I'm still deciding why exactly I like this so much. One aspect is certainly the reduced amount of overall work -- I don't work the full 14 hours, and I do a LOT less paperwork because I'm not responsible for daily charting. Another is the fun of emergency diagnosis and treatment, a totally different beast from regular psychiatry. Regular psych is a longitudinal process of building relationships and slowly changing behavior. This is one of quick evaluations, decisionmaking with limited data, and planning in the moment of acute crisis. The decisionmaking in particular is nice -- as with regular emergency medicine, I actually get to try to diagnose, instead of treating something that someone else already figured out. The third, as noted above, is the autonomy. It's the only time when I am, for real and genuine, the Doctor In Charge. There's of course an expectation that I'll seek second opinion for any dicey judgment calls, but for 99% of stuff, I'm free to use my own judgment about what meds to give, how to manage the patient, and what not to do. I also get to experience the consequences of my own mistakes, e.g. getting called back into the hospital last night at 5:30 AM (after going to bed at about 12:30 AM) because I didn't realize a particular patient might be a fall risk. Experience is an excellent teacher.
And, of course, night is when all the absolutely ridiculous stuff happens, the stuff that becomes an intern's standard happy-hour conversation. In particular, at night I'm responsible for urgent consults. The past two weeks are two of the stranger consults I've ever done, even counting some odd ones as a med student:
- I get called by the surgery patient to request a consult -- on a patient who's not in the hospital any more. You see, the patient in question has a habit of swallowing things when he gets upset, and particularly of swallowing dangerous things. Like, in this case, three razor blades[1]. The surgeons decided to wait and see if he pooped them out -- and in the mean time, kept him NPO[2] for days. They meant to call psych to see him, but never quite got around to it. And then, the patient left the hospital, because he was sick of his team. Eventually, he realized his stomach hurt and came back to get pain meds, and I did see him, after midnight (He wasn't thrilled about that either.) The ostensible reason was "Well, he's crazy, does he have the mental capacity to leave the hospital?" The answer was "He's not so much crazy as just a pain in the butt, and the patient himself says so. Yes, he has mental capacity. Sorry, you're stuck with having to be nice to him." (The official declaration of "not crazy" is a common reason for psych consultation, actually.)
- Called to see patient in ED for suicidality. Turns out patient is deaf. And can't sign very well, plus no sign interpreter available. And can't read lips. And also is refusing to write any answers to anyone's questions. And, according to the deaf staff workers at patient's current housing, is suspected of not actually being deaf. And just moved to Seattle with no ID or anything, having apparently lost all of the above during multiple sexual assaults in another state. And is terrified of men. The diagnostic interview was... limited. To a single written statement of "I refuse to answer this question". Diagnosis: everything in the book. Plan: Keep on suicide watch until she feels like "talking", and refer for involuntary mental health commitment as presumed suicidal/grossly disabled until/unless she does "talk".
One of the many many things I love about psychiatry -- it NEVER gets boring. There may be a small set of diagnoses, but they present in a whole lot of different ways.
[1] You may ask how it is possible to swallow razor blades without getting the [bleep] cut out of one's tongue and oral apparatus. I don't know. Nobody I've asked knows. But it is, because this is definitely not the first patient I've met who does this.
[2] "Nil per os" = "Nothing by mouth". A very unpleasant state to be in for a few hours. For a few days? You'd be ready to punch someone.
