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.
Friday, September 11, 2009
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.
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