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!