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.
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