Again today, I hoofed it around the hospital. I put 43
floors and a little over 4 miles on my step counter.
I don’t like waiting for elevators so I take the stairs. And
a Consult-Liaison Psychiatrist is like a fireman, running all over putting out
fires.
I did other things today. I gave the usual lecture on
delirium and dementia to the medical students. I notice that as I have gotten
older, I tend to tell more anecdotes about my experiences managing delirium in
patients on the medical side of the hospital.
I’m in my anecdotage, as I told the students today.
I also lamented the decision by the powers that be to
copyright the Montreal Cognitive Assessment (MoCA). The medical students will
be able to use it for free, but faculty won’t.
I think that’s ageism. I won’t pay so I won’t use the MoCA anymore.
Well, I’m pretty tapped out, so it’ll be a short post today.
I’m back in the saddle, running around the hospital on the psychiatry consult
service. This is my last year of phased retirement and in 11 months—I’ll be fully
retired.
I put 36 floors and 3 miles on the step counter. I’m feeling
every one of those. Sena bought me some banded collar shirts and I’m wearing
those instead of a shirt with a necktie. I don’t need a tie bar.
And I don’t worry about a delirious, violent patient
strangling me with my necktie.
We had a small scare tonight. We were looking at my total compensation statement (the last one) and got the Sharp Elsi Mate EL-505 vintage calculator out to crunch some figures. The calculator went dead.
Still going…
I put some new batteries in it, hopeful. It still didn’t work. We’ve had this calculator for over 30 years and it ran more than a decade on the first set of AA batteries.
I tried another pair of batteries. It worked! The vintage calculator lasted longer than the batteries. It’s nice to know that just because something’s old doesn’t mean it’s useless.
We visited Hickory Hill Park today in Iowa City. We’ve lived in this area for 30 years and have been near it but never walked a trail until now. It’s full of trees, birds, and other wildlife, including deer, which seemed to pose for the camera.
Deer posing
I say we’ve been near it because we have visited Oakland Cemetery, where the famous Black Angel monument is. At least one of the trails leads to one end of the cemetery—which we discovered today.
There are many legends about the
Black Angel, most of which are in the vein of various curses and some of which
claim that the curses can kill visitors—not true, of course. Many take selfies
in front of the Black Angel and toss coins in the base (probably to ward off any
curses, just in case).
I was feeling pretty reckless on the day Sena took a snapshot of me in front of the Black Angel. I left a little pocket change. That was a few years ago. The object of the visit was not to visit the Oakland Cemetery but to take part in the picnic and Psychiatry Department Matball Challenge game, Faculty vs Residents at Happy Hollow Park about a block away from the cemetery.
The Black Angel of Oakland Cemetery
Anyway, it was pretty hot today,
in excess of 100 degrees with the heat index. We kept the walk short for that
reason. It was warm, but the tree canopy kept the heat down a little. There’s
something about walking through a thickly wooded area in which most of the
sounds you hear are of nature. It tends to make me a little reflective.
Because I’m in my last year of a
phased retirement contract and will fully retire next year, I’ve been thinking
about transitions, the end of one era of my life and the unknowns about the
beginning of another. There are a lot of unknowns. Sometimes I feel a little lost.
Retirement tends to lead me to
think about death, which is pretty morbid, I know. I don’t ruminate about it,
but walking past some of the park benches, some of which are memorialized to certain
persons, got me to wondering about the next bend in the path. On one of them
was a small plaque bearing a quote,
“Not all those who wander are lost.”
JRR Tolkien
There was a baseball on the bench.
And not long before we got to that bench, we saw a shoe, apparently lost by someone—who might have been lost. Hickory Hill Park is big. A person could get lost in there.
Lost shoe
We followed a path that others seemed
to be taking. It led to the back of Oakland Cemetery where we saw a couple of
headstones which puzzled us. The names were very familiar; man and wife, with
only the birth years carved in them. But the strange thing was—as far as we
knew they were still very much alive! The man had been the closest thing to a
mentor that I could remember ever having.
Naturally, later I realized that
it was just that they had thought through their own transitions a lot farther
than many of us do. They had planned not only for retirement. They had planned
for their own deaths. But until I finally got it, I actually searched on the
web for obituaries.
Strange, I actually found a pdf
file posted that sort of sounded like one—an exquisitely written letter from a
relative who described the person we knew in enough detail that it seemed to
identify him beyond much doubt. Why would such a beautiful and presumably
private remembrance be posted on the web?
Maybe because the relative wanted the world to know how deeply loved this person is—while he is still alive.
This afternoon after we returned home after lunch out, I got a picture of what could have been the bird that made off with a mouthful of house finch chicks last month.
I don’t know why I didn’t draw up the window blind when I first heard the sound of what reminded me of a bed sheet flapping in a high wind a month ago.
When I finally did crack the blind, I saw the huge, black bird with what seemed like a wingspan as long as my leg beating those wings mightily at the air to stay aloft as it plucked the baby birds from the tree.
It was fast as lightning and the theft was done so quickly, I had no time to be more than a witness.
I vowed not to go pawing into trees anymore looking for bird nests just to get snapshots. I think I gave the big predatory bird, whether crow or turkey vulture or whatever it was a visual cue to where its prey lay helpless.
Most of this post is an updated redux from years ago about an
informal bedside test for delirium called the oral trails test. I learned about
it from my senior resident when I was a junior psychiatry resident in training
at the VA Medical Center.
There was an elderly patient admitted to the psychiatry unit
who was thought to be psychiatrically ill but who actually seemed confused to
me and the senior resident. We consulted medicine in order to get him transferred
to the general medicine unit but it was tough going. I think the medicine
resident disagreed with our clinical impression that he was confused and didn’t
think medical transfer was necessary.
Anyway, my senior resident showed me her version of the oral version of the mixed Trails A and B Test for executive function. There is a written form which is part of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). First, she asked him to count from 1 to 7; then she asked him to recite the letters of the alphabet from A to J. She then asked him to try reciting those letters in alternating sequence. Of course, he failed miserably and was eventually transferred to internal medicine. The Trails actually is a paper and pencil test and it looks like a dot to dot game, like the example below:
Trails Test
My senior resident told me she learned the oral Trails test
from her senior resident and couldn’t remember anything else about it. I used
the test for years but a neuropsychologist criticized the practice, questioning
the test’s validity, and rightly so.
Of course, I’d been doing it wrong. You’re supposed to have
the patient count to 25, then recite the letters of the alphabet, then recite
the numbers and letters in alternating sequence from 1 to 13 and A to M. More
than two errors in pairings indicate cognitive impairment.
There are limitations to the verbal Trails and caution is
advised in more recent literature, indicating that there are moderate education
effects in older patients and that it may be wiser to use both paper and pencil
and oral versions together.
Still the search goes on for quick and dirty ways to screen
for cognitive impairment in the elderly because this and advanced age are two
main risk factors for delirium.
Nowadays, I do the Mini-Cog (shown in the video below) or the Single Question in Delirium (SQiD) test, which just involves asking a family member if the patient seems confused lately.
References:
Mrazik, M., Millis, S., & Drane, D. L. (2010). The oral
trail making test: effects of age and concurrent validity. Archives
of clinical neuropsychology: the official journal of the National Academy of
Neuropsychologists, 25(3), 236–243.
doi:10.1093/arclin/acq006
Sands, M., Dantoc, B., Hartshorn, A., Ryan, C., & Lujic,
S. (2010). Single Question in Delirium (SQiD): testing its efficacy against psychiatrist
interview, the Confusion Assessment Method and the Memorial Delirium Assessment
Scale. Palliative Medicine, 24(6), 561–565. https://doi.org/10.1177/0269216310371556
Just a short post on the Gerbera Daisy (common name Gerber).
Sena planted it in our garden recently and it is firetruck red. They symbolize innocence,
purity, and, most of all, cheerfulness.
When I need a little cheering up, I just look at the Gerber Daisies.
OK, my top ten YouTube videos are going to get pretty low ratings anyplace else. But where else are you going to see the list but on my blog? In a world where popular videos are viral at a million plus views, I’m way in the back yard.
I wasn’t very picky, of course, because these are the videos
I made. I didn’t include any others, especially the ones that were
professionally produced. I kept the bar pretty low because I had to. Any video with
over 900 views made it to the list, which goes from lowest to highest number of
views.
By the way, the only way I could come up with a Top 10 list
was to make the bar 900.
10. “Dr. Jim Amos’ Dirty Dozen on Suicide Risk Assessment” published
2012: 940 views
9. “Dr. Jim Amos’ Dirty Dozen on Alcohol Withdrawal
Treatment” published 2012: 1,063 views
8. “Dr. Jim Amos’ Dirty Dozen on Catatonia” published 2012:
1,668 views
7. “Mall of America Video” published in 2016: 1,728 views
6. “Dr. Jim Amos’ Dirty Dozen on Interpersonal Psychotherapy”
published 2012: 1,840 views
5. “Dr. Jim Amos’ Dirty Dozen on Catatonia, NMS, Serotonin
Syndrome” published 2013: 1,960 views
4. “Dirty Dozen on Dr. Allen Frances’ Dozen General Tips on
Psychiatric Diagnosis” published 2013: 2,492 views
3. “Pseudobulbar Affect Top Ten” published 2015: 2,613 views
2. “Dr. James Amos’ Dirty Dozen on Somatoform Disorders”
published 2012: 8,191 views
1. “Dirty Dozen on Factitious Disorder and Malingering”
published 2012: 12,465 views
Now why would a video about abnormal illness behaviors like
Factitious Disorder and Malingering be number one?
And why would “Mall of America Video” be my most popular
non-work-related video? My wife and I did have a lot of fun there.
I like to think people enjoy “Pseudobulbar Affect Top Ten” because of my superb pseudo-rap acting style—and my hat.
I don’t read the news much at all these days. It’s almost always bad, anyway. I was a paperboy in my youth. I delivered the Des Moines Register and Tribune for a year and earned a certificate as Honor Salesman.
My paperboy certificate
Let me tell you a little something about being an Honor Salesman back in those days. First of all, I had to cross some railroad tracks to pick up my papers at the drop up the street from my house. Evidently, tree swallows like to nest around railroad yards sometimes, because they dove at my head like bombers. I had to swing my paper bag at them to fend them off.
And I had to deliver my papers in a little red wagon on Sundays
to get the big Sunday edition out. My paper bag wasn’t big enough to carry
around my skinny neck with all those supplements, ads, and tons of news.
In the winter, it was twice as bad. If I’d had a sleigh, I
could have made like Santa Claus. But I didn’t. All I had was the wagon and
dragging it through a foot or more of snow did not put me in a holiday mood.
I learned a little about business. One of the lessons was
that you sometimes meet some pretty strange people on a paper route.
I was embarrassed a few times when I had to collect, which
was to gather payment from my customers for a paper that one guy said wasn’t worth
a shit. In all fairness, he’d been drinking and had fallen on hard times—but he
paid me anyway.
Another awkward moment was collecting from a young newlywed couple
who always answered the door while wrapped in large bath towels. “Large” is a
relative term, especially on the young lady. It left a little to the imagination,
but not much.
I folded my papers, which is, of course, a lost art nowadays
since everybody gets their news on their electronic devices. I didn’t pitch
them on to porches though, because that was frowned on at the time by my boss. We
were taught to place it carefully inside the storm door so it wouldn’t get wet
or dirty.
Dogs were not as much of a problem as bumblebees,
particularly at one house on my route where the guy raised fields of Hollyhocks.
They were well over 6 feet tall and they covered his back and front yard, crowding
around his front door which I had to open to deliver his paper. The air was
always alive with the drone of bees, some of them as big as golf balls (well,
it seemed that way). The place scared me to death—but I had to do my job.
I didn’t really develop a head for business but it was good
training for life in general.
My wife and I were watching an episode of Antiques Roadshow
this evening and saw a spot about a pair of cufflinks that turned out to be
worth a lot of money.
That reminded me of the first and only pair of cufflinks I ever owned. Back when I was an undergraduate in the mid-1970s at the private, historically black Huston-Tillotson College (now H-T University), in Austin, Texas, a wealthy, successful white businessman who was fond of my English professor bought me a suit, dress shoes, tie, and cufflinks.
I was ambivalent about the gift as I was being fitted for
the suit at the men’s store in downtown Austin.
I wasn’t sure what cufflinks were supposed to do for me. I
suppose I shouldn’t judge the guy too harshly. After all, he was just trying to
be generous—and probably trying to impress my English professor.
It was the 1970s and it was not a great time for black
people in America. There was violent racism of course. There was also a sort of
paternalistic generosity which may have emphasized superficial symbols of
economic success.
Anyway, after a while the shoes started to squeak. I outgrew
the suit. Despite those losses, I became successful through hard work and good
luck.
We were out for an adventure today, shopping for a retirement
home. That’s what it was, really, although we really didn’t make any hard
decisions or commitments.
Nowadays there are considerations for whether to build from
the ground up, buy and modify a spec home, buy an older home, go condo, even rent,
move to a retirement village, and whatnot.
You have to think about mud rooms, pantries, walkout basements, whether to finish the basement or not, lot size, square footage of the house and the yard, two car or one car garage, Jack and Jill sinks, lawn sprinkler systems, Home Owner Associations (HOAs), fences, ceiling fans, gas fireplaces, whether or not you want to live next door to a high school baseball stadium and more even beyond that.
What you don’t have to think about is whether or not there’s
indoor plumbing.
When my brother and I were little boys, our pastor and his
family took us on a long drive up to the sticks somewhere in Minnesota in the
dead of winter. Man, it was cold up there. The object of the visit was to visit
a family who lived out on a farm and they didn’t have indoor plumbing.
There was an outhouse and a well. I remember the pastor’s
little girl and his brother and me and my little brother stood by the well and
talked about how pure the water was in the well. While we were talking, the
pastor’s daughter picked up a rock and, before anyone could stop her, dropped
it into the well—just to see how it would float down to a bottom nobody could
see.
Her little brother was pretty annoyed. The member of the
family we were visiting had just remarked how clear and pure the well water
was. After the rock spiraled out of sight into the water, her brother spat out,
“Well, it was but now it isn’t!” She just snickered.
Because we were staying the night at the farmhouse, we went
to bed. There was a large pan for urinating but if you had to move your bowels,
the only option was the outhouse.
I had to go. I waited as long as I could because it was really
cold out there. Finally, I just couldn’t hold it any longer, and I had to pull
on some clothes and trudge over the frozen ground to this shabby little shed
that I could smell long before I got to the rickety door.
There was some paper in there but—it wasn’t real toilet
paper. It might have been magazine pages. I was so cold it was impossible to
relax enough to let go.
I had problems with constipation after that for a good long
while, well after we returned home.
Things have changed a lot—mostly for the better in many ways but you still have to pay a high price in other ways.
Go Retire Psychiatrist 