Go Retire Psychiatrist

A Little Too Exuberant

I think a sense of humor is a wonderful thing. I was the class clown in my youth. I remember my English teacher, Miss Piggott, wrote in my report card that I was “A little too exuberant.”

Actually, I was a great deal too exuberant. My sense of humor tends to fall into the broad category of what author Dave Barry would call “booger jokes.” By the way, I just finished his latest book, Lessons from Lucy: The Simple Joys of an Old, Happy Dog. I highly recommend it. He mixes a little wisdom in with the booger jokes.

Dave Barry can do more than booger jokes.

As a psychiatrist, I’ve learned to look for a sense of humor, exuberant or not, in the patients I’ve met. I point it out to them when I think I detect it. They usually like hearing that. Only a very few are nonplussed.

One of my teachers was George Winokur, MD, who everyone knows was a giant in psychiatric research. Dr. Winokur was the department chair at University of Iowa Hospitals and Clinics from 1971 to 1990 and had a unique and memorable style. I thought he had a fair amount of exuberance. He had a rolling, sort of gravelly laugh, especially during rounds when he would sometimes make a point of reminding trainees like me that we had a lot to learn, “You all don’t know how to diagnose Somatization Disorder!” I made sure I learned how.

When Winokur was department chair, he created a set of “commandments” regarding personal behavior and comportment that have stood the test of time. I don’t know if anyone else has tried to ensure that Winokur’s 10 Commandments be remembered, maybe even cast in a pair of stone tablets. Read them and follow them.

Winokur’s 10 Commandments

Thou shalt not sleep with any UI Psychiatry Hospital patient unless it be thy spouse.
Thou shalt not accept recompense for patient care in this center outside thy salary.
Thou shalt be on time for conferences and meetings.
Thou shalt act toward the staff attending with courtesy.
Thou shalt write progress notes even if no progress has been made.
Thou shalt be prompt and on time with thy letters, admissions and discharge notes.
Thou shalt not moonlight without permission under threat of excommunication.
Data is thy God. No graven images will be accepted in its place.
Thou shalt speak thy mind.
Thou shalt comport thyself with modesty, not omniscience.

More evidence that a sense of humor is prevalent amongst psychiatrists is the work some residents put into making a video (in two parts) about managing violent patients. I realize that the recent news stories about health care professionals often being the victims of violence from patients might make some think this is nothing to joke about. They were not joking. The video makes a good case for a method to manage the violent patient. It just makes it with an exuberant sense of humor.

Violent behavior by patients in the general hospital is often caused by delirium. The proxy for delirium in the form of violence could be what is called the “Code Green” here at our hospital.

The Code Green team at our hospital consists of a group of people specially trained to use non-violent measures to help patients who are violent get under control in order to minimize the risk of injury to themselves and others. These events are often intense encounters in patient’s rooms, hallways, lobbies, and other places in the hospital where patients who are confused and out of control can wander. First and foremost, we try to contain the patient to maintain everyone’s safety, and then ascertain why the patient is confused and at risk for imminent violence or already perpetrating acts of violent behavior toward themselves and others. This has to be done quickly so as to minimize injury.

One mnemonic, described in my chapter in our book, Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry is [1]:

1. Amos, J.J., M.D., Assessment and management of the violent patient, in Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry, J.J. Amos, M.D., and R.G. Robinson, M.D., Editors. 2010, Cambridge University Press: New York. p. 58-63.

Containment before

Assessment before

Non-violent

Intervention before

Take down

The so-called CAN IT mnemonic is a reference mainly to containment before all else in order to protect everyone involved in a Code Green situation. An excerpt from the chapter on the importance of containment is:

“Containment refers to ensuring that you and the patient both feel relatively safe in the assessment area. Preferably, both of you should have easy access to the door for escape if necessary. At first, it may seem odd to recommend letting the patient escape from the room, but the point is not to force the patient to run over you to get to the door.

Another issue of containment is to ensure that the patient gives up any weapons before you agree to do the evaluation. Sometimes, offering food or drink (not hot enough to injure if hurled in your face) will help set a non-threatening atmosphere. It’s helpful to avoid making intense or prolonged eye contact with the patient, because this may be viewed as threatening.

Always make sure that plenty of other people are available to help you if a take-down situation develops.

Containment under these conditions sometimes is achievable by simply being honest with the patient who is still able to hear you by admitting that he/she is saying or doing things that make you afraid. This may seem counter-intuitive. But, provided it’s delivered calmly as a statement followed by reassurance that you and everyone else involved are committed to maintaining the safety of all persons present (including the patient), this may capitalize on the patient’s own fear of losing control by assuring that you’ll do everything in your power to keep the lid on the situation.”

You can see the exuberant YouTube videos below, illustrating these principles made by talented trainees in our psychiatry residency program in 2008.

In 2009, Dr. David Mair, MD was the producer and director of the video. I see he’s now with Innovative Psychological Consultants (IPC) in Maple Grove, MN (they get a lot of snow up there!). Below is his introduction to the videos:

Early in my training, I didn’t quite know how to react with potentially violent patients. No amount of knowledge of medicine, physiology, or the DSM provided me the skills to address these situations. Though we had excellent training during orientation, I really learned by observing skilled clinicians, and through my own encounters, both good and bad. This was exemplified during my rotation in consultation-liaison psychiatry, when working with Dr. Amos, to learn his logical, step-wise approach, see him in these problematic scenarios, and to practice what I had learned.

In making this educational video, I wanted to give incoming residents a quick way to make these observations, and present it to them in a way that was both useful and entertaining. It helped that I had a cadre of multi-talented peers and a faculty supervisor who recognized the utility of such a project. Though managing these patients will be an eternal source of anxiety for all psychiatrists, my hope is that with this video, they will feel just a little better prepared. —David Mair, MD.

Well said, Dr. Mair. You were all very exuberant.

Gauging My Readiness for Retirement

I’m noticing something about my readiness for retirement. Certain activities are starting to be at least as interesting as my work as a consultation-liaison psychiatrist at the hospital—maybe even more so.

For example, my wife and I are hoping that the cardinals will come back to our backyard evergreen tree. They were building a Hoorah’s Nest in there a week ago, which I took a picture of and then they left when they saw us spying on them. This evening, my wife noticed they were back. We rushed to the window (me with camera in hand) and I swear, they peered at us with intense suspicion. Pretty soon, they flew off in a huff.

They are among the most stand-offish backyard birds I’ve ever seen.

Why is this so important? It’s because I am getting so absorbed in birdwatching again now that I’m in phased retirement that I find it fascinating enough to look forward to more than going to work. I think that’s a sign I’m finally beginning to adjust to retirement.

I spent 4 years in medical school, 4 years in residency, and have worked for more than 23 years as a psychiatrist, mostly as a general hospital consultant. Nothing used to jazz me as much as running around the hospital, seeing patients in nearly all specialties, evaluating and helping treat many fascinating neuropsychiatric syndromes, teaching medical students and residents, and I even wrote a book.

On the other hand, I don’t want to hang on too long. When people ask me why I’m retiring so early (“You’re so young!”), I just tell them most physicians retire at my age, around 65. I also say that I want to leave at the top of my game—and not nudged out because I’m faltering.

I saw a blog post that identified that reason for retirement. It was entitled “When Physicians Reach Their Use-By Date,” by James Allen, MD. The site is identified as “Not secure” unfortunately, so I’m not giving a link to it. However, the web site is The Hospital Medical Director and it’s sponsored by Ohio State University–so it’s probably safe.

Now if you do read Dr. Allen’s post, you’ll think I’m flattering myself as a “master clinician.” I don’t think of myself that way. I’m actually more of a demigod.

I’m just kidding. The descriptions of how physicians finally reach retirement sound fascinating. I’m not sure I could just abruptly stop—that’s why I chose phased retirement. Staying on as a preceptor is not appealing to me because I liked the clinical action too much. I’m actually afraid of becoming someone who knows only medicine. It’s one of the best reasons for me to retire sooner rather than later. You’d think I’d identify with the consultant model; I’ve briefly thought of carrying my resignation letter around with me, although not in my coat pocket and not with malice in my heart.

Although I joined the fraternity of medicine, so to speak, I’m really not a joiner. In fact, I’ve gradually given up membership in organizations like the Academy of Consultation-Liaison Psychiatry, the American Psychiatric Association, and the American Medical Association. I’ve let go of social media accounts like Doximity and LinkedIn—all of them actually, including Twitter and Facebook; I just couldn’t get the hang of those.

There’s a National Association of Retired Physicians (NAORP) that I’ve peeked at. There’s the University of Iowa Retiree Association (UIRA) that I learned about a couple of years ago when my wife and I attended a seminar about retiring from the university. I probably won’t join either one.

I’ve been getting invitations from AARP for many years now (who doesn’t?). The tote bags look nice and I am glad that somebody is lobbying for people my age. I haven’t joined so far.

And I joke about my own fictional organization, Retiree On My Own Time (ROMOT). No dues, no meetings, no minutes, no Robert’s Rules of Order. I’m the President, Secretary, Treasurer (Har!), and the only member—for now.

I’m keeping my schedule open.

Wes Ely Brings House Down

I know I’d been saying that I probably wouldn’t have time to attend Wes Ely’s Grand Rounds presentation yesterday, “A New Frontier in Critical Care: Saving the Injured Brain.” But against all odds, I actually got to go, along with some medical students and a Family Medicine resident.

As I expected, Dr. Ely brought the house down. His talk was similar to the one he gave at Emory University in Atlanta, Georgia, but not identical. He described the results of the study “Haloperidol and Ziprasidone for treatment of Delirium in Critical Illness,” published last October in the New England Journal of Medicine. There’s a YouTube video of that in my March 28, 2019 post announcing his visit to Iowa City.

He also discussed in detail the ABCDEF bundle for protecting the brains of patients in the ICU.

When he outlined the history of intravenous haloperidol for the treatment of delirium in critical care units, I had to cringe because I remembered the continuous IV haloperidol infusion protocol (running at 5-10 mg an hour) developed by Riker and colleagues. I mention it for historical reasons only. I don’t recommend using it.

Riker, R. R., G. L. Fraser and P. M. Cox (1994). “Continuous infusion of haloperidol controls agitation in critically ill patients.” Critical care medicine 22(3): 433-440.

After his presentation, Dr. Ely asked for questions. I asked him what he thought the role of the psychiatrist is regarding ICU delirium. He actually recognized me; we met very briefly at a meeting of the American Delirium Society in Indianapolis several years ago.

Even better, he knew enough to mention the catatonic variant of delirium and the irony of using a benzodiazepine to treat it, which you would avoid like the plague in delirium (except for alcohol withdrawal, for example). However, benzodiazepines can reverse catatonia. See my post from April 10, 2019 (“Delirium and Catatonia: Medical Emergencies”). He thought psychiatrists would know more about that and would be important collaborators in managing catatonia.

It’s difficult not to be excited by the advances in medicine and psychiatry when an inspirational scientist, humanist, and visionary leader like Wes comes to town. It makes me wonder how I’m going to get a buzz like that out of anything I do in retirement.

On the other hand, I get a kick out of making silly videos.

Wes Ely at University of Iowa Today

Wes Ely, MD will be giving the Internal Medicine Grand Rounds today at noon at University of Iowa Hospitals and Clinics. The title of his presentation is “A New Frontier in Critical Care: Saving the Injured Brain.”

I’m on duty today in the general hospital as a psychiatric consultant. I’m pretty sure I won’t be able to attend Dr. Ely’s talk, ironically because I’ll be helping colleagues care for delirious patients.

But I found a YouTube video of the talk he gave with the same title. He delivered it in 2017 at a Critical Care Summit meeting at Emory University in Atlanta, Georgia.

I gave a talk to the medical students yesterday about delirium and dementia, which you can view in yesterday’s post. I urged them to try to attend Dr. Ely’s talk today because it would be a stellar, eye-opening, inspirational presentation. I talked about many of the same topics relevant to delirium that he does–but he’s a rock star. He’s a scientist and a humanist. I met him briefly at a meeting of the American Delirium Society several years ago and he’s brilliant.

I was listening to his talk via this YouTube video as I quickly tapped out this post. He’s an intensivist and focuses on delirium in critical care. While the focus of his talk is called “ICU delirium,” I think it’s important to realize that delirium is delirium–anywhere in the hospital or in nursing homes, skilled care facilities, and hospital emergency rooms.

The first-person video that Dr. Ely shows of a patient who developed what is essentially a dementia from prolonged delirium in the ICU is compelling. It’s a stunning revelation from someone who has not recovered from the neurocognitive injury that we call delirium. Some patients have even committed suicide because of the long-term brain injury resulting from delirium.

Dr. Ely makes the point that changing the culture of hospital medicine regarding the approach to assessing and managing delirium is a baby step process. It takes time.

Change happens, especially if we approach it as a team.

Delirium and Catatonia: Medical Emergencies

It was a very busy day on the consultation psychiatry service today. Besides that, I gave a lecture about delirium and dementia to the medical students. The talk is similar to the one below:

As a reminder, Dr. Wes Ely, MD will be in Iowa City at the University of Iowa Hospitals and Clinics to talk about delirium, “A New Frontier in Critical Care: Saving the Injured Brain.” It will be at noon.

I’m urging medical students and residents to attend. Unfortunately, I’ll probably be too busy in the hospital to go.

I sometimes see what is called a catatonic variant of delirium in patients who are medically very sick.

A condition called catatonia can occur in the setting of delirium. Most commonly, patients with this condition are mute and immobile. They may have a fever and muscular rigidity that leads to the release of an enzyme associated with muscle tissue breakdown called creatine kinase (CK). The level of CK can be elevated and detectable on a lab test.

Many patients will have a fast heart rate and fluctuating blood pressure. They may sweat profusely which can lead to a sort of greasy facial appearance. They may have a reduced eye blink rate or seem not to blink at all. They may display facial grimacing.

The patient may exhibit the “psychological pillow” (some call this the “pillow sign”). While lying in bed, the patient holds his head off the pillow with the neck flexed at what looks like an extremely uncomfortable angle. The position, like other odd, awkward postures can be held for hours.

Catatonia can be caused by both psychiatric and medical disorders. It tends to be more common in bipolar disorder than in schizophrenia even though catatonia has historically been associated with schizophrenia as a subtype. You can also see it in encephalitis, liver failure, and in some forms of epilepsy and other medical conditions.

The patient may perseverate or repeat certain words no matter what questions you ask. He may simply echo what you say to him and that’s called “echolalia”.

Although catatonic stupor is what you usually see, less commonly you can see catatonic excitement, which is constant or intermittent purposeless motor activity.

The usual way to assess catatonic stupor in order to distinguish it from hypoactive delirium is to administer Lorazepam intravenously, usually 1 to 2 milligrams. A positive test for catatonic stupor is a quick and sometimes miraculous awakening as the patient returns to more normal animation. The reaction is usually not sustained and the treatment of choice is electroconvulsive therapy (ECT), which can be life-saving because the consequence of untreated catatonia can be death due to such causes as dehydration and pulmonary emboli.

Another less invasive test that doesn’t use medicine is the “telephone effect” described in the 1980s by a neurologist, C. Miller Fisher. It was used to temporarily reverse abulia, which in a subset of cases of stupor is probably the neurologist’s word for catatonia. Sometimes the mute patient suffering from abulia can be tricked into talking by calling him on the telephone. It’s pretty impressive when a patient who is mute in person answers questions by cell phone. I have never tried texting.

The goal is to identify any medical condition left undiscovered and treat it. Both delirium and catatonia should be thought of as ominous indicators of a medical emergency.

Patience is a Virtue Redux

This transition to retirement has me looking back at times to an earlier transition in my life—college. I wrote a blog post 8 years or so ago about a few of my experiences at Huston-Tillotson College (now Huston-Tillotson University, a private, historically African American school) in Austin, Texas. We called it H-T for short. The post was entitled “Patience is a Virtue.”

You have to remember, this was in the ‘70s. A lot has changed, including me. The blog post is going to be different now.

I’m not what you’d call a patient person by nature although I’m much older and patience comes easier nowadays. Patience is arguably the physician’s most valuable asset, so it was worthwhile for me to work at cultivating it. We’ve all heard that doctors start yapping almost before patients are through talking.

I’m still learning to be patient. I think I first realized that people thought I was impatient when I was a freshman at H-T. They were right; I just didn’t know it then.

I remember a day when I was pretty annoyed about some remarks a peer made during a class in Black History (we were still “black” in those days). After class, I vented about it with the teacher, Dr. Lamar Kirven, who was also a Major in the military. We called him Major Kirven.

We loved Major Kirven. He had a wonderful sense of humor and laughed along with us when we had to tell him we just could not read his indecipherable scrawls on the blackboard. We didn’t have PowerPoint—and I don’t think it would have helped him.

Anyway, Major Kirven listened without saying a word during my long diatribe. I’ll never remember what that nonsense was all about; it doesn’t matter now.

He listened deeply and, at the time it didn’t occur to me to be surprised about that. I was too busy liking the sound of my own opinions. Several times he could have interrupted and justifiably corrected me.

He didn’t. He waited until I was finished.

And then, very gently he said, “Brother Amos, patience is a virtue”. It suddenly struck me that he had been very patiently listening to a very impatient young man’s philippic about the shortcomings of everyone but himself for almost a half hour before he made that brief observation.

I’ve been trying to be more patient. Along the way, I’ve discovered and rediscovered the truth of a statement that has often been attributed to Stephen Covey,

“With people, if you want to save time, don’t be efficient. Slow is fast and fast is slow.”
Stephen Covey

There’s a lot that goes into being an effective psychiatric consultant, not the least of which is the skill of transforming “That’s all I can do” into “I will do all I can.” That’s usually a lot easier if I listen patiently to what my colleagues, my trainees, and my patients want.

Meaning and Purpose in Retirement

As you know, I’m back in the saddle at work, according to the terms of my phased retirement contract. When I’m off service, I feel less pressured. However, when I’m on service, I’m like a fireman, thriving on pressure. I’ve done Consultation-Liaison (C-L) Psychiatry for so many years that, when I stop to think about it, I realize I get a good deal of my sense of meaning and purpose through my job.

I sometimes tell residents and medical students that I “do it for the juice.” That means I work for the adrenaline: rushing to emergencies, making quick decisions (some of them far from perfect), teaching on the run, telling funny stories about how my work as evolved over the years.

When I spent less time on the job during the first two years of phased retirement, I felt lost. There’s no better word for it. That’s not as much of a challenge now, but meaning and purpose in retirement can be difficult for a fireman to define.

I had a blog called The Practical C-L Psychiatrist until I dropped it last year. There were a couple of reasons. One of them was the expectation that bloggers write their own Privacy Policies in response to the European Union’s General Data Protection Regulation (GDPR) going into effect. I rebelled against it.

Please read my Privacy Policy on this blog. I worked pretty hard at it. I asked a few attorneys for guidance and only one of them got back to me, humbly admitting he didn’t know anything about it really, but had a helpful suggestion nonetheless.

The other reason I dropped The Practical C-L Psychiatrist was that it was less relevant to my stage of life in that I’m not racing all over the hospital nearly as much nowadays. I don’t have as much to write about that life anymore.

But I still love to write and so I swallowed my pride, wrote the Privacy Policy and decided on making a chronicle of my transition into retirement, which is this new blog, Go Retire Psychiatry. So far, I’ve more or less just made jokes about it. I realize that’s a defense. I need to move on and confront the search for meaning and purpose in retirement.

I’ve done a lot of fun things on the job over the years. I used to have mascots for the C-L service, like the one below. You can tell that it was from some time ago. The mascots were usually inflatable animals I bought from the hospital gift shop. The residents, medical students and I gave them silly names. The trouble was that the mascots, being balloons, were always running out of gas.

And that meant that somebody had to take the mascot for a walk all the way across the hospital back to the gift shop to get a healing shot of helium—and walk all the way back. The volunteers there got a big kick out of an old geezer doctor walking the mascot. It was an exercise in humility, which I admit I often needed.

And I took group pictures of trainees and me at the end of rotations by using an app on my old iPad. It’s called CamMe. The way it worked was that I set the iPad up on a stack of books or something; then we all stood for the shot. I would hold up my hand and make a fist to start a 3-2-1 countdown, which gave you just enough time to make a big smile for the automatic group selfies. Everybody got a kick out of it.

I was so proud of those pictures I thought nothing of posting them on my blog, with nary a thought about their privacy. All of them thought they were fun.

That’s about enough on meaning and purpose for today.

Fine Weather for Ducks

Today we had fine weather for ducks—who waddled across our front yard lawn and across the street. They sampled the worms the robins evidently wouldn’t eat. They didn’t like them much either.

I wonder what kind of romance life ducks have—probably about the same as humans.

That reminds me; my wife made another Hoorah’s Nest under her dining room chair this afternoon. She told me I could show you this.

Fine weather for ducks today

Who’s a Hoorah’s Nest?

I asked my wife this morning if she ever got any food in her mouth, pointing to the floor under her dining room chair—where there was a small pile of crumbs and whatnot.

It was a regular Hoorah’s Nest (also known as Hurrah’s Nest). That’s just about anything (hairstyle, person, place, situation, my so-called cooking) that’s a big, disorganized mess. Don’t worry, she gave me permission to blab about this. I still have a place to live. You can send cash donations to my GoFundMe campaign if you want, though. I’ve got renovations planned.

My new digs, before renovation.
My new digs, after renovation.

My side of the floor is immaculate, of course. No Hoorah’s Nest on me.

You can look on the web for definitions of Hoorah’s Nest and the origin of the term, which includes speculations about a cryptid bird called a Hoorah. It doesn’t excite cryptozoologists as much as Bigfoot does.

On the other hand, we think we saw the Hoorah about three years ago. I have several snapshots of its nest—which was a certified mess and a sign the bird needed professional help.

We tried to assist this Hoorah. Every time it started to go wrong in the construction of the nest (which was immediately), we tried removing the mess from the spot it chose to erect it.

The site was between our house and the back porch rail. Apparently, it was unfamiliar with trees.

Hoorah!
Hip Hoorah!
Hip Hip Hoorah!
Hip Hip Hip Hoorah!

It might have been high on drugs. On the other hand, the only bird I know of who has a substance abuse problem is the Cedar Waxwing. It overeats fermented berries and gets so drunk it can’t find its way home, much less build one.

But this bird might have been from another planet—a world where trees don’t exist and nest-building skills are optional. I could get only one picture of the Hoorah—also known as a Robin. Their nests get the big Hoorah.

The shy and rarely seen Hoorah…otherwise known as a robin.

Other birds make really messy nests, though: Mourning Doves, even the Cardinals (on the right) who we might have already scared away just by staring at them through our window.

Holler if you see a Hoorah.

Start My Engine!

Good Gahd Amighty, it was busy today! I really had to start my engine. It felt like I logged a lot more than 2.6 miles and 21 floors on the step counter. It’s days like this one that I’m not going to miss when I retire.