consultation liaison psychiatrist – Page 6

The Groundhog Effect

Last year, we noticed a groundhog waking up and bulldozing our back yard, even though snow was forecast that day. It’s pretty good at just putting its head down and pushing through almost anything in its path including leaves, sticks, small rocks, flowers, and so on.

Their single-minded digging has helped uncover bones and pottery of old civilizations and aided medical researchers study a lot of things including the role of viral hepatitis in liver cancer.

I can compare them to those who bury themselves in the single-minded study of medicine in the transformative path to medical practice. I can recall my medical school classmates and their clicker pens taking notes in class. They weren’t called “gunners” for nothing. Call it the Groundhog Effect.

Even if you weren’t a gunner, you had to apply yourself just like a groundhog to your studies. It could lead to another characteristic common among these creatures. They tend to be loners.

The analogy is far from perfect, of course. Groundhogs aren’t lonely. People can be, which is why medical students and residents are often advised to always remember H.A.L.T.

H.A.L.T. refers to trying to avoid letting oneself get too hungry, angry, lonely, or tired. It’s probably a warning about incipient burnout, a problem that affects at least half of physicians and which is the hot topic these days.

I’m always a little puzzled that so many physician wellness programs and meetings seem to devote a lot of time trying to teach doctors how to improve their resilience. It’s as though we’re somehow to blame for getting burned out.

I’m not saying learning things like mindfulness are not important for promoting physician wellness. I have my own daily mindfulness practice and it is certainly helpful.

It would also be nice to spend more time addressing the systems issues contributing to physician burnout, such as very full clinic schedules, overly complicated electronic health records requiring hours of data input that create the need for “pajama time,” which is bringing your job home with you, board certification busywork, managed care rules that marginalize physicians, and so on.

This is a continuation of the hassle factors that can lead to physicians just learning to put their heads down and dig through the mess—sort of like the groundhog, and often in isolation from each other.

Transformative processes can also occur at the end of a physician’s career. I’ve spent a long time learning to be a physician and now that I’m in phased retirement, I’m finding out how hard that can be. It would be helpful to know that others are passing through this stage as well, and that I’m not alone.

Could it be that one way to counter the Groundhog Effect is to come together and share this retirement experience? There will always be those who work well into their nineties and that’s great. Statistically, though, most of us will retire in our mid-sixties.

The graying out of the psychiatrist population is contributing to the shortage, to be sure. But we could still be useful to the next generation of doctors acting as role models for how to navigate the other transformative process—reflecting on the task of becoming somebody other than a physician. I think it would be easier if several doctors did this.

Animals do this. I saw this several years ago when we owned a house with a fountain, which was frequented by more than a couple of species of birds, including Bluebirds. They gradually arrived but were at first tentative about immediately diving in. One would perch on the rim. Another would come along and do the same, maybe drink a little water while watching the other.

Eventually, one would dip its tail feathers in just for a moment. Pretty soon, they would make like ducks.

I guess you could call it the Bathing Bluebird Effect.

Dirty Dozen on C-L Psychiatry

I’m back in the saddle again after a brief hiatus according to the terms of my phased retirement contract. During my time away, I thought about what a short introduction to Consultation-Liaison (C-L) Psychiatry might include to give medical students and other trainees a snapshot look at what CL psychiatrists encounter in their work in a busy general hospital.

As I considered what to include, it occurred to me that common consult questions typically could be classified into three basic groups:

Manage Crises: This often involves assessment of medically ill patients for whom there are concerns about suicide or violence toward others, including health care professionals.

Manage Medications: Frequently, I get questions about how to manage psychiatric medications, often in patients who are being treated with multiple medications; or need authorization for clozapine (an atypical antipsychotic which usually must be authorized initially by a psychiatrist); or need adjustment of medications in the setting of medical problems like cardiac disease or bowel resection (in which absorption might be affected).

Manage Behavior: This doesn’t always involve violent behavior but may include challenging and potentially disruptive acting out in the setting of delirium, or associated with patients who might have personality disorders or abnormal illness affirming disorders.

These broad categories make up the biggest share of the concerns my colleagues in general medicine hospitalists and surgery have about a significant proportion of patients in a large hospital.

Short video illustrating the Dirty Dozen in broad overview.

Clinical Problems in Consultation Psychiatry

Long day on the C-L Psychiatry service. I logged 2.8 miles and 33 floors on my step counter. I barely had time to eat lunch. This post is going to be short.

We were treated to outstanding presentations on fascinating topics over the last couple of days and they were given by top-notch medical students. One of them summarized the literature on mental illness in the population of incarcerated women. The other was a great overview of catatonia.

The students put a lot of work into them. The data search was obviously thorough and their presentations were polished. They had very well organized PowerPoint slides.

They were among the best examples of Clinical Problems in Consultation Psychiatry (CPCP) learning sessions in recent memory. The CPCPs were a frequent feature in my previous blog, The Practical C-L Psychiatrist.

The CPCP was developed by a former teacher of mine, William R. Yates, MD. He was the head of the C-L Psychiatry service years ago before moving on to the University of Oklahoma in Tulsa.

He’s a part time research psychiatrist for the assessment team at the Laureate Institute for Brain Research. They do research diagnostic assessments for a variety of imaging, genetic and biomarkers studies in mood, anxiety and other brain disorders.

The CPCP format is:

A weekly case conference held Wednesdays from 8:00 a.m. to approximately 8:45 a.m. Each week, a case is selected from the Daily Review Rounds Records to illustrate a clinical problem for the next week’s meeting. The residents are assigned dates when they rotate. The medical students are welcome and even encouraged to participate as well.

This is a practical way to approach teaching the Practice-Based Learning & Improvement Core Competency. This helps develop the habit of reflecting on and analyzing one’s practice performance; locating and applying scientific evidence to the care of patients; critically appraising the medical literature; using the computer to support learning and patient care; facilitating the education of other health care professionals. This is applying principles of evidence-based medicine (EBM) to clinical practice.

Evidence-based medicine is a systematic approach to use up to date information in the practice of medicine
Skills are needed to integrate the available evidence with clinical experience and patient concerns
Application and evaluation of EBM skills will provide a frame-work for life-long learning.

Self-evaluation is vital to the successful practice of EBM:

Am I asking answerable clinical questions?
Am I searching the literature?
Am I becoming more efficient in my searches?
Am I integrating my critical appraisals into my practice?

The assigned resident is responsible for searching the literature and selecting one or two teaching papers for the conference. Presentations will begin with a review of the case, followed by a summary of the references with subsequent round table discussion.

Circulate copies of 2-4 pertinent articles to team members including psychiatric nurses and faculty. A copy machine is available in the departmental administration office. Consult staff can also assist with obtaining copies.

Presentations begin with a 5-minute summary of the case with discussion of both psychiatric and medical aspects of evaluation and management. The remaining time is spent summarizing the pertinent data in the articles. Residents and medical students are encouraged to use the case conference material as preparation for submitting a case report or letter to the editor.

Bill and a former chief resident of psychiatry, Dr. Terri Gerdes, published a paper about the CPCP (then called problem-based learning in consultation psychiatry) in 1996:

Yates, W. R. and T. T. Gerdes (1996). “Problem-based learning in consultation psychiatry.” Gen Hosp Psychiatry 18(3): 139-144.

Abstract: Problem-based learning (PBL) is a method of instruction gaining increased attention and implementation in medical education. In PBL there is increased emphasis on the development of problem-solving skills, small group dynamics, and self-directed methods of education. A weekly PBL conference was started by a university consultation psychiatry team. One active consultation service problem was identified each week for study. Multiple computerized and library resources provided access to additional information for problem solving. After 1 year of the PBL conference, an evaluation was performed to determine the effectiveness of this approach. We reviewed the content of problems identified, and conducted a survey of conference participants. The most common types of problem categories identified for the conference were pharmacology of psychiatric and medical drugs (28%), mental status effects of medical illnesses (28%), consultation psychiatry process issues (20%), and diagnostic issues (13%). Computerized literature searches provided significant assistance for some problems and less for other problems. The PBL conference was ranked the highest of all the psychiatry resident educational formats. PBL appears to be a successful method for assisting in patient management and in resident and medical student psychiatry education.

The year that was published was the first year of my appointment to the Clinical Track faculty in the department of Psychiatry at The University of Iowa Hospitals and Clinics. I learned a lot from Bill.

And I’m confident that the students who presented their own CPCPs this week will teach many other trainees in their careers.

The Last White Coat I’ll Ever Wear

I’m a big fan of the Men in Black movies. I’m not going to tell you how many times I’ve watched them on TV (78 million and if that number reminds you of a scene from Men in Black, you’re just as much a fan as I am, if not worse). One of my favorite lines is when Zed says to Edwards, “Edwards. Let’s put it on.” Edwards asks, “Put what on?” And Zed says, “The last suit you’ll ever wear.”

Today, I asked my secretary to order some new white coats for me. I went down to the Uniform Shop and checked on it. All they need is the requisition and they’ll get it.

Since I’m retiring after this year, these are the last white coats I’ll ever wear. There’s no Zed to tell me that. The Uniform Shop staff person won’t know it when the coats arrive—unless I tell her, of course.

I found a very long, involved discussion on the web about the meaning of Zed’s “last suit you’ll ever wear” statement. All I got out of it was that some people take that movie way too seriously.

But for me the last white coat I’ll ever wear means exactly that. I’m going to wear the coat until I retire (in about 14 months according to the countdown)—and then I’m never going to wear white coats again.

I can almost hear certain persons snickering in the background. I suspect there may be a few bets about this retirement thing being another temporary leave-taking, like the times I left for private practice and came back, sort of like bringing Agent K back after neuralyzing him at his request. He really did retire—temporarily.

But nobody is going to neuralyze me. I’ll keep a lot of memories about my time as a Consultation-liaison (C-L) Psychiatrist, even though some of them are sort of like Agent K’s memories of being swallowed by a giant interstellar cockroach.

However, that reminds me of a few thoughts I have about institutional memory. I’ve mentioned my concerns about being practically the only C-L Psychiatrist in a pretty big hospital and retiring. I’m a geezer, but I know a lot about the ins and outs and moving parts and what it means to be a one-man hit-and-run fireman psychiatric consultant in a large academic medical center.

Institutional memory has been defined as “the collective knowledge and learned experiences of a group. As turnover occurs among group members, these concepts must be transitioned. Knowledge management tools aim to capture and preserve these memories.”

Institutional memory can also be characterized briefly as:

Accumulated knowledge, skills, “this is the way we do things”
Some of it gets hardened into policies and procedures
Much of it “…resides in the heads, hands, and hearts of individual managers and functional experts.”- “How to Preserve Institutional Knowledge” by Ron Ashkenas, Harvard Business Review, 2013
Too much of anything for too long can be bad, including institutional memory

The bullet point that Ron Ashkenas makes above is relevant to employers of baby boomers like me who know informal procedures, and have the skills (and they chose us so they recognized the skills, so don’t be calling us sport, feisty, hon, sweetie, or anything like that) and knowledge that’s in our heads but may not be stored anywhere else.

That makes the baby boomer retirement phenomenon a real challenge. About 10,000 boomers will reach the age of 65 every day for the next 15 years. And most of us aren’t kidding around. There’s no way to just deneuralyze us to make us come back. You can’t make it happ’n Cap’n.

There are ways to package institutional memory into handy things like mentoring partnerships, knowledge wikis, snappy videos (just shoot the damn thing!) and other media that are easily accessible and geared for the adult learner.

You can’t beat the Internet Archives for history. You can borrow and read the first edition of the Massachusetts General Hospital Handbook of general hospital psychiatry published in 1978, just like checking it out from a public library. Read the chapter, “Beginnings: liaison psychiatry in a general hospital.” You can learn from Dr. Thomas P. Hackett about the difference between a consultation service and a liaison service:

“A distinction must be made between a consultation service and a consultation liaison service. A consultation service is a rescue squad. It responds to requests from other services for help with the diagnosis, treatment, or disposition of perplexing patients. At worst, consultation work is nothing more than a brief foray into the territory of another service, usually ending with a note written in the chart outlining a plan of action. The actual intervention is left to the consultee. Like a volunteer firefighter, a consultant puts out the blaze and then returns home. Like a volunteer fire brigade, a consultation service seldom has the time or manpower to set up fire prevention programs or to educate the citizenry about fireproofing. A consultation service is the most common type of psychiatric-medical interface found in departments of psychiatry around the United States today.

A liaison service requires manpower, money, and motivation. Sufficient personnel are necessary to allow the psychiatric consultant time to perform services other than simply interviewing troublesome patients in the area assigned. He must be able to attend rounds, discuss patients individually with house officers, and hold teaching sessions for nurses. Liaison work is further distinguished from consultation activity in that patients are seen at the discretion of the psychiatric consultant as well as the referring physician. Because the consultant attends social service rounds with the house officers, he is able to spot potential psychiatric problems.”—T. P. Hackett, MD.

By the way, have you seen my YouTube Channel? I’ve been beaming me up into educational videos for residents and medical students for a while now.

Next year I’ll be doffing the white coat for good—but I’ll be on THIS planet.

Reference:

Hackett, T. P., MD (1978). Beginnings: liaison psychiatry in a general hospital. Massachusetts General Hospital: Handbook of general hospital psychiatry. T. P. Hackett, MD and N. H. Cassem, MD. St. Louis, Missouri, The C.V. Mosby Company: 1-14.

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.

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.

Remembering My Calling

Back when I had the blog The Practical C-L Psychiatrist, I wrote a post about the Martin Luther King Jr. Day observation in 2015. It was published in the Iowa City Press-Citizen on January 19, 2015 under the title “Remembering our calling: MLK Day 2015.”

I have a small legacy as a teacher. As I approach retirement next year, I reflect on that. When I entered medical school, I had no idea what I was in for. I struggled, lost faith–almost quit. I’m glad I didn’t because I’ve been privileged to learn from the next generation of doctors.

“Faith is taking the first step, even when you don’t see the whole staircase.”
Martin Luther King, Jr.

As the 2015 Martin Luther King Jr. Day approached, I wondered: What’s the best way for the average person to contribute to lifting this nation to a higher destiny? What’s my role and how do I respond to that call?

I find myself reflecting more about my role as a teacher to our residents and medical students. I wonder every day how I can improve as a role model and, at the same time, let trainees practice both what I preach and listen to their own inner calling. After all, they are the next generation of doctors.

But for now they are under my tutelage. What do I hope for them?

I hope medicine doesn’t destroy itself with empty and dishonest calls for “competence” and “quality,” when excellence is called for.

I hope that when they are on call, they’ll mindfully acknowledge their fatigue and frustration…and sit down when they go and listen to the patient.

I hope they listen inwardly as well, and learn to know the difference between a call for action, and a cautionary whisper to wait and see.

I hope they won’t be paralyzed by doubt when their patients are not able to speak for themselves, and that they’ll call the families who have a stake in whatever doctors do for their loved ones.

And most of all I hope leaders in medicine and psychiatry remember that we chose medicine because we thought it was a calling. Let’s try to keep it that way.

You know, I’m on call at the hospital today and I tried to give my trainees the day off. They came in anyway.

Darn Weird Socks

Today, a colleague and I compared socks. I noticed he was wearing a pair of Go Iowa Hawkeye-type socks. They looked pretty good—and then I showed him my brand-new Taco Avocado Alien socks. He was pretty impressed. They are the Darn Weird socks of America.

On the other hand, around 3 years ago, I found out about Darn Tough socks and got a couple pairs. They’re still tough, no matter how many stairs I climb.

Darn Tough socks have an unconditional lifetime replacement guarantee. They’re made in Vermont. They’re not cheap. But hey, if they’re good enough for dairy farmers in Wisconsin, they got to be good enough for me.

I’m not sure how long my Taco Avocado Alien socks are going to last. I usually get about 2-3 miles and 20 floors and more logged on my step counter as I hoof it around the hospital in my job as a Consultation-Liaison Psychiatrist. Today I logged 2.9 miles and 27 floors. And when I got home, I exercised in them. I wore my geezer Velcro tennis shoes, of course.

That kind of punishment often leads to my wearing out socks in a few weeks. Usually the toes go quick. Maybe my Darn Weird socks won’t last. I Like the Taco Avocado Alien theme anyway. I still haven’t figured out what the connection is between aliens, tacos, and avocados. Sure, you make guacamole from avocado for tacos and so they’re all green. Maybe that’s all there is to it.

Then again, we have to ask ourselves, do aliens like tacos with guacamole? I guess you’d have to ask the guys on the Ancient Aliens TV show (it’s on the History Channel), which I watch every Friday. It’s relaxing and often puts me to sleep. Does Giorgio A. Tsoukalos, a.k.a. the hair guy, wear Taco Avocado Alien socks? There are so many memes out there about him, it wouldn’t surprise me if you could find a picture of him wearing them—photo-shopped, of course.