迷失東京

I take language for granted.

You probably do too.

I go to work every day thinking that the least of my worries is going to be how I communicate with the people who come to me for help. I’ll have to help them deal with alcohol problems, depression, hearing voices and thoughts of suicide, but the common language between us, English, will facilitate this process, not hinder it.

But as Robert Burns said in his 1786 poem To a Mouse,

But, Mousie, thou art no thy lane [you aren’t alone]
In proving foresight may be vain:
The best laid schemes o’ mice an’ men
Gang aft a-gley, [often go awry]
An’ lea’e us nought but grief an’ pain,
For promised joy.

I was tasked with evaluating a patient the other day, a patient with the usual family problems, mood changes, and possible paranoia and delusional thinking that many of my patients have. The history given me by the hospital emergency department staff was pretty straightforward. I needed to see whether or not this person needed to be hospitalized for safety, medicated for psychosis, treated for depression and anxiety, or simply sent home because of a cultural misunderstanding.

The problem? I speak fluent English and absolutely no Mandarin Chinese. He spoke fluent Chinese and very, very little English.

Now, I have written about the positives and negatives of telepsychiatry before. The picture is crystal clear, the sound quality is usually very good, and the ability to assess and intervene from hundreds of miles away is remarkably and surprisingly easy. Except when the two parties involved do not share a common language.

We tried the usual say a few words and use sign language thing. No go.

We tried to find a family member to help, but they had already left the hospital.

We then turned to a translation line out of California, something that most all facilities nowadays must have ready access to in order to provide care for anyone who might walk through their doors, especially if they receive any Federal monies as payment for services at all.

Problem solved, right?

No.

We could not get the translator hooked up through the speaker phone on the hospital’s end so that both the patient and I could hear her.

We tried having her call in to my desktop speaker phone, which would then be picked up through the mic on my Polycom unit and heard by the patient in the ED. No go.

We finally worked out a three-way call that involved her talking to the patient on a corded phone in the ED, on camera, and me on my iPhone in my office at the same time. The patient was on camera and could see me and vice versa. I turned the sound on the telepsych unit all the way down to prevent the double double transmission transmission of of every every word word.

We were then able to proceed, albeit awkwardly and gingerly, through an intimate conversation about marriage, business, and madness with the help of a very patient and very helpful young woman in California who spoke both Mandarin Chinese and English.

Once we were able to communicate, the cultural issues, nuances, and differing manners and cultural protocols became more obvious between us, doctor and patient. This added another layer of richness and frustration to what should have been a fairly easy, fairly straightforward thirty minute conversation and assessment.

Two and one half hours later, I hit send and my consult was on its way to the emergency room doctor and staff.

I was emotionally exhausted. I got up and walked around, got some air, and contemplated what had just happened.

Sometimes we go through our days not even noticing the miracles around us. We take so much for granted. We are sure of what we are going to do and exactly how we are going to do it. We set out schedules and feel that we are in perfect of control of our lives. We think that our way of doing things, our language, our culture and our priorities are the best, the most important and the ones that everyone else in the world espouses and holds dear.

We would be dead wrong there.

Practicing telepsychiatry has taught me many things in the last four years.

I have learned that people are people, with similar problems and hopes and dreams and fears, no matter the color of their skin or the way they dress or the language they speak. I have learned that being patient is absolutely essential to doing my job. I have learned that being flexible saves me, the hospital emergency room staffs, and my patients a lot of heartache.

I have learned that communication is key. Without it, my services are absolutely useless.

Enjoy your day. Talk to someone today. Really try to understand what they are saying to you. Take nothing for granted. You will be richer for it.

The title above is Lost in Translation, written in the traditional Chinese.

Aftermath

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Good morning, everybody.

I have another question from our studio audience today. (Please keep those cards and letters coming)

“What happens after a telepsychiatry consult? Do you get any kind of feedback about what happens to your patient?”

Excellent query.

As I have mentioned in previous posts, doing telepsychiatry is a lot like any other emergency room work. It can be tediously slow and boring. It can be horrendously busy. It can get stale when one sees the same thing over and over again. It can be tremendously exciting when a fresh new problem associated with a rare diagnosis presents itself. Another caveat of doing this work is that we often see a patient, are very invested in the story they tell, make recommendations for their care, and then never see or hear from them again.

So, what usually happens after I do a telepsychiatry consult? What is my ongoing connection to the patient? This can break out several ways.

First, if a recommendation is made to release the patient to outpatient followup, and the ED staff agree with this, then they may be sent home minutes to hours after the consult report is sent it. In that case, of course, no more contact is made. The patient is off to follow up in a local mental health clinic or with a private psychiatrist, and that is that.

If the feedback from the telepsychiatrist is to admit for safety, to restart medications, or to further observe to make a more definitive diagnosis, then it can go two ways. An inpatient bed may be found fairly quickly (something that is getting more and more rare in the state of South Carolina, where I practice) and the patient will be transferred to the other facility as soon as that is practical. There is  no real “active mental health treatment” in the ED per se, so this scenario is optimal if inpatient intervention is needed.

More common is the recommendation for inpatient admission followed by days (or sometimes weeks, unfortunately) of waiting for an appropriate bed to open up. In this case, treatment may be started, at the very least the medication portion of treatment, while the patient waits. If that happens, then within seventy two hours, when the commitment papers need to be recertified in order to hold the patient in the ED, a follow up consult may be sent, and the same telepsychiatrist (or one of his or her colleagues) will re-evaluate the patient. If sufficient progress in relief of symptoms has been made at that time, suggestions for release and follow up may be made. If not, then continued hold may be suggested to the attending in the ED.

The latter is one scenario that allows for me as a telepsychiatrist to actually see, paradoxically, progress in my patient. If an antipsychotic is started for a patient who is floridly delusional and agitated to the point of needing physical restraints and intramuscular medications to prevent harm to himself and others, forty-eight to seventy-two hours of treatment and observation can sometimes work miracles. Someone who was afraid of the camera and tried to hit me through it (yes, that has actually happened) may be able to much more calmly explain how they felt on admission after three days of treatment. That is the closest we telepsychiatrists usually get to seeing a positive outcome or even a “cure”, as much as one with true mental illness can ever be “cured”.

A spinoff of this is the patient who is seen, for whom a treatment plan is crafted, who is then discharged, but then “bounces back” with the same or similar problem that got them there in the first place. This happens quite often with folks who have substance abuse problems.

Alcoholism, for example, is a “cunning and powerful” disease, and the patient who reappears in the ED with a blood alcohol level of 450 a week after being seen for intoxication is far too common. Other patients who have chronic mood disorders, psychotic disorders, or even personality disorders may revisit the ED many times with superficial lacerations to forearms or wrists, repeated overdoses with sub-lethal amounts of pills or other problems that recur. This is good in the sense that the telepsychiatrist gets a much more accurate picture of the pathology involved over time. It is bad in the sense that the patient may be traumatized over and over by the admission and evaluation experience, and emergency resources are used where outpatient mental health services should be employed instead.

Finally, if the patient has presented with a one time, first episode, self-limited process, then a consult may be done, a disposition reached and the patient discharged, never to be seen or heard from again. I like to think when that happens that we have helped them move through and past a bad patch in the road and that they go forth and live their life well and happy. I am not so naive that I think this really happens in every case, but it’s a nice thought. This may also happen with those who are itinerant or transient patients. They may or may not be back the next time the direction of the wind shifts and the leaves begin to fall with the temperatures.

I hope this gives you a sense of what happens after telepsych consultation is completed.

In the style of Steve Jobs, I have one more thing for you before I move on with my day and let you do the same.

I received an email yesterday from the powers that be that told me our merry little band has received tentative approval to work from home. Up until now, to do my telepsychiatry duties I have had to physically go into an office in the local mental health center. Now granted, this has not been an extreme hardship, in that the office is exactly six  minutes from my apartment. However, working from home would mean that I have control over the thermostat, that I get to make my own coffee, that lunch is ten steps away, and that when a sixteen hour shift is over I can walk two rooms over and fall into bed if I wish.

It’s the little things people.

I’ll be sure to let you know how that scenario plays out. Could make for some interesting writing about autonomy versus isolation and other associated issues.

As always, thanks so much for taking a little time out of your own day to read my musings. I welcome your comments, feedback, and suggestions for things you’d like to read about here.

Have an excellent day (or evening, for those of you who insist on staying fourteen hours ahead of me. You know who you are.)