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