Dream Interpretation: My Blanket

Dear Psych Doc:

I have had a LONG string of not remembering my dreams lately. I think it is b/c subconsciously I know you will interpret them for everyone to hear. Finally....I had a dream and remembered it. It was kind of dumb.

The background to the dream is as follows; I have had a blanket since junior high that is awesome. Everyone who stays the night wants to use it. It has the perfect material consistency. I'm not a total dork....I don't sleep with it every night. My wife and I have a comforter so it's not like I have to have it to sleep. I usually use it when on the couch or need extra covers and such. It is striped green and white...not even my favorite colors.

So my dream took place with me on vacation visiting friends from early childhood that I haven't thought of in 15 years. My green and white blanket was with me. I walked a few blocks to go to the grocery store, and for some reason I brought my blanket. On the way home from the store I noticed I left the blanket, so I turned around to hurry back to the store. Before I made it to the store, I noticed two lady's with my blanket. They molded it into a horse and made it look like a pinata. I asked for my blanket back, and they offered me $500 for it. I felt like that was too much money, so I said they could have it for $300. Soon in my dream I regretted the decision of selling my blanket. The rest of the dream I searched for the lady's I sold the blanket to. I don't remember anything after that. What the hell is the matter with me?

-ER Doc

Dear ER Doc,

Welcome back to my office. First, let me explain the blanket. The blanket is a common transitional object used by a toddler during the separation phase from the mother. The blanket signifies a representation of the mother that comforts the child when the mother is away, therefore easing the transition into individuality. In many ways, adolescence is a lot like being a toddler, so I can see that the blanket could be your "teenage" transitional object.

This also sets the time frame: 15 years ago, you were a teenager, a time that you remember your blanket and your mom providing you security.

I think that the 2 old ladies probably refer to your 2 "old ladies"- whoever fulfills the 2 dominant female roles in your life right now. Could be your current and ex girlfriend or current girlfriend and mom. You feel as though they are battling for your attention. Whatever it may be, you're refusing to let go of something in the past. You're holding onto some behavior or personality trait that reminds others of a teenage boy. I'll let you figure that out.

As for the horse/pinata part, that's just a fantasy. You wish you had genital anatomy the size of a horse. And you want women to beat you like a pinata because you're into S & M.

-Psych Doc

Cash Baby

A mother brought in her 8 month old baby today for "breathing difficulty." She stated that for the last 2 months her child had been breathing worse and worse. He had a non productive cough and no fever. They had been to her pediatrician multiple times. Despite treatment with medicines, including breathing treatments, the child was getting worse. When she went to see her doctor today...she realized the baby had lost 4 pounds in the last 2 months...so she decided to come to the ER for a second opinion.

Up until his presentation today, no one had ordered a chest x ray. A similar CXR to my patients is pasted above.

So the diagnosis was easy. Swallowed a coin. Consult for endoscopy....

But if ya think of it....this doesn't really make sense. The kid has been losing weight so I am confident that the coin was probably the culprit. But how does a baby that small swallow a coin? We are taught that a coin that is swallowed but doesn't make it to the stomach is a surgical emergency. But presumably the child swallowed this coin 2 months ago?!?! That means by now the child would have been septic, had a perforated or eroded his esophagus, the list could go on and on.

So....I'm stumped. Don't know if the swallow was recent and a red herring to what was really going on, or if he swallowed it 2 months ago and is some kind of miracle baby. He was admitted to the hospital to have the coin removed and further workup. I'll have to follow up and see what comes out of it.

-ER Doc

Greed

Below is a link of a blog post from a different website. I think it brings up important points that we don't hear enough of:

http://thecentralline.org/?p=642

The next is an article on the basis of how physicians get paid....the relative value unit (RVU):

http://www.slate.com/id/2227082/pagenum/all/#p2

For those of you who are interested in medical care and the "free market," here is an interesting take by a leader in medicine:

http://www.kevinmd.com/blog/2009/09/free-market-health-care-exist.html

-ER Doc

Cake

Here is a copy of a nurses triage note from the other night.

"Patient presents to triage complaining of tooth pain. He has obvious tooth decay and was already seen at an outside facility last night for the same complaint. He has prescriptions in his hand from that visit which he has not filled. He is asking for utensils to eat his 3 large pieces of cake that he has with him, a place to do his laundry, and also requesting to be allowed to sleep and shower in an inpatient bed. Explained to the patient that the hospital cannot provide laundry or residential facilities and offered the patient information about local area shelters. Patient declined and responded by shoving a piece of cake in his mouth and wiping hands on his soiled shirt. Nurse X"

Needless to say...I don't think we got good patient satisfaction scores on this one. If we only had a shelter and plastic forks in the emergency department...

-ER Doc

Great Article on Healthcare

http://www.washingtonpost.com/wp-dyn/content/article/2009/08/21/AR2009082101778.html?referrer%3Dfacebook

-ER Doc

Anonymous said...

I am a "green" R.N and just pulled a 36 hour shift in a very understaffed hospital. I was tired, emotionally spent and considering my career choice. After reading your blog and seeing the way you use humor to deal with the day to day happenings it rekindled my faith and reminded me that I wasn't alone. Thank you.

Re Anonymous: I really appreciate your comments. In medicine, we see a lot of sick things...and even more sad things. It is emotionally and physically grueling. This is especially true for the young docs (residents) and "green" nurses b/c we start out in understaffed and county type places. We really don't help people as much as we would like. There are many reasons for this. One is b/c of things that are out of our hands...like social and financial constraints or the resources available. Other reasons are as simple as the people who flood us who "aren't sick" and have secondary gain usually outnumber those that truly need help. That being said...in psychology humor is regarded as a mature defense mechanism. Sometimes the only way to get through a situation is to laugh at it. Humor as a defense mechanism takes feelings that are uncomfortable to talk about "straight up" and allows us to express them in ways that don't hurt others and at the same time help us. (Albeit I tend to do this sometimes in sick ways and go too far, but that's me and my problem, not most peoples.)

The patient you are referrering to was a good example of this. She was horribly sick in the head, smelled terrible, high maintenance, had been in the ER daily for 4 days, and drained ALL of our staff. She made me mad at her, mad at society, and just mad in general. I honestly didn't want to take care of her again. But I found something funny about it and knew I could share it with you guys. All of a sudden I wasn't as mad anymore.....

Thanks for your understanding anonymous.

-ER Doc

Chief Complaint: My Cat's Burning

Here is a direct copy of a chart I saw when looking up a patient's past history:

Chief Complaint:
Patient presents with

• "My Cat's Burning"

HPI: Patient very difficult to interview and giving strange inappropriate responses to questions. Shouts, "AIDS!" long pause "Gonorrhea!" long pause "you want to see my penis?" long pause "My cat's burning and I need someone to look up under me." Finally interpreted to mean that she has burning when urinating for several days. Also complaining of vaginal pain and burning. Unsure if she's had any discharge. No abdominal pain, nausea, or vomiting.

-You can't make this stuff up!

-ER Doc

Misconceptions

It seems that some people out there have misconceptions of what psychiatrists can do. One of my attendings warned me about this last year, but now that I'm in clinics, I believe him. For some reason (probably Hollywood), a lot of the public believe that psychiatrists can read minds. Several recent events, including the gun post by my colleague, bring this to light.

I was at the mechanic the other day. I knew I needed some work done on my brakes, and I was getting a quote. Meanwhile, I made small talk with the brake guy while he was telling me all that I needed. Of course, I felt like he was trying to sell me more than I needed. I went with the minimum service. He said something like, "I bet that your psychiatry training helps you out with negotiations like this," implying that somehow I knew that he was trying to scam me. I did, but it had nothing to do with my psych training.

Another example is when someone recently mentioned that a way to keep guns out of the hands of suicidal/homocidal people is to make them undergo a psychiatric evaluation. Of course there would be a lot of logistic concerns (which psychiatrists would do it, who would pay, etc.) But what I want to make clear is that Psychiatrists can NOT read minds. I can only help you if you want help. If you are lying to me, maybe I can figure it out, but I probably can't. Sure, I may be able to tell if you're depressed or hearing voices. I can obviously tell if you're manic. But I can't tell if you're going to kill unless:
1. You tell me you're going to or
2. Your family/friends/police heard you make those statements or
3. Other aspects of your personal history (which you can lie about anyway) send up a red flag.

The third aspect of all this is what really hits home. I recently found out that the father of one of my daughter's classmates died. It made me confront my own mortality; I had seen him a few days before. He was fairly young and appeared happy and healthy. He did NOT look depressed. I figured he had a heart attack or car accident. Then I checked the medical examiner's website. He committed suicide. This was a person who on the surface had a loving family, a successful career, wealth, you name it. These are all protective factors for suicide that almost none of the patients that I treat at a county hospital possess. Who knows what his own personal demons were. But the point is: I'm sure nobody saw this coming.

I can't stop thinking about the hole that he left for his wife, kids, and friends. My initial sympathy turned to anger due to the selfishness of this action. That night, I told my family I loved all of them and promised to never do such a thing. It has been haunting me for a week now. Even though I didn't really know him, it touched me deeply. I am a mental health professional. I am supposed to help people like him.

Please, if you are having thoughts of suicide, or know someone who may be, please get them the help they need.

Sometimes they don't seek help on their own.

And don't expect a random psychiatrist walking down the street to read their mind.

Anyone can fake it.

Anyone can lie.

And I wouldn't know.

-Psych Doc

Daddy's Little Girl??

Interesting shift in the "Children's" ER the other day.

Patient 1: Fifteen year old female presented with a sore throat. She also wanted a pregnancy test b/c she was late on her period. When I walked in the room....I saw a young female with tattoos on her neck and arms that said "bad ass." + nose and lip ring. Overall she was a sweet girl. She was concerned about being pregnant (which she wasn't...thank goodness). She did, though, have gonorrhea in her throat. The kicker...her t shirt said in big letters "Daddy's Little Girl." Having daughters myself, this saddened me. Let's just say we had a little heart to heart.

Patient 2: Fourteen year old female presented with abdominal pain. She was with her FOUR MONTH OLD child. She had been pregnant 2 times before, one resulting in an ectopic pregnancy. Again... this girl was fourteen years old!! She admitted to doing cocaine, marijuana, and "occasional" alcohol. Her last period was 4 months ago. Long story short...pregnancy test was positive, and she was transferred to the adult ER for another ectopic pregnancy workup. We consulted social work b/c she just didn't seem fit to be caring for her four month old.

-ER Doc

More Fun With Guns

Latest victim of a gun shot wound was a 46 year old male who was shot by his...FOUR YEAR OLD SON!!!

Story was that an 18 year old was teaching his 4 year old brother how to "target shoot" from the back of his pick up truck. When dad came outside, the 4 year old turned to show him what he could do and accidently fired a bullet through his dad's spleen and esophagus.

Who's to blame in this one??

-ER Doc