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.