My Psychiatry rotation took place at Queens Hospital Center in the Psychiatric ED (CPEP) and in retrospect I can say it was full of learning experiences. I was provided with a lot of new information about medication management and the uses of different combinations. For example, agitated patients were frequently given Haldol 5 mg and Ativan 2 mg with each contributing a significant effect regarding the stabilization of the patient. Haldol being a first-generation antipsychotic exerts its influence by blocking dopamine D2 receptors helping to suppress agitation and any disorganized behaviors related to psychosis. Ativan being a benzodiazepine enhances the effect of GABA providing sedation and a calming effect. Together they offer a potent and rapid means of controlling agitated and aggressive patients who may be a threat to other patients and staff. I also learned about several formation of long-acting injectable tailored towards patients who exhibit non-compliance, examples included Invega Sustenna and Invega Hafyera which are both forms of a 2nd generation neuroleptic called Paliperidone palmitate.
There were of course challenges that required me to step out of my comfort zone such as interviewing pediatric patients in the presence of a parent. What makes this challenging in my opinion is the emotional intensity of some of these discussions especially when dealing with suicidality in a child. An example of this was when I had to interview a child who was struggling with adjusting to life in the U.S. after moving over from Colombia with his mother. He felt immensely isolated and was having a hard time making new friends which made him notably depressed and begin to consider ending his life. I could see the mother become increasingly tearful as I asked a series of questions that unraveled the true extent of his inner despair which made it difficult for me to continue my investigation. Despite how uncomfortable the situation made me I maintained my composure in line with my training so that I could thoroughly assess the severity of his symptoms to determine the appropriate course of action. Another challenge I encountered was becoming proficient in translating a patient’s often long and exhausting story from my notes into a concise and coherent presentation. This is something I can say that I improved on mainly by experience and listening to the feedback from my preceptor. In terms of challenging patient populations, again I believe that pediatric patients are the most challenging and this sentiment was even expressed by the PA’s working in CPEP. I learned that they tend to not be the best historians and often require redirection so it’s best to keep allow them to talk but as the professional you must know when to intervene. Overall, I think I would benefit from more exposure with conducting and documenting mental status exams as well as cognitive assessment methods such as the MMSE, MOCA, and CAM. Although I unfortunately won’t get another opportunity to rotate in Psychiatry, these are tools that I can use in other domains of medicine and so I plan to use them, when necessary, just to solidify my expertise in their use.
A memorable case that I experienced was when a middle-aged patient presented after expressing his intent to jump on the train tracks following an outpatient rehab appointment. Further history revealed that he was in remission for alcohol abuse disorder and was heavily afflicted by medical burdens related to a stroke he had last year, a brain aneurysm s/p coiling and other chronic medical conditions. On presentation he was visibly dysphoric and showed little to no emotion, thus the safest course of action was to keep him overnight for evaluation and stabilization. The next morning, we went to speak with him he looked much better and was thankful for our efforts even though he noted that he was still overwhelmingly depressed. To me the case was a reminder that we have a unique role as clinicians to be there for patients in their moments of vulnerability, and each patient represents a chance to make a difference. I will certainly take this forward into future rotations remembering why I chose to embark on this path and doing my best to make an impact by being a good listener and demonstrating empathy. Some things I learned about myself are that I learn best when I am presented a question by my preceptor directly and especially If I answer incorrectly. When this happens, I often feel disappointed in myself but its these moments of disappointment and subsequent self-reflection that really solidified some key concepts for me. I remember being asked about if it were a possibility for a patient to have Schizophrenia and Parkinson’s simultaneously and I quickly rushed to say no while completely ignoring the fact that they are both driven by different dopamine pathways. This was just one example but again it was instances like this that really helped to grow my knowledge base. I think my overall perspective on medicine hasn’t changed but I have developed a greater appreciation the importance of Psychiatry in addressing mental health issues. Furthermore, I was able to see that mental health issues don’t discriminate based on any characteristic whether it be age, race, or sex as people from all walks of life presented to the Psychiatric ED. Finally, one thing I’d want my preceptor & colleagues to notice about my work is that I’m always open to criticism because I’ve come to recognize that is the best means of improvement. I don’t take offense to suggestions but rather invite them as I desire to get the most out of each rotation.
