Saturday, May 7, 2011

Memories...

My first rotation as a 3rd year medical student (determined randomly at my school) was psychiatry.

Your first day on clinical rotations you never know what to expect. I was assigned to evaluate Mr. Binford, who'd been picked up by police (for vandalism) the night before.

I sat down and nervously spoke to Mr. Binford. He was a bit disheveled, but seemed intelligent and reasonable. He owned a home improvement company. He employed several handymen (including himself) and had a central dispatch office. They did all ranges of home and yard work.

It all sounded pretty reasonable to me. So, being young and naive, I presented the case to my attending psychiatrist. When he asked me what I thought, I told him that this person didn't seem to need psychiatric care.

Then he asked me if I'd read through his past chart. Sheepishly I admitted I hadn't, because I'd been in a hurry to interview the patient early on my first day.

So he handed me the chart.

OMG

The patient owned no such business. He had a remarkably intricate delusional system.

He owned a truck full of power tools, paint, and various other home repair supplies. Of which he had some knowledge about using them.

He drove around the city, day and night, and would randomly stop at houses where he thought they'd called him for work.

People would come home (or be woken up at night) to find him doing unneeded work on their houses. Cutting down trees. Painting their outside walls. Knocking holes for windows in their homes. Taking apart pool filters. In one case he'd actually painted a guy's car with house paint.

I learned that old charts were useful.

I also learned that even the incredibly delusional could make a lot of sense when you didn't know their background.

We called him "Psycho Home Repairman".

And to this day, if one of our neighbors turns on a lawnmower or other loud equipment after dark, I go to the window... Just to make sure.

29 comments:

Hildy said...

I think I'm married to your psycho home repairman. I wish you had been able to convince him that owning a tool didn't mean he knew how to use it.

Anonymous said...

Send him over, my car needs painting.

Mr Mobius said...

Patients like this are why I found Psychiatry so interesting during placement there. I'll hopefully get to try Psychiatry for F2 (2nd year after graduation in UK) for a 4 month placement, and then decide if I want to do it for a career after that.

Not House said...

Haha, wow. That - to me - is one of the most terrifying things about psychiatric disease, that the person affected might never be cognizant they were sick.

Heck, for all I know, I'm just walking into random patient rooms and asking them questions about their health, when in fact, I'm a home repairman :P

Lynda Halliger-Otvos said...

Just to make sure..... cracked me up !~! Odd how those kinds of experiences stay with a person for decades. I’ve a few left over from my days in the ambulance/ED.

clairesmum said...

at my psych rotation in nursing school on a long term locked ward, there was a VERY nice, older man, very grandfatherly. We students couldn't understand why he had to be there, he was so sad and sincere talking about wanting to go home to his wife. The instructor had one of us review the chart and present it to the group - turns out every time he went home on a pass, he tried to strangle his wife!

spectrumom said...

I was told to interview a lady I thought was visiting a patient in our county lock-down unit. She was nicely dressed in a jogging suit with her hair freshly coiffed. She told me about how there were invisible PVC pipes running in the ceiling so people could listen to her thoughts, how people talked to her on the tv and how the lady next door was jealous of her baby and got pregnant to steal the baby. Appearances are deceiving.

Anonymous said...

LOL!!

I also liked the very practical lesson learned!

I'm a critical care pharmacist and regularly precept 1st year pharmacy residents. One lesson residents have to learn is how to juggle the demands of patient care vs. managerial demands. My one rule, is NEVER miss morning rounds.

So, a particularly enthusiastic resident informed me that she had determined drug regimen changes for Mr. Hopeless. Since she missed rounds to attend a meeting with the director of pharmacy, I decided NOT to tell her that Mr. Hopeless was now Mr. Dead and if she wanted to bounce her ideas off Dr. God that would be OK with me.

She proceded to tell Dr. God all her recommendations and his response was "Those are good recommendations. Too bad the patient died this morning."

All comes back to rule #1. NEVER skip rounds! I think she learned the lesson. (And shared with her cohort as no one ever skipped rounds for the rest of that year!!)

Prissi said...

Unfortunately I did psych at the VA and all my patients *were* truly psychotic... even in appearances... my guy kept talking about collecting water from the rings of Saturn....

Mallory said...

Hmm... I wonder what would happen if you apprenticed him to a real handyman, taught him to use the tools, and employed him (under supervision, of course) doing this kind of work.

Would it enable him to function normally, or just change the expression of his psychosis?

Watercolor said...

Wow. Sounds like doctoring that would be fun! No blood.... ha.

PA Supertammy said...

He must have been really deluded to be so convincing to an outside observer, who was aware he had psychiatric problems.

Tim Allen Fan said...

heh... I laughed at him being called Binford until I realised you probably changed that for the blog...

I'll crawl back to my hole now.

Mark p.s.2 said...

Who paid for his gas ( to drive) and the paint he used?

Doctor Blondie said...

Still sounds a lot better than the one who thought he had therapeutic superpowers and tried to treat ME... (and discovering that his boss/trainer actually existed, except that along with ripping off the patients, the boss also ripped off this dude who was doing some shady therapist training... all very unaccredited of course)
Or the woman who claimed to have 37 personalities.


Ah, MS3....

gloria p said...

No wonder your crazy neuro patients don't faze you now.

Ladybug said...

See this is why I love my job. I've learnt to take everything with a grain of salt.

I think my favourite patient to date is the one who saw geckos everywhere and would shoot them or throw bombs at them (I asked him if he'd seen Patch Adams). Anyway one day he threw a "bomb" inside the nurses station right next to me. I asked him if was trying to blow me up. He said the bombs wouldn't hurt humans, they were gecko specific. I told him that was fine but no bouncing betties as I didn't want to clean up gecko bits from the ceiling.

Anonymous said...

My last patient to round with and I stood outside the cubicle where Ms. Geri Hip Surgery was talking to the nurse. It sounded as if the nurse was taking out the staples for hip repair, as the patient was counting them so I dutifully reported to the orthopedic surgeon the next morning something to the effect that she must be going home soon since her staples were out. I never will forget the expression as he raised his eyebrows and replied that he would be taking them out soon.

But, I truly feel quite sorry about the 1-2% of those with schizophrenia in the world. Too bad that along with severe depression and bipolar make up about the 10-15% prevalence of severe mental illness in the world.
Mental illness is treatable for the most part, but patients often have anosognosia.

Anonymous said...

Mr. Binford! That gave me a good chuckle... you have to laugh, because sometimes that is the only way to make sense of the world. And think of all the practice it gave you in dealing with your current patients... Your blog has continued to convince me that there is a very fine line between a neurology patient and a psychiatric patient. LOL! On a serious note, as one who has a Bipolar disorder - thank heavens for those that choose psychiatry as their profession!

Old MD Girl said...

I always did wonder whether there was ever something to it when our schizophrenic patients would rant about people stealing their money. I mean, it could be true, right? Still, we always told them that it was part of their elaborate delusional system. I don't know how I fell about this.

Anonymous said...

Several years ago I spent a few weeks in an induced coma, the accompanying delusions were very strange, especially when I tried to explain them to the people who were trying to kill me. Major lolz

Anonymous said...

....and you always look at the chart now, right?

I've been tempted more than once to make up symptoms (e.g., my urine is bright blue!!), just to see if anybody read all that paperwork they made me fill out. Just last week I had my ortho's Fellow ask me why I didn't tell him I had RA earlier in the exam. Ummm...cuz it's all over the chart, and I assumed you looked at that?

Shalom said...

@Prissi -- he's giving you a literary reference there. In the classic short story "The Martian Way" (Isaac Asimov, 11/1952), the protagonists do exactly that. Ask him if he's a Scavenger and see what his response is.

ERP said...

That's awesome. Hopefully he won't develop Parkinson's or else you will be seeing him again.

Jess said...

Great. Now I have something else to be worry about.

Knot Tellin said...

One of my early role models taught me two great truths:
1. Psych patients die of physical causes. (So practice due diligence.)
2. Just because you're paranoid, doesn't mean they're not out to get you. (So practice due diligence.)

A couple of years later I had a patient come in from the patio to tell me there was "a huge rat" on the roof of the adjacent building. "Never mind," I comforted her. Come sit in the dayroom where the rat can't get you." She insisted and started to become agitated, so I decided to go out to the patio with her for some reality testing.

There was an opposum, a creature that looks not unlike a huge rat, on the roof.

When became a grown-up NP and had students of my own, I added a third rule:
3. Sometimes there really is a huge rat on the roof. (So practice due diligence.)

stargirl65 said...

On my first rotation I also got psychiatry. A patient on the unit was there for paranoia. He was kept for several days after stating the cops were out to get him. On a hunch we contacted the police to see if there was a warrant on this man. Turns out he was not crazy, just hiding in the psych ward. Notified police of his discharge time and he was arrested as soon as he walked out of the unit.

j said...

The real repair dudes must LOVE this guy - great for business!

Lois said...

That reminds me of a woman I met while working in a nursing home. She was only 46 or so and suffering from dementia. She told a very convincing story of her husband coming to pick her up, except something may have happened to his car. If she had gotten out, anyone would have believed her and given her a drive. Very sad.

 
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