The Patient Did What???!!!!

Perhaps one of the most “ewww” inducing factor I had come across happened to one of my patients. And it’s not very frequent where I go “ewww” because of a patient’s actions, but this one patient really did it for me.

So, having arrived at the psychiatry ward right after morning meeting, I go about my business ready to start my task of mundane ward jobs. One of the nurses approaches me, and I know that she wants to talk about the patient she’s looking after.

“Oh yea, I was wondering if you’d be able to write up some laxatives for Mrs A. She states she’s been suffering from constipation the last 2 days. ”

I reply “oh yea, so has she still been unable to open her bowels this morning?”

“She went to the toilet this morning. But she states that she had a lot of difficulty, and used her fingers to manually evacuate.”

“Manually evacuate”

I couldn’t help but let a wide grin form on my face. The patient manually evacuated because of constipation. It just doesn’t seem right when a patient does it.  I mean, I’ve done several rectal examinations (with gloves of course), but a patient doing a manual evacuation was just somehow very gross.

I saw her later that day, and asked about her bowel habits.

“How have your bowels been lately?”

“Doctor, they havn’t been to great. I tried to go this morning, but I’ve been really constipated, so I had to use my fingers.”

I fought back laughter, and tried thinking of lots of sad things to prevent myself bursting out into inappropriate laughter.

“Well, I can put you on some coloxyl and senna and some movicol”.

Whenever I see this patient now, images of two fingers manually evacuating faeces always conjures up. I can’t help it. I don’t know why after having done probably 20+ rectal exams, it’s only been this one patient that brings up such a strong image of fingers up bottoms.

How I Handle Nudity

If you were to handle a nude person, how would you go about doing so?

I never considered this question before, but when circumstances put you in front of a nude person, you try and do your best when it is a wholly unexpected situation.

And so it was, she a female in her 60’s, completely stark naked in front of me. Being in the common area, patients and nursing staff were around.

All I had asked for, was to have a quick look at the rashes on her thighs that were present yesterday. I was warned by nursing staff that “she’s not wearing any underwear”. Bearing that in mind, I thought it would be appropriate to ask her to return to her room where I could examine the rash on her thigh. But bringing up the subject of the rash, she went off.  Asking her about the rash led to one thing after another, then she started hammering her fist down on the table, appearing more and more frustrated.

“If you want me to take my clothes off, I’ll do just that!” And just like that, she removed her top off, to expose her naked body right in front of my very eyes.

“Please put your clothes back on” I said calmly. She refused to do so, and fortunately with female staff around, they eventually helped persuade her back into her clothes.

I felt embarrassed and shocked at the same time. Before retreating to the doctor’s room while she stood naked before me, I made sure to take a good look. That way, I got to see her rashes on the thigh had definitely resolved.

Guess what this patient had? She was bipolar, and manic.

Good heavens, I hope I don’t need to deal with another naked patient in psychiatry. But then again, anything goes in psychiatry…

On Being Genuine

The other day, my consultant saw me as we were about to do ward rounds and said “Hey doctor, how would you like to do a mental state exam on our next patient while we give you feedback later on?”

That was not a question at all I must say, in firstly, saying something like “no thanks!” would reflect badly on me. So I ended up saying “yea sure!”, and then felt the fear build up inside of me.

So in to the interview room we went, where there were two consultants, my colleague, one medical student, one nurse, one student nurse, and finally the patient himself. The patient himself was a man I had done the admission work for, so I knew his history.He is a man in his 50’s, who was brought in by police from his flatmate in regards to suicidal intent, and alcohol intoxication.

What happened next, was that I proceeded to establish rapport with him, asking basic things like “how have you been feeling lately?”, through a nervous bodily sensation. As I asked a few more questions, I felt more comfortable, and followed up on important cues such as his recent nightmares.

On closing, the consultant told me I did pretty well. He followed up with a few questions, such as “what specifically in hospital has contributed to your mood improvement?”. I wish I had asked that.

What surprised me next, was the consultant’s feedback that I was genuine in my interview with the patient. My interview persona was a reflection of how I interacted with others normally, and in a way, I brought my personality with me as the doctor, to how I am as a colleague.

In a way, it’s something I never really considered, but it’s something I feel is actually quite important. Being genuine with patients is a way of building rapport, and of being sincere to the patient. It helps to establish trust, in that in a way, it lets the patient know a little about the doctor’s true self. And I guess that being doctors, we don’t share our personal life stories, so the patient has very little knowledge about us as a person, other than their first impressions and the personality/persona we display to them. In that sense, to put forth a fake persona to patients, is really in a way distancing ourselves from the patient, in that a mask is worn so that patient’s don’t get to know the person behind the mask.

In a way, I guess my consultant has seen the fair share of other doctors who wear a mask, and adopt a different persona to patients compared to how they are normally. In my view, it isn’t authentic, and it would be difficult to maintain. Perhaps some feel the need to hide their true character between a persona to patients because of the fear of revealing too much? Maybe some try and adopt a more confident persona, or try and tailor themselves as a person similar to the patient to try and build rapport?

Now that I’ve come to it, I think I’d prefer a doctor who showed their personality through in a consult over someone who tried to be someone they are not. Eventually, it’ll show through that they are trying to be someone else.

But it’s definitely something I didn’t consider until now. From now on, I’m going to continue being genuine in my patient interactions.

On Perceptions

Delusions and hallucinations have been something that always puzzled me.

A delusion can be defined as “a fixed false belief that is resistant to reasoning with actual facts”, whereas a hallucination can be defined as “a distortion in a person’s perception of reality”.

For the past two weeks, I’ve been encountering patients who have delusions and hallucinations. For delusions, the puzzling thing is that I don’t understand how any person can have such conviction in their beliefs about something, that almost anyone can see is absurd. But then again, I guess with psychiatric illnesses, such distortion of realities is something that those unwell experience. It’s something that I’ve never experienced before, so I don’t know what it’s like to have such absurdly false beliefs.

The other day for instance, one of the patients (let’s call him Mr A) was seen shadow boxing in the courtyard. When asked about his actions, Mr A explained that he was practicing boxing, because he believed (a delusion) that a “fat man” will be coming in a helicopter to have a fight with him, and if the “fat man” loses, he’ll take Mr A’s spot in the hospital, while Mr A himself can take the helicopter to escape from the hospital.

In dealing with such patients, my consultant gave me a very important word of advice; rather than dismissing or directly challenging such delusions, we should neither accept or dismiss their delusions, but ask them about it. It was explained to me, that the patient lives in a reality completely different to the treating doctor, and any pertubation of such reality by challenging or dismissing it, could possibly lead the patient to close them  self off, or destroy the rapport already built. In a way, it reminds me of a physics principle known as the “observer effect” which asserts that in trying to measure an event or outcome, the measurement itself has the potential to disrupt such an event or outcome.

What the patient believed seemed like absolute reality to him, enough for him to do some shadow boxing in preparation for the supposed “fat man” fight. I pondered about Mr A’s reaction to the non-event of the “fat man” turning up for a fight. Would Mr A think to himself that maybe his belief was wrong? Would Mr A continue to have further delusions that would feed into his primary belief, (for instance, the “fat man” was training as well, so would come in a few days time)? I suspect that it’s more likely the latter option that Mr A would continue the line of thinking for.

I don’t live in Mr A’s reality, so his belief seems absurd to me. He would probably contend that I’m absurd to point out that these are delusions, and that he is unwell with a psychiatric illness, for indeed his illness has probably affected his insight into his illness.

In a way however, I think I have my own delusions at times. There have been times I thought that I would make a fatal error in judgement, and that the medical governing bodies will come and deregister my medical registration. Well, it’s not as much a delusion, as it is probably negative thinking, and a lack of self esteem and confidence on my part.

What I’ve learned from patient’s like Mr A, is that to me and other doctors and health professionals, a psychiatric patient’s delusions are completely absurd. But to them and their reality, they live in a different reality where it makes sense to them, just as much as it makes sense for us to believe that the sun would come up the very next morning after night time.

On many levels, psychiatry in a way is like the movie Shutter Island (if you haven’t seen it, I recommend watching it). Reality can seem to be so engrained to a patient, that they seem to have a distorted reality in which everything to them makes sense and seems normal, whereas to other people, it is highly abnormal.

After a Month’s Break

So I’ve been really lazy recently, and havn’t blogged much because of a lack of time, and because I feel there is a need to really write great posts, which of course take time.

Now on psychiatry, which should be a cruisy rotation, but for some reason, I’m not feeling the ease of the rotation. Perhaps it’s because I’ve just come back from a 1 month vacation overseas to China, South Korea, Hong Kong, Singapore and Taiwan, and I’m still wishing I was over there rather than working.

I’m starting to settle back to my normal work routine, and blogging should be something I do at least once per weekend.

A few more minutes, and I have to leave. I’ll write some more posts soon detailing my vacation and recent work experiences in my current rotation.