Psych Consult

Mr. A is a 40-year old male. After checking in his items with the clerk, and obtaining a full evaluation from the ER doc, the psychiatrist and students begin the interview.

Mr. A: You have to check me into the psychiatric unit. Otherwise, I'm going to hurt somebody! And I'm going to kill myself!

Student: Mr. A., Which do you plan to do first, hurt someone else or kill yourself? [Yes, I know it's a weird question, but we use it to assess the viability of the plan. Some patients take the bait].

Mr. A: Hurt someone else first!

Student: Who do want to hurt?

Mr. A: Anyone who pisses me off! I was already going to hurt at least 5 people today, before I checked in.

Student: How do you plan to harm someone else?

Mr. A.: I'm gonna stab them with a fork!

[After full assessment]

Physician: Mr. A, we're going to admit you into the psychiatric unit of the hospital... students can you please bring over Mr. A's belongings?

Student: Clerk, can you tell us which one's Mr. A's locker?

Clerk: Yeah, it's over here. But he only brought one item with him. I think it was a fork.

Narrative Medicine

Ms. Smith is a Caucasian 68-year-old morbidly obese (400+ pounds) woman being treated for congestive heart failure. She takes short, labored breaths, and has symmetrical pitting edema in her legs.

Ms. Smith cannot get up to move herself to sit on the bedside commode, so the petite Chinese nurse leaves to request additional help. As the nurse exits the room, Ms. Smith turns to me and says, "She can't do this by herself? What are they paying her for?"

Ms. Smith's father was an abusive alcohol addict. Ms. Smith divorced her husband about 30 years ago, after she discovered that he had cheated on her, the first clue being the gyn's diagnosis of chlamydia and gonorrhea. She had had a hysterectomy at age 28, due to a prolapsed uterus, following birth of twins. When she announced her intentions to divorce her husband, he said, "I wasn't going to stay with you, anyway. I wanted more kids, and you can't have any." Ms. Smith's ex-husband recently died of a stroke, following surgery for prostate cancer. Ms. Smith says "I am glad that G-d let me see him in such pain in my lifetime, the bastard deserved it."

Ms. Smith never leaves her house, but a kind neighbor drops off some groceries about twice a month. She has no relationship with her children or grandchildren, for reasons she did not specify. She has no plans to improve her life (her one pleasure is "spraying her sheets with perfume," which reminds her of the way her mom smelled, and provides an "aromatherapy" feeling). However, she does faithfully take her 13 medications every day.

I asked Ms. Smith what she had to lose by sending her grandkids Christmas or birthday cards. If she didn't have a relationship with them, the worst thing that can happen is that the situation remains the same. Ms. Smith, bitter during most of the conversation,lightened up during my blunt challenge. "Yes. That is true. What do I have to lose?" Then her smile faded. "I just don't think I'd be able to deal with the rejection."

In many ways, I'm privileged to work in a hospital; For better or worse, I get to witness and learn from other people's life mistakes. This is a woman who spends the overwhelming majority of her day watching TV in her bed. It would seem to an objective observer that a genuine attempt to live in any different way ought to be wholeheartedly embraced. Ms. B is not afraid of death ("I'm just waiting for God to take me, when he wants to take me"), but is utterly panicked about sending a Christmas card.

When I see situations like this, I realize just how irrational it is to be nervous about contacting an old friend or putting up an inarticulate blog post or do anything else, for which I might be judged. I see the ultimate futility of caring too much about what other people think.

I suggested an alternative for Ms. Smith- perhaps she can keep journals, which her granchildren could one day read. Ms. Smith started to ramble excitedly, "Yes. It could by my legacy to them. Something for them to know me by...It won't get my voice inflections...but I could still give them advice..make sure they don't make the same mistakes. I can tell them to always stay celibate. That is the only way to stay safe."
I've recently read about "Narrative Medicine," a movement pioneered by Rita Charon, in which patients, even (especially?) those in palliative care, write and reflect about their illnesses. To me, the narrative medicine is particularly seductive, as it provides opportunities for doctors to inculcate values in which they're often criticized for being remiss- empathy, consideration of the "whole" patient, and integration of other fields- all without sacrificing a commitment to evidence-based medicine.

The evidents suggests that narrative medicine may help mitigate pain, or even increase survivorship and longevity. Promoting science-based medicine is not in conflict with recognizing the bio-social-psychological model of medicine, nor realizing that the effects of, say, loneliness can discernible physiological consequences.

I had no major suggestions that were acceptable for Ms. Smith, on how she could perhaps improve her life (Therapy? No Nutrition Counseling? No). She will likely remain alone for the rest of her life. However, she might punctuate her TV-viewing with journal keeping. So, maybe I've my part to ensure Ms. Smith's lasting legacy.
I wonder when I'll start recommending to all the lonely seniors that they ought to start blogs.

My First Drug Addicted Patient

This post is about a (likely dual-diagnosis) patient whom I visited last year. As usual, many details have been changed.

When I first saw Ms. Smith, she was sleeping quietly in her dark area behind the curtain, her two legs in casts raised on a tuft of pillows. When I called her name, she awoke and, with a sweet Southern drawl, agreed to talk to me.

Immediately, pandemonium struck. Ms. Smith desperately needed to urinate, and demanded her bedpan right away. I rushed to put on gloves, and handed her the bedpan that was under her bed. However, the bedpan had apparently not been washed after the last time it was used, and Ms. Smith screamed that she did not want it on her clean bed. I nervously washed it with soap and water at the sink, and, in the nick of time, tossed it to Ms. Smith. This was the first of many narrowly averted crises.

During the bedpan incident, I noticed Ms. Smith’s extensive injuries. She had what must have been over 100 stitches lined up along her spine. She moved her individually bundled legs with great difficulty, and was constantly clutched what she called her “busted” rib. She also had cuts and old scars on her chin and scalp, which she later explained matter-of-factly with “my ex-boyfriend was kind of bad.” When I proceeded to ask Ms. Smith about the source of her injuries, a second crisis commenced. Ms. Smith suddenly felt extremely hot, and demanded that the air conditioner be raised. Other patients in the room felt cold, however, so I looked to the nurse to make a verdict. Eventually, a compromise was reached.

Throughout the interview, these interruptions continued. Ms. Smith was clearly in terrible pain, and constantly buzzed for the nurse to administer more pain medication. When the nurse continuously refused, Ms. Smith pleaded and sobbed that the last doses did not go through when she hit the button on the drug delivery machine (I do not believe that Ms. Smith was intentionally misleading- she thought that the machine would beep when the drugs were delivered, until the nurse explained that that is not necessarily the case). Ms. Smith called her nurse so often that eventually she was summarily ignored. This proved to be problematic when Ms. Smith had legitimate concerns.

Ms. Smith had interesting things to say about her 34 years of life, but had trouble staying on point, and every few minutes of conversation were halted by her feelings of pain, or her need to readjust in her bed. While I learned a little about the source of her wounds- apparently it was caused by a (stolen) motor vehicle accident, with her intoxicated boyfriend as the driver - after a while, I realized that I had not broken much ground in my questions, and decided that I would just allow Ms. Smith to talk freely.

Ms. Smith’s chart noted that she had attended college, and her language was relatively sophisticated. However, after about 15 minutes, after I asked her to list all of the injuries she had sustained, Ms. Smith responded, “I’m not usually this religious crazy, but these last few days- by the way, all this is off the record, they can’t publish this-I have learned some things. All of life is based on opposites. Yin.Yang. Keeps the world spinning. Right.Wrong. Good. Bad. You see I could have gone to any university on scholarship, but I went to Southern State University. I wrote a paper about dogs and their origins. My grandfather used to say, “You can lead a horse to water, but you cannot make him drink- but you can put salt in his oats! Get it?” After 10 minutes of rambling, Ms. Smith would become composed and thoughtful, telling me about her childhood.

When I visited again the next day, Ms. Smith seemed to be experiencing some drug withdrawal symptoms, as she was nervously shaking and saying she was cold in the very warm room. After a while, I decided to speak to Ms. Smith principally about her drug use.

This conversation taught me a lot about the power dynamics between drugs, drug users, mental illness, and the physicians who would like for their patients to quit. I once had a certain utopian vision of a prototypical conversation about drugs between a doctor and a patient. The doctor would inquire about how the patient feels about her addiction, and how the substances have changed his life for the worse. The patient would admit that the drugs have hurt him socially, personally, mentally, physically. The patient may never actually quit- he would perhaps rebound after some bouts of trying. But I thought that at least one point was pretty much standard: that the patient would recognize that the drugs were hurting him.

This is why talking to Ms. Smith about this topic was so difficult. Ms. Smith wanted to get back to the drugs when she was out of the hospital. This was not simply because she craved them or because she had poor self-control. Ms. Smith actually believed that the drugs made her life better. When I asked her to reflect upon how the daily use of crack cocaine and ecstasy have changed her life, I thought that maybe she’d find a link between the drugs and her current homelessness, her string of abusive boyfriends, her contraction of Hepatitis B. But Ms. Smith didn’t respond that way. She believed that she never had such good friends as the people she’d met on Skid Row, friends who would tell her where all the good dealers were. She had never been so happy nor had experienced so much fun in her life before she started doing drugs. This really made me ponder- how can you help someone to “get off” drugs if she doesn’t even recognize the harm that the drugs are doing to her? The first step of addiction therapy has to be, at an absolute minimum, a admission and dislike of the addiction. So I just decided to sit and listen, all the while getting schooled on doctors’ limitations to help people.