God I haven't written on this is so long, and I was pleasantly surprised to be greeted with pictures of such delicious food when I came back on this! I completely forgot it was a keto blog for a short while. But this post won't be keto, though I suspect come March, there might be some of that resurfacing.
Today I'm writing about a patient. I have recently decided to pursue psychiatry (possibly child/adolescent) as a career. It was a stressful career shift for me since I was hardcore neuro for the longest time. But it hasn't come as a surprise; I was always kind of humanistic and psych minded.
I've been following a patient for a few days now. In medspeak, she is a 55 year old Vietnamese female with a past medical history of bipolar disorder, currently not on medications who presented to the hospital with an acute manic episode with psychotic features. She was put on 1 mg Risperdal (an antipsychotic) and is showing clinical improvement. In humanspeak, she's literally the cutest little Asian lady ever. She doesn't speak much English but somehow we communicate our feelings pretty well for the most part. She extremely friendly and trusting, though also rather childlike. I met her the first day and spoke to her through the translator (the most tedious experience where we both talk to a distant third party through two telephone lines on the wall.) She told me about how she came to the hospital with shortness of breath, how she has heart problems, and headaches. These were all logical issues. But she also said that the headaches were from how her brother beat her head with a stick decades ago, and that sometimes her hand talks to her. In the notes from the ER and from collateral information from her brother, she had been sleepless for days and was breaking all the dishes in the kitchen, which was actually why she was brought to the hospital. So you see, it's hard to know what's real and what's not with psych patients. I kind of saw her as another psychotic patient who was sweet but not altogether with it, and did not think too much of it.
The next day I found her coloring at a table. She smiled this toothy, smile with unbridled pleasure. She was tracing her hand onto countless pages of a notebook. She took my hands as I asked her about her sleep (of which she got none, according to the night nurses), and she traced them onto paper. I don't normally touch the patients as a rule of thumb, but her lack of hesitation regarding physical contact didn't worry me. She start coloring in my hands and she named off the colors: green, blue, yellow, red. I asked her which color was her favorite: yellow. I asked her if she had breakfast: no good breakfast, I love eggrolls. She told me that her family ran a Vietnamese restaurant on Bailey avenue (that I actually have been two a handful of times), that she helped make noodles there. She told me how much she loved candy. After finishing coloring, she tore out the paper and gave me the picture of my hand, as a gift. I thanked her profusely and noticed that I didn't see her as this crazy, psychotic patient. I saw her as a woman with an illness, an immigrant hospitalized for a reason she didn't know, surrounded by people using a language she didn't speak, yet she connected with me, shared with me her interests and created a bond with me. I started feeling protective of this woman twice my age. She reminded me of my parents: immigrants never completely feeling like they belonged, but toughing out the current situation and adapting to whatever comes. I felt a special softness for her in my heart as I took my gift to the conference room and showed it off to my residents and attending.
I was about to type up a note in the afternoon, when I heard from the speakers: "rapid response on 5/3. rapid response." I stopped, confused. That's my floor and zone; I guess I should check it out? As I walked toward the patients rooms I saw a crowd of people staring down at someone on the floor. It took a solid minute before I registered that the woman laying on the floor was my patient, my sweet Vietnamese lady who hours before was coloring happily next to me. Her vitals were stable and it was unclear as to why she seemed to lose consciousness. Apparently she was walking down the hall when she felt her knees give out, and she clutched onto a nurse, who lowered her onto the floor. After a minute or so of unresponsiveness, she opened her eyes. They put her in a wheelchair and took her to the ER to be evaluated. In the ER she sat, expressionless in her chair as people took her temperature, asked her what happened, how she felt. I tried to explain that she didn't speak much English, but the ER is no coddling environment. At some point she reached out and took my hand. She clutched it close to her chest, making no eye contact, and my heart nearly broke in half. How afraid was she, waking up on the floor to unfamiliar faces looming above her, bombarding her with questions she couldn't understand, taking her to a place she didn't know, connecting her with leads to some strange machine? I clutched her hand back, and told her it would be OK, trying somehow to show her that she at least had me on her side. When we were finally left in the room with just us and a social worker, she seemed more calm. She told us that her head hurt and her chest hurt. She said she was thirsty. And she said she wanted to go home. We held her hand and chatted, asked for Tylenol, got her water. She told us that her brother used to work in a casino, and was good at blackjack and poker. She and the social worker gave each other head massages. People came in and out, connecting her to the monitor, getting an EKG, chest Xray (now there's a rational use of resources). She remained stoic, cooperating with each instruction the best she could as I desperately tried to explain what they were for. She said she was hungry and they brought her a packet of graham crackers and a sandwich. She waved the sandwich away ("no good") but opened the crackers and ate one. She handed the packet to me. "There's still one left", I told her, showing her. She nodded and smiled, closing my fingers over it, motioning for me to eat it. My heart swelled as I insisted on giving it back to her. "You eat it!" I laughed. "I have food at home, this is for you!" I could not get over how this woman was trying to feed me, thinking of my wellbeing when she is going through this stressful ordeal. Who she was as a person never shone through to me as clear as it did then. She wasn't a bipolar with psychotic features who had a possible syncopal episode, awaiting further evaluation. She was my patient, sweet and caring, resilient and strong, yet so vulnerable. I stayed with them for maybe another extra hour, long after when I normally go home. Yet I left with an immense sense of guilt. She had no family with her, no one to speak her language, and one of her only advocates is leaving.
As I drove home I kept telling myself "work stays and work." It's not the first time I've gotten too invested in a patient and had it affect my mood and thoughts long after the event. I wonder about her even now. Is she scared? Asleep? Cold? Can she communicate what she needs well enough? Why did she have that fainting episode anyway? Was it neurogenic or psychogenic? Aside from her being a genuinely sweet and adorable lady, I always feel a special tenderness towards middle aged Asian people because I'm so strongly reminded of my parents. Her silent cooperation and hesitance to ask for help makes me feel even more fiercely protective of her. But if it gets to the point where I"m losing sleep over her, worrying about her care, is it too much? Obviously it's good to care about your patients, but where do you draw the line? I guess it's something that comes with experience, learning to leave work at work, to balance your emotions between getting invested and caring enough, but also maintaining a professional distance.
I've only followed her for two days yet somehow she has taught me so much. How to never judge who a patient is, regardless of how disorganized they may present. That who someone is lies in the actions and behavior as much as in what they say. That each patient deserves an advocate, someone who truly holds their best interests at heart, preferably at a personal level, not just a professional one. That I still need to learn how to toe the line between being an involved and empathetic doctor, yet maintain a distance from which I won't get sucked in and overwhelmed. It's an emotional journey for me with certain patients, and I do believe that it's a good thing. And though today has been difficult, I think it has solidified my choice in psychiatry. This is where my heart lies, where I am drawn. I want to be the voice for patients who can't organize their thoughts well enough to speak what I want to say. I want to help patients find themselves when they are lost. I want to help them navigate this twisting, confusing, frustrating, terrifying system. I think I'll be good at helping them; but I need to learn somehow to help me too.
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