Surprise and Delight

 

I recently had a surprise when biting down on some soft, supposedly non threatening morsel of food.

A tooth cracked. A major tooth. You know, one of those that you’d like to keep around in your head for a few more years. Sort of like a wonderful idea.

So I grab my phone and call my dentist, who has always been more than responsive in situations like this. My anticipation about how this whole scenario would go?

I would call. They would be booked for weeks if not months. (He’s a very good dentist. The most fantastic dentist with a HUGE practice. Believe me.) They would get me in on a standby basis, sort of like when I fly now. I would get a seat in his office, be surprised at how much leg room I actually had, but then there was always the negative, right? They would poke me with a needle, make my face droop and cause me to repeatedly bite my lip for six hours after the appointment, and charge me an arm and a leg. So much for the need for leg room, since I would be short a leg from then on.

Nothing is guaranteed in life. Yes, you may quote me on that as long as you give the proper attribution. Don’t you pull a Melania on me…

Well, the first surprise came right away. They could rearrange their schedule for me and get me in that afternoon. Like right away. Very little waiting with a cracked tooth in my head. This was great news. Not entirely unexpected, since my dentist is the GREATEST dentist EVER, the most FANTASTIC dentist, I can assure you.

So, you know how this goes. I already knew that since the entire cusp of the tooth had broken off ( I was holding it in the hand attached to the arm that I would NOT  let them take in payment for this procedure, my right arm, which I needed, of course, since I am right-handed.) that I would most likely need a crown. It’s good to be king, after all, isn’t it? That would mean that this first appointment would be for evaluation and measurements and all that jazz, and that I would most likely have to come back at least two more times to get the whole thing fixed and back to semi-normal. (#sad) This, you see, was not my first dental rodeo. I had ridden this pneumatic chair named Foo Man Choo and stayed on for, well, maybe three hours before.

So, to recap (you see what I did there), broken tooth, FANTASTIC response from my dentist’s office, semi-emergent appointment on the same day as my call, anticipated amputations of at least one arm and one leg in payment for what would most likely be a beautiful porcelain tooth that no one would ever see but that would allow me to eat almonds again. (#ilovealmonds). My expectations were fairly mainstream and clear.

Now, I get to the office and I am told (GASP) that they have further arranged the dentist’s schedule (did I mention to you how truly FANTASTIC this guy is? Truly great, the best dentist ever, believe me, the absolute best.) so that they will be able to do the entire repair of my cuspless molar in one appointment.

Excuse me?

One appointment? Like same day service on a flat tire? Like a one hour photo store back when people knew what real photos were? How can this be? What parallel dental universe am I operating in here? By the way, the answer is 42.

How could they do this?

#TECHNOLOGY

New technology. COOL technology.

Now, some of you may already be aware of the existence of this new machine that my dentist and his assistants used to patch me up like the Six Million Dollar Man. I was not, but when it was wheeled in and I was allowed to watch in real-time as the assistant called for volunteers from the audience (Pick me! Pick me! She did.) and then did a real time mapping of the contours of my mouth and teeth, and then made a crown from that measurement and fired it up and hardened it and fitted it in my mouth and had me out the door in about two hours TOTAL? OMG, I could not believe it.

I was surprised and delighted and hopped about on my one leg, dancing and waving my remaining right arm and feeling like I was the happiest one-armed, one-legged man in the whole wide world.

Well, I exaggerate. They only had to take the arm. They left the leg. That is good, because after that appointment I could, once again,walk and chew gum at the same time.

How often in today’s world are we truly surprised and delighted?

Can you remember the last time someone, some store, some government agency (wait, wait, scratch that-I lost my head for a moment there) surprised you by going above and beyond what was expected of them?

Can you remember the last time you were truly delighted, amazed, or made speechless by the sheer joy that accompanies a product, service, or personal contact that surpasses your wildest dreams?

How can you, how can I, surprise and delight someone today? How can we foster that feeling in someone by doing something unexpected, saying something truly and sincerely uplifting, or giving of ourselves in ways that no one (including us) ever thought we could?

Go out and surprise and delight someone today.

If you do, that someone might even be you.

Us versus Them: A False Dichotomy?

My friend Jordan Grumet MD wrote a piece in his blog on January 20, 2017 entitled “Us and Them”. In it, he described how a coworker had been diagnosed with a deadly brain tumor, a glioblastoma multiforme, which is normally thought to be a  “uniformly fatal brain cancer”. When he and other residents learned of her diagnosis, “that day in the ER, she ceased being one of us, and became one of them. The sick people.”

Although Jordan and I usually see eye-to-eye on most things, in his case I must disagree.

Doctors are a pretty tight group. We stick together most of the time, no matter the issues, and we have each other’s back. We never really expect to get sick, much less contract a potentially fatal illness ourselves, but of course being human just like our patients, we do. I believe that when a doctor gets sick, he or she is still very much one of us, just ill and in need of help.

Much like when a doctor gets addicted to pain killers or drinks too much and becomes impaired, he is still a doctor, still one of us, although a demonstrably flawed member of our group who may face sanctions due to his ongoing behavior. He does not suddenly become an alcoholic or an addict only, but is simply a doctor with an addiction problem.

I think that using the false dichotomy of Us and Them, or Us versus Them in the current politicalspeak, is not helpful or accurate.

We should not, as professionals, distance ourselves from trouble or heartache by putting patients in the “them/sick people” box. It insulates us from the pain, that is indeed true. It also takes away our ability to be more real, present and human with our patients. Even if, especially if, the patient is one of us.

If I am sick, I still want to be treated as a person who also happens to be a doctor. I am well-trained in some aspects of medicine, but my training may be all together inadequate to face my own illness without the help of my doctors, who also may happen to be my peer group and perhaps even my friends.

I would never want to be involuntarily removed from my peer group due to circumstances beyond my control.

Too Big for My Glitches

He was a small but very intelligent and articulate young man. I had seen him before, but it had been quite a while. He came to me complaining (as did his family) that he was having some trouble controlling his anger, dealing with quarrelsome students at school, and not always getting his assignments inside or outside of school completed in a timely manner.

We discussed the usual ways to approach this, I asked him about his goals that he wanted to work on with his counselor and we established that he was not in need of any medication from me.

When I asked for triggers for his troublesome times, like the  times that his assignments went missing in action, he told me that he had the most trouble right after someone made him angry or slighted him in some way.

“I call those times my glitches,” he stated matter-of-factly.

Glitches.

We all have them, don’t we? I know I do.

When I have been up for too many nights until too late, have been working too hard, or have neglected to exercise or eat right, I am prone to be glitchy.

How do my glitches show up?

I am (more) forgetful. I might forget a name, which doesn’t mean much for me since I did NOT inherit the gene that allowed my father to remember someone’s name, the number of children they had and what all their shoe sizes were, twenty years after he first met them. I might let an important piece of an assignment slide, then remember it the next day. I might think about something I need to do, but then forget to put it on my master to do list.

I get fearful. I worry about things that I have no control over, that might not even concern me, or that I have no business fretting over in the first place. If my guard is down, and my worrying is up, look out glitches!

When I am overwhelmed emotionally, look for a glitch or two to be in the mix. I wrote previously about a week when “I had all the feels”. That kind of week, with its stresses good and bad, its changes big and small, and its uncertainly about the future, is a glitch magnet.

If I have too many tasks on my plate, too many projects to finish easily, or too many interactions that will be stressful for me, I tend to not pay close enough attention to the things that are important.

If I say yes too often, even knowing that I have no more time or energy to possibly do what I just told Mr. Jones I would be happy to do, glitches are coming.

Yes, my friends, sometimes I am just too big for my glitches.

How about you? Are there times that you forget, don’t complete something or that you are not thorough enough?

 

 

No Excuses

I attribute my success to this-I never gave or took any excuse.”

Florence Nightingale

 

I was publically thanked today for doing my job. No, really. By two of my coworkers, actually. It sort of took me aback just a bit.

Over the Christmas holiday a couple of patients, being human like we all are, forgot to get their medications squared away before the clinic was going to be closed for a total of five days running. They panicked, thinking that if they ran out of medications it could come to no good (probably an accurate assessment showing some degree of insight), so they contacted the clinician on call. She, doing her job, texted me, asking if I would consider calling in the medications for these folks.

I was in Atlanta, probably in my bathrobe or at best a pair of shorts and a t-shirt, but reach me she did, and respond I did in kind.

It took a little finagling (it was Christmastime, after all), but the scripts were duly called in, the clinician relayed that to the patients and everyone was free to go forth and celebrate.

This was no onerous task. It was no superhuman feat. It was good care provided when asked for, best practice response, and the kind of support that builds trust not only between team members but between providers and patients as well. Why would I not respond exactly like this, every time the scenario occurred? Nowadays, I try to do just that. A few short years ago, that might not have happened. Why? Come back in time just a few years with me and let’s take a look.

In the days of yore, the old paradigm saw us working pretty standard 8:30 AM to 5:00 PM clinic days, with a half hour to an hour off for lunch. We were on site then, everyone knew that everyone who worked there was in the building,  and it was not really very hard to find people.

There were phones on site, but they were the most basic back then, having two lines, maybe three if you were lucky. It was not uncommon in those days to have to wait for all the little lights to go off so that you knew you had a line open to make a call. There was no voicemail. There were pads of various sizes of yellow sticky notes that were used to leave messages everywhere, from doors to desktops to coffee cup handles.

Communication in the office was largely word of mouth. In other words, if you wanted to speak with someone, you actually had to (gasp) go find them and talk to them! Oh, you could also write a letter or a formal memo that had to go through the office courier to get to the party you sought.

The key thing was, the hours were 8:30 to 5, and that was when most of the work got done. If you did not reach your party and state your case and get your business done within those hours, chances are nothing was going to happen before 8:30 the next morning.  When quitting time rolled around,  most folks headed out toward home, and they did NOT want to be found or hassled or hounded before they came back to the office the next business day.

As you might imagine, this lead to frequent missed contacts, unfinished business, lost sticky notes, and poor outcomes sometimes.

Flash forward to 2017. The new paradigm. Meet the new boss, same as the old boss, but with a few technological and logistical enhancements.

We now have much more flexible business hours, with some folks working until seven or eight at night, and many jobs requiring weekend hours. It is hard to define “after hours” now, especially if you work two very different  jobs like I do, one of which involves shifts of six to thirteen hours and can last until one in the morning.

Our phones are now internet based, meaning that I can have a physical phone on each of my four desks in three separate offices, but all I have to do is sign in with my number and a passcode and all my previously programmed information and my voicemails follow me wherever I am, with little work on my part.

I have had an iPhone since 2007, and my life lives on and in that little pocket computer. All of my contacts, my to do list, my calendar, my schedules all live on that phone. It is with me from the time I wake up until I lie down to sleep at night.

For that reason, voicemails are now ridiculously easy to leave, in multiple places if necessary.

I now have Skype for business open on my computer desktop all day long, so I have yet another way to communicate in real time with my coworkers. I can send a message in real time and chat with someone, instead of sending an email and waiting perhaps all day for a response.

Word of mouth and actual productive conversations are still necessary and effective, but one must be more proactive to make them happen now. Memos and physical letters among coworkers hardly exist anymore.

We are living an “always on, always connected” life in 2017. I am almost always accessible, but it quickly becomes apparent that if I do not decide on what the appropriate limits are for that availability, it will most assuredly be abused. Limit setting is key.

So, the bottom line is, in this day and age, to say that I never got the message from my coworker about the patients who needed medications called in, or that I had not checked my voicemail one single time during the Christmas holiday would simply not fly.

If I put myself out there as available and willing to respond, then I must make good on that promise, build trust that I will do what I say I will do, and allow my patients and coworkers alike to benefit from the trust that builds over time.

In 2017, there is simply no good excuse to do otherwise.

 

Why Do We All Want to Die?

I use an ongoing spreadsheet to keep track of and to report my demographics and stats for each telepsychiatry consult shift I do.  I’ve done thousands of consults in over two dozen South Carolina emergency departments over the last half-dozen years. We have now gone over thirty thousand consults as a group.

It never ceases to amaze me, as I fire up my computer, log on to my systems and bring up that spreadsheet for the shift ahead, that one column is remarkably uniform and consistent, sometimes for days at a time. It is the column that asks for an abbreviated reason for the consultation request. It usually looks like this:

SI

SI

SI

SI

SI

SI

SI stands for suicidal ideation, and that is one of the most common chief psychiatric complaints that we see in the emergency department.

Sometime I am simply so busy trying to see all of these people (there was a multi-day stretch recently that we had up to thirty different consults queued up waiting for one of us to see them) that I cannot afford the luxury of slowing down, looking for trends, trying to analyze why we might be so busy during that particular weekend, and the like. There is just not time. However, it is hard not to see the obvious pattern created by the number of people who come into the EDs and state to a staff member that they want to kill themselves.

Why do we all want to die?

Sure, the world has its ups and downs and stresses, but there seem to be so many people who are bent on their own destruction lately that it is mind-boggling.

Allow me to posit some reasons for this disturbing trend.

We do not feel that we belong.

I heard something on the way to something else the  other day that stated that folks who are forced to check that box called “Other” on standard forms do not feel special when doing so. They actually can be made to feel apart, cast out, cut off from the mainstream, in that they do not fit any of the standard groups listed on such forms. To be “other” is to be different, odd, not a part of the group. It is socially and emotionally ostracizing. It means that we do not belong. That hurts.

We do not feel loved.

Okay, okay, I know that is shrink talk and too touchy feely for some of you, but hear me out. I hears over and over from folks in the ED that they do not feel loved by their parents, their spouse, their children, or anyone else. Once again, whether it is feeling like the “other” or not loved by anyone at all, it is a massive cause of self loathing, isolation and hopelessness that will drive someone towards not wanting to exist at all.

Everything seems too hard these days. Nothing is guaranteed.

It used to be if you went to school, graduated, kept your nose clean and played by the rules, you would almost certainly succeed in life. You would be able to find a job, you would have a place to live, you might find love and even raise a family. Today, it seems that none of this is guaranteed, and that for some it all seems just out of reach. Sometimes, people who appear at first blush to be lazy are just depressed, unmotivated, not well-trained, not educated, and simply down on their luck. They see little hope for success no matter how hard they try, so they don’t try. It is sometimes easier to just give up, find someone or something to blame, and give up, rather than really working to make things better.

We feel hopeless.

Hope keeps us getting up in the morning. Hope keeps us going to school, working our way up the ladder, doing the jobs that no one else wants to do, taking on challenges that we are afraid of. If we lose hope, we have lost our will to challenge ourselves. We have lost our dreams for the future. We have lost our ability to see ourselves in the distance, happy and healthy and successful.

What exacerbates these core states and feelings? What makes it hard to fight back and move past them? What do I see most often in the emergency department when someone has come in after cutting, swallowing a bottle of Tylenol, or drinking themselves into oblivion?

Relationship problems are always in the mix. A teenager breaks up with the love of her life and now thinks that life is over. (She cuts herself on the arms and legs where no one can easily see her attempts to deal with her pain). A middle-aged man is a raging alcoholic but has no insight into how this is devastating his family. His wife leaves him, taking their three small children with her. He comes in with a blood alcohol level five times the legal limit. An elderly man has just lost his wife of sixty years to cancer. He is quite literally lost without her, and he does not want to go on. He is a retired police officer, owns several handguns, and knows how to use them.

Financial problems and reversals can produce high levels of anxiety that seem insurmountable. Some folks are almost paralyzed by just not being able to buy gas for the car or groceries for the kids this week. Others may be more well to do, but the shock of losing value in their retirement portfolios or not being able to make the mortgage payment on a huge house that they really cannot afford leads to guilt and shame and feelings of failure. Both can feel like the easiest way out is to simply not be here any more.

Some patients are dealing with chronic mental or physical conditions that they are simply tired of. The ups and downs of bipolar disorder, the pain of congenital spinal malformations, the physical and emotional trauma of cancer and its treatment can all lead to feelings that it would just be better to end things on your own terms rather than waiting on the  diseases to decide when it is time for you to die.

Perceived failures and disappointments (both disappointing yourself or others) often leads to the mistaken notion that if you kill yourself, the problem goes away for not just you, but everyone involved with you. The thing that most of these folks have not thought about to any degree is the pure devastation that is left in the wake of a suicide. The family members, spouses and friends who must live on after you are gone must ask all the hard questions, the “what ifs”, the whys. The guilt and emotional suffering they feel is tremendous and it never really, truly goes away.

Fear and anxiety drive many suicide attempts. Odd, in that most people think that only those who are severely depressed kill themselves. Anxiety, severe and unrelenting, actually leads more folks to actually successfully complete an attempt than depression. The underlying shame, guilt, or other emotions that drive the anxiety are often not discovered in time, or are so well hidden by the patient that it is only after the successful suicide that these are uncovered and better understood, often from the note or other communication left by the deceased.

What is the common feeling that weaves its way through it all? Hopelessness. If you think that there is no way out, that there are no viable solutions left, that you have exhausted all reasonable possibilities for making your situation better, then that gun or bottle of pills or telephone pole look like rational and logical answers for your unanswerable questions. You give up. You quit looking for answers. You feel lighter, happier, more confident because you have made that decision to just let it all go. If there is no intervention, swift and appropriate, you will die.

What are all these stresses and problems complicated by, as if it could get any worse?

One of the most common accelerants for suicidal ideation and attempts is intoxication with alcohol and other drugs. Decreased inhibitions, poor judgment, impulsivity and poor decision-making all lead to potential problems when one is already contemplating self harm. If you are already stressed, at the end of your rope, and contemplating ending it to escape the anxiety and pain you feel, reach out and get help. Drinking, smoking and popping pills rarely makes things look better.

Poor social support is another major deficit that exacerbates suicidality. I see countless patients who truly do not have family, friends, church or anyone else they can call on in time of need. They are really, truly alone. Isolation and disconnection from other people kills.

Lack of access to care also makes things worse just when the help is needed the most. The shrinking of available mental health resources in this county has lead to a dearth of programs that address acute illness and this does not bode well for someone who needs help now, not three weeks from now or at the next available appointment time.

Concomitant mental and physical illnesses can spell disaster. Those dealing with longstanding cardiac disease, severe diabetes, metastatic cancer, and other devastating illnesses may be overwhelmed with the emotional counterpart of the illness and if not noticed or addressed, it may steadily worsen and become malignant itself.

What to do if you find that you are one of those people who is thinking that death looks like your only option?

Call 1-800-273-TALK.

Talk to your family, your girlfriend, your husband, your minister or priest.

See a psychiatrist or other qualified mental health professional right away. If you are turned away when you call, call somewhere else. Don’t accept anything less than an option for immediate assessment. This is your life in the balance, and it is important.

Suicide kills over forty-four thousand people in the United States every year. For each completed suicide there are twenty-five attempts. On average, there are over one hundred twenty suicides per day in the US.

There are many reasons that many of us really want to die.

The job for the rest of us is to convince those folks on the edge that there is help.

There is treatment.

There is hope.

 

 

Too Ill to Treat

rAn article posted in the Augusta Chronicle newspaper on January 13, 2017 by Bianca Cain Johnson, Staff Writer, has left me no option but to write this blog post today. I would like to quote some parts of the article, then address some of the comments in turn, as they are provocative or distressing to me.

I should say right away that this is my personal mental health musings blog, and that my opinions are my own, in no way reflecting the policies or procedures or opinions of my employer. I should also state that there was very little factual or historical information in this article about this particular case, but for me it just brought up several broad issues of the treatment of mentally ill persons, our approach to violent behavior and other broader issues that I wanted to address.

From the article:

“According to a sheriff’s office incident report, the 31-year-old had been at the hospital for several days, but because of his mental illnesses and history of being violent, the hospital was having trouble finding a mental institution to take him.” (italics mine)

“A doctor re-evaluated him on Tuesday morning and determined he could be released.”

“…the patient stated, “the only way to get attention is to show out”.”

After he had allegedly injured a guard and nursing staff, “the patient was restrained and given medication to calm down, (and) employees heard him comment “this is what I wanted”.

Remember “too big to fail“, as it pertained to banks or motor vehicle manufacturers? Well, in mental health nowadays we run up against admission and placement issues for those patients who are “too ill to treat”. It may be because they have some element of intellectual disability. It may be that they are floridly and actively psychotic. They may be actively suicidal with access to a lethal method and a serious, specific plan. It may be, like the patient in this article, that they have a previous history of violence. For these and other related reasons, what you find is that some facilities among our dwindling number of mental health hospitals now cherry pick the patients that they want to take. If patients are too sick, too acute or too potentially violent towards themselves or others, they are denied admission and treatment, and are often stuck in emergency departments for days or weeks.

Can you imagine the outcry if a patient with chest pain that was too severe was denied admission to a cardiac care unit, or if a patient with a stroke that left him prone to emotional outbursts was denied neurological treatment?

A doctor re-evaluated the patient and made the determination that he was ready to be released. We do not have nearly enough information about that determination to be able to comment on it all, but we can say that we as physicians are notoriously bad at using our (non-existent) crystal balls to predict violent behavior. Of course, there are known risk factors, characteristics, static points of history, and previous episodes of violence that might sway one towards thinking that there was a better than average chance that some violent behavior or acting out was coming, but to be able to predict that with any significant degree of certainty is fraught with problems.

Please see this article on mental illness and violence for more detail about these related issues.

The issue of the patient knowing or learning or figuring out that in a busy emergency department the best way to be heard or to get drugs or to be assessed is to act out is another huge issue. This involves separating out acutely ill patients who act out unwittingly or because of lack of control, versus those persons who know exactly what they are doing and plan to be violent or agitated with a specific goal in mind (to be separated from the general population or to be given injectable medications, for example).

The comments about this article, which I will leave you to read on your own if you wish, were predictable. This issue is politicized, psychiatric patients are called nuts and commenters express nostalgia for the days when they could just be locked up “for a long time”. One commenter stated that the evaluating doctor should have his license pulled immediately. In my opinion, none of these kinds of comments is helpful.

What do I see going on here as a medical director for a mental health center, and even more so as a telepsychiatrist who sees patients in over two dozen South Carolina emergency departments? What did this particular case make me think about?

First of all, we know that deinstitutionalization was a real thing. Hospitals were closed, patients were discharged to their families, to supervised living situations, or to the streets, and the local mental health centers were supposed to pick up the slack and treat them as outpatients, all in the name of streamlining care and saving money. When I started medical school thirty eight years ago and did my very first psychiatric rotations as a junior and senior student, state hospitals, VA hospitals and mental health nursing homes were still very full of patients who were too ill to function well in society. Many were there for long term stays of weeks, months or even years.

Gradually over my career I have seen many inpatient facilities cut back and close beds and finally close their doors entirely. The ones that survive are much smaller, treat patients for much short length of stays, and are run via much more stringent business models than ever before.

Many patients now get their medical care and most of the psychiatric care in an emergency department, not from their own personal doctor. Once admitted there for evaluation, it can sometimes be a very difficult and complicated ballet to assess the patient for his primary illnesses or presenting problems, available resources, need for inpatient versus outpatient treatment, payor sources and requirements, and family involvement. Add to that the hospital administration’s take on treatment, as well as pressure from ED doctors to get patients in and out as rapidly as possible, and it becomes somewhat overwhelming.

In those past years, patients who were truly psychotic or actively suicidal or a danger to others could simply be committed to the state hospital and held there as long as necessary to achieve remission, or as close to it as possible. This is not nearly as easy or smooth a process now as it once was.

As I mentioned above, we do not have crystal balls, but we do have fairly detailed screening procedures for harm to self or others, for example. We can assess, apply evidence based guidelines, offer the best recommendations we can based on these parameters, and decide if a patient must held or can be released. Recommending and treating based on numbers alone, administration goals, or by algorithm rarely work well.

If a patient is acting out of his own volition, is cognitively processing things appropriately, is not overtly psychotic  or in withdrawal from substances, and he still destroys property or intentionally  hurts others on the staff or other patients, then he should be charged for these actions accordingly and would perhaps be better served in the county jail than the emergency department.

I would welcome stories of  your own experiences in this area, your opinions and ideas for how to make these tense situations more rewarding and beneficial for both staff and patients.