Train of Thought

Thomas Robey -- The following entry was inspired by a patient encounter. But first, a preamble:

There's enough in medical school that's hard to deal with that it's worth trying to make the most out of enjoyable assignments. Two of my favorite clinical rotations in medical school thus far have been emergency medicine and psychiatry. This month, I'm combining the two by working in our county hospital's psych ER. Inpatient psychiatry exposes students to really sick patients, but these folks are typically stable via detox, medicine, a roof or what have you. This is not the case in the psychiatry emergency service (PES) section of the emergency department. Life in the PES goes a little more like this:

So what brought you to the hospital today?

Well, I was riding the bus thinking about what I needed to read next because the Step 2 had just completed and remembered that there were 783 (or was it 873?) steps in the Cathedral of Learning where the nations gather in their own rooms to talk about the current financial crisis, but that doesn't matter because liquidity is the best approach right now and this orange juice is delicious like an Orange Julius from Czechoslovakia and we used to send his family packages with American money hidden in green objects so that the mail inspectors wouldn't find it like the way Watson actually did all of Holmes' dirty work, but stole the data from Rosalind because she wouldn't sit in the back of the bus which is where I happened to be when the voice announced “Harborview, next stop.”

Are you hearing any other voices?

Coffee. They say, “coffee.” Sometimes, “Coffeemate.”

Are you thinking of hurting yourself?

With coffee, actually.

Do you feel like hurting anyone else?

Cigarettes.

I didn't know you smoked.

No. I want to hurt them. With fire.

Is there anything the doctors can do for you?

Coffee. <devious giggle> Coffee. <looking over your shoulder toward a non-existent cup of coffee> Yes, the coffee will do just fine.

Are there any medicines that have worked in the past?

Other than coffee? No, not really. Just coffee, cigarettes and olanzapine.

Maybe it's the fatigue secondary to endless education, but for me, the line between train of thought and flight of ideas is increasingly blurry these days. And who of us doesn't fixate on caffeine sometimes? To you, my response above is nonsense, or a puzzle at best. But to my wife or family, it all makes sense. It's a little circumferential yes, but is based in reality. Logical from one perspective. Seeing how my thought jumble is not unlike my patient's idea of a coherent response makes it easier for me to handle psychiatric illness, and dare I say, empathize with him. And if I cross the blurry line of sanity, at least this month, I'll be in a place where I can get the help I need.