July was a month of consultation/liaison work, which is sort-of-but-not-exactly "psychiatry for patients who are medically ill". The concept is simple -- something is off in the mental function of patients who are in the hospital for something else, be it medical or surgical. The primary doctors feel like they can't quite diagnose and manage the problem on their own, so they call psychiatry for advice. I go see the patient, think very hard, then provide that advice.
In practice, it's not that simple, because the problem could be anything. In the first week alone, I saw patients who are delirious because neurosurgeons have taken a tennis-ball-sized tumor out of their brain, patients who are depressed in the context of complex life-threatening cancers that put them in the hospital for months, and patients who simply are frustrating for their medical team to deal with. This is one of the reasons I like consultation work -- you never know what you'll find until you walk into the patient's room and sit down. It offers a lot more of a general-psychiatry experience than the chronically mentally ill who tend to be our population on the locked inpatient wards, and I find the change of pace refreshing.
The other really fun part of the job is the way we function as sort of "ambassadors for psychiatry". Fact is, most docs outside the specialty don't quite get what it is we do, or how we do it. When they call us, they're experiencing a problem where they feel out of their league, and we're able to come in and (usually) offer something, even if it's only reassurance that there isn't a serious problem going on. It takes psychiatry from being a bunch of jargon-slinging "fake doctors" to being a specialty with a meaningful role to play, and I like proving that my training is useful. That's particularly important in my own personal situation, given that I'm an engineering-oriented psychiatrist who needs collaborators in other disciplines (especially neurology and neurosurgery) to make my ideas translate to projects and clinical applications. That same first week put me back into contact with a neurosurgical attending who I haven't seen in over a year, but who's directly involved in a couple projects that I needed to know about. It's a rare day for a resident when the clinical cases line up with research interests, and it's made the job particularly satisfying of late.
The third cool piece is that we don't just treat the patients. A huge part of the consult psychiatry job is taking care of doctors' mental health. I don't mean in the sense of "sit down for an hour and talk about your feelings". Instead, unsurprisingly, a "difficult patient" doesn't exist in isolation. The patient might have an angry or help-rejecting or demanding or dependent personality, but they don't become "difficult" until their doctors come into the picture and have trouble coping with that personality. When we get called because of a patient like that, there isn't anything we're going to do for/to the patient themselves. Psychiatric drugs treat major mental disturbances; they don't do jack for personality structure. Psychotherapy helps, but most patients aren't in the hospital for months in order to build therapeutic rapport and do the work, and most inpatient psychiatrists aren't trained therapists anyway. So, we're left to intervene on the doctors and nurses instead.
For a stressed-out medical team, the simple act of validating their feelings helps. A lot of the folks in this business really do have a near-boundless love for humanity, and it deeply disturbs them when they find themselves angry at a patient. There's usually a part of them that feels like a failure for simply not being loving enough or patient enough. It helps them to hear from us us that yes, we agree, there's just something not quite right with their patient, and it's OK to be mad at them. In some patients, we'll even go so far as to mediate communication, if that really seems beneficial. In other patients, their fundamental need is just more time with their doctor, and we can be a pretty reasonable substitute. The beauty of psychiatry is that for us, the one-hour or at least half-hour patient encounter is still possible and expected; we can spend time that others teams can't. And then, in some patients, all we can do is suggest ways for the physicians to act in order to avoid triggering too many tantrums. Even that helps -- we see a lot more personality pathology than anyone else, so even if it's just trial and error, we have a sense of what to try first. We usually don't get the team out of the woods on the first try, but just having a guide instead of wandering blindly seems to make things easier for them. Even if we don't make the patient better in these particular encounters, we still walk away having made someone else's day go a little easier.
Wednesday, August 4, 2010
Sunday, July 11, 2010
The Other Brain Doctors
I'm starting to think that I need to get back to traveling frequently. Not because I'm getting wanderlust, but because that's what makes me want to write. It's a lot easier to decide to write something when you're stuck in an airport with half an hour to kill and not enough brain cycles for real work.
June was more forays into the world of "real doctoring", i.e. neurology. I got a little lucky -- it was a slow month for them, which left me time to actually think and talk to patients as opposed to scurrying around doing paperwork at breakneck pace. As some of you know, I seriously considered neurology as a specialty choice before settling on psychiatry, since they both treat the same organ. This second neurology month only confirmed my choice. It was interesting, I learned a lot, I had a pretty good team, and I got some good cases. That said, it's sort of like a city you enjoy visiting but could never live in. I'm quite happy to be back to shrinking heads.
The reason I like to visit neurology but not live there has to do with the nature of their patients and the overlap between our two disciplines. Part of neurology is dealing with patients who are Really Sick -- strokes, brain tumors, autoimmune diseases that can leave someone temporarily on a ventilator or permanently disabled, seizures that aren't quite controlled by medication, and degenerative diseases like Parkinsons. That's about half their patients. The other half are Really Not Sick. They have headaches. They have pain syndromes. They have odd weakness or paralysis that doesn't fit the anatomic pathways, which implies there's not actually something wrong with the structure of their nervous system. All of these people have what we politely and semi-euphemistically call "functional neurological syndromes".
There are two important things to know about functional syndromes. First, they tend to occur more in people who have chaotic, unfulfilling, or emotionally stressful lives, complicated and not-always-supportive family dynamics, and diagnoses of depression or anxiety. Second, they get worse when the stress gets worse. Imagine yourself for a moment as a neurology resident. The evening is dragging on, but instead of going home, you're paged to the ER for the third time that day, because there's a patient here with headache and she's unwilling to go home. She's had headaches every day for years, but in the context of recent job troubles, they're getting worse, and she feels nauseous and in constant pain. Over the years, she's taken migraine meds, every over-the-counter known, narcotics both oral and IV, and even herbal supplements. She tells you she's in "eleven out of ten" pain, but yet is able to sit there, keep her eyes open, talk on her cell phone when not talking with you, and generally not act like someone who's in truly excruciating pain. The physician response is not universal, but pretty common -- frustration and anger (of the "You think you're stressed? Try doing MY job!" variety), plus a general feeling that this patient is simply exaggerating, failing to Suck It Up And Deal, and a healthy dose of insecurity given that there's no easy way to make her symptoms better.
From one perspective, there really is nothing "medically wrong" with these patients. They don't have any traceable anatomic or chemical problem, nothing that any objective or quantitative measure can diagnose. There's another perspective, and it's the point at which the border between neurology and psychiatry gets fuzzy. Your nervous system consists of many paths and circuits, and they're interlinked in ways that no human can truly understand. Some of those pathways deal with pain. Some deal with emotion. Some deal with motor function. Some appear to spend all their time just keeping the others in line and balanced, and those tend to be up in the "higher" parts of your brain that theoretically separate us from the "lower animals". Ultimately, what's wrong in patients with functional neurological syndromes is exactly what the name says -- their functioning is off. Pain is much more than just nerve endings going from your skin to your spine to your brain. The bits of your brain that perceive physical and emotional pain are right on top of each other, so close that some speculate they might actually be one entity. In these patients, those high-order "executive" circuits that are supposed to be regulating their pain system aren't doing their job. It's no surprise that no modern medication can control their pain -- the systems at the heart of that control are broken!
How does a circuit in the brain, or the connection between two circuits, go haywire? What kinds of life experiences cause the "program" to venture into "diseased" territory? More importantly, what the heck do you do to fix it? All of those questions are squarely in the domain of psychiatry. When we tweak your neurotransmitters with drugs, the goal is to boost up some brain areas and let them reassert control. It's the same with talk therapy, except that we're trying to modify brain activity by pushing in various inputs through the language system. If you can gently nudge the system in just the right way, the patient's natural capacity for self-control can take over, and they can get at least some mastery of their pain (usually not total, especially when you're only seeing them in the hospital, but some).
That's why I like visiting neurology. Functional-syndrome patients drive most neurologists nuts, because they don't have the right tools. I am still far from having a complete psychiatric toolbox, but I've been trained from a perspective that helps me reframe the patient's problem. I've also been trained in the delicate art of being frustrated and annoyed at a patient without showing it too much. (I'm not always good at it, and particularly not outside of work, but at least I've had practice.) Most importantly, there are actually evidence-based therapeutic techniques for working with these patients, and while I'm no expert, I've at least had some exposure to them this year. In the usual case, that means that I at least can be calm about a patient while the rest of the team is developing headaches of their own. In the best case, when I'm lucky enough to have actually used the techniques correctly, I can get the "difficult patient" to agree to leave the hospital, take a particular med, get a follow-up appointment, or do whatever else they've been resisting doing. It only happens about once in a one-month rotation, but when it does, it makes you feel like a magician. Psychiatrists on a neurology service tend to get a little bit of short shrift -- we don't have the detailed physical exam skills or knowledge of anatomy that our colleagues do, and there's sometimes a sense that they consider us mildly mentally defective. (Not actually true, it just feels that way sometimes.) It's nice, once in a while, to be able to do something that makes your colleagues from other specialties jealous.
It'd be nicer if I could actually "fix" some of these patients and make their pain disappear more permanently, but that's a bit more advanced; maybe in another couple years I'll have at least a one-in-ten chance of that.
June was more forays into the world of "real doctoring", i.e. neurology. I got a little lucky -- it was a slow month for them, which left me time to actually think and talk to patients as opposed to scurrying around doing paperwork at breakneck pace. As some of you know, I seriously considered neurology as a specialty choice before settling on psychiatry, since they both treat the same organ. This second neurology month only confirmed my choice. It was interesting, I learned a lot, I had a pretty good team, and I got some good cases. That said, it's sort of like a city you enjoy visiting but could never live in. I'm quite happy to be back to shrinking heads.
The reason I like to visit neurology but not live there has to do with the nature of their patients and the overlap between our two disciplines. Part of neurology is dealing with patients who are Really Sick -- strokes, brain tumors, autoimmune diseases that can leave someone temporarily on a ventilator or permanently disabled, seizures that aren't quite controlled by medication, and degenerative diseases like Parkinsons. That's about half their patients. The other half are Really Not Sick. They have headaches. They have pain syndromes. They have odd weakness or paralysis that doesn't fit the anatomic pathways, which implies there's not actually something wrong with the structure of their nervous system. All of these people have what we politely and semi-euphemistically call "functional neurological syndromes".
There are two important things to know about functional syndromes. First, they tend to occur more in people who have chaotic, unfulfilling, or emotionally stressful lives, complicated and not-always-supportive family dynamics, and diagnoses of depression or anxiety. Second, they get worse when the stress gets worse. Imagine yourself for a moment as a neurology resident. The evening is dragging on, but instead of going home, you're paged to the ER for the third time that day, because there's a patient here with headache and she's unwilling to go home. She's had headaches every day for years, but in the context of recent job troubles, they're getting worse, and she feels nauseous and in constant pain. Over the years, she's taken migraine meds, every over-the-counter known, narcotics both oral and IV, and even herbal supplements. She tells you she's in "eleven out of ten" pain, but yet is able to sit there, keep her eyes open, talk on her cell phone when not talking with you, and generally not act like someone who's in truly excruciating pain. The physician response is not universal, but pretty common -- frustration and anger (of the "You think you're stressed? Try doing MY job!" variety), plus a general feeling that this patient is simply exaggerating, failing to Suck It Up And Deal, and a healthy dose of insecurity given that there's no easy way to make her symptoms better.
From one perspective, there really is nothing "medically wrong" with these patients. They don't have any traceable anatomic or chemical problem, nothing that any objective or quantitative measure can diagnose. There's another perspective, and it's the point at which the border between neurology and psychiatry gets fuzzy. Your nervous system consists of many paths and circuits, and they're interlinked in ways that no human can truly understand. Some of those pathways deal with pain. Some deal with emotion. Some deal with motor function. Some appear to spend all their time just keeping the others in line and balanced, and those tend to be up in the "higher" parts of your brain that theoretically separate us from the "lower animals". Ultimately, what's wrong in patients with functional neurological syndromes is exactly what the name says -- their functioning is off. Pain is much more than just nerve endings going from your skin to your spine to your brain. The bits of your brain that perceive physical and emotional pain are right on top of each other, so close that some speculate they might actually be one entity. In these patients, those high-order "executive" circuits that are supposed to be regulating their pain system aren't doing their job. It's no surprise that no modern medication can control their pain -- the systems at the heart of that control are broken!
How does a circuit in the brain, or the connection between two circuits, go haywire? What kinds of life experiences cause the "program" to venture into "diseased" territory? More importantly, what the heck do you do to fix it? All of those questions are squarely in the domain of psychiatry. When we tweak your neurotransmitters with drugs, the goal is to boost up some brain areas and let them reassert control. It's the same with talk therapy, except that we're trying to modify brain activity by pushing in various inputs through the language system. If you can gently nudge the system in just the right way, the patient's natural capacity for self-control can take over, and they can get at least some mastery of their pain (usually not total, especially when you're only seeing them in the hospital, but some).
That's why I like visiting neurology. Functional-syndrome patients drive most neurologists nuts, because they don't have the right tools. I am still far from having a complete psychiatric toolbox, but I've been trained from a perspective that helps me reframe the patient's problem. I've also been trained in the delicate art of being frustrated and annoyed at a patient without showing it too much. (I'm not always good at it, and particularly not outside of work, but at least I've had practice.) Most importantly, there are actually evidence-based therapeutic techniques for working with these patients, and while I'm no expert, I've at least had some exposure to them this year. In the usual case, that means that I at least can be calm about a patient while the rest of the team is developing headaches of their own. In the best case, when I'm lucky enough to have actually used the techniques correctly, I can get the "difficult patient" to agree to leave the hospital, take a particular med, get a follow-up appointment, or do whatever else they've been resisting doing. It only happens about once in a one-month rotation, but when it does, it makes you feel like a magician. Psychiatrists on a neurology service tend to get a little bit of short shrift -- we don't have the detailed physical exam skills or knowledge of anatomy that our colleagues do, and there's sometimes a sense that they consider us mildly mentally defective. (Not actually true, it just feels that way sometimes.) It's nice, once in a while, to be able to do something that makes your colleagues from other specialties jealous.
It'd be nicer if I could actually "fix" some of these patients and make their pain disappear more permanently, but that's a bit more advanced; maybe in another couple years I'll have at least a one-in-ten chance of that.
Tuesday, June 1, 2010
Strange Thoughts in a Strange Land
One month of pediatric neurology down; three weeks of adult neurology stand between me and passage over the threshold into second year (and more psychiatry, as opposed to all this medical mucking about).
In theory, these final three months of the year represent a diversion from psychiatry into "real medicine". In practice, it gets a little more complicated. Take, for instance, April's stint in the emergency room. Our ER has two rooms that are set aside specifically for patients who come in with a primarily psychiatric problem -- feeling suicidal or anxious, being intoxicated but no so intoxicated that they're at risk of dying, or sometimes just being so unpleasant that they need a locked room to keep them from hurting others. Unlike my time at Harborview, this current hospital doesn't have a psychiatrist on-site 24/7. Instead, there's a social worker trained in emergency psychiatry who does the evals. That creates a workflow issue -- our social workers can solve (well, triage and stabilize, which is all anyone does in an ER) most psychiatric problems, but once you walk through the doors of an ER, good practice says that you ought to get seen by a doctor. The solution is "medical clearance" -- the doc sees the patient quickly to establish that they're physically stable and that their problem is limited to being "crazy", and then signs them over to social work to be fixed and provided with a disposition. Usually, that works pretty well. On one of my last shifts in the ER, things got more complicated.
He's from what would, in other times, have been called the Near East. From what I know of his parents, they're both professionals in their home country, and they nervously sent their son off to study overseas. He's in his later years at UW, and from the accounts of his friends, he was doing pretty well -- until a few months ago. Something changed. He'd always been odd, but he seemed more paranoid to them. He started to talk about people who were stalking him, strangers outside his window at night. They were calling to him, making him come outside, and he felt compelled to obey. Sometimes he felt as though his friends were being mind-controlled, fed messages to manipulate him. He began to spend more and more time in his room, locking out everyone except his roommate. He began to speak less and less, eventually conversing almost entirely in his native language. Then, even that stopped, and by the time I saw him, he couldn't even write his name or tell me the date.
Across oceans and timezones, his parents had stayed in touch via email, Skype, and instant messaging. They noticed that the messages had become stranger -- statements that people were harassing him, drugging him, maybe even beating him. Despite speaking almost no English, they knew that their child was in some kind of danger, and so they came to take him home. With the help of some VERY large-hearted graduate students who happened to study his native language, our young man's friends managed to convey to his parents their concerns. Something is wrong, they said. Those of them who knew a little something about mental health even suggested antipsychotic medication. No, his parents said. He's telling us he's being beaten, being drugged. That's the problem. Someone here has taken our son and done something awful to him. We have to get him back home, where he can be taken care of, where he can know he's safe and loved. Somehow, with much negotiation, it was agreed that he should come to the emergency room for at least a medical evaluation before they tried to get on a plane, and that's the situation I found when I walked in for "simple medical clearance".
What I found was a young man so paralyzed by fear and his own inner demons that he could barely stand to walk through the door of a room. He was terrified to sit down. After twenty minutes of trying, he still had not managed to write more than a single letter on the required form where he could consent to be evaluated and treated. Without that form, technically I shouldn't even have been talking to him, since it wasn't authorized. In practice, after a few minutes, it became clear that he was barely able to process what was happening around him, let alone the complex legalese of a consent form. Slowly, through rounds of amateur interpreters and a great deal of coaxing, we made his parents understand that they would have to be the consenting parties, since their son lacked capacity to express decisions concerning his care. And then, with that formality out of the way, we began a long process of waiting.
When you present with this level of disturbed behavior, our first priority is to try to prove that it's not, in fact, psychiatric. We test your nervous system with physical exam maneuvers, draw your blood, and run you through a CT scanner looking for brain tumors. If you won't cooperate, we ask the nice large men from Security to help us restrain you first. All well and good -- but when I've got nervous parents and an even more nervous kid, as well as a gaggle of translators and concerned dormmates milling around an increasingly-crowded corner of the ER, the last thing I want them to see is their loved one being forcibly restrained. And so, over the course of about four hours, we ate the apple by nano-bites. A single low-dose sedative pill, swallowed after literally half an hour of his parents standing there repeatedly telling him to just put it in his mouth. Then, after that had time to take effect, his father and mother gently holding his arms to keep him seated while a nurse ever so slowly drew some blood. I still don't know what they did to get him onto the gurney or to get him to hold still for the CT scan, especially because we had to put in an IV and inject contrast dye (to make any tumors or other weird diseases light up as we checked out his brain).
There are very few times when I actually wish for someone to have a serious medical condition, but this is one of them. If you've ever taken or read even introductory psychology, you'll have recognized the description of the first episode of schizophrenia. Many people with schizophrenia do in fact lead normal, happy, and productive lives, but A Beautiful Mind it ain't. It's not a diagnosis I feel comfortable trying to explain to parents across a language barrier when they're scared, far from home, and trying to figure out how they could get their son onto a plane if he can't even be reliably asked to sit down. Ultimately, I never had the chance -- the end of my shift came before he even hit the scanner, I had another appointment booked just an hour later, and away I went.
The scan, as you might guess, came back negative. So did all the bloodwork. I still don't know how, but a more senior psychiatry resident managed to get through that explanation, and somehow he convinced this young man not to leave the hospital. He signed in to the same voluntary unit where I worked last summer -- and lasted about a week. They did manage to start him on medication, but the ongoing lack of a formal medical interpreter meant that his treating physicians were never able to really establish contact or rapport with our patient's family. The last note in his chart says his parents were taking him out of the hospital to board a plane to his native land; I will be a little surprised if he ends up returning to our neck of the woods after everything they've experienced.
The case sticks in my mind because first-year residents rarely get to see the first presentation. Most of our patients have years of diagnosis, multiple medications, and often at least one suicide attempt under their belt. It's kind of refreshing to see someone so early in his course, when all our tools are untried and still have the potential to work. Of course, it also means that we get to see the unraveling caused by the slow decline of function, and we see everything that's just been lost. Refreshing still, but also a reminder of why these illnesses are just as lethal as cancer.
The classic teaching with schizophrenia is that if you're young, have good family support, have a "good brain" beforehand, and have it come on quickly, your long-term prognosis is better than average. I'm sure hoping he follows the statistics.
In theory, these final three months of the year represent a diversion from psychiatry into "real medicine". In practice, it gets a little more complicated. Take, for instance, April's stint in the emergency room. Our ER has two rooms that are set aside specifically for patients who come in with a primarily psychiatric problem -- feeling suicidal or anxious, being intoxicated but no so intoxicated that they're at risk of dying, or sometimes just being so unpleasant that they need a locked room to keep them from hurting others. Unlike my time at Harborview, this current hospital doesn't have a psychiatrist on-site 24/7. Instead, there's a social worker trained in emergency psychiatry who does the evals. That creates a workflow issue -- our social workers can solve (well, triage and stabilize, which is all anyone does in an ER) most psychiatric problems, but once you walk through the doors of an ER, good practice says that you ought to get seen by a doctor. The solution is "medical clearance" -- the doc sees the patient quickly to establish that they're physically stable and that their problem is limited to being "crazy", and then signs them over to social work to be fixed and provided with a disposition. Usually, that works pretty well. On one of my last shifts in the ER, things got more complicated.
He's from what would, in other times, have been called the Near East. From what I know of his parents, they're both professionals in their home country, and they nervously sent their son off to study overseas. He's in his later years at UW, and from the accounts of his friends, he was doing pretty well -- until a few months ago. Something changed. He'd always been odd, but he seemed more paranoid to them. He started to talk about people who were stalking him, strangers outside his window at night. They were calling to him, making him come outside, and he felt compelled to obey. Sometimes he felt as though his friends were being mind-controlled, fed messages to manipulate him. He began to spend more and more time in his room, locking out everyone except his roommate. He began to speak less and less, eventually conversing almost entirely in his native language. Then, even that stopped, and by the time I saw him, he couldn't even write his name or tell me the date.
Across oceans and timezones, his parents had stayed in touch via email, Skype, and instant messaging. They noticed that the messages had become stranger -- statements that people were harassing him, drugging him, maybe even beating him. Despite speaking almost no English, they knew that their child was in some kind of danger, and so they came to take him home. With the help of some VERY large-hearted graduate students who happened to study his native language, our young man's friends managed to convey to his parents their concerns. Something is wrong, they said. Those of them who knew a little something about mental health even suggested antipsychotic medication. No, his parents said. He's telling us he's being beaten, being drugged. That's the problem. Someone here has taken our son and done something awful to him. We have to get him back home, where he can be taken care of, where he can know he's safe and loved. Somehow, with much negotiation, it was agreed that he should come to the emergency room for at least a medical evaluation before they tried to get on a plane, and that's the situation I found when I walked in for "simple medical clearance".
What I found was a young man so paralyzed by fear and his own inner demons that he could barely stand to walk through the door of a room. He was terrified to sit down. After twenty minutes of trying, he still had not managed to write more than a single letter on the required form where he could consent to be evaluated and treated. Without that form, technically I shouldn't even have been talking to him, since it wasn't authorized. In practice, after a few minutes, it became clear that he was barely able to process what was happening around him, let alone the complex legalese of a consent form. Slowly, through rounds of amateur interpreters and a great deal of coaxing, we made his parents understand that they would have to be the consenting parties, since their son lacked capacity to express decisions concerning his care. And then, with that formality out of the way, we began a long process of waiting.
When you present with this level of disturbed behavior, our first priority is to try to prove that it's not, in fact, psychiatric. We test your nervous system with physical exam maneuvers, draw your blood, and run you through a CT scanner looking for brain tumors. If you won't cooperate, we ask the nice large men from Security to help us restrain you first. All well and good -- but when I've got nervous parents and an even more nervous kid, as well as a gaggle of translators and concerned dormmates milling around an increasingly-crowded corner of the ER, the last thing I want them to see is their loved one being forcibly restrained. And so, over the course of about four hours, we ate the apple by nano-bites. A single low-dose sedative pill, swallowed after literally half an hour of his parents standing there repeatedly telling him to just put it in his mouth. Then, after that had time to take effect, his father and mother gently holding his arms to keep him seated while a nurse ever so slowly drew some blood. I still don't know what they did to get him onto the gurney or to get him to hold still for the CT scan, especially because we had to put in an IV and inject contrast dye (to make any tumors or other weird diseases light up as we checked out his brain).
There are very few times when I actually wish for someone to have a serious medical condition, but this is one of them. If you've ever taken or read even introductory psychology, you'll have recognized the description of the first episode of schizophrenia. Many people with schizophrenia do in fact lead normal, happy, and productive lives, but A Beautiful Mind it ain't. It's not a diagnosis I feel comfortable trying to explain to parents across a language barrier when they're scared, far from home, and trying to figure out how they could get their son onto a plane if he can't even be reliably asked to sit down. Ultimately, I never had the chance -- the end of my shift came before he even hit the scanner, I had another appointment booked just an hour later, and away I went.
The scan, as you might guess, came back negative. So did all the bloodwork. I still don't know how, but a more senior psychiatry resident managed to get through that explanation, and somehow he convinced this young man not to leave the hospital. He signed in to the same voluntary unit where I worked last summer -- and lasted about a week. They did manage to start him on medication, but the ongoing lack of a formal medical interpreter meant that his treating physicians were never able to really establish contact or rapport with our patient's family. The last note in his chart says his parents were taking him out of the hospital to board a plane to his native land; I will be a little surprised if he ends up returning to our neck of the woods after everything they've experienced.
The case sticks in my mind because first-year residents rarely get to see the first presentation. Most of our patients have years of diagnosis, multiple medications, and often at least one suicide attempt under their belt. It's kind of refreshing to see someone so early in his course, when all our tools are untried and still have the potential to work. Of course, it also means that we get to see the unraveling caused by the slow decline of function, and we see everything that's just been lost. Refreshing still, but also a reminder of why these illnesses are just as lethal as cancer.
The classic teaching with schizophrenia is that if you're young, have good family support, have a "good brain" beforehand, and have it come on quickly, your long-term prognosis is better than average. I'm sure hoping he follows the statistics.
Tuesday, April 13, 2010
Sometimes Crazy Can Be Sane (Part 2)
(Posting delayed because of major developments in the case; see end.)
It turns out that the answer to "what do you do with a situation like this?" is "cheat!" Specifically, defer decisions as much as possible to the next day when hospital administrators, lawyers, experienced consult attendings, and so on, are available. The patient himself did us a favor -- he let himself be admitted for pain control and monitoring, thus sparing me the problem of figuring out how to make a case for commitment. Thankfully, he also didn't crash during the night. If he had, we'd have been in trouble. I wasn't on, but had I been, I'd have probably recommended resuscitation despite his do-not-resuscitate paperwork. A patient can always die another day, but if you decide you were wrong in withholding care, you can't bring them back to life. Now, that probably would have gotten the hospital sued for battery, but I still think it would've been right.
The ensuing days were a flurry of ethical and legal consultation, both internally and with the county evaluators who determine whether we're allowed to hold someone for involuntary treatment. Ultimately, they decided that he could and should be held -- not because we could diagnose major depression or any other form of known mental disorder, but because he had an "emotional disorder". In essence, wanting to kill yourself is per se evidence that you are crazy. (The availability of "not otherwise specified" diagnoses, such as "Depression NOS" instead of "major depressive disorder", helps.) Exploration of that ethical concept, particularly in a state with a Death With Dignity act, is beyond the scope of this blog, and also beyond the scope of this author's sophistication.
So, he spent some time on the inpatient psychiatric unit. Specifically, he spent three business days, which is the duration of a legal hold. During that, he talked with yet more psychiatrists (in total, this guy saw something like ten to fifteen shrinks and mid-level psychiatric practitioners within a single week) and of course, didn't change his underlying personality structure or life philosophy one iota. He did get his hearing aids. They didn't help much. Mainly, being as his brain is functioning just fine, he learned the basic rule: if you say you're going to kill yourself, they lock you up. When you say you're not going to kill yourself, they have to let you go. His 72 hours expired, he told the judge "heck, no, I'm going to give living a try", and home he went -- right back to the same favorite armchair in which he shot himself just a week earlier.
I visited him a couple times while he stayed with us, hoping that maybe I could make a bit of a connection, not as a doctor but as a human being. He claimed to his other docs that it worked and that he was glad to know someone else cared about him that much. I remain skeptical. About a week and a half after he'd left us, I tried to give him a call at home, and got his daughter. (Unsurprisingly, with that hearing, he doesn't use the phone much.) While I did find out that he was alive and in relatively good spirits (good), he was also working to try to talk his primary MD into prescribing medication for physician-assisted suicide (not so good).
Half of me feels like I just didn't try hard enough. The other half points out that a 90-year-old man on blood thinners is going to die soon enough of something; within 3 years if the Social Security tables are accurate. He knows what he considers quality of life, and he knows he's not getting it. I never could decide whether I have any right to interfere with that thinking or with its eventual outcome. In the meantime, I've added the Seattle Times obituaries to my usual set of browser tabs. He's going to show up there eventually; the only question is whether it's in a month or in a year.
The Sequel:
The above was written roughly early March. Since then, I'd corresponded once or twice with his daughter via email; never with the patient himself, although I did drop him a snail-mail note when he spent two weeks in assisted living (daughter was taking a trip to China). Came back undeliverable, but eventually forwarded to his home. It wasn't much, and I still don't know whether it's more annoyance than help, but it felt necessary.
Yesterday, as I was getting ready for bed, I got another email from his daughter, informing me that he'd passed away earlier that week. She didn't say, but the subtext suggests that it might have been hastened a bit. Rationally, I think this is the right outcome based on his values, but I still can't help but feel a bit sad.
It turns out that the answer to "what do you do with a situation like this?" is "cheat!" Specifically, defer decisions as much as possible to the next day when hospital administrators, lawyers, experienced consult attendings, and so on, are available. The patient himself did us a favor -- he let himself be admitted for pain control and monitoring, thus sparing me the problem of figuring out how to make a case for commitment. Thankfully, he also didn't crash during the night. If he had, we'd have been in trouble. I wasn't on, but had I been, I'd have probably recommended resuscitation despite his do-not-resuscitate paperwork. A patient can always die another day, but if you decide you were wrong in withholding care, you can't bring them back to life. Now, that probably would have gotten the hospital sued for battery, but I still think it would've been right.
The ensuing days were a flurry of ethical and legal consultation, both internally and with the county evaluators who determine whether we're allowed to hold someone for involuntary treatment. Ultimately, they decided that he could and should be held -- not because we could diagnose major depression or any other form of known mental disorder, but because he had an "emotional disorder". In essence, wanting to kill yourself is per se evidence that you are crazy. (The availability of "not otherwise specified" diagnoses, such as "Depression NOS" instead of "major depressive disorder", helps.) Exploration of that ethical concept, particularly in a state with a Death With Dignity act, is beyond the scope of this blog, and also beyond the scope of this author's sophistication.
So, he spent some time on the inpatient psychiatric unit. Specifically, he spent three business days, which is the duration of a legal hold. During that, he talked with yet more psychiatrists (in total, this guy saw something like ten to fifteen shrinks and mid-level psychiatric practitioners within a single week) and of course, didn't change his underlying personality structure or life philosophy one iota. He did get his hearing aids. They didn't help much. Mainly, being as his brain is functioning just fine, he learned the basic rule: if you say you're going to kill yourself, they lock you up. When you say you're not going to kill yourself, they have to let you go. His 72 hours expired, he told the judge "heck, no, I'm going to give living a try", and home he went -- right back to the same favorite armchair in which he shot himself just a week earlier.
I visited him a couple times while he stayed with us, hoping that maybe I could make a bit of a connection, not as a doctor but as a human being. He claimed to his other docs that it worked and that he was glad to know someone else cared about him that much. I remain skeptical. About a week and a half after he'd left us, I tried to give him a call at home, and got his daughter. (Unsurprisingly, with that hearing, he doesn't use the phone much.) While I did find out that he was alive and in relatively good spirits (good), he was also working to try to talk his primary MD into prescribing medication for physician-assisted suicide (not so good).
Half of me feels like I just didn't try hard enough. The other half points out that a 90-year-old man on blood thinners is going to die soon enough of something; within 3 years if the Social Security tables are accurate. He knows what he considers quality of life, and he knows he's not getting it. I never could decide whether I have any right to interfere with that thinking or with its eventual outcome. In the meantime, I've added the Seattle Times obituaries to my usual set of browser tabs. He's going to show up there eventually; the only question is whether it's in a month or in a year.
The Sequel:
The above was written roughly early March. Since then, I'd corresponded once or twice with his daughter via email; never with the patient himself, although I did drop him a snail-mail note when he spent two weeks in assisted living (daughter was taking a trip to China). Came back undeliverable, but eventually forwarded to his home. It wasn't much, and I still don't know whether it's more annoyance than help, but it felt necessary.
Yesterday, as I was getting ready for bed, I got another email from his daughter, informing me that he'd passed away earlier that week. She didn't say, but the subtext suggests that it might have been hastened a bit. Rationally, I think this is the right outcome based on his values, but I still can't help but feel a bit sad.
Friday, April 2, 2010
Sometimes Crazy Can Be Sane (Part 1)
Admittedly, I'm only an intern, and I don't do my serious consultation psychiatry rotations until next year, but this is certainly the most interesting consult I've seen in my life thus far. To set the scene, I'd agreed to take a second call on a weekend (normally we only have one call night per week) in order to be off on a future weekend with my wife. It was 4 PM, on a shift that ends at 8. I'd seen multiple consults, hadn't actually written my notes, and was trying to get the med student out the door when the pager (ah, the pager) rang. It was the attending down in the psychiatric ER, who has to deal with things on her own on the day shift when the resident's scurrying around the hospital doing consultations. She had for me what she described as "an interesting and educational consult":
Step one when doing such consultations (after regaining one's composure and being careful not to swear in front of impressionable young students) is to establish the medical picture, so that you can understand whether the patient really gets what's going to happen or not happen to him. The picture, in this case, is that he really did shoot himself thrice with a .22 handgun -- twice in the head and once in the chest. I still do not know what happened; our best theory is that he had old and poorly stored bullets[3]. A .22 is not big, but should be able to do substantial damage from point-blank range. These bullets didn't even crack his skull. The one in his chest put a hole in his lung, but didn't deflate it or otherwise compromise him. He's 90 years old, mostly healthy except for a heart rhythm problem, some orthopedic pain, and now some holes in his body. At that moment, he wasn't fixing to die, but anyone who's worked in trauma knows that someone can go from looking fine to crashing in a very short time.
So off I went, with a new medical student in tow, to see our unbreakable man. What we found was a thin but hale-looking fellow, totally covered in blankets (it's cold in the trauma bay), and totally awake and alert on a gurney. Despite being shot three times, he denied being in pain. He also denied being able to understand us -- he's got miserably bad hearing, and in fact, the only way you can ask questions is to lean down and shout them slowly and clearly into his right ear. Now, a psychiatric interview is meant to be both diagnostic and therapeutic. In the process of the patient providing data, the physician provides reflections and interpretations that are hopefully able to help someone feel better, or at least feel respected and understood. Shouting short phrases into a patient's ear somewhat limits the delicate subtlety of these techniques.
Nevertheless, shout we did. We shouted "Why did you want to kill yourself?", "Are you depressed?", and various other personal questions, and he told us his story. He's a local boy who finished college, then heard a recruiter's pitch and ended up in the Navy on the Pacific side of WW2. (It turns out that the Japanese weren't just trying to bomb tropical atolls, but were quite active in the North Pacific and up into the Aleutian Islands, and both Puget Sound and Alaska were actually considered to be part of the battleground.) He didn't see enough combat to get traumatized, but did see enough to earn himself a long naval career, including time as a junior officer and a whole lot of desk work. When he retired from the service, he took another job in a totally unrelated field, and when he retired from that, he worked as a volunteer for over a decade. Way back at the start of it all, he married a girl he'd known since he was a young man, and they stayed married over 50 years.
That's where the trouble began. A bit over a decade ago, she developed Alzheimer's, and began to dwindle. He traces his thoughts of suicide back to that time, when he realized the prospect of life without the woman he'd loved for more than half his life. He went so far as to propose a joint suicide to her -- they'd go out to the garage, shut the door, run the car, and pass on together. (It's hard to describe how simultaneously romantic and creepy the story is as he tells it.) She decided that wasn't the right path for her, but shortly afterwards died suddenly of "natural causes", leaving him alone. That's when he decided to take the next step and buy the gun. According to him, the only thing that kept him going was his daughter. She was in the area, recently divorced, and he figured he'd move in with her to keep her company. Fast forward 10 years and she's remarrying, in retirement herself, traveling the world, and generally doing quite well. From our patient's perspective, he's no longer needed, he can't work, he can't drive, his friends are all dead, and he's just costing society money. Hence, he spent a few months writing his note and obituary, and on a day he knew she'd be gone, he brought out the gun and attempted to remove himself from the world.
Normally, when someone's got genuine major depression, they show other signs besides feeling worthless and suicidal -- they stop eating, they can't sleep, nothing brings them pleasure anymore, they can't think well enough to even read a book, and so on. He had, at least on the surface, none of that. He can enjoy life -- he just doesn't, because his worldview is totally focused on being a productive breadwinner, not on being someone who just sits back and enjoys extended retirement. His memory's pretty much intact, he actively reads and can discuss philosophy and metaphysics, and he's got tons of interesting history archived there in his brain. From his perspective, the preservation of that history isn't worth the cost of his room and board.
There's a lot of details I'm leaving out in order to keep the veil of privacy over him, but it was clear that if he left the hospital that night, he'd end up trying to take his life again. Not that day, but eventually. His family and other social supports weren't going to stop him, nor could his primary doc. Hence the quandary -- there was a duly executed legal document and an apparently cognitively intact patient seeking to refuse medical care. If he were mentally ill, I'd have the power and the obligation to have him committed for involuntary treatment -- but treatment of what, if I can't fit him into the diagnostic criteria for depression? If he's not mentally ill, and if we let him refuse treatment, is the hospital abetting a suicide? Am I as a psychiatrist becoming complicit in a suicide? Is that ever something that could be allowable under professional ethics codes? Can I bring into the picture the fact that I genuinely like this guy and want to save his life?
Not the sort of questions you want to be trying to answer on a Sunday evening with minimal senior backup available. Ponder it for a bit; in Part 2 I'll tell the tale of what actually happened.
[1] Rat poison in accurately measured pill form. Thins your blood so it doesn't clot. You get put on it when you have a history of forming clots in your blood vessels that would otherwise break loose and swim to inconvenient places like your kidneys, your coronary arteries, your pulmonary arteries, and especially your brain. Relatively minor trauma suddenly becomes an Interesting Experience.
[2] A complex concept that can be oversimplified as"We want to do X and he won't let us. Is he nuts? And if he's nuts, can we just do it to him anyway?"
[3] My preferred explanation is that God wants the dude alive for some reason. The patient is not impressed with this theory.
The medical ED called me. There's a 90-year old gentleman in the trauma bay. He shot himself three times and is still alive and neurologically intact. He's on Coumadin[1]. He's got a DNAR form and is refusing all medical care. They want us to assess him for decision-making capacity[2].
Step one when doing such consultations (after regaining one's composure and being careful not to swear in front of impressionable young students) is to establish the medical picture, so that you can understand whether the patient really gets what's going to happen or not happen to him. The picture, in this case, is that he really did shoot himself thrice with a .22 handgun -- twice in the head and once in the chest. I still do not know what happened; our best theory is that he had old and poorly stored bullets[3]. A .22 is not big, but should be able to do substantial damage from point-blank range. These bullets didn't even crack his skull. The one in his chest put a hole in his lung, but didn't deflate it or otherwise compromise him. He's 90 years old, mostly healthy except for a heart rhythm problem, some orthopedic pain, and now some holes in his body. At that moment, he wasn't fixing to die, but anyone who's worked in trauma knows that someone can go from looking fine to crashing in a very short time.
So off I went, with a new medical student in tow, to see our unbreakable man. What we found was a thin but hale-looking fellow, totally covered in blankets (it's cold in the trauma bay), and totally awake and alert on a gurney. Despite being shot three times, he denied being in pain. He also denied being able to understand us -- he's got miserably bad hearing, and in fact, the only way you can ask questions is to lean down and shout them slowly and clearly into his right ear. Now, a psychiatric interview is meant to be both diagnostic and therapeutic. In the process of the patient providing data, the physician provides reflections and interpretations that are hopefully able to help someone feel better, or at least feel respected and understood. Shouting short phrases into a patient's ear somewhat limits the delicate subtlety of these techniques.
Nevertheless, shout we did. We shouted "Why did you want to kill yourself?", "Are you depressed?", and various other personal questions, and he told us his story. He's a local boy who finished college, then heard a recruiter's pitch and ended up in the Navy on the Pacific side of WW2. (It turns out that the Japanese weren't just trying to bomb tropical atolls, but were quite active in the North Pacific and up into the Aleutian Islands, and both Puget Sound and Alaska were actually considered to be part of the battleground.) He didn't see enough combat to get traumatized, but did see enough to earn himself a long naval career, including time as a junior officer and a whole lot of desk work. When he retired from the service, he took another job in a totally unrelated field, and when he retired from that, he worked as a volunteer for over a decade. Way back at the start of it all, he married a girl he'd known since he was a young man, and they stayed married over 50 years.
That's where the trouble began. A bit over a decade ago, she developed Alzheimer's, and began to dwindle. He traces his thoughts of suicide back to that time, when he realized the prospect of life without the woman he'd loved for more than half his life. He went so far as to propose a joint suicide to her -- they'd go out to the garage, shut the door, run the car, and pass on together. (It's hard to describe how simultaneously romantic and creepy the story is as he tells it.) She decided that wasn't the right path for her, but shortly afterwards died suddenly of "natural causes", leaving him alone. That's when he decided to take the next step and buy the gun. According to him, the only thing that kept him going was his daughter. She was in the area, recently divorced, and he figured he'd move in with her to keep her company. Fast forward 10 years and she's remarrying, in retirement herself, traveling the world, and generally doing quite well. From our patient's perspective, he's no longer needed, he can't work, he can't drive, his friends are all dead, and he's just costing society money. Hence, he spent a few months writing his note and obituary, and on a day he knew she'd be gone, he brought out the gun and attempted to remove himself from the world.
Normally, when someone's got genuine major depression, they show other signs besides feeling worthless and suicidal -- they stop eating, they can't sleep, nothing brings them pleasure anymore, they can't think well enough to even read a book, and so on. He had, at least on the surface, none of that. He can enjoy life -- he just doesn't, because his worldview is totally focused on being a productive breadwinner, not on being someone who just sits back and enjoys extended retirement. His memory's pretty much intact, he actively reads and can discuss philosophy and metaphysics, and he's got tons of interesting history archived there in his brain. From his perspective, the preservation of that history isn't worth the cost of his room and board.
There's a lot of details I'm leaving out in order to keep the veil of privacy over him, but it was clear that if he left the hospital that night, he'd end up trying to take his life again. Not that day, but eventually. His family and other social supports weren't going to stop him, nor could his primary doc. Hence the quandary -- there was a duly executed legal document and an apparently cognitively intact patient seeking to refuse medical care. If he were mentally ill, I'd have the power and the obligation to have him committed for involuntary treatment -- but treatment of what, if I can't fit him into the diagnostic criteria for depression? If he's not mentally ill, and if we let him refuse treatment, is the hospital abetting a suicide? Am I as a psychiatrist becoming complicit in a suicide? Is that ever something that could be allowable under professional ethics codes? Can I bring into the picture the fact that I genuinely like this guy and want to save his life?
Not the sort of questions you want to be trying to answer on a Sunday evening with minimal senior backup available. Ponder it for a bit; in Part 2 I'll tell the tale of what actually happened.
[1] Rat poison in accurately measured pill form. Thins your blood so it doesn't clot. You get put on it when you have a history of forming clots in your blood vessels that would otherwise break loose and swim to inconvenient places like your kidneys, your coronary arteries, your pulmonary arteries, and especially your brain. Relatively minor trauma suddenly becomes an Interesting Experience.
[2] A complex concept that can be oversimplified as"We want to do X and he won't let us. Is he nuts? And if he's nuts, can we just do it to him anyway?"
[3] My preferred explanation is that God wants the dude alive for some reason. The patient is not impressed with this theory.
Sunday, March 21, 2010
The Nutritional Gulag
(Something I wrote in October, about a patient who was mine for a few weeks on psychiatry, another example of both severe psychiatric illness and the dangers of non-portable health insurance. There's a bunch of these in the archives; I'm trying to finish them and get them posted.)
I've never seen her smile. The only expression she's ever shown me is a determined scowl, on the occasions where she's willing to talk to me at all. She has clothes in her room, but dresses only in scrub pants and a hospital shirt. Every muscle is tensed, every word dismissive and angry. The uniform only adds to my sense of speaking to a prisoner, some dissident locked away for daring to speak her mind, determined to do everything she can to resist her captors.
She's with us for what everyone who meets describes as "the worst eating disorder case I've seen in years". When she came to the hospital, she had a body mass index (weight over height squared) of 11. That's a 6-foot-plus woman weighing under 90 lbs. For reference: human "normal" runs anywhere from 19 to 24; I'm a 21.5 if you've seen me lately. When you get down to half the weight your body is supposed to be, your organs stop working. She came in by ambulance, because she'd grown too weak to move from her parents' couch. Her kidneys could no longer regulate the sodium, potassium, phosphorus, magnesium, and other ions of her blood. Her liver cells were one-by-one rupturing and spilling their enzymes into the bloodstream. Her bone marrow was no longer making white blood cells to protect her from infection. As you might imagine, she went straight to the ICU, where she stayed for a month. She had at least one cardiac arrest from malnutrition during her stay. Since she was barely conscious, they had to use "total parenteral nutrition" to keep her alive -- simple nutrients poured directly into her veins. When that finally kicked in and she woke up, she refused to eat. A semi-permanent feeding tube had to be placed through her abdominal wall. It couldn't be placed into her stomach, because she would deliberately throw up the tube feeds. The tip of the tube had to come out in her jejeunum (middle small intestine), from whence it's hard to vomit.
Eventually, with daily forced tube feeds, she got to the point of being able to move again. Everyone agreed she couldn't go home, because she very clearly stated that she was too fat, needed to go on a diet, and that this whole thing was not serious at all. (From her perspective, she'd been in cardiac arrest before, been shocked back, so what's the big deal?) Where to go next? By order of a court which declared her a danger to herself, she went to the locked, high-staff-to-patient-ratio, low-stimulation "psychiatric ICU". My unit. That was back before I even started residency. Except for a brief trial on a less-restrictive unit (didn't work well), she's been there ever since.
This is one smart lady -- high level of formal education at excellent schools, strong evidence of prior creativity when she was working. She believes, in her heart of hearts, that she is medically healthy, and in fact is getting sicker the longer she stays because we're making her fat. The result is that every day is a war. Unless she's threatened with tube feeds, she refuses to order food at all. Unless dietary enforces a menu and we require her to eat the whole tray, she will not order anything with carbs or fat in it. Unless we lock her out of her room for two hours, she will immediately purge after meals. (She still does purge, regardless. Her latest strategy was hoarding towels and milking liquid out of her feeding tube into those towels.) When she is not being semi-force-fed, she walks up and down the unit halls as fast as she can to burn off the extra calories. She refuses all medications, even vitamin supplements, except for the few we're legally permitted to force her to take. (Even those are hard -- how do you do an intramuscular injection in a woman who literally has starved away her muscle tissue?) If she can find a way, she refuses to talk to her treatment team on morning rounds. Three attending psychiatrists and a host of residents have all failed to build any connection, because ultimately, we're her jailors. We fight a daily war with her, and it's a war we can't win. Our attention is split across a ward of sixteen complicated patients. Hers is focused like a laser on a single goal: keep the weight off. In four months, putting over 3000 daily calories into her body, we gained only about ten pounds. If you or I were subjected to that same regimen without purging, we'd have gained about thirty (and that's not counting the antipsychotics, which cause your metabolism to switch to fat-building).
So what do we do? We may be nourishing her physical body, but we're not helping her underlying illness one iota. She's a young woman. We can't keep her locked up in these few thousand square feet for the next few decades. There's occasional talk of her going to Western State Hospital, our last operating public "mental institution". They can't keep her forever either. This isn't the 1950s anymore. For a while, our hope was that she could go to an inpatient eating disorders program, where she could at least be around others with her same illness, and thus maybe get some insight into her own health. Only problem -- there's none of those in Washington. They closed for lack of revenue. Our patient hasn't been able to hold a job in a long time, so she's uninsured and on public assistance. Could the state and county pay for her to go to an out-of-state program? Maybe -- if forms can be filled in triplicate, beans can be counted, budgets can be adjusted, Saturn is in conjunction with Mercury in the house of Libra, and we present someone with a shrubbery. A long line of social workers have pounded on this problem, and the latest answer is "not until 2010".
Three more months. Eight months total, maybe more, as a prisoner of the county hospital. Three more months of having her body invaded on a daily basis. Three more months of nothing to do except pace and do the same jigsaw puzzle over and over again. Three more months of watching people come in who are literally so paralyzed by mental illness that they can no longer speak, and watching those same people leave while you remain. Is it any wonder that all she can feel towards us is rage?
Ultimately, it may not matter. Whether it's three or six or twelve, whether she goes to an eating disorders program or not, someday she'll be back out in the world. Someday, she'll be free. The chances that we'll have really changed her mind are slim. Someday, this woman is going to be on her own, is going to find a quiet little corner, and go back to starving herself until her heart stops again, this time without anyone around to bring her back. Everything she could have been or done is lost because her brain got stuck on the idea that she's too fat, and we've yet to find anything we can do about it. It's one of the more sobering/saddening cases I've seen thus far.
I wrote everything above in October 2009. In late February 2010, it was determined that funding for eating disorders treatment would not be forthcoming. (In the meantime, they'd also given up on the feeding tube, having replaced it a good twenty times after it was pulled out.) She was now minimally medically stable, and transferred to the state hospital. She lasted about two weeks. In that time, she continued to starve, and messed her serum electrolytes so badly that the state hospital had to send her back -- to our institution and the locked psychiatric ER.
Ultimately, she spent something like twelve hours waiting in the locked psychiatric emergency room while attendings and county supervisors and her parents all discussed, argued, and bargained. The attending note from that day is a small novella documenting the process. The final conclusion: everything above sure as heck didn't cure her, so what would be the point of doing more of it? After those twelve hours, she went home with her family. It's been almost a month now; we haven't seen her since. I like to tell myself that's because she's alive and doing marginally OK.
I've never seen her smile. The only expression she's ever shown me is a determined scowl, on the occasions where she's willing to talk to me at all. She has clothes in her room, but dresses only in scrub pants and a hospital shirt. Every muscle is tensed, every word dismissive and angry. The uniform only adds to my sense of speaking to a prisoner, some dissident locked away for daring to speak her mind, determined to do everything she can to resist her captors.
She's with us for what everyone who meets describes as "the worst eating disorder case I've seen in years". When she came to the hospital, she had a body mass index (weight over height squared) of 11. That's a 6-foot-plus woman weighing under 90 lbs. For reference: human "normal" runs anywhere from 19 to 24; I'm a 21.5 if you've seen me lately. When you get down to half the weight your body is supposed to be, your organs stop working. She came in by ambulance, because she'd grown too weak to move from her parents' couch. Her kidneys could no longer regulate the sodium, potassium, phosphorus, magnesium, and other ions of her blood. Her liver cells were one-by-one rupturing and spilling their enzymes into the bloodstream. Her bone marrow was no longer making white blood cells to protect her from infection. As you might imagine, she went straight to the ICU, where she stayed for a month. She had at least one cardiac arrest from malnutrition during her stay. Since she was barely conscious, they had to use "total parenteral nutrition" to keep her alive -- simple nutrients poured directly into her veins. When that finally kicked in and she woke up, she refused to eat. A semi-permanent feeding tube had to be placed through her abdominal wall. It couldn't be placed into her stomach, because she would deliberately throw up the tube feeds. The tip of the tube had to come out in her jejeunum (middle small intestine), from whence it's hard to vomit.
Eventually, with daily forced tube feeds, she got to the point of being able to move again. Everyone agreed she couldn't go home, because she very clearly stated that she was too fat, needed to go on a diet, and that this whole thing was not serious at all. (From her perspective, she'd been in cardiac arrest before, been shocked back, so what's the big deal?) Where to go next? By order of a court which declared her a danger to herself, she went to the locked, high-staff-to-patient-ratio, low-stimulation "psychiatric ICU". My unit. That was back before I even started residency. Except for a brief trial on a less-restrictive unit (didn't work well), she's been there ever since.
This is one smart lady -- high level of formal education at excellent schools, strong evidence of prior creativity when she was working. She believes, in her heart of hearts, that she is medically healthy, and in fact is getting sicker the longer she stays because we're making her fat. The result is that every day is a war. Unless she's threatened with tube feeds, she refuses to order food at all. Unless dietary enforces a menu and we require her to eat the whole tray, she will not order anything with carbs or fat in it. Unless we lock her out of her room for two hours, she will immediately purge after meals. (She still does purge, regardless. Her latest strategy was hoarding towels and milking liquid out of her feeding tube into those towels.) When she is not being semi-force-fed, she walks up and down the unit halls as fast as she can to burn off the extra calories. She refuses all medications, even vitamin supplements, except for the few we're legally permitted to force her to take. (Even those are hard -- how do you do an intramuscular injection in a woman who literally has starved away her muscle tissue?) If she can find a way, she refuses to talk to her treatment team on morning rounds. Three attending psychiatrists and a host of residents have all failed to build any connection, because ultimately, we're her jailors. We fight a daily war with her, and it's a war we can't win. Our attention is split across a ward of sixteen complicated patients. Hers is focused like a laser on a single goal: keep the weight off. In four months, putting over 3000 daily calories into her body, we gained only about ten pounds. If you or I were subjected to that same regimen without purging, we'd have gained about thirty (and that's not counting the antipsychotics, which cause your metabolism to switch to fat-building).
So what do we do? We may be nourishing her physical body, but we're not helping her underlying illness one iota. She's a young woman. We can't keep her locked up in these few thousand square feet for the next few decades. There's occasional talk of her going to Western State Hospital, our last operating public "mental institution". They can't keep her forever either. This isn't the 1950s anymore. For a while, our hope was that she could go to an inpatient eating disorders program, where she could at least be around others with her same illness, and thus maybe get some insight into her own health. Only problem -- there's none of those in Washington. They closed for lack of revenue. Our patient hasn't been able to hold a job in a long time, so she's uninsured and on public assistance. Could the state and county pay for her to go to an out-of-state program? Maybe -- if forms can be filled in triplicate, beans can be counted, budgets can be adjusted, Saturn is in conjunction with Mercury in the house of Libra, and we present someone with a shrubbery. A long line of social workers have pounded on this problem, and the latest answer is "not until 2010".
Three more months. Eight months total, maybe more, as a prisoner of the county hospital. Three more months of having her body invaded on a daily basis. Three more months of nothing to do except pace and do the same jigsaw puzzle over and over again. Three more months of watching people come in who are literally so paralyzed by mental illness that they can no longer speak, and watching those same people leave while you remain. Is it any wonder that all she can feel towards us is rage?
Ultimately, it may not matter. Whether it's three or six or twelve, whether she goes to an eating disorders program or not, someday she'll be back out in the world. Someday, she'll be free. The chances that we'll have really changed her mind are slim. Someday, this woman is going to be on her own, is going to find a quiet little corner, and go back to starving herself until her heart stops again, this time without anyone around to bring her back. Everything she could have been or done is lost because her brain got stuck on the idea that she's too fat, and we've yet to find anything we can do about it. It's one of the more sobering/saddening cases I've seen thus far.
I wrote everything above in October 2009. In late February 2010, it was determined that funding for eating disorders treatment would not be forthcoming. (In the meantime, they'd also given up on the feeding tube, having replaced it a good twenty times after it was pulled out.) She was now minimally medically stable, and transferred to the state hospital. She lasted about two weeks. In that time, she continued to starve, and messed her serum electrolytes so badly that the state hospital had to send her back -- to our institution and the locked psychiatric ER.
Ultimately, she spent something like twelve hours waiting in the locked psychiatric emergency room while attendings and county supervisors and her parents all discussed, argued, and bargained. The attending note from that day is a small novella documenting the process. The final conclusion: everything above sure as heck didn't cure her, so what would be the point of doing more of it? After those twelve hours, she went home with her family. It's been almost a month now; we haven't seen her since. I like to tell myself that's because she's alive and doing marginally OK.
Thursday, January 28, 2010
The Worst Night of Your Life
My past two weeks have been another round of night float, this time at Harborview, our county hospital. It's a very different experience from this summer's time at the main UW hospital, partly because it involves being the covering doc for nearly 60 inpatients (as opposed to 14), but also because Harborview has a dedicated psychiatric emergency room. Most of my night is spent hanging out down there in the PES (that's Psychiatric Emergency Services) and trying to help whomever comes in the door. Early in the rotation, one of my attendings said to me "Remember, anyone who comes in here is probably having the worst night of their entire life." I think a lot about the experience from the patient's point of view. I can imagine it being fairly harrowing.
It's midnight on a weekday. Maybe your long-standing depression is getting the better of you, and you've been sitting alone with a bottle of vodka and contemplating a second bottle full of pills. Maybe you have no home, and you've been wandering the streets of Seattle in the drizzling mist, trying to get your thoughts to quiet down. You're miserable, edgy, and you think you'd be hungry if your stomach weren't tied up in knots. You didn't sleep last night, if you've slept well at all in weeks. Maybe you called 911 or the Crisis Line because you feared what you might do. Maybe a cop stopped you and you figured you'd just scream and maybe punch him -- let him just shoot you and get it over with. Maybe you can't remember exactly what happened, or what day it is, or much of anything, because you're too exhausted to remember what's real and what's just the chaotic whispering of voices from your brain. Somehow, you find yourself being wheeled on a gurney into the hospital.
Your first stop is the regular medical ER, surrounded by coughs, the occasional moan, the rambling pleadings or loud snorings of the severely intoxicated, and a constant rush and beep of doctors, nurses, and aides. You get a cursory once-over (usually, if things aren't too busy -- after all, you're a psych patient, so probably there's nothing wrong with you physically, right?) and then it's off to see the shrinks. They put you back on the gurney, fasten a strap around your waist, and wheel you to an unmarked door on a side hallway. A grey television screen hangs next to it, letting those outside be aware of any lurking menace, ongoing emergency, or potential escapee. A swipe of a badge, the beep and click of a magnetic lock, and you're in. A small grey hallway offers enough room for perhaps two of these gurneys side-by-side and several of them end-to-end. A nurse in light blue scrubs unlocks one of ten identical wooden doors, turns on the lights inside, and escorts you in.
Your room is roughly one step up from a prison cell. The only reliable piece of furniture is the gurney/bed on which you sit. If you ask nicely, you can have a blanket or three. The walls are a uniform grey, unmarred by windows, highlighted only by occasional scuffs, scratches, or missing chunks. A metal speaker, set flush into the wall, is your connection to the locked and glassed-in nurses' station. In the ceiling, a closed-circuit camera transmits your grainy image back to a bank of monitors, watching you for signs of violence or self-harm. Until you're seen by a doctor and cleared, the light stays on, no matter the hour. You couldn't adjust it if you wanted to -- the light switch requires a key.
In the next room, someone is shouting and singing at the top of her lungs, sometimes angry, sometimes happy. Across the hall, you see a pair of tattered sneakers protruding out from under a blanket as some unseen person occasionally tosses and turns. Further down the hall, there are moaning wails. Not screams of pain, not calls for help, simply the helpless keening of an infantile brain trapped in a grown man's body. A tall, thin man with a scraggly brown beard paces the hallway, not speaking, not looking at anything, just staring straight ahead. If you look all the way down the hall, at the far end, you can see a fishbowl-office with reinforced glass windows. People in scrubs and professional clothes sit and talk and type on computers and pick up phones. Are they talking about you? Do they know you're even here? Does anyone even know you're here?
And so, sometimes for hours, you sit alone with your thoughts, in this small grey cell with its faint odor of unwashed humanity. You wonder about calling a friend or at least playing some games on your cell phone, but that, along with all your other personal possessions, is now in an orange "patient belongings" bag behind a locked door. If you ask nicely, and it's not been a busy night, you might be able to get some water, or even a small snack. Need to use the restroom? Wait for the nurse to unlock it, and be prepared to give a urine sample. At some point, sometimes even before anyone comes and talks to you, that same nurse comes back in to ask for some blood for our routine screening labs. A pinch, a few seconds of anxious breath-holding, and then it's back to waiting some more.
Of course, you could also choose not to wait. If you've had a few drinks, or something a bit stronger, you might be feeling a bit aggressive or entitled, and thus you might choose to go up to that office and demand to be seen immediately. Or you might get sick of all these other people making noise, and so you might decide to go into their rooms to tell them to shut the heck up. Or you just can't stand the tension, and decide that you need to get out of this semi-prison right this moment. Or maybe it's as basic as your nicotine craving getting the better of your frayed nerves and telling you that you either get outside and smoke this second, or you're really going off the deep end. None of these ideas turns out particularly well for you. You're doing something perfectly reasonable, and suddenly there's three very large people in bright blue "Public Safety" vests around you. You protest, but are met only with "Sir, you need to go back into your room now." There's a clank of chains, a press of bodies, and suddenly you find your bed chained to the wall, and yourself held to that bed by clever padded Velcro wrist and ankle cuffs. Waiting for hours with minimal creature comforts is unpleasant. Doing the same waiting while restrained is doubly so.
Eventually, five minutes or five hours will pass, and a reasonably nicely-dressed person will walk into your room, plunk down a beige plastic lawn chair, and start asking questions about your journey to what now seems like a lesser circle of Hell. Those questions start to get pretty personal, too. Sexuality? Recent stressors? How far did you go in school? Substances of choice? How often? How much? Where's your family now? How do you manage to keep yourself housed/clothed/fed day-to-day? The actual focus on your current, short-term crisis can actually be pretty minimal; we're more interested in knowing how you got here than where "here" actually is. (Unless we know how you got here, it's a lot harder to get you back out.)
Maybe you pour your heart out and answer everything as completely as you can, eager to just give vent to your troubles. Maybe you've had enough of know-it-alls by now, and you grumble out the minimum necessary to get this guy to go away. The outcome is often similar either way, because unfortunately, psychiatry doesn't have much in the way of quick-fixes. It's an inherently slow specialty. Our medications take two weeks or more to kick in. Psychotherapy takes months. Stabilization of a chronic disease might take a year. Whatever's going on tonight, the end result is that after half an hour to 45 minutes of telling your life story, you're most often told than we can't fix it. Unless you're genuinely about to take your own life or harm another person, there's not much benefit to bringing you in to the hospital.
So, instead, after waiting in the prison cell for who-knows how long, you'll get tossed some scraps of short-term stabilization: the number for a community clinic that does sliding-scale work and could maybe see you in a week or two. A prescription for two weeks of meds. Permission to sleep in our ER until morning (if it's late and we're not full) or a bus ticket and a swift boot in the tail (if it's a normal night and there's someone waiting to use your room). A reminder that you have a case manager, what her number is, and a strong suggestion to call her first thing in the AM. If we have some left, a turkey or tuna fish sandwich.
And that's the end. You call a friend to pick you up, or you make your way on your own with a bus ticket and your own two feet, or if you've a long way to go, we might arrange a cab ride. A nurse hands you back that orange plastic sack with your personal effects, you put your shoes back on, and one of us escorts you back through that ominously-locking door. Assuming you didn't get medications (we very rarely give them out, perhaps one person per night), the only thing we've really given you is hope. You've made it through your darkest hour and are still alive, no matter how ragged. You have one more idea to try when the sun comes up, and you can cling to that little strand of hope that someday, things will be better than they are now. It's a far cry from the sutures, antibiotics, and surgical miracles we'd work on you if you came in with a medical problem, but sometimes a little hope is more powerful than any drug.
It's midnight on a weekday. Maybe your long-standing depression is getting the better of you, and you've been sitting alone with a bottle of vodka and contemplating a second bottle full of pills. Maybe you have no home, and you've been wandering the streets of Seattle in the drizzling mist, trying to get your thoughts to quiet down. You're miserable, edgy, and you think you'd be hungry if your stomach weren't tied up in knots. You didn't sleep last night, if you've slept well at all in weeks. Maybe you called 911 or the Crisis Line because you feared what you might do. Maybe a cop stopped you and you figured you'd just scream and maybe punch him -- let him just shoot you and get it over with. Maybe you can't remember exactly what happened, or what day it is, or much of anything, because you're too exhausted to remember what's real and what's just the chaotic whispering of voices from your brain. Somehow, you find yourself being wheeled on a gurney into the hospital.
Your first stop is the regular medical ER, surrounded by coughs, the occasional moan, the rambling pleadings or loud snorings of the severely intoxicated, and a constant rush and beep of doctors, nurses, and aides. You get a cursory once-over (usually, if things aren't too busy -- after all, you're a psych patient, so probably there's nothing wrong with you physically, right?) and then it's off to see the shrinks. They put you back on the gurney, fasten a strap around your waist, and wheel you to an unmarked door on a side hallway. A grey television screen hangs next to it, letting those outside be aware of any lurking menace, ongoing emergency, or potential escapee. A swipe of a badge, the beep and click of a magnetic lock, and you're in. A small grey hallway offers enough room for perhaps two of these gurneys side-by-side and several of them end-to-end. A nurse in light blue scrubs unlocks one of ten identical wooden doors, turns on the lights inside, and escorts you in.
Your room is roughly one step up from a prison cell. The only reliable piece of furniture is the gurney/bed on which you sit. If you ask nicely, you can have a blanket or three. The walls are a uniform grey, unmarred by windows, highlighted only by occasional scuffs, scratches, or missing chunks. A metal speaker, set flush into the wall, is your connection to the locked and glassed-in nurses' station. In the ceiling, a closed-circuit camera transmits your grainy image back to a bank of monitors, watching you for signs of violence or self-harm. Until you're seen by a doctor and cleared, the light stays on, no matter the hour. You couldn't adjust it if you wanted to -- the light switch requires a key.
In the next room, someone is shouting and singing at the top of her lungs, sometimes angry, sometimes happy. Across the hall, you see a pair of tattered sneakers protruding out from under a blanket as some unseen person occasionally tosses and turns. Further down the hall, there are moaning wails. Not screams of pain, not calls for help, simply the helpless keening of an infantile brain trapped in a grown man's body. A tall, thin man with a scraggly brown beard paces the hallway, not speaking, not looking at anything, just staring straight ahead. If you look all the way down the hall, at the far end, you can see a fishbowl-office with reinforced glass windows. People in scrubs and professional clothes sit and talk and type on computers and pick up phones. Are they talking about you? Do they know you're even here? Does anyone even know you're here?
And so, sometimes for hours, you sit alone with your thoughts, in this small grey cell with its faint odor of unwashed humanity. You wonder about calling a friend or at least playing some games on your cell phone, but that, along with all your other personal possessions, is now in an orange "patient belongings" bag behind a locked door. If you ask nicely, and it's not been a busy night, you might be able to get some water, or even a small snack. Need to use the restroom? Wait for the nurse to unlock it, and be prepared to give a urine sample. At some point, sometimes even before anyone comes and talks to you, that same nurse comes back in to ask for some blood for our routine screening labs. A pinch, a few seconds of anxious breath-holding, and then it's back to waiting some more.
Of course, you could also choose not to wait. If you've had a few drinks, or something a bit stronger, you might be feeling a bit aggressive or entitled, and thus you might choose to go up to that office and demand to be seen immediately. Or you might get sick of all these other people making noise, and so you might decide to go into their rooms to tell them to shut the heck up. Or you just can't stand the tension, and decide that you need to get out of this semi-prison right this moment. Or maybe it's as basic as your nicotine craving getting the better of your frayed nerves and telling you that you either get outside and smoke this second, or you're really going off the deep end. None of these ideas turns out particularly well for you. You're doing something perfectly reasonable, and suddenly there's three very large people in bright blue "Public Safety" vests around you. You protest, but are met only with "Sir, you need to go back into your room now." There's a clank of chains, a press of bodies, and suddenly you find your bed chained to the wall, and yourself held to that bed by clever padded Velcro wrist and ankle cuffs. Waiting for hours with minimal creature comforts is unpleasant. Doing the same waiting while restrained is doubly so.
Eventually, five minutes or five hours will pass, and a reasonably nicely-dressed person will walk into your room, plunk down a beige plastic lawn chair, and start asking questions about your journey to what now seems like a lesser circle of Hell. Those questions start to get pretty personal, too. Sexuality? Recent stressors? How far did you go in school? Substances of choice? How often? How much? Where's your family now? How do you manage to keep yourself housed/clothed/fed day-to-day? The actual focus on your current, short-term crisis can actually be pretty minimal; we're more interested in knowing how you got here than where "here" actually is. (Unless we know how you got here, it's a lot harder to get you back out.)
Maybe you pour your heart out and answer everything as completely as you can, eager to just give vent to your troubles. Maybe you've had enough of know-it-alls by now, and you grumble out the minimum necessary to get this guy to go away. The outcome is often similar either way, because unfortunately, psychiatry doesn't have much in the way of quick-fixes. It's an inherently slow specialty. Our medications take two weeks or more to kick in. Psychotherapy takes months. Stabilization of a chronic disease might take a year. Whatever's going on tonight, the end result is that after half an hour to 45 minutes of telling your life story, you're most often told than we can't fix it. Unless you're genuinely about to take your own life or harm another person, there's not much benefit to bringing you in to the hospital.
So, instead, after waiting in the prison cell for who-knows how long, you'll get tossed some scraps of short-term stabilization: the number for a community clinic that does sliding-scale work and could maybe see you in a week or two. A prescription for two weeks of meds. Permission to sleep in our ER until morning (if it's late and we're not full) or a bus ticket and a swift boot in the tail (if it's a normal night and there's someone waiting to use your room). A reminder that you have a case manager, what her number is, and a strong suggestion to call her first thing in the AM. If we have some left, a turkey or tuna fish sandwich.
And that's the end. You call a friend to pick you up, or you make your way on your own with a bus ticket and your own two feet, or if you've a long way to go, we might arrange a cab ride. A nurse hands you back that orange plastic sack with your personal effects, you put your shoes back on, and one of us escorts you back through that ominously-locking door. Assuming you didn't get medications (we very rarely give them out, perhaps one person per night), the only thing we've really given you is hope. You've made it through your darkest hour and are still alive, no matter how ragged. You have one more idea to try when the sun comes up, and you can cling to that little strand of hope that someday, things will be better than they are now. It's a far cry from the sutures, antibiotics, and surgical miracles we'd work on you if you came in with a medical problem, but sometimes a little hope is more powerful than any drug.
Sunday, December 13, 2009
You May Be Right (We May Be Crazy)
A humanities friend of mine asked a question in response to the last post: if the intern workload produces bad incentives and potentially suboptimal care, not to mention emotional burnout/family trauma/car accidents[1]/general crabbiness, why the heck do we do it? There are certainly plenty of people who want to be doctors, not to mention the number of nurses/physician assistants/other providers who'd love to extend their scope of practice. Why would we set this up so that so much burden falls on the most junior (i.e., least competent) doctor? Are we, in fact, just nuts?
This is a question I work on quite a bit in my organized medicine activities. The answer is tricky. There is some of the problem that's good old-fashioned "I did it, I suffered, now it's your turn" mentality. But, there's also good economic reasons for it, and that's really what keeps it going (in my opinion, anyway). The economics from the hospital's side are simple. The median salary for a nurse practitioner in Seattle (if you believe salary.com) is about $90,000. My pay, as conveniently advertised on the web, is half that. I don't have a union, I don't have to be paid overtime when I work beyond 40 hours, and in general, I do perhaps 1.5 times the work (as measured by hours; productivity would be less) of a free-market NP for half the cost. If I save the hospital perhaps $50K a year, and there's at least 400 residents in the hospital, that's $20 million a year. That's not even counting the extra revenue that the surgical residents can generate because of the extra volume in high-reimbursement procedures.
It isn't just one-way exploitation, though. In theory, it's also designed to benefit me. Between the cap on the number of residents Medicare will pay for, and the general tight-fistedness of the accrediting bodies, the residency system acts as a choke on the physician supply. As you'd guess if we're working almost 80 hours per week, the supply is controlled to a level substantially less than demand, and has been for decades. Econ 101 tells us that high demand and low supply equals an increase in the price of the good. Or, in other words: the residency system creates an artificial scarcity of doctors in almost every specialty, leading to recruitment battles and higher physician salaries [2]. One of the major reasons everybody tolerates this system is that (again, in theory), in exchange for getting hosed while you're a resident, you thereafter get to be permanently employed with a salary in the top 3rd to 5th percentile. It also lets you feel a bit prestigious -- sure, you work hard and maybe it messes up the patients, but think about how much better you are than all the people who applied for your job but didn't make the cut!
The interesting thing is that aside from the twin profit motives above, there's a very anti-profit motive that also props up the system. Somewhere along the way, we acquired the notion that excellence in doctoring is comprised mainly of working harder. In general, many physicians' solutions to the problems facing health care as a whole, or individual patients, is simply to throw more of their own person-hours into the furnace. We're quite proud of it, too. We'll regularly boast about how many extra hours we put in to get the job done for that one particular patient. Whoever self-inflicts the most suffering is somehow ennobled. It's hard for me to say where this mindset comes from; as you can guess from my tone, I don't think it's quite right. You can't build a sustainable health care system on the notion of individual heroism. Yes, it's nice to know you've got the doctor who'll go the extra mile -- but do you still want him when, as almost inevitably happens, he burns out and loses the ability to care altogether? More importantly, who among us hasn't been told approximately a trillion times to "work smarter, not harder"?
And that, in the nutshell, is the real reason why a system persists even though it probably doesn't do anyone (except maybe the hospital management) much good. We could design something better, but to do so goes against the #1 survival skill taught during training: keeping your head down, working harder, and just plowing through. Furthermore, everyone's so focused on the short-term gain they expect to get out of the system that they ignore the broader interest. Unless physicians of all stripes get together and make the teaching system more sensible for doctors and patients alike, we're going to be so busy with nobly working harder that we won't notice while all those traditional prerogatives of the profession (prestige, money, the "right" to be "in charge", even being the only person on the team who's called "Doctor") get carved up and carried away by the many other players in the modern health care enterprise.
We willingly and perhaps even knowingly perpetuate a system that messes up our future colleagues, sets us up for economic problems in coming decades, and doesn't do any better by the patients. We are, in fact, nuts, or at least just really dumb. Unfortunately for me and many others, this turns out to be yet another one of those diseases I can't fix -- at least, not yet.
[1] All of the above are, in fact, documented in the peer-reviewed literature. Yes, car crashes. It's in the New England Journal of Medicine. Brings new meaning to "work yourself to death", no?
[2] Econ 102 goes on to explain that supply-demand curves are ironclad unless a substitute good is available at a lower price. And that NP may be expensive at $90K... but he/she is a lot better than the median psychiatrist salary of $200K. (It's about the same for a hospitalist in general medicine.) So in fact, a rationally-acting hospital or health insurer will not pay physicians what they expect, but will instead substitute cheaper products when possible. The storm coming from that particular collision in expectations is another entry unto itself.
This is a question I work on quite a bit in my organized medicine activities. The answer is tricky. There is some of the problem that's good old-fashioned "I did it, I suffered, now it's your turn" mentality. But, there's also good economic reasons for it, and that's really what keeps it going (in my opinion, anyway). The economics from the hospital's side are simple. The median salary for a nurse practitioner in Seattle (if you believe salary.com) is about $90,000. My pay, as conveniently advertised on the web, is half that. I don't have a union, I don't have to be paid overtime when I work beyond 40 hours, and in general, I do perhaps 1.5 times the work (as measured by hours; productivity would be less) of a free-market NP for half the cost. If I save the hospital perhaps $50K a year, and there's at least 400 residents in the hospital, that's $20 million a year. That's not even counting the extra revenue that the surgical residents can generate because of the extra volume in high-reimbursement procedures.
It isn't just one-way exploitation, though. In theory, it's also designed to benefit me. Between the cap on the number of residents Medicare will pay for, and the general tight-fistedness of the accrediting bodies, the residency system acts as a choke on the physician supply. As you'd guess if we're working almost 80 hours per week, the supply is controlled to a level substantially less than demand, and has been for decades. Econ 101 tells us that high demand and low supply equals an increase in the price of the good. Or, in other words: the residency system creates an artificial scarcity of doctors in almost every specialty, leading to recruitment battles and higher physician salaries [2]. One of the major reasons everybody tolerates this system is that (again, in theory), in exchange for getting hosed while you're a resident, you thereafter get to be permanently employed with a salary in the top 3rd to 5th percentile. It also lets you feel a bit prestigious -- sure, you work hard and maybe it messes up the patients, but think about how much better you are than all the people who applied for your job but didn't make the cut!
The interesting thing is that aside from the twin profit motives above, there's a very anti-profit motive that also props up the system. Somewhere along the way, we acquired the notion that excellence in doctoring is comprised mainly of working harder. In general, many physicians' solutions to the problems facing health care as a whole, or individual patients, is simply to throw more of their own person-hours into the furnace. We're quite proud of it, too. We'll regularly boast about how many extra hours we put in to get the job done for that one particular patient. Whoever self-inflicts the most suffering is somehow ennobled. It's hard for me to say where this mindset comes from; as you can guess from my tone, I don't think it's quite right. You can't build a sustainable health care system on the notion of individual heroism. Yes, it's nice to know you've got the doctor who'll go the extra mile -- but do you still want him when, as almost inevitably happens, he burns out and loses the ability to care altogether? More importantly, who among us hasn't been told approximately a trillion times to "work smarter, not harder"?
And that, in the nutshell, is the real reason why a system persists even though it probably doesn't do anyone (except maybe the hospital management) much good. We could design something better, but to do so goes against the #1 survival skill taught during training: keeping your head down, working harder, and just plowing through. Furthermore, everyone's so focused on the short-term gain they expect to get out of the system that they ignore the broader interest. Unless physicians of all stripes get together and make the teaching system more sensible for doctors and patients alike, we're going to be so busy with nobly working harder that we won't notice while all those traditional prerogatives of the profession (prestige, money, the "right" to be "in charge", even being the only person on the team who's called "Doctor") get carved up and carried away by the many other players in the modern health care enterprise.
We willingly and perhaps even knowingly perpetuate a system that messes up our future colleagues, sets us up for economic problems in coming decades, and doesn't do any better by the patients. We are, in fact, nuts, or at least just really dumb. Unfortunately for me and many others, this turns out to be yet another one of those diseases I can't fix -- at least, not yet.
[1] All of the above are, in fact, documented in the peer-reviewed literature. Yes, car crashes. It's in the New England Journal of Medicine. Brings new meaning to "work yourself to death", no?
[2] Econ 102 goes on to explain that supply-demand curves are ironclad unless a substitute good is available at a lower price. And that NP may be expensive at $90K... but he/she is a lot better than the median psychiatrist salary of $200K. (It's about the same for a hospitalist in general medicine.) So in fact, a rationally-acting hospital or health insurer will not pay physicians what they expect, but will instead substitute cheaper products when possible. The storm coming from that particular collision in expectations is another entry unto itself.
Saturday, December 12, 2009
Three More Weeks...
I've been off in a wilderness called "medicine" for the past two months; all psychiatrists are expected to do four months of general medicine training in our first year. Mine is split as one month of adult inpatient, two months of pediatric inpatient, and one of adult emergency (which everyone loves, because it involves neither call nor morning rounds).
As you might surmise from the months of sudden silence, it's been busy. It's not just the call, though. It's taken me a while to adjust emotionally to a very different environment and a different way of taking care of patients. There is, obviously a lot less talking to your patients, and a lot more talking about them -- presenting them to the attending on rounds, telling consultants about them, talking to their nurses, calling radiology about their x-rays and CT scans, calling social work to arrange discharges, and so on. For someone who went into psych specifically because it's the specialty where you get to spend an hour minimum with every new patient, that's less than desirable.
The bigger issue, and the one that constantly frustrates me, is that medicine wards everywhere are basically set up such that my survival depends on taking bad care of patients. The issue is simple: a medicine intern's patient load is not fixed, as it is on psychiatry. In psych, we have a bed shortage, nationwide. As such, the inpatient units are always full. The workload has been calibrated such that taking care of a full unit will be difficult, but still doable while keeping work/life balance (and attending to all the non-patient-care items that constitute "work", such as conferences, research, reading, teaching, etc.) No so the medical floors. Every intern has a variable census. At Harborview, our adult hospital, you can be responsible for up to ten patients. Roughly speaking, you're required to pick up five more every fifth day when you're on call, plus two more in the middle of the call cycle -- seven additions every five days. You keep caring for them until they leave. The problem is simple -- nobody can take competent care of ten adult medicine patients. The paperwork and diagnostic/treatment load required is beyond a junior doctor's faculties. The actual "happy medium" for learning varies, but mine is somewhere between five and seven. At Seattle Children's, where I am now, it's similar but without the cap -- each call night could be anywhere from three to ten patients, and I've had my service hit thirteen[1]. (Thankfully, at that point the senior residents took mercy and did some redistribution before I died.)
In such a system, all your efforts have to focus on one thing: get the patient out the door as fast as you possibly can. When you're on call, the principle is similar: do the minimum necessary work on each new patient, because a flurry of admissions or a serious crisis on existing patients could happen at any minute. It's a constant race to get ahead of the tide. Personally, I feel that this leads to suboptimal care; maybe not actually "bad", but definitely not the care I'd want my own family to get. How can your doctor truly care for you when all his/her incentives are about minimizing contact, minimizing time, and getting you just stable enough to be hustled out the door? It does function -- most patients don't get readmitted, at least not immediately. It just doesn't provide the quality I'd want from the world's most expensive health care.
Of course, it's not all bad. I'm not going to say it's educational; the actual amount of learning about medicine is minimal. Mostly I learn how to do paperwork and what this particular hospital's protocols are. At best, it's an exposure to ward workflow so I can be more helpful in second year, when my primary role will be consulting psychiatrist for those medically ill patients who also have mental health needs. What it does do is really make you appreciate your free time. I find myself being more efficient in my days/hours off, because I know the clock is about to start again. I also think I will never again complain about psychiatry's less-than-once-per-week call schedule.
The other nice thing is occasionally getting one of those medical patients with psych issues, because for once, I can take care of someone from both angles. The average medical resident tends to be profoundly uncomfortable with someone who's suicidal, or majorly drug-addicted, or psychotic. I'm no expert on any of those, but at this point I've seen them enough to not panic. What I don't yet have is enough experience in the management of the many kinds of toxic overdose, or the infections that result from IV drug use, or the complications of rampant diabetes. Having someone teach me about those while I get to also treat the psychiatric problems is profoundly satisfying, and almost fun. I've daydreamed about trying to find a way to make more of our "medicine" time focus around that scenario, but haven't quite come up with it. It'd require having a kind of dual-attending med-psych service and the underlying administrative structure; a great project for a chief resident to undertake, but not really doable by an intern (at least, not one on medicine months).
In the long run, mostly the past two months have confirmed to me that I picked the right specialty. Some of the patients were interesting, the pediatric ones are cute, and a few have even been grateful. Still, if you told me I was going to spend the rest of my life managing electrolytes and infections, I'd quit and go back to the lab for good. There's only three (ish) more weeks and six more call nights before I get to put off the white coat, mothball the stethoscope, and get back to shrinking heads. It's good to be in the home stretch.
[1] The astute will note a potential upside -- if you are REALLY lucky and get just the right kind of simple admissions a given call night, it is possible to actually discharge everybody before your next call. This has happened to me twice in my three months; it's a magical feeling.
As you might surmise from the months of sudden silence, it's been busy. It's not just the call, though. It's taken me a while to adjust emotionally to a very different environment and a different way of taking care of patients. There is, obviously a lot less talking to your patients, and a lot more talking about them -- presenting them to the attending on rounds, telling consultants about them, talking to their nurses, calling radiology about their x-rays and CT scans, calling social work to arrange discharges, and so on. For someone who went into psych specifically because it's the specialty where you get to spend an hour minimum with every new patient, that's less than desirable.
The bigger issue, and the one that constantly frustrates me, is that medicine wards everywhere are basically set up such that my survival depends on taking bad care of patients. The issue is simple: a medicine intern's patient load is not fixed, as it is on psychiatry. In psych, we have a bed shortage, nationwide. As such, the inpatient units are always full. The workload has been calibrated such that taking care of a full unit will be difficult, but still doable while keeping work/life balance (and attending to all the non-patient-care items that constitute "work", such as conferences, research, reading, teaching, etc.) No so the medical floors. Every intern has a variable census. At Harborview, our adult hospital, you can be responsible for up to ten patients. Roughly speaking, you're required to pick up five more every fifth day when you're on call, plus two more in the middle of the call cycle -- seven additions every five days. You keep caring for them until they leave. The problem is simple -- nobody can take competent care of ten adult medicine patients. The paperwork and diagnostic/treatment load required is beyond a junior doctor's faculties. The actual "happy medium" for learning varies, but mine is somewhere between five and seven. At Seattle Children's, where I am now, it's similar but without the cap -- each call night could be anywhere from three to ten patients, and I've had my service hit thirteen[1]. (Thankfully, at that point the senior residents took mercy and did some redistribution before I died.)
In such a system, all your efforts have to focus on one thing: get the patient out the door as fast as you possibly can. When you're on call, the principle is similar: do the minimum necessary work on each new patient, because a flurry of admissions or a serious crisis on existing patients could happen at any minute. It's a constant race to get ahead of the tide. Personally, I feel that this leads to suboptimal care; maybe not actually "bad", but definitely not the care I'd want my own family to get. How can your doctor truly care for you when all his/her incentives are about minimizing contact, minimizing time, and getting you just stable enough to be hustled out the door? It does function -- most patients don't get readmitted, at least not immediately. It just doesn't provide the quality I'd want from the world's most expensive health care.
Of course, it's not all bad. I'm not going to say it's educational; the actual amount of learning about medicine is minimal. Mostly I learn how to do paperwork and what this particular hospital's protocols are. At best, it's an exposure to ward workflow so I can be more helpful in second year, when my primary role will be consulting psychiatrist for those medically ill patients who also have mental health needs. What it does do is really make you appreciate your free time. I find myself being more efficient in my days/hours off, because I know the clock is about to start again. I also think I will never again complain about psychiatry's less-than-once-per-week call schedule.
The other nice thing is occasionally getting one of those medical patients with psych issues, because for once, I can take care of someone from both angles. The average medical resident tends to be profoundly uncomfortable with someone who's suicidal, or majorly drug-addicted, or psychotic. I'm no expert on any of those, but at this point I've seen them enough to not panic. What I don't yet have is enough experience in the management of the many kinds of toxic overdose, or the infections that result from IV drug use, or the complications of rampant diabetes. Having someone teach me about those while I get to also treat the psychiatric problems is profoundly satisfying, and almost fun. I've daydreamed about trying to find a way to make more of our "medicine" time focus around that scenario, but haven't quite come up with it. It'd require having a kind of dual-attending med-psych service and the underlying administrative structure; a great project for a chief resident to undertake, but not really doable by an intern (at least, not one on medicine months).
In the long run, mostly the past two months have confirmed to me that I picked the right specialty. Some of the patients were interesting, the pediatric ones are cute, and a few have even been grateful. Still, if you told me I was going to spend the rest of my life managing electrolytes and infections, I'd quit and go back to the lab for good. There's only three (ish) more weeks and six more call nights before I get to put off the white coat, mothball the stethoscope, and get back to shrinking heads. It's good to be in the home stretch.
[1] The astute will note a potential upside -- if you are REALLY lucky and get just the right kind of simple admissions a given call night, it is possible to actually discharge everybody before your next call. This has happened to me twice in my three months; it's a magical feeling.
Thursday, October 8, 2009
The Needs of... Who?
The needs of the many outweigh the needs of the few.
-- Spock, stardate 8130.4 (or thereabouts)
One of the biggest unspoken challenges currently facing all of medicine is a simple question: who do we serve? This seems obvious at first glance; we serve the patient. But who is our patient? Do we consider only the person who is in front of us right at this very second? Or should we step back for a second and consider all the other patients currently under our care, or all the teeming millions who might someday need our help? And if we think about them, what obligation do we have to them when we're thinking about what we do for the guy or gal in front of us?
We can argue until we're blue in the face about how much health care should be as a percentage of GDP, or what amount of taxes is fair to ensure universal coverage, or how much any given drug should cost. The answer to any of those doesn't change the general truth that resources are finite. An academic center may have six CT scanners, but it has six, not twelve. When my patient slips and bumps his head at eleven PM, does he or does he not get a CT of his brain? If all I care about is his individual welfare, chances are he gets the CT. The radiation dose poses relatively low risk compared to the potential harm of a bleed in his head, to say nothing of the potential harm to me and my hospital if he had said head bleed and I chose not to look for it[1]. But, let's stop and think for a second about those six scanners. We have a busy emergency department. If my patient is in the scanner when a trauma or a stroke rolls in the door, that's fifteen minutes longer they're waiting for their turn. Fifteen minutes in a stroke is a hell of a lot of potentially dead brain tissue, and that CT scan is critical to determining whether the patient can get clot-busting drugs. Fifteen minutes in a severe abdominal bleed is life versus death, or at the very least a question of several extra days in an ICU. Is this likely to happen from ordering one extra CT scan? Of course not. But an inpatient physician will order thousands of such scans over the course of a career. Roll the dice enough times and you're bound to make a losing roll eventually.
Even when the scan doesn't tie up resources someone else needs, it still uses resources. There's techs, and orderlies, and nurses. Their time gets billed for. IV meds get billed for. Wear and tear on the scanner gets amortized. Somebody's gotta pay. Sometimes it's the patient. More often, it's their insurer, which ultimately means, it's everyone else in their patient pool. That's a penny or less to the other patients, but multiply a penny times the number of patients your insurer covers, and that's Real Money. Either your premium goes up (which stresses you, causes you to cut back in other areas, and generally worsens your health) or your insurer cuts costs elsewhere (which deprives you of a benefit you otherwise might have gotten). This is a serious deal. With one relatively cavalier penstroke, I and every other doctor in this country can start off cascading events that seriously mess up the lives of large numbers of people.
Which brings me back to the question: am I, ethically speaking, required to take that into account? The Declaration of Geneva[2] says "the health of my patient will be my first consideration". The majority of attendings (the ones who aren't themselves relatively fresh from residency) are of the opinion that my patient is My Patient, that it is my moral obligation to provide whatsoever they might need, and to not do so is a breach of fiduciary duty. I, coming from a background in policy, as well as being the sort of annoying person who'll pick other people's soda cans up to throw them in the recycling, lean more towards conserving resources for the people who truly need them. The result is that I am either a very good doctor, or a very bad doctor, depending on your personal values.
This comes up a lot, especially in psychiatry. Psychiatry attendings haven't practiced general internal medicine in years. They thus have a relatively high level of anxiety about medical symptoms evidenced by psychiatric inpatients, and will almost always err on the side of getting a consult, or doing a test, or otherwise intervening. This tends to bother me. On the other hand, I am an intern, so therefore (A) don't know Jack and (B) am not the one whose posterior is on the line. Thus, I tend to shut up and order what is suggested. It causes me a great deal of internal conflict, hence this post.
When we talk about "controlling health care costs", one of the things we're talking about is finding ways of enforcing this idea that the collective good outweighs the marginal benefit that might accrue to any one individual patient. That means cutting back in some way on doctors' autonomy, and it means changing a value so ingrained in medicine that it might as well be one of the Ten Commandments. It also means realizing that the guy in the white coat isn't going to be 100% on your side anymore (if he ever was). It's likely to happen. It might even be inevitable. Still, for most people, that's not a happy proposition.
[1] Some may argue that the liability issue is really the thing driving my decision to scan. They are probably not wrong.
[2] The artist formerly known as the Hippocratic Oath.
-- Spock, stardate 8130.4 (or thereabouts)
One of the biggest unspoken challenges currently facing all of medicine is a simple question: who do we serve? This seems obvious at first glance; we serve the patient. But who is our patient? Do we consider only the person who is in front of us right at this very second? Or should we step back for a second and consider all the other patients currently under our care, or all the teeming millions who might someday need our help? And if we think about them, what obligation do we have to them when we're thinking about what we do for the guy or gal in front of us?
We can argue until we're blue in the face about how much health care should be as a percentage of GDP, or what amount of taxes is fair to ensure universal coverage, or how much any given drug should cost. The answer to any of those doesn't change the general truth that resources are finite. An academic center may have six CT scanners, but it has six, not twelve. When my patient slips and bumps his head at eleven PM, does he or does he not get a CT of his brain? If all I care about is his individual welfare, chances are he gets the CT. The radiation dose poses relatively low risk compared to the potential harm of a bleed in his head, to say nothing of the potential harm to me and my hospital if he had said head bleed and I chose not to look for it[1]. But, let's stop and think for a second about those six scanners. We have a busy emergency department. If my patient is in the scanner when a trauma or a stroke rolls in the door, that's fifteen minutes longer they're waiting for their turn. Fifteen minutes in a stroke is a hell of a lot of potentially dead brain tissue, and that CT scan is critical to determining whether the patient can get clot-busting drugs. Fifteen minutes in a severe abdominal bleed is life versus death, or at the very least a question of several extra days in an ICU. Is this likely to happen from ordering one extra CT scan? Of course not. But an inpatient physician will order thousands of such scans over the course of a career. Roll the dice enough times and you're bound to make a losing roll eventually.
Even when the scan doesn't tie up resources someone else needs, it still uses resources. There's techs, and orderlies, and nurses. Their time gets billed for. IV meds get billed for. Wear and tear on the scanner gets amortized. Somebody's gotta pay. Sometimes it's the patient. More often, it's their insurer, which ultimately means, it's everyone else in their patient pool. That's a penny or less to the other patients, but multiply a penny times the number of patients your insurer covers, and that's Real Money. Either your premium goes up (which stresses you, causes you to cut back in other areas, and generally worsens your health) or your insurer cuts costs elsewhere (which deprives you of a benefit you otherwise might have gotten). This is a serious deal. With one relatively cavalier penstroke, I and every other doctor in this country can start off cascading events that seriously mess up the lives of large numbers of people.
Which brings me back to the question: am I, ethically speaking, required to take that into account? The Declaration of Geneva[2] says "the health of my patient will be my first consideration". The majority of attendings (the ones who aren't themselves relatively fresh from residency) are of the opinion that my patient is My Patient, that it is my moral obligation to provide whatsoever they might need, and to not do so is a breach of fiduciary duty. I, coming from a background in policy, as well as being the sort of annoying person who'll pick other people's soda cans up to throw them in the recycling, lean more towards conserving resources for the people who truly need them. The result is that I am either a very good doctor, or a very bad doctor, depending on your personal values.
This comes up a lot, especially in psychiatry. Psychiatry attendings haven't practiced general internal medicine in years. They thus have a relatively high level of anxiety about medical symptoms evidenced by psychiatric inpatients, and will almost always err on the side of getting a consult, or doing a test, or otherwise intervening. This tends to bother me. On the other hand, I am an intern, so therefore (A) don't know Jack and (B) am not the one whose posterior is on the line. Thus, I tend to shut up and order what is suggested. It causes me a great deal of internal conflict, hence this post.
When we talk about "controlling health care costs", one of the things we're talking about is finding ways of enforcing this idea that the collective good outweighs the marginal benefit that might accrue to any one individual patient. That means cutting back in some way on doctors' autonomy, and it means changing a value so ingrained in medicine that it might as well be one of the Ten Commandments. It also means realizing that the guy in the white coat isn't going to be 100% on your side anymore (if he ever was). It's likely to happen. It might even be inevitable. Still, for most people, that's not a happy proposition.
[1] Some may argue that the liability issue is really the thing driving my decision to scan. They are probably not wrong.
[2] The artist formerly known as the Hippocratic Oath.
Tuesday, October 6, 2009
Mike and the Demon Rum
The recent blogging hiatus is because your humble narrator was off getting married. That is now accomplished. In the calendar year of 2009, I'll have lived for three months in the Third World, moved across country, started a new job, gotten married, and possibly have sold my house (condo). No wonder I feel exhausted. At any rate, I'm committed to getting back in the blogging saddle and putting more ideas into words.
To set today's scene, I'd like you to pretend you're sitting in an emergency room. This is not the bright lights and bustle you see on "ER". A psych emergency center involves small, windowless rooms without furniture, wall fixtures, or much of anything else. You bring in a plastic lawn chair to interview. At the moment, it's about 2 AM, and you're sitting across from a guy we'll call Mike. Mike is here because he's feeling suicidal. He's been here a while; when he came in, he had a blood alcohol of 450, and you've been waiting for him to sober up enough so you can talk. (For reference, at 200 mg/dL, a "normal" person should be staggering, falling-down, blacking-out drunk. At 400, you or I would be comatose and on our way to dead. Mike was walking and talking, albeit incoherently.)
Sometimes Mike is fat, sometimes he's thin. He's usually in his 40s. He often has tattoos. He's always alone. The story has some variations, but in the aggregate, it goes like this: Mike started drinking young. Sometimes his daddy did too. But, at the start, Mike had a job, a wife, usually kids. Eventually, though, he was hitting it harder and harder, and he lost his job. So he went into treatment, finally. That got him sober -- for a few months, tops. Lather, rinse, repeat. After two or three cycles of this, his wife finally left him. He moved around a bit, staying with family and friends, repeatedly trying to get it together. Slowly, inevitably, he burnt out those supports too, and ended up living in his car. When the car stopped running, got stolen, or just plain got lost, he joined the ranks of Seattle's homeless.
Mike has been in every kind of hospital you can imagine. Outpatient chemical dependency treatment. AA. Inpatient treatment, sometimes for months. Sometimes he's even tried aversion therapies, where they forced him to drink while administering a medication that makes it painful to ingest alcohol. In the hospital, he gets clean. He wants to be clean. He really does want to give it a try. But, when he gets released on that final day, he gets nervous. He thinks of all the times he's tried this and it hasn't worked. He thinks of how alone he is now, of everything he's lost. That old, familiar anxiety worries at him, and a few hours later, he's opening that can of beer or that bottle of cheap liquor.
Mike's problem now is that, even though he's on public assistance, the county will only pay for so much inpatient time each year. So, chances of him getting inpatient detox, inpatient alcohol rehab, or even ordinary inpatient psych are pretty slim. Your task now, in the middle of the night, is to figure out what to do with him. He did say he was suicidal -- but according to the notes in the computer, he always gets suicidal when he's been drinking, and wants to live again when he sobers up. There's also the fact that withdrawing from alcohol might kill him. You see, while alcohol might not be as addictive as heroin or crack, it can be far more deadly. Withdrawing from most street drugs is painful, but ultimately just involves feeling like an utter wreck for a week. Withdrawing from alcohol involves tremors and an altered mental state -- the legendary delirium tremens. If your brain is sufficiently dependent on alcohol, we progress to seizures, and then to seizures of the autonomic nervous system that regulates your circulation. Either you get some alcohol in you, you get a sedative that acts on the same receptors, or your wildly-firing brain actually drives your heart to stop beating.
So, in theory, you could just let Mike hang out in the ER for a bit until he decides to leave. He won't seize immediately -- it takes a day or two to get there. If he leaves, he'll drink, which will solve the problem of withdrawal. If you're feeling like he has a good story and you have time to argue on the phone with insurance authorization, maybe you can bring him in. He can get meds to ease withdrawal and taper himself back to sobriety, then get discharged to a halfway house. Of course, if you think you're going to magically break his addiction, you're more delusional than the patients. Alternatively, you can let him go. He'll drink, and eventually he'll be publicly drunk and get arrested. Jail will sober him out and maybe even court-order him back into treatment. That is, assuming he doesn't fall off a wall, or in front of a car, or into the bay. Or drink, get suicidal, and take that final step off the Aurora Avenue Bridge. Options aplenty, but good options are scarce.
Everyone, including Mike, wants him not to drink. The problem is, nobody understands why he does. You or I don't do this. There is something in his neurons, something specifically tuned to alcohol, that pulls him to drink like a magnet. It's not just personal weakness. This is beyond that -- it's a need that's almost as bad as the need to keep breathing. Some of it is certainly inborn. If we caught it early enough, maybe we could have undone the rewiring, kept the brain from learning this deep dependency on the drug. Instead, as Mike kept drinking through his 20s, it burned itself in deeper and deeper. As one after another social support burned out and cut him off, the restoring forces that would pull him back to sobriety disappeared.
There's no moral or easy answer at the end of this story. I don't know what to do with the Mikes who show up at my door. I try to get them referrals, and if they want to come into the hospital, I usually let them. The only thing it really changes is helping me feel like I've done something for a fellow human. It also reminds me why I wanted to be a research psychiatrist as opposed to primarily a clinician -- there's a whole lot of Mike out there, and right now, we're letting them down.
To set today's scene, I'd like you to pretend you're sitting in an emergency room. This is not the bright lights and bustle you see on "ER". A psych emergency center involves small, windowless rooms without furniture, wall fixtures, or much of anything else. You bring in a plastic lawn chair to interview. At the moment, it's about 2 AM, and you're sitting across from a guy we'll call Mike. Mike is here because he's feeling suicidal. He's been here a while; when he came in, he had a blood alcohol of 450, and you've been waiting for him to sober up enough so you can talk. (For reference, at 200 mg/dL, a "normal" person should be staggering, falling-down, blacking-out drunk. At 400, you or I would be comatose and on our way to dead. Mike was walking and talking, albeit incoherently.)
Sometimes Mike is fat, sometimes he's thin. He's usually in his 40s. He often has tattoos. He's always alone. The story has some variations, but in the aggregate, it goes like this: Mike started drinking young. Sometimes his daddy did too. But, at the start, Mike had a job, a wife, usually kids. Eventually, though, he was hitting it harder and harder, and he lost his job. So he went into treatment, finally. That got him sober -- for a few months, tops. Lather, rinse, repeat. After two or three cycles of this, his wife finally left him. He moved around a bit, staying with family and friends, repeatedly trying to get it together. Slowly, inevitably, he burnt out those supports too, and ended up living in his car. When the car stopped running, got stolen, or just plain got lost, he joined the ranks of Seattle's homeless.
Mike has been in every kind of hospital you can imagine. Outpatient chemical dependency treatment. AA. Inpatient treatment, sometimes for months. Sometimes he's even tried aversion therapies, where they forced him to drink while administering a medication that makes it painful to ingest alcohol. In the hospital, he gets clean. He wants to be clean. He really does want to give it a try. But, when he gets released on that final day, he gets nervous. He thinks of all the times he's tried this and it hasn't worked. He thinks of how alone he is now, of everything he's lost. That old, familiar anxiety worries at him, and a few hours later, he's opening that can of beer or that bottle of cheap liquor.
Mike's problem now is that, even though he's on public assistance, the county will only pay for so much inpatient time each year. So, chances of him getting inpatient detox, inpatient alcohol rehab, or even ordinary inpatient psych are pretty slim. Your task now, in the middle of the night, is to figure out what to do with him. He did say he was suicidal -- but according to the notes in the computer, he always gets suicidal when he's been drinking, and wants to live again when he sobers up. There's also the fact that withdrawing from alcohol might kill him. You see, while alcohol might not be as addictive as heroin or crack, it can be far more deadly. Withdrawing from most street drugs is painful, but ultimately just involves feeling like an utter wreck for a week. Withdrawing from alcohol involves tremors and an altered mental state -- the legendary delirium tremens. If your brain is sufficiently dependent on alcohol, we progress to seizures, and then to seizures of the autonomic nervous system that regulates your circulation. Either you get some alcohol in you, you get a sedative that acts on the same receptors, or your wildly-firing brain actually drives your heart to stop beating.
So, in theory, you could just let Mike hang out in the ER for a bit until he decides to leave. He won't seize immediately -- it takes a day or two to get there. If he leaves, he'll drink, which will solve the problem of withdrawal. If you're feeling like he has a good story and you have time to argue on the phone with insurance authorization, maybe you can bring him in. He can get meds to ease withdrawal and taper himself back to sobriety, then get discharged to a halfway house. Of course, if you think you're going to magically break his addiction, you're more delusional than the patients. Alternatively, you can let him go. He'll drink, and eventually he'll be publicly drunk and get arrested. Jail will sober him out and maybe even court-order him back into treatment. That is, assuming he doesn't fall off a wall, or in front of a car, or into the bay. Or drink, get suicidal, and take that final step off the Aurora Avenue Bridge. Options aplenty, but good options are scarce.
Everyone, including Mike, wants him not to drink. The problem is, nobody understands why he does. You or I don't do this. There is something in his neurons, something specifically tuned to alcohol, that pulls him to drink like a magnet. It's not just personal weakness. This is beyond that -- it's a need that's almost as bad as the need to keep breathing. Some of it is certainly inborn. If we caught it early enough, maybe we could have undone the rewiring, kept the brain from learning this deep dependency on the drug. Instead, as Mike kept drinking through his 20s, it burned itself in deeper and deeper. As one after another social support burned out and cut him off, the restoring forces that would pull him back to sobriety disappeared.
There's no moral or easy answer at the end of this story. I don't know what to do with the Mikes who show up at my door. I try to get them referrals, and if they want to come into the hospital, I usually let them. The only thing it really changes is helping me feel like I've done something for a fellow human. It also reminds me why I wanted to be a research psychiatrist as opposed to primarily a clinician -- there's a whole lot of Mike out there, and right now, we're letting them down.
Friday, September 11, 2009
Stranger Than Fiction
Today, my medical student and I had the chance to accompany one of our patients to court for an involuntary commitment hearing. Picture, if you will, a small courtroom, not entirely unlike a TV courtroom without the audience section. The defendant, a rather large woman, has three of her four limbs restrained in a wheelchair. She is carrying several rolled up wall-chart pieces of paper, and is sitting with a blanket over her head. She states that she has fired her public defender and wishes to represent herself. The judge does allow this... for about two minutes, at which point it becomes clear that the patient has no concept of what this trial is about, or about law in general, and thus the public defender is reinstated.
Once the trial re-commences, the patient states that she wishes to speak on her own behalf. This motion is granted. She removes the blanket from her head and proceeds through her series of charts (which are covered with semi-sensical diagrams and random technical phrases), becoming louder and angrier. After running out of charts, she states that "You want to know my evidence? Here's the evidence against you!" With this statement, she proceeds to lift up her hospital gown, spread her legs (to the degree that one can do so while restrained), and, um, manipulate herself. The judge's bench happens to be positioned such that our esteemed jurist has a view pretty much straight down the barrel.
I tell you with the greatest respect and amazement that our judge did not bat an eye or in any way become agitated. She continued the trial, her face perfectly composed, and merely asked whether a blanket was available to cover the patient. A blanket was provided, the trial resumed, and the patient continued to engage in her behavior, but mercifully away from our eyes.
It's not quite a Johnnie Cochran strategy, but it certainly did make an impression. Fortunately for our patient, it made the right impression and she'll be spending a few months on mandatory hospitalization so we can get her back to normal.
Once the trial re-commences, the patient states that she wishes to speak on her own behalf. This motion is granted. She removes the blanket from her head and proceeds through her series of charts (which are covered with semi-sensical diagrams and random technical phrases), becoming louder and angrier. After running out of charts, she states that "You want to know my evidence? Here's the evidence against you!" With this statement, she proceeds to lift up her hospital gown, spread her legs (to the degree that one can do so while restrained), and, um, manipulate herself. The judge's bench happens to be positioned such that our esteemed jurist has a view pretty much straight down the barrel.
I tell you with the greatest respect and amazement that our judge did not bat an eye or in any way become agitated. She continued the trial, her face perfectly composed, and merely asked whether a blanket was available to cover the patient. A blanket was provided, the trial resumed, and the patient continued to engage in her behavior, but mercifully away from our eyes.
It's not quite a Johnnie Cochran strategy, but it certainly did make an impression. Fortunately for our patient, it made the right impression and she'll be spending a few months on mandatory hospitalization so we can get her back to normal.
Sunday, September 6, 2009
One More Jane
I've changed hospitals as part of our rotation, and am now at the county hospital. It's quite different from our voluntary University unit, as you'll hear in a future entry. In the meantime, as the health care debate continues to rage, the story of one patient I saw at the U just before transferring, and what it means for the American health care system.
I'll call her Jane. That's not her original name, obviously. When she was a young girl, Jane was raped/molested by an older male relative. She suffered through it for a while, but ultimately it came out in her late teens, caused a ton of family turmoil, and landed Jane in the hospital while she worked through her trauma. Despite this, she ultimately thrived, graduating from a well-known East Coast university and landing a series of interesting and decently-paid jobs in her field of study (one which turns out to be, in general, hard to find a job in). She overcame a battle with some very unpleasant cancer, despite some permanent functional impairment from the surgery. She even had children, although without a supportive spouse to remain in the picture for her.
Then, one year ago, lightning struck twice and Jane was sexually assaulted again. As she was dealing with that, the recession and political factors combined to eliminate her job. She persevered, looked for work, but ultimately realized she needed to draw on family supports, and came home to Seattle. Without a job or health benefits, she ended up living in friends' homes and sending her children to stay with their grandmother and great-grandmother nearby. She felt anxious and unsettled much of the time, but kept the same brave and cheerful outward face she always had. Tending to her own mental health was not high on the priority list, although she did find a counselor who would work on a sliding-fee scale.
And then, as one might expect with someone who's had a history of trauma and is now facing major life stresses, Jane started to come unglued. She'd always had nightmares about the abuse; they began to get worse. She began to have frequent panic attacks, and avoid even places like the grocery store, for fear that being out around others would trigger her panic. And then, one Friday, as her host family was headed away for a weekend, she began to have thoughts of shooting herself with the gun they kept at home. Jane had the sense of mind to get herself to a hospital and thus get sent to my inpatient unit, where (apparently for the first time) I informed her that she was showing classical symptoms of pretty significant post-traumatic stress disorder.
After about a week of getting started on some medications, participating in our therapy groups, getting some of her chronic medical issues tuned up, and generally getting a break from the world, Jane was doing a lot better. She still had the occasional panic attack, but not as bad, and her nightmares were under control. Most importantly, she'd finally found ways to get her anxiety sufficiently handled that she wasn't thinking of ending her own life. All well and good, but now we had a problem: how could she continue this outside the hospital? We'd chosen the cheapest medications we could, but they were still $100 or more per month. Moreover, she'd need someone to prescribe them for her on an ongoing basis, because hospitals can't really act as long-term management.
And so we turned to that evil bastion of socialism, the government. Specifically, Medicaid and Washington State's General Assistance for the Unemployable program. The only problem: Jane had to be unemployable. Was she, really? It depends on your point of view. The Jane who showed up on my unit that Friday night couldn't handle a grocery store, let alone a demanding work schedule. Disabled by mental illness? You bet. But the Jane who was leaving us was capable of holding down a job -- IF she got ongoing treatment. And thus, we came to the Catch-22 underpinning much of the "safety net" health system -- you can only have health care if you stay sick. Jane's only way to get better... was to make sure she didn't get better, or at least, to convince some physician somewhere that she wasn't getting better. Net result? One intelligent and potentially quite productive lady effectively taken out of the workforce and one more drain on the public purse.
It's pretty easy to see how this could go differently. How there could be a minimum safety-net plan for everyone. How health insurance could belong to the person, instead of keeping us all shackled to particular jobs. There's a lot of people standing up in town halls this summer trying to keep that from happening, because it would somehow make us not be America anymore. If they get their way, we'll continue to be a free country -- where people are free to force themselves to stay as pathetic and helpless as possible, because it's the only way to keep themselves alive. Where productive citizens are forced to declare themselves disabled and go on the dole, because hey, at least it's not socialism. (Which is true -- under socialism, a potentially productive individual would be forced off her duff and back to work.) People will die and suffer, many of them pretty ordinary hard-working folks who used to comprise the "middle class", but at least Jose the illegal Mexican won't get free health care. Well, unless Jose shows up at an emergency room, in which case he'll still get taken care of, because we're ethically and legally required to, and you'll still pay for it, either through taxes or higher insurance premiums.
Around the country, hospitals, and psychiatric units in particular, are full of an army of Janes. Jane won't show up to a town hall or think about writing her Congressman -- she's too busy trying to survive. You, on the other hand, have the time and the means, and there are people making it easy for you. You, or someone you love, are one bad day away from being the next Jane on the list.
I'll call her Jane. That's not her original name, obviously. When she was a young girl, Jane was raped/molested by an older male relative. She suffered through it for a while, but ultimately it came out in her late teens, caused a ton of family turmoil, and landed Jane in the hospital while she worked through her trauma. Despite this, she ultimately thrived, graduating from a well-known East Coast university and landing a series of interesting and decently-paid jobs in her field of study (one which turns out to be, in general, hard to find a job in). She overcame a battle with some very unpleasant cancer, despite some permanent functional impairment from the surgery. She even had children, although without a supportive spouse to remain in the picture for her.
Then, one year ago, lightning struck twice and Jane was sexually assaulted again. As she was dealing with that, the recession and political factors combined to eliminate her job. She persevered, looked for work, but ultimately realized she needed to draw on family supports, and came home to Seattle. Without a job or health benefits, she ended up living in friends' homes and sending her children to stay with their grandmother and great-grandmother nearby. She felt anxious and unsettled much of the time, but kept the same brave and cheerful outward face she always had. Tending to her own mental health was not high on the priority list, although she did find a counselor who would work on a sliding-fee scale.
And then, as one might expect with someone who's had a history of trauma and is now facing major life stresses, Jane started to come unglued. She'd always had nightmares about the abuse; they began to get worse. She began to have frequent panic attacks, and avoid even places like the grocery store, for fear that being out around others would trigger her panic. And then, one Friday, as her host family was headed away for a weekend, she began to have thoughts of shooting herself with the gun they kept at home. Jane had the sense of mind to get herself to a hospital and thus get sent to my inpatient unit, where (apparently for the first time) I informed her that she was showing classical symptoms of pretty significant post-traumatic stress disorder.
After about a week of getting started on some medications, participating in our therapy groups, getting some of her chronic medical issues tuned up, and generally getting a break from the world, Jane was doing a lot better. She still had the occasional panic attack, but not as bad, and her nightmares were under control. Most importantly, she'd finally found ways to get her anxiety sufficiently handled that she wasn't thinking of ending her own life. All well and good, but now we had a problem: how could she continue this outside the hospital? We'd chosen the cheapest medications we could, but they were still $100 or more per month. Moreover, she'd need someone to prescribe them for her on an ongoing basis, because hospitals can't really act as long-term management.
And so we turned to that evil bastion of socialism, the government. Specifically, Medicaid and Washington State's General Assistance for the Unemployable program. The only problem: Jane had to be unemployable. Was she, really? It depends on your point of view. The Jane who showed up on my unit that Friday night couldn't handle a grocery store, let alone a demanding work schedule. Disabled by mental illness? You bet. But the Jane who was leaving us was capable of holding down a job -- IF she got ongoing treatment. And thus, we came to the Catch-22 underpinning much of the "safety net" health system -- you can only have health care if you stay sick. Jane's only way to get better... was to make sure she didn't get better, or at least, to convince some physician somewhere that she wasn't getting better. Net result? One intelligent and potentially quite productive lady effectively taken out of the workforce and one more drain on the public purse.
It's pretty easy to see how this could go differently. How there could be a minimum safety-net plan for everyone. How health insurance could belong to the person, instead of keeping us all shackled to particular jobs. There's a lot of people standing up in town halls this summer trying to keep that from happening, because it would somehow make us not be America anymore. If they get their way, we'll continue to be a free country -- where people are free to force themselves to stay as pathetic and helpless as possible, because it's the only way to keep themselves alive. Where productive citizens are forced to declare themselves disabled and go on the dole, because hey, at least it's not socialism. (Which is true -- under socialism, a potentially productive individual would be forced off her duff and back to work.) People will die and suffer, many of them pretty ordinary hard-working folks who used to comprise the "middle class", but at least Jose the illegal Mexican won't get free health care. Well, unless Jose shows up at an emergency room, in which case he'll still get taken care of, because we're ethically and legally required to, and you'll still pay for it, either through taxes or higher insurance premiums.
Around the country, hospitals, and psychiatric units in particular, are full of an army of Janes. Jane won't show up to a town hall or think about writing her Congressman -- she's too busy trying to survive. You, on the other hand, have the time and the means, and there are people making it easy for you. You, or someone you love, are one bad day away from being the next Jane on the list.
Thursday, August 6, 2009
Night Float
Tonight's my last night (for a couple months) of "night float", a lovely invention that reduces everyone's call stress. Basically, for the past two weeks, I've not had to come in during the day. Instead, starting at 6pm and going till 8am, I carry the pager. Anything that happens in the hospital that needs urgent psychiatric attention, it's my job. The really fun part of this -- no attending or senior resident in-house. Just me and a back-up attending available by telephone. Three nights a week, I've got a med student. And, at least at this hospital, it's home call. If something happens, I get my rear into the hospital; if nothing happens (as it blissfully has twice this week), I get to sleep in my own bed and mostly deal with requests for Tylenol over the phone. This is extremely conducive to wedding planning.
I'm still deciding why exactly I like this so much. One aspect is certainly the reduced amount of overall work -- I don't work the full 14 hours, and I do a LOT less paperwork because I'm not responsible for daily charting. Another is the fun of emergency diagnosis and treatment, a totally different beast from regular psychiatry. Regular psych is a longitudinal process of building relationships and slowly changing behavior. This is one of quick evaluations, decisionmaking with limited data, and planning in the moment of acute crisis. The decisionmaking in particular is nice -- as with regular emergency medicine, I actually get to try to diagnose, instead of treating something that someone else already figured out. The third, as noted above, is the autonomy. It's the only time when I am, for real and genuine, the Doctor In Charge. There's of course an expectation that I'll seek second opinion for any dicey judgment calls, but for 99% of stuff, I'm free to use my own judgment about what meds to give, how to manage the patient, and what not to do. I also get to experience the consequences of my own mistakes, e.g. getting called back into the hospital last night at 5:30 AM (after going to bed at about 12:30 AM) because I didn't realize a particular patient might be a fall risk. Experience is an excellent teacher.
And, of course, night is when all the absolutely ridiculous stuff happens, the stuff that becomes an intern's standard happy-hour conversation. In particular, at night I'm responsible for urgent consults. The past two weeks are two of the stranger consults I've ever done, even counting some odd ones as a med student:
One of the many many things I love about psychiatry -- it NEVER gets boring. There may be a small set of diagnoses, but they present in a whole lot of different ways.
[1] You may ask how it is possible to swallow razor blades without getting the [bleep] cut out of one's tongue and oral apparatus. I don't know. Nobody I've asked knows. But it is, because this is definitely not the first patient I've met who does this.
[2] "Nil per os" = "Nothing by mouth". A very unpleasant state to be in for a few hours. For a few days? You'd be ready to punch someone.
I'm still deciding why exactly I like this so much. One aspect is certainly the reduced amount of overall work -- I don't work the full 14 hours, and I do a LOT less paperwork because I'm not responsible for daily charting. Another is the fun of emergency diagnosis and treatment, a totally different beast from regular psychiatry. Regular psych is a longitudinal process of building relationships and slowly changing behavior. This is one of quick evaluations, decisionmaking with limited data, and planning in the moment of acute crisis. The decisionmaking in particular is nice -- as with regular emergency medicine, I actually get to try to diagnose, instead of treating something that someone else already figured out. The third, as noted above, is the autonomy. It's the only time when I am, for real and genuine, the Doctor In Charge. There's of course an expectation that I'll seek second opinion for any dicey judgment calls, but for 99% of stuff, I'm free to use my own judgment about what meds to give, how to manage the patient, and what not to do. I also get to experience the consequences of my own mistakes, e.g. getting called back into the hospital last night at 5:30 AM (after going to bed at about 12:30 AM) because I didn't realize a particular patient might be a fall risk. Experience is an excellent teacher.
And, of course, night is when all the absolutely ridiculous stuff happens, the stuff that becomes an intern's standard happy-hour conversation. In particular, at night I'm responsible for urgent consults. The past two weeks are two of the stranger consults I've ever done, even counting some odd ones as a med student:
- I get called by the surgery patient to request a consult -- on a patient who's not in the hospital any more. You see, the patient in question has a habit of swallowing things when he gets upset, and particularly of swallowing dangerous things. Like, in this case, three razor blades[1]. The surgeons decided to wait and see if he pooped them out -- and in the mean time, kept him NPO[2] for days. They meant to call psych to see him, but never quite got around to it. And then, the patient left the hospital, because he was sick of his team. Eventually, he realized his stomach hurt and came back to get pain meds, and I did see him, after midnight (He wasn't thrilled about that either.) The ostensible reason was "Well, he's crazy, does he have the mental capacity to leave the hospital?" The answer was "He's not so much crazy as just a pain in the butt, and the patient himself says so. Yes, he has mental capacity. Sorry, you're stuck with having to be nice to him." (The official declaration of "not crazy" is a common reason for psych consultation, actually.)
- Called to see patient in ED for suicidality. Turns out patient is deaf. And can't sign very well, plus no sign interpreter available. And can't read lips. And also is refusing to write any answers to anyone's questions. And, according to the deaf staff workers at patient's current housing, is suspected of not actually being deaf. And just moved to Seattle with no ID or anything, having apparently lost all of the above during multiple sexual assaults in another state. And is terrified of men. The diagnostic interview was... limited. To a single written statement of "I refuse to answer this question". Diagnosis: everything in the book. Plan: Keep on suicide watch until she feels like "talking", and refer for involuntary mental health commitment as presumed suicidal/grossly disabled until/unless she does "talk".
One of the many many things I love about psychiatry -- it NEVER gets boring. There may be a small set of diagnoses, but they present in a whole lot of different ways.
[1] You may ask how it is possible to swallow razor blades without getting the [bleep] cut out of one's tongue and oral apparatus. I don't know. Nobody I've asked knows. But it is, because this is definitely not the first patient I've met who does this.
[2] "Nil per os" = "Nothing by mouth". A very unpleasant state to be in for a few hours. For a few days? You'd be ready to punch someone.
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