Chapter 2.1: a missing bone?!

Welcome back, and welcome to the first blog post of 2021. Last year was quite a ride; amongst the perpetual sh*thousery of the pandemic, I managed to regularly post my reflections, securing a permanent historical artefact that future scientists will surely study. “Past medical students were inexplicably obsessed with puns” they will conclude. And they will be right.

This last week I finished my Psychiatry placement, focusing on the mental health of the elderly. The theme for this week is communication in the mentally unwell. Communication is approximately 87.6% of the skills needed for a doctor (give or take), and we encounter barriers to communication in many instances:

1. Masks are not helpful! Patients can already barely hear above the beeps and bustling of the ward
2. Language barriers can make the hospital even scarier for patients, as well as impeding discussion
3. We rarely see patients without having an agenda, a focus, or a funnel which restricts discussion of the less “medical” information- this isn’t necessarily unimportant information

But what happens when the brain doesn’t work as usual? When the information coming in and going out is muddled or processed differently? Spending time on psychiatry has given me some really important points for reflection.

I’d like to share one of these with you.

The missing bone
Onto the titular story, which I promise isn’t clickbait.

A psych patient complained to the team about a discomfort in his foot. My registrar, a wonderful doctor who is very passionate about psychiatry, conducted an examination of the patient’s foot as part of the routine work-up. Was it a bruise? Ligament damage? Had there been any blunt trauma?

In musculoskeletal exams, it’s important to palpate (aka, systematically “feel”) all of the bones and joints of the symptomatic area, and ideally the joints above and below. The bones of the ankle were fine, as were the midfoot bones, and so were the metatarsals.

Except… there were only four. There should be five.

I’m no mathematician, but I don’t think five equals four? The registrar, with a good decade + of experience over me, also came to this astute conclusion. Cue further investigation and imaging to reveal something astonishing.

The patient’s metatarsal has been completely eroded away by infection. He had osteomyelitis, a rip-roaring infection of the bone.

As you can probably imagine, a patient with osteomyelitis is usually in incredible pain and they require pretty fast treatment. This patient had complained of “discomfort”. I couldn’t believe it, but it represented a very important learning point for me: the brain of a psychiatric patient does not function in a predictable way. There are many ways in which this could manifest, but it’s important to remember this because it may affect any aspect of their care.

Some learning points if you’ve made it this far:

1. The information coming in will be affected: they may perceive stimuli in a very different way, they may misinterpret things, and they may not have predictable sensory processing.
2. The information going out will be affected: they can’t always express things as they wish, may respond unpredictably and may be unaware of things they are doing

Of course, this is not just limited to psychiatric patients, but I think there are some surprising instances when this can be particularly important, and we can sometimes forget that the brain is incredibly complex. Even seemingly innocuous things like changes to medication, everyone suddenly wearing masks and deciding to alter a patient’s treatment plan need to approached even more sensitively and carefully with psychiatric patients.

I thoroughly enjoyed my time on psychiatry, and it remains in my (admittedly very long) list of potential future specialties. I have unending respect for those who protect the mental health of the population, and an equally unending list of insults for those who belittle or disregard the importance of psychiatry.

I’m sticking with the brain for now as I enter three weeks of neurology, which before my time out was a really challenging specialty for me. A combination of very difficult theoretical concepts (hello neuroanatomy) and some less-than-forthcoming neurologists made this a difficult specialty in the past. However, the new me has taken time to appreciate and study these concepts, accepts that I won’t have a perfect understanding of them, and is ready to challenge the aforementioned doctors if they decide to re-enact teaching methods of the 1930s.

With my Covid-19 vaccine booked, multiple projects bubbling away nicely and a new year to put my stamp on, I’m doing alright all things considered. I hope you are too.