Lost in Central Pennsylvania

My thoughts on Bin Laden's death

2011-05-05T21:55:00.004-04:00

There has been a lot of talk flying on the media about the death of Osama Bin Laden from should they show his picture to was it fair to shoot an unarmed man to blah, blah, blah. I posted one comment on Facebook and it set off a nationwide (literally) debate between people that have never met and lasted for days. Not that I like to set off that much conflict, but I was kind of proud that my single thought could spark that much interest.

Obviously much of how our society has functioned over the past ten years has been strongly influenced by this man and I know I had given up hope that he was ever going to get caught so this event has certainly taken my by surprise. Some that I have spoken to are of the opinion that we are safer with him gone. I am not so easily convinced. I am certain that Al Quaida will continue on. Any organization of such power has built in backup systems in case its leader is lost. The US Government is the most obvious example that comes to mind. Bin Laden was not a nice person, but he was not dumb enough to assume that he was invincible and I am sure he had some kind of "in case I go on to my 67 (0r whatever the number is) virgins in the sky" plan in place for a replacement to take over.

The newest opinion I read was that the death of Bin Laden should have been kept secret for a certain period of time to allow the military longer time to evaluate the material in his compound. The writer of this editorial felt that the rapid announcement was only a way for Obama to gain popularity points. Now he is withholding the photographs of Bin Laden for his own gain as well. My guess is that the writer is not an Obama fan and needed to find something to criticize him on. Tell the public now or tell them later, they will get the news, and this is the kind of news that they have waited for a long time.

Personally I think that it is a silly thing to worry about. There are too many other things going on in the world to worry about minutia. I still maintain we are not safer as I mentioned above. Al Quaida has strong holds in Yemen and Somalia and do not need orders from Bin Laden anymore. The world is not a better place. There are something like 6 billion people on the planet. Killing one bad person is not going to make that much of a difference. Maybe I feel better that he is gone, and I know that a lot of people certainly do but if we let one bad person have too much influence on our life, we will let him win.g

Continued Bath Salt Rants

2011-05-02T17:32:00.000-04:00

The number of admissions to the psychiatric unit here continues to be a fairly steady rate of 2-4 a week caused by psychosis secondary to MDPV, or bath salts (as they are commonly called) abuse. In some cases the patients have nothing else wrong with them and if it were not for this, would not come in contact with the mental health system. Some of them have other comorbid conditions. For a patient who has bipolar disorder, adding a hefty dose of "Blizzard" can set off a psychotic manic episode in no time. Not that one has to have a history of psychosis to get psychotic on MDPV. Most of the patients admitted do not have any psychiatric history. The common factor with all of these patients is that they are grossly psychotic.

And addicted. Many have turned to stealing to find the money to pay for their addiction. This stuff runs at about $35-40 a packet and the version sold around here, Blizzard, runs around $50-70 for a small jar. Break ins have been reported in areas that never had to deal with them before because of the presence of a "head shop" that sells MDPV. This is all to pay for a legal substance, not a so called "street drug". At these costs, the price is simply too high for most people to sustain their habit without resorting to illegal means to pay for it.

I am not sure about the weight or volume that is in a jar of Blizzard, but I know this is about enough to keep one person doped up on an out of control speed binge for about a weekend. It goes further than crack certainly, but still not cheap. In other words, enough to keep someone awake for three days straight and end up so flagrantly psychotic that one is either going to end in the hospital or dead. Much longer would cause the heart to give out from tachycardia (racing heart). That or the delusional patient ends up running into the street fleeing an imagined assailant and gets hit by a car. That or the person just dies of an overdose.

Although the user will come off such a long binge swearing he or she will never go through that experience again, they inevitably do. By now the user is addicted. The withdrawal symptoms make the user miserable and the actual experience of a binge is not always pleasant, but the drug's effects are stronger than the intellect. I have talked to people who have been fighting this battle for years.

And there are still people who think that legalizing drugs will solve the country's problems. I just hope that if a store decides to sell this product, that this store is in their neighborhood and not mine. If they want legal drugs, they can have them. I do not want them in my, or my family's (especially my child's) neighborhood.

2011-04-18T22:30:00.008-04:00

I have returned after a much needed vacation in Costa Rica. It has been one of the most beautiful places I have ever been but in talking to the people there, I have found that it;s outward beauty goes more than just skin deep. Costa Rica is the only country in the world without a standing army which I had known, but not why until this trip. In 1948 there was a civil war and after the end of this, the president felt that violence was not the answer and that government money could be better spent. The army was disbanded so that more money could be put towards education and medical care. Since that time, the country has instituted compulsory K-6 education, and free education for K-12. There is talk about increasing the requirements from K-12. The standard of living has improved enough that teenagers are not needed to be working to support the family nearly as often as in the past. Medical care is growing in availability and there is universal health insurance through the government. Clinics and hospitals are not as widely available as is probably ideal, but this is slowly improving with time. What is more important is the fact that both areas are a priority of the government and that both areas are slowly improving in availability and quality every day. Another positive effort made by the government was to limit greenhouse gases and pollution and now 95% of the electricity that the country uses is generated by renewable means.

They still have their struggles. Battles for land from developers threaten the coastline, but the money generated from tourism is a large part of the country's income and to turn them away would threaten that source of income. The other large income generator, exportation of fruits and plants demands large areas of land risking loss of rainforest land to agriculture. About 60% of the rainforest in Costa Rica has been lost to agriculture and rainforest land is very poor in quality once the actual rainforest has been removed from it. The tourism industry itself puts the fragile ecosystem of the rainforest at risk with tourists coming to see the rainforest in increasing numbers. The government has been paying attention to this more now, but this is a more recent development and some things cannot be taken back. And while the country is not out trying to generate adversaries, they have no army and are essentially unguarded if another country were to decide they wanted the land. Nicaragua is just to the north and the political instability there has affected Costa Rica.

Striking a balance between "progress" and conservation is not easy. Trying to maintain the viability of the "ecotourism" industry without damaging the fragile ecosystem is tricky. Many governments that rely heavily on tourism pay too much attention to the needs of the tourists and neglect to realize the impact that this has on the people of the area. Big new highways that make it easier to get the beach take land away from family lands and pollute the surrounding areas. I have travelled to a lot of countries seeking respite from the cold air and for the most part, these countries are fairly impoverished. Some seem to be working towards pulling out of that position, some seem stuck. Costa Rica is by far the most forward thinking of all of them.

People who I would most like to kick in the ass if I could.

2011-04-03T21:31:00.001-04:00

We all have people on our s#$t list, many likely to stay there for a while. The marjority of mine are only temporary visitors, however. Most of us have a supervisor that we can get along with most of the time but have their "Midol Momenents" and really piss us off. I have some coworkers that I really like but because we have fairly intense personalities to begin with, will go through spells where we are constantly at each others throat. And then you come upon the inescapable celebrity gossip. Try as I might, I cannot avoid that drivel. It is everywhere and the more I am forced to here about the Kardashian sisters, the more they piss me off. Who are there chicks anyways, and what value have they contributed to society? After dealing with your personal list, do you not start having fantasies of wanting to just kick some of these people in the ass? Jessica Simpson- The issue of whether or not she has gained weight or not does not warrent the designation of "controversy". No one is that important. Just go away already. Paris Hilton - The only thing worse than a tramp is a rich tramp. Tom Corbett (R) Governor of Pennsylvania - If you lived here you would understand. The person on the high end sports car show who said that all Audi drivers play golf. Do not, have not, and likely never will play golf. But I do drive an Audi. Dick Cheney - the name says it all. The Kardashian sisters - Since I mentioned them, I have no idea who they are but the people at work tell me that they have a reality TV show about them. Why they deserve such an honor I do not know. The tabloids seem to talk a lot about them fighting about who has the biggest butt and who has the biggest loser boyfriend so I guess if I were single, had a big butt and dated a loser boyfriend, I would get to have a reality show too? I have a lot of patients who fit that description and they do not have TV cameras following them everywhere. It has nothing to do with looks. The pregnant chick is downright homely. I will wait until the baby is born to kick her ass. Glenn Beck - No smarter than Sarah Palin and a lot less attractive. Rupert Murdoch - The one who made Fox News what it is today and revived the little gem above after his tenure ended (thankfully) at Headline News. Then he bought the Wall Street Journal and is in the process of spreading his right wing propaganda via this medium. Mohamar Khadaffi - If not for the impossible to spell name, for those nonsensical rants he goes on where he rambles about some kind of issue that seems important to him and does little but confuse the rest of us. ...and speaking of nonsensical ramblings... Sarah Palin - Ex Governor Palin, no one knows what you are talking about anyways, so please just do us a favor and SHUT UP ALREADY!

Bath Salts Revisited

2011-03-11T17:59:00.000-05:00

The knowledge of artificial bath salts is working its way across the country although I am not sure how far it has spread. The compound, with a very long chemical name formally is shortened to the name MDPV. There are other similar designer drugs that have appearing on the scene fast enough that governmental control has been unable to keep up with their emergence. MDPV is new to the United States but had been around for a few years in Europe. Another similar compound, mephedrone has been blamed for significant loss of life in England. Some states in the US have already banned MDPV and others are considering bans. Considering the significant effects it has had on communities in Pennsylvania, it is likely it will soon be banned here. A measure to ban it has already passed the State Senate, and is pending in the House.

A recent incident that illustrates it's potential dangers occurred a few days ago. The police were dispatched to a call on a domestic disturbance where a man was tearing the wiring out of the walls of a woman's home. Upon attempting to subdue the man, he became combative, was tazed twice and still put up a fight, tearing the pocket off one officer's uniform. In the end, several police officers were injured. The man had been shooting up bath salts. He is facing numerous charges at this point. He is one of the lucky ones who lived through an overdose of MDPV but many have died. These cases of PCP like strength are not unusual. We frequently see patients showing up in the ED acting like this that we strongly suspect are using bath salts. The problem is, we cannot prove it and even if we could, there is nothing that can be done to stop it. As of a few weeks ago, 22 admissions to this hospital were estimated to be caused by complications of bath salts and those were only estimates. I know of three admissions this week to psychiatry alone that we are fairly certain were motivated by bath salt induced behaviors. That kind of number rivals alcohol and outnumbers opiates on an average week.

One of the most recent stimulant compounds to be banned in the US was ephedra. Popping ephedra in the past was a bad idea and there were people who died from complications from it. Cases of psychosis or heart problems did occur, but nothing to the extent that this, substance has caused and the highly addictive nature of it makes it an even greater danger. MDPV is a far greater threat, producing a high compared to cocaine and Ecstasy and similar to Ecstasy in structure.

For those that advocate legalizing drugs as it is a "victimless" crime, I hope they stop to see the thousands of dollars of property damage a bath salt user on a binge can cause. I hope they stop to talk to the parents whose only child just died of an overdose of what they thought was a "safe" high since it was legal, after all. I hope they see the people who are involuntarily committed to psychiatric units and forever have their records marred by the commitment because they were floridly psychotic from excessive bath salt use. And I hope they see the medical and law enforcement workers that are injured trying to restrain a violent and irrational user on a wild binge. I see lots of victims here.

I hope that Sen Charles Schumer pushes ahead with his drive to ban MDPV as even though there are multiple agencies that must be involved before a national ban can happen, the sooner it happens, the better. Which will not be soon enough.

Random Thoughts

2011-03-03T17:57:00.023-05:00

There are always times when I have neither the time nor the inspiration to think of anything worthwhile to say. I have hit one of those impasses and have chosen to fill the slot with some of those random ideas and musings that one encounters that warrant being documented for history's sake but are not that lengthy enough for a whole post. Some of those follow.

If you ever really want to annoy a guy named Doug, go up to him and ask him why he does not spell his name Dug rather than Doug. The same goes for Phil and Fill.

If you look at this really closely, you can see a tiny Ben Roethlissberger chasing a terrified woman in this.

If you can tip a stripper with cash by sticking a dollar into his/her thong, why can you not install a card reader in his/her butt cheeks so you can swipe a credit card and give a tip this way?

This is just wrong. This is a Volkswagen Beetle- with a dragon painted on the side! VW Beetles have bud vases standard! Not marijuana buds you smart asses- flower buds! The very same Beetle had an Ed Hardy steering wheel cover with bulldogs with fangs showing and spiked dog collars. VW Bugs are available with such options as flower covers for the rear tail lights. These cars are not intended for such violent images. If you really look closely, you will notice that the VW symbol on the rear wheel cover is missing. This is nothing short of blasphemy for VW fans. VW bugs have always had all of their VW symbols in the hub caps. ALL of them. Not SOME of them, ALL of them. VW bugs are about peace and love and happiness and this bug has images of anger and violence and is just WRONG. I am going to have to kick some major ass over this one. This REALLY PISSES me off!

This is a Dodge Viper RT/10. It is the finest piece of street legal automotive engineering the Americans have ever mass produced. There is nothing funny or obnoxious about this car with the exception that is not MY Viper. (For those of you who would argue that the Shelby Cobra a better specimen of American engineering, I would remind you that the true name of the Shelby Cobra is the AC Cobra and is not, in fact, 100% American. It is, in fact a Ford motor on an AC {ie British} chassis.)

Why is the local news I am currently watching about to show a news story about a new gas station opening? Even a real ugly mullet sighting would be more newsworthy. No, I am not making this up. They once covered a Wendy's opening, too.

Look, twins!

OH MY GOD!, the new gas station story just played! You can get a FREE COFFEE OR CAPPUCCINO just for stopping in! No wonder they covered it on the evening news! I feel so much better now.

The Fashion World Must Be Insane

2011-02-27T16:43:00.000-05:00

People who know me know that I expend an exorbitant amount of time trying stay in step with the fashion world. This is probably an overreaction to having spent the majority of my life being deprived of the opportunity to actually be "in style" having grown up in the Midwest where unless you live in Chicago, you are by definition, behind the times. In the modern area of Amazon.com, Zappos.com and the like, anyone with access to a computer can get pretty much anything they want, anywhere in the world. The result is one does not have to live in New York to look like one lives there. I have never even been to New York but will always aspire to cultivate this city's unique look. Despite my interest, there are some aspects of the fashion world that have me convinced that the people who run it are not fully reality based. I have always wanted the chance to vent these frustrations because those of us that support the system should have the right to have our views heard.

1)Refusing to put pockets in clothes. This is apparently based on the idea that putting things in your pockets makes you look fat. I am not sure how, but somehow a tube of lipstick and a pen have the capability of transforming a model thin woman to a candidate for bariatric surgery in seconds. It is not enough to simply not use the pockets for the "thin obsessed." I read in one magazine that rather than risk the danger of being helplessly compelled to put things in one's pockets a woman must take her clothing to a tailor and have them removed! Fortunately the fashion world has been thoughtful enough to save us a few dollars by making clothing with "faux pockets" to keep us safe from that risk. Okay, it is true, I am thin and do not worry about whether or not I look one pound heavier by carrying a pen in my pocket, but come on, I am a real woman, in the real world with a real job. I want and I need real pockets.

2)Cheeky underwear. What misogynist invented these? All the discomfort of a thong, all the visible panty lines (VPL for those not in the know) of standard panties. All in one package. Now widely available but originally produced by Victoria's Secret, the marketing geniuses who made the thong a household item. Not to rest on their laurels, they had to come up with an item even more uncomfortable and more impractical. Knowing that they are always on the hunt for new ways to make underwear uncomfortable, several women at work and I came up with the MOST ULTIMATELY UNCOMFORTABLE PANTY IN THE WORLD design. I will decline to describe it. We plan to sell it to Victoria's Secret and expect a healthy cut of the profits. Not that any of us would buy it. We will leave that to the 20 year olds in New York that seem to think this kind of thing is sexy.

3)Ridiculous clothing design. I was given a very nice pair of black pants with a short tab belt made out of leather in the center. Those two pieces that constitute the belt are no more than 2 inches each, but since they are leather, the entire pair of pants must be dry cleaned via leather process which runs around $50-$75. All for two 2 inch pieces of leather. Had those two pieces been mounted on snaps so they could be removed, I could have the pants dry cleaned for around $12. Is there any reason those two pieces could not be mounted that way? No. In fact, I took those pants to a local seamstress who did just that. I did that about four years ago and have not had a problem since, but I am paying a whole lot less to have those pants cleaned. The people in New York? Probably are paying $75. As far as to the age of those pants? Are they out of style? No, they are just black pants, they never go out of style. By the way, they do not have pockets, either.

4)$400 haircuts. Do I need to elaborate?

5)Miniskirts 2 inches below the crotch. Considering the popularity of "going commando" recently, these things are not a good idea to begin with. Not to mention, why would anyone want to wear something so short that she cannot bend over, sit down, walk, reach her arms over her head, etc without running the risk of flashing the whole room. Did these things not used to be reserved for strippers?

6)6 inch high spikes heels for work. Fashion magazines will show "work appropriate" outfits that are as on the mark as Lady Gaga is conservative. They invariably feature a pair of shoes that are so high one needs an oxygen tank to breathe. I wear heels at work, more so than most of my cohorts and get teased for doing so by some. My husband is probably my biggest critic in regards to my excesses. But my obsession is shoes in general, be they flat, medium or high heeled and the majority of the time, my heel height is a moderate height which is the most comfortable level for me. One thing is for certain, if they hurt, they do not get worn. I am on my feet all day and the idea of wearing something so toweringly high that I am limping by mid-morning is ridiculous. Any serious career woman knows what I am talking about.

7)Size 12 is a "plus size". In the 80's the average woman weighed 120 pounds and wore a size 12. Since that time, the weight of the average woman has grown as has the average size. It is also true that as years have gone by, what an article of clothing that is considered a size 12 is larger than it was 25 years ago. That said, plus sizes start at size 14 at the smallest, and to hire models that are smaller than that is just an insult.

8)5'4" is short for a woman. Actually it is the average height of the American woman. It is the models that are freakishly tall. So why are average height clothes cut for woman the height of models?

9)Ultra low rider jeans. There is a reason women's waists are thinner than their hips- so their pants do not fall down. Up until a few years ago, that is where we wore our jeans- at our waists. If we wanted jeans that rode low, we borrowed our boyfriend's. Then they gave us our own low rider jeans. Then to really ramp up the refrigerator repairman effect, they gave us ultra low rider jeans. This way, it was impossible to find a pair of uncomfortable Victoria's Secret panties that did not pop out over the top in back and a rising moon was certain to be sighted several times a day.

10) Saying anything so ultra-trendy that it will only be in style for one season, yet still costs $5,000 is a "good investment". Unless you have the money of Oprah Winfrey, this is more money than most women can pay for an outfit they will use for the rest of their life, save three months.

It is a shame that all of the people behind the scenes in the fashion world not be required to have a psychiatric consultation before embarking on their careers. If they were more reality based to begin with, a lot of us would suffer a lot less in the end.

On the Issue of Bath Salts

2011-02-19T22:44:00.006-05:00

I am embarrassed to admit that I fell for the ruse (briefly) like many others that the drug that so many kids were getting high from that was said to be a bath salt is not a bath salt. The same product is marketed as a plant food as well. This was a ruse to cover its real active ingredient. It is a highly addictive amphetamine known as MDPV for short. It has been banned in England and many members of the European Union already. Louisiana and Florida have banned it, and it will not be long before Pennsylvania does. We have had many rather tragic stories and at least two direct overdose deaths end up at the hospital here. I have not posted in a while as my time has been occupied working on a presentation relating to some of the results of this drug and have not been doing much on my blog.

Well, maybe I have a bit of writer's block.

But putting in work on the Blizzard, Powdered Rush, Vanilla Sky, call it what you will, epidemic has taken up a lot of time and certainly has interfered with the time I might have spent farting around coming up with ideas to write (more accurately, type) about.

Desperately Seeking Spring

2011-02-08T12:47:00.015-05:00

If you are a follower of the woolly worm form of winter weather forecasting you have probably noticed that they were way off last fall. The ones we saw had a black front band that was moderately wide. The middle was mostly brown and the back tip was black. Instead, the entire winter has been cold and snowy. We live in a valley and were spared the depth of snow that nearby communities have endured, but we had snow nonetheless. And it was very cold and windy. The entire winter. According to the woolly worms, the early winter would have severe weather and snow for a while then a mild middle followed by a brief blizzard at the end of the winter. So much for the woolly worms.

Punxsatawuny, PA is about one hour away from where I live so I hear all about the Groundhog Day festivities. Since the woolly worms blew it my hope was maybe Punxsatawuny Phil would be right. It is certainly my I hope now since he saw his shadow and ran back in. An early Spring is predicted. We actually had a few days above freezing over the weekend and that was the first time in weeks. I was almost disappointed that is was not going to snow having gotten so used to this particular weather pattern.. I wanted to take my son sledding one more time, anyways.

But all things considered, I would welcome a respite from my car being covered with salt, the biting wind and being stuck inside. I notice the Sun rising a little earlier each morning and the days getting longer in the evening. I really miss dinner on the back deck after work and playing ball with my son in the yard. The melancholic mood that develops over time during winter grows old and it is getting time for this season to move on.

I am rooting for you Punxsatawuny Phil. I need a dose of Spring euphoria.

To Stop or Not to Stop

2011-02-02T19:00:00.013-05:00

"So how do you stop?"

That is a question that should never have been asked about a sledding hill. Sledding is not about stopping, it is about adrenaline. The goal is to find a good hill that provides the ultimate excitement with plenty of opportunity to get injured in all sorts of unpleasant ways. One with lots of jumps, twists and snow banks offering cushioning from sledders sent airborne. Messy details like how to stop can be worked out later, but anyone who insisted stopping in some form of "safe" manner is likely to get written off as a woos. When I was a child, our favored means of stopping usually involved trees or for the more daring, rusty barbed wire.

My husband knows this, but parenthood does weird things to people's brains. So when we stood at the base of "Double Dips", a local sledding haunt, he had the audacity to ask this question. We had only that day been made aware of this hill and had driven by to check it out. Our son is five now and it was time to initiate him into the world of real sledding. He had gone down small slopes in our yard but these were the equivalent of sledding bunny slopes. He was not ready for the hard core X Games version of sledding yet, but it was time for more than this. The Double Dips were actually not that dangerous at all. If they were, the city would not have gone to the length of actually blocking off the two city blocks that comprised the slope to traffic every year with saw horses. This was a decent place to take a kid sledding but how to stop should not have been a concern in my eyes.

This hill was set up with a long stretch at the end of the hill for one's sled to slow down. We took our son sledding and his plastic saucer just drifted to a stop. Fine for young children. But I still long for the days of my youth when we were always in pursuit of "extreme sledding". This was far before the X Games were conceived and no one used any trendy terms like "airs" or "gnarly" to describe our self destructive behaviors. We never knew there was anything that could be viewed as a sport to our activities. We just knew that if we could find the biggest, most dangerous, scariest hill to go sledding on, we had succeeded in our quest.

For us the kind of sled that was used was almost as important as the hill. The old fashioned wooden sled had the advantage of control so it could be used on the more tortuous slopes or on the more treacherous side paths that a simple toboggan could not navigate. Of course having a total lack of control had its own attraction as it significantly increases the danger element. Toboggans lack control, but inner tubes are far superior as they raise the center of gravity making the fall off the sled more dramatic. The best ones are the real ones intended for use in a tire, especially an old one with a bulge on the side that guarantees it will not go straight and one will end up running into a tree or other obstacle

Which goes back to the question of "How do you stop?" Easy, roll off the sled before you hit the barbed wire fence at the bottom of the hill. Run head on into a tree. Steer into the snow bank at the bottom of the hill and hope that you do not get buried. Take your chances with the barbed wire. Sure, you can do the spin out maneuver with a wooden sled if you know how, but the above options are scarier, riskier and far more gratifying. The goal is to get a thrill and scare the Hell out of Mom, not be safe. Safe is for dorks.

Which brings us back to the hill where we brought our five year old son. My husband is not a wimp when it comes to sledding. He knows all about sledding into barbed wire and hairpin turns with a wooden sled. It is just that he is the worried parent now and is not ready to face his son sledding straight into a snow bank. At least not yet.

A Pigeon by Any Other Name...

2011-01-25T20:47:00.018-05:00

My recent journey to Pittsburgh gave me the opportunity to visit the National Arboretum. This was perhaps at my family's own peril as this was dangerously close to Heinz Field, home of the Pittsburgh Steelers and even in the morning there were throngs of Steelers fans, ticket scalpers and memorabilia vendors that had gathered for the evening's festivities.

I love the Aviary. It is set up in a manner that allows the birds to move around freely in much of the display. In many cases the birds will roam into the walkways where the visitors move through the aviary. It allows the visitor a unique opportunity to encounter the birds' behaviors up close.

The birds in these photographs are pigeons. Very exotic pigeons with fancy head feathers, long legs and bright colors, but pigeons nonetheless. Known as Crowned Pigeons or Gouras, they reside in New Guinea and are close to the size of turkeys. Normal American pigeons are more prone to run away and fly off when threatened, but these birds will lie down and play dead. I had the opportunity to observe this behavior several times while on my visit there. There were two pigeons on an elevated walkway that ran over their display who, despite the constant disturbance by humans, refused to yield their ground. They would stand there displaying their beautiful plumage and whenever someone would come just a bit too close would lie down and "play dead". Sort of like a possum, except less annoying and less likely to get run over by a car in the rainforests of New Guinea.

On the job with the boss looking- human world.

On the job with the boss looking - pigeon world.

Now do you not wish that when your boss (or whomever else) was getting on your nerves, that you could just lie down and play dead as a means of defense?

It's Playoff Time

2011-01-19T13:06:00.010-05:00

I have been swallowed by a sea of black and gold. It is a bit of a drive to Pittsburgh but this is definitely Steele rs country. Since the playoffs are going on, that fervor is driven to new heights.

Last weekends game was quite the nasty one. Steelers fans really HATE the Ravens so that game was a nasty one as expected. The upcoming game against the Jets does not carry the same kind of animosity, if only because the dislike of New England around here is so intense that anybody that can pull off an upset against them, especially in a playoff game, must be okay. Personally, I do not care. I do not like the Ravens only for the reason that they used to be the Browns and abandoned Cleveland. I am okay with the Jets because they took on Boomer Esiason when Cincinnati realized that they sucked and did not deserve him. Otherwise, I am not that rabid of a fan. I guess I will root for the Steelers.

So who do should I root for? Well I am from Ohio (state motto: During the Presidential Primaries we are actually relevant), which you may have guessed from my defense of Cleveland. Actually I am from Cincinnati and have grown up with the long, proud tradition of hating Cleveland- aka- the mistake on the lake, the armpit of the midwest, etc. Despite that, it is in Ohio and you do not betray fellow Ohioans like that. I did at one point support the Bengals when they played professional football. I am not sure what they play now, but it does not look like professional football to me. Professional teams do things like score touchdowns and defend their quarterback and have defensive lines. The Bengals have not incorporated these elements into their game since 1989 when Boomer Esiason was quarterback and they went to the Superbowl. Cleveland is out as a team I could root for since they are the rival team of the Bungals (take that Mike Brown!) The Browns have not been the same since being re founded so pretty much both Ohio teams are out.

Prior to living here, I lived near Indianapolis and that was where I found a real football team- the Colts. They had the advantage of both being a good team, and they had Peyton Manning who played for University of Tennessee where I had been a student briefly. He was a cool dude to boot. Besides, Indianapolis was a lot like Cincinnati, except much hipper and larger. So I became a sworn Colts fan. Whenever there is playoff game that the Steelers are in, the hospital allows staff to wear team colors of the involved teams. I am sure to show up in white and blue, even if they are not playing against the Steelers. Sure, I look like a douche bag, but if you cannot look like a douche bag amongst trusted friends and colleagues, who can you look like a douche bag in front of?

This weekend, I just so happen to be spending in Pittsburgh, which I am probably going to regret considering there is going to be a playoff game on Sunday and the city is going to be a zoo, but I planned this weekend first and am holding firm. It does not matter that a winter storm just dropped 5-6 inches of snow in the city and the high temperature is running below 20 degrees. The fans are going to come to the game. And I am going to be rooting for the Colts. Except when a Steelers fan is watching. They are not so forgiving about the lack of allegiance in the city proper. With that in mind...

Go Steelers (unless the Jets win)!

The Forecast

2011-01-17T21:44:00.009-05:00

There have been plenty of stories about newer legal drugs floating around that kids have been getting into so they can subvert the system. K2 and Salvia are the ones I have heard the most about, but I am sure there are more. Like Ecstasy, it will only be matter of time before they are outlawed but a lot of people are going to be harmed before that happens.

The newest one I have heard of around here is called Blizzard. It is apparently a no more than a bath salt that has fallen into favor in the drug crowds. For the time, it is legal and can be bought at large chains that sell bath products. For their benefit, I will not mention any names. As the form Blizzard which is very finely ground and packaged in small jars labeled as such, this is probably more likely found in head shops, but it is not hard to get a mortar and pestle to grind up the legitimate version if one does not have access to such an establishment. I would have never heard of it either, but word of this sort of thing worked its way to me via my patients, like so many other tidbits of information. The recent story on the death of a Blizzard IV drug user has increased its notoriety since then. I have been told that some states have become more aware of this becoming a problem and are making steps to ban the product. Much like Ecstasy, K2 and Salvia, these compounds will have their heyday before being recognized and regulated. The compound is not harmless and more people are sure to die from use of this product.

While it is not funny, do you not just want to say "are you completely stupid, or just mostly stupid?" when you hear that someone shot up their veins with BATH SALTS? Still I wonder since it is a cleansing type product is the user less likely to get an infection than, say a heroin user? At least they will smell spring fresh.

Of course there was the bath salts as a drug discussion that came up at lunchtime the first time that Blizzard was introduced to the psychiatric unit here. How is it used? Are there different scents? It is not that our lunchtime discussions do not reach the lowest common denominator of poor taste to begin with, but since this is likely to hit the teenage set out of its sheer accessibility, we pondered if were likely to be used the way high school students use to get drunk during school- the vodka enema. Useful if one can squeeze really tight for a long time. Unfortunately, this form of alcohol delivery has been implicated in a good number of cases of alcohol poisoning. Nonetheless, it is easier than trying to sneak a bottle of vodka into school so the practice continues. Would not a bath salt enema be a great way to pull off a buzz, avoid track marks and leave one's colon smelling fresh? They might even expand the practice into one of those colonic type spas where one could choose the size of the buzz- flurries, light accumulation, a clipper or the full blown blizzard.

So that was the main topic of discussion during lunch in the conference room yesterday- bath salt enemas. I do not wish to make light of the tragic loss of a young person's life, but if people are stupid enough to do something as stupid as shoot up bath salts, we are going to joke. Our jobs are stressful enough that we need a break sometime.

They kind of look like Devil horns don't they? on Twitpic

2011-01-17T13:21:00.002-05:00

They kind of look like Devil horns don't they? on Twitpic

2011-01-17T13:14:00.000-05:00

They kind of look like Devil horns don't they? on Twitpic

The Drive Home

2011-01-11T17:13:00.008-05:00

"Why are you driving so slowly?"

One thing was for certain, that F150 could manage the snow at a lot faster velocity than it was if it was a 4X4, and if it was not, it should have been. No one with half a brain in this area would buy a rear wheel drive vehicle if there were a four wheel drive version available.

It was not as if the road conditions were bad, not yet, at least out here. The city streets were warmer and have already started to slush up from the city heat and the endless barrage of cars rushing home to beat the oncoming storm. Once outside the city was a different picture. The streets were cooler and the rush of cars home had not peaked yet so the roads were still covered only with a fine powder of snow. Unfortunately, the only road home lasts for several miles and is a single lane road over a mountain. One slow vehicle can slow up traffic for quite a distance. And that was exactly what that F150 was doing at the front of the line. The uphill climb is always worse in this situation with angry drivers if only because there are more cars heading in the same direction. As the line moves along, the group slowly diureses off as cars reach their various turn off points. I am not worried about stopping in time if needed, but I am driving in auto shift mode just in case. Still I can only manage to get the car in third gear and get any reasonable semblance of power. The speed limit is 45 mph.

At the apex of the climb is several turn offs to the "it" subdivisions and most of the cars turn off leaving me virtually alone with Mr F150. The downhill speed limit is 55 mph and he seemed to only muster up the guts to go 35 mph. The last cars in the line turn off and it was just the two of us now. My drive home is my refuge from the hustle of the day and I have calmed down by the bottom of the hill. I will maintain that satellite radio is one of mankind's greatest inventions as it is virtually impossible to go without finding something I want to hear. Once I get tired of flipping channels, I usually pick out exactly what I want on my Ipod which is hooked into my sound system. The one song stuck in my head that day, and play it on repeat. It is my car, I can do as I please.

Once found, the song in my mind was playing, and I was in a state of Zen calm. I have grown fascinated with the swirls of snow that dance behind the tire tracks made by the truck ahead of me. He somehow seems destined to be my lead car on the entire trip home as he makes all the same turns that I do. The entire time the snow swills in an endless pattern behind the tires of the pickup. They twist and writhe in an endless array of figures that much like a snowflake itself, never repeats. The lines they create move as if they were choreographed to move with the song on the sound system. I can understand the lyrics of the song, but I do not pay them any mind. The river that runs to the right of me is starting to ice over from the cold but do not even notice it's progress. I am still forced to drive too slowly if I am to keep a safe distance from my nervous companion but at this point, do not care. The only time I glance away from the road ahead of me is to check the gap between the rocks on the left where the deer are known to dart out unannounced, otherwise, it is back to the swirls of snow.

I finally turn into my subdivision and leave the F150 to nervously work his way to wherever he is going. Coming out of the subdivision is a Jaguar with a Union Jack on the front plate holder. Another driver whose car was quite likely ill prepared to face the oncoming storm. Another rear wheel drive car on the road. Do they even get this kind of snow in Brittan? But I am almost home now and it is not my worry. Just up one hill and a few poorly laid turns before turning up the last hill to home. By now the snow is starting to build up on the road, and the gentle wisps are slowly being swallowed up by more heavy accumulation. I could have managed the building inclement weather but I am home now and ready to enjoy the evening.

A few minutes after arriving home, the salt truck came up the road with its plow and load of salt and gravel to treat the road before the oncoming storm fully flexes its muscles. They are predicting 4-6 inches, more than we have had so far this entire winter.

The Best Memories

2011-01-10T07:57:00.011-05:00

I set my toast on fire this morning. Who cares, right? Not many would, really, but it my circle, it is something worth bragging about. Hey, guess what stupid thing I did this morning! Funny, huh? Anything for a laugh. It makes for a great pick up line in a bar. Sort of like "Hey, I'm a rock star and drive a Ferrari" but instead I can say "Hey, I'm a dork and I set a piece of toast on fire this morning."

I am not writing this to tell you about my culinary misadventures. It was to talk about memories. That incident brought back one of those memories that I will probably remember all my life. We all have a few, some important, like our wedding day, the day our child was born, etc. Some stupid like the day that "someone" put Ben Gay in Uncle Bob's underwear drawer and he ran out of church grabbing his crotch and screaming in agony just as the sermon was starting. I never did that to my Uncle Bob, no really, it is just an example, but you get the idea.

My "Smoke on the Toaster" incident brought back an old college memory out of the dusty old attic of memories and brought me a smile. A roommate of mine in college was more interested in reading the newspaper one day than paying attention to her breakfast. When I walked into the kitchen, her Pop Tart was in the toaster and on fire. "Jen (not her real name) your Pop Tart is on fire." She just brushed it off without a glance. The flames spread and the room started filling up with smoke. "Jen, your Pop Tart is on fire!" This time she looked to see the flames shooting out of the top of the toaster and rescued the remains of the Pop Tart. Word of advise: if a toaster is on sale for $.25 at a yard sale, there is a reason.

Some memories are notable enough to stay with us forever. This one was based on the humor of the situation. One of my favorites carries a significant amount of importance to me for far more profound reasons.

A few years ago we had gone on vacation to Ocean City, MD. We were told by numerous people that this was the beach to go to and heard long stories about how wonderful it was. Unfortunately our experience was far from what we were promised. It was crowded, overrun with teenagers and young adults looking for a party, and lined by rows and rows of tacky high rises that spoil the ambient beauty of the shoreline. We did have fun on the vacation, but it was not the kind of beach that we would return to in the future.

Despite our disappointment in the beach itself, it did leave me with one of those memories that I will never forget. We had a very nice condo with a balcony overlooking the beach. One very nice evening we had just come in from swimming and my husband stripped off my son's swim trunks and hung them out to dry. My son had been running around on the porch with nothing but a towel on. I just sat on a lounge chair to enjoy the evening and dry off. It had been sunny all day and the temperature was still pleasant. The ocean breeze was just perfect. He was scanning the road for signs of the ice cream truck and I was watching on the horizon for dolphins. Age certainly makes for different ideas about what is an exciting siting.

After some time, I wondered if he may have grown tired of sitting wrapped in nothing but a towel and asked if he wanted to do something else.

"Do you want to go take a bath?"
"No."

"Do you want to get dressed and walk on the beach?"
"No."

"How about go look for the ice cream truck?"
"No."

"What do you want to do?"
"Just sit here on Mommy's lap."

And so we sat there, watching the ocean and listening to the waves crash against the shore. That memory will stay with me forever. I can still hear the sea gulls calling out and smell the salt in the air when I think back to that day. I never felt more at peace than I did at that moment. I never felt more important either.

New turbine array near Altoona, PA getting ready to go live. ... on Twitpic

2010-12-24T19:34:00.001-05:00

New turbine array near Altoona, PA getting ready to go live. ... on Twitpic

Clean energy is moving into the area slowly but local power companies are unlikely to buy to because this area is so connected to the coal industry. Coal is one of the top offenders in contributing to greenhouse gasses and needs to be phased out.

Early Winter Musings

2010-12-24T15:59:00.023-05:00

It was a cold night in downtown State College when I left to drive home from a late appointment. Although the University was out for the semester, the streets were anything but deserted. Graduate students taking a break from their never ending pursuits of the almighty thesis sipped lattes in one of the many cafes that line the streets. Last minute shoppers were still roaming the streets trying to get those last minute gifts bought before Christmas and there were always a few students who remained for the season. The streets were brightly lit with Christmas decorations on the trees, lampposts, storefront windows. It was a festive sight. Normally I love Christmas, but was overcome with a mood I had not felt in years. I knew I should not be feeling this way, but emotions often override the logical mind. I am prone to getting depressed and was getting those dark moments again. They do not last long but certainly are not welcome visitors.

The fact that my husband lost a close family member just a few weeks ago only compounded an already somber mood. He went into the hospital with side pain and left with an unknown and incurable disease that no one had suspected. In just over two weeks of constant pain, he was gone. Every day the family vacillated between not wanting to lose a family member and not wanting to see him suffer, but we all knew his time on Earth measured in days, not months. We knew that his life involved more than anything else a great deal of pain and expedience in reaching an end was probably the best thing for him. When it was all over my husband was left battling with finding himself having to assume new role in the family that he never expected to play. I was left with a lingering fear myself about my abilities to be the person he needed to support him emotionally in that role.

But this is all a part of the grief process and completely normal. Nonetheless, it makes for a difficult start to the the holiday season. Thanksgiving spent apart. Our young son crying for his father. An eerie emptiness in the dining room for Thanksgiving dinner and nobody paying attention to football.

Back to the present scenario, I put my focus on the hour (more or less) drive home. It is usually a welcome period of solace. They are few and far between in my busy life, trying to maintain the balance between work and family. This one was just not a happy one. I had recently bought Pink Floyd's "The Wall" on CD, an album that had not been in my mind for some time. Had the son of one of the members not bothered to get himself arrested, it still would be. But while the miscreants of youth usually only attract the attention of persons close to us, those of us who have parents of note make headlines when they get arrested, even if for less than newsworthy offenses. Since reading that story, "The Wall" had been running through my head. Not just one song, the whole album. I decided that before I went through anymore undue emotional trauma, I had better just breakdown and buy the CD. Then I played it on the drive up, over and over, the end result being undue damage to an already low mood.

As if I were not being perseverative enough, I played the CD (well actually there are two) over and over on the trip home. I was on a roll and saw no reason to break my momentum. I returned in a very foul mood. Things at home were usually a relief so I knew this would probably not last.

Everyone needs to have a reason to get out of bed in the morning, and to my delight my son was still awake when I returned home. "I missed you Mommy" was all I really needed to cheer up my mood for the time. Even if he had been asleep, just seeing him sleeping seems to boost my mood. I have made the observation that no matter how horrific a child's behavior can be during the day, once asleep, he will always have the face of an angel.

That particular episode did not end up lasting very long and I was back to myself soon. If I have learned anything in this life, I have learned to allow myself those occasional spells of self indulgent pity- the crying spells in the shower that nobody else knows about, the tendency to play choice songs over and over in my car or on my Ipod when I am alone, the playing on the computer for hours so as not to have to deal with people. If I do, the noxious mood will pass, if not, it is going to hang around for a while. I have learned enough to know that in this area of the country, there can be some very long winters. Those really fun euphoric episodes do not show up until the bulbs start popping up.

I

The Real Meaning of Christmas

2010-12-19T21:24:00.019-05:00

There is a small mountain that borders along the town I live in. It has a beautiful overlook of my city and the valley that comprises the metropolitan area of where I work. During the holidays, there is a single star that is illuminated on the top of that overlook that can be seen from most of the city. Since there is no development behind the cliff that the overlook stands on, the star is on a black background and appears to be floating in the night sky, as if it really were the Star of Bethlehem. I like the star, but my son who questions the star, has not been able to understand the significance of it yet. The story of Jesus itself is one that he is unfamiliar with itself, and the concept of the Magi seems too much for a child's mind to understand. In these days of GPS systems, even maps are considered archaic, let alone following a star?

Sadly, I am not as religious a person as I ought to be. Raised in the Episcopal Church and very active in church activities as a child, I went off to college to study in the physical sciences which turned everything I had learned on end. Since then I have been a proper dyslexic agnostic who lays awake at night wondering if there really is a dog. There is still a bit of Christian in me however and I respect the value of the Christian holidays at least. I am very offended by the commercialization and secularization of the Christmas Holiday. I do not say "Happy Holidays" unless I know the individual for certain is not Christian. I have even gone through spells of attending select churches, lead by certain priests that I feel have a particularly good message to relay. My battle this year is trying to convince my son that there is more to Christmas than Santa Claus and getting presents. They tell me the obsession with Santa Claus will be over soon enough so just let it go and I have done my best to heed this advise.

So why do I have much concern for the sanctity of Christmas? Why do I bother to attend church at times when I am so agnostic in my own beliefs? Simple. When one weeds out the propaganda, outside influences, medieval dogma and other outside influences, I feel very strongly that the message that Jesus himself had to convey carries great wisdom and is worth hearing. Some of the things that he said actually sounded quite similar to teachings of other religions that had origins in faraway places. Perhaps these are the real universal truths that are so actively sought for.

For me to be convinced a particular belief in Christianity is valid is knowing that it was one that was put forth by Jesus himself. There is a huge laundry list of conclusions that have been drawn from the writings of the New Testament that were never involved Jesus himself. In fact, the vast majority of writings included in the New Testament were written post mortem. Even if excluding the accountings in the Gospels of Jesus returning to Earth after rising from the dead, there is still very little of the New Testament that documented the actual life of Jesus Christ. An enormous part of the New Testament is written by a man who never even met Jesus and largely involved his interpretation of what he believed to be the message Jesus was trying to convey. If we do not accept second hand information today as reliable, why do we allow a religion to be based on it?

So much for my proselytizing. There is a great deal of wisdom that Jesus had to share and his message was actually very simple in complexity of things that he asked, but at the same time, extremely hard to follow. If everyone were able to follow his teachings, the world would be a better place. I am certain of that, but this planet is populated by a diverse group of people with their own religions, cultural norms, and belief systems and it would be unrealistic for this to happen. There are some things that Jesus himself said that have always stuck with me as having great enough value to heed whether I resolve my own doubts or not because they are so profound in their wisdom that they reach beyond the norm put forth by ordinary man.

Love thy neighbor. - This is not always easy when the guy's dog keeps digging up your garden and his kid throws beer cans in your front yard. People had been killed over trivial disagreements like this. If we cannot get along with our own people, who can we get along with?

I feel I need not mention love thy God. That is a given.

Love thine enemy - He meant it when he said it. Even the most corrupt, evil person in the world can love his neighbor. It takes a special person to love his enemy. We need to try to understand each other better. Love terrorists? Perhaps we need to understand why they came to be- Western interference with Middle Eastern affairs. The root of anger is fear. They are afraid of the power of the Western world and losing control of their lives. They just choose the wrong way to show it. A little more understanding between both parties would save a lot of suffering.

To reach the Kingdom of Heaven we must become like little children. - Really not that surprising when you consider it. It is a central tenet of Zen Buddhism. We are perfect at birth and become tainted with time. To fully be enlightened we must cast off this dogma and return to our pure state. Babies are not evil. They are babies, are pure, unadulterated. They are somebody's perfect little child with pictures being sent all over the globe on Facebook. Even the ones that grow up to be criminals and terrorists.

If thine enemy smite thee, turn the other cheek. - A hard point to swallow, but one cannot lose a fight that one does not get into. Sometimes the bigger man is the one who shows a little humility.
Let he who is without sin cast the first stone. - What gives any of us the right to judge another person when we are not perfect ourselves? We all do it, though and it is very hard not to.

Of course those who are Christians celebrate the birth of Savior each year to forgive our shortcomings. Every year I place candles in the window to welcome the baby Jesus to our home and there is a star on the tree to lead the way for the Maji (who arrived two years later, by the way). And that is the real meaning of Christmas, whether Wal Mart likes it or not.

So if you are Christian have a Merry Christmas and I hope you are able to celebrate with family and friends. If you are not, I hope you at least get some time off to enjoy your family and friends.

Peace to all.

Card Sentiments That we Really Need

2010-11-29T13:51:00.007-05:00

I am not a typical woman, sending soppy greeting cards for even the slightest event in one's life. You know the kind- the covers are usually graced with butterflies, sailboats in the sunset or still lifes, most often with kittens in the foreground. On the inside, they have VERY long verses, so long that they have to be written on both sides of the card's interior. Face it, no one reads that. Usually the nausea starts kicking in too strong halfway through the first side for the reader to go any further and the rest is skimmed to the ending to see the business end- what the card is trying to convey - Happy Birthday, Congratulations on your new baby, etc and who sent the card. I do not send those cards. That said, I do not send fart joke cards either. I have some degree of taste. I will send humorous cards, just not Delta House frat boy cards.

There are cards that I would have liked to have sent, but did not for reasons of family unity, world peace, decorum, etc. I know there are some who will send those "I can't believe he did it" kinds of cards, I have seen it happen. A friend in college sent a sympathy card to a friend who married a woman with a case of raging borderline personality disorder. Was it the right thing to do? Probably not, but it was funny as hell and none of us in our social group got along with his new spouse very well. We hated to see him suffer and new that as long as he was with her, that was what was going to happen to him, so it did seem appropriate.

There are a lot of card sentiments that really could be put to good use by those of us who are gusty enough to send them. If only they could just divert the poets long enough to write them. For example:

Congratulations on your new baby...

-Too bad he/she is so damn ugly.
-I think he looks like the mailman, how about you?
-Maybe this one will beat the odds and have brains.

Congratulations on your Marriage...

-we wish you the best, but he is sleeping with your maid of honor so we all know were that's going.
-maybe this time it will last.
-It had better last considering the washcloths on your registry cost $90.

I'd send you flowers on Valentine's day but...

-I think you're and asshole.
-But I figured we might as well skip the dying flowers and get to the point so I sent condoms.
-I sent them to yo mama.

Happy Birthday!

-Try not to puke in your designated driver's back seat this year.
- You don't look a year older than 100!
- Don't forget to check your blood sugar before you eat that cake. Remember how you ended up in the ER last year in diabetic ketoacidosis.

Happy Father's Day

- I got you your favorite- cheap beer and generic cigarettes!
- even if you did beat the crap out of me and mollest my sister whenever Mom went to visit Grandma.
- I hope you enjoy your card because if you do not stop whining about the condom breaking, this if the last one you will see.

Happy Mother's Day

- to the Travel Agent for Guilt Trips of the Year.
- even if you did like my brother better.
- I liked you a lot more when you were still in the State Hospital.

Card Categories that should exist but do not

2010-11-26T22:30:00.004-05:00

Rather than
-For the Happy Couple
try
-For the Unhappy Couple

Instead of
-New Baby
we need
-New Crack Baby

Instead of
-"Sweet Sixteen" birthday party invitations
we need
-"Sweet Sixteen" 10 Kegger While the Parental Units are in the Bahamas invitations

Instead of
-Baby Shower cards
we need
-Unplanned Baby Shower cards

Instead of
-Wedding invitations
we need
-Shotgun Wedding invitations

Instead of
-Mother's Day cards
we need
-My Baby Mama Day cards

Instead of
-Father's Day cards
we need
-My Baby Daddy Day cards

Instead of
-Generic "Happy Holidays" cards
we need
-I hate the F#&*ing Holidays cards

Instead of
-Ridiculous "Happy Hanukkah/Christmas/Kwanzaa/Chinese New Year/New Years Eve/Some vague Catholic Saint that no one has ever heard of day cards
we need
-Let's All Go Act Like Douche bags for Two Weeks at the End of Every Year for World Peace cards

Instead of
-Valentine's Day cards
we need
-I Bought You This Card Because You Would Think I'm a Dick if I Didn't Day Cards.

Instead of
-Happy Sweetest Day cards
we need
-Happy Increase the Profit Margin for Hallmark by Creating Another Stupid Holiday Card.

Next entry- card sentiments that we really need rather than that soppy Hallmark poetry crap that no one had the patience to read.

A Child's Love

2010-11-11T13:00:00.007-05:00

In our busy days we sometimes forget the innocence of children. My son knows that I am a doctor and I have tried to explain what a psychiatrist is, but it is certainly hard to explain what depression or psychosis is to a four year old who has not experienced it first hand. He has been up to the staff lounge where I work briefly, but because of confidentiality reasons, not to mention safety, he has never been on the actual unit proper. He has no idea what an inpatient psychiatric unit looks like. All he knows is on weekdays, Mommy goes to the "hosipal" to help sick people who are sad. He also knows there is a helicopter outside Mommy's window and that is pretty cool.

Fortunately, with the exception of the month he spent in the NICU after he was born, he has never been admitted to a hospital. He has visited some very nice ER's though, where he gets stickers and people tell him he is cute and a very brave boy and he gets to lay or sit on a special bed with bars with Mommy or Daddy. Once, he even got "a big pill up my butt", a fact that, rest assured, he will tell you about. In all three of those visits, he was sent home with more stickers and people telling him he was a brave boy. It never occurred to me that he did not realize that people stay in the hospital as inpatients.

I discovered that earlier last week, the last time I had to take call. I took a call from the ER about a potential admission. Business has been good and we have been running full. "Do we even have a bed?" I asked. Once that was clarified, I accepted the admission. My son overheard the conversation and his response was not what I expected. He gave me a quizzical look and asked "We have a bed upstairs?" Of course we do not. Our house is a ranch house without an attic and I could understand his confusion as he does not always separate telephone conversations from the one in the room. I explained that I meant, do we have a bed on the psychiatric unit where I work, which is upstairs from the ER. He still seemed surprised by this and had to tell my husband. "Daddy, they have a bed upstairs at the hosipal!" followed by the question as to why we kept beds in the hospital. I explained that these were for the patients to sleep in when they stayed there. "They stay there at the hosipal?" I did not realize that he did not know that patients stayed at the hospital. His only experience with hospitals that he would remember are the ones above. He had never been exposed to a situation where he had to experience someone as an inpatient. This idea was all new to him. I got a good laugh about this and went to work with a new "my son said something this morning that was so cute" story and went about my day.

I thought maybe I should show him some pictures of his month long ordeal in the NICU when he was first born. He had been told he was a "preemie" and spent a month in the hospital before but never paid much attention before. I asked him if he recalled being told about being in the hospital for a month after he was born which he really did not have much memory of. This time was interested to see the pictures. I showed him pictures of the warmer he stayed in at first, then the small crib where he was kept tightly swaddled to help with muscle development in a premature baby. He saw all the tubes, heart monitor leads, oxygen monitors. I told him that we came by three times a day to feed him and that the nurses fed him with a tube the other times. I showed him the feeding tube. That's when his response really moved me.

We probably felt worse leaving our son than he did being left behind. Preemies in general cry when they are disturbed too much. They have important things to do, like grow, so they do not mind being left alone. The mind of a four year old is different. When I told him that we came three times a day to visit then went home, he started crying and said that he missed us when we left. It was very touching. I reassured him that babies that little do not have that kind of awareness but he insisted "but I really loved you guys and I didn't want you to leave." Of course at his age, it is hard for him to process having feelings any different than the ones he has right now, but I also know from his response how much my husband and I are loved by our son. That means a great deal to me.

Money can buy you things that might make you happy at times, but a child's love must be earned and will bring more than happiness. It will give you a reason to get up in the morning every day.

Why I Changed My Name

2010-11-01T12:43:00.009-04:00

Artistic license only goes so far in medicine and I have run into a road block in that arena. The dilemma I have run into is that the powers that be have concerns about the content of my blog possibly compromising patient confidentiality and have put limitations on what I may write in the blog. While I understand their side, it does put fairly strong limits on what I am able to write about. I am fearful of writing anything that could offend them. The end result is the vast majority of things that I write about do not have anything to do with psychiatry at all. That or if there is any psychiatric content, it comes out more like a textbook than anything of much interest.

I felt that considering this situation, it would be best that I change the name of the blog to one that is more suited to what I am really writing about. This will allow me to write my posts without the pressure of trying to find a completely neutral topic in psychiatry but end up with one that is not very interesting. There is plenty of things to talk about in my life here. I am, after a big city girl who is essentially stranded in a small to medium size town in the middle of nowhere with very limited access to Nordstrom, true fine dining and cultural activities. What they do have is hunters with guns. There are also monster trucks with deer head decals on the back windows and rubber testicles hanging from the trailer hitches. There are critters here that we do not encounter in Ohio, like bears and bobcats, some of which tear down birdfeeders and poop all over our lawns during the Spring and the Fall and the people here just accept that as the way it is. There is also another fine selection of critters to dodge on the roadways, not the least of which is skunks. I could go on and on about the differences of the area in which I reside and the area in which I grew up but suffice to say that there are a lot of things to talk about. Which is why I have chosen to change the focus of the blog. Therefore I give you...

Lost in Central Pennsylvania

An Old Home Dies

2010-10-30T17:20:00.020-04:00

On a busy corner of a main street in my town there sits a blighted house. Not much different from all of the hundreds of other blighted houses out there, but this particular house sits near a friend's shop and I drive by it quite frequently. Devoid of all exterior coverings that one would expect to find on a home, it is particularly hideous in appearance.

She tells me that it was reputed to have last been occupied by drug dealer. Once he was caught, the occupants disappeared and the house has been vacant ever since, at least by official occupants. Empty homes are a magnet for rats, pigeons and mice. Not to mention unwelcome human visitors who find such homes a good shelter from busy eyes, therefore useful for drug dealers and "shooting galleries".

Not that the house is totally without value. When I drive by, I see pipes, wires and windows, all which could be reused. There are two Satellite dishes that appear to be in good condition mounted on the side of the home. The pipes could be stripped and sold for scrap metal. Some of them may be reusable. The windows appear to be recent installations, albeit done shoddily in plywood nailed onto the original window frame. It is possible that they could be reused. If not, the glass could be recycled, as could the metal frames. The house is obviously quite old and on the interior there could be some quite beautiful light fixtures, hardwood flooring and other pieces that might be reusable. Of course those sorts of reclamation type demolitions take money. Old walls bear lead paint. Old tiles and insulation have asbestos. But eventually, that house is going to have to come down.

As do probably a couple hundred other blighted homes. It bears a red condemned tag on it as do all of the condemned homes. Most of the red tags posted on homes like these have long faded to pink or even near white. The owners are supposed to bear the burden of bringing the homes back to code or demolishing the building, but the cost to tear down the structure is greater than the cost that the property would sell for. In some cases the owners have simply died of old age and their children, if they had any do not want anything to do with the property and simply abandon it. The city is supposed to give the owners every opportunity to reclaim their property before razing the building causing even more delays. Federal stimulus money did have some benefit to the community in allowing several houses long awaiting demolition to be brought down and cleaned up. But the hundreds more waiting have yet to be touched.

The number grows every day. The area's long standing Republican representative does not live in the city proper and never sees the decay that his constituents see every day. Riding in on the coattails of his father, his long time tenure as Representative to Congress has done nothing to improve the economy in the area and the layoffs in the area grow daily. This is a working class community to begin with and many of the homes in the city are of little value on the real estate market. Certainly nothing worth fighting for when the foreclosure notice comes. The end result is another home is left to decay.

The recent removal of some of the blighted homes in the area of the city surrounding the downtown area has removed a few of the eyesores around town but it is only a drop in the bucket compared to the growing numbers that remain. The holes they leave look like the gaps in a line of poorly cared for teeth. This always leaves the question of what to do with the property. For the adjacent owners, the property would probably be a welcome addition to the anemically narrow lots they survive on. Homes from this era were built with little more than a few feet for a walkway to pass between them. The problem is that most homeowners in the area are either slumlords who do not care or poor homeowners who cannot afford to buy this land. The areas are too run down to redevelop without tearing down the entire area. The end result is displacing an entire neighborhood of people who can barely afford what they have. In some areas, local businesses have bought some of the properties, largely to pave over as parking lots, but the land does not go unused at least.

In one area where a large enough strip of land was cleared to be useful, the city made the decision to convert the area to a park. This, on the surface sounds like a good idea. To someone who has seen this before, it is a terrible one. I have lived in a big city long enough to see what happens in a small park surrounded by a decaying neighborhood. The children do get a playground to play on but the drug pushers quickly find a new whole new location in which to pick up customers. Get them young while they are too naive to know better and they become your slaves. Driven to dealing themselves to support their own habit, an entire new and growing network of addicts is born. There are always abandoned houses to hide in to shoot up.

I know what this city needs. We need jobs. But bringing jobs in is a lot easier said than done.

Can this city be saved?

Things I Tell My 4 Year Old that Nurses Tell Our Patients

2010-10-22T22:38:00.004-04:00

-Put your underwear on!

- If you are not going to wear clothes you are going to have to stay in your room. Nobody wants to see you naked.

- Stop playing with your penis in public.

- Don't use your sleeve as a tissue. That's what Kleenex is made for.

- You need a shower/bath. .... No you are not clean. You stink. And it does not count if you do not use soap. I know if you haven't used soap so do not try to sneak.

- Dinner is here. WASH YOUR HANDS before coming to dinner. I don't know where those hands have been but I know it is somewhere pretty disgusting.

- If you are going to yell like that you are going to need to take a time out in your room. (NB: 4 year old's who refuse get privileges revoked. Some patients get prn medications if they get really bad so there is some difference here.)

- Pull those pants up. Your underwear is showing. (Of course the 4 year old's reason for droopy drawers is the more benign thin body build while the adult/adolescent patient is just trying to play the "gangsta" role.)

- Stop picking your nose/butt at the dinner table.

- No biting!

- Watch your language!

-When was the last time you took a brush to that hair?

-You need to brush your teeth. Your breath is disgusting.

Internet Party Tonight

2010-10-19T13:17:00.008-04:00

"TV party tonight
TV party tonight"

"Don't want to talk about anything else.
We dont wanna know
We're gonna watch our favorite shows."

The song resonates through my head as clear as day. Like I was listening to the grainly old tape itself.

"Be back soon! We are down due to connection issues. We are sorry for the inconvenience."

That was the message the greeted me at the top of my ISP's home page when I sat down for my evening ritual of computer time. I have little time to use the computer and the brief time after my son has gone to bed and before I do is my time to catch up on email, Facebook, my blog and Twitter. Until this unwelcome visitor greeted me above.

Is is a tacit assumption that most readers are not familiar with the Black Flag song "TV Party" so I will explain the lyrics above. The song surrounds a group of pathetic losers who have essentially no lives and do little with their day but "watch TV and have a couple of brews." Their lives are totally devoid of any value and they take great efforts to avoid dealing with the reality of the world. When the TV breaks, their lives fall into chaos and they are forced to actually talk to each other, something they have never had to do before and are at a total loss on how to survive.

When I saw that notice about the internet being down, my first inclination was to actually play video solitaire rather than do something of real value. I realized then how my addiction to the computer and the internet, especially Farmland, had overtaken me. I have been able to cut back my use of Facebook and Twitter to a low roar, but Farmville is a consistent addiction. I HAVE CROPS TO HARVEST, FRIENDS' CHICKENS TO FEED AND GIFTS TO SEND! I need to stay on top of this as I need 2 MILLION COINS to get the HUGE farm. Whithered crops are just wasting money and that just will not do.

My mind pleads for mercy- "My Lord! How have I offended Thee?"

I think his response would likely have been "Do you want the whole list or just the top 10?" Fortunately, I was not that high up in his priority list to warrant a response.

So I am a pathetic loser. I could write these thoughts down now and transcribe them later (which obviously I did). I have done it before, I can do it again. There are always other things that need tending to either way that are of far more importance that electronic solitaire.

Then a light turned on in my head...

...I can still access the internet from my IPod and at least harvest my crops.

And another display in my mental Hall of Lame is opened.

"We stay tuned to the TV set all night-
and every night.
We don't go out into the world at all-
it's such a fright.
We've got nothing better to do than to watch TV and have a couple of brews."
Lyrics: Greg Ginn Performed by: Black Flag

Obamacare and Illegal Aliens

2010-10-14T21:25:00.006-04:00

I realize the Healthcare Reform Act has been very controversial. Some love it, some hate it, some support the idea but feel it needs revision. It is certainly being brought up a lot in the current campaign year. People have the right to their own opinion, but what really irks me is the constant misrepresentations of what the bill actually says. Political ads constantly bombard the public with half truths and sometimes outright lies to sway the public towards their candidate. Since so many people make their decision on those ads alone, and not on the reality of the candidate's true record or principles, I wanted to throw in my two cents on a few points as an example of how the truth can be distorted.

First thing, is I do want to make comment on the journalistic abilities of Fox News. It is not just because Glenn Beck is on my top ten list of men in the world most deserving of a thorough ass whooping, but I have issues with the station as a whole. Fox News was bought by noted conservative newspaper man, Rupert Murdoch solely for the purpose of pushing a hard core right wing agenda. They have no interest in the truth or providing non-biased information and often broadcast information that is blatant lies. If one is looking for the most objective reporting available, The Christian Science Monitor has long been noted for this, surprisingly enough. Even Oscar the Grouch's grouchy girlfriend on Sesame Street said she was going to watch Fox News because "now that's some really trashy news." I played that over numerous times on the TiVo to make sure what I was hearing was correct, and yes, the writers at Sesame Street went that far out on a limb. They helped to propagate the whole "death committee" rumor which never existed to begin. If done in error this shows the signs of very incompetent journalism. If done on purpose it is apparent this was reported with a great deal of intent of malice. The rumor initially propagated by a republican politician whose name escapes me put forth the statement that Medicare recipients would be required at regular intervals to meet with a committee to discuss their plans on how they intend to shorten their lives and prevent unnecessary medical expenses. There was never anything close to this proposed, but when Fox News and Sara Palin got word of this work she wrote to the story and ran with it. What really was suggested was to offer Medicare recipients "end of life" counselling, but it was never mandated. End of life counselling addresses issues such as designating a power of attorney, writing a living will or advance directive, etc. These are issues that do need to be addressed, and probably long before someone reaches the age where one can qualify for Medicare. Many families and providers have been put in a quandry when an incompetent patient without a power of attorney demands to return to an unsafe situation. Most famillies do not have the thousands of dollars needed to hire an attorney to start the process to declare a family member incompetent. Either way the process takes weeks, forcing providers to send these patients home. Many patients die as a result. Having a designated power of attorney to speak for the patient may result in the patient placed in a safer setting. In the long run, this could end up costing the system more, not less as implied by the "death committee" principal. I am not sure if the end of life counselling was dropped from the final product but do believe people are often too quick to act and make assumptions about something without really reading what the clause actually says. This type of behavior can have dangerous consequences in the long run.

My biggest area of contention is the constant barrage of political ads that distort that truth of a given candidate's opponent by taking certain clauses out context and twisting them to mean something completely different than the truth. I have seen far too many ads recently that stated that supporters of the Health Care Reform Act are giving out millions of dollars in health care to illegal aliens. Much of this stemmed from the initial version that did not have a clause in it that specifically stated that illegal aliens (or undocumented persons, or whatever term is the term du jour) were to be excluded in this plan. It did not state that illegal aliens were to be included in the plan either. It is very easy to take the phrasing of the act out of context and state that supporters of the bill are throwing dollars at illegal aliens for health care. That does not make it true.

I work in a setting where a large percentage of our patients are uninsured and have lived in area of the country that played host to large populations of migrant workers at certain times of the year. Tuberculosis runs rampant in these populations as does diabetes. Dental problems are a huge issue. HIV and syphilis are an increasing problems. With the exception of dental caries, these are communicable diseases that could get passed on to American citizens. But they are not monsters, they are humans, and yes, they too need medical care sometimes. These people do not receive health insurance from their employers. The American people need to stop bickering about who is giving money to illegal aliens for health care and who is not and face the fact-

We always have covered the cost of healthcare for illegal aliens, we continue to cover the cost of their care and as long as they are living in this country we always will. These people simply do not crawl in a hole and die when they get diabetes, they go to the ER. They do the same for TB, pneumonia of any other malady they suffer from. There are some areas where clinics have been set up to address their health problems but for a large percentage of them, they end up as high end utilizers going to the most expensive place possible to receive health care because it is the only place they can go when they do not have the money to pay for their care- the ER. Federal law forbids hospital ER's from turning patients away just because they do not have insurance. If they need inpatient care and there is a bed available the hospital must admit the patient or the hospital faces some hefty penalties. If there are no beds, the hospital pays at its own expense to send the patient to the nearest hospital that does have a bed. That law applies to every patient who walks in the hospital doors, citizen or not. Even without those laws, the Hippocratic oath does not only apply in cases of resident aliens and citizens and any physician who refuses to care for a patient because that patient is an illegal alien should have his license revoked.

Of course, the other issue is that doctors never walk into the exam room with the patient and start out the interview with "So Mrs S, are you an illegal alien?" I have never asked a patient of mine if he/she was an illegal alien and would put down good money nor has the vast majority of the practicing physicians out there. We do not know, we do not care. We do not treat "Green Cards". We treat people.

So who pays all those ER bills? You do. Personally, I would rather pay for a $40 office visit to a family doctor but that would be "throwing millions to pay for medical care for illegal aliens." Those that oppose the Health Care Reform Act may have a lot of good reasons to be opposed to it. There are a lot of stipulations that are not popular and some things that may not be the best option for the nation. Not wanting to pay for medical care of illegal aliens is not a good one. Repealing the Health Care Act would result in the taxpayer covering a $600 ER bill rather than a $40 clinic bill. Why? Is it because one does not want it "on the books" that illegal aliens can access health care. Doctors and hospitals are still going to treat our patients, whether they are illegal aliens or not. We have an ethical duty to do so and a federal statute (EMTALA Act) that requires it. Let the Tea Party say what they will. We would still be paying for health care for illegal aliens, just a WHOLE lot more.

Things I Just Do Not Understand

2010-10-06T21:55:00.008-04:00

Thongs on really heavy guys.

Men driving cars with Tinkerbell seat covers. Especially if the gear shifter has a skull for a handle.

Really ugly tattoos that look like one's skin is rotting off.

Glenn Beck

Women who bleach the top layer of their hair white and leave the rest dark so they look like a skunk.

Country music. Apologies to my brother, but we made fun of country music as kids, and I am not going to change now.

What the hell a Tarheel is?

Why they had to put this sign up at New Orleans Airport's security scanner. And why they did not notice that they wrote children twice?

How anyone would think that handpainting flames and putting a 2x4 as a spoiler on the trunk of his car is going to make it more attractive.

How 5'2" women with 2 children can justify owning a huge gas guzzling Chevy Suburban just because they have those 2 children and "need the space."

Who Justin Beiber is, and why he is such a big deal on twitter.

What a breakfast burrito is, and why anyone would eat such an aberration? Gross, sorry, but gross.

Why people pierce their tongues, lips, nipples, genitals, etc. It is sort of like the anti-dress for success. Like saying to an employer "Don't hire me. I'm on drugs and will steal your money and sleep with your daughter."

Why anyone would want to wear really huge ring dilators, except in the case when these are use to hide heroin or cocaine.

People who get hooked on heroin and meth despite knowing what it will do to them.

People who have children at 16 years old because they are partying so much that they make bad judgements.

People who neglect and abuse their children because they are too interested in their addiction to deal with them.

People who get so hooked that are driven to trafficking heroin to support their habits and still do not want to quit.

People who have watched all their friends die of heroin OD's but continue to shoot it.

People who have 2 and 3 year old children who are still children themselves who die of heroin overdoses because they could not choose their addiction to heroin over the lives they created.

I would rather put up with Justin Beiber.

Top 10 Songs to Wallow in a Sea of Your Own Misery To

2010-10-02T21:34:00.021-04:00

Autumn is traditionally a time people with seasonal affective disorder dread. The days are getting shorter and they know that they are going to start getting depressed. A lot of people are actually affected quite a bit by the change in the length of the days. The advent of artificial lighting has done wonders in creating depressed patients to fuel the mental health industry. I can discuss that in another post. In honor of the oncoming season, I present my favorite ten songs that I find particularly good at listening to over and over and over when I am feeling down. I apologize that most of the songs are rather dated, but since I have been working in small towns and did not until only recently acquire a satellite radio, I have been out of touch with "real music" as it were. Rest assured, though most of these are oldies, they are goodies:

10

"People Who Died" - The Jim Carroll Band

A song enumerating many friends of the writer who died, several through drug use. The sad point is driven home if one aware of the fact that this song is true. These were actually real people who died, and there were quite a few.

"Everybody Hurts" - REM

Until the release of Automatic for the People, REM's music was largely upbeat, and at times rather silly. Lyrics were most notably incomprehensible much of the time and this was a signature feature of the band. Not to mention their refusal to print the lyrics on the liner notes. This album changed that tone notably. This song, intended to cheer up the broken hearted missed the mark with its slow pace and melodic tones that had not been heard from Micheal Stipe previously and only made people feel even more alone. That said this was one of their best, if not their best album ever made. Then they started to suck. (Sorry boys. I love you, always will, but the truth is the truth and new REM is just not old REM.)

8

"The Rat" - Dead Confederate

One of the few contemporary songs on the list. Anyone who has ever felt brushed aside or labeled as insignificant can sympathize with the rat killed in the song because it is viewed as vermin to humans. Even worse for the rat is that it is brushed off at the Pearly Gates as well so even in death gets no respect.

7

"Every Day is Like Sunday" - Morrisey

I hate to use the Smiths/Morrisey more than once, but Morrisey is by far the best depressing music writer ever. Lacking the talent of guitarist Johnnie Marr, his solo music did not have the musical quality as the Smiths. Despite that, the depressing tone of the music lasted. Only Morrisey could successfully portray the image of being miserable while on vacation in a resort town. And to tie it in with imagery from the movie "The Beach" where the Australians are awaiting the nuclear dust cloud to come and rain down on them after WWIII and slowly kill them- absolutely brilliant!

6

"Misplaced Childhood" - the entire album, minus the last song- Marillion

Being so desperate for love one man falls in love with a prostitute. Then buys her a ticket to England expecting her to meet him there and actually get on the plane. Not surprisingly, he gets stood up and totally breaks down into a miserable heap of self pity. This concept album by one hit wonder Marillion must be heard in its entirety to fully get the entire range of emotions. The down side is the last song turns it all around and makes everything better, spoiling the whole effect.

5

"Wish You Were Here" - Pink Floyd

Written as a tribute to former (and now deceased) member of Pink Floyd, Syd Barrett. In many ways, an attempt to apologize for kicking him out of the band. Not that it did not need to happen. Barrett's bizarre and unmanageable behaviors interfered with his ability to perform as a musician. Ironically what was initially believed to be the result of excessive drug use turned out to be severe mental illness. Anyone who has been separated from a loved one can identify with this song and it is very useful to play it repeatedly, at least 10 times to really get one's mood down.

4

"Heaven Knows I'm Miserable Now" - The Smiths

Enough said.

"Grapevine Fires" - Death Cab for Cutie

Just the name of the band is morbid. A song about a couple, presumably in California, sitting in an elevated graveyard drinking wine while all of their worldly possessions burn to the ground. The woman's daughter dancing happily through the gravestones. Could there ever be a more peaceful sight? The lyrics, the pace of the song, everything, leaves this very solemn feeling of doom and destruction that hangs with you for hours. Great way to really feel blue all day long.

"How Soon is Now" - The Smiths

Not to be perseverative, but these guys are by far, the masters of misery and unhappiness. The Smiths have perfected the depressing song to such ridiculous heights that they actually become humorous. This one is a six plus minute long masterpiece of whiny lyrics, whiny sounding guitar licks, whiny everything. And it drags on long enough to really drive home the point. Most songs cut out after 3-4 minutes and do not have the chance to really sink in and ruin your day. This one has just enough time to do that without the endless droning of those songs produced by 70's acid rock bands that just got annoying after a while. The lyrics are indescribably depressing: "...so you go and you stand on your own, and you leave on your own, and you go home and you cry and you want to die." You simply cannot beat that.

and finally....

"The Wall" - Pink Floyd

This includes the movie and the album. The entire two record long album, for those of us who were lucky enough to have survived the years living with roommates without it getting stolen. Even the writer was miserable when he wrote it. The majority of the album was written while Roger Waters was going through heroin withdrawal in rehab. The theme of the story is semi-autobiographical in that the main character, like Waters, lost his father as an infant while away at war in WWII, developed a terrible heroin addiction and had a lot of unresolved emotional conflicts. It helps to see the movie, but only in a good movie theater or at least a home theater system with a good surround sound system, and it helps to watch the movie a good three of four times. At first it seems rather incomprehensible. It takes a couple viewings or the explanation of a veteran of the movie to understand what is going on. What is quite certain is the main character, Pink, is quite miserable, and spends the vast majority of the movie pondering the terrible experiences he has had throughout his life and really does not like to be disturbed while he is busy being miserable. If you do not want to go so far as to see the movie, the album is still pretty depressing, but the story is not as clear. You might best to well to listen to "Hey You" and "Comfortably Numb" over and over again until your roommate whacks you over the head with the turntable that you worked so hard to hunt down so you could play that two album set that you worked so hard to keep from getting stolen.

Now for the instructions on how to wallow in your own misery:

Pick out your favorites, and I am sure you know many of your own, download them onto your IPod shuffle, lock yourself in your room with too much ice cream/cake/cookies, pop, beer, Red Bull, whatever makes you happy and play over and over and over and over and ...... Ignore the rest of the world. Blow off your roommate, especially if you do not like him. Or family, SO, etc. Repeat.

In the end of it all, after you have had your few hours of crying in your beer/energy drink/diet pop, eaten three gallons of double chocolate chip ice cream and missed the biggest party of the year sitting locked in your room burning out your IPod, it is time to realize that while it is good to have some time to let the pain out and stop internalizing your feelings so much, that life goes on and you need to break out of it. If you find yourself following this ritual every night, there is a problem and you need to seek help. More people than you might realize do, including many of the musicians that wrote the dreary depressed music above because they were, after all, depressed when they wrote it. That did not mean they were unable to write after being treated, but the tone of their music was different. Besides, you have been hogging all the double chocolate ice cream and I want some, too.

Objects in Your Mirror are Larger Than They Appear

2010-09-22T21:40:00.022-04:00

"It's just a bug." That is what the social worker on the unit told me the other day when I related the heroing tale of my treacherous drive to work. Normally I would agree with him. Most bugs do not bother me, nor do spiders or snakes for that matter as long as they are not pit vipers. Even in Pennsylvania, we have a few species of those. But this was no ordinary bug. This was a monster, by far the largest dragonfly I have ever seen, and I have been in the rainforest in Costa Rica so I have seen some pretty big bugs. This thing did not belong in the Eastern Allegheny Mountains. But it was there, and it was IN MY CAR AND IT WAS GOING TO GET ME! NO REALLY!

Actual size photo of a different man eating dragonfly.

To begin the story, it was any normal Monday. I was driving along my usual road with the once polluted river on the left. There was the strange house with rusty farm equipment and a chicken running loose in the front yard on the right. There was an SUV in front of me, a pickup truck behind me and we were all going 10 mph too fast. Any normal Monday. We all turned right on the US highway and made a fast left on the two lane road that is badly in need of widening. There we all tried to drive 10 mph too fast, but were as expected slowed down by a school bus, dump truck carrying gravel or some old guy who just does not get the point that some of us have somewhere to be at 08:00 and drives 15 mph too slow just to piss us off.

It was somewhere in that transition between going too fast to too slow that I heard the loud buzzing noise in the back of my car. It did not take too long to identify the creature that was making the loud buzzing noise looking in my rearview mirror as it was a HUGE BLUE DRAGONFLY WITH A FUZZY TAIL THAT WAS A BIG AS A WOOLLY WORM. I am not exaggerating this. I am not the kind of person that would normally fear a dragonfly. This was the sort of nightmarish creature that only appears in B rated science fiction movies from the 50's with names like "Attack of the Killer Dragonflies". This abhorrent monster was keeping me company on the way to work while trying desperately to get out of the back window by pounding on it with sheer force and not succeeding. So there I was on a busy road in a line of cars being deprived of any reasonable chance to arrive at work on time and there was nothing I could do about it. I tried the usual interventions. Open the rear windows, no bites. The dragonfly briefly strayed from the base of the window to the top so I tried opening the sun roof thinking maybe it would continue its upward ascent. No go. The monster went back down to its point at the base of the window where it had been on guard most of the trip. I should point out that it was about 55 degrees outside and opening the windows was not exactly pleasant, especially at speed greater than 40 mph. It was a sacrifice I was willing to make if it would get this creature out of my car but it never did work. I had that bug in my car the whole trip and worried the whole time that something awful might happen like it might fly in front of me and get in the way of my view or poop on my leather upholstery or worst of all...

IT MIGHT TOUCH ME! Bug germs! Ewww!

By the time I got to work, the dragonfly had wedged itself between the glass and the shelf below and I was not ready to have a dragonfly carcass decorating my rear window. Like it or not, I was going to have to extract the monster myself. My first attempt by trying to scare it out with a pen made it dig in even deeper into its hole. By then all that stuck out was the tip of the tail which looked surprisingly like the stinger of a scorpion to me. A bigger woman would have just grabbed the tail and pulled the dragonfly out herself. I am not a big woman. In a panic, I dived into the front seat to extract a tissue from my ever present tissue box that resides in my car for my ever allergic sinuses and with that, I grabbed the dragonfly/woolly worm tail and extracted it.

The dragonfly, apparently finding itself under attack, turned around and attacked back, twisting its body around on its tail 180 degrees and attaching to the tissue with a steel grasp. Up until this point, I had not realized that dragonflies had flexible tails. But apparently, the Mothra species does, and this one turned quite readily. I was at least able to get the tissue out of the car along with my radioactively altered friend who had decided he did not want to let go of the tissue and clung to it for dear life as a shook it like a madwoman trying to get it off. Thankfully when it finally did let go, it did not go back into my car but took off into the strange environment it had been transported to. Sadly, the "big city" is mostly concrete and urban blight and this creature came from a mostly wooded area. It may not feel all that comfortable in the blocks of row homes it will find here. Perhaps there will be enough trees to survive in the cemetery across the street from the doctor's lot. (How's that for irony?) I honestly wish the dragonfly no harm. I just do not want it serving the role as my new navigator.

One thing was for sure. I was not going to offer it a ride home.

Shanksville

2010-09-14T21:52:00.008-04:00

With it being so close to 9/11, I hear a lot about Shanksville. I do not live all that far away from the city since moving here, and it seems to be a fairly sleepy town for the most part were it not for the tragedy that happened that day. I thought of Shanksville writing my last post as the site where the plane crashed was actually near an abandoned strip mine.

Every crash site from 9/11 seems to have taken on a different symbolism in American culture. "Ground Zero" will always be know to Americans as the former site of the World Trade Center and have a strong association with firefighters and emergency workers who lost their lives charging into the building trying to rescue survivors. This is sometimes taken to a fault as the multicultural nature of the building was lost in the tragedy. People from many places in the world died, probably some from countries that are sympathetic to terrorist causes. The World Trade Center was the WORLD Trade Center. It was not just Americans who suffered that day but people of many countries and this seems to be a neglected fact.

The Pentagon was the military site, regimented and organized. The loss of human life was kept to a minimum. The military does not leave itself vulnerable. The frightening thing was that there was loss of human life. They were hit totally unprepared and the fact that they were was scary. It meant that we were not as safe as we thought and the bad guys could come and get us when our scouts were not looking.

Shanksville was the site of the common man. There was still a crash and a terrible loss of life, but the terrorists failed in their objective, apparently to crash into the White House. This was the only plane where the passengers had the courage, stealth and fast thinking to be able to overcome the terrorists before this happened. As a result the airplane crashed in Shanksville, essentially in the middle of nowhere. Sadly none of them survived. Had they crashed into the White House, none of them likely survived either, but the loss of life and chaos that would have resulted might have caused irreparable damage to our nation. They saved our country.

They are a symbol of what average people can do when they get together and try. It does not take great strength, intelligence, wealth or power to achieve things if people work together.

While there is work being done on what will certainly be an elaborate memorial at Ground Zero and a very elegant memorial has already been built at the Pentagon, lowly Shanksville is just beginning to start on their memorial. They still have yet to raise the funds to pay for it. One of the hold ups was getting land owners to agree to sell their land to make the memorial. This is a conservative area of the country and people are very devoted to their little piece of the Earth. This is the only place I have ever lived where people regularly talk about living on "the family homestead." This is an area with pockets of Amish, Mennonite and Brethren communities that live off the land and simply are not used to this kind of attention. The "memorial" today still is a makeshift hodgepodge of ribbons, flowers and notes left by the visitors to the site. In a lot of ways more moving and bearing the pure emotion of the people who left these items.

But maybe the people on the plane who lost their lives would have wanted this anyways. Something more human, less exotic and more in touch with the real world. Something that represents them.

GPS and the Coal Mines- part II

2010-09-10T22:03:00.009-04:00

I left you at the point where the pavement disappeared. We started to question if the road was going to disappear altogether, but that continued, in the form of a gravel road. We had gone that far and survived enough adventures that we figured it was worth continuing. Besides, the little box on the dashboard said this was a road. Must obey the little box.

So the road continued over a slight rolling hill and it reached a point where it certainly did not look like there was any more road ahead, but the GPS said to carry on. The road started withering away into mostly dirt at that point and was largely indistinguishable from the ambient dirt if it were not for the tire tracks. The tire tracks let us know that some humans had driven there at some point. Otherwise there was no sign of human life here. No farmland, no road signs, fences, nothing. Just a dirt road and a GPS that indicated that a road went through this space.

Even my husband had serious questions as to whether or not to press on at this point. I felt that since we had gone this far, we had probably reached the point of no return and needed to press on. "Are you sure there is a road up there?" was his response. I reminded him that he had put his faith in the GPS so far, he was going to have to suffer the consequences of the results now. So we continued on the vague scars on the dirt that comprised a road over this hill. At the bottom of the hill, we finally found signs of human life, just not what we were expecting.

"Oh, look Mitch!" I said to my four year old son. "There's some dump trucks. Your favorite." And there were dump trucks. BIG dump trucks. The kind that one has to climb a flight of stairs to get to the cabin dump trucks. The ones that are so huge that they have to be built on site because they are far too large to be driven on a street.

The kind that are used in mines. Strip mines, generally, and in Central Pennsylvania, this is coal country. And we were driving right towards the entrance of a coal mine.

That @%#ing GPS had just navigated a suburban family in a midsized SUV into a coal mine. A white SUV to be exact. Not that the color should mean that much, but really. It was obvious to all present that we did not belong there. Remember that Garmin commercial where it suggested that a Garmin GPS would prevent the disaster of getting oneself stuck in the middle of a coal mine or other unsavory place? The commercials they show at Christmas where they totally cheapen the Christmas carol in order to sell their product? If you do not, wait a month. It will be back on the TV soon enough. So Garmin, hey! WTF?

That said, there were no "No Trespassing" signs, gates or other markings to say that we could not drive down the road that passed the coal mine, so we kept driving. We had already violated the inner sanctum. We might was well go whole hog and drive right through. Every few feet the constant question of whether or not the road was going to continue on to some sort of paved type state route came up, and surprisingly, the road did continue onwards. The problem was that as we drove on, we came closer and closer to those really big dump trucks that are not allowed on standard roads. We also moved closer to really big front end loaders that could pick up ten of our horrifically bourgeoisie SUV's and dump us into one of those really big dump trucks. If the drivers of those front end loaders knew how much I dislike the coal industry and how supportive I have been of their nemesis, wind farms, some located in clear view of the mine, one of them just might have done that. Probably the scariest part is when one of those really big machines decided it needed to go somewhere else in this barren landscape, it drove out of the mine proper and right past us on the minimally visible dirt path that the GPS sent us down.

"I can't believe you drove us into a d.....arn coal mine!" was stated more than once and had a four year old child not been in the back seat, the commentary would not have been nearly so G-rated. Yes, it was a struggle to censor that commentary. "We're gonna get arrested or killed or something!" My husband's response was basically we ought to just move as quickly as we could but that there were no signs saying that we could not drive on the road so he hoped no one would give us a problem.

My response to anyone who would tell you that there is such a thing as "clean coal" is bull&%#. Coal is not clean and anyone who has ever driven a white SUV through a coal mine can attest to that. Although the ordeal of actually driving past the actual strip mine probably only lasted 5-10 minutes, the coating of black soot that covered the car was amazing. This was not just dirt from driving on a dirt road. That dirt is light brown and hazy. This was pitch black and literally coated the entire car. My husband had to scrub down the rear doors for fear that our four year old would touch it and spread black hand prints on everything in Somerset County. The car looked like it had been passed through a cloud of volcanic ash and the residue rather had the consistency of ash.

Not too much longer after finally clearing the danger of the huge coal mine machines, we actually did get to the road that we were looking for as promised. The GPS did actually get us to the resort without a hitch from that point on.

Our lungs are hopefully not too scarred from the experience and the car was able to be restored to its original color eventually after a thorough scrub down. I am sure the boys at the coal mine got a laugh at their befuddled suburbanite visitors that day. And at least I can say that I can add "driven through a coal strip mine" to my list of interesting experiences, and I am lucky as I have had quite a few. I imagine that if we put our trust into that little brainless box too much in the future, we will probably have more. The problem is I am afraid to find out what.

At least I cannot say "set the cake table at my wedding on fire and had the firemen show up" as one of my direct adventures. I was witness to that event but it was not my wedding. That honor goes to my cousin, who also has a blog on Blogger. I will leave it up to her to choose whether or not she wishes to divulge the details of that little adventure. That's a pretty good one, too.

GPS and the Coal Mines- part I

2010-09-06T21:43:00.007-04:00

I admit it. I love technology. I grew up in that cusp between giant mainframe computers that took up a whole building and Blackberry's with more memory than the original Macintosh computers. I took the usual computer programming course in high school, learning BASIC on TRaSh 80's. I learned about binary numbering systems. I watched the Macintosh revolution. I even know how to program the time on my parent's VCR. I have saved both sets (they are divorced and remarried) of parents from the horror of having to hook up a DVD system and actually get sound out at Christmastime. I do not have every gadget that comes out the second it comes out, but I have a lot.

But I love technology with one caveat. Machines are dumb. They do not think. Computers are machines and they do not think. I like technology to the extent that I am in control of it, it is not controlling me. Which is why I do not have a GPS system in my car and am hesitant to use my husband's GPS when he offers to loan it to me. That machine definitely does not think, and using it requires that one allow a snotty little voice be the boss.

I like maps. I like to look at maps. I always have. When preparing for a road trip, I would pour over the maps, plotting out the most interesting, the fastest, or most scenic route to take. My excitement for the trip growing daily with every little turn I figure. I know how to read a map. I can tell a four lane divided road from a small by-road. I can tell roads that are likely to be curvy motion sickness barf-fests by looking at the map and where the road goes. I can tell when a side road is likely to have a lot of delays by looking at the map. That is why I have AAA. So I can always go and get the most up to date maps. Roads do change with time so one has to prepare for this inevitability after all. They are not perfect, but I like them. Maps do not think but I think. I am in control.

So I really do not like my husband's GPS that much. That little box has caused more trouble in our life than a bevy of gremlins (not the AMC kind) could. In one particular instance, the road map showed clearly that one could not turn from Union Ave to 8th St as it was an overpass. The GPS did not see that. It saw an intersection and told us to turn onto 8th St. It gave us a lot of grief when we did not turn off the bridge on to 8th St, hurtling 20 feet or so down to an almost certain death. After it threw its little hissy fit, it "recalculated" and told us how to get to our destination. I have never had a map try and kill me before.

Our most recent escapade with the GPS involved a trip to the local resort where we discovered the previously mentioned most totally awesome AMC Pacer Wagon in existence. My husband was the one who wanted to take the side trip to the tallest point in Pennsylvania before checking in. He likes to go to really remote places that require driving on a lot of curvy roads that take you to scary places where people do not have running water or teeth. You can hear the sound of banjos in the distance. The curvier the road the better, especially if it has a lot of pot holes because I have problems with motion sickness and it really makes for a fun trip when Mommy wants to throw up and gets a terrible migraine. Puking over a guard rail is one of those things that I really do not aspire to put on my list of experiences that I am proud to say I had before I died.

So we went up a lot of curvy roads to get to a nice enough state park where there was an observation tower that gave us a beautiful view of lots of trees. No breath taking view over a valley, no mountains in the background, just a lot of trees. Not worth puking over the guard rail. So we headed out to our final destination to the mountain resort on more curvy roads.

But the GPS directions were confusing, sending us on overlapping roads so we could not tell which road we were supposed to be on. We ended up on the wrong road. So we tried to figure things out with the map. It did not take us very long to figure out that we were going the wrong direction on the highway and needed to make a 180 degree turn. No problem, just turn around and it would take us to the road we were trying to get to. That would have been the smart way to go. I had the map and a handle on the situation at that point. I knew exactly where we were going.

But NOOOOOO!

My husband wants to let the GPS give directions since it has more detailed roads in its files. He turns off the road before we were supposed to on the original directions. "Are you sure about this? This road looks like a pretty minor road. Maybe we should go back to the main road." was my response. He responded with "This looks like it is shorter and will get us back to where we are going more quickly. The GPS says the road will take us straight there."

So we drove on the minor side road for a short time. And it got a little narrower, and we reached a point where it was obvious the road was not used much, as the edges were crumbling. Then all of the houses disappeared, then the farms, then signs of human civilization.

Then the pavement disappeared.

That is where I will leave you in the tale, but the good part comes up next so check back.

The Week in Review

2010-09-05T21:39:00.002-04:00

Not much time, so I thought I would summarize the interesting events of the last few weeks at work for you.

-I met a patient who thought that the rock singer Billy Idol was the Messiah. I would hate to see who she thought was the anti-Christ. Personally, if I were in the position to pick a rock star as Jesus, I would think more like Bono or Peter Gabriel, or someone else who has put a lot of work towards improving the Earth/Human condition, etc. Somehow the pseudo pop punk sneer just does not do it for me. I have been hearing a lot of songs from my youth in my head as a result. I am sure I do not like it.

- I was flipped off in a new and even more creative way than all the past creative ways that I had been flipped off by a patient. He even had the style to deny that he was flipping me off, stating he was just showing me how swollen his middle finger was since he broke it years ago. It was the wagging both middle fingers around trying to compare them that pushed it over the edge. I will have to keep that maneuver for my extensive "flip off" repertoire. Some of those gestures come in handy, you know?

- We have had a mysterious underwear burglar on the unit. Some of the patients (all female victims so far) have been fairly polite about the whole thing, but some have not been as so gracious. The worst part is hearing a description of the kind of panties your patient wears. The best part is knowing that your patient does in fact wear panties.

- Morning team rounds got off track one day, straying from a patient's eating disorder as a way to cover up her poor self esteem, to why would anybody want to buy a set of underpants that makes one's butt look bigger? The name of said product was something like "Booty Buddy". I have this suspicion that I will get a pair at my next birthday which is coming up in a few weeks. I take a lot of torment for my rather slim build and I do not expect that to change.

- We have one patient who thinks everyone but one patient and me are trying to kill her. That one patient thinks she is trying to kill him. One patient who things everyone is out to get her. We have one patient who talks to God, one who preaches the word of God. One who has had a case heard in from of the Supreme Court and is preparing to have a case seen in front of "Federal Court". Then we have one really depressed guy who just tries to stay sane.

- None of our patients were caught in any drug busts, but one was hauled in on assault and battery charges.

- And the staff sits in the back and tells politically incorrect jokes about booty buddies trying to keep themselves sane.

Peace.

Wind Turbines and the Coal Mine

2010-09-04T21:38:00.006-04:00

One thing you may find about me is that I have a lot of concern for the environment. That may surprise you with my obvious love for cars, but the majority of our carbon emissions actually come from electric producing coal plants and cars can be made more fuel efficient. It does not matter what the industry says, coal is pure carbon and when burned it makes carbon dioxide and carbon monoxide. There is no such thing as "clean coal". Or as a work colleague of mine pointed out, it was clean in the mesozoic era, when it was in the form of dinosaurs and plant life. Now it is just carbon. Oh, and sometimes sulfur and other contaminants that create acid rain.

But the problem is that I live in central Pennsylvania which is Coal Country with a capital C. It is ironically a very good place to develop wind farms and the two industries make for strange bedfellows. They do not like each other, that is for certain. There is a lot of anti-wind power propaganda in this area. So much that they have even been able to convince the Audubon Society, of all people that wind power is bad and kills birds. What, and global warming does not? I have watched those wind turbines daily and they go so slow that only the sickest or most inept of all birds would be likely to get entangled in their blades.

The actual building of the turbines is something that one could have an objection to. The blades themselves are enormous, being longer than a standard truck trailer and requiring an oversize load carrier to be transported. There is a facility that stores them very close to where I reside and when they try to bring one through town, it makes for some sticky traffic snarls. The engines are no better being just as bulky and difficult to transport.

One of the biggest complaints offered against wind turbines in this area is the damage caused construction done on the tops of the mountains. To this I respond, it is better than scraping the tops off and dumping the remains in the valleys below causing certain environmental disaster and a flattened mountain in its place. This is a practice known as mountain top coal mining. Through a loophole in environmental regulations during the GW Bush years, this practice increased exponentially causing massive damage to homes, mountains and forests in West Virginia ever since. Yes, there will be damage to the environment to build the roads up to the top of the mountains, but this is no less damaging than that damage caused by roads built to put up cell or radio towers.

Certainly the question of aesthetics has been put forth. Wind turbines are no worse than all those cell phone towers they are putting up and nobody complains about those. Those cell towers are an ugly scar against the sky. The wind turbines are actually quite elegant in the way they slowly sweep though the air.

In the aesthetics debate, wind power still trumps coal power. If you saw my earlier post, you would have seen my first hand account of what it is like to drive through a strip mine, and no, it is not very pretty. And to reiterate, it is not clean.

There are other arguments about noise, light blinking causing headaches, and other distractions for local neighbors to the actual turbines. Much of the responsibility of being a good neighbor rests on the hands of the power company. The newest array of wind turbines going up is very visible from the city, but they went to great lengths not to build near enough to populated areas that they would be disturbed by them. People have had their lives disrupted by having wind turbines plopped down in their backyards. People have had their lives disrupted by coal mines, landfills, nuclear power plants, and strip malls, also. These are things that happen and people need to turn to their local government leaders for ways to work with this, but this does not mean that an entire industry as a whole should be rejected.

Coal and wind power are at odds largely over jobs. Coal was always been here and certainly does not want to give up its market share, but wind power companies have seen a market that is ripe for the picking when it comes to locations, available workforce and room to expand and have a newer option that sooner or later is going to have to become more of a mainstay. Coal power is one of the number one producers of greenhouse gasses currently and the survival of the planet depends on us moving away from coal as a mainstay and towards cleaner options. The sooner the better.

After the Hurricane

2010-08-30T21:26:00.013-04:00

I was riding the bus to my exam destination and it first had to stop at Charity Hospital and drop off some candidates scheduled to complete their exam there. I looked up at its towering presence, aging cement walls with somewhat art deco designs on them. The harsh environment that was New Orleans was evident as I looked upon the enormous towering monolith. Dripping down from the top of the building was the blackened soil of years of urban smog, oil wells and decay. It covered the top of the building and streaking down probably one third of the upper part of the building in ever thinning streaks, like streaks of chocolate syrup on a sundae. Only this did not have the appeal of ice cream at all. I looked up at that building and it gave me the creeps. I was thankful that I did not have to go in it. Something about it just made me uncomfortable.

At the time, I had no idea what fate awaited Charity Hospital.

That was in 2004, the year I took my American Board of Psychiatry and Neurology Board oral exam, the final step in the process of becoming fully board certified. The process is a tedious process and the exam is only administered once or twice a year at one site at a time. Every candidate in the country is expected to fly in from wherever they are to the designated location for what is ultimately a one hour long exam. As far as exams go, it has been very criticised for being very subjective, with results varying on the willingness of the patient being interviewed by the candidate to cooperate, the nervousness of the candidate, the mood of the examiner, etc. It is indeed a very nerve wracking time for a board candidate.

The oral portion is in fact, being phased out, but I was one of the "lucky ones" that got to endure the torture of an exam that has a 45% failure rate. To be honest, I did not pass it my first time, or my second. I passed one portion, but not the other, both times. I needed to pass this time. By now, I had relocated to a job where I had more colleagues to help me practice and felt better about the exam going in, but still nervous.

Through the whole process, candidates are loaded into buses and shipped throughout the city to various hospitals and outpatient psychiatric centers where we examine a live patient as part of the exam process. The first stop my bus made was at Charity Hospital. I honestly did look up at the grimy towers of the hospital and the building gave me the creeps. Perhaps it was my nervousness, perhaps the knowledge that this was not a safe part of town, perhaps just the whole feeling that there was a lot of suffering going on in this part of the city that got to me. I was glad I was not taking my exam in that building. It just made me uncomfortable.

I did not know at the time that it was the only hospital in town that treated uninsured patients. I now know I judged the hospital unfairly.

It is not in a good area of town, sandwiched between two interstate on ramps and surrounded by decaying slums. Location wise, Charity Hospital is not really all that near Lake Pontchartrain and the area that was most noted to have been flooded so badly. It actually was closer to downtown and the French Quarter, so I would not have expected it to have taken the hit that it did. Just that fact that the facility was damaged as badly as it was is a testimonial to the extent of the flooding that occurred. Charity Hospital is further away from the lake than the Super Dome. It now sits, fenced off with chains to keep people from entering. The building is considered a total loss and is somewhere on the long list of buildings that are scheduled to be demolished. The sordid tales of doctors and nurses euthanizing patients who they felt would not survive the ordeal continue to plague this facility, but I do not believe them in the least. One more ghost to haunt this facility.

To this day, there is a part of me that feels like my initial dislike of the building somehow played a role in its eventual demise. Like if I had not thought that it looked creepy, somehow it would have survived the flooding. Of course, the logical side of me knows that this is ridiculous. The city was going to flood regardless and the building is very old and outdated. It would not have taken much to render the building unusable. I know I am not the only person to look upon the dripping grime and soil on the towers and feel uneasy. My husband felt the same way for one. I am sure there are others.

I paid Charity Hospital a visit this New Year's to pay homage to the once so important institution in this city's history. Partially to make peace with myself that I was not the cause of the demise of the facility but also to honor any institution that cared for so many who had so little. The closure of Charity Hospital left a lot of people out in the cold. The gaps are slowly getting filled but like the lower ninth ward, the gaps are still larger than the areas that have been repaired.

My hospital cares for the uninsured quite a bit itself. It puts a big financial strain on the system, but people need care and they are human beings, not numbers. Sometimes I look up at the white cement tower at the hospital here, and it looks a little creepy, too. I have learned to see past the grime and look at the people inside.

Hurricane Katrina

2010-08-29T21:17:00.004-04:00

"New Orleans is below sea level and if a serious hurricane were to hit them, they are all like sitting ducks. It's only a matter of time." - Former resident of New Orleans speaking before Hurricane Katrina hit.

It was five years ago today that Hurricane Katrina changed the lives of a lot of people. It was a day that I remember well. I was pregnant at the time and already emotional and easily teary eyed over sad things. I remember hearing the news reports on the radio at work saying that the roof of the Super Dome was starting to make strange noises and they were fearful that it would give. I have been in the Super Dome before and it is big, very big, and if the roof came down, countless lives would have been lost. I had this worried feeling but I cannot even begin to imagine how it must have felt to be in there. Fortunately the dome held although the chaos that occurred in there afterwards was almost as disastrous. I am not sure that anyone could have imagined the chaos in the city that ensued after that.

I took my psychiatric oral board exams in New Orleans and passed them so the city will always have a special place in my heart. We spent some extra time there just exploring the city and taking a mini vacation afterwards. We talked to people there and there were several people that came home with us in our memories. The patient I had to interview certainly stuck with me. There was an owner of a small store in the French Quarter that we talked to. And a worker at Cafe Du Monde. Sometimes I still wonder if these people survived, and if so, did they return? I tried to find the shop in the French Quarter when I was in New Orleans over New Years and could not find it. It is easy to get lost in those square grid streets so I will never know.

What I do know is that I knew real people, so they were more tangible, not just a demographic or number. I worried about those people I met. I felt badly for them. I still worried about those that I did not maybe becuase it was easier to extrapolate from the ones I did know. I got choked up when they showed women with sick babies or parents separated from their children, especially anything about mothers and babies. That was all the pregnancy thing, mother/child bonding, lives shared, blah, blah, blah. Only women can understand. Sorry guys. I saw a lot of real people suffer a real lot. Nothing was going to be able to stop the levees from breaking at that point, but the rescue efforts were pathetic and inexcusable.

So why did I not do more myself? I wanted to. My employer was allowing people go help out with rescue efforts, but like everywhere else in the country, there were not enough psychiatrists on staff for me to leave on short notice. There was no one to cover for me. And I was pregnant and it was not safe for me to be there. So I gave my money to the Red Cross and prayed for a miracle. The miracle never came. But the people of New Orleans are a hardy bunch and had continued to rebuild despite the disaster.

I salute you.

The Rest of the Story

2010-08-25T21:35:00.019-04:00

I still have yet to fully explain the beauty of this particular Pacer Wagon I saw. From first looks, it had the usual POS appearance, falling apart, rust bucket type with some of the floor reinforced with plywood, a certain amount of duct tape as part of the body work, rust holes for decorations. Unless you live inland in the South or in places like Arizona, you have seen this sort of vehicle.

I was taken by a region below the gas tank. There was a strip about six inches wide and extending down to the bottom of the car of a sooty gray color. In the evening light, I had mistaken it for duct tape. Upon closer inspection, I realized it was some kind of grime built up, I guess from having leaded gasoline spilled on the side and never being washed off as the patch was most obviously emanating from the gas tank. The gas cap itself appeared to be a chrome door knob. It stuck out from the body several inches and I am not sure how street legal it is. The wheels were standard issue bland AMC wheels missing their hub caps, of course. It would have been better if three of them were mismatched doughnuts, but hey, you can't win them all. The body was standard issue paint with heavy patches of rust and holes permeating around the tire wells. The kind of car that might come equipped with a high tech eight track player and possibly even an FM radio if one were to really go all out. Us old farts will recall the row of buttons that one had to pull out and push in to save a radio station. Not that there was anything good on AM radio anyways.

Most of these cars had seats with the usual frayed fabric in the middle with a sort of houndstooth design with an outer edging of high quality pleather. Usually really worn seats are covered by either "faux" tiger fur seat covers or Tinkerbell ones if the owner is female. In the summer since many of these vehicles rarely had AC and if they did this has long since stopped working, they have those seat liners consisting of rows of wire coils covered by mesh fabric elevating one's butt and back off the seat slightly in order to provide some circulation as pleather does not feel all that great in the heat. Most hideous in appearance but better than the alternative of sitting on frayed fabric, rotting yellow Styrofoam and pleather in 90 degree weather.

I did not get a chance to inspect the seating arrangements of this particular vehicle as I was so quickly distracted by other features. This one was apparently not meant to die a slow POS death. It was in the process of being reborn into so sort of dorky redneck hot rod. Although the outer tires were bland, there was a very flashy chrome plated mag wheel spare tire in the trunk. One with one of those trillium looking projections coming out from the middle. Brightly polished, expensive and the tire was a high performance low profile tire at that. It was surrounded by, of course, the huge subwoofers that any "cool" car must have in the trunk.

The front was much more advanced in its progression towards awesomeness. The steering wheel was a highly polished chrome chain with a triple barred configuration that is always seen on true muscle cars, and impractically small in diameter. I would estimate no more than 12 inches. Being too small to control one's vehicle is really cool, at least that I what I am surmising from this as I have seen the tiny diameter chain link steering wheel before.

The gear shift was a very stylish chrome skull. Nothing like gripping shrunken model of a dead guy's head to shift gears to make one feel powerful. Personally, I prefer the one that blatantly advertises the gears with the six speed manual pattern clearly mapped out, signifying a high end performance engine, but if this guy wants to grab a dead guy's head, be my guest.

The hood was quite advanced in the customization procedure. It was obvious that it had been cleaned up, the color being a bright white with a good shine to it. It was the middle attachment that impressed my husband and I both the most. I was told the name of the type of body alteration this was, something like an air intake manifold which is often molded into the hood, but this is probably not readily available in a AMC Pacer so would need to be custom. Often they can be attached by welding, but also apparently by bolting, which was the owner's route of choice. I am not sure if this was particularly street legal as it looks and the job seems a bit botched as there are some gaps between the hood itself and the manifold. Note the sky blue bolts. Nice touch, huh?

My husband and I have had some debate about whether or not the final product will contain decals of naked women or not, he siding for the latter, me the former, but we both are expecting neon lights to show up somewhere. I am quite certain I would be very disappointed not to see flames painted somewhere. Whether they were done by a professional or done sloppily by hand has yet to be seen. Air shocks? Perhaps too 70's but remember this is a 70's vintage car and may be quite appropriate to round out the look.

If well done, this car could end up looking somewhat like "DJ" from the Disney/Pixar movie "Cars". If you have seen the movie and need a reminder, he's the one with all the CD's in the back. If you have not seen it, the movie comes highly recommended whether you have children or not. It really is a good movie despite its G rating.

The botched job on the air intake manifold, alas does not bode well for this poor vehicle and poorly done, it is going to look like any other failed attempt at rescuing a dorkmobile and making it a chick magnet and getting a dorkychick magnet instead.

My feeling is because it takes someone with los huevos muchos grandes to drive it in the first place, regardless of the direction this car takes, it is going to be one bitchin hot ride.

The AMC Pacer Wagon

2010-08-21T21:49:00.007-04:00

As I had mentioned before, I have been on a two week sabbatical from work and partially out of touch with the world. Perhaps sabbatical is not an appropriate term since this implies it involved some form of scholarly activity which my time off most certainly did not. Last week, we spent a few days at a resort a few hours away from home and were stunned by a site that so overwhelmed me that I could not resist the temptation to write about it. It had nothing to do with psychiatry at all. But it amused me so much that I felt it was worth sharing with the world. Some stories are worth repeating.

The AMC Pacer Wagon has always had a certain geeky but cool mystique about it. Nerdy and awkward, but somehow the person who drove one was kind of a happening person. Sure they look like a Volkswagen Rabbit (the older ones) in the midst of anaphylactic shock, but the bubbly appearance just sort of works for some. I am not sure what the overall view of the Pacer was when it was made in the 70's, but in the 80's the view of the Pacer wagon could not have been better personified than in Wayne's World, the Movie where Garth drove a souped up version of a Pacer Wagon. His had cup holders, licorice dispensers and all other sort of additions to it. It was so nerdy that it was cool. It was cool that you did not have to take seriously.

Not that I would personally disparage AMC as a whole. Despite its image, I respect the company and mourn it's loss. AMC was the last of the independent car makers in the US and did make decent cars at one time. They were the owners of the Jeep line for one. That was why Chrysler bought them out in the first place. Their signature engine, the straight 6 certainly provided a surprisingly powerful configuration.* Porche has been using the straight 6 engine for some time in some models of the 911 for years so it must have some value. The AMX is still considered a classic in the muscle car circles. Perhaps not as popular as the Mustang, but still a car of note.

So the poor homely Pacer wagon comes out. I am not sure what the design team was thinking when they produced this bubble on wheels. Perhaps it was an attempt to completely reverse the boxy image imparted by the Ambassador. Maybe a poorly executed attempt at mimicking the AMX?

I have not seen a Pacer in years, but this one was the best one I have ever seen. An amalgam of POS (Piece of #&@) and souped up hot rod, this thing was an absolute laugh riot. We got a thumbs up from a passer by for even looking at this beauty. The details I will save for another post.

*As a testimonial to the power of the straight 6 engine, I have information that a 1972 brown AMC Hornet with a straight 6 configuration was driven in 1986 at 100 mph without difficulty on the Ohio Turnpike. The only reason for slowing was fear of the mighty Ohio State Troopers. This comes from a reliable source.

Back from Vacation

2010-08-14T22:19:00.002-04:00

I have been absent as previously mentioned for one week, and have not able to access a computer, which is probably for the best. I truly believe that when I go on vacation, it is not healthy for me to be thinking about psychiatry or any aspect about work at all. As it ended up, I spent much of the time thinking about proper parenting for an overstimulated and often tired four year old little boy. The dynamics of when to say no, when to give in, how much to allow and not allow is never easy to figure out. Things on vacation are a lot different than home, and children do best with a routine. When that is changed, they tend to get worked up by it and test boundaries more than they would at home.

In reality these situations do give a real life example of where a lot of things have gone wrong in my patients lives. Especially in dealing with adolescent patients whose parents never did set limits and are now becoming dangerous. A four year old can hit and throw toys, but is unlikely to do much damage and I am bigger than him. This is not the case for a 17 year old whose outbursts can reach the point of being criminal. The parents all of a sudden try to exercise some control but get a very hostile response, one that they cannot control. So they drop them on our doorsteps and hope for a miracle. It had not happened yet. Nor has a pill that will make one good parents. Sad, and many of these kids end up in the legal system. If they have any hope of getting control of their lives, this is going to be the only place where it is going to happen.

We had a good vacation, but yes, there were a few days where there were a lot of rattled nerves, there was a lot of limit testing, and someone did not get to go on the rides because he was whining all day and was not the agreement. He also had his mini DVD player taken away and the "Toy Story" DVD was confiscated, because we think that it is teaching him some rather aggressive behaviors. Daddy was cranky, Mommy had a headache, it was a bad evening.

The next day we woke up, and the same little boy was a perfect angel. Amazing how a little persistence can make all the difference. He still loves us, too.

Vacation

2010-08-05T22:01:00.005-04:00

I am going to be taking a much earned two week vacation and may not have much computer time to keep up so I will try to put in one last post before I leave. I will come to the crystal on my rear view mirror later.

I will be leaving my covering colleague with his job cut out for him. The unit cencus includes a unit full of depressed people who are having relationship problems and many of them have done something really stupid to get them in heat with their S.O. and are now trying to get out of trouble. This ploy usually works, until the next time. There is always a next time.

There is a large group of really sick people hearing a lot of sounds that no one else hears and seeing things that are not there. One is so disorganized that his behavior goes beyond description. Something about turning a tee shirt with a wolf on it into a tiger, or something similar. New age alchemy I guess. It is best not to try to think too hard about what this kind of patient is trying to relate as it is likely to cause one's brain to explode.

We have the usual selection of bratty teenagers who have never had limits set on them. Now they are uncontrolled and often violent monsters who are sent to us after they trash their parents house with the hopes that we will be able to find some kind of magic pill to fix their child's illness. What they need is a good dose of structure and discipline but by this time, most of them are beyond hope and if they are not in the legal system, are soon going to be.

We have several paranoid patients, often talking to themselves, very watchful of the other patients and mistrustful of staff intentions. I like these guys. They are the real deal. It is too bad that they think that I want to kill them.

There are victims of the downturn of the economy, but in reality, many of these people could have jobs. They just choose not to look for one and have set their sights on disability as a long term solution to their worries. Frustrating group to work with as they clearly can work. They just do not feel like it. A life of nothing but watching TV, drinking beer and smoking cigarettes seems like such a waste to me.

Of course there are some legitimately depressed people out there, too. The ones whom often are described during morning report as living the life in a country music song- loose your wife, your house, your truck, etc. It is easy to like these guys, but hard to know what to tell them. Surprisingly, these people usually pull through.

And lastly, the addicts. These can range from those pushed into treatment and came to the psychiatric hospital over detox because they did not really want to get pushed into rehab. They just wanted to look like they were quitting the drugs/alcohol. Some were too mentally ill to tolerate the rehab program where they were getting treatment and were sent to the hospital. Some of them were able to have enough clarity of mind to look back over their lives and see what they did have vs what they have bow. Many times they realize that they have nothing left- no home, friends, family- nothing. And they realize that they have nothing to live for. Some of these guys may not make it I fear.

But, I am going on vacation, the pager is turned off and I already chewed one staff member who dared page me after 5PM today when I was not even on call. The doctors who are covering are good doctors, I trust their judgement and know my patients will get good care. You may not hear from me in a while. I will be busy working on my heavy dose of high SPF and self tanner mix (defies logic, does it not?) and may not have access to a computer.

We are going in my husband's boring "crossover" type big POS monster vehicle with no satellite radio, no Bluetooth, no chrome tailpipes. Now if I could just get over the separation anxiety from MY car, I would be fine.

The Crystal on the Mirror

2010-08-05T12:22:00.007-04:00

After a long hiatus, I am finally returning to why I have a crystal on my rear view window. The crystal on my rear view mirror probably does not have the same importance as my dreamcatcher, but I have always wanted one for my car and when I saw the right one at a craft festival I snatched it up.

As do most people who have them, I wanted it because crystals bend light in such a way to create a rainbow of the ray that hits it. I love the rainbows scattered throughout my car on a sunny day. They are beautiful, graceful, fascinating. The "New Agers" as they have been referred to have held certain beliefs in regards to crystals that I personally do not hold. A chemistry major is never going to be fully impressed by stories of magic powers in any form of rock. We know the chemical structure which takes all the mystery out of it. There is no mysticism about crystals, just that they hold great beauty. *

Rainbows are another story. In the old testament, the rainbow was said to be the covenant between God and mankind that he would never subject the Earth to such a devastating flood as the one he subjected the world to prompting Noah to build the ark. I am not one to view the rainbow in any kind of religious sense but the rainbow did come after a devastating flood and symbolized good news to the people who saw it.

They are fleeting things but especially here in the mountains, can be stunning beautiful. I have seen some of the better ones stop traffic. Rainbows here are more beautiful than I have seen anywhere else in the world. I was treated to my first double rainbow only after moving to central Pennsylvania and have been lucky enough to have seen several since. At times, it seems that they were meant to occur around times of happiness. I saw a stunning one around the time that a colleague gave birth to her son. The picture here was taken on the day we finally were moving from our cramped apartment to the dream home that we had finally been able to build after a long struggle. That was a very happy time for our family.

But then, sometimes they are just pretty. So I like to see them, and see them frequently. They bring happiness, sometimes good news and at least signify that the Sun is coming out to nourish the plants and help life thrive on the Earth. So I have a crystal hanging from my rear view mirror. My own little piece of civil disobedience to bring light into my life. A minor traffic regulation is not enough of a reason for me to take it down from my rear view mirror. They will have to catch me speeding first.

*Gentlemen, DO NOT take this to mean that a woman who has majored in chemistry is not going to show interest in "bling" as it were. Very few women, regardless of their level of scientific training is going to be able to resist the deep sparkle of a perfectly cut flawless diamond, especially when they are really clean and under the lights at a jeweler's case. The same goes for rubies, emeralds and a whole array of colors of sparkly stones that look good adorned on a woman's body somewhere. Dating a scientist will not get you off easy. Sorry.

The Dream Catcher- Part V

2010-07-30T22:01:00.009-04:00

Once a medical student has graduated from medical school, he/she has earned the title of "Doctor". They are required to complete only one more year of training, once referred to as an internship (generally the first year of the residency) and completing the third part of the Medical Boards to get a license and practice medicine independently. Nowadays, medicine is much more advanced and one year of an internship is not truly considered adequate training for a person to be a solid physician but legally a person could do this. To be able to practice in one's chosen field and expect to be able to bill an insurance company, one needs to complete a complete residency. Ideally one should become board certified in that area, although this is not always necessary. (One of the reasons they warn people to be so selective about plastic surgeons is that loophole that allows physicians to practice without being board certified or board eligible.)

On "Match Day" every 4th year medical student in the country is given a letter informing them of where they will be doing their residency. During the 4th year, a good amount of time has been spent applying for, and interviewing for residencies. A very complex computer system that matches up the students' preference list with the residency programs' preference list and assigns students to residency programs. This is announced in a big party with a great deal of fanfare where each student goes in front of the class, opens up their envelope and reads where where he or she will be going and in what field. Then they cry and give a speech where they thank their mother and father for bringing them into this world and comment on their friend's Chanel Couture gown and Mariah Carey performs, and...

OK, I made that part up, but there is a lot of celebrating and balloons and banners. People cheer and the few that got stuck in some "transitional year" because they did not match anywhere they wanted try to hide their disappointment. One hopes this does not happen too much, but there are always a few. And there is a keg in the student lounge. No, I am not making that up. Some lucky people even have beers in their mailboxes. After four years of hell they figure these guys have earned it.

That is is beginning of the end. Those last few months, rotations are more lax because the students are making preparations to move, obtain limited licenses in some cases, and filling out A LOT of paperwork. They have their residency assignment so all they need to do is pass, not well, just pass. They are about to earn that long coat and no one is looking back.

And neither did I. I survived the end of the year and graduated. I recieved my four foot long hood, the most coveted of all hoods signifying I had a doctorate degree. I was a doctor now. No one could tell me that I was not smart enough, did not try hard enough or did not have what it took. No one could tell me that I was not allowed to be a doctor, that I needed to be a nurse or needed to know my place in life. I realized that it is true when they say that people can only put limitations on a person if one lets them. This time, I did not let them.

Not that residency was easy. Residency was tough. Taking call is brutal, but psychiatry is often referred to as a "lifestyle specialty" because it is not so abusive and exhausting. Nothing like internal medicine or surgery. And it was what I wanted to do.

As far as changing, I probably changed in those four years more than in medical school. Working with patients who often do not like you for no reason except that you remind them of their mother takes a lot of strength. Learning to cope with verbal abuse, threats, and statements that at times can be downright cruel can be hard to do, but if one cannot learn to do this, one cannot expect to survive in psychiatry. They will be uttered by some patients with reckless abandon. Some will be too psychotic to be able to give a history at all. Some will be violent and require a great deal of caution. I have been assaulted by a patient once, largely unprovoked and I know that it was not her illness that caused it. She was just sociopathic. They will push your buttons, insult you and refuse to cooperate. They will do just about anything they can to get you angry, and sometimes they will. They will hurt your feelings, call you stupid, incompetent, ugly and a litany of expletives that I will refrain from listing. If you let it bother you, you will not survive in psychiatry. It took a lot of changing to learn to feel good about myself and be able to endure this kind of treatment.

Ultimately, my journey through college, graduate school, medical school and residency took me 14 1/2 years to complete. Although I passed Part III of the Medical Board one year into residency and was able to become an independently licensed physician after that, it took me several years after completing my residency to finally complete the process of becoming Board Certified as a psychiatrist, which is the usual process.

Despite anyone who doubted me at some time in my life, I DID catch my dream. It took a lot of soul searching, tearful nights, pep talks by supportive friends and roommates to get there, but I did it. I had a great deal of my own self doubt to overcome and it took years of counselling to work through this and to find the strength to pull through. Many would have viewed the detour that I took through graduate school as a waste of time, but I realized that I was simply not emotionally ready to enter medical school right out of college and had I tried, I very likely would have failed. I left graduate school on good terms with a much higher GPA than I had in undergraduate school which certainly did not hurt in getting me into a more respected medical school either. I feel good about the things I have achieved in these years because I know that I was the one who did it. Maybe I made mistakes, but I fixed them. No one else was left to clean it up. And I did by myself. I am proud of that fact.

So why do I keep a dream catcher hanging over my rear view mirror? The old native American tale was that grandmothers would hang them over their grandchildrens' beds to catch the bad dreams and protect them from their grandchildren. For me it is the opposite. My dreamcatcher is a reminder that I had a dream, I struggled for years to get it, and I caught it. It is a reminder that I can achieve my goals if I really want them. It is a reminder to never give up hope, to appreciate my blessings in life, but to never give up on those things I aspire to.

Never give up on your dreams.

The Dream Catcher- Part IV

2010-07-28T21:46:00.004-04:00

Surviving medical school was certainly a challenge. The first two years were tortuous in both the amount of information that was thrown at us and that we were expected to learn in a short amount of time. The entire process it to prepare the students to take Part I of the Medical Board exam. THE BOARDS are always on a first and second year medical student's mind. At the end the first two years all medical students are given three weeks to study for this exam which is ultimately the first part of the three stage process that must be completed to become a licensed physician. Learning a specialty is a separate process. Immediately after we took our boards, we were to begin our third year which was the start of our clinical rotations.

During the six week wait until we heard the results of our board exams, we not only had to go on the with the stress of learning how to actually practice medicine in a hospital setting, but worry about if we passed our boards, as if we did not, we were not allowed to continue our third year further and would have to go into remedial classes. Each year there is a specific date when every medical school in the country is notified who did and did not pass. The official scores are sent later. I recall the day that the pass/fail list was to be announced running into the registrars office (she knew us all by name) and had apparently stopped breathing out of sheer anxiety. She looked up at me and said "You can breathe now, you passed." That was when I realized that I was standing in the door holding my breath. I really did not care that much about the actual scores. I just knew I passed and did not need to worry anymore. I thanked her and left. THE BOARDS PART I had been put behind me. Now I could focus on earning that long coat. The one that if you have read my earlier posts, I refuse to wear.

The long coat meaning that I was a physician, not a medical student. Medical students were relegated to short white coats. Not that any of the medical students on the show ER ever wore short coats. There is a reason doctors do not watch ER. We get so irritated with all the gross inaccuracies that occur on that, and all other "doctor" shows that it just makes for a miserable viewing experience. So we watch the Colbert Report.

But back to the crusade for the white coat. The last two years of medical school largely involve following a resident around and slowing learning the ropes of working in a hospital. It is pretty much a junior residency without the same level of responsibility. Oh, and instead of getting paid a moderate salary, we paid out about the same amount in tuition plus room, board and textbooks. Initially we would just follow a resident and play a largely passive role. We were usually assigned some menial tasks to take care of, giving rise to the term "scut monkey" as a common one used to describe the medical student's role on the treatment team. With time, our skills would grow and we would do more of the tasks that we would need to be doing in the "real world" - writing progress notes, orders, physical exams, helping with procedures. We did have some outpatient exposure, but much like a standard residency, most of the work was based on hospital work. This has been a flaw in the training of medical students and residents for some time now as the system has for decades become reliant on the services of residents to care for inpatients. This leaves little time for preparation for what will become the final endpoint for most trainees which is office based work.

Those years did include taking call along with the residents so medical students too, suffered the 36 hour long work days. The frequency of call varied depending on specialty, surgery generally 1:3 and psychiatry 1:6. Most specialties were 1:4. Most work weeks were seven day work weeks, perhaps 6 days a week or we would get one or two days off a month, but the schedules were grueling. It was not just clinical work we were expected to do. Once we got home, we were expected to go home and study up on the various maladies our patients suffered from and review notes from the various lectures we had to attend during each rotation. Attendings varied in their personalities from very inspiring to humorous to verbally abusive and threatening. One had a bad reputation for behaviors that were on the edge of sexual harassment, but woe to the medical student that tried to do anything about it, as his power in the hospital was too great to be overcome.

It was a very trying time. Not just for the crushing workload but from the human aspect. On the first call night I ever took, I saw a severely premature infant nearly die. He had been at a higher level NICU elsewhere because his case was so unstable, while his two triplet brothers were stable enough to remain at the one I was assigned to. He had just been sent back from the other hospital to be with his triplet brothers - so he could be with them when he died. He had heart deformities and was simply too small to survive an operation to correct them. That night he destabilized and I stood there with the whole family, the mother in hysterics, holding her son who was just barely over one pound in size telling him how much she loved him and how she prayed she would see him in Heaven. He made it through that night, and I am not sure how much longer but he was not going to survive. Hard way to start one's clinical rotations in medical school, huh?

Those NICU memories hung heavy on me when I stared down at my much more stable premature son in that heating bed 4 1/2 years ago. But my son now asks me how to operate the gear shift on my car and scares the hell out of me. I think he's fine.

I survived the third year of medical school, and the forth year was not nearly as bad. There was a great deal of time for electives and not the rigid rotations of the third year. There were two months of required "acting internships" in internal medicine where the medical students were expected to take on the role of an intern with the same responsibilities of an intern and those two months were hell but most of my fourth year was much more relaxed and had more of a focus on outpatient areas and more diverse areas of psychiatry. I was even able to arrange to spend a month at another highly respected university in another state doing a rotation on the psychiatric unit there. This was one of the top psychiatric residencies in the country and was an experience I would not have missed for the world. We also had to tackle Part II of the Medical Boards during the 4th year of medical school. This one was not nearly as terrifying as Part I and passing this was not as essential as it could be retaken during residency if need be. I passed Part II without difficulty and was 2/3 of the way towards being licensened as a physician.

I had nearly reached a dream that I had had for some time and never thought I would ever see come true.

To be continued.

The Dream Catcher- Part III

2010-07-22T21:52:00.006-04:00

My interest in psychiatry had been growing during my first year slowly although it was something I never put much thought to when I first entered medical school. My first year was tough and I had been through enough treatment of my own by that point to realize several things about psychiatric treatment. #1- It worked. A patient really could be happy after years of depression and sadness. #2- It was not just witchcraft. There was serious scientific data to back up the treatments used and with neuroimaging a growing science, data showing changes in the brain function and structure in mental illness was becoming quite prominent. #3- People did not have to suffer, so why should they? The treatments available were growing rapidly, bringing the promise of much better qualities of lives for patients who received the right care. I wanted to be a part of that.

Psychiatrists do not talk about their personal lives as they are not there to burden their patients with their issues or bias them in any way. Truth be told, though, a large percentage of them have struggled with mental illness at some point or dealt with it in family members. This is part of what drives them into the field. They know how it feels to hurt. They know how it feels to be told "just get over it" or "you just need to pray more, you're a bad Christian" or "you're weak" and so on. They understand the pain their patients feel when they hear that, and how much harder it makes recovery from illness become. So they know how to listen to their patients and empathize with what they are feeling.

I am no different having struggled with depression on and off for years and finally found myself in the hands of a competent psychiatrist who helped me lock the pain away and move on. The world became a different place, more beautiful, less angry. One that I could more easily separate myself from the negative parts and enjoy what I had. Does that mean that I do not worry about the wars in Africa? Or the unspeakable acts of cruelty that occur in Darfur and the Congo and ask why did I deserve such happiness and why to those women suffer so? No, I still ask that, I still give money to Doctors Without Borders, and hope someday I can take a sabbatical to work with them. But it does not rule my life. I can enjoy the things I have and consider myself blessed.

So I had found I field that I felt called to but was still unsure as I knew that most of my patients were not going to be depressed medical students. I applied for and was accepted to an internship in a program in my city that placed interns in sites that helped underserved populations. I had requested and was placed at a facility that provided housing for homeless mentally ill people. This is one of the finest facilities providing for the homeless that I have ever seen. More than a shelter, they provided permanent housing to persons who were far too ill to be able to tolerate more structured settings and ensured that they were safe, warm and fed. They did monitor their medications although they tolerated medication refusal to some degree. Many of these patients without this facility were wandering the streets, living in boxes, sleeping on grates for heat in the winter. They were leaving themselves open to assault, rape, the elements, and starvation. These were the sickest of the sick patients out there.

I spent the summer helping out with various activities, monitoring the front desk, helping residents out with tasks, but much of the experience was to introduce me to the services available to the needy in the city. I learned a lot there. Like the Antichrist is really a pretty nice guy who will always offer to buy you a pop. Like schizophrenic patients often tell you about having past careers in fields they did not have to fill the void of their empty past. That a patient who is catatonic looks scary, but is pretty much harmless. That mentally ill women who have gone homeless have often been raped, assaulted, mistreated in terrible ways adding PTSD to their already disabling list of diagnoses. That a homeless women without legs who has her wheelchair stolen may get no help from her "sane" neighbors, but that a mentally ill friend may go to the to ends of the Earth to make sure her friend gets a new wheelchair. That just because a patient is mentally ill does not mean they are just crazy and do not deserve respect.

That was when I was certain that I wanted to pursue psychiatry. That was my dream.

To be continued.

The Dream Catcher - Part II

2010-07-18T21:53:00.008-04:00

The whole idea of going to medical school in the first place was a fairly radical idea when I first came up with it. In the early 70's girls went to nursing schools to be nurses and boys went to medical school to be doctors. That was the way it was. Girls did not like science, boys did. All the resistance I got from the people around me made me even more determined to pursue a career in a scientific field. And it would NOT be a "female oriented" field at that. Nursing was out. In my years, I have grown to realize how skilled and talented nurses really are, but at that time they were undervalued andlargely held back in their ability to achieve by the system and the sexism in said system.

Entering college to study chemistry probably raised more eyebrows than medical school did as this was the 80's and there was still the relative prohibition on women entering scientific fields. By the time I entered medical school in the ninety's, 40% of our entering class was women and that trend was being seen nationwide. Not to say that I did not experience some attendings and instructors who obviously favored my male counterparts. There were some, but for the most part, I did not see the resistance that I would have expected.

Entering medical school was one of the most nerve wracking things I have ever done. Certainly I was excited, but the was far more intimidating than college. Unlike undergraduate school where I made every effort to avoid attending orientation activities, preferring to socialize and party, I went to every one here. I had no idea what to expect but from having roommates who were medical students, I knew it could be Hell. We were told numerous times during orientation that medical school is a life changing event. I scoffed at the idea, believing that once we were adults, our personalities were fundamentally set in stone and while maybe we would be modified, nothing could fully change us.

I was wrong.

I was still shy when I entered medical school, but not as shy as I was as a child. I was still moody, emotionally labile but certainly more mature than I had been at the age of seventeen when I entered college. By then I had sought out help for my moods and was on a much more even keel and more prepared to take on a challenge like this.

Medical school has a lot of ways of breaking one's spirit and hardening one's stomach. Weak stomachs just do not fly well in medicine, even in psychiatry. Gross anatomy is the most obvious example. In pretty much every medical school that I have ever heard of, the very first day starts with a gross anatomy lecture for one hour, then the class is sent up to gross anatomy lab to begin their first cadaver dissections. Three hours later, an instructor comes in and says something to the effect of "Time's up! Take an hour for lunch and be back in the lecture hall for biochemistry lecture." Formaldehyde and meat do not make for a very appetizing combination. Formaldehyde and anything for that matter do not mix well but meat, especially attached to bones is pretty nauseating. Like chicken. I did not eat meat for weeks. I still do not particularly like chicken legs and that was 18 years ago.

I did not enter medical school with the intentions of being a psychiatrist. I had actually wanted to be a trauma surgeon, something with is pretty much the antithesis of a psychiatrist. I was told of the long hours, grueling call schedules and emotionally abusive training techniques used in surgery residencies, but I was sure that I had what it takes. I knew that to have any hope to get into a surgery residency, one would have to be at or near the top of one's class. I was doing fairly well early on although the long hours of studying was getting to me. I am not good at rote memorization and the early classes like gross anatomy were basically that. I did my best to keep up but near the end of my first semester received the word that a close friend from college who had been quite ill from cancer had taken a turn for the worse. I had been able to spend only a few minutes with him in the hospital, 200 miles away from home while attending a friend's wedding. As usual, the pressures of medical school were always there and I had to rush home to resume my studies.

It was only a few days later that one of my roommates left me a post it note on my door stating that my friend had passed away. It was just a few days shy of his 31st birthday. Another trip back to my old college haunt with a quick exit back home ensued leaving my friends from college disappointed but there was too much at stake to sacrifice any more study time than I already had. As expected, my grades plummeted along with any hopes of being a trauma surgeon.

I had been a lucky person to have never had to deal with a lot of death in my life up until then. Only two great-grandmothers who I did not know well when I was quite young and a couple of hamsters. Losing a friend so young was devastating to me. It gave me nightmares. I carried all my books and spent the next few nights at my mother's, making the much longer drive to class for her comfort. My late friend had always pushed me to go into hematology-oncology to help people like him. Seeing my friend who was once a healthy army reserve corpsman who still went on active duty in the summer reduced to skin and bones with no energy and his eyes sinking in his head made me all the more determines that I was not going to go into heme-onc. I could not watch my patients leave the world like this.

I never failed a class in medical school and despite this setback pulled through intact. My emotions were shot, I went through countless antidepressants and when I went to the end of semester parties, I went overboard. But I eventually pulled myself together. With time I came to the realization that I had been changed after that experience, though. I was stronger, I knew how to keep my composure when I was internally a wreck, but I also learned that medicine was sometimes rather cruel to the providers.

Save for that outlying event, the first two years of medical school for the most part were a blur. We would go to class, go the lab, study, repeat. Then we would take an exam and repeat the process. It was exhausting, very damaging on our relationships with our friends and families outside of medical school but so constant that one did not really notice time passing.

During that time, I did start to realize that I did not want to be a surgeon. Not only were my grades not high enough to pull it off, but I started to realize that I really did not want to become a lifelong slave to my job. I love my work, but I have a family and a life that I love also, and I want to live it. I knew that the seven or more years spent in medical school and residency were a sacrifice in my life that I would make for my future, but once completed, I really did not relish the idea of working 80 hour weeks for the rest of my life. Even if that did mean not ever owning a Ferrari like the ones that show up on the doctor's lot at work. My little Audi makes me quite happy and is a lot more than many people will ever have. I am thankful for it and the many other things I have in life. Sure, I earn significantly less, but I work a 40 hour work week, and I am home to have dinner with my family every night.

So I was still on track to be a physician, just a different kind, and I was still out to catch that dream.

To be continued...

The Dream Catcher- Part I

2010-07-14T21:50:00.010-04:00

Hanging from my rear view mirror is two items. In the state of PA, hanging things from the rear view mirror is apparently illegal, but a minor infraction that I have chosen to commit for my own reasons. I figure if I get called on it, I will probably be answering to a much worse offense likely involving excessive velocity, and will be too busy kissing major butt of the police officer to even worry about it. If he calls me on it, I will play the stupid Buckeye immigrant and state that I am from out of state and I was never made aware of such an ordinance but I will immediately comply, yes sir, no sir, whatever you say sir, and so on. I once pondered doing the "right thing" and removing them, but both these items carry meaning to me and are more than just mere decorations. To remove them would be to remove an important reminder of the journey I have taken in life and an important symbol in my life.

According to "The Official Preppy Handbook", the only appropriate item that may be seen hanging on the rear view mirror of a truly preppy car is "nothing, ever." "The Official Preppy Handbook" was a popular book when I was in high school, meant to be the ultimate resource for all that was the prep culture. Of course, it was quite tongue in cheek. It was the first book that introduced the idea that preppy was more than just their clothes. It was the entire culture of the old money network in this nation that has built up over generations. The preppy style of clothing was all the rage at the time. Of course, few of us really knew what it meant to be a true "Prep" as it were. We just all lusted after Lacoste polo shirts and Lilly Pulitzer bags. My mother bought me this book which is where I learned the true meaning of preppy. For some reason, I always remembered this quote, along with quite a few others, but this one is the one relevant in this case.

I do not recall all of the cars that were listed as appropriate preppy cars, but I do remember that Volkswagen was listed, and as an Audi is the luxury line of Volkswagen, I will assume that it could count as a preppy car. (Not that an Audi is to any degree an expensive Volkswagen.) So I do have what would probably pass for a preppy car, save one element- the violation of the no rear view mirror decoration prohibition.

Not that I could be interpreted in any way shape or form as a preppy. I was raised on a steady diet of middle class fare- public school education, car vacations stuffed in the back of a two door Chevy Chevette, and boxed macaroni and cheese for dinner. I would occasionally be able to compel my parents into buying me an article of clothing from the designer du jour but for the most part, it was no name brands for me. At around age 15, I was told that I would be responsible to buy all of my own clothes so if I wanted expensive designer clothes, I had better be willing to beg, borrow or steal a lot to get the money for them myself.

I also knew that I was going to be going to college from as far back as I can remember. I also knew that I was going to be paying for it myself. I recall as a young child being told to save the checks I received as gifts on my birthday or holidays for my college fund. I grew up with a very steady reminder of how expensive college was but also how important it was to choose my major wisely, to study hard to get into a good school, etc. College was never not an option for me. I never questioned the idea and never really wanted to do anything else. I wrote in my school memories book about wanting to be a doctor in my early grades, quite scandalous for a girl in the early 1970's, actually. My choice of vocation changed through the years, but there was never any time when my favored choice did not involve a college education.

I remember one fateful day in the middle of August when my mother and I managed to pack up most of my belongings into the back of a Volkswagen (the non-preppy kind) Rabbit and drove me off to a 10' x 15' dorm room 180 miles away from home. I was 17 years old and very nervous but at the same time, indescibably excited. This was the start of the best five years of my life. I was immature, emotionally unstable, prone to depression and insecure, but what I learned there far exceeded the information in the textbooks I read. I entered college an insecure kid and came out an adult, still not fully grown, but much more ready to take on the world than when I came in.

Paying my way through college during the late 80's was not easy. The Reagan administration did not like the idea of independent students and it was extraordinarily hard to obtain financial aid. Majoring in chemistry was not exactly easy especially when part of my financial aid package included work study and there was simply no hours in the day to work a second job to bring in any more needed cash. Chemistry majors average four laboratory sessions a semester, each three hours long, but only accounting for one credit hour each so the typical 18 semester hour schedule that it took to graduate in four years was completely unmanageable. I was forced to take five years to graduate. I felt defeated and demoralized for making this choice, but in the long run, this allowed me to specialize in biochemistry, take more classes just for the sake of obtaining pure knowledge and do research for credit, exposing me to much more advanced learning than I would not have had otherwise. Not to mention lighten up the crushing schedule of work/study/sleep/repeat.

I had long given up on the idea of going to medical school years prior, being told that I was essentially not smart enough to get in. When I was in college, I started to question my naysayers. I took the blind leap of faith and went through the grueling process of applying for medical school. I was accepted at one school, not the best one, not my first choice, but I was accepted which is better than more than half of the applicants who try to get in.....

...And I chickened out. Medical schools are tough. You fail one class, you are kicked out of the school. No second chances, that is it. One chance only. The whole prospect terrified me. So at the last minute, I changed my mind and applied to graduate school to pursue my PhD in biochemistry. I love teaching, and loved the idea of being the eternal student via being a college professor. After spending 1 1/2 years doing this, I realized that college professors spend more time writing grant proposals and doing research than actually teaching. By that time, I had two roommates who were medical students at the same university as I and had convinced me thoroughly that, yes, I had the aptitude to get through medical school. I will admit that some of those discussions were held after one too many drinks at a hairy buffalo party, so were probably not that coherent, but they made their point. I left graduate school, worked as a lab tech for 1 1/2 years while trying to get into medical school and this time, got into my first choice. This time, I did not chicken out.

I was off to catch my dream.

To be continued...

Thing You Really Hear on a Psychiatric Unit

2010-07-11T21:38:00.008-04:00

Now for the good stuff. Weird things get said on the psychiatric unit. Patients say weird things. Staff says weird things. Weird things happen. To be honest, weird things happen in med/surg units of the hospital, but the difference is med/surg people do not always appreciate it. Sometimes it scares them, sometimes it annoys them. They do not always understand what is a threat or not but if the behavior seems grossly psychotic, they tend to get uncomfortable and want it fixed.

When a patient who always believes he is God was admitted to the medical floor for legitimate medical problems, he acted the same way he always did. He stood by the door of his room blessing people. He did not threaten anyone or do anything that could in any way be interpreted as dangerous. He just stood at the door with his hand up in the air saying things like "Bless you, my child." That seemed pretty nice to me. The nurses did not think so and called for a consult about what to do to curtail this behavior. They were not happy with the response they were given. Our response was this was a fixed delusion, and no amount of medication was going to change that. He was not a danger to himself or anyone else and there was little that could be done to stop him from blessing people. We did advise that they were free to request that he remain in his bed because he needed rest. We also advised them they had the right to make the request that he not bless people in the hall of a hospital but beyond that, they were stuck treating God. But maybe it might buy them some brownie points with the Big Guy in the future.

Psychiatric units are fraught with bizzare comments, occurences and events that the workers tend to relish and retell with great joy. Here are some examples of things that I have actually heard on a psychiatric unit:

1) Pt X gave himself a swirly in a suicide attempt. (Given in morning nursing report.)

2) You will just have to accept the fact that I am Jehovah.

3) It's the beta rays doing it.

4) Are you one of those King James politicians?

5) He's got his underwear on now - on his head. (Before that he was naked so it was an improvement.)

6) Are you sure you want to see pt Y? Because he's naked.

7) Hey, this is an emergency! I'm hearing voices and he's hearing the same ones.

8) Am I naked? (No, you are not and we thank you for that.)

9) You've got a big butt! (Said by a patient to a nurse by the way.)

10) No one brought in me a bra. Can I use two spent nicotine patches as pasties?

11) No, really man! I'm not paranoid! I've just gotta get out of here before these people kill me!

12) There's a party going on in his head. (Description of a patient who had more visitors at one time than the rest of the unit combined. The problem was that none of them were real, but that did not stop him from having ribald discussions with them at all hours of the day and night.)

13) I am having normal bowel movements and so is the rest of my family. (Good you keep the lines of communication open.)

14) I don't hear voices. I just hear God talking to me.

And perhaps my all time favorite:

15) I need your help. I am a former Agent for Special Forces and they have me locked up in here against my will. I need you to get Delta Force to come up here and bust me out before they assassinate me. (Phone conversation between patient and, most likely, unprepared receptionist at the Pentagon. No, I am not kidding.)

To fully enjoy this kind of comment requires being there first hand and does not fare so well when retold by another which is why one has to actually work on a psychiatric unit to get these kinds of stories. Even with that, I will always maintain that psychiatrists have the best stories to tell.

Things People Think Are Heard on a Psychiatric Unit But Are Not

2010-07-07T13:10:00.003-04:00

There are a lot of misconceptions about psychiatric units in popular culture causing people to have the wrong idea about what really does occur up here. Some of these stem from what really did occur in the past, with the ongoing images of state hospitals remaining in the minds of many people. Some are perpetuated by the entertainment industry. There is a reason that doctors in general do not watch "doctor shows" and the same is true for psychiatrists. There are far too many occurrences that are completely inaccurate and we just end up getting annoyed with the blatant disregard for the truth in favor of a good story. The same goes for movies.

So we frequently experience people who have unrealistic ideas about what to expect from a psychiatric hospital and what services will be provided. The following is a list of some of the things I have run into that patients, referring physicians or family members have expected they would hear, but in reality, never will:

1) I anticipate his length of stay will be about one year. (So you can have a very long vacation.)

2) I will be providing one hour long individual psychotherapy sessions.(As a bonus, I will do this once a day, seven days a week including holidays. I do this for all 19 of my patients.)

3) She will probably need a frontal lobotomy.

4) We have had him in restraints for the past week because he will not take his medicines.

5) Homeless? Sure, we have a special budget for that and will be able to rent you an apartment for a year. Our social worker will help you with that. (Perhaps we can get you a membership to the health club nearby, also.)

6) She has a bad case of OCD and has spent ten years here as a result. She may never go home.

7) Yes, we can involuntarily commit your son to drug rehab after he leaves the hospital here. (Most likely he will stop using heroin and alcohol after he goes there forever and ever, and will marry a beautiful princess and live in a castle, too.)

8) Since you were admitted here you should qualify for the not guilty by insanity plea. We will support you on this. Have your attorney call the doctor. (She might not use any vulgar terms to describe him if he talks real nice to her.)

9) A diagnosis of bipolar disorder means you automatically qualify for disability. All I need to do is sign a form.

10) Get out the straight jacket! Pt X is talking to herself again.

11) I am taking a few blood tests to see if he has a chemical imbalance or not so we know what medicine to put him on.

12) There is a giant bird's nest in his room because he thinks he is a bird. (No, we do not have any issues about this being in there.)

Things Never Heard on a Psychiatric Unit (or at least should not be)

2010-07-05T21:35:00.004-04:00

I have mentioned before that psychiatric units are different from other hospital units in many ways. There are two basic other inpatient variants seen in the hospital- units that deal with med/surg issues of various types and intensities, and L&D units. Most of the inpatient units would fit into one of these categories for the most part, mostly med/surg.

Psychiatric units, unlike the above units, do not want our patients in bed, in hospital gowns and expect them to be up and about. Treatment includes groups, one to one interactions and various activities. Patients need to be considered medically stable, meaning they could be sent safely to their home if they did not need psychiatric treatment. If not, we are not able to provide appropriate treatment safely.

To illustrate the difference I compiled a list of things one would never hear on a psychiatric unit. Or if one did, there would be hell to pay.

1) Give him 60mg of morphine IV STAT.
2) Make sure she is NPO (nothing by mouth) after midnight. She is scheduled for surgery at 7:00.
3) She is showing signs of fetal distress. I think we need to prep her for a crash C-section.
4) Suction!
5) I want the patient on total bed rest.
6) Call the family. I am not sure he is going to make it through the night.
7) Forget the alcohol withdrawal protocol! Just give him a beer with each meal tray. (An intervention that I actually did see a surgical team use on a routine basis to prevent an alcoholic from going into withdrawals. Not recommended.)
8) I don't care if he weighs 300 pounds or not. You still have to do a rectal exam on all patients admitted to unit 4west.
9) Mr X pulled his foley out last night- do we need a consult?
10) Ready, one three, everyone lift!

My Best Dumb Lawyer Comments

2010-06-28T21:48:00.009-04:00

It is no secret that doctors are not fond of lawyers. I do not hate all lawyers. I have met some very nice ones in my life. The ones that helped us close on property we bought and the one who helped us write our wills; those guys were okay. I hear that lawyers that represent families battling schools that are not providing appropriate services for their children with disabilities are pretty nice people. We deal with laywers in the risk management department who advise us on issues of medical ethics and cases that can be rather messy. Those lawyers are decent people. It is the malpractice lawyers that really tic doctors off.

I have not had the misfortune of ever having to deal with a malpractice case, and psychiatry is actually a low risk field for getting sued so we do not worry quite as much as, say, a surgeon or obstetrician. The lawyers we deal with and really get into conflict with are public defenders who work with patients in involuntary committal hearings and disability attorneys.

Disability attorneys annoy us for the reason that they are constantly pressuring us to fill out paperwork to declare patients permanently disabled who are not, and need to get a job. Some psychiatric patients need disability and are never going to be able to handle the stresses of a full time job, but most of them are capable of working, and really should. Being on disability is a barrier to getting well in fact. If one were to get well, one looses his source of support and faces an uncertain job market. Worse then that, he has to go to work and some people do not have the best work ethics in the world. Many people have gotten into the rather bad habit of watching a lot of TV and playing a lot of video games and are none to excited to change that pattern. I hate to say it, but it is true. I have worked in many states with very different types of communities and have seen this happen everywhere.

The other type of attorney that really gets psychiatrists goats is the public defender. Not that they are always bad, but for the reasons that we need to work with them. No psychiatrist enjoys committing a patient against his/her will, but sometimes it is necessary. The laws are much more strict than in the past to prevent abuse of patients, and if it is felt that a patient needs to be hospitalized involuntarily, there will have to be a hearing of some sort. Each state's rules on how this is done vary but have some similarities. One is that the patient has a right to be represented by an attorney, which most of the time is going to be a public defender. I would never imply that a patient does not have the right to appropriate legal representation in a committal hearing, but I will never attempt to commit a patient unless I truly feel that the patient is putting him/herself in danger by not receiving treatment or is a risk to society. Some PD's will see when a patient is really sick and not try to secure a really sick patient's release solely to say they won the case. These ones will often know when releasing the patient is going to potentially have very disastrous consequences (suicide, homelessness, bankruptcy, loss of home, family, life savings, etc.) and will not push too hard because often the patient is too sick to realize the risk him/herself. This is very commonly why we are seeking commitment in the first place. To try to help a patient with poor insight before he ruins his life and kills himself. Some PD's will fight to the death to get the patient released at all costs, regardless of how ill the patient is or how obvious it is that the patient needs treatment. Often in the case where the PD sees that he is fighting a losing battle, will start to ask rather ridiculous questions in order to catch the doctor off guard, often making himself look like an idiot in the process. I love those moments. I keep them cataloged in a special cubby hole of my mind to be brought up again at unit Christmas parties and anytime someone looks like they need a laugh.

Some of the best:

PD: How do you know the patient's homeopathic medication is not effective at controlling her symptoms?

Me: Well, she is here, isn't she?

PD: So you say that the patient could not come to the hearing because he refuses to wear clothes?

Me: Yes, that is correct.

PD: Is that a problem?(Not if he were Daniel Craig, but he was not, so yes.)

As a side comment, a social worker at the hearing who knew the patient told the PD "trust me, if you had ever seen him, you would know, yes, it is a problem."

PD: Tell me, if the patient's delusions were to turn out to be true, would she still need to be committed?

Me: Well, no, then she would not be mentally ill.

PD: Why do you think this man is a danger to his son?

Me: He is well established as an alcoholic and has been court ordered not to drink around his son, which he still does. Also, he has held his ex wife at gun point more than once and threatened to kill her.

PD: What makes you think that just because he will willing to kill his ex wife that he poses any danger to his son? (Maybe beecause he is a sociopath?)

PD: Exactly where is the danger in what she was doing that night?

Me: She was walking in the dark in a neighborhood with numerous "shooting galleries" and crack houses where there was a high risk of dirty needles being on the ground. She had no purse, cell phone, money or means of defense. She was barefooted. This is a high crime area where she is just a likely to be kidnapped and raped as be held up at gunpoint by a desperate addict seeking money for a fix. She had not slept in three days and was confused and had no idea what kind of danger she was putting herself in.

PD: Yes, but what has she done that is a danger to herself?

PD:You say that the patient has left the hospital two times before with a court order to take his medications and did not anyways. He told me that he would take his medications after discharge this time. What has he done to give you any indication that he would not take his medication after he was discharged? (If that was not proof enough, I had to respond.)

Me: He told me he was not going to take his medication after discharge this time. Has it occurred to you that he may have lied to you?

I save the best for last:

A big headed PD who had visions of being the next Perry Mason was trying to make me look bad during an appeal hearing by questioning my credentials. This is how this proceeded:

PD: Are you a licensed psychiatrist in the State of Pennsylvania?

Me: No, I am a licensed physician in the State of Pennsylvania.

PD: Whoa,whoa,whoa, now hold on there! Can you please explain to the court just why you are not a licensed psychiatrist in the State of Pennsylvania.

Me: Because there is no such thing as a license for psychiatry, we are physicians and licensed as such. I am a Board Certified psychiatrist if you have any concerns.

PD: (defeated) I have no further questions.

Me: In my head I was thinking "Can you explain to the court just why you are not a licensed dumbass in the State of Pennsylvania?" but I kept my mouth shut.

We had a really good laugh over that one. This attorney has since moved on to bigger and better things in the legal system but he continues to this day (even though this was years ago) to bear the moniker "Licensed Dumbass". When there was a hearing scheduled on the unit, the question, "Is the licensed dumbass defending today?" was often overheard. This is a fact that he may, or may not know but if he does, I really do not care. If the Foo Shi......

By the way, the licensed dumbass lost the appeal.

White Coat Dilemma

2010-06-24T12:10:00.013-04:00

One can call it tradition. One can call it habit. One can call it dogma, butone fact remains clear.

Psychiatrists do not wear white coats.

We are the only field of medicine where this is a consistent situation. While some non-clinical fields like radiology or pathology may find persons who do not feel the need to wear a white coat, head shrinkers will not wear white coats even if told they are supposed to. It is not done. Period. Some residencies go so far as to forbid the practice. Emory University is a highly respected residency and does not allow residents to wear white coats, even while completing inpatient rotations. I do not wear one even though I work exclusively on an inpatient setting, and to be honest, could really use the pockets. But I do not and refuse to change my mind.

Why? The official reason is because white coats are too clinical. Psychiatry has a history that, in truth, was not always that pretty. We are not afraid to admit our legacy of excessively long hospitalizations, mistreatment of the patients and ineffective treatments that could in some cases put the patient's life at risk. These days are long gone now and we no longer wish to be associated with the overly authoritative image of the white coated doctor who came in with an emotionless face and sentenced a patient to whatever treatment he felt would somehow fix the patient of his/her ill defined ailment.

The other branch of psychiatry that existed was the psychotherapeutic arm where analysts in suit coats analysed patients lying on couches. The usually affluent patient unloaded all of her inner traumas until some resolution of their problems was arrived at. No white coats. Dated, but still much less threatening, nonetheless.

As a side note, for those of you that have come in contact with several, especially older, male psychiatrists, you are not imagining things. There is a large population of psychiatrists that cultivate the Sigmund Freud look. Most of the men that bear this look are older and trained back in an age when psychiatrists actually did do psychotherapy and used the principles of psychoanalysis in their daily work. I am not sure why, and I really do not have the guts to ask. Maybe I do not want to hear the answer. I am not afraid of the wordy "psychobabble" response. I am just as good at dishing one of those responses out as any other psychiatrist, and actually would know what was being relayed to me. It is a fear of angering the ancient legacy of the "great ones". Much like the curse of Tutankhamen, one does not dare question the past teachings of the old psychoanalysts lest one risk some horrible fate befall him or her.

Returning to the white coat issue, this one is common to all psychiatrists, older and younger, male and female. Psychiatric units are also often regarded differently in that the nurses are often allowed to wear street clothes rather than nursing uniforms. Lately, there has been a movement to have them wear uniforms but the more traditional people, myself included, are opposed to mandating this. This is for the very same reason. Nursing uniforms remind too many people of the evil nurse behind the window in "One Fell Over the Cuckoo's Nest", with her cap and curt dress and tend to be too threatening. Obviously, nursing uniforms have changed quite a bit, looking more like surgical scrubs today, but the connection is still there. Do not even think about asking a male nurse to wear one of those caps. The nurses at my hospital are very quick to respond to my requests and have a very rigid pecking order where the doctor rules. This strict order makes me feel to some degree uncomfortable, but this might be the one time in my career that I would risk getting backhanded.

On a deeper level, psychiatrists like to be the rebels of medicine. They will not say this, but there is that undercurrent. Touching a patient is considered a boundary violation in therapy and while it does sometimes have to occur while working with inpatients, effort will be made to avoid it. Many hospitals actually have psychiatrists examine each others patients to prevent them from actually coming in direct physical contact with their own patient at any time, even in a clinical setting. This is not rebellious, it goes back to the very rigid boundaries that need to be kept to maintain a healthy therapeutic relationship with our patients, but it does make our relationship with our patients much different than other medical fields that provide direct medical care and helps to define us as somehow "different" from other fields of medicine.

In a similar vein, we do not wear stethoscopes, carry oto/ophthalomoscopes, reflex hammers or penlights. Our patients wear street clothes while in the hospital and are expected to be able to get up, go to groups and eat in a general area. No IV poles, electronic beds, heart monitors or oxygen masks allowed. If the patient requires these sorts of treatments, they are not ready to come to our unit yet.

Since our units are different and our treatments are different, psychiatrists tend to be different. Hospital rules tend to require shoes not have open toes, women wear hose, men wear ties, etc. The usual office dress code. They tend to discourage excessively high heels, long necklaces, multiple rings on a hand, more than 1-2 piercings per ear (certainly nothing besides the earlobes, and no lobe dilators). These rules have a tendency to be viewed as "suggestions" by a lot of psychiatrists. I did not have the guts to show up to work with biker boots like a former medical director once did, but I live for my malignantly high heeled sandals and do not handle hose when the temperature rises above 60 degrees. I do not fear my blatant disregard for my consistent violation of the no open toes rule. Or the limit of two rings per hand, two earrings per ear (I have three on one, so I am not really that bad) or not dangly earrings/necklaces policy. A lot of men I know have long forgotten about the tie as an accessory. None of us worry about retribution. I have always said, if someone in administration says something about the way I dress, I will change my errant ways, but only if someone does.

Except for the white coat. I will not wear a white coat. Shrinks do not wear white coats.

The Lunch Room

2010-06-14T21:52:00.009-04:00

In the last post, I alluded to the discussions that occur in the conference room at lunch time. Our unit is small and the conference room doubles as a lunch room. The designated lunch room is too small and too cold for most to tolerate. The staff of a psychiatric unit is more constant than med-surg because it requires a different kind of knowledge to work with this patient group, so the staff get to know each other pretty well. Lunch conversations can get rather, well, interesting to say the least. Among recent topics covered:

Who amongst us was the biggest nerd in high school.

Who had the most dysfunctional family while growing up and what they are like now.

Naughty things we did while in high school/college that we were not too proud of. Children of dysfunctional homes do tend to have rather rebellious pasts and those who fit into this category were not different.

Naughty things we did that we were proud of.

Amazing feats of nature that one can accomplish if one is intoxicated enough. In a related note, amazing feats of shear stupidity that can be accomplished in intoxicated enough. We put that park bench back, by the way.

Naughty things that we would probably be doing now if we did not have a reputation on the line to maintain.

What our naughty things were: sex, partying, skipping school or stealing park benches.

Reminiscing about past road trips to various college football bowl games and the debauchery that occurred during said road trips.

Who is most deserving of a swirly: Glenn Beck, Sarah Palin, the CEO of BP or Dick Cheney.

Who is most deserving of a total ass whooping: Ben Rothlissberger, Chris Brown, Rush Limbaugh, or Paris Hilton.

What is more boring: CSpan II or Mitch McConnell on one of his "tirades"?

That Fox News is nothing more than a bastion of right wing propaganda headed by Rupert Murdoch and that the staff members who come in with all the delusional sounding horror stories about what is going to happen in health care need to stop watching that station.

New and more creative ways that our patients have found to abuse prescribed medications.

The most hysterical thing a patient has said to us in the past 24 hours.

The most hysterical thing our children have said to us in the past 24 hours.

How we responded when an angry patient called us a tramp/asshole/douche/MF'er, etc.

How we would have liked to respond.

Jokes about who present in the room is most likely to have a pair of leather pants with the butt cheeks cut out, handcuffs and a cat o'nine tails.

Speculation on who owns the two Ferraris that park in the doctor's lot and how I can coerce said individual to letting me drive one of them.

Asking about just exactly did BP intend to do about all those walruses in the Gulf of Mexico?

How disgusting some of our patients tattoos were.

If anyone staff had a tattoo. If so, where it is and what it is. Most of the time, the tattoo NEED NOT be revealed, please. Usually there is the usual discussion about how that dragon on one's butt at 30 is going to be a walrus on the back of one's knee at 80 and then the owner is going to look like a real douchbag. Of course, if that person were to go swimming in the Gulf of Mexico, he could rest assured that BP would protect him.

The conventional wisdom states that one should never discuss religion or politics in a public venue. Both of those topics do come up in the conference room setting and seem to usually get discussed peacefully, although beyond the above mentioned discussion about swirlys and Fox News, the level of discussion tends to be superficial. There are a few topics that are never discussed under any circumstances. To bring these up would most certainly destabilize the fabric of the universe and cause most certain disaster. They are:

Whether or not anyone actually does own pants with the butt cheeks cut out, or related type items.

Personal opinions on the nurses union by anyone who is not a nurse.

Specifics about one's salary.

If one owns any stock in BP.

The Inside of Depression

2010-06-14T14:29:00.010-04:00

Severe depression is a monster the lurks in darkest regions of the mind. It slowly eats at the sufferer slowly, draining her of her strength until only a speck of the person she truly was survives. She is a lost soul, caught in a deep well that she cannot escape and feels powerless to change her situation. They have a feeling of weakness, desperation and pain that others do not always understand. Comments from friends and family to "just get over it" or "just pray harder" only serve to worsen the pain and make the sufferer feel more helpless as every effort she makes fails and damages her weak self esteem further. At times they find the pain so unbearable, that thought of death and suicide do seem like the only option to relieve their suffering. Most people will fight this choice, but many will make attempts. Fortunately, most will fail. Sometimes they succeed, leaving a lot of questions and grief in the survivors of the lost person. But sometimes a person is just done. She has had all the agony she can take and cannot go on any further.

Patients describe what they are feeling in many different ways, but they all have a similar feel to each other. There are milder cases of depression which are far more common. And there are the ones that reach the point of desperation like this.

A very wise supervisor of mine once told me that people do not want to die, they just want the pain to end. I have told this to many of my patients who have made serious suicide attempts, and they for the most part relate to that statement. Depression is a pain that cannot be seen and although it is hard to judge the extent of physical pain a person may be experiencing, there are objective signs that can be observed to give one an idea of what the patient is feeling. There are signs of severe depression, but sometimes they are more subtle. A trained eye can pick them out better than a lay person, but there are times when the sufferer can hide the pain well enough that the amount of emotional despair they feel is not evident. I have had patients that have committed suicide that did surprise me, but most of the time, I saw it coming. Some people will never be cured fully and the best treatment available will not help all. Cancer is a lethal disease, and depression is, too.

Patients have described what they feel in various ways. Severe depression is hard to explain. It must be experienced first hand to truly understand the full intensity of the suffering one can feel so they rely on metaphors to relay their feelings.

I have heard the monster analogy repeatedly, or the description of a demon controlling a person's soul, a vampire like creature draining the life from a person slowly.

I have heard about the feeling of being lost in a tunnel with no light at the end and no hope of rescue. Of being in a deep hole, unable to climb out, trapped and no one is there to come to one's rescue.

I have been told of feelings of being unable to move, feeling like one is walking through gelatin or heavy syrup, or rigor mortise. Technically called leaden paralysis, difficulty with slowed motor skills is noted in some variants of depression.

They speak of having their brain slowed down. Unable to process information or think. Like their mind has shut down and is moving in slow motion. They cannot concentrate or stay on task. In fact, there is some truth to this. It is believed that part of depression is cause by the decreased production of some neurotransmitters, the compounds that the brain uses to send its signals. The brain essentially is running too slow.

Some talk about having a coating on their brain cutting them off from reality, like a thick syrup or paint that closes them off from reality. Some even feel like their eyes have been covered by a haze that clouds their vision.

The most severe forms of depression are accompanied by psychosis where the patient loses touch with reality and often develops paranoia about friends and family. Trying to talk with them can be more difficult because the paranoia is so pronounced and patients have a hard time trusting the people they have come to for help. They are often tormented by voices telling them things and cannot always distinguish what is real and what is not but the voices will often tell them that people are trying to harm them

Depression can be treated, although sadly, most cases are not treated to remission, either due to lack of aggressiveness on the part of the provider, non compliance with the patient or both. If the initial case is not treated to remission quickly, the patient may never fully recover. Even for those that do fully recover, the chances of relapse is well over 50%. Returning to treatment is often successful, but only if aggressive and the patient may need to accept the idea of remaining on antidepressants for life if she does not want to run the risk of another relapse.

The monster can be controlled, locked away in a dungeon and possibly ignored for a time, but once someone has been overtaken by the monster, it will always be there with her. The threat that the monster will return will always be there, as the likelihood that it will escape its cell is high. Even if it never does, the sufferer will never forget the experience of being controlled by another creature and the memory will always be there. The victim will have to carry that "what if?" fear forever because she knows, the monster lurks.

For the College Graduate

2010-06-10T11:13:00.006-04:00

Every year NBC News has a medley of college graduation speech clips and one of the clips struck a nerve with me. The comment was something to the order of "You do not need to make anybody proud but your parents, and you have." That statement bothered me because I know it is not true. The only person a college graduate needs to make proud is the college graduate him/herself. Sometimes, the graduate has no one else. Sometimes he does and those people are not supportive or simply just do not care. No one should ever say that graduating from college is not a laudable achievement, but there are times when the only person who celebrates that achievement is the graduate.

Lunch in the conference room on the psychiatric unit here can be interesting. It is not unusual for the converstation to deviate to the "my family was more dysfunctional than yours" competition. Mental health workers often go into the field because of a past history of experience in the area, either personally or with family members or both. Dysfunctional families are not uncommon. We have plenty of staff who did not have a firm support system to get them through high school, college or even further education.

Not every successful professional out there comes from a stable home. Some people had the strength of character to fight the battle to get an education and a solid future solely out of their own desire for a better future for themselves. It is not an uncommon maneuver to get married young to get out of an abusive home, but there are some people who have the sound minds to graduate from high school as quickly as possible, go off to college in a town far away and get an education. For some, proving their parents' assertion that they will never amount to anything is almost an act of rebellion. Some of these people are not the most emotionally stable people in the world and have a tough time surviving, but are smart and fight their way through. Some were lucky enough to have some kind of mentor to help them build up some kind of self esteem. A lot need a lot of Prozac and years of therapy before they truly feel confident in their abilities, but they pull through and often, become the kind of people who help those children who do not have a good support system at home.

We were joking about how disgustingly soppy the Mother's Day cards available tend to be and how often they just do not fit the occasion. Many people love their mothers, they gave them life after all, but do not have the kind of loving, entwined relationship these cards often seem to portray. Some of the sentiments that were toyed with for more appropriate cards were pretty hysterical:

Die!

You were sometimes verbally abusive, but you taught me how to get away with speeding, made sure I got a good education and how to check my motor oil level. Thanks Mom.

Mom, you put me through Hell but I am glad to be alive so thanks for making me.

Despite everything, I turned out okay.

I will refrain from naming which persons were active participants in this conversation, and for some, this amount of anger was a bit exaggerated, but sometimes a bit of sarcasm helps one get through the day.

My ultimate point is this. NO ONE can stop you from reaching your dreams but you. YOU DO NOT NEED ANYONE to believe in you to reach your goals but yourself. People who appear to be confident and popular may have been shy and awkward as children. Successful and wealthy persons may not have come from money. Loving, nurturing parents may have been badly abused. That does not mean they cannot change their lives for the better. I have seen it many, many times. And the people who have come from unhappy situations to happy ones find more joy and happiness in what they have achieved than anyone else. Because there is no true joy without sadness. And they know that everything they have in life, they earned themselves. No one gave it to them, it is theirs. Because they had no help, it was even harder to obtain and they know it.

Many people walk into that graduation ceremony with no one there to be proud of them and they may feel very alone and scared. You may be in that situation. You may know someone like this. Tell them to read this. If this is you always remember: Be proud of yourself, walk tall. You are stronger than you think.

Healthcare and the Caribbean

2010-06-06T21:44:00.007-04:00

I have been off on vacation at the beautiful island of St Lucia for a week and made my best attempt at not thinking about my job during that time. Everyone needs a break here and there and I am no exception to that rule.

I must say that as flawed as I find our health care system, it could be far worse. I looked through the phone book, which is a habit I have when I travel. It gives me a feel for the country and what life is like there. St Lucia had more physicians listed than attorneys, which is a positive sign, but they have precious few of either, and the physicians listed were almost exclusively listed as primary care providers. There are only two hospitals on the island, one public with only limited services, and one private with more extensive services, but obviously, at a cost. That hospital actually had listed two psychiatrists on staff. A tour guide said that at one time there was an effort to build a psychiatric hospital on the island, but the funding dried up and the project came to a halt. Many other specialized services appear to be fairly limited on the island of St Lucia, a situation that appears to be pretty much more the rule than the exception in Caribbean islands.

St Lucia, if anything, appeared to be economically more stable than other islands I have visited, although poverty is still quite rampant. Health insurance is provided for the elderly by the government, but not for younger persons and it is not generally provided by employers. A tour guide told us that if one wanted health insurance, it was the responsibility of the individual to buy it oneself. He did not say how much it cost but from the appearance of the homes on the island, it could be safely inferred that this was a luxury that not everyone could afford. It did not have the feel of desperation and utter hopelessness that one sees from the images in Haiti, even the ones prior to that tragic earthquake. I did not get the impression that most people were living "high on the hog" either and money was probably pretty tight.

In Caribbean islands I have visited, and Mexico also, people who work at resorts work six days a week, twelve hours a day or more and despite this, somehow always seem to have a positive attitude. It never seems to amaze me how they can maintain spending their lives catering to wealthy people who they know work many fewer hours, for much more money and with many more luxuries in their lives and still be so pleasant. Of course a good attitude gets tips, but these are all inclusive resorts and the guests are told tipping is included in the cost so employees do not expect to be tipped. That said, resort employees probably are much better paid than many of their peers. One would hope that most of the guests treat them with a fair degree of respect. Personally for myself, when I am on vacation I am in a pretty good mood and am not likely to be giving an employee a lot of trouble, but there are always outliers who do overindulge and can get pretty nasty.

It is inspiring to see such a positive attitude in people despite such harsh conditions. Things do tend to run more slowly and we learned on this vacation that five minutes in Caribbean time was a lot longer than American time, but considering how much people endured in their lives, it was easy to be forgiving if things did not show up as quickly as one would expect in the USA. And we could guarantee when it did show up, it would be delivered with a smile.

Caribbean drivers are the exception to the Caribbean time rule, and drive with an alacrity that makes even me nervous on curvy roads that are certain to cause motion sickness without a hefty dose of Dramamine for other nausea medicine of choice on board. Returning to the snail's pace I endure in a community heavily populated with retired persons stressed me more than the shock of the temperature drop. At least they appreciate a good thrill.

I do not feel bad for visiting the Caribbean islands although I know some do, feeling that we are exploiting a poor country. If they did not want us there, they would not treat us with such open arms. Tourism is a significant money generator for small islands that have few resources to exploit without destroying natural resources such as the rainforests, pristine beaches and mountains. Many areas have found a balance between allowing some development and too much, and improved their standard of living in the process. I hate to see this level of poverty so close to our own home and feel that people deserve better.

I wish them well.

Fighting the Stigma

2010-05-27T21:43:00.005-04:00

I am leaving on vacation for a much needed rest tomorrow and will probably not be writing anything during that week so you will likely not hear from me. It has been a year since I have had a proper vacation and even the most dedicated professionals need a break now and then. I have reached the point where the staff have felt the need to reactivate the once dormant "F-bomb jar" because my language has been getting a little rough. I will discuss the jar in a later post. A few parting things before I go.

People do not choose to be depressed. They develop this condition over a time of prolonged stress. To pressure them to "just get over it" is one of the worst things one could ever tell a depressed person.

Prozac does not cure a person's problems. It just gives him the strength to go out and solve them himself.

Thorazine was far from the perfect medicine, but it was a start. It gave a lot of people hope where there was no hope before.

Most of the time the difference between the patient with bipolar disorder who is wildly successful and the one who is homeless and talking to a dumpster is compliance with treatment.

Every time a patient goes off his medication because he does not like the stigma of having a mental illness, he ultimately ends up decompensating, acting out of control in public, and being committed to the hospital. This only reinforces the negative stigma of mental illness.

Every time a patient remains compliant with treatment and goes back to her life, is successful and lives a happy and productive life helps to fight the negative stigma on mental illness. People like Jane Pauley, Fran Tarkenton, Mike Wallace and Kay Jameson, PhD have all come forward and discussed their struggles with mental illness and despite those struggles, continue to be productive citizens. If only more of my patients would follow their lead, the stigma would continue to lessen and the burden of mental illness become less overpowering.

Case in point. I will always be haunted by the memory of a man who when on his medication was very functional, personable and had lot going for him. The problem was he would never accept his diagnosis of bipolar disorder and would always stop his medication even though he was working, had friends, a stable life, etc. Ultimately he would lose it all and have to start all over again. This was usually after a tumultous hospitalization. One day we received word that his girlfriend had stopped by his apartment to see him, and found him hanging from a light fixture. This did not have to happen. I identified with him a lot. He was very close to me in age and I have a lot of life left to live, and so did he.

Despite the losses, if I had to do it all again, I would still choose to go into psychiatry. Even if I will never make enough money to afford a Ferrari like the heme-onc docs do. At least I can dream of that Audi R8 some day.

Things I Have Learned

2010-05-25T21:46:00.006-04:00

I have been out of residency close to ten years and have seen a lot of patients in those years. Psychiatry is more complex than other fields of medicine and learning the subtleties of it can take some time. Certain knowledge only comes with experience and time. I wanted to share some of the knowledge that I have acquired over the years that one will never read in a textbook, but is still interesting, nonetheless.

I have met God/Jesus on several occasions as well as the Antichrist. In general, the Antichrist is a much nicer person. God/Jesus is usually not a very nice person, although there are a few exceptions to that rule. Jesus seems to like to smoke a lot of pot.

A lot of dentists are in cahoots with aliens and the FBI and implant radio transmitters in people's teeth.

Any patient that threatens to sue me for keeping him/her in the hospital against his/her will is far too manic to be discharged. These patients will always call numerous attorneys in an attempt to sue me. They have so far never succeeded in hiring one.

A patient that presents as "an excellent therapy candidate" at the on sent usually is a lousy therapy candidate.

Antisocial patients (meaning criminal, not shy) almost always present as the most charming and likable individual one would ever want to meet. For anyone who would question this, I would recommend they watch "The Last King of Scotland" to see how effective the antisocial mind is at winning over allies.

Sometimes the incredulous things that a schizophrenic says that sound like delusions are, in fact, true.

Sometimes the very believable things that non-psychotic appearing patients report are, in fact, quite delusional.

Every single patient who is admitted to the psychiatric unit is going to complain about problems with bowel movements at some time during their hospitalization. Even the young ones.

In fact psych patients, even if seen by a primary care doctor, will fail to tell him/her about their gross rash, genital sore, hemorrhoids, etc. They will save those problems for me. When I ask them why they did not ask the primary care doc, they all have the same response: "I forgot."

When a criminal is sane enough to figure out the idea to plea not guilty by reason of insanity (NGRI), he usually is not NGRI.

The criminal who is truly NGRI is too sick to realize that he is NGRI and usually ends up in the criminal system as a result.

An amazing number of patients have tried a drug only one time in their life. Even more amazing is that that night just happens to be the night before they are admitted to the psych unit as it always seems to show up on a drug screen. Sometimes they have tried that same drug only one time in their life on multiple occasions, each of those singular occasions being the night before they are admitted to the psych unit.

A lot of patients will expect you to believe that two beers will give you an alcohol level of 0.460.

Most patients that are sighted running naked in public are not the people one would really want to see running naked in public. Most incidents of people caught running naked in public occur in the Spring.

There is a phone number that civilians can call to contact the Pentagon that is apparently accessible to the public. The Department of Defense will not necessarily show up and investigate if one of the patients calls that number, fortunately.

If someone makes any sort of statement that could be interpreted as a threat to the President, the Secret Service will show up.

The guys from the Secret Service and the DEA do look like the guys from Men in Black. They are not accompanied by a cute alien pug, however. To the best of my knowledge, I have not have not had my memory erased by one of those flasher devices, but I guess if I did, I would not.

Real men do cry.

Lots of women return to abusive relationships repeatedly and there is nothing I can do to stop them.

We can provide the best care humanly possible to our patients and there are still going to be patients that commit suicide. Some people are just in too much pain to continue and there is no intervention that anyone can provide that is going to alleviate that pain.

Some patients that curse my name when they are admitted thank me for their help by the time they are discharged.

Try as I might, some patients are never going to like me for various reasons that may, or may not, have anything to do with me personally. It is a fact in this field that one must accept and not take personally because if one does, it will eat one alive.

One hundred years ago, many, if not most of these people would have spent their lives locked away in "lunatic asylums" never having any freedom or dignity. This was perhaps better than being chained up in a relatives attic like a rabid animal. Now my patients have hope and many of them live perfectly normal lives once stabilized. If it were not for the stigma that society unfairly places on the mentally ill, many more would comply with treatment and do better as well.

We need to open our mind as a society and rethink our beliefs.

Cutters for the Layperson

2010-05-17T21:37:00.009-04:00

* I am writing this because I know there is a lot of misunderstanding about wrist cutting and people who cut on themselves in other locations in general and thought some people may want to know more about this phenomenon. I recall my cousin's struggles with a college roommate who cut herself on a regular basis and her difficulties in knowing whether or not to

press the panic button as it were or not when this occurred. We deal with "cutters" on a daily basis in psychiatry and are not as uncomfortable in dealing with this behavior. If anything, there is a level of frustration at it because cutting is so often used to manipulate and control other people and becomes very old after a while.

First, to clarify some misbeliefs about cutting one's wrists. It is almost impossible to die from cutting one's wrists. I have had many patients tell me that they know they need to cut lengthwise, or soak their wrists in water to keep the cuts from clotting or take rat poison (a potent blood thinner) to prevent the blood from clotting, etc. None of this is true. A healthy adult can donate a pint of blood without risking his/her life and would have to lose far more to die, and one is simply not going to lose that much blood from an incision on the wrist. If one were to cut clear down to the artery, which would in fact be straight across, maybe one could bleed out enough. The problem is cutting that deep is extraordinarily painful and most people are simply not able to do that. For someone to die of cutting his wrists, the plan must be very carefully planned and the cut must be pretty deep. The person also needs to make sure that he/she is somewhere very remote because it is going to take hours to bleed out that much. I have never seen a patient die from cutting themselves anywhere and only had one close call. Morbid to keep a head count, but that is the reality.

Cutters know that cutting is not lethal. They often say they are making suicide attempts when they cut, but in all reality, they are upset and saying something out of anger that they do not really mean. It is true that some people do intend to kill themselves by cutting their wrists, but these people are usually not chronic cutters and di not really know how unlikely it is to die from cutting themselves.

So why do they cut? Many will describe it as a release. This could be a release of anger, frustration, panic, just about any powerful emotion that the sufferer cannot tolerate. A large percentage of cutters have the diagnosis of borderline personality disorder, but this is not the case in all cutters. Certainly when this behavior becomes a pattern, this diagnosis needs to be entertained. Borderline personality disorder is a complex disorder in itself and volumes have been written but suffice to say for this piece, these people have very immature and chaotic coping mechanisms and cutting is a frequent way they turn to to deal with their frustrations. Often cutters have been victims of abuse as children and they have learned to abuse themselves when they perceive themselves as having done something wrong. This often manifests as cutting.

For others, it is a way of manipulating others. I see this more with men who cut themselves when their girlfriends break up with them to get them back. This is sadly, surprisingly effective and the men usually get their wish. These relationships are often chaotic and there is most of the time a fair amount of domestic violence involved. Drugs and alcohol usually come into play as well. They almost always make a statement about "showing her how much I love her because I cannot live without her". I usually try to point out that if this person truly loved his girlfriend, he would want her to be happy. If she is not happy with him, coercing her to go back to him is not showing love, it is showing a need to control. My confrontation usually goes unheard or receives an angry response, but I feel compelled to tell the truth in these cases. Women are certainly not immune from this behavior and can be just as manipulative but usually there is not the domestic violence element involved.

The reason that people pick up the habit of cutting is multi factorial but the element that is in these cases most often is a history of abuse, especially sexual abuse. This is probably why it is much more common in women. Other forms of abuse may be involved but for some reason, sexual abuse seems to show up most often. Behaviors in adulthood are learned in childhood as is one's view of oneself. Children who are abused regularly as children learn to abuse themselves. It is what they know, and what their "inner child" tells them should be the result of being "bad". People who cut often do so over a sense of guilt from events that may or may not have been their fault, an they are very prone to blame themselves for things that are not their fault. They probably always were as children.

There are endless aspects of cutting that could be discussed, more than could be realistically talked about in one essay so I am excluding a large amount of information simply for lack of space. Understand self mutilating is something that cannot be taught in a book and takes years of experience to fully understand and interpret but I tried to touch on some of the basics.

The biggest problem one runs into with cutters is how to treat them. There is simply no magic pill that will stop this behavior and very few therapies that are very difficult to access and get insurance companies to pay for that can effectively treat this problem. Cutting is not necessarily a sign of depression, and the cutter may not be depressed at all. Whether or not to hospitalize a cutter is also an issue. People who cut themselves superficially know they are not going to harm themselves and are just venting. Putting them in the hospital every time they cut may be counterproductive. Trying to find the balance between what was a serious suicide attempt or a serious action vs a baseline cutting behavior can be tricky. As hard as it seems, sometimes the best way to deal with the behavior is to ignore it. Maybe not when the person in question locks herself in the bathroom, texts suicide notes to her friends and shouts out "this time you'll be sorry!" But for the women who every time she gets in a spat with her abusive boyfriend makes some superficial cuts on her thighs, sometimes paying too much attention just increases the behavior. The best that a layperson can do is get the person in question to a good therapist, psychiatrist or if the person is really making a lot of suicidal threats, to hospital ER or crisis center, if available, and allow a professional figure out a treatment plan. Do not expect a miracle cure or long term hospitalization in most cases. This simply does not happen, but with the right, long term, treatment this behavior can be reigned in to a manageable level.

One caveat with this is that cutting in adults if often a long standing and habitual pattern and very difficult to stop. This is not true for children and adolescents. Cutting behavior at this age is a sign of a person who may truly be suicidal and needs to be taken seriously. Never tell an adolescent they are cutting "for attention". Sometimes once they realize that cutting does not work, they move up to more lethal measures, and a bottle of OTC Tylenol is quite lethal, and easy enought to obtain. Get them help quickly. In some cases, cutting could be a case of an evolving personality disorder that will become a lasting pattern in adulthood, but if an intervention is made early enough, teenagers can grow out of cutting patterns, so do not ignore this. It could save them a life of misery and thousands of scars. Or it could save a life.

*Photo courtesy Scott Feldstein on Flickr

Mismanaged care

2010-05-12T21:29:00.024-04:00

We have all heard the term "managed care" as the new paradign for running medical insurance. Designed to decrease what was most certainly abuse of the system, these programs are becoming very overbearing, tightly controlling the way doctors practice medicine and dictating areas that they have no business interfering with. The word "care" truly has no business in the name at all. The true name of this practice should be "managed medicine" if not "dictated medicine". I have no issues with trying to contain the spiralling costs of medical care or to prevent abuses that have occurred in the past, but insurance companies have immunity from litigaton. They cannot be sued if something negative happens to the patient when they refuse to pay for a treatment that is felt to be medically necessary, and they know this. Doctors and hospitals are forced to decide between doing what is right for the patient and face significant financial losses or not provide care and face malpractice suits for a negative outcome. This is not my gripe today, but the utter silliness that some of these companies. The length they will go to to dictate how care is rendered can be quite ridiculous and bears mentioning.

I have mentioned before that the economy in my city is not good and the majority of our patients are either uninsured or have Medicaid. The psychiatric benefits for Medicaid in this county were farmed out a few years ago to a private, and sadly, for profit company that has spent a great deal of effort trying to tell us how to do our jobs. Much of this is because if every little piece of busywork that they want completed is not done, they can deny payment for the service . This is the ultimate goal of any insurance company. Sometimes, however, I honestly believe that there are some poorly qualified individuals with a correspondence degree and a GED who think that they are improving care by coming up with suggestions to help our patients in the so called "recovery model".

The recovery model of treatment is a perfectly reasonable approach to treatment but needs to meet the patient where he/she is at. The idea is to help people to look beyond their diagnosis and strive towards recovering to a higher level of function. Hopefully the patient will be able to return to a work setting, or at least remain in the community, living independently and living a healthy lifestyle. This was opposed to the older model with tended to lock patients in psychiatric facilities for years or even life, a system which has been abandoned decades ago.

Our particular managed care company, I will call NBH (Nag,Bitch,Harass), not their real name, has decided they want an individualized safety plan to prevent suicide in every patient we discharge. They suggest we have them plan such activities as: walking, meditation, attending a church, joining a gym, getting a volunteer job, etc. Of course, not all of our patients are suicidal when they are admitted to begin with. Some become quite defensive when you ask them if they are suicidal and refuse to participate in such discussions. Some are homicidal, some psychotic, some are just trying to get their girlfriend to come back to them so they cut their wrists and claim to be suicidal. But they think that they have a great idea and if we are to get paid, we have to do this.

Some of us were sitting around trying to come up with some ideas that would fit their criteria but might be more appropriate for our patient population. When a patient claims to be suicidal because she got a second floor apartment and now has to climb a flight of stairs to get home is not going to get a volunteer job. In fact, she is too lazy to put her street clothes on when she is on the unit and we are just happy if she will shower and put her underwear on. Meditation? The closest thing to a meditative state our patients will ever see is drug induced are we are trying to discourage that. Join a gym? These guys will not pay a $1 copay for medication. Where are they going to get $50 a month to join a gym? So we tried to come up with ideas that would calm NBH's jets. They are not going to work, but they will fit the criteria. Then we came up with what our patients would be more likely to be receptive to. Not to sound cynical, but you have to be realistic sometimes.

What NBH Expects	What They Will Do
Call a friend	Call a friend and tell her you took an OD
Join a club	Join a drug gang
Reconnect with family	Have sex with a family member
Read a self help book	Read a porno mag
Meet you neighbors	Get in a knife fight w/ the neighbors over a man
Go to AA	Go to AA for 13th stepping(picking up chicks)
Take a walk	Take a walk to the stop'n'rob to buy smokes
Start a garden	Grow marijuana in the closet
Start an exercise program	Get drunk and run naked through the streets of downtown
Get into art and paint a painting	Get a new tattoo
Get a volunteer job	Volunteer to be the lookout in a drug deal
Go to church	Join a Satanic Cult

And finally...

Go to a public event

Go to a bar and get shit faced.

The Real World

2010-05-08T14:23:00.008-04:00

Mental health workers deal with the sometimes odd behaviors our patients exhibit every day so we are not always bothered by it. Psych patients do have medical problems, though and sometimes we end up calling consults from often unprepared medical specialists. Sometimes their responses to our patients is quite hysterical.

Sometimes the reason for the consult is tragic and one learns something new. As a resident, we were brought a patient who was transferred from another facility after trying to pluck her eyes out and was left with nothing but the ability to see a little bit of light. There is nothing funny about this case and it is terrible to see a horribly psychotic patient who slowly starts to come out of her delusional state and realizes what she has done. In a failed attempt to change from a very effective medication with terrible side effects to a newer one with fewer side effects, she fell apart and became religiously preoccupied. This is a very common theme in psychotic patients' presentation. The voices took over and told her "If thine eyes offend you, pluck them out" and that is what she did. The irony is that the patient is an atheist.

The ophthomologist, a quite respected and experienced one, was consulted to see her and provide whatever treatment that he could. He told us that this was the eighth case in his career where he had treated a psychiatric patient who had tried (or succeeded) at plucking his/her eyes out. It is sad to know that this is not an exclusive case. I have never seen this happen again, and hope never to, but I know something to look out for now.

Usually these encounters are not so tragic. Just a basic medical issue that needs addressed and a sometimes humorous result. For those who do not know, psychiatrists are medical doctors, and our training in medical school is no different than any other physician's. The difference is we chose to specialize in psychiatry rather than say, family practice or surgery. To do this, we complete a residency after medical school in that area specifically, just as other doctors complete residencies in their own fields. We are able to treat minor issues, mild hypertension, bladder infections, reflux, but when the patient shows up with uncontrolled diabetes, we are going to need to call a consult. Some consulting physicians handle these situations well, some do not.

We had one patient who was quite insistent that he did not hear voices that tended to carry on conversations to himself all the time. We knew he was hearing voices and did not even bother to ask because it would just get him riled up. He did not tolerate a lot of stimuli and stayed in a quiet area isolated from other patients much of the time. When his diabetes spiraled out of control (this is a common problem in psychiatric patients) we called an endocrinologist to see him. He did make the mistake of asking the patient about hallucinations, and got a very terse response that, no he did not. He would have better to stick with blood sugars but for some reason, asked. Our consultant walked out of the quiet room and stated "You know, when I was walking out Tim (not his real name) turned to the air and said 'Did you hear that? He thinks we're hearing voices!'" Our amusement was more with the doctor's reaction than the patient's. My response was a simple "Yeah, he does that." He seemed bothered that we were not more concerned, but there was nothing to that could be done about the situation. We were just glad that he was not throwing chairs across the room or assaulting security officers, which he has been know to do. If he wants to talk to an invisible man, let him.

Sometimes people are just too intimidated by the patient's behavior to know how to approach it. We had a patient who tended to stand at the end of the hall and walk down it in a series of lunges that reminded me of the "Ministry of Funny Walks" sketch in Monty Python's Flying Circus, for those who know the show. For those who do not, just know that it was a rather strange exhibition. Most psychiatric units at some time or another have nursing students doing rotations and we had some around the time of his stay. Some of them seemed bothered by this behavior and came to me about it, wanting to know why he did this. I gave them a very simple response- "Have you asked him why he does that?" Of course they had not, and seemed rather shocked at the whole idea. "I could never do that, he might get angry at me" was one response I got. I reminded them that he must not mind answering the question that much or he would not be behaving that way in a public setting. I already knew his response because I did ask him, but tortured them by not telling them. They needed to learn on their own. Part of treating a patient is asking questions. If the patient says he hurts, you ask where. If a patient acts strange, you ask why.

He told me he walked like that because he liked to walk that way. And he did not get angry when I asked. Fair enough.

Sometimes the issue is dealing with patients who tend to be rather disinhibited. The manic patient who started propositioning the public defender before a committal hearing will always remain in my mind. Everyone who was to be at the hearing was there to witness this interaction, also. He turned all kinds of shades of red, but still fought like hell to argue that she did not need inpatient psychiatric treatment. He did not win, which is probably good or he might have had an unwanted paramour stalking him if he did. I do not get along with this particular PD anyways.

The best encounters I have seen are with non psychiatric residents, solely because of the fact that their inexperienced nature can result in such shocked expressions when they hear comments they do not expect to hear. We had a very sexually preoccupied patient fall and split her eyebrow open and had to consult family practice to come and suture her back together. I am not sure what crime against humanity the poor intern they sent up had committed for him to get chosen for this detail but the poor kid was as green as the rain forest during the rainy season. He had been given no warning that he might hear something odd or out of the ordinary. He was probably expecting the typical patient who comes in with their face cut open, pretty nervous and not saying a whole lot. Instead, he was treated to her nonsensical ramblings about being a model and a porn star (she was in her late 50's, a heavy smoker and looked much older than her age) with added mumbles, which is her baseline behavior. He was really startled when she asked him "Can I still have intercourse with these in?" The expression he had on his face was priceless. The advice to the intern: just ignore that and keep suturing. He survived to continue his internship and eventually complete his training, but not quite as naive as he once was, and perhaps a bit wiser.

The Unreal World

2010-05-04T21:31:00.008-04:00

My favorite population to work with is the very chronically mentally ill, especially very psychotic patients. They are frequently misunderstood, isolated and rejected by their families and friends. Their lives can be a very lonely and sad one of lost dreams and little hope for the future. With the emergence of newer antipsychotic medication, there has been more hope for these patients, and their prognoses have been much improved but there is still quite a way to go before we can truly say we have fully controlled these conditions. They are by far the most interesting people to work with and their behaviors, although bizarre to the outside world are not that hard to understand if one understands why they do what they do. Despite this, some of what they say is still fairly comical.

A patient we have been dealing with has refused to accept her diagnosis and will stop her medication after discharge from the hospital invariably. Despite this, she functions and manages to survive until her behavior becomes simply too strange for the neighbors to tolerate and she is dragged in on an involuntary commitment. We repeat the cycle of resuming medication to clear her just enough that she makes some sense and send her home and the whole thing repeats. She is most noted for having what is called disorganized thoughts. She denies hearing voices, although it is clear she does, but her biggest problem is her inability to communicate in a coherent manner. Today she accused me of being a women who she believes has been tormenting her for years, pretends to have many jobs and aliases, the most memorable of which was "Ringbo Money Money Monkey Potato Gun." It took everything within me not to break out in laughter. It is very bad form to laugh at your patient when he/she is not trying to be funny. My contract is in the process of being renewed and I am pretty sure the hospital is not going to be willing to change my name to Dr. Ringbo Money Money Monkey Potato Gun. It will not fit on my ID tag for certain.

Disordered thinking is something that is hard to fully appreciate unless one has actually heard it in person. It is noted by rather nonsensical rambling, often where the patient will jump from one topic to the next in the same sentence and tie unrelated ideas together through words. Sometimes they will talk in rhyme, known as clang associations. They often do not make much sense until you get to know them, but once you do, you start to understand as least some of what they are talking about, usually by knowing what is concerning to them in life. Many people will never encounter this in person as so many psychotic patients tend to isolate and do not socialize often.

Most people have encountered people talking to themselves, though. Not just those that are frustrated and grumbling, those that are carrying on full conversations. Comedians make jokes about pairing them up so they have someone to look like they are conversing with. People cross the street and shelter their children from these people. They are quite misunderstood. Most of the time, these people are totally harmless and would be happy to carry on a conversation with you if you were to approach them. In truth, they are not talking to themselves. They are talking to someone else, or maybe many people, but the outsider just cannot see them. Most of the time they cannot, either. But the voices are very real sounding to them and are very much a part of their reality. Often it is not very fruitful to ask a patient if they are hearing voices because "hearing voices" implies one is hallucinating, and the patient does not view the experience as a hallucination. I have found it useful to ask if they hear the neighbors through the walls, people walking outside of their homes, or in the distance. Often they believe they are reading other people's thoughts. If someone is truly hearing voices (as opposed to those who claim this for personal gain) they believe the voices are real and it is not uncommon for them to talk back to the voices, hence the people who talk to themselves. Some know enough to go in private to have a conversation, so do not. Even those who do not openly talk with their voices are often preoccupied and looking around at other parts of the room when they are being talked with. They cannot tell where the voice is coming from, whether the interviewer, the invisible voices, or another person in the room. So they are looking around to find the source.

It is how a psychotic patient deals with the voices that can sometimes be rather amusing. It is not that we spend out days making fun of our patients but when a patient is standing in the hall talking to the fire extinguisher much of the day, one must admit that this behavior is comical. Some can get into pretty heated arguments with the voices, even threatening violence, yielding knives, etc. Sometimes they just look over and talk to the air. Commonly they whisper to themselves, sometimes mid sentence during a discussion with another person.

Treating for this population has gotten much better than in previous generations, and some have reported near total relief of their symptoms, or at least a dulling enough to be able to return to regular function. It is gratifying to be able to offer options that can actually give these patients the hopes of some degree of normalcy. Most will never be able to get married, have a FT job, raise a family, etc, but the days of being locked away in a run down state hospital for years is long gone. Many people are able to have friends and live independently. It is nice to see that and give people some of the life they lost back.

The Silent War - Part V

2010-04-25T21:22:00.008-04:00

My final rant on this topic (I promise) is the issue of methadone clinics and Suboxone maintenance. Methadone clinics have been around longer and have always carried a degree of controversy with them. The idea is to replace one addiction with one that is more easily controlled. Methadone is also an opiate, but not as impairing as heroin and as it has a longer half life, only needs to be taken once daily. The hope is to get the addict of the crave-rush-crash-crave roller coaster they have been on. In general, the patients are supposed to go through a rigorous screening process to assess their motivation to truly get clean from opiate addiction and are regularly drug tested to ensure compliance with treatment. Most patients must come to the clinic daily to receive their once daily dose of methadone to ensure it is not abused. In some cases, it is given in a liquid form that must be taken in front of staff, but not always. Tablets are sometimes used, and it is not unusual for patients to "cheek" their tablets and turn around later and sell them, often in exchange for more potent drugs. The sale of methadone often occurs in close proximity to the clinics themselves and there was a recent legal battle with a community and a methadone clinic that wanted to open a clinic in close proximity to a school for that exact reason. Many of the clinics out there turn a blind eye to the extent as which this drug is being diverted and abused and how the services they provide are being manipulated.

In order to ensure compliance with treatment patients are subject to routine drug screening, but there are clinics that do not strictly enforce standards about abstinence. The idea with methadone use is that the patient must abstain from use of all other opiates to remain in treatment and unless prescribed by a physician, any other drug that could be abused. Truly good methadone clinics will not tolerate use of any controlled substance, even prescribed ones as addicts are likely to replace one addiction for another. Methadone, although an opiate, is screened separately from other opiates and does not test positive on general opiate screen. If a patient tests positive for opiates and methadone, he/she is using again. If the test is negative for methadone, one often would suspect that the methadone is not being taken at all, and perhaps being sold for something else. Other common drugs of abuse are tested for as well. In general, repeated "hot" urine's are grounds for dismissal from a clinic but this is not always followed like it should be. We have had several circumstances of patients admitted to the unit who tested positive for several drugs, often freely admitting to using numerous drugs, even returning to IV drug use. When their methadone clinic was notified they stated that they had no intention of discontinuing services. I have had patients who have told me that some clinics never kick a patient out of services. As long as the insurance is paying, the patient gets his methadone.

Eventually patients work their way up to a status where they only need to come in once a week for their methadone and receive a weeks supply at a time. While one hopes that this is because the patient has been compliant and motivated to get well, manipulation is part of the addiction process and many patients given a weeks supply abuse the methadone or sell it for something else.

Suboxone is a newer medication that has been used in treatment of opiate dependence. It is a combination of an opiate with a medication that blocks the absorption of the medication if it is taken IV or snorted. The idea is to discourage misuse of the medication. Its use is not as strictly regulated and can be dispensed by family physicians who have had the training and licensing to prescribe the medication. Physicians are limited on the number of patients they may treat at any time preventing this from being dispensed in a clinic setting. Since the number of patients a given physician may treat is more limited and the monitoring is more easily done, this medication is not abused to nearly the degree that methadone is. Overall the outcomes generally tend to be better and patients on Suboxone do tend to be more compliant. With time, however, people have found ways to get around the opiate blocker and misuse this medication as well. This medication also has a street value in that it prevents withdrawal symptoms for an addict who cannot afford his/her next fix, so it is always worth keeping a tablet or two around. Suboxone is dispensed in one month prescriptions at a time, and many patients take less than they are prescribed and sell the rest so even this is not the perfect answer.

The opiate addiction problem in this city grows daily and as a result, the methadone clinics also grow in number and their locations spread further into remote areas putting more young people are risk of exposure to an unhealthy environment.

None of this is speculation. I work with addicts every day and they tell me the stories about what happens on the street. Sometimes they admit to what is going on, sometimes they do not, but when a patient in methadone maintenance has a drug screen positive for cannibanoids, cocaine and benzodiazepines but no methadone, the patient is not being compliant with treatment. Somehow methadone is being used in a manner it is not supposed to be. And rarely is anything done about it.

Although the city has put in place various drug reporting programs, educational programs and increased security in the schools, as long as there is a continued influx of court ordered addicts and drug pushers from larger cities like New York, Philadelphia and Brooklyn this problem is going to continue to grow. Court ordered treatment rarely does any good. Too many of the persons ordered into treatment choose not to return home, either running from drug gangs or having found a new place to market their deadly product. I hope that city leaders will see what damage that all the drug rehabilitation centers, methadone clinics and halfway houses have done to the city and put a stop to it soon. I am tired of hearing about "mystery people" being found dead of heroin overdoses in public. I am tired of hearing about my teenage patients dying of drug overdoses. And I am tired of dealing with the grief of the parents who have lost a child to drug addiction and not having any comforting words to give them.

The Silent War - Part IV

2010-04-23T13:18:00.006-04:00

There have been a few very high profile deaths by heroin overdose here in the past few months. People die from overdoses every day, but they are usually at home or in a shooting gallery out of the public eye, hence the vague and brief obituaries in the paper. These occurred in public. There were two cases, one person dead, and a companion nearly dead who survived only by heroic efforts at the hospital. Names are not given publicly to protect the families, but we found out the names dealing with the inevitable emotional breakdowns that are associated with this sort of tragedy.

Heroin addiction, and addiction to other drugs in general is not a victimless crime and I would argue that point with anyone who advocates legalizing drugs to the bitter end. I have seen families that have been forced to declare bankruptcy because a family member has stolen all their money to buy drugs. I have seen an epidemic of hepatitis C from women, and men for that matter, that prostitute themselves to get money for drugs. I have seen a local carry out burned to the ground over a robbery intended to obtain money for drugs. I have seen the elderly held prisoner in their homes out of fear. I have seen people murdered over a few dollars.

And I have seen the grief that a mother feels when her child dies of an overdose. I am a mother myself and could not begin to imagine the pain these women must go through. It starts with watching their child become enslaved to such a powerful master, to fighting with the battle of how much to support to give or not. Or when set limits with this person and send them away homeless to the streets. And finally to the final day when that dreaded phone call comes through. We get patients admitted every day that are dealing with the grief over the death of a child, but this kind does not need to happen.

But despite all of the warnings, the death, and the horror stories, kids continue to experiment with heroin. The rehab facilities are thriving, and continue to bring in court ordered drug addicts and dealers from larger cities every day. We see them on the inpatient unit frequently and most of them plan to remain here after their stints are completed, rather than returning home. They continue bringing their illicit business with them. Now though, the rehabs are filling up with local people who have been drawn into a culture that they were ill prepared to face. The number of methadone clinics and suboxone prescribers grows daily.

The rehab facilities' answer is to move their sites and methadone clinics further out of city limits into the outlying suburbs ensuring that the school populations of the smaller cities are exposed and addicted as well. And with time, a problem that had been largely focused in the inner city has grown into the suburban population. Some of these communities have challenged these placements in courts and lost. Those living within the city say that the wealthy and middle class are being unfair for attempting to block the placement of drug rehab facilities in their borders, why should they get special treatment? To that I have one response. These communities did not invite these businesses, and yes, they are for profit businesses, into their communities in the first place. Why should they suffer for the mistakes of the larger community? The break in rate in the suburban communities is increasing, and if anything makes for a much more enticing hit since the homeowners are generally much wealthier and have more to offer and the rates of drug use in the high schools is increasing even higher than the larger city itself.

Somehow, I do not see this as the great savior of the economy that the city leaders had expected and the people of this area deserve an answer on what they intend to do to reverse the damage done.

I will touch on the farce of the methadone clinic and the misuse of taxpayer's dollars (via Medicaid) that go to fuel the drug diversion industry and finally put my rant to an end next.

The Silent War - Part III

2010-04-18T21:37:00.009-04:00

The short commute from work to my home is only about eight miles long but the change in environment is astounding. I live in a quite area at the edge of the woods where bears are the biggest threat we worry about. A much smaller town is only a mile away and relatively quiet. The city I work in is only a few miles further.

The city where I work is fraught with decay that only feeds the heroin culture. As I drive home, I drive through rows of tightly packed homes, separated by barely a few feet in a few limited designs that seem rather indigenous to this area. Not quite row homes, most of them are the same ones that were built when the city was founded in the late 1800's. Aside from a few major thoroughfares, the streets are narrow, in a tightly laid out grid pattern. A pretty impressive feat considering this is a mountain town and hills are not usually amenable to this degree of order.

The center of town is divided down the middle, much like Chicago, only not with a scenic river, but with a very polluted system of railroad shops and tracks. The tracks run the entire length of the town, north to south and in most of the city, one cannot traverse east to west without crossing a bridge. The grime and dirt permeates the inner city and only adds to a feeling of decay. It reminds me of the grime I saw coating the towers of the now ill-fated Charity Hospital in New Orleans years ago.

Ruined in Hurricane Katrina, the building is considered a total loss and will eventually be torn down, but for the uninsured of New Orleans, Charity Hospital was the only public hospital they had to turn to pre-Katrina. I saw Charity Hospital when I took my Board Certification exam in 2004, before Katrina hit, and it gave me an uneasy feeling that never left me. Ironically, I passed my board exam, a very difficult thing to do in psychiatry. A victory for me that day, a loss for many more not much later. I have since returned to New Orleans for the Sugar Bowl, but I felt the need to visit this now defunct institution and pay my respects. The photograph above was taken on New Years Eve 2009 and the top of the building does not look much different than it did all those years ago. Although this town has not suffered the tragic loss near the degree of New Orleans, sometimes I see the same creepy sooty grime dripping off the taller buildings of the city here and that same feeling comes to me. Something is not well in this town.

Many of the residents of the inner city are retirees on fixed incomes who do their best to maintain their homes. They often live in fear but cannot or will not leave their lifelong homes. There is a certain number of working class families that remain in this area, but a large part of this area has fallen to low income and section 8 housing. The crime rate has skyrocketed and those that have the luxury of moving out of the inner core of the city do, often without being able to sell their inner city homes. Many elderly residents, and there are quite a few here, pass away and the homes are left abandoned. Foreclosures have left many properties vacant as well.

This has left a growing problem of blighted homes, many with red condemned signs posted so long ago that they have long since faded to pink or even white. Absentee landlords have little interest in paying the money to demolish a property that has been condemned. This will only cost them money and leave them with an empty lot that will go unsold. Better yet to ignore the property. The city has limited ability to demolish blighted homes without a lengthy legal process and since the age of the homes is quite old, many contain asbestos and lead paint making the demolition quite expensive. Funding for this is limited. Most abandoned homes have long been stripped of any resellable items. Copper pipes, light fixtures, and wood paneling that could have been salvaged and sold to finance the demolition are stolen by drug addicts desperate for money for their next fix, cutting a viable source of funding for these projects out, also.

Abandoned home are well known to be obvious health risks, attracting rats, pigeons, raccoons and the like, but they have other lurking hazards. Abandoned homes are a perfect cover for "shooting galleries" and make for a discrete location from which dealers can make their transactions out of the public eye. The number of blighted homes grows daily. Not all of the heroin use in the city is restricted to abandoned homes but to me they are a constant reminder of a city in pain. The middle class flees to the outlying communities with sprawling rows of new subdivisions that offer safety and respite from the troubled inner city where they work. No different than Detroit, just on a smaller scale.

Something needs to change....

The Silent War - Part I

2010-04-13T21:44:00.004-04:00

There was another obituary for a young person in the paper a few days ago. I am not a morbid person, but in this field, one tends to scan the obits to see if a patient has died, especially in a town as small as this. It happens more than one would think, especially since we are the only hospital and mental health center in the county. We know everyone who has been in treatment for anything more severe than mild depression or anxiety. I digress. These obituaries stand out from the others. Brief, listing no details about the person except to say where the person died, no reason given as to why, no listing of surviving family members, funeral information, nothing. Just a note that this person died. Usually they are in their late teens or early 20's. No emotion is conveyed, no sense of loss, no sad story. Many of them are well known to the mental health system.

There are always obituaries for young people that do give details, long stories about the tragic loss and the mourning family members, where to send donations, etc. These are different. The families are involved for one, and have nothing to hide. They are proud of their lost loved one and want the world to know about what a wonderful person the world has lost. The reasons are always sad: leukemia, auto accidents, military casualties. All with stories that have a great deal of emotion and angst that make one feel like they know the family, if they do not already.

The reason for these brief obituaries are many, but the primary one being that those involved do not want it to be known how the person died. The family may in fact be in a great deal of pain but too ashamed to admit the details of their loved ones demise. Sometimes the person has burned all his/her bridges with their family and friends and no one is there to care. Sometimes the cause of death is never made public, but all too often the people who work in the mental health system find out. Sometimes before receiving official word, we know already. It has overtaken this city in an epidemic the likes I have never seen before. It is the unfortunately all too silent killer...

Heroin.

The Silent War - Part II

2010-04-09T21:11:00.007-04:00

Heroin has been a specter looming over this city for as long as I have lived here and it amazes me how long it has been allowed to continue without public outrage. Our young people die at rates that never cease to astound me. I am not trained to deal with substance abuse, my training is in general adult psychiatry, but every day a significant portion of my time is devoted to dealing with the walking dead. I cannot stand to keep my silence any longer.

This city is of moderate size, about 100,000 if one included the outlying suburbs, two hours away from any truly large city and quite industrial although the surrounding areas are quite rural. Much smaller than my hometown of closer to two million, but wracked by a heroin problem like I have never seen anywhere else. Not even in much larger cities have I seen this. Too small and naive to understand the problem and too underfunded to fight it, the epidemic grows like a cancer in our youths, mostly high school aged and early 20's who are too young to know any better. Before they know it, they are enslaved to the big drug dealers in Brooklyn and Philadelphia who supply them with their so desperately needed hits. Desperate to fund their addiction, they turn to trafficking themselves and go into the high schools creating more and more addicts to fuel the fire.

The problem, I am told, is of recent origin. Many of the mountain towns in this area were founded by the railroads for the purpose of supporting the westward movement of the railways, some time in the late 1800's. Entire towns were built for this purpose and the entire economy was dependent on the railroad. The emergence of the high reliability diesel engine which replaced the high maintenance steam engine guaranteed the loss of a lot of those jobs. Further job losses due to environmental safety concerns and robotic repair facilities left an indelible mark on the community, and the companies that once built the city, seemed to have turned their back on it, leaving the economy in a shambles.

These cities appeared to be the perfect place to build a series of drug rehabilitation facilities and halfway houses to send court ordered addicts from Philadelphia and New York. They were miles away from any large city, and surrounded by conservative Amish and Mennonite communities. It seemed the perfect way to keep these people out of mischief. The cities themselves facing soaring rates of unemployment and a faltering tax base jumped at the opportunity to bring new jobs and money into the area and allowed these facilities to be brought into what was otherwise a quiet community, one by one.

But they bit off more than they could chew. Court ordered rehab does little to solve a problem when the person ordered to treatment does not wish to change. AA members will be fast to remind you that the "geographic cure" never works as the addict has to take him/herself along. Not to mention the fact that while the city may be a few hours drive from Pittsburgh, interstates are the major route of travel of the drug traficking trade and this city is on an interstate.

I have been told that within the past fifteen years, this area has gone from a quiet working class community to one of high crime, drug gang warfare and urban blight....

to be continued

Health care reform

2010-04-07T21:20:00.004-04:00

Well, we may, or may not have some kind of health care reform passed in Congress now that may or may not be amended to death in the next few months, but hopefully we will have some kind of change for the better. I have nothing witty or interesting to say, but I can say that we have had a lot of patients being admitted recently who have Medicare and have hit the "doughnut hole" already and are falling apart because many of the generic medications available in psychiatry are in no way related to the newer, name brand ones. Even some of the second generation medications that have come out in generic are still running in the several hundred dollar range a month. Somehow I do not see that the prescription drug benefit program for seniors and the disabled has done what it is supposed to and it does not make a lot of fiscal sense. Sure, Seroquel can run around $1000 a month, but a patient who decompensated and ends up on the psych unit for seven days costs the taxpayer $7000. I would not worry about us having enough patients to keep us busy on the psych units. The drug dealers will always make more. This reform bill is supposed to closed the so-called doughnut hole, but it is going to take years, and I fear that partisan bickering is going to whittle the bill into some worthless piece of bureaucratic nonsense and the Medicare patients will fall by the wayside. I hope for the best. My patients do not have much time to wait.

Weird news week

2010-04-05T20:56:00.003-04:00

I am not that inspired this week but there have been some interesting events on the unit lately। We have had a larger than normal number of really psychotic patients so the interactions tend to be a bit more interesting. We had a woman who came running out of her room insisting that her roommate had died and we needed to start planning the funeral right away. She managed to drag several staff members back into the room to find her sleeping roommate who woke up to shouts of "Look! She's dead!" and responded "I'm not dead yet!" This had all the Monty Python fans on the unit buzzing. For those who are not Monty Python connoisseurs, I would suggest renting "Monty Python and the Holy Grail" for an explanation. You will only have to watch about 15 minutes into the film to get the joke. Unfortunately, she called someone else who was a patient somewhere else in the hospital and told this person that her roommate had died and now there are rumors that a patient died on the psychiatric unit.

One of our nurses caught one of our patients trying to fly, Superman style in her room. Once she knew she was being watched, she backed down, but I would have been interested in the results had she been able to pull it off. Maybe she could have brought our not dead patient back to life.

We also had a faith healer who tried to purify a patient of some horrible trauma that she was not aware that she had not endured. She was not very happy about the laying of the hands on her very much. He was a decent singer which was good since he spent hours serenading us after that incident. Most of the time, when we get budding American Idol contestants, they are generally in the does not make the cut catergory.

So the news is just a little weird this week. One would have to be here to get the effect in its full glory, but hopefully one can see why I prefer this to treating this to diabetes and hypertension. My stories are better.

The Hall of Lame

2010-04-02T20:36:00.000-04:00

The Hall of Lame was established to honor those whose stupid actions go above and beyond the call of duty. For example, we have all worked with people who have gone to ridiculous efforts to call off sick from work, but have any of you had your Mom call in to say you were sick? Especially when she lives 600 miles away. Lame, very lame. Have you ever had that coworker try that stunt twice? - That goes in the Hall of Lame.

Some of my patients are very sick. Many come from dysfunctional homes. Some are addicted. Some are just not that bright. I hate to say that, but sometimes one needs to face reality. I have had a few situations where a patient was caught trying to tamper with a prescription I wrote in order to get more of what they were supposed to receive on a few occassions. It happens to all of us. This situation stood out in its sheer lameness that it bears noting.

For a patient to write on the prescription she was given at discharge from the hospital while still on the psych unit is not too with it. Most would run off to their car where no one can see them. When the prescription was written for 28 tablets, one might have thought to "go for the gusto" as it were and add a zero at the end of the number and try to get 280 tablets. No, this lady tried to alter the number 2 to a number 3 so she would get 38 tablets. And she was on parole from prison to boot. And I had a carbon copy of the script to show that it had been tampered with. And she did this in plain view of one of the psych nurses who does not put up with a lot of bull#@*. Tampering with a prescription for a controlled substance is a felony. So she got caught, and her PO violated her and she went back to prison. All for an extra 2 1/2 days worth of pills.

At least she was nice enough to plead guilty so we did not have to go to the court hearing that day. That would have really make my work difficult. But I did dress really nice in case I did, and I got a lot of compliments that day.

So I present to you the newest inductee to the Hall of Lame:

The Great Benzo Heist

2010-03-25T13:20:00.005-04:00

It was a rare spring afternoon last year when I was able to leave the hospital early when I made a very eerie discovery in the doctor's lot. It was an odd hour to be leaving, so there was no one else in the lot and it was quiet in a rather ominous way. All I heard was the breeze through the trees in the cemetery across the street (creepy in its own right) and the whirr of the cooling motor that runs on an Audi that has recently been shut off. As I left the building, I made a shocking realization. I looked out into a sea of almost exclusively German made cars, expensive ones at that- BMW's, Mercedes-Benz, Audi's, even a few Porsche's. There were a few slumming it in Volkswagen's and Mini Coopers but most went for the big guns. And in the corner, there was a pack of BMW 3-Series cars whispering amongst themselves, looking at me in a very suspicious way. I had never noticed such an enormous collection of precision engineering all in one place in my life. Considering that Germany contributes a relatively small percentage of automobiles that are sold in the US every year, the fact that this lot was occupied by well over 50% German based cars just did not seem right. Looking back, I realized that this was not the first doctor's lot that I had seen this situation happen and I came to a startling realization.

Contrary to popular belief, not all physicians come from wealthy families. Our backgrounds are surprisingly diverse. The somewhat homogeneous presentation they exhibit is part of a slow and laborious process that they themselves are not even aware is occurring. At some point in a physician's career, most likely early on, but sometimes a bit later, the victim finds him/herself driven by an uncontrollable urge to go out and test drive a German made automobile. Sucked in by seductive advertising, offerings of unique options that are sure to make the cover of Car and Driver (seen in most hip doctor's office's) and sponsorship of "intellectual" sports (skiing, European motocross, biking), their attraction is irresistible. Eventually the unknowing victim is drawn into the world of high performance, precision tuned machinery that can only be found in the world of the German automobile industry. Each victim finds him/herself pulled helplessly into the direction of one of the manufacturers, much like a naive college student drawn into a cult. One cannot just like German cars, one must favor one brand, be it Porsche, Audi, BMW, etc. The victim will with time, learn all of the specific advantages of his/her chosen line over the others and will mindlessly spout those statistics towards anyone who dares ask. With time, the process becomes so entrenched in their mindset, the victim ceases to exist as an independent thinker and is transformed into a mindless, non-thinking German Car Zombie. These poor victims roam the halls of the hospitals and medical offices staring blindly flashing enormous German Car key fobs, talking about needing to have their car taken in to have their oil changed with full synthetic oil and complaining about the price of high test gasoline loudly. They shuffle to their cars at the end of the day, arms outstretched, mumbling in a monotonous tone "must have high performance German technology." When their cars get old, they trade them in for the next level car of the same brand, never wavering from their blind obsession with their maker of choice. They will use words like "4matic", "Quattro", "Ultimate Driving Machine" with reckless abandon.

Having chosen a pet manufacturer, they will argue about the pecking order by which cars must yield right of way to one another on the Autobahn. They will be very fast to criticize any other manufacturer and quote specific reasons for their dislike of said manufacturer. They will talk about how the Germans put down said manufacturer, even if they have never actually been to Germany, which most of them have not. They park their cars in groupings, Audi's in one cluster, BMW's in another so as not to be infected by mechanical "cooties." They cluster in set regions of the lot much like the Crips and the Bloods have their turf wars and much woe will fall upon the unsuspecting Lexus that tries to breach that territory. The victims of such cults take on a certain paranoia about the "other" cars out there with time, as if those cooling engines one hears were more than just high tech devices designed to fail, so as to give the dealership more business at the service department. They are growling monsters set to pounce on anyone who dares to disrespect their clan.

Which leads me to my daily struggle. I never should have listened to the psych nurse on the unit who told me that the Germans called BMW's "Euro Trash". That only let me to the habit of making a point to every BMW owner that I met that Audi has moved ahead of BMW in the pecking order on the Autobahn, especially since the inception of the TT. But hey, my TT gave me some of the most fun I have ever had in a four wheeled vehicle, and besides, the new A4 did outrank the BMW 3 series in horsepower, acceleration and gas mileage. Besides, no one has ever beaten the Quattro all wheel drive system at road handling, especially those lousy BMW rear wheel drive transmissions, so HA! Beat that! Hey 3 Series guys, just try to catch me in a snowstorm! You will be stuck in a ditch in a heartbeat! I DARE you!......

...As ashamed as I am to admit it, I too, am a German Car zombie.

The Doctor's Parking Lot Horror - Part I

2010-03-22T21:15:00.004-04:00

Some would call me crazy, but I know I am being stalked by a gang of BMW 3 series cars that park in the physician's lot outside the hospital where I work. Since I work at the hospital full time, I get a good view of the cars that are parked there and they know me. They lurk in the corner of the lot when I walk to my car, whispering amongst themselves, plotting some unknown evil scheme that they will one day spring on me when I least expect it. My paranoia arose from a horrible realization that I made one spring day last year. It is the kind of story that Steven King novels are made of.

Doctors, as a general rule, drive one of two types of cars. One is the ridiculously overpriced status symbol which may, or may not have any real need to large/expensive/fast but they are that way nonetheless. Many are enormous gas guzzling POS SUV's that have no real purpose for existing. Sure, they carry all the kids, and they are all wheel drive which helps in the winter which is important. The fact that a Pontiac Vibe has all of those qualities does not count. It is not expensive, flashy and overloaded with all kinds of high tech gadgets that are bound to malfunction but look really cool and are sure to impress. Then there are the expensive luxury imports, usually German with all their high performance engineering, fast race inspired engines, gleaming chrome and sleek beauty. There are eternal arguments about which make is above which other in the pecking order on the Autobahn in the medical staff lounge. Not that it matters here but it makes one look really cool.

Second is the "I don't buy into that nonsense" doctors who drive decaying POS junkers that are usually missing a hub cap or two, part of the body molding, and blow black smoke out of the tale pipe. Some have black smoke coming from underneath the hood as well. These doctors are determined to drive their vehicles into the ground then will hopefully inherit a late aunt's old 1984 Crown Vic so to save them from have to actually deal with buying something new. Depending on the particular physician's leanings, their ride may bear bumper stickers declaring their support for very outdated political figures such as: Bush/Quail or stating "Bush (as in HW) lost, get over it." These guys are the ones who will have the audacity to park next to the most expensive car in the lot. The ones that even the standard issue expensive car owners will not park next to due to fear of being "not worthy." Every doctor's lot is going to have the occasional showing of the outlandishly expensive car- Bentley, Ferrari, Dodge Viper, Rolls Royce, etc. to make sure everyone feels inadequate. Except the for the POS owners. They are not impressed by any of this nonsense and are going to park next to these cars just to prove it. I wish I had that kind of gall, but I must confess, I am too much of a pussy. I have parked near a Ferrari just to get a look at it, but would never dare park adjacent to it.

There are always a few outliers who do not fit into either category. Those that have the "practical" car, not too expensive, but well built and reliable. Usually they are noted for good reliability (Toyota used to be one of them), able to manage well in the snow, can carry a lot of cargo and have good fuel efficiency. In other words, indescribably boring. Some doctors have common sense, but they are by far in the minority.

With all of that said, this leads me back to why I am being persecuted by a group of rogue BMW's. Having been a bit verbose, I am going to pull a Quentin Tarantino and continue this story in my next entry.

2010-03-21T21:22:00.000-04:00

Have you ever tried to find a phone book that does not have an ad for an attorney on the back? I have travelled a lot of places in this country and always make a point of checking the back of the phone book to see. Most of the time, they are malpractice attorneys at that. So far, in my years of searching, I have probably checked over 100 different phone books in at least 15 states and have only found one phone book that did not, and that one was very out of date. The phone book we receive here even has a magnet of a malpractice attorney firm on the cover so one can put it on the refrigerator just in case one comes upon the emergent need to file a malpractice lawsuit.

Do not get me started on the class action lawsuit ads against every medication that has that possibility of have some unpleasant side effect. Many of those ads are targeting some of the very precious few decent medications that psychiatry has available to help people improve their quality of life. Realistically, the benefits of the medications far outweigh the risks of the side effects, which are at times extraordinarily rare and often cannot be proven to have actually been caused by the medication itself vs the fact that some people are going to get diabetes, weight gain, etc.

The problem is there are too many lawyers. Law schools do not do a good job at limiting the amount of new lawyers to the amount that the market is going to need. A lot of new lawyers are graduating with no job and $75,000 or more of student loans to pay off. Even when they do get jobs in a criminal or civil law firm, there are only so many criminal or civil cases out there. So they create work by drumming up malpractice cases, class action suits and social security disability cases.

Lawyers know there are too many lawyers out there when they enter the field. I have spoken to many of them who admit that it is very difficult to get by so I do not have a lot of pity on these guys. They knew what they were getting into when they entered law school. Like most doctors out there, there is not a lot of love lost between all those Social Security disability/malpractice/class action suit lawyers and me. The guy that did the closing on our home mortgage, he is okay. But he is not stabbing anyone in the back to pay his bills, either.

The debate has raged endlessly about putting limits on excessive malpractice suit payouts, and I, like most doctors support this, but I do not expect to see this happen anytime soon. For one, there are a lot more lawyers than doctors. Medical schools do not overproduce doctors, they try to use some common sense. Second, most of our legislators are attorneys and there are very few doctors elected to public office. My response to the whole thing is to at least stand up as a group and voice our dissatisfaction with the corrupt malpractice attorneys but designating an official:

National Give a Malpractice Attorney a Wedgie Day

During that time, all reasonable adults should be allowed to, without fear of repercussion, be allowed to give as many wedgies to as many malpractice attorneys as they like. It may not get anything done, but it would sure be a lot of fun and for once maybe these guys would know what it was like to be on the receiving end.

Thank God for Generics- part II

2010-03-19T21:02:00.000-04:00

Returning to the issue of money buying happiness, and the endless debate about health care reform, the lines between money and happiness get blurred in this arena. It takes money to have health care, and it takes money to buy health insurance. I can think of a lot of situations where lack of money and, therefore, health insurance would have guaranteed certain suffering. The mere existence of health insurance brought a great deal of happiness into a person's life. Most people can probably think of a case in their own life of a friend or family member struck with a life threatening illness that would not have survived without treatment. Most people do not stop to think about the cost until they are faced with the bill and no way to pay for it.

In my own life, the happiest thing that ever happened to me came at a very great expense. It is very easy to criticize the enormous cost of Neonatal Intensive Care Unit (NICU) care until one becomes the parent of a child who is a patient in one. After that, there is no test, procedure or intervention that is too expensive if it was needed to help ensure one's own child's survival. I faced this situation four years ago, quite unexpectedly one winter day while eating lunch at work. Without warning, at 34 weeks pregnant, I felt my amniotic fluid leaking. Up to that date, everything had gone perfect, no problems, complications, the baby's size was good and I felt great. I did not smoke, drink, do drugs or abuse my body. I ate well, took care of myself, had good prenatal care, a supportive husband and so on. My only sin was advanced maternal age but no one else seemed too worried about this so neither did I. Until that day.

The series of events that followed were somewhat of a blur with a lot of panicked phone calls to my husband at work, a trip to the obstetrician and hospital and the eventual comedy of errors that lead to the birth of a somewhat distressed boy who was healthy for his age and able to breathe on his own, thankfully. He spent the next 31 days in the NICU and my husband and I spent our days going between our home and the NICU several times a day to visit him. I even returned to work part time so not as to burn up all of my maternity leave. I would dutifully see patients for two hours then hiking down the block to nurse him and return to see more patients. Neither one of us thought we could endure but one of the other NICU parents told us "you get used to it" and he was right. Eventually we learned the routine enough to endure until the magical day when he was finally released to go home. He wore oxygen by nasal cannula for several months and an apnea monitor for several more. The oxygen tanker that came every two weeks to fill up the big silver missile in our living room did tend to attract some odd looks in the neighborhood and it was hard enough being inexperienced parents without family nearby to help us learn how to care for a newborn as it was. We certainly could do without the hindrance of a 30 foot tube that he had to be kept tethered to 24 hours a day, but somehow we endured.

Today, our son is a perfectly healthy four year old who knows how to read quite a few words, asks questions like "how do Ipods work?", and loves to go to Preschool and swimming classes. No one would ever know how rocky his start to life was unless we told them. For all the torment we went through, I would do it all again to have a healthy child now. I was lucky enough to have health insurance to cover most of the bills, although I still had around $5000 out of pocket expenses to pay. Not a problem for a doctor, but the cleaning staff working at minimum wage might have a tough time stomaching this kind of bill. Imagine life for those without insurance. For those who do not want health care reform, think about those people and their children before rejecting the idea entirely.

In summary:

The total bill for the NICU alone: about $75,000.

The cost of the RSV vaccine he received every month for several months after discharge: $1600 per injection.

Apnea monitor:$350 per month rental fee.

Home oxygen and equipment:Your guess is as good as mind.

Having a healthy, happy child:Priceless.

2010-03-16T21:10:00.000-04:00

Today was not a good day at work. The unit was full, a lot of the patients were angry about being there, and far too sick to be released and the staff's nerves were frazzled. These days will happen. They go in cycles and these are one of the more difficult times. It will get better sooner or later but after hearing a litany of profanities all day, being told about how incompetent I am and hearing repeated threats that I will be sued/arrested/killed, etc. it tends to get to a person. To make matters worse, it was a warm sunny day for the first time in months, and we were all stuck inside. Maybe that is why the patients were so agitated.

Either way, it was a good day to leave work which I did with a great deal of alacrity once I was able. I was a great day to drive with the sun roof open, and the satellite radio cranked. Too bad all of the cars in front of me did not seem to think that driving as fast as I like to drive was part of their way to have a good time driving home. For some reason, I have found that part of the best way to enjoy driving with the sun roof open and the music turned up is to do the same, only drive the car faster. People in this are drive slow. Real slow. It drives me nuts. The whole driving conservatively thing is one area that I admit that I have failed to be very Zen about, and probably always will and did little to soothe my frazzled nerves.

Despite my rather sluggish peers' attempts to reform me, I eventually did get home alive and well and was reminded of something that is far more important in life that the opinions of a few select individuals who struggle with illnesses that impair their insight. My husband and four year old son were in the front yard cleaning up the remnants of the wind storms that have torn apart the trees this winter and the gravel the township throws on the road to make it passable to get to work in the snow when I got there. The reception that my son gave me could not have been any more joyful if he tried. He immediately abandoned helping Daddy (a very important job, indeed) and came running up to my car shouting for "MOMMY!" loud enough to hear over the satellite radio and the gravel on the road. He was so excited to see me that one would have thought that he had not seen me in months. I have not felt so important in a long time. Money, prestige, respect, all of those things are nice perks of being a doctor, but their value pales in comparison to the love of a child. There are joys in life that are easily taken for granted, but can mean so much.

Thanks, MRM for making my day.
Love, Mommy

Thank God for Generics- part I

2010-03-15T21:11:00.000-04:00

We have all heard at some point that money cannot buy happiness. I truly believe this as I have seen some very wealthy people who were still quite miserable people. The smart ass response "yeah, but poverty ain't so hot either" does make a valid point, however. Going without food/shelter/heat, etc is not a whole lot of fun either. But the overall point, that happiness comes from within is all too easily forgotten, especially when one is bombarded with images of the "Cribs" of the stars, exclusive vacation islands of the wealthy and cancerous Manhattan penthouses owned by CEO's of large corporations.

Despite its propensity to drive people to greed and corruption, money is not all bad. $4.00 can buy you a month's supply of generic Prozac at many pharmacies. And $125,000 can buy you an Audi R8 so you can get to the pharmacy really fast and look really cool to boot. My husband does not understand this point, but I am fully of the belief that I could derive a whole lot of happiness out of an Audi R8. Not that I am not happy now, I am, but if I had a really bitchin' ride like that, it would be off the charts.

In stark contrast, lack of money has caused a definite level of misery that cannot be ignored. Now I am getting political as a warning. I realize that the whole health care reform debate is heated and has caused a lot of division in this nation, but I work in a system where probably 1/2 of my patients are uninsured. Struggle though we might to scrounge and get them Medical Assistance, this often falls through and a very common cause of readmission of patients is lack of access to care. It is heartbreaking to work with a patient to get him/her well and on the path to recovery to hear that a few weeks later the same patient is in the ICU on a ventilator after an overdose. Once stabilized, their stories often sound very familiar "they denied me medical coverage because I was working and earned just a few dollars too much" or "some piece of paperwork got lost in the mail and the shut of my Medicaid." The end result often is the same. The patient cannot afford to come in for outpatient appointments, cannot afford his/her medications and suffers a relapse of his/her symptoms. This especially bothers me in patients that are employed and trying to get by but cannot afford the $1000 monthly cost for (individual) medical insurance or do not qualify at all due to pre-existing clauses. Forced to make choices between paying the bills or coming in for appointments, they pay the bills, prescriptions do not get filled and they decompensate. True, some psychotropic medications can be bought for $4.00, but many of the newest ones with the fewest side effects can cost hundreds of dollars a months.

I am not going to say that a $4.00 script for Prozac can make someone totally happy, there is no true "happy pill" out there, but it is a good tool to help our patients on the road to getting well and solving the problems that got them depressed. Without the medications, relapse into the torment of depression or psychosis is almost certain. People do not like the idea of health care reform, but without some kind of change, a lot of people are going to continue to suffer and put a strain on an already overburdened health care system. Those people are not just numbers, they are real people with real feelings and deserve care just as much as those of us who are lucky enough to have jobs that provide health insurance.

I am not sure if the bill in front of Congress is the answer to our ailing health care system, but I do know that doing nothing is certainly not. Nor am I suggesting that reforming the entire health care system in a few months with a bill thrown together by a bunch of mostly attorneys is the way to go about reforming the system, but at least someone is trying to address the problem. If I had the chance to talk to the President, I would recommend he form a committee comprised of doctors, nurses and other health care providers, hospital administrators, and yes, even insurance execs and have them come up with a plan that makes sense for the American people. Attorneys need not apply. When they come up with a plan, present it to congress, put it up for a vote and fix this system before it bankrupts the country. Then I would let all the doctors of the country go out and kick the @%*& out of all those ambulance chaser attorneys who are driving up the cost of malpractice insurance and prescription medication by suing every pharmaceutical company out there because it gave someone a headache.

Now THAT would make me happy. But not as much as the Audi R8.

Next - Thank God for Generics - part II

The Best of the Worst

2010-03-12T21:32:00.000-05:00

The best part about working in psychiatry is that the stories we take home are a whole lot more interesting than the ones that our colleagues in other specialties do. Surgery may have a great deal of prestige and responsibility, but when it comes down to it, an appendectomy is an appendectomy. In my work have have met God, the Antichrist, top CIA operatives, and people important enough to be monitored by the Navy and aliens. I know people who have spend hundreds of thousands of dollars in a day (literally) that were not top execs for a Fortune 500 company. I have heard elaborate delusional systems that took years to put together. Now that is interesting. With that, I leave you with some of the "Best of" stories I have collected through the years:

1)Best excuse given for the need for an early refill of Xanax: "Shamu ate my Xanax."

2)Most cars bought by one person in a weeks time (who was not an auto dealer):15.

3)Most extravagant purchase that a patient that I have treated has ever made: a strip mall.

4)Most extravagant purchase that a co worker's patient has ever made: a Boeing 747.

5)Largest testicles I have ever seen: about the size of a soccer ball.

6)Best delusional system devised to explain having testicles the size of a soccer ball:"It's the beta rays that did it."

N.B. Real reason for testicles being that large: severe untreated congestive heart failure. They returned to normal once he was treated.

7)Most memorable question asked of a male family practice intern sent to suture up a gash in the eyebrow of a middle aged female patient with schizoaffective disorder:"Will I still be able to have intercourse with these in?"

N.B.-Advice to intern- "Just ignore that question and keep sewing."

8)Worst mislabeling of a patient's diagnosis: schizodefective disorder. Correct Dx: schizoaffective disorder.

9)Strangest thing I have ever been accused of being from a delusional patient: a member of the Freemasons.

And finally....

10)The most unpleasant piece of information I have heard imparted from one nurse orienting a new nurse to the unit: "You'd be surprised how many people in (our town) don't wear underwear."

The Third Sign of Spring

2010-03-10T21:04:00.000-05:00

The third sign of spring is probably the most predictable, and requires the most patience, but these can also be the most entertaining. That is the Floridly Euphoric Manic Patient Who is Just Thrilled to See You! By the way, is your friend over there married? He seems to be a bit young, but I just LOVE green eyes and men in Levi's and did I tell you about the guy that my daughter was dating who wore Levi's three years ago? Boy, he was a catch, she should have never let that one go, but well, he did not want to move when she got that promotion and it was a good opportunity and I guess that I cannot blame her because she has dental and that is hard to get now, besides........

Manic patients have always traditionally be thought of in popular culture as euphoric, happy-go-lucky types that are full of energy and life. In reality, they rarely show up this way, and certainly not on a psychiatric unit. They are more often angry, labile, demanding and can be quite dangerous. There is NOTHING wrong with them and they DO NOT want to be in the hospital and they are not going to be nice about telling you this. They really do not want to take any medication that slows them down. The fact that the patient was just fired from a minimum wage job for threatening to kill the supervisor and just bought a brand new Dodge Viper is not a problem. He has just written a rap lyric that he is quite certain he plans to sell to Eminem and make millions and being in the hospital is just an impedance in doing that. The patient is in a hurry too. That first payment for the Viper is due in a week and $125,000 is a lot of car loan to pay off.

Springtime manic patients are not always very nice either, but there are always a few that come in looking like they have been in hibernation for the past three months and have saved up all those thoughts and are going to tell you them in the next 1/2 hour. Then they are going to set you up with their son, find themselves a new husband, buy new cars for everyone on the unit that does not have one, open up a new stock portfolio, negotiate world peace, and so on. They need to get to that NOW because they have a bunch of stuff to get to tomorrow, also. They are best kept away from classified ads and younger men. I recall a patient several years ago who came upon a much younger man, pulled up a chair and announced loud enough for the whole unit to hear "Well, aren't you just the most handsome young hunk of meat I have ever laid eyes on!" I was not sure if she was talking about a side of beef or the patient. Lots of fun, these guys. Sometimes they can be a bit verbose and it can be hard to get them out of your office, especially when they are talking about their grandchildren or some rude store supervisor at the mall that they had a run in with, but they do add a lot of color. Once they show up, I know that the bright colors of Spring are sure to show up soon, too.

Or at least a lot of bear poop in my back yard.