Friday, December 6, 2013

"Wait, did that make sense to you?!" 2 days Psychiatry-- A Review

Well, its been a whirl wind of two days in the psychiatric hospital.

Yesterday morning, I was picked up by my friend with her car which was already packed with other friends. Our destination was the same. The psychiatric hospital on the outskirts of town (typical for old psychiatric hospitals).

After wandering around the very Harry Potter-esque grounds, we eventually found the conference room. The medical director was responsible for my group. He gave us a short history on psychiatry before heading onto the wards. We were split up into groups of two and then dispersed onto different wards. The set up on the two days was the same:

Ward with 1 or 2 patient interviews
Discussion of cases
Ward with 1 or 2 patient interviews
Discussion of cases

And that both days. Essentially we were on 4 different wards and saw between 4-8 patients.

So yesterday morning, I was on the addiction ward. My friend and I talked to two alcoholics. They were very honest with us. They had different ways of becoming alcoholics and it was interesting to see how it started with each of them. It was also amazing how sweet the lady was. She really doesn't want to be an alcoholic and quickly sought help this time around. Neither of them had very supportive social circumstances. It is hard to tell how much of that is because they are alcoholics or they became alcoholics in part due to those circumstances. In the end, it is devastating to see what alcoholism does to the people. I wish them both the best on their way to recovery.

The medical director was a character. He did a great job explaining things and we had quite the laughs during lunch. He was motivated, which is important for such days.

After lunch, we had two schizophrenic patients to interview. This was exhausting. The conversation was fluid and on first glance made sense but if you did the math of the years they proclaimed things happened it didn't quite add up. At the end of the conversation, I felt like I had a lot of information but it didn't fit together. Luckily, my friend felt the same. Even luckier, the doctor told us that that is the way conversations with schizophrenic patients often go.

After the discussion with the group about their patients, we were free to go. We were all a bit exhausted from all the impressions we had gained that day.

Today was not different. During the morning meeting, the medical director gave us a history lesson on how psychiatric patients were euthanized during World War II and how the medical director of the hospital at the time was one of the very, very few psychiatrists that were against it and were active about stopping it.

My partner from yesterday wasn't here today, so I was on my own (which was absolutely no problem for me, the others hated doing things alone). I was sent to the depression ward. I had a very nice lady to interview. She was at the end of her treatment and it had worked very well for her. It was nice to see that with the right therapy, these people can be helped. After our chat, I chatted with the ward doctor a bit and then headed back for group discussion.

Then came lunch! They have quite the good food there.....almost everything is better than what we have in the hospital were we study.

After lunch, I grouped up with two of the others and we had two patients to interview. One of them was an Oxycontin addict (although he didn't tell us that, the patient records did) and the other was also schizophrenic and his symptoms had worsened, leading to his admission. Both of them were some what difficult to interview. The second just got up at some point and said he had to go and would see us next week.....?! I guess he will be disappointed this time next week, if he can remember it.

I was quite drained after the three interviews today. It is literally crazy to see how quickly someone can develop a psychiatric disease. It's frightening sometimes to see how many characteristics I share with some of the patients. In the end, everyone has their issues. It is about how you deal with them which differentiates where you are at in life. And a stable, supportive and loving social surrounding is essential. So love the people around you and be nice to them. Don't do drugs. And don't be afraid to ask for help should you need it.

The last few weeks in psychiatry have definitely changed my views on some issues and the way I perceive things. It was very enlightening.

We start with Pediatrics on Monday and that continues through winter break and into January. After Peds, we have a few weeks of OBGYN.

You can all catch me here again in February, at the latest, when I do my Peds Internship and OBGYN rotation.

I wish you all a lovely holiday season. Enjoy your family and friends. Be thankful for your health, your family and hopefully supportive social surroundings!



Wednesday, December 4, 2013

Psychosomatic Medicine--Should I be here?

So sorry I didn’t post the last two days. No Internet connection will do that to you. And very big lack of sleep.
I had a night shift Thursday, Friday and Sunday. After the night shift on Sunday, I directly went to the train station to catch a train to a town 1.5 hours away from Göttingen. A few friends and I were attending an internship in psychosomatic medicine.
We arrived in the town and took a taxi to the hospital. It is a huge hospital specialized on psychosomatic medicine and psychotherapy.
We found out room on the top floor in the medical directors department. We had a conference room waiting for us including a cart with tea, coffee and cookies. (We had so much of tea, coffee and cookies over the two days that none of us wanted to see cookies anymore.) I was very happy about the offering of caffeine.
The director of the hospital welcomed us and discussed what to expect for the next two days. Then we were asked what our expectations were.
The next point on the schedule was a patient interview done by one of the doctors. Patients in this hospital have psychological issues that cause bodily ailments or the other way around. I tried to listen as much as I could, fighting the tiredness, drinking more black tea and doodling to keep myself awake.
After the patient interview, the patient left and we discussed what had just happened. The interesting thing about how they taught us the patient history taking here apposed to how they do it in the university hospital is that we have a lot more time and we discuss how we felt during the process.
Over the course of the days, I noticed that a big difference in psychology compared to the other specialties, is that the interaction is so dependent on the therapist as well. In other specialties, the patient has an ailment and there is a process of taking care of it (hopefully, and this is a extremely simplified statement). With one patient, half the group thought he was a nice guy and felt bad for what had happened in his life whereas the other half didn’t like him at all. That shows that the therapy could be completely different depending on what the therapist feels, has gone through in life personally and how he identifies with the patient.
I mentioned this point in one of the discussion and was then informed that the doctors have a period in their training where they focus very much on themselves and their own issues to better understand them while treating patients.
We had lunch in the hospital and then were off to music therapy. That was fun. We all grabbed an instrument and started playing and seeing where it goes. Afterwards we discussed it and found that many had had musical training, which might have led to us quickly finding a rhythm.
We had another patient interview to see before the last thing on the schedule. Relaxation therapy! We were all in a cozy room, got a mat, a pillow, a blanket and a cherry seed pillow and the therapist starting explaining a few things to us and telling us how to relax. After 24 hours of no sleep at this point, I totally fell asleep and slept for about 10 minutes.
We stayed in the hospital for dinner before heading to our hostel. There was a Christmas market in town and everyone wanted to go. I was at 27 hours without sleep and managed to go along for one hot-spiced wine before I headed back before the group and slept…like a rock.
The next day we had more coffee and tea and cookies while interviewing a patient again.
Then we had the opportunity to have a one on one conversation with a patient. We were given 50 minutes for the talk. I talked with my patient for an hour before realizing it and having to go meet up with the doctor. My patient and I got along so well. I’d say we were on the same level on 80% of the time. The other 20% is the reason he is in the hospital for treatment and I am not.
After the one on one, we talked to doctors about our experience and got feedback.
After lunch, we had another patient interview. This time a friend and I did it for the group. It was amazing. Again, I could identify with about 90% of what this patient felt and had gone through and those little 10% were the reason I wasn’t in the hospital as well.
It was crazy just how well the patients fit to my personality that I saw yesterday. Maybe this should concern me on some level.
After that last interview, we had Qigong. That was fun to experience. It’s the Asian exercise you see people do in the morning. Slow movements and energy flow.
We had a last discussion with the chief and then caught a cab back to the train station and then headed back to Göttingen.
Tomorrow starts the first of two days psychiatry. Let’s see what that brings.

Thursday, November 28, 2013

Call me Mrs. Shepherd Day 4 HAPPY THANKSGIVING!


I really wish I was home today. All my siblings drove home from all over the place to spend the day with my parents. Unfortunately, I can't make it.

I love fall and Thanksgiving in America. I love pre-christmas season in Germany. But today, I am missing the Carmel apples, hot apple cider, apple pie, stuffing, mom's cookies and so much more. I would love to be sitting at the table with my family. Hear how college is going for my brother in Steven's Point and how med school is coming along for my sister in Erie and I want to know what's happening in High School as a pretty awesome senior from my little sister. I want to cuddle my puppy (he is 11 years old). I want to sit by the fireplace and chat for hours with my parents. All these things I want. But Thanksgiving is not about wanting, its about being thankful for what you have. And I have a whole lot to be thankful for!

I am SO very thankful for the support my parents give me through medschool (and through life). It's not always easy....okay, it's never really easy. But you learn to grow with your challenges.

My dad gives me the opportunity to focus on my studies and not have to work to pay off my student loans as well. He is always there when I have a question and loves to show me around work when I visit. He also reminds me that I need to let go every once in a while and go party. Believe me, if he were closer, I'm positive there would be more than one occasion that we would be partying together.

My mother is always there for me. We skype so much we could go 6 months without physically seeing each other but never having the feeling as though we lived so far away. She takes the time to listen to me and give me her point of view. Random letters and packages from the states brighten up my day. She makes sure that I stay balanced, reminds me not to over work myself and that I can do it all! She has helped me through some of the toughest times.

It is never easy being so far away from them but I am so thankful I have them (and skype!).

I've had quite my ups and downs the last year, emotionally and physically. I've laid in bed not wanting to move because of my stomach aches, I've gone days with eating the absolute minimum possible because everything I would eat would cause the pain to come back, I've woken up on days where the pain was there and wouldn't leave. I lost the excitement for cooking and eating good food. But I am thankful that that is really the biggest medical issue I have!

Working in the medical field grounds you (or so it should). I see patients on a daily basis dealing with illnesses that change their whole lives and the lives of the people around them. The have to spend their days in the hospital, I can leave at night (unless of course I've got the night shift like right now).

Dealing with these patients and listening to them, has made me not care about so many other insignificant things. I don't get involved in petty fights or get upset about little things. Not to say that I don't ever get upset, of course I do. But I can calm myself down fairly quickly. I don't appreciate it though when others try to make issues out of issues that don't actually exist. It just makes life stressful to do so. So today and every other day, I am thankful for my relatively good health.

Since Thanksgiving isn't a holiday in Germany, I had a normal college day.

We had a patient to see, take history on and examine. This morning we had a friendly old man who had a stroke. He was very chatty and I think enjoyed the break up of the daily routine and being interviewed by three female med students. We spent a fairly long time examining him as well because the others came to join us. Afterwards, we discussed various neurological topics and then had lunch. After lunch, we got to go to the video EEG department and see some footage. On this particular ward, patients are hooked up to EEG machines and video taped in their rooms. This way, when they have an epileptic seizure, it is on tap and we can see what is going on in the brain. We looked at various patients and it was interesting to see how what happens in the brain correlates with what the patient is doing. Sometimes their brain is freaking out but they are just sitting in bed saying they feel weird.

We discussed a few more points before we were done for the day.

I went and got my bank card back, did a quick grocery store stop and was off to bed to get some rest for my night shift :)

Enjoy the food and company of your family and friends!



Wednesday, November 27, 2013

Call me Mrs. Shepard Day 3

Today was a half day....Neurology-wise.

Since it was only a half day in the hospital, we only had time to examine one patient to allow enough time to discuss the findings.

We had a nice young Neurologist show us one patient before we went to our own.

Neurology, as mentioned before, has never been my favorite specialty. German medical college requires you to complete a 3 month internship within the first 2 years of med school as a "nurse's assistant" lets call it. We work the same shifts as the nurses and get to do all the dirty work: clean, wash patients, answer bells, run around like a chicken with its head cut off. I did half of this time on the Neurology ward.

Every morning I had about 5 patients to completely wash and get ready for the day. A lot of the patients couldn't even move so we were constantly rotating between rooms and moving them around. It was really, really hard work. The second half I did in OBGYN was heaven compared to that.

A lot of the patients are difficult to talk to because they straight up can't or don't understand what you are trying to tell them. It is frustrating.

Then there is the point of them not operating.

Anyways, the first patient the doctor showed us had a stroke and was not able to understand what we were saying or asking her to do. She would either just look at us with blank eyes, do something completely different than that what we asked or keep saying she doesn't understand.

We didn't get a lot of examinations done on her.

My friend and I had our patient assigned and we went to go see her. Our patient's situation isn't completely diagnosed yet. We took her history and followed that with a complete neurological examination. We didn't find a lot of things that were pathological. Our best guess was that she might have a peripheral polyneuropathy. The doctors are still running all kinds of tests though.

After all the groups had seen their patients, the doctor took us to see one more patient. The patient most likely has Creutzfeldt-Jakobs disease. It was impressive to see. The neurologist told us that the hospital was a sort of center for prion diseases so she has seen quite a few cases but most neurologists go their whole career without seeing a patient like this one.

After that visit, we looked at some CTs and MRIs and then went to a conference room to discuss our patients. I had baked cookies last night so I brought some for the others.

We spent a good 1.5 hours discussing our cases and were then done for the day.

I continued my day teaching english, attending a work meeting for my night shifts and then running errands in town.

Little life lesson, don't leave your bank card in the machine too long without operating the computer (by, for instance, looking for the right amount of money you want to deposit) because if you wait just long enough, the machine will eat your card. Fml. I got mad for about 3 minutes and then decided to let it go, have to deal with it tomorrow (although it doesn't fit my schedule what so ever) and move on since I couldn't do anything about it anymore. I met up with a good friend of mine for a quick Christmas market visit (opened today, yay!).

The next few days will be a little crazy. I have night shift tomorrow, Friday and Sunday and leave for a hospital Monday morning 1.5 hours after my night shift ends......oh my.

Thus, I won't be up long today. (hopefully)



Tuesday, November 26, 2013

Call me Mrs. Shepherd Day 2

Today was a very information loaded day.

We spend the whole morning reviewing and practicing a thorough neurological examination.

This included:
-the basic things non-neurologists have to at least complete if they see a patient (for instance in the emergency room)
-the cranial nerves and how each one is individually examined (see below for more information if you'd like to know more)
-examining muscle strength
-motor function
-muscle tone (muscle tension)
-muscle trophy (muscle mass)
-autonomic nerves system

I offered to be the genuine pig for the demonstration of the exams. This meant I was poked, hammered, touched, moved and asked to walk, stand, touch my nose with eyes closed and so much more for a good cause. :)

After many hours of all of that, we had a quick 20 minutes lunch break (just enough time to inhale a sandwich) and were off to the neurophysiology department to get an introduction into EMGs.

EMG= electro-myo-graphy
basically using electricity to record the muscle (myo) activity

For this examination, it is necessary to insert a needle probe into a muscle. As always, I was the guinea pig (I like being the guinea pig, it's like a free check up at the doctor).

Getting mentally prepared
Here comes the needle
The needle is in

Okay let's do this

Pressing against the docs hand
The electrical potentials in my muscle

It didn't really hurt having the needle inserted. It was a bit odd leaving it there for a bit.

We recorded the electrical potentials while relaxing and then while contracting the muscle. All is good with my deltoid muscles :)

After we discussed a few more possible pathological EMG findings, we were done for the day.

It was just around the time that some of my American friends tend to be in the hospital restaurant grabbing lunch so I stopped by to see if they were there. Indeed they were. I sat and chatted with them a bit. I try to use these opportunities to see people (these are the same friends that complained about seeing me too little).

After weeks of just opening letters and putting them to the side, I used my time at home to finally catch up on all of that, do laundry and clean my room.

Tomorrow is only a half day in the hospital and then I have to teach English.

Below I described how to do a rough exam of the cranial nerves. It's really only for those interested. It is kind of funny to test them all on a friend though, who knows what you'll find. Hopefully nothing pathological :)

See y'all tomorrow!



The cranial nerves:
We have 12 cranial nerves

I olfactory nerve
II optic nerve
III oculomotor nerve
IV trochlear nerve
V trigeminal nerve
VI abducens nerve
VII facial nerve
VIII vestibulocochlear nerve
IX glossopharyngeal nerve
X vagus nerve
XI accessory nerve
XII hypoglossal nerve

So how do you roughly examine the function of each? Well here we go...

Olfactory Nerve: 
Function: smell
Test: Ask the patient if he still smells the same or if food still tastes good (a lot of our taste sensation comes from the smell)

Optic Nerve:
Function: sight
Test: A very basic test would be to use one of those boards with the letters or numbers that keep getting smaller and see how much the patient can read. Even more basic: "How many fingers am I holding up?"

Oculomotor, trochlear and abducens nerve:
Function: They all innervate the eye muscles.
Test: Have the patient look at your finger or pen and tell them not to move their head (or you can hold onto it). Now move the pen up, down, left, right, upper right, lower left, upper left, lower right (not necessarily in that order), make sure it is far enough that the whole scope of the eye movement is examined and see if the eyes move along nicely and symmetrically. It is okay for the eyes to show a nystagmus (a jerking back and forth) for about 2-4 times when on the far left or right if it stops after a few beats.

Trigeminal nerve:
Function: sensory innervation of the face and motor innervation of the chewing muscles. Also sensory innervation of the cornea of the eye
Test: The nerves exit the face at very specific points. You press those spots and ask if that hurts the patient (beyond the feeling of the pressure). Then you stroke the patient along the forehead, below the eyes and the chin and ask if they have the same sensation on both sides. The corneal reflex is performed by touching the cornea with a Q-tip and the patient should blink or shut his eyes (contact lens wearers usually can tolerate more since they overcome this reflex while putting their contacts in). The chewing muscles can be tested by asking the patient to clench his teeth and you touching the muscles to see if they contract.

Facial nerve:
Function: sensory innervation of the face and taste
Test: Ask the patient to show his teeth with a big smile and see if the mouth opens equally or if one side droops. Ask the patient to lift his forehead (again, looking for symmetry if they are healthy and asymmetry if something is wrong with the nerve). Ask the patient to scrunch his nose. Ask the patient to fill his cheeks with air like a hamster. Ask the patient to pretend to whistle (or really whistle I guess, unless you are my sister Fran who absolutely hates it when people whistle.) Again, this is a nerve to ask the patient about taste differences.

Vestibulocochlear nerve:
Function: innervate the balance center and the hearing center in the ear.
Test: Ask if the patient has experienced dizziness. Depending on the direction, the appearance and duration one can differentiate the origin. Rub your fingers together next to the patients ears and ask if they hear it at the same loudness on both sides. Hold the patients head in your hands, tell them to focus on your nose and quickly turn their head from side to side. They should be able to not lose focus of your nose the whole time you move their head.

Glossopharyngeal nerve:
Function: innervation of the uvula and muscles in the back of your throat.
Test: Look into the patients mouth and tell them to say "AHHHHH". The uvula should rise symmetrically. The other muscles in the back of the oral cavity as well.

Vagus nerve:
Function: This guy does a whole lot of things. For the purpose of a rough neurological examination, we will concentrate on his contribution to the vocal cord innervation.
Test: Ask the patient if he can still speak normally. Is he hoarse?

Accessory nerve:
Function: innervates the sternocleidomastoid and trapezius muscle.
Test: Place your hands on the patients shoulders and ask them to shrug their shoulders while you try to push down to see how strong they are (test for trapezius). Ask the patient to turn his head from side to side (test for sternocleidomastoid).

Hypoglossal nerve:
Function: motor innervation of the tongue.
Test: Ask the patient to stick his tongue out and then move it from left to right.

These are obviously not all the nerves' functions or all the tests available but if these are performed, you've done a good job for a rough neurological examination of the cranial nerves.

Have fun examining!