands.  His eyes look mildly bloodshot and the lids look a little red, as if he hasn't slept very much.  He's repeating that he needs his medications particularly because he has a term paper due in two weeks or so.  He describes an erratic sleep schedule.  He is extremely intelligent and knowledgeable, citing research articles from pubmed and arguing "Why shouldn't ADHD people take amphetamine derivatives if it means they will be functional members of society instead of bums?" or "Studies have shown people taking lower doses have had heart complications but people taking higher doses haven't, so the cardiovascular risk is overestimated."  Then he goes into his own research about this or that, in logical medical jargon that is beyond my level of education.  Then at the end he adds that he wants to be castrated because he identifies as asexual.

If this person wasn't on medication before, and wasn't as knowledgeable as he was, I would want him in a psychiatric facility and watched for 72 hours without medication, and then probably put on an anti-psychotic.   Don't get me wrong, I think that bipolar disorder, major depression, and ADHD are grossly overdiagnosed, misdiagnosed, and overtreated.  I would rather send a person with major depression to counseling than give them an SSRI.  If he wasn't on insane amounts of supposedly "therapeutic" adderall, then I would think he had schizoaffective disorder with manic qualities - meaning a combination of schizophrenic symptoms and a mood disorder like depression or mania, in this case mania.  

Adding in the asexual identification just further complicates thing.  I am all for people modifying their bodies to suit their unique psychological needs.  We all do it to some extent, modifying how we look: Adding tattoos or makeup to affect our appearance.  Some people don't feel particular genitalia are suited to them, in this case just the testicles.  That is fine, if that is the decision of a rational, unmedicated person, or a person with a psychiatric disorder who has found a stable medication dosing that allows him to have coherent thoughts.  Honestly, I hadn't seen someone with these characteristics since seeing bipolar and schizophrenia in Stockton, and these people were nonfunctional.  We are talking covering themselves with mud and telling cops that they know jiujitsu and are ninjas and you can't see them kind of nonfunctional.  

Something else you notice about people with psychotic disorders is the way they respond to questions.  When you ask a normal person, "So, how much sleep do you think you're getting per night?  Just average it over a week, about how much?"  The typical person with sleep trouble might say, "Well, sometimes I have trouble getting to sleep, I'll go to bed and lie in bed for an hour two, then fall asleep and wake up early and not be able to get back to sleep, I probably get about 4 or 5 hours a night."  On the other hand, someone who is psychotic, paranoid, or delusional might respond initially in an evasive manner, i.e. "You know, that's a very good question, a very good question.  How much do I sleep.  I think I sleep pretty well." "Well, how much, if you could put a number on it.  Just an average, over the course of a month."  "Hehe, that's a good question.  I suppose... I mean, I take naps, I sleep, I might sleep at times other people don't or take a nap under a desk but people do that sometimes, there's nothing wrong with that, ..."  

You still haven't given me a range of hours.

It's a very different train of thought.  It's very distinct.  You pick up on it immediately if you have been around psychotic individuals more than once.  In thinking about it right now, I almost wonder if deep down this patient knows he is abusing his drug, and that his behavior, to any rational medical professional, looks like someone who is addicted to chronic low levels of amphetamines, and he is trying to circumvent it despite his own knowledge.  Why conceal something if there isn't a problem?  He isn't lying, yet he isn't answering the question clearly, and either he lacks insight as to the purpose of the question (assess how much sleep he is getting) or is afraid the answer would affect him negatively or impact his ability to get medication.  

It's an odd internal conflict between having a psychotic disorder that prevents you from having insight into your condition, yet at the same time being so knowledgeable and rational that you DO have extensive knowledge about the condition.  It's a very unique situation, since he IS a medical professional.  The last time there was a patient similar, it was a schizophrenic woman who spoke of having been in the military and the CIA being at her house checking up on her because it was a service that all ex-members of her group got, and she explained it in a very rational descriptive manner.  Very logical.  Reasoning.  And yet, it was all a fabrication.  This person almost certainly is who he says he is.  It is likely all effects of the medication.  I've seen the effects of amphetamines, I know what they look like at a lower level of use, and this is amphetamine abuse x 1000.  

This patient reflects a harrowing vision of the dangers of treating ADHD with stimulants - at what point do you decide the medications aren't appropriate?  What was his psychiatrist thinking giving him slowly increasing levels of amphetamines?  With what reasoning would he prescribe this?  In some cases, physicians are so convinced that medication is the only answer, they will exhaust all non-amphetamine medications and finally, have to resort to amphetamines and gradually increasing the dosages.  This patient was on dosages far exceeding the regular amount.  By comparison, a 10 year old with supposed ADHD would probably be getting 10 mg in the morning, and a half tablet at lunch.  Compare that to this individual, with 120 mg evened out throughout the day.  It is scary to think what unbridled medical treatment of possibly behavioral disorders can lead to.  I have no idea what this patient is like at baseline, without medications.  I wonder if he would be functional.  I wonder if he would suddenly have more insight to his condition, or have an epiphany that he can live without the constant push from amphetamines to be electrified into focusing on something.  I wonder how much difference we can make at this point, and how much of him is him, or the drugs.  

As a doctor, you want to believe patients, be their advocates, and fight for them when no one else will.  However, when you can't trust that a patient is even himself, where does that leave you?  Ultimately you are left with your interpretation of the scientific and clinical data, the knowledge and experience you and you peers have, and that intangible feeling of "your gut instinct."  I don't know when I will see a patient like this again, but it is one of those dilemmas where you are truly torn.  

Friday, October 12, 2012

Sub Internship - Week 3

Well, I know I haven't been updating much - it's been busy.  A lot of fun stuff going on - seeing all kinds of patients, getting to know the residents and faculty... it's really enjoyable.  I had almost forgotten how much I enjoyed family medicine - there are so many things you get to do in family medicine that you can't do in other fields of medicine.  A day could involve diagnosing a patient with anorexia, managing a patient with depression, removing a sebaceous cyst, performing maneuvers to treat a patient's vertigo, putting a cast on a 10 year old boy, identifying a rash and prescribing antibiotics to prevent future heart complications, managing a patient with hypertension + diabetes + chronic kidney disease + depression + foot ulcers + macular degeneration, managing a patient with sinusitis, counseling a patient on weight loss, removing an ingrown toenail, identifying a urinary tract infection... and so on.

Essentially any medical problem a patient has, they go to you first.  So much fun.  I'm at the point where I know enough that sometimes it feels like I really have the answers.  There have been many encounters that would be blog-worthy in these past weeks, I just don't know where to start.  A woman at 37 weeks gestation who has gestational diabetes, who also just developed symptomatic gallstones, who has an OB/GYN physician who seems indifferent to the fact her pregnancy is one problem away from becoming an emergency surgery?  Breaking the news to a young skinny girl that she has dieted to the point that she isn't having periods and needs to gain more weight when that's the last thing she wants?  A man with crippling chronic pain from an accident years ago who is allergic to morphine?  

The residents have been great, the attendings have all been great, I feel like I fit in really well.  I love the area, the city, our new place.  I really hope I get into this program.  

Currently my tally is 8 interviews scheduled out of 11 programs I applied to.  I think I'll get an interview with Davis, and I am still hoping for at least one more interview offer.  I'm not holding my breath for one of the programs.  I'm kind of looking forward to interviews as well - two places are covering my lodging.  One of them is letting me stay with a resident, and another is paying for my hotel room.  Tomorrow hopefully I can relax a bit.  I need to get back on my exercise regimen but I strained my calf muscle two weeks ago and it still hurts really bad and I don't want to be impatient and hurt it even more.  After next week I start Pediatric Psychiatry - should be nice.