Hello Steemians, I bring you a new series that I had some time wanting to write, I was just waiting to collect enough interesting experiences to tell, and finally, I think I have a good collection of anecdotes. Hope you like it!

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As can be deduced from the content of my publications, I am currently a medical student; an undergraduate intern in my 4th year of studies, doing internships in the hospital of my city. Part of our service consists in being on-call every 6 days; at night during the week and 24 hours on Saturdays and Sundays. I lie if I say that this has a lot of resemblance to TV shows like ER, however, we have had some very interesting cases, that have given me the idea of sharing them with this community, and teaching at the same time about the diseases suffered by the patients of these stories. Medicine and curiosities, explained with touches of humor: the basis of my blog.

To preserve medical ethics and doctor-patient confidentiality, there are some facts that I have to omit. That said, I will describe wounds, injuries, medical conditions, and other details that may be somewhat hard to stomach. I leave it here as a warning: _ there will be explicit content in these articles, both written and visual _. This specific article does not contain photos of the kind that you will never be able to erase from your memory and that you will still see even when you close your eyes, but it does have descriptions about a case of a character that is not exactly suitable for minors. Without further ado, I present:

Tales From a Night on-call: Iron Rods and Douches

It had been a fairly uninteresting night; we were under the service of internal medicine, and aside from an electrocardiogram or taking vital signs, we had not had much activity. My partner @korotkov and I had decided to stay a few hours in triage; where patients with common illnesses came to consult, and those in more grave conditions were referred to the corresponding service. After about 30 minutes discussing whether we should drink a bottle of water without a lid that we found in the office (we did it, and we are still alive. Bear Grylls has got nothing on us), a female patient came into the triage office, just as the only doctor who kept us company went out for a moment to help in another area.

It was a lady of 59 years, somewhat careless in her appearance, but with nothing that could indicate the existence of any disease at first glance. When asked about the reason for consultation, and she told us that she felt a burning sensation when she urinated (dysuria, classic symptom of some kidney diseases and urinary infections). I performed fist percussion on the lumbar fossae, a maneuver to detect nephropathies, resulting positive, which meant that the existence of renal pathology was possible. "Case resolved", we both thought, my partner began to write a prescription ordering the patient urine and blood tests, while I dedicated myself to cut some papers to write more recipes (there is a shortage of paper in the hospital. Venezuela: the land where there is none of what you never thought could go missing.)

@korotkov on the left, me on the right, so you can better imagine our faces in a few moments.

That was when the consultation really began. While @korotkov wrote and I cut papers, the lady began to tell us more details about the possible origin of her condition:

Doctor, another thing that I forgot to tell you: sometimes when I have sex it also burns, last year I was with a man, and every time we did it, it burned. Does it have something to do with this?

I thought it was unusual for her to have an active sex life at her age, although it is a healthy habit even on the third age (as long as they do not tape it and upload to the internet, please), and I appreciated her honesty; Many cases would be easier if more patients were that forthcoming. We told her that it was possibly due to an infection of the urinary tract, and that we were going to order her some laboratory tests to confirm the causative agent. She was satisfied with this explanation, but a few seconds later, she added more details to her story. I write everything textually as she said it (they are some things that cannot be forgotten):

Doctor, there´s something else, you see, last year I was crazy. Yes doctor, I was insane! But it was only last year, I am fine now. See, I got the habit of sticking iron rods down there...

My partner and I stopped what we were doing, and we both looked up in almost coordinated fashion. Noticing our faces of incredulity, amazement, and slight trauma, she continued with her story:

Yeah, well, I grabbed the rods and stuck them in whole; I don’t know what I was thinking! I masturbated with iron rods, and sometimes with douches. I stopped doing it because once I started to bleed, and it burned for a few days. Is that why it´s burning again now?

I admit that my mind went blank for a few seconds, not knowing what to think. I felt the same as I assume a computer would feel when showing the famous blue screen of death, and looking at my partner, I realized that he had suffered the same brain implosion. We recovered our mental faculties after a few moments, although the gift of speech and critical thinking was not fully restored; the only thing that occurred to us as an answer was a "yes ... it´s possible…"

After the initial trauma, @korotkov asked the patient to explain to us the nature of her psychiatric condition; what did she mean when she said she was "crazy"? The possible nephropathy or urinary infection was the least of its problems; she told us that she had been diagnosed with schizophrenia, during some studies in the city of Maracay, and that she had been on a treatment that she had abandoned, since according to her "she was better". This statement was slightly far from reality, so we continued to inquire about their background and personal data in the hopes of channeling psychiatric help and treatment for their condition. When asked about her address, she exclaimed with a smile on her face (during the whole consultation she always had a pretty jovial mood. Bad weather, good face, they say in here...):

Here doctor, the hospital!

"What do you mean the hospital?” We asked.

Yes, I live here. You see, my sons also suffer from schizophrenia, and they are in here as psychiatric patients, so I stay here to sleep. I have been living in the hospital for more than 15 days now

It was a requirement to write her address on the list of morbidity, so we asked about a previous address. When we could not get answer with the specificity we needed, we hesitated about what to write, then a few seconds later we thought "screw it" and wrote down the name of the hospital as the patient's address. Our mind was in other places, imagining things that nobody should ever imagine (and that surely you are imagining right now. Sorry for the mental image), and trying to make sense of the whole case.

Here, so you can picture it better. You're welcome.

We gave the lady the medical recipe, knowing that due to her social condition she would most likely not be able to perform the required exams (in the hospital we ran out of the reagents to perform simple exams for free a long time ago), and giving her the indication that she returned during the morning of the next day and explained her case to the doctor on duty; unfortunately we were unable to offer much more help, still being students. She reminded us that she would remain in the hospital anyway, and that she was going to the waiting room to spend the night.

We went with the only doctor on duty that night (it was already around midnight, the other doctors on call had gone to sleep), and explained to her the case and asked her if there was something else we should do. She showed the same doubts than us, and together we decided that the best way to proceed was precisely the one we had thought; to tell the patient to come back later, when there was more staff able to handle her situation. Discussing the case with our other colleagues, a question arose that eats away at us since then: you see, in Spanish, the words for “douche” and “pear” (the fruit) are the same, so the translation of what she really said to us was “I masturbate with pears”. It is my assumptions that she was talking about douches, since a pear costs several minimum wages here in Venezuela (I´m not exaggerating for comedic purposes, by the way. Feel free to read my previous articles about it), but I suppose there is always the possibility that she was talking about the fruit. Guess we will never know for sure.

Although the lady said she did not have active bleeding since that event that made her stop her insane way of giving herself pleasure, it was possible that, gynecologically speaking, the urinary infection was the least of her worries. But her main condition, and that which deserved more urgent treatment, was her schizophrenia. Now, we've all heard about it, but exactly what do we mean by this disease? Is it limited to auditory and visual hallucinations?

Schizophrenia is a mental illness present in 1% of the world population. Its causes are not yet fully known, although several investigations have made it clear that there is a genetic and hereditary factor involved: people with a relative who suffers from schizophrenia have a 10% chance of developing the disease, compared to 1% of the population with no family history. Some (probably overpaid) experts affirm that the manifestations of schizophrenia arise due to a combination between the existence of alterations in the brain structure (increase in the size of the hippocampus, alterations in the activity of dopamine and glutamate, and other changes that you probably only try to understand), and environmental factors that affect the levels of stress, the use of drugs, the break-up of a romantic relationship ("he’s only a friend", she said...), or living in Venezuela.

Its symptoms are more diverse than we think, and go far beyond mere hallucinations. It can begin to manifest with slight changes in personality and a decrease in social competence, such as isolation, unusual thoughts, perceptual distortions or disorganization. Distinguishing these symptoms from the typical behavior of teenagers can be complicated, if anything. Its detection becomes easier when classic symptoms begin to appear: both visual and auditory hallucinations (the famous "hearing voices", the most frequent hallucinatory manifestation), and delirious ideas (the belief of being persecuted or deceived, that others can read your mind, that passages of books or songs are meant for you, or that pineapple pizza is good). It can also lead to disorganized thinking that causes incoherent speech, inappropriate behavior, lack of sociability, memory impairment, difficulties in problem solving, and in severe cases it can lead to violent behavior, catatonic states and suicides.

Its diagnosis is complicated, because despite what the online tests that your younger brother with too much free time does might make you believe, there is no single exam that confirms the existence of schizophrenia. The normal procedure is to investigate if there is a family history of the disease, and to make a thorough evaluation of the signs and symptoms of the patient: it is sought to find out if there is a presence of at least 2 of the symptoms described above during at least one month, along with mild signs such as social deterioration or in carelessness in the self-care, with a minimum of 6 months of evolution. Then, a differential diagnosis is made with the other psychiatric disorders with manifestations similar to schizophrenia, such as psychotic or personality disorders.

The treatment aims to reduce the intensity of psychotic symptoms, prevent relapses and avoid functional deterioration. It is based on the rehabilitation and teachings of self-control of the condition in community support centers, and the administration of antipsychotic drugs, such as Chlorpromazine or Thioridazine, among a wide variety, and taking into account that the faster the disease is detected and the faster the treatment begins, the patient better the patient´s response will be. Psychotherapy is also used to develop a collaborative relationship between the patient, the family, and the attending physician, and to educate them about the nature of the disease, and provide psychological and empathic support.
This was our first psychiatric patient in consultation, and one of the most peculiar, disturbing, and heartbreaking cases we have had. We never knew if the lady returned the next day for a consultation; despite supposedly living in the hospital, we did not see her again, nor did we know about the sons she mentioned. I just hope she listened to us, and that somehow she got treatment for both the urinary tract infection and her schizophrenic disorder. And while I keep my hypothesis, I will never be entirely sure if she really meant douches.

Hope it wasn´t one of these, but I guess anything´s possible if you let your imagination fly.

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References:

• Beers, Mark H., et al. The Merck Manuals of Diagnosis and Therapy, 11th ed., 2007.

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If you enjoy medical-themed articles, or general curiosities, remember to follow me, there is much more on the way! And as always, I leave my thanks to @steemstem and @air-clinic for their constant support to all scientific content; you inspire us to keep improving.