Friday, February 26, 2010

Marveling at my Greeters

For the last month, my morning has always started the same. I turn my key clockwise until the light turns green and the door unlocks. Before opening the door, I carefully make sure no patient has crossed the yellow line and will AWOL the moment the pink door opens. I quickly slip in and close the door, letting myself into the unit, while gripping my coffee in my hand. And my day begins.

In may ways, it's like Groundhog Day, it is the same routine over and over again.


And it always starts with my greeters, who have become a part of my routine. *Lena and Joe, without fail, have been there to draw me into their world, daily reminders of this new habitat I visit.

From the common room, Lena stares at me. She is a forty-something year old woman, with the mental capacity of a child. She intermittently laughs, claps, or throws tantrums. Her frizzy black and gray hair is pulled back in a pony tail and she wears a stained white t-shirt that tightens around her mid section. Today she wears blue hospital pants instead of her usual patterned dress. The daily antipsychotic medications have calmed her down, but caused her to gain weight and retain water; her face is swollen and she looks sedated as she pouts with her arms crossed across her chest. This morning, she ran up to me to give me a hug. Later on, she finds me while I interview a patient to give me some of her half-eaten animal crackers. I politely decline and she moves on to offer the food to one of her peers.

In many ways, she appears blissfully unaware of her mental illness and the discussions that happen each morning during acuity rounds that focus on transferring her to another facility. "She was evaluated, but they don't think she is eligible for placement," her providers say. So, she has taken residence in the unit. As far as she knows, the unit is her world; her major concerns are when she gets to eat and if she can get an extra soda.

There there is Joe. An older gentleman in his seventies, whose face has been thinned down to the bones. With his dark eyes and bony face, he reminds me of my childhood image of a walking skeleton, who lurks in the shadows. He speaks no English and when he talks, you can barely understand what he says; he has barely any teeth. He likes to opens his mouth, which reveals the darkness of his oral cavity. His yellow skin is accentuated by his silver hair. You intermittently hear the gurgles from his throat when he sits quietly to watch the afternoon Court TV.

He is infamous for his pranks, which have included clogging sinks, jamming locks, and hiding things. He always wears the same dark blue jacket with red stripes over blue pants. He shuffles around the unit with small steps, shifting from one chair to another. Each morning, he utters something incomprehensible to call my attention. Each day, his goal has been the same- "get out of the hospital."

But for some reason, he has remained in the hospital, becoming a resident of the unit.

Similar to how the greeters have become a part of the unit, they have become a part of my world.

At 9:30 AM every day, the chairs and sofas are arranged in a circle. Patients emerge from their rooms to congregate for the community meeting. Some patients stroll in after being prompted, some wander after being waken up, while other patients are already seated from the previous stretch session. The providers join the meeting later.

It's the same process every morning. Go around the circle, introduce yourself, tell everyone how you are doing, and state a goal for the day.

Today, many patients were feeling good. A common goal was to get out of the hospital, or go to the patio. One patient declared he wanted "to take over the world." Another patient, said, "F*%@ you all. I do not belong here."

It's also a time to bring up community issues, read the unit rules, and orient new patients to the staff and daily schedule. Today, occupational therapy had scheduled an art exercise and a movie matinee for the afternoon. Patients would be able to select the movie to be played.

You can learn from the community meeting. You get a sense of the patient's mood, their goals, and how they interact in a group setting. I could see Lena pouting at me from the corner of the room. Joe arrived late and slowly made his way to his usual seat. Today his goal, like every other day, is the same. "I want to get out of the hospital," he said in the few English words he knows.

"If the weather holds up, we'll go out to the patio. You need a patio pass to go. To get a pass, participate in your care and go to groups," said the occupational therapist.

To conclude the community meeting, one of the patients picked an affirmation from the "I Can Can." Today, the laminated card echoed Aristotle's words. "In all things of nature there is something of the marvelous."

"You can marvel at your recovery. That concludes community meeting. Now, go have a good day." the group leader said.

The patio is in the center of the seventh floor surrounded by the units. You have to use your key to enter and leave the patio. The square area has a basketball hoop and a seating area made of metallic-shaped blue sofas. There is a painting on concrete the wall of a nature scene. The patio can be viewed through the windows from inside the unit.

Lena and Joe had both earned patio passes and were outside in the patio. Everyone was standing in a circle completing a series of stretches. I joined the circle, feeling weird standing still. I was reminded of the childhood game, Simon Says, where you imitate the action that someone tells you to do. During the exercise, we each went around the circle and choose a stretch and we all followed. I was amused, when the taller more fit patient, had the patients run in place; many of the patients could not keep his pace. The more unsteady patient had us roll our heads. I choose the calf stretch, since my legs were tight from my morning run. Lena had us put our arms in the air and move side to side. She was uncoordinated and clapped afterwards.

She always know how to put a smile on my face.

It's an odd scene. A bunch of grown adults locked out, standing in a circle and performing stretching exercises. I could see the staff watching us from inside.
It's a strange feeling to be watched.

Although I did not directly take care of Lena and Joe, I feel as though I have come to know them vicariously through our daily interactions. They have been the constant during my time in the unit. My other patients have come and gone. But Lena and Joe have been in the unit on conservatorships, completely distanced from the outside world. The unit has transformed into their homes; they have outlived many previous residents and medical students.

They will repeat this same cycle when they are transferred to another facility during the remainder of their lives. I wonder what their lives were like before they were admitted to the unit.

Lena and Joe remind me about some of the greatest responsibilities we possess as physicians. We are charged with making decisions for our patients, who are gravely disabled, either because of medical or mental illness. Joe and Lena can not function in the world we live in; they would be unable to feed themselves, take their medications, communicate with others appropriately, pay their bills, ride the bus, and find their way around the city. They are severely impaired and vulnerable. We become their conservators, taking on a parental role in these patient's lives, figuring out what we view as being in the patient's best interests. And it comes down to one thing--institutionalization.

For these patients, I feel we are placed in a precarious position. We are limited by our lack of understanding of our patient's true wishes. They have no family and our patient's can not clearly communicate with us and they lack insight into their illness. We resort to using the medications in our tool box. And when the medicine fails, we have to move to the next step, placing our patients in a facility. It's a bitter bill we swallow when we have exhausted all of our placement options, even when our patients do not want to go. What other options do we have?

It's a daily reality we confront on the unit. Today it's Lena and Joe. Tomorrow a new patient will arrive in the unit with a similar story (and probably the same outcome). And the cycle continues.

On my last day, Joe and Lena were in the community room watching Court TV. They were there greeting me, reminders of the world I was about to leave and the reality of the inpatient unit. As I walked out of the unit for the last time, I marveled at the lives of my greeters.

*Names have been changed to protect patient identities*

Tuesday, February 23, 2010


The pattern in the brown wooden floor is quite ironic. A small square is encompassed by another larger square, which is surrounded by another square. The pattern screams entrapment. It's an odd design choice for an inpatient psychiatric unit. Perhaps, it's just a mind game.

When I started my psychiatric rotation over three weeks ago, I instantly noted this pattern on the floor. I'm not sure why it called my attention. One of my colleagues elegantly pointed to a reason, drawing on Freudian themes.

"Perhaps, the pattern in the floor reflects you own internal preoccupation/conflict with being trapped on the unit," he said.

Quite an insightful comment not to far from the truth. Sometimes, you can feel trapped, even when you know you can leave.

The Seventh floor inpatient psychiatric unit at SF General Hospital is an interesting place. I'm situated in what used to be a themed women's unit. However, the themed units have disappeared due to budget cuts and the need to place acute patients in inpatient beds for stabilization.

The unit is set-up much like a traditional inpatient psychiatric hospital. There are individual units on the seventh floor with a central patio area. A key is required to enter and exit the unit to prevent any patients from AWOLing. A common room set up with chairs, tables, a TV and a piano, is located right next to the entrance. The Nurse station sits in the middle of two long pink hallways; one hallway for the male rooms and the other hallway for the female rooms. The charting room, where the physicians, nurses, and social workers congregate is just across the Nurse's station. The charting room door remains open during the day and patients pass by, sometimes demanding to see their physician or asking to be discharged, other times requesting for Ativan or food, or stopping to stare at you.

My experience on the unit has been a unique experience with it's share of ups and downs. In many ways, it's been a whirlwind learning experience that has made me reevaluate my emotional boundaries.

With inpatient psych, you bear witness to some of the most difficult patient situations you will see in medicine. You will see patients at the lowest points in their lives. You see the entire spectrum, everything from suicidal patients that attempted to jump off the Golden Gate Bridge to manic patients who in a fit of rage threatened to hurt others to psychotic patients who believe they are emperors of the world to violent patients with personality disorders to psychotic patients who hear the voice of God telling them to hurt others to delusional patients who believe they have HIV despite negative testing.

While on the unit, I've had patients yell at me, flirt with me, lie to me, cry in front of me, refuse to speak with me, talk only to me, write notes to me, or stare at me.

Many of our patients are admitted from the Psychiatric Emergency Services, where they are initially evaluated. Typically, patients can self-present, be transferred from the medical emergency ER, or brought in by the police or other providers. In the process, some patients are placed on a 5150 legal hold for either danger to self, danger to others, or grave disability.

The stories of our patients are heart-wrenching; you see the frailty of the human mind due to mental illness. You also see the darkest shades of human nature and behavior. Common themes thread through many of their stories-- histories of substance dependence, violence, abuse, neglect, lower socioeconomic status, marginal housing--just a few of the common themes that pervade the lives of our patients.

Mental illness deteriorates the lives of our patients. Some patients are just driven by basic instincts to survive, while other patients are completely out of touch with reality. Sadly, many of our patients with debilitating mental illnesses crumble in society; the hospital becomes a revolving door and their only security net. We become responsible for these patients.

Amidst the emotional turmoil, you (the provider) must take a history and determine the next steps. You are called to "stabilize" these patients and develop an appropriate discharge plan. For patients placed on a hold, we are given a 72-hour window to act (unless we obtain a 5250 hold, which extends th hold to 14 days). At any point, a patient can contest their hold in front a judge. Until the patient demonstrates insight into their condition, you make decisions on their behalf, quite a responsibility.

At times, you find yourself getting devoured by patients who seek your undivided attention so they can yell at you for hospitalizing them.

Other times, you struggle to process the gravity of your patient's words, trying to assess if they actually plan to hurt others, or if they are truly that ruthless. You find yourself losing your patience, having to remember to monitor your countertransference.

At times, you are simply overwhelmed by a patient's history of abuse and the tragedy of their life that you find yourself searching for the empathetic words to say (those PEARLS we were taught in first year), knowing well that what you say can not change or offset the damage. You remain silent, as your patient cries.

You either become skeptical and jaded, or you become emotionally overwhelmed and confused as you process the unimaginable. The constant exposure chips away at you, testing your boundaries and patience. Despite the challenges, you must find a way to remain dedicated to helping your patients.

All day long, you hear similar strokes of the same song. Through it all, you try not to let your own voice be silenced by the noises of the unit, so you can find your escape.

Sunday, February 7, 2010

My First Half Marathon

After many years of contemplating and many years of running, I finally did it; I ran my first half marathon (13.1 miles) and finished within my time goal.

It was a perfect running day. "The weather was selected specifically for this race," the commentator joked during the finish.

After many months of rain and cloudy weather, the sun shined. There was a light breeze. We were able to fully enjoy the outdoors as we traversed the path through the Golden Gate Park past the Pan Handle back to park all the way down to the great highway right along the Pacific Ocean. The views were breathtaking.

10,000 runners registered for the Kaiser Half Marathon and 5K. And the masses could be visible at the start line, jumping in place, stretching, conversing, or standing still. Proceeds from the race benefit organizations such as the Koret Family House, The Harbor Light Center for Alcoholism and Drug Abuse, and Support for Families of Children with Disabilities.

Although I've run these paths before, today it was special, because I went non-stop and was in the company of many other runners. The feeling is electrifying to be in the pack, and you are pushed to go faster and farther.

In many ways, running has been therapeutic over the last three years of medical school, getting me through the stress of exams, anxiety of evaluations, and uncertainty of third year. I felt so lucky to have this opportunity, counting my blessings for the strength, health, and determination to make it to the finish line.

My calves were a little tender at the finish line. But after some hydration and a hot long shower, the soreness has improved and I can say I feel good. We'll see if I can take the next step and train for a full marathon in July.

For now, I'm going to savor the feeling of completing my first half marathon.

Wednesday, February 3, 2010

Open Head

"I left my heart in San Francisco." In the background, the muffled voice of Tony Bennett coming from the old AM/FM radio was barely audible over the drilling. With the hand-held drill, the neurosurgeon slowly moved along the purple line he had drawn on the skull of the patient. As he moved his drill, the bone slowly detached from the skull. White bone powder sprinkled all over the field.

"Irrigate!" he said.

With a green dropper that fit in my palm, I carefully squeezed the bulb and a couple of drops coated the cracked skull, caking the bone dust. I squeezed some more not sure how much pressure to apply. It was not coming out fast enough. The surgeon grabbed the dropper from my hand and proceeded to squeeze all the clear fluid out.

"I never liked this song, until I moved to San Francisco," the neurosurgeon said to scrub tech as he continued to irrigate.

He said little to me except instructing me to irrigate. He spoke in a low voice and made general conversation with the operating room staff about everything from football to abstract art to the Grammy awards to weekend plans.

He had dark wavy hair streaked with some specs of silver and wore glasses that framed his dark eyes. He would squint periodically and the fine wrinkles around his eyes became more prominent. He was a couple of inches taller than me with a medium build. Originnaly from the East Coast, he had moved to SF and was completing his neurosurgery training, which probably made him thirty-something years old. He spent most of his hours in the hospital, either operating or attending to patients in the ward or ICU.

The circular bone flap eventually became detached and the neurosurgeon (with some pressure) pulled off the bone piece.

"These are good drills for these kinds of case. But probably would not be fast enough during the emergency craniotomies," he said to the company rep.

Prior to drilling he had started by making a horseshoe incision along the hair line just above the ear, he reflected the skin back. The skin was tethered with white plastic clips.

With the bone removed, a glistening layer of tissue could be seen. This was the dura mater, also known as the "hard mother," a protective covering of meninges that sits below the skull and over the brain.

To get to the tumor, the neurosurgeon carefully cut along the layer of exposed dura until he uncovered the maze-like structure below--the brain.

This was my first time seeing open brain surgery. As part of our neurology rotation, we have the opportunity to observe neurosurgery cases. On my last day of neurology, I was able to finally see the brain, a subject we had spoken endlessly about during our case discussions and rounds.

Open brain surgery is quite something.

The last time I had seen a brain was during anatomy of my first year. We had sawed the skull and pulled out the brain after identifying many anatomic landmarks, which have escaped my memory. With the brain outside the head, we used a kitchen knife to slice the brain in horizontal planes to see the cross sectional anatomy. The light brown slices were uneven and moist to the touch, having been soaked in tissue-preserving chemicals.


Our patient, a seventy-three year-old gentlemen had presented with acute-onset seizures a couple days prior to his surgery. After the seizure, he had imaging studies, including a CT and MRI, which demonstrated that he had a large mass in his left hemisphere with radiographic characteristics suspicious for a meningioma.

A meningioma is a tumor of the meninges (the layers covering the brain) arising from the cells the produce the cerebrospinal fluid, liquid that coats the brain and meninges. Over 90% of cases are benign and have a low recurrence after surgical resection. Oftentimes you'll hear the neurosurgeons say that "if you have a brain tumor, you want to it be a meningioma." The prognosis is usually pretty good.

Before the case began, we closely examined his MRI scans to strategize the surgical approach. The bright circular mass was penetrating at least 2-3 cm into the brain parenchyma, which means resection is a slow and meticulous process.

Grossly, the tumor was visible on the exposed portion of brain. The oval, light purple mass looked like it could be scraped off the brain. But the mass went deeper than the surface.

The neurosurgeon, examined the mass with fine instruments and started dissecting the tumor with a fine scissor, periodically cauterizing. I was surprised when he turned to me and asked, "why do I start dissecting here?"

As he asked the question, he pointed to nondescript area of the brain away from the midline. Although the terrain of the sulci and gyri of the brain looks identical all around, you always remember that there are some regions that are sacred.

"To avoid the motor and language areas." I said. (The most obvious answer I could conjure)

Satisfied with my answer, he continued to dissect away silently. He looked through a microscope to magnify the margins of the tumor.

As I stood there looking into the scope, I continued to wonder how deep he would dissect. He was guided by the MRI because the tumor tissue is almost indistinguishable from the brain parenchyma. But I still wonder how one really knows. That's probably what distinguishes "us" from "them" (the neurosurgeons), who from experience just know.

Whatever the approach-- it was slow, deliberate and meticulous. Every motion is precise. He would snip and pause, repositioning his pick-ups. He would take a closer look and then snip some more with a pair of fine scissors. And would repeat the same steps, slowly resecting the mass.

I stood there watching the fine cutting, in awe of the sight in front of me. With an open skull, we had a window to our patient's brain and we were cutting this man's tumor out slowly.

It was only hour two of the operation and there was long way to go to fully resect the tumor...