Guest post: Killing Stalin

Since my last post, I have been absolutely snowed under with work; last week, I pulled double the number of usual full-time shifts at my job. My free time has largely been devoted to cuddling the crap out of the new cat I adopted from a shelter in July, and neglecting this blog. Good for me! Bad for you!

In light of this, I’ve solicited some guest content from a friend of mine. If you’ve been reading the comments, you may have seen ladystardust19 chime in with tales from her own work. She and I met in the nerdy teenage girl regions of the internet lo these many years ago; now she attends medical school in the US with an eye to rural general practice when she graduates. This is the first of two guest posts she’s written for the Book of Jubilation.


 

Hello, readers! I am also here to write about mental health care, but from a very different perspective than this blog’s owner.

You see, I’m a third year medical student.

The first two years of medical school (in the U.S., anyway, which is where I am) are what are called the Preclinical Years. We spend a lot of time in classrooms and very little time with patients. Occasionally we get to pretend to be a doctor to an actor who is pretending to be sick, but otherwise we are stuck with the Ph.D.s and retired physicians teaching us.

Oh, and each other. We’re definitely stuck with each other. I’m kind of sick of other medical students.

But in May I took Step 1 of my boards, and in June, I entered the Clinical Years.

I may know what you’re thinking: “Oh, you’re in the first season of Grey’s Anatomy!”

Much to my disappointment, the first season of Grey’s Anatomy comes after the Clinical Years. In the Clinical Years, you are given to a physician called an attending, and are instructed to Learn Your Profession in four-week intervals called rotations. If your attending in June is Dr. Chao the OB/GYN, you live, eat, breathe, and sleep OB/GYN for four weeks. You learn how much you don’t know about OB/GYN. You learn way more about OB/GYN than you thought there was to know about OB/GYN. In the few hours you sleep, you dream about OB/GYN. In one glorious moment on day 27, you finally do something right and begin to hope that maybe you might one day be halfway competent at OB/GYN.

Then four weeks are over, you are given to a different attending on a different service, are instructed to Learn Your Profession, and the process starts over.

So yes, it’s like the first season of Grey’s Anatomy, but you have never seen real patients before, know nothing you didn’t see in a textbook, never get anything right, and have to learn surgery plus everything else in a year.

I started this particular goat rodeo on Psychiatry with an excellent attending who I will be doing another rotation with because of an awesome thing called elective rotations. We are in an area with few psychiatrists, so we do psychiatry in all sorts of settings including an outpatient clinic, some hospitals, and assisted living facilities.

We don’t do a lot of cohesive therapy, which is partly my attending’s preference, but also because physicians bill by the patient and by the procedure (we also see a lot of patients with Medicaid and Medicare, which do not reimburse well or even necessarily at all for psychiatrists doing therapy), so a big part of my training is learning how to evaluate a patient quickly, decide if they’re a danger to themselves or those around them, if they need meds or if their meds need adjusting, and what and how much of those meds to give or adjust.

But I’m also learning that sometimes, meds are not the answer.

I was pre-rounding at an assisted living facility a couple of weeks ago, so I showed up without my attending to see our patients, make my assessments, and formulate treatment plans before she arrived.

Remember, I’m a third-year. Most of these assessments and treatment plans will be thrown out because I barely know my own head from a hole in the ground, but it’s important that I try, because I’m told this is how I learn.

I’m not sure how much I buy that explanation, but seeing patients and getting my work thrown out still beats the heck out of sitting in classrooms with other med students, so I’m going with it.

I went up to interview a little old man as he was eating his lunch, introduced myself, stated I was my attending’s student, and said, “How are you?  May I sit here?”

He looked me over skeptically, and whispered, “Well, I can tell you’re on the right side, so that’s fine.”

“Excellent!  I’m so glad you recognize that!” I said, sitting in the chair kitty-corner from him.  “How are you doing?”

“Well, don’t say this too loud, but Our Dear Leader Stalin has three days to live,” he said, leaning in close.

“Does he?  I didn’t know that!” I whispered.

“You must be coming out from cover!” He exclaimed.

“Oh, deep cover!” I confirmed.  “I don’t even know what the date is!  Say, what day is it?”

He thought it was early February of 1953.

He also thought we were in Moscow.

“You know, I’ve heard rumors that Stalin is already dead!” I commented after a few minutes.

“Oh, I know,” he said, smiling slyly.  “You see, I started those so he’ll have to make a public appearance to disprove them.  And once he does…Boom!”

We kept talking about his plans to kill Stalin and transitioned to chatting about him and how he was doing, during which he was very pleasant, extremely cooperative, make a few jokes, laughed at the jokes I made, and denied he was feeling suicidal or homicidal toward anyone but Stalin, but really, he was on a mission, same as I was. Stalin is an evil man, my patient explained, but even so, he didn’t exactly want to kill him. It was just a mission.

I excused myself at the conclusion of our interview, went to the LPN on that unit, and began, “So…About Mr. Patient…”

“It’s something different every day,” she confirmed.  “He’s always as sweet and polite as can be–never violent or aggressive, though he did get upset the other day when he was going to explore the Amazon and we wouldn’t let him out to catch his boat.  We told him it was late and he got a little agitated because it was going to throw off one of his experiments, but we had him go to his room and double-check his ‘supplies’.”

“Cool,” I responded. “So, he never hits anyone?  Hurts himself?  Seems upset?  Acts paranoid?”

“Nope. He’s actually a lot happier these days because he seems to have forgotten about his wife, which is nice, because we used to have to keep telling him that she was late or in the next room, and that worried him because apparently she was always careful to be on time,” the nurse said.  “His wife has been dead for almost fifteen years, of course, but no point in telling him that and upsetting him every ten minutes.”

I concluded that the patient seemed to be doing well, jotted down my plan, and gave my attending a run-down on what I observed when she arrived.

We went to go look in on him together.  Since my attending is Eastern European and has an accent, I told him she was a defector and would be able to help him.  Once she said she wanted to free her country from the Soviets, he warmed right up to her and we had a chat about his plans to kill Stalin.

My attending and I left his room and found a place to confer.

“I honestly don’t know that I want to give him anything,” I admitted when she asked for my treatment plan.  “He seems pretty happy to me, honestly, and he’s not paranoid or agitated, so I think we should just keep monitoring him.”

“That’s what I’ve been doing,” she confirmed.  “Killing Stalin seems like a pretty good hobby to have in your old age, don’t you agree?  I hope I’m that lucky!”

Honestly, I hope so, too. If I’m going to have dementia, there are far worse ways to spend my days than cheerfully working on my plan to kill Stalin!

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5 thoughts on “Guest post: Killing Stalin

    1. My dad helped me pay for med school applications (WHICH ARE SUPER EXPENSIVE, OMG) on the condition that I would, in his words, “put [him] to sleep” when he gets old.

      After taking care of some patients in ALFs, I texted him (because Dad is a software engineer and Doesn’t Do Feelings) and said, “Hey, Dad? I thought you were joking about me putting you to sleep when you get old, but actually I’d totally do that, provided it wouldn’t get my license revoked and stuff. No pressure, but we should probably discuss end-of-life plans for both of us at some point, because life isn’t certain and it’s good to know! Thanks, love you!”

      And he texted back not even two minutes later, “Oh, you thought I was joking? Because I wasn’t. Please put me to sleep before putting me in a nursing home! Thanks! :)”

      We did discuss it in person when I went to visit him, but that’s his story, and he’s sticking to it.

      I’m 90% sure my dad is going to outlive everyone because he’s 56 years old and bicycles 20+ miles in and out of work every day, is part of the running club at work and outruns the kids my age at lunch (after the 20+ mile bike ride) and bitches that his mile was slow when it’s six minutes or more, referees football in the local high school district, takes care of three horses, and puts roosters in their place in his spare time, but as I told him, end-of-life plans are good to know!

      1. …And as a caveat (because I went to shower and as I was conditioning my hair thought, “WOW, HOLY UNFORTUNATE IMPLICATIONS, BATMAN!”), I am in no way suggesting that my dad’s route is the route everyone wants to or, heaven forbid, should (! what a crazy, obligation-laden word that one is) go–the patient I wrote about here was fantastic both this time and subsequent times I saw him, he definitely lives a meaningful life, and he certainly added a lot to my life and the lives of those around him and who were caring for him. I learned a lot from my interactions with him, and am deeply, deeply grateful to have met him.

        It’s just that ALFs in the US can be a bit of a mixed bag, and I’m 99.9% sure my dad would not be a Killing Stalin sort of dementia patient. Even more importantly, he’s 99.9% sure he would not be a Killing Stalin dementia patient, and is not willing to go through the stages between “Dad as We Know Him” and “Killing Stalin”, which I only hinted at in this entry–the stage where this patient remembered he had a wife, but not that she had died; the stage where the patient was no longer his former self but had not yet started living a life where he explored the Amazon or was an Undercover Agent.

        Luckily this patient’s family was able to place him in a facility with staff who were happy to let him explore the Amazon or kill Stalin and a psychiatrist who was happy to present herself as Soviet-era defector so she could assess his mental state and agitation levels and comfort, but unfortunately, not every dementia patient I met was so lucky, and that reality was a reality I had to struggle with and that my attending has to struggle with still. These other facilities weren’t doing anything wrong, necessarily, but their philosophy toward patient care was quite different, and didn’t allow for residents/patients to kill Stalin, no matter how nicely and agreeably and unobtrusively they were doing so. It was difficult for us and I know we felt rather caught in the middle–the patients weren’t upset! They weren’t hurting anyone! Why was the facility upset? Tell him to go back to his room and check his supplies and look for maps, don’t ask us to snow him with medications!

        So I get where my dad would rather check out rather than kill Stalin, and I will be happy to help him live the life (and death) he wishes, because it’s an issue that is personal and complex and has a lot of variables. I understand that he’d rather not run the risk of ending up in a facility where the psychiatrist thought it was preferable to snow him than to let him kill Stalin, and I support him in what he decides, and will keep the (awkward, Software Engineer) lines of communication open as he gets older to make sure that’s what he wants.

        At the same time, I would never, ever assert that patients like these aren’t valuable people living meaningful lives, nor would I ever say they shouldn’t be receive the utmost respect, consideration, and care.

        And hey, I’m more than happy to chat with them about their plans to kill Stalin in February of 1953! Goodness knows it taught me a lot and made my day! 🙂

  1. YAY NEW KITTIES! Some things are more important than blogs, cuddling new kitties being foremost among them! 🙂

    Thanks for posting my stories! I feel silly putting them out there, but there’s so many bizarre notions about psych patients, and I’ve always found them to be awesome, awesome folks. I hope I communicated some of their awesome, and how blessed I feel to learn from them!

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