The On-Call Diaries / Blog

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Nothing surprises me anymore.

Take solace in the knowledge that this degenerate will be caught again.

For someone with so much raging sociopathy, it doesn't take much for them to reoffend and get re-caught.

He'll get a foley next time.
:)
Members don't see this ad.
 
Heh, at least it was one less patient we had to see on post-call rounds.

I found out what the "weapon" was he used to "threaten the life of a security guard" -- a weenie plastic knife from his breakfast. :rolleyes:

And I also heard he made CNN. :rolleyes: :rolleyes:
 
Anasazi23 said:
Nothing surprises me anymore.

Take solace in the knowledge that this degenerate will be caught again.

For someone with so much raging sociopathy, it doesn't take much for them to reoffend and get re-caught.

He'll get a foley next time.
:)
Click to expand...

Isn't that a violation of due process, civil liberties, AND the Geneva Convention? :eek:
 
Members don't see this ad :)
Hurricane said:
Heh, at least it was one less patient we had to see on post-call rounds.

I found out what the "weapon" was he used to "threaten the life of a security guard" -- a weenie plastic knife from his breakfast. :rolleyes:

And I also heard he made CNN. :rolleyes: :rolleyes:
Click to expand...

Thus proving the maxim that it's only REAL news if there's video...:rolleyes:

(You think the story made NPR? I think not...)
 
This one p***** me off....

Chronic somatic complainer (57 yo male) comes to ER...chart thick as a brick, complaining again of chronic back pain. Turns out he was discharged from the medical floor two days earlier.

Appears and presents as drug addict, requesting IM valium since he's been 'vomiting' all day and is constantly wretching in the ER. Overzealous intern convinces ER attending to call consult for the valium issue...which is another pet peeve issue of mine. Pt. does not appear to be in withdrawal, and is taking multiple other narcotics prescribed from multiple doctors for chronic pain, including Avinza. Brief but standard interview conducted whereby he swears he's not suicidal, without perceptual disturbances, etc. I inform him that he'll not be receiving IM valium from me...

I'm called two hours later and was informed that he "cut his wrists" with the knife that he actually had on his person, that security failed to find and confiscate. When I question him, he says he "just can't take the pain anymore." The "cutting" appears as excoriations over right wrist, none of the abrasions of which penetrate the dermis. Some blood evident from the scratching. Now medicine is jumping up and down in excitement telling me that now I have to admit him to psych. Mind you this is at 4am. Relatively light argument ensues whereby I tell them I'm not a robot, and don't operate on a protocol of wrist scratch = admit to psych.

He's cachectic appearing, disheveled, with multiple homemade tattoos and is constantly spitting up saliva into his bucket. Claims he's not homeless, and gives an address.

Differential and all that is obvious...he has a severe personality disorder for sure, along with all the standard rule outs, including somatoform disorder, etc.


Hmm...let me count.....
10 calls left in my residency. :thumbup:
 
Anasazi, enquiring minds want to know, what exactly is your avatar pledging to never forget?
 
I'm flattered that people notice and take interest in my avatar.

I just got done with my medical grand rounds presentation I have to give at noon today...it's 1:34 am. Nothing like procrastination !

Topic: Psychiatric Effects of Neurotoxin Exposure:
Focus on Heavy Metals and Solvents

58 ppt slides, baby. but i think 1/2 are jokes...
 
Anasazi23 said:
I'm flattered that people notice and take interest in my avatar.

I just got done with my medical grand rounds presentation I have to give at noon today...it's 1:34 am. Nothing like procrastination !

Topic: Psychiatric Effects of Neurotoxin Exposure:
Focus on Heavy Metals and Solvents

58 ppt slides, baby. but i think 1/2 are jokes...
Click to expand...

I had an anorexic male who presented for his 3rd hospitalization in 8 months. Interestingly on his first hospitalization they had no idea what was wrong with him and why he had lost 80lbs in 6 months. At one point they thought it was mercury poisoning (despite it's clinical picture resembling nothing like mercury poisoning). But they found out later that he had such high levels of mercury because all that he had eaten for the past month was tuna fish. I think they calculated it out so that in order to get that level of mercury in his blood he had to eat 12 cans of tuna a day, or something like that... he was an interesting case. not exactly an on-call experience, but you said heavy metals ...
 
Anasazi23 said:
I'm flattered that people notice and take interest in my avatar.
Click to expand...

Man, who _doesn't_ love the mooninites? (except Boston.) But I gotta say I'm a bigger fan of those *****s from Pluto, Emory and Oglethorpe.

"I thoought the plan was to, you know, barbeque and stuff." "Plans are for fools!"
 
I laughed out loud when I read the "plans are for fools" part. They're great also.

"Do you have any corn flavored chips or mini-pizzas?"
 
Chewbacca Jung said:
I had an anorexic male who presented for his 3rd hospitalization in 8 months. Interestingly on his first hospitalization they had no idea what was wrong with him and why he had lost 80lbs in 6 months. At one point they thought it was mercury poisoning (despite it's clinical picture resembling nothing like mercury poisoning). But they found out later that he had such high levels of mercury because all that he had eaten for the past month was tuna fish. I think they calculated it out so that in order to get that level of mercury in his blood he had to eat 12 cans of tuna a day, or something like that... he was an interesting case. not exactly an on-call experience, but you said heavy metals ...
Click to expand...

Interesting. I have a slide outlining many popular fish types and the respective mercury levels of each. Lots of controversy right now about pregnant women eating fish while pregnant. Most studies seem to show an increase in IQ and other measures at 3-7 years old if women consume a good amount of fish, but that higher fish intake can be assoiciated with concerning mercury levels.

Here are a couple interesting links if people are interested:
http://www.cfsan.fda.gov/~frf/sea-mehg.html

http://www.atsdr.cdc.gov/HAC/PHA/viequesfish/viequespr-p12.html
 
Members don't see this ad :)
Anasazi23 said:
I'm not a robot, and don't operate on a protocol of wrist scratch = admit to psych.
Click to expand...

I think all on-call psych residents should wear t-shirts that say the above. :D


Anasazi23 said:
Interesting. I have a slide outlining many popular fish types and the respective mercury levels of each. Lots of controversy right now about pregnant women eating fish while pregnant. Most studies seem to show an increase in IQ and other measures at 3-7 years old if women consume a good amount of fish, but that higher fish intake can be assoiciated with concerning mercury levels.
Click to expand...

Correct me if I'm wrong, but the only fish that pregnant women are advised to avoid are swordfish, shark, king mackerel and tilefish. Not exactly the most popular varieties. Yet everyone is wigging out over tiny bits of tuna and salmon. (I remember this vividly from my wedding rehearsal dinner, because a certain pregnant person in attendence got all het up because there was salmon in one of appetizers, and how could we be so inconsiderate to her delicate condition :rolleyes: )
 
Ok so there is this patient on the unit who is having pseudoseizures and a lot of histrionic and somatization sx. He's not mine - belongs to the other team - but I was on cross-cover last weekend when he arrived and had to send him to the Neuro service when he had his first episode in the day room, so I've been keeping up on his hospital course from the sidelines.

Anyway, now he's back after a week, and goes around the unit alternating between intermittent episodes of obviously non-epileptiform seizures, tremors and paralysis in various body parts, and holding his head moaning asking for pain meds. Without getting into too much detail, he does have some brain pathology that is being appropriately treated, and would not account for all these sx. So now some of the other patients, in addition to their baseline frustration about not being able to go smoke as often as they'd like, are voicing their concern that the staff doesn't care about "this guy who is obviously really sick." Of course it's a HIPAA violation to tell them this guy isn't really having seizures.

Add to the mix that there is this reporter snooping around trying to sneak into the locked units and talk to the patients so he can break the next Walter Reed related scandal (this is at a VA). I can see the headlines now. Sigh...
 
Hurricane said:
Ok so there is this patient on the unit who is having pseudoseizures and a lot of histrionic and somatization sx. He's not mine - belongs to the other team - but I was on cross-cover last weekend when he arrived and had to send him to the Neuro service when he had his first episode in the day room, so I've been keeping up on his hospital course from the sidelines.

Anyway, now he's back after a week, and goes around the unit alternating between intermittent episodes of obviously non-epileptiform seizures, tremors and paralysis in various body parts, and holding his head moaning asking for pain meds. Without getting into too much detail, he does have some brain pathology that is being appropriately treated, and would not account for all these sx. So now some of the other patients, in addition to their baseline frustration about not being able to go smoke as often as they'd like, are voicing their concern that the staff doesn't care about "this guy who is obviously really sick." Of course it's a HIPAA violation to tell them this guy isn't really having seizures.

Add to the mix that there is this reporter snooping around trying to sneak into the locked units and talk to the patients so he can break the next Walter Reed related scandal (this is at a VA). I can see the headlines now. Sigh...
Click to expand...


Yah, we've caught reporters too. In fact, there are times (and my colleagues confirm they'd had similar fears) that I feel certain patients I see in the ER are actually actors or reporters faking illness. I could have sworn on a couple of cases that this was happening.

I've seen enough pathology to know what's normal abnormality and what's abnormal abnormality.

Anyone ever experience this?

By the way, and as I'm sure you know, a large percentage of pt's with pseudoseizures have real seizures as well....just to keep in the back of your mind. Very interesting topic those pseudoseizures.
 
Hurricane said:
Ok so there is this patient on the unit who is having pseudoseizures and a lot of histrionic and somatization sx. He's not mine - belongs to the other team - but I was on cross-cover last weekend when he arrived and had to send him to the Neuro service when he had his first episode in the day room, so I've been keeping up on his hospital course from the sidelines.

Anyway, now he's back after a week, and goes around the unit alternating between intermittent episodes of obviously non-epileptiform seizures, tremors and paralysis in various body parts, and holding his head moaning asking for pain meds. Without getting into too much detail, he does have some brain pathology that is being appropriately treated, and would not account for all these sx. So now some of the other patients, in addition to their baseline frustration about not being able to go smoke as often as they'd like, are voicing their concern that the staff doesn't care about "this guy who is obviously really sick." Of course it's a HIPAA violation to tell them this guy isn't really having seizures.

Add to the mix that there is this reporter snooping around trying to sneak into the locked units and talk to the patients so he can break the next Walter Reed related scandal (this is at a VA). I can see the headlines now. Sigh...
Click to expand...


Pet topic of mine... how do you know he's not having seizures?
 
Well, like I said he's not my patient, but yes, the primary team is aware that he is at risk for having real seizures as well (he has a small ICH, probably cocaine induced) and is being followed by neuro and is on dilantin for sz prophylaxis.

However, when one stops to talk in the middle of a seizure, or is observed (without his knowledge) carefully getting down on the floor of the bathroom, then starts to shake only after somebody walks in, then later claims he "collapsed and broke my head open and had a seizure" it is suspicious. And he's been checked out by Neuro with video EEG monitoring.

Unfortunately, this behavior is disruptive to the milleu, and some formerly agreeable patients are starting to show their frustration.
 
Hurricane said:
Well, like I said he's not my patient, but yes, the primary team is aware that he is at risk for having real seizures as well (he has a small ICH, probably cocaine induced) and is being followed by neuro and is on dilantin for sz prophylaxis.

However, when one stops to talk in the middle of a seizure, or is observed (without his knowledge) carefully getting down on the floor of the bathroom, then starts to shake only after somebody walks in, then later claims he "collapsed and broke my head open and had a seizure" it is suspicious. And he's been checked out by Neuro with video EEG monitoring.

Unfortunately, this behavior is disruptive to the milleu, and some formerly agreeable patients are starting to show their frustration.
Click to expand...

The observed deliberate staging is hard to argue with. Depending on how its done and the symptomatology involved, vEEG can be valuable, but isn't as universally reliable as our Neurologist colleagues would have us believe.
 
Staging them for your benefit wouldn't be pseudoseizures, that's factitious or malingering. Real pseudoseizures (ie conversion d/o) are not done consciously. They're more of a dissociative process.
 
My theory is that some of are conversion disorder and some of them are factitious/malingering, because he doesn't think he belongs on the psych unit because of his seizures/tremors/temporary paralysis, etc, so he staged the one in the bathroom in an effort to get himself transferred back to the medicine floor.

Any advice on reassuring the other patients without violating HIPAA?
 
Hurricane said:
My theory is that some of are conversion disorder and some of them are factitious/malingering, because he doesn't think he belongs on the psych unit because of his seizures/tremors/temporary paralysis, etc, so he staged the one in the bathroom in an effort to get himself transferred back to the medicine floor.

Any advice on reassuring the other patients without violating HIPAA?
Click to expand...


If the other patients are concerned, just let inquiring minds know that you are aware that the patient is ill, and that he/she is getting the best treatment. I usually add that the other patients should go to the nursing station and ask for help if they are concerned about another patient on the unit.
 
Hurricane said:
My theory is that some of are conversion disorder and some of them are factitious/malingering, because he doesn't think he belongs on the psych unit because of his seizures/tremors/temporary paralysis, etc, so he staged the one in the bathroom in an effort to get himself transferred back to the medicine floor.

Any advice on reassuring the other patients without violating HIPAA?
Click to expand...

I can sympathize with your plight. I've had similar things happen with intractible self-induced vomiters, and other patients.

Ward milieu is a delicate thing, and it doesn't take much to set it off balance. Often, balance is never even reached to begin with. The so-called "ward milieu" even varies by hospital, depending on the sort of subconscious attitude toward patients by nursing and physicians. Unfortunately, our ward milieu, because of the head attending, is that of dependence - which can make our lives hell.

A simple, "We're aware of that patient's particular situation, and we assure you that he's receiving proper care" is usually enough to quell some concerns. Usually it doesn't take that long for other patients to figure out what's going on.
 
Not that I can complain (but sometimes I still do), as my calls this year have been increasingly easy, since I'm mostly supervising my PGY-1........BUT......


I have one call left in my residency career, and I'm likin' it!

It'll probably be a doozy, but my interns are trained well. A little extra work in the beginning pays off big dividends in the end.
 
Doc Samson said:
Pet topic of mine... how do you know he's not having seizures?
Click to expand...

Probably because his eyes are closed during the ictal event, a great way to know as recent published reports observe. Otherwise, there are many other clues, I'm sure. And while people with epilepsy are the ones most commonly with pseudoseizures, I would bet that someone on the inpatient psychiatric ward who has a "seizure" is far more likely to being having a nonepileptic event, but I haven't seen data. And of course, the usual disclaimer applies that you can't neglect medical problems of psychiatric patients etc, and life threatening things take precedence etc. But it doesn't change the fact that pseudoseizures in my opinion should not neccessarily be treated like a diagnosis of exclusion. That being said, in this day and age, and anyone who is humble about their diagnostic skill will do the following: try to get an EEG during an event at least once. I have done it before on the psychiatric unit and it was quite reassuring/confirming my suspicion of nonepileptic event.

I also believe by the way, that panic attacks should not be treated like a diagnosis of exclusion for chest pain/rule out MI, as some medicine doctors have taught me. I find it infuriating when everything psychiatric is treated as the diagnosis of last resort. It should be given equal consideration and clinical skills should be developed to try to differentiate these things. The eye closure paper for pseudoseizures is clinical gold.
 
Hurricane said:
Well, like I said he's not my patient, but yes, the primary team is aware that he is at risk for having real seizures as well (he has a small ICH, probably cocaine induced) and is being followed by neuro and is on dilantin for sz prophylaxis.

However, when one stops to talk in the middle of a seizure, or is observed (without his knowledge) carefully getting down on the floor of the bathroom, then starts to shake only after somebody walks in, then later claims he "collapsed and broke my head open and had a seizure" it is suspicious. And he's been checked out by Neuro with video EEG monitoring.

Unfortunately, this behavior is disruptive to the milleu, and some formerly agreeable patients are starting to show their frustration.
Click to expand...


Don't ever say that to an attending. I had gotten the third degree for over 10 minutes from a rads attending a few nights ago because I said that. I was on call (at the time not rotating on the inpt psych service) and a the intern had requested an urgent imaging procedure on one of her patients. Needless to say it was not done all day and the patient had wanted it done. I was paged at about 8pm when the patient had asked to see the patient advocate and demanded to see a doctor as well. I went over to the unit and physically examined the specific area of concern (with a female nurse present).

I quickly reviewed the chart (didn't really memorize it) and called the rads fellow and asked for this to be done. She said she would take care of it and the next thing I know a rads attending is calling me from home! She asked me to tell her about the patient and that's when I said it! This patient isn't mine I am covering for the night. Oh noooooo! She asked to speak to my attending because I wasn't taking responsibility for the patient, saying she wasn't mine...and this lasted about 10 minutes. I frankly didn't care if she talked to my attending and the procedure didn't get done until Monday and the patient went to surgery on Tuesday. Needless to say, rads just doesn't do much except urgent CT's and MRIs over the weekend and they didn't want to call in a tech so they decided to try and scare me away. Only ONE more PGY I call left then its about Q10-15call PGY II
 
People that go insane over innocuous comments give clues to their own hang-ups and personality problems. Often times extreme narcissism.

This doesn't mean that one should not know the patient at least semi-well when presenting for most reasons, but it's 'funny' how quickly attendings forget what it was like to be covering 200 patients on-call and are expected to know every detail about all of them when the **** hits the fan.

Let her bitch...so what. Your life goes on, and you'll be board eligible in a little while. Just remember not to do that to some poor intern when you're an attending in a few years.
 
worriedwell said:
Probably because his eyes are closed during the ictal event, a great way to know as recent published reports observe. Otherwise, there are many other clues, I'm sure. And while people with epilepsy are the ones most commonly with pseudoseizures, I would bet that someone on the inpatient psychiatric ward who has a "seizure" is far more likely to being having a nonepileptic event, but I haven't seen data. And of course, the usual disclaimer applies that you can't neglect medical problems of psychiatric patients etc, and life threatening things take precedence etc. But it doesn't change the fact that pseudoseizures in my opinion should not neccessarily be treated like a diagnosis of exclusion. That being said, in this day and age, and anyone who is humble about their diagnostic skill will do the following: try to get an EEG during an event at least once. I have done it before on the psychiatric unit and it was quite reassuring/confirming my suspicion of nonepileptic event.

I also believe by the way, that panic attacks should not be treated like a diagnosis of exclusion for chest pain/rule out MI, as some medicine doctors have taught me. I find it infuriating when everything psychiatric is treated as the diagnosis of last resort. It should be given equal consideration and clinical skills should be developed to try to differentiate these things. The eye closure paper for pseudoseizures is clinical gold.
Click to expand...

Couldn't disagree more. I've seen seizures causing the presenting symptoms in patients presumed to have everything from schizophrenia to OCD. A few weeks ago I saw a kid in his early 20s who had been on disability for schizophrenia since his late teens who turned out to have subcortical complex partial seizures - switch the Abilify for Depakote and we have a "cure." I've seen a fair number of patients whose seizures don't show up on surface lead only EEG, but throw in the sphenoidal leads and the yield dramatically increases. Similarly, I've seen a few diagnoses made with SPECT when the EEGs were normal. Even the study you quote (which I'm assuming is the 2006 article from Neurology) had a handful of patients who did close their eyes while seizing. As psychiatrists we see the "weird" cases that aren't easily pigeonholed - jumping to a diagnosis without appropriate exclusion can lead to a patient losing function for years of their lives.
 
Doc Samson said:
Couldn't disagree more. I've seen seizures causing the presenting symptoms in patients presumed to have everything from schizophrenia to OCD. A few weeks ago I saw a kid in his early 20s who had been on disability for schizophrenia since his late teens who turned out to have subcortical complex partial seizures - switch the Abilify for Depakote and we have a "cure." I've seen a fair number of patients whose seizures don't show up on surface lead only EEG, but throw in the sphenoidal leads and the yield dramatically increases. Similarly, I've seen a few diagnoses made with SPECT when the EEGs were normal.
Click to expand...

I saw a case on C/L where a young man with known temporal lobe epilepsy was diagnosed with schizophrenia, admitted to a psychiatric unit on an involuntary commitment, loaded on Prolixin decanoate and 2 atypical antipsychotics after multiple "psych emergencies" on the unit, and ultimately discharged with court mandated outpatient psychiatric treatment and an ACT team. His presenting problem to the ER prior to that admit per the admit note, "hears voices, disorganized thought process." During his Epilepsy Monitoring Unit admission to our hospital (when C/L was called), he was videotaped to have relatively bland partial complex seizures with prominent post-ictal agitation. Parallel history from the family revealed onset of post-ictal AH and thought disorder while on Keppra that went away with prolonged seizure-free periods and did not resolve with cessation of Keppra. Our C/L treatment recs included stopping the 2 atypical antipsychotics, giving him Benztropine for his severe EPS (barely moving on admission), and recommending to outpatient psychiatrist tapering of his Prolixin decanoate. The follow-up several months later is that seizure frequency dropped to 10% of pre-EMU levels and no interictal psychotic phenomenon with tapering of the Prolixin decanoate. Ultimately the patient will get wide temporal lobe excision to treat his epilepsy (and likely his "schizophrenia"). I was saddened to see the impact that this misdiagnosis had on this young man, his family, his significant other, and his self-esteem.

MBK2003
 
At no time did I ever imply not doing a thorough and accurate diagnostic procedure especially in new onset cases of things including psychosis. There is a difference between temporal lobe activity presenting as psychosis, perserverations etc and full blown shaking around on the ground on the inpatient psychiatry unit. So its apples and oranges. Believe me, I am all for refining the diagnostic tools of neurology and psychiatry. I'm not saying stop doing a workup, I'm saying psychiatry is not a field where the illnesses should be separated from "real illnesses". In new onset presentations it is good practice to be comprehensive and rule things out, of course. But lets not get carried away with examples of zebras and M and M cases as examples of how to practice sound clinical medicine. I assure you that most of these tragic cases of people getting misdiagnosed forever are more of a function of psychiatrists being inept and lazy from the beginning (as I've noticed a lack of diagnostic and clinical rigor in such a huge proportion of psychiatrists) rather than them paying close attention and then being "wrong" due to random chance. I remain humble about my skills but I also recognize that I know a heck of a lot about neurologic exam and disease including seizures. Thus, I stick by my opinion and feel that the best medicine is done by excellent history taking and physical/mental status exam.

And of course, running "tests" are not always a gold standard, even in some "gold standard" tests. They miss things and are inaccurate frequently. For example, doing an isolated random EEG has less than 50% yield of catching seizure activity, isolated 3 times is over 80% I believe in someone with known epilepsy. So where does your test get you, unless of course you catch it during the event?

There are horror stories in every field of medicine, so telling a sob story about people with seizures who are diagnosed as schizophrenia, while interesting and tragic for that individual, is not really that useful in day to day medicine and might even be labeled as "sensationalism" if its in a persuasive attempt to sway people to "think" a certain way. It smacks of the Bush administration and their examples about terrorism and the safety of this nation. If one practices based on the zebras, one may be a safe doctor (and an expensive one to the healthcare system, thus harming more people than you save) but one is not a great doctor. I submit to you that being a thorough diagnostician from the get-go trumps anything else.

Using the phrase "jumping to a diagnosis" implies that I would do this without taking into account all the relevant information including tests that are "clinically indicated". It is one thing to train doctors to determine when things are indicated, but I feel strongly that "tests" are not always indicated in much of medicine. Its just that doctors are lazy. We have the opportunity in psychiatry to not fall into that trend and rather really try to sharpen our skills through understanding clinical patterns...especially because it may be a while until imaging or other "tests" provide a useful yield for psychiatric disorders. The medical consumption model is a force to be reckoned with though and it is unstoppable. It is quite hard to measure how much damage it is doing alongside all the good it is doing. Where does one draw the line? It seems I draw the line in a different place than you Sampson, misdiagnosed epileptics notwithstanding.

worriedwell

Doc Samson said:
Couldn't disagree more. I've seen seizures causing the presenting symptoms in patients presumed to have everything from schizophrenia to OCD. A few weeks ago I saw a kid in his early 20s who had been on disability for schizophrenia since his late teens who turned out to have subcortical complex partial seizures - switch the Abilify for Depakote and we have a "cure." I've seen a fair number of patients whose seizures don't show up on surface lead only EEG, but throw in the sphenoidal leads and the yield dramatically increases. Similarly, I've seen a few diagnoses made with SPECT when the EEGs were normal. Even the study you quote (which I'm assuming is the 2006 article from Neurology) had a handful of patients who did close their eyes while seizing. As psychiatrists we see the "weird" cases that aren't easily pigeonholed - jumping to a diagnosis without appropriate exclusion can lead to a patient losing function for years of their lives.
Click to expand...
 
Wouldn't call these cases "zebras". Parital complex seizures of the temporal lobe and subcoritcal structures are, in my experience, fairly frequently mistaken for primary psychiatric illness. My individual anecdotal experience seems to be borne out by an extensive literature on the topic. FWIW, the most "typical" pseudoseizure patient I've ever seen (with preserved consciousness, pelvic thrusting, and eye closure) actually had seizures of the SMA. I've seen clinicians (from both psychiatry and neurology), far more experienced and skilled than I, misdiagnose "pseudoseizures" based on the clinical exam - fortunately they pursued the appropriate standard-of-care work-up, changed their diagnosis, and likely the course of the patient's life.
 
I think that what I lost in my point was that not all psychosis is psychotic illness. There's a whole cohort of people with postictal psychosis who may never get referred by their neurologists to psychiatrists because the epileptologist manages the patient with antipsychotics and anticonvulsant optimization. While I don't do EEGs on all my first episode psychosis patients, I do perform a careful history looking for a signs from pt and parallels which might suggest a seizure disorder. It's not so different from delirium - lots of zebras can cause it, but what can kill the patient and what don't you ever want to miss, and those are where you focus your diagnostic effort initially.

MBK2003
 
So I *finally* received my schedule today, including the call schedule for the month of July. My first call ever is on a Wednesday. "Not bad," I thought, and then realizing it was the 4th I still remained upbeat and unperturbed. It wasn't but several hours later that it would be revealed that U of Maryland considers the 4th one of its recognized holidays, and that to my horror my first call was going to be a 24 hour understaffed junket. :eek: Oh, you bet I'll be updating when the fateful day arrives. Lord, have mercy!
 
jjbmsiv said:
So I *finally* received my schedule today, including the call schedule for the month of July. My first call ever is on a Wednesday. "Not bad," I thought, and then realizing it was the 4th I still remained upbeat and unperturbed. It wasn't but several hours later that it would be revealed that U of Maryland considers the 4th one of its recognized holidays, and that to my horror my first call was going to be a 24 hour understaffed junket. :eek: Oh, you bet I'll be updating when the fateful day arrives. Lord, have mercy!
Click to expand...

May I suggest that you start it as a new thread?
"Intern Class of 2007 Call Horrors" or some such thing.
 
I can do that. I'm sure that plenty of us newly minted doctors will be happy to contribute. Let the (painful) learning commence!
 
Doc Samson said:
Wouldn't call these cases "zebras". Parital complex seizures of the temporal lobe and subcoritcal structures are, in my experience, fairly frequently mistaken for primary psychiatric illness. My individual anecdotal experience seems to be borne out by an extensive literature on the topic. FWIW, the most "typical" pseudoseizure patient I've ever seen (with preserved consciousness, pelvic thrusting, and eye closure) actually had seizures of the SMA. I've seen clinicians (from both psychiatry and neurology), far more experienced and skilled than I, misdiagnose "pseudoseizures" based on the clinical exam - fortunately they pursued the appropriate standard-of-care work-up, changed their diagnosis, and likely the course of the patient's life.
Click to expand...

fair enough. i yield to clinical experience from the honorable attending at the big H. but i would submit to you that at times, its reasonable to treat common things as common in regular old clinical medicine (the same way a primary care doctor treats a cough like its a viral illness). if this seems to fail, then you can do your TB workup for a cough. But it depends on the diagnosis and the "meaning" carried by that diagnosis. The problem is not that psychotic symptoms are misdiagnosed, its that once somebody carries the psychiatric label, especially schizophrenia, nobody is willing to pay attention to them anymore, including psychiatrists.

I still believe this to be true even among experienced clinicians. as we understand brain function and deficit in psychiatric illness, and as that is incorporated into training, i still think a clinical diagnosis will be of high practical yield. its an opinion, and granted i have a bias against the loose and un-rigorous way psychiatric diagnoses are made, even among "thought leaders" in the field that I work with. everybody has their own agenda and bias to propogate (even if its in their own mind) and this influences how they teach psychiatry. And neurologists inherently are arrogant about "finding the lesions" and once they make up their mind that something is psychiatric, they then turn their brains off, even the best and most experienced ones.

i've started babbling now and am defending a point of view that is still open to flexible thinking, but this has been my impression thus far and i'm angry about something that goes on, just not sure what i guess and not articulating it coherently anymore, so i'll stop.

out of curiosity though, are you arguing that every "psychiatric patient" should get an eeg?
 
worriedwell said:
fair enough. i yield to clinical experience from the honorable attending at the big H. but i would submit to you that at times, its reasonable to treat common things as common in regular old clinical medicine (the same way a primary care doctor treats a cough like its a viral illness). if this seems to fail, then you can do your TB workup for a cough. But it depends on the diagnosis and the "meaning" carried by that diagnosis. The problem is not that psychotic symptoms are misdiagnosed, its that once somebody carries the psychiatric label, especially schizophrenia, nobody is willing to pay attention to them anymore, including psychiatrists.

I still believe this to be true even among experienced clinicians. as we understand brain function and deficit in psychiatric illness, and as that is incorporated into training, i still think a clinical diagnosis will be of high practical yield. its an opinion, and granted i have a bias against the loose and un-rigorous way psychiatric diagnoses are made, even among "thought leaders" in the field that I work with. everybody has their own agenda and bias to propogate (even if its in their own mind) and this influences how they teach psychiatry. And neurologists inherently are arrogant about "finding the lesions" and once they make up their mind that something is psychiatric, they then turn their brains off, even the best and most experienced ones.

i've started babbling now and am defending a point of view that is still open to flexible thinking, but this has been my impression thus far and i'm angry about something that goes on, just not sure what i guess and not articulating it coherently anymore, so i'll stop.

out of curiosity though, are you arguing that every "psychiatric patient" should get an eeg?
Click to expand...




One of our inpatient attendings usually gets an EEG on every patient that either is "new" to us on the unit and/or presenting with atypical symptoms.

On the flip side, those neurologists and techs that read the EEGs are really hard to track down.

And let me add, that out of the four months on this particular unit (two other months at the VA inpt psych) I've only seen about three patients that had abnormal EEG. They all had schizophrenia and they only had some slow wave readings...which can't really be interpreted as anything as per the neurologist.
 
worriedwell said:
out of curiosity though, are you arguing that every "psychiatric patient" should get an eeg?
Click to expand...

No, far from it. The original case raised was one of suspected pseudoseizures. In my experience, while the clinical exam can be suggestive of pseudoseizure (eye closure, pelvic thrusting, etc.), the endless possible presentations of complex partial seizures require you to pursue at least some clinical w/u. I've seen pretty much every "clinical rule" of identifying pseudoseizures broken - including the supposed gold-standard of bilateral motor activity with preserved consciousness (can occur with seizure of the SMA). I do tend to rely on my clinical "gut" in terms of deciding how far to push the work-up (eeg vs. LTM vs. SPECT).
 
To revive my narcissistic need, I am again declaring that tonight is my last. call. ever. (as a resident)


And you can be damn sure that I'm avoiding it as an attending as well....unless I'm paid well to do it.

4am drunks who are "suicidal," 2:45 am borderlines whose boyfriends yelled at them, the good 'ol 6:30 am malingerer who still has the ink wet on the Bellevue hospital bracelet from his last ER visit, from whence he was kicked out, which is 10 blocks down the street. Who, might I add, called 911 from inside that hospital parking lot - meaning that EMS is obligated to take him to another hospital. God forbid he should walk 10 blocks. But I digress.

Ahh, yes. Memories......memories....

Again, sort of anti-climactic since the interns are 'almost' on autopilot, but still. I've waited a long time for this.

Who else is finishing calls this week?!
:hardy:
 
Anasazi23 said:
To revive my narcissistic need, I am again declaring that tonight is my last. call. ever. (as a resident)


And you can be damn sure that I'm avoiding it as an attending as well....unless I'm paid well to do it.

4am drunks who are "suicidal," 2:45 am borderlines whose boyfriends yelled at them, the good 'ol 6:30 am malingerer who still has the ink wet on the Bellevue hospital bracelet from his last ER visit, from whence he was kicked out, which is 10 blocks down the street. Who, might I add, called 911 from inside that hospital parking lot - meaning that EMS is obligated to take him to another hospital. God forbid he should walk 10 blocks. But I digress.

Ahh, yes. Memories......memories....

Again, sort of anti-climactic since the interns are 'almost' on autopilot, but still. I've waited a long time for this.

Who else is finishing calls this week?!
:hardy:
Click to expand...

Not quite the same thing, but my last ever moonlighting shift will be tomorrow. Hopefully my attending day job will be lucrative enough to keep me out of single beds for the rest of my career.

Congrats on finishing Sazi... it's a long road.
 
Thank you DS....all's quiet on the home front right now (knocking on wood). Looks like the last call will go out with a wimper, instead of a nightmare, which is of course preferrable.

Ironically, I start my moonlighting next month. Maybe that will deserve a whole new thread:

Riker's Island Moonlighting :oops: Hour 17
 
Riker's Island Moonlighting Hour 17
Click to expand...

Oh please, tell me that's not the best you could do for a cush moonlighting gig in NYC :eek:

Just plan a good 20 min to get across the bridge, and another 15 min to get inside the building before you can clock in. Oh, and hope they're not on "alarm" when you are trying to get out 'cause you're stuck :mad:

FYI, one of my sources revealed that the payscale for psychologists at Riker's is nearly the same as for psychiatrists because Prison Health Services pays psychiatrists the lowest salary of any of the medical specialties.

Good luck!
MBK2003
 
Gov't payscales are often screwed up like that. Someone had a thread a long time ago about VA hospitals offering rads attendings like 75k.

Apparently, the incentives and bonus packages for medical doctors puts the salary much higher, since they need the medical licenses.
 
MBK2003 said:
Oh please, tell me that's not the best you could do for a cush moonlighting gig in NYC :eek:

Just plan a good 20 min to get across the bridge, and another 15 min to get inside the building before you can clock in. Oh, and hope they're not on "alarm" when you are trying to get out 'cause you're stuck :mad:


Good luck!
MBK2003
Click to expand...

You take the subway there? I'm thinking of just using the Harley...
 
Anasazi23 said:
You take the subway there? I'm thinking of just using the Harley...
Click to expand...

I was driving my car there. It was still a pain in my a$$.

I was told that people who negotiated for moonlighting at Rikers through locum tenens agencies got paid a higher rate than people who went through PHS. From hearing the recruiting pitch from the director of mental health while I was there, they are DESPERATE for decent psychiatrists, but unable to pay adequately to attract or keep decent psychiatrists.

MBK2003
 
MBK2003 said:
I was driving my car there. It was still a pain in my a$$.

I was told that people who negotiated for moonlighting at Rikers through locum tenens agencies got paid a higher rate than people who went through PHS. From hearing the recruiting pitch from the director of mental health while I was there, they are DESPERATE for decent psychiatrists, but unable to pay adequately to attract or keep decent psychiatrists.

MBK2003
Click to expand...

You're absolutely right, but I just got back from there, and was told that they are no longer taking Locums people - no more new locums hires.

And I think you're spot on about the desperation for psychiatrists. They're talking signing bonuses now.
 
Anasazi23 said:
Gov't payscales are often screwed up like that. Someone had a thread a long time ago about VA hospitals offering rads attendings like 75k.
Click to expand...

That explains a lot. Such as why it takes 2 weeks and multiple phone calls to get a chest x-ray read at the VA.
 
You must log in or register to reply here.
Next unread thread

Similar threads

Asklepian
Inpatient psych call rate
2
Replies
51
Views
3K
clozareal
clozareal
justalittlestar
What is call like in a psych residency?
Replies
47
Views
4K
Wheatbread
Wheatbread
milan95
What are some CAP fellowships with minimal to no call?
Replies
2
Views
485
Merovinge
Merovinge
lockian
Call
Replies
13
Views
1K
Mad Jack
Mad Jack
A
Psychiatry residency on call at night
2
Replies
50
Views
3K
smalltownpsych
smalltownpsych
Top