The code

Recently, I've been working on the MICU service. This is a team of interns, residents and attending physicians who take care of all patients in the intensive care unit. Physiologically, the science is the same. But the patients are sicker. And everyone's about to die.

One of our responsibilities is to respond to any "code blues" around the hospital. That means that any time a patient is found down, or without a pulse, or not breathing, a "code blue" is called and our team rushes to the bedside to implement a series of actions designed to revive a patient from death/near-death.

On Monday, a "code blue" was called and we all sprinted three flights of stairs to reach the patient's bedside. From report, we were told that she was recovering from surgery and all of a sudden, collapsed and stopped breathing. After the code was called, 15-20 physicians, nurses and respiratory therapists ran to the bedside. The commotion was palpable and tensions ran high. In the end, it was decided that the patient would have to be intubated. Intubation involves carefully placing a small tube down the patient's trachea so that we can hook her up to a ventilator.

All in all, it was a success and the patient was revived. This actually isn't a very rare occurrence except for one detail: she was awake, but paralyzed for the whole thing.

Apparently, somehow, the paralytic from the surgery had some secondary action and acted a second time. She wasn't sedated and she could consciously perceive that she couldn't breathe and couldn't move. She heard the "code blue" over the intercom, saw people run into the room and waited, helplessly, while a tube was put into her throat.

The hospital is a scary place.

Happy Thanksgiving!

Unfortunately, I'll be spending my favorite holiday not with my family in South Carolina but with my patients in the hospital. I've switched to Internal Medicine and I've really enjoyed the switch. I spend all my time in the hospital - being on call every 3 nights is really a drag, but it's really challenging and interesting. I'm still at the point where I feel like I can't do anything right, but I'm quickly improving. It's a tough learning curve.

I'm definitely in the thick of it now. I spent two weeks in the ER , which I loved, and jumped right into the action. You never knew what was coming through the door. I found Psychiatry to be very helpful in that situation. In the end, I found it exciting but a bit depressing. My second day on the job, I found myself cleaning the wounds of a 13-year old who shot himself (accidentally) in the thigh. I irrigated his wounds, made him an outpatient appointment, and sent him on his way. After doing chest compressions on a 15-year old with a bullet in his head, I realized this wasn't the field for me.

This past weekend, something happened that gave me a quick gut check as to where I lived. I was on call Friday, and I remember thinking "hmm...we haven't had an admission in a while."

Apparently, the hospital was diverting all admissions to the ER because the water on the entire East Bank of the city was compromised. The water pressure around the entire city was low due to some sort of turbine breakage and technically, we were on a "boiling water advisory" until Sunday evening. We were urged to boil the water we shower with and bathe with for 48 hours. It reminded me of India. In the early 90s. New Orleans - what's so great about this place is that it's so damn close to America.

As a nice change of pace, I'm coming back to South Carolina for about 36 hours this weekend. I'm flying into Columbia on Friday, post-call and coming back Sunday morning. I'd stay a few more hours, but there were no available flights. Coming out here, I had no idea how much I'd miss home, but sometimes it takes leaving to figure out what you already had. Don't get me wrong, I love it here, but it will be nice coming home.

In the mean time,

Happy Thanksgiving...

Ahmed

Goodbye Psychiatry...

Today marks a transition in my intern year. As you might know, I am a combined internal medicine and psychiatry resident. My first four months of training have been spent in inpatient psychiatry and now I'm transitioning into eight months of internal medicine. I start on a night shift in the ER tonight and, to say the least, I'm apprehensive.

I think I'll survive. But in the mean time, I wanted to take a trip through memory lane - my top 3 moments of Psychiatry training. Cue the montage.

1. Having a very delusional patient tell me that he can "make it rain". To which I respond, "outside or in a strip club?". Unfortunately, he meant outside.

2. Being told "there is no way I can have a urinary tract infection because after I pee I put antibacterial soap in my pussy."

3. A patient insisting that the former cheerleader medical student perform his physical exam. After his request, I looked down and noticed his erection. He was kind of senile, so it was funnier than creepy.

And with that, I move onto Internal Medicine. I'm basically nocturnal the next two weeks and if this afternoon filled with anxious tossing and turning is any indication, it won't be fun.

Peace,

Ahmed

Medical University of AstraZeneca

Here's the question: Who is responsible for your medical education?

I ran across a really interesting website the other day. Apparently, there were multiple lawsuits involving pharmaceutical companies that helped disclose 260 million dollars worth of pharmaceutical payoffs to physicians. See the searchable database here.

I took a curious look because I, being in the medical field, understand the temptation involved in pharmaceutical speaking fees, consulting fees, "educational reimbursements", etc. After searching my friends and family, I went to the next obvious target, my alma mater. It only took a second to realize that the results were appalling.

At quick glance, it seems that clinical faculty at MUSC have been paid $230,000 in speaking fees in 2009 alone.

You know, I've thought about this for a while and come to this more moderate conclusion.

I can get over the fact that you get pharm dollars, just tell me about it.

I had no idea that my clinical faculty had these ties to pharmaceutical companies. I don't know if anyone did. But the bottom line is this: If you're telling me that Seroquel is first-line treatment for schizoaffective disorder, tell me that AstraZeneca, who makes Seroquel, also happened to give you $63,000 last year.

Which isn't to say that this problem is isolated to MUSC. As you can imagine, this is a problem in conflict of interest that pervades all medical institutions. Just recently, Harvard Medical College had its own pharmaceutical scandal develop and decided, in response, to institute its own monitoring program for potential conflicts of interest.

And in that vain, there is an easy solution to this problem. Require all of your academic faculty to disclose financial conflicts of interest. Then, put them online and send an e-mail.

In summary, a lesson: Forget betadine. Sunlight is the best disinfectant

Peace,

Ahmed

I've been away for a while...

Damn boards...most of my free time for the past month has gone towards studying for Step 3. Now it's done. Here's a quick picture update of my life and a resolution to post at least once, maybe twice a week. I'm sure this happens to all blogs made by procrastinating, intermittently busy people, but here goes.

Brad and Ellen got married. Awesome time and happy for them. Here's the first dance.

Slapshots!

Beautiful day surfing

Saw the family...

Art for art's sake. This guy is pretty intimidating. In retrospect, I'm not sure if he was part of the show or just happened to be there.

Took Step 3. Parkview Bakery. Nothing beats a shrimp/roast beef po'boy after a 14-hour test. I'm back and will keep everyone updated.

I'll talk to everyone soon,

Ahmed

Song of the week - Cee Lo - "No One's Gonna Love You"

The history of Psychiatry...

Last week, I took a trip to Jackson, Louisiana. Most people don't know that this town exists and if you blink, you miss it. What is interesting about this town, though, is the East Louisiana State Hospital. This hospital has been in existence since 1890 and for years was the mainstay of psychiatric treatment in the state of Louisiana.

The first part of the trip was to the forensic unit. This unit was so aptly named because it is where patients who are deemed unable to tell right and wrong during their crime or "not guilty by reason of insanity." Also, this is where people who are deemed incompetent to stand trial stay until their competency is restored. The facility was interesting and really was in-between a hospital and a jail. We met a few classic patients including one psychotic patient who had pulled out both of his eyes. Why, you may ask.

Matthew 5:29

"And if thy right eye offend thee, pluck it out, and cast it from thee: for it is profitable for thee that one of thy members should perish, and not that thy whole body should be cast into hell.

He apparently took the bible pretty literally.

Then, we met another patient who didn't realize that he had burned down a local supermarket and another who spoke "French" and "Chinese" but really just spoke jibberish. Interesting place with some really sick patients.

Then, we went to the other side of town to visit the long-term inpatient unit. This side was notable for its history. It was founded in the 1880s and was known as the place where psychotic patients were sent "up the river" from Charity hospital. We live in an age of antidepressants, ECT, antipsychotics and medication management. It's hard to fathom what psychiatrists will think of our practices 50 or even 15 years from now. For some perspective, we visited the dungeons.

The dungeons were in operation until around the Great Depression. When patients became acutely psychotic or manic, they were chained underground and held. There were no bathrooms and there was no air conditioning (temperatures regularly got above 100). There were no medications and there was no use of sedatives. The picture speaks for itself.

We then took a look at the records. They were a very interesting reflection upon the understanding of psychiatry at the time. I know that we use a DSM and that we have standardized ways of looking at patients, but records like these really bring home the point that we don't understand psychiatric processes and that most of what we do is in theory. We know we can help, but we don't really understand how. When looking at these records, remember that these patients were seen by doctors once per year and that their one record is this line. The left column is the "diagnosis" and the right column is the "cause".

"Diagnosis: Acute Mania. Cause: Religion."

"Diagnosis: Dementia, Chronic. Cause: Masturbation"

Apparently your palms grow hair and you become demented.

Lastly, we stopped by to bathe in the solace of the cemetery. It was a nice day outside and we strolled through the graveyard, pausing at the sheer number of patients who died at this facility. So many of these patients' birth names were not known, so these tombs of unknown patients gives this facility an Arlington cemetery-like feel. We stood at the graves, paused in reflection, and went back to New Orleans.

Peace,

Ahmed

Red Dress Run

So, as I may have mentioned, New Orleans is the craziest city in the world: Two examples -

1. On Monday, I hear about a festival in town. We go to the quarter, right by Jackson square and see a parade roll through. There are beads and t-shirts being thrown from floats and a pretty sizable crowd forming. At the end of the parade, there's a free concert by Cowboy Mouth which was a blast. Although I was working the next morning, it was pretty evident that everyone else had been drinking all day. After the concert, we get some frozen yogurt in time to watch the fireworks show. After the fireworks show we left, but later on there was a free concert by Galactic and a free concert by Big Boi at the House of Blues. I had to work in the morning, so I couldn't make it.

Oh, and I forgot to mention why the parade was being thrown. It was a celebration of Madden Gras - the fact that the new Madden video game is being released and that Drew Brees is on the cover. New Orleans, Louisiana. Where we find any excuse for a party.

2. Yesterday was the annual Red Dress Run and yes, it is exactly as it sounds. Everyone dresses up in a red dress and parties all day. That's it. There was some money exchanging hands for some charity, but other than that it was a huge celebration of red dresses and alcohol. I, of course, could not miss the opportunity to cross dress, so I of course took part in this cultural phenomenon. The day ended with us "pool poaching" which involves going to a random hotel's pool and just swimming. So, we spent our day at the Omni which was fantastic in 90-degree heat. I'd tell you more, but I'll let the pictures do it justice.

Yes, we do look sexy.

Peace,

Ahmed

Going to court

This week I became George Huang. Most people know him as the psychiatrist on Law and Order who has some uncanny ability to blame a rapist/serial killer's behavior on their babysitter ignoring them when they were four.

For me, he was my first introduction in forensic psychiatry.

On Wednesday, one of my patients scheduled himself for a "probable cause" hearing. To put this into context, you have to understand the way inpatient psychiatric settings work. As you can imagine, most people who are placed into psychiatric settings don't want to be there. They're manic, psychotic or the remnant of a failed suicide. They want to go home and they are tired of the rules/regulations. But how can you hold someone in a hospital against their will?

In the state of Louisiana, you first have to order a Physician's Emergency Certificate (PEC). In order to do this, any physician can deem a patient to be either a 1) danger to himself 2) danger to others or 3) gravely disabled (unable to seek food, shelter or take medications). This PEC allows the patient to be legally held for 72 hours. To extend that time, a Coroner's Emergency Certificate (CEC) must be issued. The coroner must physically go and see the patient and issue a CEC. If the coroner deems the patient to be a danger and issues a CEC, the patient can be held for an additional 12 days. After that, a judicial commitment must be filed which can hold a patient up to an additional 6 months. But only a judge can decide that last one.

A patient also has certain safeguards to ensure that their rights aren't being violated. One of these is the issuing of a probable cause hearing. In this hearing, the patient can deem that the hospital did not have probable cause to issue a CEC and can go in front of a judge to challenge that.

My patient did just that on Wednesday. Now, to make this the perfect storm, Wednesday just happens to be the day that my attending physician was called for jury duty. Normally an attending goes to this hearing, but for this day, it was me. I nervously drive up to the courthouse to make my 1 pm appointment.

I walk into the courthouse and make it through the metal detectors (as a side note, the security just said "go ahead, doc" and let me through without going through the detector - the white coat does wonders). I walk upstairs and meet with the hospital's lawyer, a nice guy about my age who seemed to understand the process really well. He helped put me at ease. Awkwardly, the patient was one bench over, muttering about how I tried to befriend him and then betrayed him. Awkward.

We walked into the courthouse and stood when the judge entered. I was the first witness called. They asked me to state my credentials and where I went to medical school. They asked me how long I knew the patient and this interestingly phrased question.

"Doctor Mohiuddin, in your expert opinion, what is the psychiatric diagnosis of this patient?"

Did they know I've only been practicing psychiatry for a month? Did they know that at this point, I'm really just practicing? Nervously and taken aback, I answered.

"Schizoaffective disorder - bipolar type"

They proceeded to ask me questions about the patient's medication compliance, his behavior on the wards, etc. Then it was done. No further questions. I sat down and I was finished - my "expert" testimony was stenographed, and I sat down.

Later, the patient went up and testified. Watching a manic patient with pressured speech interact with a judge is kind of funny, by the way. I forget that we interact with mental illness all the time and understand it, but most people don't. The judge asked him some questions and made the decision. He was to be discharged in a week.

And now, I can say that I have given testimony in court. Very (un)easy but a very cool experience.

Peace,

Ahmed

Song of the moment: TV on the Radio - Love Dog

Jo' napot paca'k

Watch this video.

I know it's 19 minutes long and has no nudity, but trust me - it's worth it.

I watch this speech every 2-3 months to regain some faith in humanity.

I watch this speech to remember that, even in the city next door of Spartanburg, South Carolina, there exists a hidden example of the triumph of the human spirit.

I watch this speech to remember that a man who sees evils that you would not imagine in the depths of hell comes to the conclusion that, in the end, human beings are fundamentally good.

"No matter how risible, no matter how esoteric, no matter how seditious it might seem."

"This is our task. We know it will be hard."

Jo'napot paca'k,

Ahmed

Oh, one more...

How cute.

My first visitors

These are my first visitors. At this point, Sean is embarking on an 8-hour drive in a few hours, so his smile is fake. It's also 5 am.

Having my first visitors was an awesome experience. At this point, I've been here for about 6 weeks and have gotten to know the area fairly well (at least for 6 weeks). Our trip was filled with wonderful, long meals and crazy, long nights. We played corn hole by the river and celebrated Matt's promotion and Sean's imminent move to Madrid. Seeing old friends in new places is a surreal, grounding experience and was as much fun as I hoped it could be.

It was great to see everyone and have our own little reunion, so that brings me to the next point - visit me! I'll give you the tour and we'll make it round two.

Peace,

Ahmed

Song of the moment - Stevie Wonder - Pastime Paradise

The costs of residency

Unfortunately, I didn't make it to this. I was excited for weeks for the New Orleans' Running of the Bulls. Yes, it's a running of the bulls, through the french quarter, but instead of bulls there are roller derby girls with whiffle bats. In any other town, it would be the event of the year. In New Orleans, it's the first festival of July.

I was hit with a dose of reality, however, when I realized on Friday afternoon that I had to round in the hospital on Saturday morning. I made it out of the hospital as soon as I could and joined with the revelers for the after-party. People went all out with their costumes and still had bruised asses from the whiffle bats. From the pictures and from the reaction, it was a masochistic magnificence. Next year, Ahmed, next year.

In other news, work is going well. I've got great students and am really getting into teaching - which is great since I want to go into academics one day. My friends Matt and Sean are coming in and it will likely be our last hurrah until Sean moves to Spain. So, look for a post full of pictures and debauchery this weekend.

For now, I'm making sure I have time off on August 14. On that day, the city will be full of excitement for the red dress run, aka Ahmed's excuse to cross dress in a socially acceptable manner.

Until then,

Ahmed

Song of the moment: Kid Cudi - Pursuit of Happiness

My first call

Contrary to popular belief, psychiatry is not what Jack Nicholson experiences in One Flew Over The Cuckoo's Nest. Popular culture has spread the belief that psychiatric wards are menacing, terrifying places where people are strapped down to beds and electrocuted against their will. Overall, psychiatric wards have become much more pleasant and patient-centered than they once were, but the stigma usually still prevails.

The Charity hospital system is a healthcare system in New Orleans that cares for anyone, free of charge, that lives at less than 200% of the poverty line. It was housed at the famous Charity hospital, but due to the damage of Katrina, Charity hospital was closed. Since then, psychiatric beds in the city have been cut in half and the ERs are filled with psychiatric patients waiting for a bed.

One such ER is at the University Hospital. It was supposed to be a temporary structure post-Katrina but found itself being used permanently as a psych-ER. Monday was my first day on call, and I spent the majority of the day in the 20-bed "temporary" unit, intimately known among the staff as "the trailers."

I got there around 7 am and was happy to find that, although the trailers were outdated and leaked a little in the rain, they were not something out of a horror movie. The staff was nice and the nurses extremely competent. The ER is certainly not a place for psychiatric treatment, though, and is no place to house psychotic patients for 3-4 days while waiting for an inpatient bed. I rounded from patient to patient, trying to get to know the patients and their treatment protocol. Then I, with the help of the LSU resident, tried to ascertain whether they needed to be admitted.

There are a few major problems with this approach to psychiatry. For one, I was working a holiday weekend. The primary team doesn't usually work weekends, so I was likely the third doctor working that weekend. Because of the lack of continuity, no one (I included) started medications that were any more frequent than an "as needed for agitation" basis (it's standard protocol and appropriate practice to delay major treatments until patients were admitted). Some of these patients were in the hospital for three days without any real, continuous medication plan. Secondly, a psych-ER is not a psych ward. Psychiatric wards have multidisciplinary teams of social workers, psychologists, nursing staff and physicians that work in a supportive environment to stabilize mental illness. A Psych-ER is a place for patients to go so they don't hurt themselves or others. It's a place where the police officers are doing a lot of protective work and the physicians are sedating patients who cannot keep calm. It's not a place that anyone should have to be treated for long periods of time. Still, it's better than nothing (and with psychiatric funding these days, it's not going anywhere anytime soon).

As I was saying, I made my rounds and tried to figure out who needed to stay and who could go. Twice on Monday, I made the very novice and intern-ish mistake of giving patients a hope that they may be able to leave that day. After talking with the other, more experienced resident, I changed my mind and had to go through the joyous experience of telling them that they can't leave. At this point, the patients are under emergency commitment and can be held against their will for 72 hours. They usually have figured out that the only person who can send them home is the physician.

They weren't happy with me. In fact, one patient was livid with me. To the point where I tried to stay on the opposite side of the ward because I had this strange feeling that he might jump over the nurses station and attack me. My evasiveness worked, though, and the night went on without incident.

The night flew by and I was able to leave, exhausted, at about midnight. 17 hours after I arrived (I know, that's nothing for an intern), I came back home and collapsed on the couch. I woke up to my alarm a few hours later, a little less tired and a lot more experienced and made my way back to the wards.

Sing it, Marvin...

Happy Birthday, America!

Here goes...

So, this is it. This is what it's like to have an inexpensive (read: free) piece of the internet. This is what it's like to come home, tired from the day and spout out my thoughts and my life and therefore, with no real validity or affirmation, call myself a writer. So here goes...

For those of you who know me, it shouldn't surprise you that it took me at least a month to come up with the title. I moved to New Orleans from Charleston, South Carolina about a month ago and only yesterday, in some brief epiphany while sitting in traffic, did I come up with The Big (Un)Easy. It's how I felt and it's where I am, so I jotted it down and here it is.

Although I'm sure this will evolve, I'm really going to focus upon three things.

1 - Internship. How much I love it. How much I hate it. All the weird subtleties and not-so-subtleties that go with being a medical and psychiatric intern.

2 - New Orleans. This city is nuts and, in my mind, is the most unique place in America. Crazy things happen here and will be recorded on this blog.

3 - Reviews. I'm a consumate consumer and will try to review books, CDs, movies, articles, politicians, celebrities, jokes - whatever come to mind.

So, there it is. I'm sitting here, the night before my first day on the job, writing my first blog entry. For the next four months, I'm entering the world of New Orleans inpatient Psychiatry and will no doubt, in some HIPPA compliant (read: non-identifying) way, have stories for you. So follow me, read the blog from time to time and hopefully be entertained. Until then -

Peace,

Ahmed

Song of the moment: Steve Earl - "This City"