Medical School 2020, Year 3, Week 35 (Consult Service)

Consultation and Liaison (C&L) service. I meet the team at 7:45 am in the C&L workroom, a windowless room that crams 3 computers and a loveseat. The 35-year-old attending who completed an Internal Medicine and Psychiatry dual residency runs the list with the 40-year-old PGY3 resident who was a psychiatrist in India and myself. We then go down to the ED to begin seeing the new consultations for the day where we are joined by the ED psych social worker. 

I interview the first patient, a 40-year-old obese Black female with major depressive disorder presenting for suicidal thoughts. She has been working with the homeless assistance team (HAT) to get set up in housing. She has rejected two different apartments. When the social worker informs her that she needs to work with HAT, she responds: “I want an apartment that I want. It cannot be across town.” She adds, “Also when I get admitted, I want a good doctor, not just any doctor.”

The next patient is a 28-year-old obese female with bipolar disorder presenting for suicidal ideation. She is also a regular. When our team goes into her alcove, she is busy eating french toast. We barely understand her one word responses. She proceeds to get up from her bed, and beds over to reach her purse on the floor. “What other specialty would you get to see that?” asks the attending. “She doesn’t stop stuffing her mouth with french toast, and then moons us slowly.”

We then proceed to see consults in the hospital who have been admitted to other services. I am assigned two to see alone while the attending is busy performing transcranial magnetic stimulation therapy.

The first patient is a 65-year-old grandmother with rheumatoid arthritis who overdosed on her opioids and benzodiazepines. “I regret that it did not work,” she says. “I wouldn’t have done it if I knew it would not work. I’d have tried something different.” What are your stressors? “Well son, take a seat. My daughter is a heroin addict who brings strangers to our house to shoot up. I have custody of her and our grandson. I live in chronic pain.  CPS have already been contacted by the primary team. We recommend inpatient psychiatry after medical clearance. The primary team is surprised that she is still alive. She had a five-day ICU stay.

My next patient is a 65-year-old with Lewy body dementia admitted for a GI bleed. We were consulted due to concern for MDD. His wife has cancer and cannot have sex. “I want to express my love for her while I am still here. I know I don’t have much time left.” We explain to him that an SSRI might help improve his depression, but may cause sexual dysfunction and decreased libido. “That’s good, give me that!”

I attend psychiatry grand rounds regarding a controversial topic: Combat Addiction, a recently proposed new syndrome within the umbrella of PTSD. The former Stanford clinical psychologist presenting describes Combat Addition as an addicted phenotype in which afflicted individuals seek to recreate the adrenaline rush. “This is not a new phenomenon, but just one that is increasingly common. The soldiers in Vietnam and World War II had limited combat exposure, and the ones that did had few recurrences. The Middle East wars are different. They are the perfect storm for addiction: high intensity, repeated exposures.”

[Editor: From the above we can learn that people at Stanford were well-insulated from anything that went on in Vietnam and World War II. There were, for example, 11,846 helicopters shot down or crashed during the Vietnam War compared to roughly 400 in Iraq and Afghanistan together. Approximately 340,000 American troops died in World War II and Vietnam, compared to fewer than 5,500 in Iraq and Afghanistan.]

Our speaker goes around the country recording combat veterans’ stories. He retells one soldier’s comment: “The first fire fight is an unreal experience, better than sex. You want it again.” These experiences are defined by a loss of context, revenge, betrayal (by country and politics). They undergo an intense bonding with their brothers, then return home to what they see as a meaningless life.” In an effort to recreate the environment, he reports, “One soldier told me that he got a concealed carry permit and was ‘waiting for someone to shoot at me to make me live it again.'”  He cites dangerous speeding on motorcycles to recreate the adrenaline rush of combat.

Our hospital had set up an audio-video link to the VA and several of their psychiatrists call in with questions. “Thank you for highlighting this. Your definition so accurately portrays many of the combat veterans that I see. Are there any diagnostic criteria or evidence-based interventions?” He responds, “The VA forbids any research into this syndrome. We haven’t even characterized the progression of the disease so we have no trials investigating treatments. Some of the patients I have followed for several years seem to age out of the longing to simulate combat, but they seem to still struggle with disillusionment.” He continues, “The one item I see that helps is community with comparable peers. It is challenging for providers to engage them because they look down on those claiming PTSD symptoms, believing that patients are motivated by the prospect of disability benefits.” He ended by citing several ongoing clinical trials with psilocybin and other psychedelics that may be beneficial, although “I cannot imagine some of my older veterans doing this.”

Statistics for the week… Study: 4 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Four of our classmates brought their respective dogs for a playdate at the local park. Only one ran away.

The rest of the book: http://fifthchance.com/MedicalSchool2020