by Barbara Ebel
Chapter 2
Annabel grew up with a father who regularly spoke about his medical training and field of neurosurgery. She also heard many stories from his best friend, Casey, who was not only her uncle, but a paramedic who loved his job. She wasn’t a stranger to medical lingo even before she started med school.
However, she knew little about psychiatry since the specialty seldom came up in the household. What Victor Blake’s diagnosis meant was only a guess. During the first two years of medical school, she heard major buzz words like clinical depression, PTSD or post-traumatic stress disorder, and schizophrenia. Because she read that patients with the latter diagnosis presented the first time with the most eccentric of symptoms and were most in need of physician treatment, her best hunch for Victor was schizophrenia.
The next morning she arrived early to the hospital and rode the elevator to the fifth floor. After being buzzed into the psychiatric inpatient wing, she went to the designated staff room where the team had spent some time the day before.
After sitting down at a circular table, the door opened and Bob Palmer entered. Upon seeing her, his round face lit up with a smile. He wore his short coat and looked smart with a becoming haircut before the rotation began. His blonde hair was tapered at the sides but the top layer was kept longer and cut at an angle. With a playful sense of humor, she appreciated his presence more than any other student she could think of from their class. Their friendship had blossomed during the surgery rotation.
Bob put a soft canvas briefcase on the table. “Good morning,” he said. “I can’t believe you pulled that stunt late yesterday … following Dr. Keeton across the way to evaluate a patient. You brown-noser, you.” He tried to keep a straight face but his eyes twinkled.
“Tell me you didn’t think about doing it yourself,” she said.
“The thought hadn’t crossed my mind.”
“Well,” she sighed. “I believe you. I don’t know what possessed me to do it but I’m glad I did. Not only is my new patient colorful but Dr. Keeton is amazing.”
“We’re fortunate she’s our attending.”
“Before she gets here, however, my duty is to inform you of her three rules.”
Bob looked over at the counter. “Since we’re without any java, I’ll make some while you tell me.” He walked over to the sink and coffee machine and began scooping ground coffee into a filter basket.
Annabel walked with him and proceeded to tell him Dr. Keeton’s safety rules. She poured water into the glass pot.
“So … dress professionally,” he said, “sit by an exit door, and don’t shake hands on this rotation. Got it.”
She took two mugs down from a shelf and handed him one. “That’ll do it. I notice two days have passed and neither one of us has broken down and bought chocolate espresso beans from downstairs.
“Speak for yourself,” he said and pulled out a box from his pocket.
“Oh, you shouldn’t have,” she said and let him shake a few into her hand.
After the water finished dripping, Annabel and Bob poured coffee as the door opened. Their second-year resident, Joshua Washington, came in and went straight to the table. “My wife’s car broke down last night,” he said, “so I’m a tad behind because I had to drop her off. She owns a spa and works as hard as I do.”
Annabel walked over. “Owns it?”
“Yes. We’re both Cincinnati natives so she immediately earned faithful customers like friends and family. But I tell you, she’s a sharp businesswoman. I couldn’t manage a whole business like hers.”
“Good for her,” Annabel said. “And don’t worry about being a little late; Dr. Keeton isn’t here yet.” She placed her coffee on the table and sat back down. “So what made you decide to go into psychiatry?”
Joshua shrugged his shoulders. “I took premed classes in college, but I majored in psychology. So becoming a physician shrink is right up my alley and there are no regrets so far.” He ran his hand through his head of tight jet black curls.
“It must be nice to feel confident about your selection.” She took a sip and looked at Bob. “I’m not sure yet and neither is Bob.”
“Good morning,” Dr. Keeton said as she bustled into the room. Crisp and fresh, her platinum hair looked like it had not touched a pillow overnight. She placed a notebook stuffed with papers on the table.
“Although Dr. Washington knows our routines around here,’ she said, “I have more to explain. And then we’ll scrutinize the basics of Dr. Tilson’s new patient and go make rounds.”
She glanced over to the coffeepot and Bob sprang up. “We made it fresh,” he said. “I would be happy to bring you over a cup.”
“Yes,” she said. “Thank you.” She wore a warm lipstick color, applied like a pro, and the color matched the mauve design on her blouse. She waited for Bob to return and then crossed her legs at the knees, sitting back a bit from the table.
“Since yesterday’s orientation, there are a few more details to discuss,” she said. “Psychiatry rotations around the country are conducted at the discretion of each department and then with differences in attendings. The schedules and daily responsibilities are as varied as the sweets in a supermarket’s candy aisle.”
She moved the coffee cup closer and continued. “Every day we round on patients together and then you write your progress notes. Dr. Washington will be in charge the days I’m not here. As far as grades: your subjective evaluation from me is worth sixty percent and the one final written exam is worth forty percent. You must do full H&Ps of new patients that you pick up but you must select one patient in particular to do a full write-up during the four-week course. That must be handed in at the end; make sure it includes the psychiatric aspects of the patient’s diagnosis.”
“A patient report, not a book report,” Bob said with a friendly smile.
“Precisely,” she said. She turned to Annabel. “Dr. Tilson, my suggestion is that you select Victor Blake. He has no prior documented psychiatric history and what we diagnose and do with him will be documented in his chart forever. We’re not simply reading a new patient’s prior record but we’re evaluating him with fresh open eyes.”
Her words made Annabel appreciate her new patient that much more. “Okay,” she said. “I look forward to it.”
Dr. Keeton finally sipped her coffee and put the mug back down. “You can always ask Dr. Washington for help. All the inpatients are followed by him as well.”
She got up abruptly, went to the counter and topped off her cup, and came back over. “Here’s the first major point for the students. When we talk about major psychoses, we’re in essence referring to schizophrenia and bipolar disorder. Remember they are diagnoses of exclusion. Mr. Blake, at twenty-three, will undeniably end up with the diagnosis of schizophrenia.”
“But for instance,” she added, “last night he denied any significant drug use. One of the differential diagnoses to exclude first is an organic mental disorder such as a delusion syndrome due to amphetamines or other addictive substances. Since I’ve ordered thorough medical and biological laboratory testing, we’ll make sure he doesn’t have drugs in his system.”
Dr. Keeton uncrossed her long legs and popped up again. “Enough of this. Dr. Tilson and Dr. Palmer, today I want you both to learn about and give a mini-mental status exam. Let’s go do rounds but, for Mr. Blake’s visit, you can watch Dr. Washington give him the test.”
She turned, expecting them all to be up on their feet and following her. Because of his experience working with her, Dr. Washington was at her side in a flash. Annabel and Bob caught up behind them and walked side-by-side.
As Annabel popped an espresso bean in her mouth, Bob leaned in and whispered, “She’s a pistol, isn’t she?”
Annabel nodded. “And wait until you see Mr. Blake.”
-----
Dr. Keeton scooped Victor Blake’s chart off the desk as they passed and the four of them went down the long hallway. When they entered his room, they scanned al
l around but didn’t see him. Dr. Washington took a few extra steps and found Victor on all fours looking underneath the bed.
“Mr. Blake,” he said, “I don’t want to startle you. We are here to visit you.”
Victor came up slowly and his beady little eyes narrowed further as he looked from one to the other.
“My name is Dr. Washington. You met Dr. Keeton and Dr. Tilson last evening. What are you doing under there?”
“The voices are talking but I’m looking for the phone. When I locate it, I’ll find the voices.”
“There is no phone in here. What are the voices saying?”
He gave no response as he stood up. Annabel made sure not to walk any further into the room while Dr. Keeton sat in a cushioned chair along the doorway wall and crossed her legs at the ankles.
“That’s fine for now,” Dr. Washington said. “You can tell me later but I must ask you some questions. Come sit down at this little table.”
Victor surprised him, sat down, and pranced his fingers over his gray shorts. His grooming appeared worse than yesterday.
“Can you tell me what day, date, month, and year it is?” Dr. Washington asked.
“Don’t you know that? You said you are a doctor.”
Joshua waited without responding and in a minute Victor decided to tell him. He recited the correct answers.
“And what season are we in?”
“The season of the snake.”
Dr. Washington pulled a notepad and pen from his pocket and made an entry. “What do you mean?”
“Sometimes they drop from the sky or come up from the ground. But yesterday they came out of the screen.”
“Are they going to hurt you?”
“They can’t because I’m going to pull their heads off first.”
“I understand. Can you tell me where you are?”
“This is a school so they can’t lock me up here.”
“You can learn a lot in school. Although we’re in a hospital, we can still help you learn some things about yourself. Are you aware that you have a problem?”
Victor scrunched up his face and shook his head.
“There are issues; they will only grow worse if we don’t help you get better.”
The room took on a silence as the team let their patient consider Dr. Washington’s advice.
“Okay, I’ll get back to my questions,” Joshua said. “I would like you to name two objects. I’ll point to them.” He rose up and walked to the stainless steel sink and pointed. “This is the first one.”
“That’s a hole in the ground,” Victor said after walking over and peering down. “You better watch out. A snake is creeping out from below.” He nervously backed away.
“This sink isn’t posing any harm,” Dr. Washington said. Next, he pointed to a bar of soap but Mr. Blake backed away and sat down.
Dr. Washington jotted in his notepad, dug into his pocket, and took out a bookmark. He wanted to use it to test Victor’s ability to follow a command.
“Next, I would like you to take this in your left hand, fold the bookmarker in half, and place it on the bed.”
Victor grasped the marker and started talking to himself. “They want it. Break this thing into baby cockroaches.”
“No,” he said to the other voice talking to him. “The snakes will still be hungry and can eat you.”
‘You’re wrong. It’s their dinner.’
Victor’s small hands ripped up the bookmark in several places and threw the pieces on the floor.
-----
The air started to feel stale by the time the team left Mr. Blake’s room and they stood by a corner window in a recess off of the hallway. To settle her nerves, Annabel took a deep sigh.
“Phew,” she said. “That was crazy.”
“He has loose associations and nothing he said makes any sense,” Selina said. “Dr. Washington, explain to the students what you were testing.”
“The mini-mental test is in your psychiatry handbook,” he said. “Did you notice one subtlety in there? Mr. Blake shows poor insight and judgment because he is not aware that he has a problem. Otherwise, the questions I asked for the test were for a total of thirty points.” Joshua flipped open his notepad and scanned what he’d jotted down. “He scored less than twenty-four.”
“Over fifty percent of patients score less than twenty-four with their first episode of psychosis,” Dr. Keeton interjected. “Which indicates significant cognitive impairment.”
A ping sounded on a cell phone and Dr. Keeton looked down. "The receptionist over in the emergency care atrium is calling. We’re wanted.”
As she turned, Dr. Keeton addressed Joshua. “You and Dr. Palmer continue on. You know what to do. And please do check the status of Mr. Blake’s work-up. Depending on his results, we must begin him on some medication. And … nice job back there.” She nodded once and gave Joshua a small smile.
“Come on, Dr. Tilson,” Selina said. Annabel stayed by her side and they crossed over to the other building. The brisk walk felt good and, when they entered, they found officer Banks and Lowe.
“Good morning, ladies,” Banks said, looking more at Selina. Officer Lowe had his eyes on Annabel as Banks continued. “We were in the vicinity so we decided to personally give you our update on Mr. Blake. The movie theater manager called to tell us they are not pressing charges. Blake is now truly in your hands.”
“In your realm of expertise,” Lowe added with a smile.
“As it should be,” Selina said. “You gentlemen are aware of the HIPPA patient policy laws so I won’t be telling you any more than what you saw yesterday. He’s in good hands. And last night I did contact his only apparent next-of-kin - his mother - and she should be coming in today.”
Banks casually put his hand on his waist and tucked his thumb behind his belt. “I imagine she will say some colorful things about her son. But nevertheless, thanks. With both our jobs, we clean up the streets in different ways.”
“But I don’t put my life on the line like the men in blue do.” Selina said. “Thank you for stopping by and letting us know. Have a good day, gentlemen.”
-----
Banks and Lowe exited the front door to their waiting patrol car. “Bummer,” Lowe said. “I hope another opportunity presents itself in the future. To ask them out.”
Chapter 3
On the way back from talking to the policemen, Dr. Keeton veered off to talk to another psychiatrist and Annabel went back to their group room where her colleagues wrote notes in charts.
“Annabel,” Joshua said, “I’ve rounded up everything on Mr. Blake. Come have a look.”
She sat down next to him. The tests Dr. Keeton had ordered on her patient were all familiar from her surgery rotation except for the assessment of substance abuse. Electrolytes, blood counts, and hormone levels tested normal or minimally out of range so as to not raise a red flag. Kidney and liver function were acceptable. His EKG and chest X-ray results were fine and the lab work showed no indication of recreational drug use.
Bob looked over. “What do you think Annabel?” he asked. “Is Mr. Blake healthier than either of us while we were getting little sleep on surgery?”
“Ha,” she said. “I think I only caught up with needed rest last weekend.”
“I remember my med school rotations,” Joshua said. “This residency is demanding but I must admit if I get behind on sleep it’s usually my own fault.”
“Partying?” Bob asked. “I keep trying to get Annabel to loosen up and bar hop or party on a Friday or Saturday night, but she doesn’t budge.”
Annabel just smiled. He didn’t know what she was capable of on weekends or other nights for that matter.
“She doesn’t have a lot to say about it,” Joshua kidded. “Don’t let med school take the luster of life out of you.”
“Not a chance,” Annabel said. “Anyway, you two, it looks like we’ve ruled out medical issues with Mr. Blake.”
“Yes,” Dr. Washington said. “A
nd you still have to write up his history and physical besides your big report. You can look at my H&P in the chart but do a nice job and don’t just copy mine. Now is the time to refer to your DSM or quick reference to diagnostic criteria. You should carry the mini-pocket version every day and check in it frequently. And be sure you spend time getting to know your patient and know what makes him tick. It will make you understand the psychiatric illness better.”
Annabel pulled out the specialty’s bible from her pocket: The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. She smiled at Joshua, timidly reached over for Mr. Blake’s chart, and opened up Dr. Washington’s H&P. She skimmed to the bottom for the final, most important part - the diagnosis: Schizophrenia, Paranoid Type.
“You’re cheating,” they both said practically in unison.
“In my defense,” she said, “see?” She opened the page of her DSM that had a piece of paper sticking out. The beginning chapter of Schizophrenic Disorders. “I was already reading about Mr. Blake’s presumed diagnosis.”
Bob and Joshua both kept a straight face like they didn’t believe her and she frowned at them. Finally, the two of them laughed and she hit Bob on the forearm.
-----
Annabel carried Mr. Blake’s chart and a fresh cup of coffee over to the couch where she wanted to write his H&P. For the plan or treatment, she would need to wait for Dr. Keeton and the resident to pick out the best drugs to start him on but, for sure, they would start him in therapy. Victor’s mother would also be in to talk to them which would shed light on his family history.
Was his illness acute, out-of-the-blue? Or had there been previous signs that he suffered from schizophrenia? Surely his mother must have noticed his unusual behavior. Why don’t patients end up getting help in one way or another before a situation tumbles out of control?
She leaned the paper on a textbook and started with Mr. Blake’s appearance: his sloppy attire, poor hygiene and grooming, and the fact that he appeared older than his age. After a few more topics, she came to his thought content which was totally different than his abnormal thought process.
