Sometimes You Just Gotta Move

I have officially been a doctor about... oh... one and twelve thirteenths years now. Around the one and seven thirteenth mark I came to a realization about my job that although not particularly revolutionary is still remarkable. That is: there is no escaping the crazy and the boring. No matter what path I decide to take in medicine I will always have patients that are loony toony or just dull, tedious, and boring. For a while I had had reservations about pursuing a career in infectious disease due to the tendency for infectious disease docs to be the antibiotic monkeys of the orthopedic surgeons -- resulting often in clinic visits with nothing more than a demented patient, a handful of illegible nursing notes, and a PICC line -- but now I know we all got our burdens to bear.

This realization came during my neurology rotation. Although I already knew neurology to be full of the dull, tedious, and boring I was caught off guard by the amount of crazy. Where as rheumatologists have fibromyalgia, endocrinologists have "hypoglycemia", cardiologists have "chest pain", and allergists have their entire careers, neurologists have pseudoseizures. Pseudoseizures, for those not in the know, are seizures that aren't really there. Hence the prefix pseudo-. The more politically correct term currently is "psychogenic non-epileptic seizure" but I imagine this will be the case only as long as it takes people to realize "psychogenic" means "full of crap." In every case people twist and turn, writhe and shake, hop and bounce all convinced they're having a seizure when, in reality, they've just got a case of ants in the pants.

The reason pseudoseizures are such a pain is both because of the high incidence of personality disorders associated with them and the requirement of a 72 hour sleep deprivation study to diagnose them. Regular seizures are hard to provoke but it turns out not letting someone sleep for a long time is a pretty good way to do it. It is also unfortunately a pretty good way to make a healthy but ornery person into a healthy but fairly irrational and agitated person as well. The purpose of the study is to capture on video and electroencephalogram (EEG) a purported seizure. Comparing their movements and brain waves gives a nearly infallible assessment of whether the seizure is genuine or not. Although some people can fake seizures with the best of 'em, it turns out it is hard to fake an EEG.

Thankfully, amongst all the painful explaining that all the Depakote in the world won't stop you from having the seizures you aren't having, there are the lighter moments. Specifically, when the patients are *not* good at faking seizures. During my month on the neurology service there was all kinds of wackiness but the best "seizures" of the month were memorable. Runner up went to lady who back flipped off the hospital bed while first prize went to young dude who did some sort of fully upright hokey pokey. In the words of a colleague, "that's not a seizure. That's a dance move." I am sure people with pseudoseizures have great struggles both with their condition and in life, but, man, if you're was going to fake a disease at least take some disease faking classes first. Or go with psychotic parasitosis. Prove to me I don't have parasites!

Through the Prison Gates

Talking to some of my patients you'd think we're running a penitentiary at Wilford Hall. If I had a dollar for every patient begging me to let them go or who asked that I call the cops, FBI, OSA, CIA, etc I'd have, like, seven bucks. This is not because of particularly poor patient care -- I am inclined to believe we treat our patient's better on average than most hospitals -- but because our patients are out of their minds crazy. Delirious more specifically, but crazy nevertheless. Sometimes they try to bribe me, sometime they try to convince me through semi-coherent cookoo logic, and sometimes they just ask very nicely, but the universal statement always seems to be, "I shouldn't be here! Ahhhh!"

And how do I respond to these requests?

"Sir, would you like a BOOST?"

Actually we're instructed to talk them down which I am not sure has ever actually been scientifically shown to work, but it's what we do nonetheless. "Sir, why do you think the nurses are trying to kill you? They're sticking tubes in your penis, needles in your arm, and waking you up every few hours because they want to help you!" The restraints are good for you, ma'am.

In other news, this last week I won the lab lotto. Laboratory tests are ordered to confirm probable diagnoses and rule out improbable ones. Checking them every day is always a little like a scratch off ticket to see if we have just another case of pneumonia and diabetes or something much more exotic and rare, and a couple of days ago I won big. An insulinoma! Or at least I thought I did. The patient was hypoglycemic and with super high serum insulin and c-peptide levels but it turned out it was just a gnarly side effect of her floroquinolone antibiotic. Still pretty unusual and still quite a prize. I was excited. Now I am told I get to write up an ACP poster for it, whatever that means.

And here's our Christmas tree!


Happy New Year!

There’s Crazy and then There’s Crazy

Having just about finished my third year of medical school including my psychiatric rotation I can say with confidence, “there sure are a lot of crazy people out there.” Considering that the prevalence of schizophrenia (http://www.emedicine.com/emerg/topic520.htm) is believed to be anywhere from .5 – 1% of the population, go into any large body of people and there’s a good chance a few of them will be completely out of their minds.* While that’s a bit disturbing, what is perhaps a bit more mind blowing – to me at least – is that sometimes these unfortunate people aren’t quite as crazy as they seem. Although the following stories are mostly fabricated, they’re loosely based on accounts I in at least some small part had a role in.

One patient, who since we’re in South Texas we’ll call him Juan, lived for years obsessing over the opposite sex. While this isn’t entirely too unusual for many guys, Juan’s obsession was accompanied by a full cast of supporting characters that existed only in his head. Throw into the mix a few delusions about the world around him and some unorganized thinking and we had ourselves a typical schizophrenic patient. Or so we thought. One particular story he consistently returned to, which we of course seeing through his psychotic ruse knew to be a hallucination or delusion of some sort, dealt with his recent girlfriend who we’ll call, oh, Juana. As the story goes, Juan, who as far as we can tell had never had a girlfriend before, met Juana at a friend’s place and they quickly hit it off. One thing led to another and they shortly became friends and then more than friends. One day, however, Juana decided to share her deep, dark secret that she, in fact, was a dude. Yes, only a short time ago she had been a man, but thanks to the miracle of cosmetic surgery she had fashioned herself into the woman she had always wanted to be. Juan was pissed and we were confused. Initially we saw this as an indication to step up his antipsychotic medications but through continued questioning with Juan, friends, and family we came to the realization that, despite the weirdness of it all, Juana did in fact exist, was in fact at one time a chic, and Juan, the poor guy, wasn’t quite as psychotic as we thought him to be. A troubled guy no doubt, but not all that crazy.

Our second unfortunate patient goes by the name of Juanita and she too had a long history of schizophrenia. She also had a long history of stories relating to people breaking into her apartment, messing around with her stuff, stealing a knick knack here and a few bucks there, and promptly leaving just as mysteriously as they came. Police efforts were hampered by the fact that Juanita kept a pretty messy place and there was no sign of forcible entry into her apartment. It would be months more during which she would receive treatment for the rest of her psychotic symptoms while fully maintaining that the stories of her home invaders were true before we’d find out the real source of her scattered paranoia.

It was on one not particularly unusual evening that Juanita came home to find that yet again things in her home were not as she had left them. She couldn’t quite place it, but things just seemed different. In particular there was an open beer can on her couch which she knew had certainly not been there when she left. Armed with this evidence she once again called the cops, and once again they came to do a cursory search of the premises. This time, however, the villain made it easy for them for they found, in the bedroom, a wallet casually lying about complete with identification. The owner of the wallet and license turned out to be a local vagrant who the police were already well acquainted with and within a few days he was arrested, questioned, and had confessed that, on a regular basis, he would wait till the woman left for work, sneak in through an unlocked window in her bedroom, help himself to her snacks and drinks while he watched television, and then promptly leave again before she returned home. Once again we realized that, in reality, saying crazy shit doesn’t always mean you’re crazy. And one out of five Americans have a Soviet-era chip in their brain.

*That’s not absolutely true as many schizophrenics receive treatment and control their psychosis while the really nutty ones tend to live in hospitals and under bridges, but it’s close enough if you add into uncategorized psychotics, the depressed people with psychotic features, and those actively nuts secondary to active drug use.