Change

Mary

Consult services are called upon to answer specific questions, rather than perform full workups on patients. So, Psychiatry Consult would evaluate an AIDS patient for depression, or a surgery patient for delirium. Mary is a 35-year old Jamaican woman suffering from seizures, and is in the country on a medical visa. The question for us? Neurology wants us to determine whether Mary is faking her seizures to stay in the country. I'd rather that neuro phrased this question differently. You know - in a way that isn't so prejudicial. It shames me to admit it, but I find that I'm judging Mary differently than I would any other patient because of the immigration question.

I begin the interview, focusing on Mary's social history. We uncover a sad story, with Mary growing up in poverty, estranged from her mother and her siblings, her only support being her aunt, who lives in the United States. There is a history of sexual abuse, an abusive boyfriend, and her current boyfriend, who has multiple children from multiple other women. She knows that she needs to get out of this situation, but the opportunities are few and far between. In psychiatric lingo, Mary has quite a few "stressors" that may be factoring into her depression, to put it mildly.

Like many other depressed patients, Mary begins the interview with a slightly blunted affect, but as the talking goes on, her mood brightens a little bit as she is enjoying the attention. So what's the verdict? Mary's EEG doesn't show any abnormal activity during her seizures. To some, that could be damning evidence - however, it's not out of the realm of possibility that these pseudoseizures may be, in fact, real. Our impression, in the end: depression due to life stressors, and we make no judgment on her seizures.

I get to write up the consult and put it into Mary's chart. Mitch checks it over and praises the work. Raj, a fourth-year student doing his psychiatry consult elective, gives me a look of approval. Cool.

I check in on Mary three days later, and she greets me with a big smile.


Clive

Clive is still in the hospital because his surgery team is still concerned about his surgical incision. We see him walking the floor with a very slow gait. His limbs are trembling. When he speaks, he can't finish a thought. Clive thinks he's 'getting worse.' We're having trouble maintaining Clive's lithium blood levels within the therapeutic range. He's too sedated to bother the nurses, though, so they're not complaining.

We look up the symptoms of lithium toxicity: coarse tremor, stupor, ataxia, seizures, persistent headache, vomiting, slurred speech, confusion, incontinence, and arrhythmias. We'd noticed the tremor, stupor, and confusion, and we're concerned because prolonged elevated lithium levels may lead to irreversible neurological damage. Like me, Mitch has never seen lithium toxicity before. We're concerned.

Dr. Berg isn't convinced that this is lithium toxicity.
"Trust me," he says. "You'll know lithium toxicity when you see it."
"I'm seeing something" I think, "and I'm not liking it."
Of course, Dr. Berg is the chief, and he recommends that Clive be transferred to a rehabilitation center. Mitch and Dr. Berg exchange words. Dr. Berg agrees to hold Clive for at least another day for observation, and we alter some dosing to hopefully improve his condition.

I stop by to see Clive over the next couple days - his tremor improves slightly, and he remembers me. We talk for a few minutes. Later in the day, we hear reports of Clive giving grief to the nursing staff. Yep, looks like the Clive we know and love is back.


Herman

Herman's medical team acquiesces to his wife's wishes and restart his prednisone. His lungs still aren't clear, but his overall condition has deteriorated so rapidly that they're preparing Herman's family for the end. I'd heard that health care personnel tend to avoid the hospital rooms with dying patients. That's not true in this case. I want to go in the room to talk to Herman's wife, but some of the nurses are giving comfort to his family. I manage to peek in later, and give a smile and a wave to Mrs. Herman, who is sitting next to her sleeping husband.

Herman was transferred to another facility to spend his last days.

*******

So, in very little time, a student was starting to feel more confident about his place in the medical world; a previously gloomy patient was smiling at everyone walking into her room; an abnormally sedated patient got back to his slightly crabby old self; and another patient's family went from having hope to preparing for the end of his life.

It's striking how quickly things can change.