A year at U of R

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Friday, December 15, 2006


The skills groups on the adolescent psych unit are run by nurses. Usually they pick an activity based on the needs of the teens who are in the unit at the time. We've done group juggling exercises, discussed smoking, watched videos on nutrition and worked on team building. For one of the skills groups in the adolescent psych unit, the nurse decided to work on building self-esteem. The theme was "What I'm good at." The kids found out about the theme in the morning. By lunch time, it had evolved into an all-out talent show. Several groups of girls took over the dining room to choreograph dance routines. The boys just gawked. It was teenagerdom all over. I felt like I was in the middle of a bad teen movie.

For the final show, one girl sang a song and another shared her drawings. One read some poetry she had written. The dance routines went off very well. I taught everyone how to say a few words in Chinese. The nurse read another poem she had written. We were a pretty talented group!

I was so impressed with the dance routines that I said to another nursing student, "Hey, we should get this on camera."

She grinned at me and pointed to the ceiling in the corner of the room. "We ARE on camera," she said.

Thursday, December 14, 2006

Film du jour

Today I switched with another student to the adult psych unit, to get a change of pace from the adolescents. The film-du-jour playing in the adult unit was "Seven Years in Tibet," with Brad Pitt. I only saw pieces of it but it wasn't too bad. I'll give it a thumbs up.

The adult unit was a different experience. It was a bit of a shift to communicate with adults for a change. But to be honest, I missed the quirkiness and drama of the teenagers. I missed being able to be a little wacky myself.

There have been a number of patients on the adult unit who are college students locally. It is finals time, and students stress out. Some have difficulties with the stress, and end up in the psych unit for a few days.

The other nursing students have all seemed curious about their stories. Yet no one has gone and talked to them. Maybe my fellow students felt shy about talking to them, since they are close in age and also students. Is it too close to home for comfort? It makes you realize that anyone can end up in the unit.

Well, I’ve changed a little during psych rotation, and I’ve learned to ask those tough questions. Today, I thought, “What the hell, I’ll go talk to the patient.” I went up, and we started a conversation. I asked about school, and we compared notes on classes. The patient talked about future plans and difficulties. The client was actually very sociable, and I was glad I’d had the conversation. It reminded me of what we learned the first day of psych. Don’t make assumptions. If you see a person with their head on a table, maybe they’re depressed, but maybe they’re just sleepy.

Wednesday, December 13, 2006

Movie therapy

I wrote before about the movies that the teens like to watch when they have free lounge time in the psych unit. It is a pretty sweet clinical rotation when you can eat popcorn, watch a film, and get academic credit for it. The only complaint I've got is about the teens' taste in movies.

I've watched parts of "Independence Day" three times with them. We've also watched "The Truman Show." It was a little surreal to be locked in a psych unit, watching a film about a guy locked in a fake world.

Today there was talk of watching "Titanic." Thankfully they decided against it. I might have had to put myself in the seclusion room to prevent self-harm if I had to watch Leonardo Dicaprio drowning one more time.

Instead, they put in a movie called "Like Mike." I only made it through a few minutes of that one. I've been thinking that instead of bringing my drug guide to clinicals, maybe I should just bring some worthwhile DVD's.

Electro-convulsive therapy

As part of my psych rotation, I accompanied a patient through the entire procedure of electroconvulsive therapy. I was amazed that we were allowed to watch what most people seem to view as horrific and medieval ... intentionally delivering a shock to a patient's brain. However the reality is somewhat different.

The procedure itself is very simple. Preparing the patient takes about an hour, including a baseline set of vitals and inserting an IV for the anesthesia. This is done by a nurse (some of the friendliest I've met in the hospital!), in a consult room. The patient then goes to the waiting room.

When the patient is called from the waiting room, they are taken to the treatment room, a tiny room with a hospital bed. It was crowded with various pieces of discarded machinery. Many of them had labels, "Not Maintained or Functional - Do not use." I had the impression that since ECT outpatient treatment is only scheduled a few days a week, the room doubles as a storage closet. It reminded me of the derelict robots in Star Wars.

The patient lies down on the bed in their street clothes. The only things they need to remove are any dentures or metal jewelry. They are then hooked up to monitors for the heart rate, blood pressure, and oxygen saturation.

An anethesiologist gives them two separate anesthetic agents via IV. One of them "puts the patient to sleep," so they have no memory of the event. The second relaxes the muscles, to prevent injury due to convulsions when the shock is administered. As the muscle relaxant flows into the patient, I could see the patient's leg and arm muscles twitch slightly as the muscle cells depolarized and relaxed. The doctors put an inflated blood pressure cuff around one ankle like a tourniquet, to prevent the relaxant from reaching one foot. This foot would remain reactive, and allow the doctors to observe convulsive activity. The rest of the body was paralyzed.

The scary part to me was that the whole body, including the diaphragm was paralyzed. This means that the patient couldn't breath. A resident at the head of the bed used a manual bag to inflate the patient's lungs, and give them oxygen. To me, however, it seemed like you've essentially "killed" your patient if they no longer breath on their own. The effect wears off in a few minutes after treatment, and the patient is asleep, so they are unaware of it. However it's still a little disturbing to think that you've stopped breathing. Here's my advice if you go for ECT: make sure you've got a great anesthesiologist.

The shock itself is really nothing. It lasts only a second. The electrical stimulation to the brain creates a seizure that lasts an additional 30 seconds. Before the days of anesthesia for ECT, patients would have convulsions strong enough to break bones. Now, because of the muscle relaxant, the patient has no motion during the seizure except their face scrunches up, and their one foot may shake a little. And that's it. At least that's how it's supposed to work.

The day I observed, something went wrong with the IV or the medication. They thought that the patient was fully paralyzed, and adminisered the shock. The patient's face pinched up, and their arms and legs convulsed for the length of the seizure. It looked like other epileptic seizure I've seen. The doctors called the seizure "partially modified." "But," they told me, "we'd like them to be much more modified than that." The only negative result, though, was that the patient might have muscle soreness afterwards.

After the treatment, the patient goes to the recovery room for 1/2 to 1 hour. They come out of anesthesia within about 5 minutes of the treatment. They monitor their vitals (blood pressure often spikes up during ECT), and then the patients go home.

What are my thoughts on ECT after seeing it? There are patients who we've worked with who've been depressed for years, and tried every other treatment. Nothing has worked. The patient may have attempted suicide multiple times, or be so depressed that they can't function or leave their room. Then they go to ECT, and within a day, the veil of depression is lifted. You can visibly see how much alive and better they feel. It is an amazing transformation. How can you argue with a treatment like that? Many psychiatric drugs have numerous severe side effects. ECT has only one ... possible memory loss.

However I wonder how it is being used. Some patients go for a single course of ECT over several months. Some patients have it regularly as an outpatient, once a week, or multiple times a week for years. I have to wonder about the consequences of shocking your brain that often.

Would I personally ever go for ECT? I think I'd rather shock my brain by jumping into an icy lake, eating a bowl of raw jalapeno peppers, bungee jumping off a bridge, or just about anything else instead of ECT.