At long last, overview of the psych placement.

I've been neglecting this blog a little bit. I could say it's because I was working pretty much full-time in May, but since then I've had a blessed break of 10 days. And although I am working full-time again (more on that later), it's in 12-hour shifts, which gives me lots of days off. So I hope to begin writing again more regularly during the summer.

I think I'll begin with a description of my 3.5 weeks clinical placement at the largest psychiatric hospital in Montreal, as a sort of catharsis. Oh...what can I say. The whole thing was poorly organized to begin with. For instance, no one could really tell me the goal of my particular unit until I actually got there and talked to my preceptor. And on the orientation day, me and three other students wandered around for 2 hours because no one told us where we were supposed to meet the prof, which led us to assume that we were expected to be in the main lobby. A rather obvious supposition, no? Unfortunately, the institute is composed of many buildings like a university campus and there's a special administration building where all such orientations take place. We would have known this if we had actually made it to the orientation!

My first day on the unit was fairly uneventful. I had expected patients to be confined to their rooms and was surprised to find that they were walking around so freely when I stepped off the elevator. Then I found out that they were mostly schizophrenic patients who were in programs to be moved back into the community eventually. Some never make it, most move out and then return in a matter of weeks and very few actually live outside for a longer period of time. It was a very lax environment compared to the medical/surgical units I'd been on. Staff breaks lasted 90 minutes or so. Most afternoons were spent gossiping or in the case of a student like myself, pretending to be busy reading articles while surreptitiously playing sudoku.

I hated it at first. The giant gap under the door of the smoking room made the whole unit smell like smoke and gave me throbbing headaches. Patients thought they could take advantage of me and push me around because I was new. The very first day, I went outside to wait for my friends so that we could have lunch bitch session in the sunshine. A man who was obviously an alcoholic sat down next to me and a very awkward half an hour followed during which I tried my best to use my therapeutic conversation techniques and he somehow took that as flirting. When he finally walked away, I bolted back to the main door, fumbling with my key like the clumsy main character in a horror movie. I vowed never to go outside by myself again.

It did eventually get better. I was allowed to participate more in the unit activities. I took over medications for all of my preceptor's patients in my first week, including bi-weekly IM injections. I conducted interviews with several patients on the unit even though I wasn't officially responsible for them. I took part in rounds and called hospitals and family members to get medical records that were missing. It was a hell of a lot better than what my friends were doing down in the Memory Clinic: MMSE day in, day out, some tai chi (YEAH) and computer programs designed to stimulate memory and learning. I shadowed in the memory clinic for one hour and it was deadly dull. They do mostly paperwork down there. I do want to have a clinic eventually, but I doubt my paperwork will be as absurdly pointless as theirs.

I also got more comfortable being around patients who could potentially have a psychotic episode at any given moment. The trick, I think, is being calm and firm. Most patients were on their medications, which meant that they were very unlikely to try and choke you out of the blue. Due to a panic button shortage, I ended up not having one for most of my stay there, which was admittedly dangerous when I think about it. But I was never very far from the nursing station and there was always a staff member nearby to step in or go get help.

There were two memorable incidents, which would have escalated into something very unpleasant if I hadn't gotten help immediately. The first involved a young male patient with a history of sexual harrassment and assault, which actually landed him in the unit via a court order. I was trying to get a patient to take her morning meds when I felt something brush past my butt. I looked up and the man was walking away from me. I couldn't decide if he was just walking by and accidentally touched me, but then why wouldn't he choose to walk between the other tables where there was a lot of space? I told my preceptor as soon as the patient took her medications and he brought it to everyone's attention during the morning report. Then there was a patient meeting with my preceptor, the unit coordinator, me and the patient in a smaller office. My preceptor basically came out and told the patient that he knew the patient did it on purpose. The patient didn't try to deny it and simply left the room.
My initial reaction was perturbation, I think. I was really hoping that the patient didn't do it on purpose, because the fact that someone could deliberately do that to me was very upsetting. And I couldn't retaliate in any other way, because he is sick (and mentally retarded). The court found him not responsible for his actions because of his illness and I completely understand that, but it still took a couple of days before I could give him his medication without feeling an underlying sense of dread. In a way, it was good that I had this kind of experience early on, because now I know to be more vigilant and I know what to do.

The second incident upset me much more. It was my second last day on the unit and I was giving morning medications to the same patient I was trying to convince in the first episode. She is a really sick lady. She's completely paranoid, delusional, irrational and sarcastic. She was apparently much better when she was on lithium, but it had to be stopped because she started having kidney problems. Anyway, there was nothing new that morning. She was mocking the way I spoke and was extremely annoyed that I was interrupting her breakfast, but I was used to her insults by that point. Then she started breaking one of her many many pills in half. I asked her what she was doing and she started screaming that she always took half the pill. I reminded her that she'd been taking the same pill every morning for a long time. That's when she showed me her fist and asked if I would like being punched in the face. Thankfully, a nurse stepped in at that point and I was allowed to leave the unit to regain my composure. I sat outside on a bench and cried. It was ridiculous. I shouldn't have taken it so personally because she was...well, there's no other word than "insane" really, but in that split second when she threatened to punch me, I was shocked. Angry, too. I have a terrible temper when pushed and if I hadn't been in a mental hospital, I probably would have screamed something like "What the fuck did you just say to me?" and flipped over a table or two. When I came back, there was a patient meeting with my preceptor, the nurse who helped me and the patient. After 10 minutes of reining in her absurd tangents and digressions, they finally got her to apologize to me with much reluctance. I doubt it actually got through to her that aggression is unacceptable towards anyone, because she's in such a haze of paranoid and persecutory delusions, but she did apologize. That was an improvement enough for me.

Of course, in a place like that, the bad stuff is always more memorable. But I like to think I have some nice memories to make up for them. The nurses and other staff are very nice, for one thing. They're no Nurse Ratchet, that's for sure. They get frustrated too, because some patients are so resistant to helping themselves and psychiatry isn't exactly known for its "cures", but they genuinely like working at the hospital and they try their best to help their patients. I'll remember all the advice they gave me for the rest of my career.

Important things I learned about psych:
1) Get a damn panic button and wear it.
2) Don't assume that the patients can think as rationally as you. But try to reorient them in the real world as much as possible.
3) They're really like children. They're either extremely well-behaved or frustrating like the devil.
4) Be nice, but let them know that you're not to be trifled with when they overstep boundaries.
5) Don't take anything personally and leave everything behind when you're done for the day.


Hmm...now that I've written it, it's a bit lacking in humour, no?