e pluribus unum

She looked like a whipped puppy that had had a garden hose turned on it and slunk off to a far corner of the yard to dry out in the sun.

She sat there, wizened but hard, thin and wiry, dressed in standard issue blue emergency room scrubs, thin tanned face, long stringy, wet prematurely gray hair falling limply around her shoulders. She looked down at the floor, but when her head came up and she made eye contact with me, her blue-steel eyes cut through me like a sword.

Like many people I see in the ED, she had tried to kill herself and was damned near successful.

“I don’t want to talk about it.”

She said this not in a defiant way, not in a disrespectful way, but matter-of-factly, like she knew I would understand.

I did.

“I know, but I can’t help you unless you talk to me about whatever part of it you think you can share with me.”

The next thirty minutes were a scripted dance. I’ve partnered with thousands of patients in this jerkily choreographed yet smooth and fluid transition from defiance to half-hearted refusal to longing to reservation to willingness to despair to resignation. The new trainee gives up at “I don’t want to…”, citing respect for the patient’s wishes. The young clinician pushes gently into the land of reservation, thinking that he is doing the patient a favor by not making her express her pain in this setting of codes and glaring lights and empty suicide-proof rooms. The tender-hearted provider, overloaded with his own personal grief or depression or closet alcoholism, over identifies with the despair and leaves it there, sitting raw and bloody like a piece of meat, ugly and untrimmed by the butcher, waiting to be wrapped in white paper and neatly labeled and put away in a deep freeze somewhere. The experienced clinician, having seen this story played out thousands of times, simply waits.

I waited.

“I know where the money’s been going now. I work damn hard all week. I clear almost a thousand dollars a week, doc. He said he was paying the bills.”

I wait, because I know she wants to talk about it.

“Pissing his life away. Pissing my life away. My money up his nose.”

We explore the hurt, the betrayal, the fear, the anger, the loss of control. It’s always about the loss of control.

Killing yourself is the final act of defiance, payback, and ultimate control.

“Yes, at the time I really did want to die.”

I believed her, of course. There was no reason not to.

A sudden infusion of energy, anger, fresh anger, now directed at me, at the system.

“I just don’t believe that somebody can haul me in here and make me sit in an empty room and take my rights away and not do a damn thing for me. I promised to defend the constitution of the United States. I made a vow. This is what I get.”

She spat on the floor. If she could have spat through the camera onto my shoes, she would have.

“Why don’t you just leave me alone? Why don’t you just let me make my own decision and let me die? Does it really matter to you? To anybody? Just let me go home. I want to go home.”

Despair.

We discuss the rules of the game in the state of South Carolina. The mandates, the rights and privileges of the citizenry that hold true, always, unless there is a clear and present danger that leads to involuntary commitment and treatment.

Her head hangs, if it’s possible, even lower than before. I do not see her eyes again.

“I’m afraid that you’re not going home today.”

The hose running from the exhaust to the cabin of the truck had decided that even before we talked on camera.

A silent nod.

Resignation.

“Please just let me die.”

The newbie feels a strange mix of pity and fascination and fear.

He responds, “I can’t.”

The old dog knows that the situation, no matter how bleak, will look different once the fog and the darkness have lifted. There is every chance in the world that life will go on, should go on, must go on.

He responds, “I won’t.”

Out of the many he has seen, he will do his very best to help just this one.

Judging a Book By Its Cover

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It is tempting to use our sense of sight to make snap judgments about people, places and things.

Think about it. When you walk into a restaurant, if you see a sparkling clean dining room, you probably assume that the kitchen looks the same and that the food will be prepared in a clean, safe environment. When you see a well-dressed pilot and crew walking onto an airplane that has been cleaned, fueled and prepped for flight, you assume that you are going to safely make it to your next destination. 

The same thing happens when we meet people for the first time. It takes only a second, a small fraction of a second actually, to make a snap judgment about a person, whether you trust them or not, and whether you like them or not. 

In the emergency room, I see all sorts of people for psychiatric consultations. I see little kids who are there with their parents, self-proclaimed drug addicts who are there to score their next fix, and elderly men who have lost their spouses and are contemplating suicide. Some of them have not bathed in weeks. Some of them wear tastefully applied makeup and have expensive haircuts. Some of them smile at me with straight, gleaming white teeth, while others have two teeth left in their head if that. Some people sit as far away from the camera as possible, face fixed in skepticism and arms tightly folded across chest in the universal “don’t bother me” sign. Others sit so close to the screen that I have a hard time seeing them at such an acute camera angle.

Before the camera comes on and my next patient is seated in front of me ready for the interview, I have had a chance to review the consultation request, vital signs, nursing notes, the doctor’s physical examination, lab reports, EKG printouts, CT scan interpretations, and a few data bases of medical information. I have a pretty good idea which direction my inquiry will take, what details I still need, and what disease processes I’m going to be looking for before I ever physically see the patient. 

When the call comes in and I see the patient for the first time, the visual cues are very important. Someone who has a flat, expressionless face may be depressed, have Parkinson’s Disease, or have had a stroke. Someone who is in constant motion, fidgeting and not able to keep still may be in active alcohol withdrawal, have akathisia from antipsychotic medications, or simply be anxious about being in the emergency room. Someone who scans the room, fearful and paranoid, may have a primary psychotic illness like schizophrenia, or they may have snorted bath salts and be high as a kite. 

In spite of my training in psychiatry and many years of clinical experience across a broad variety of settings, I do the same thing you would do when I see someone on camera for the first time. I make a snap judgment, not even a conscious one at times, about the person I see. It’s human nature. 

The difference is, I have been trained to put that aside and to evaluate that person based on information given to me by the requesting emergency department, results of tests and studies that have been done or will be ordered, the clinical interview and mental status examination of the patient, and the synthesis of all that data to come up with a good, solid, working diagnosis that will then drive my recommendations to the requesting doctor. 

That can make all the difference in the world. A blinking, staring, uncooperative “psychiatric” patient may be in untreated status epilepticus. A severely “anxious” patient who has been confined to a hospital bed for days may be getting ready to have a massive pulmonary embolism that will kill them. A wildly agitated, threatening, hostile patient that frightens the ED staff may be in fact so paranoid that he feels he must “kill or be killed”. 

In the evaluation of mental health patients, as in life in general, you can’t always judge a book by its cover.

 

The picture above is of my signed copy of The Three Faces of Eve by Corbett H. Thigpen and Hervey M. Cleckley. It sits on the shelf next to my grandmother Ursula Hall’s Shakespeare Complete Works from 1927. 

 

The Halls of Medicine

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Good Saturday morning to all. 

One of you commented on one of my posts on KevinMD.com the other day about staging patients, especially mental health patients, in the hallways. This is sometimes done, along with triage and initial assessments, because of the very real lack of appropriate space in a busy, full emergency room. What do I mean by this?

Well, as any of you know who have ever been to the ED for anything at all, once you get through the front desk area and the triage nurse, you are shuffled off to a room of some sort and the initial assessment process begins, with history taking and vital signs done and maybe even a test or two before the doctor sees you. 

Sometimes this part of the process involves talking about intimate details of your presenting complaint, taking your clothes off and dressing in one of those flimsy, drafty gowns, and being poked and prodded a little bit. It’s not stuff that would normally be done right out in public for all to see, as it is your illness or injury and your history and your body, no one else’s. Most of the time, EDs are set up in such a way that we all get the level of privacy we expect and deserve in that kind of situation. It’s not a private room in an expensive medical suite in a gleaming tower somewhere, but then again it’s not meant to be. We all get that, and we deal with it.

However, sometimes this principle gets pushed to the extreme. 

I was asked to see a patient in an emergency room the other day, a routine psychiatric consult like all the others I have done over the past four years via telepsychiatry equipment and protocols. I reviewed the historical information, the labs, the ED’s assessments of the patient, and the nursing notes. As always, some of the information was sensitive, involving previous abuse and other issues that are private. I finished my review, sent word to the hospital that I was ready to see the patient and waited.

Very shortly my monitor fired up and I was presented with a picture much like the one at the top of this post. I could see a corner of the hospital hallway, a broad, flat, curved plastic bumper railing on the wall, a gleaming white floor, and sitting there, right out in the middle of it all, my patient.

I quickly swiveled the camera around, much like one might do with the camera on top of the Mars rover, to assess my relationship to the terrain. Yes, we were indeed out in the middle of the hallway. There was the nurses’ station, with a couple of people staring over at the equipment (it is still quite novel to many people who are not used to it, so you still get a lot of stares), the far end of the hallway with a whitecoated doctor walking clipboard in hand into a patient room, a mop bucket and mop sitting down at the far end of the hall. 

It did not appear that we were moving toward a room. We were stationary in the hallway. That did not bode well. I asked the question, already knowing the answer.

“Are you getting us set up in a room for the consult?”

“No, doctor, we don’t have any open rooms at all. Everything’s full. Two traumas, sick kids. Every room. We’re going to have to do this out here.”

Um, no we’re not

“I’m sorry,” I said, trying not to sound too incredulous, “but I’m not going to do a psych consult in the middle of the hallway. This should be a private conversation between the patient and me. This won’t work.”

“Well, I don’t know what we can…”

I cut her off, bless her heart.

“Listen, this won’t work, okay? I’ll be glad to interview this young lady when you have a more private place for us to talk. I’m going to move on to my next consult for right  now, but call me back on the monitor just as soon as you have a room. Thanks.”

Click.

I hung up on  her.

Now, I realize that I was abrupt. It was one of those days, as I remember. You know, lots to do, irritable people, unsolvable problems. The usual, but more so. I didn’t have a lot of patience that day. I’ll own that part of the interaction.

However, when it comes to the care of my patients, and the privacy and respect that they deserve, I do not compromise. Talking in the middle of the hallway about a history of sexual abuse or an abusive spouse or active drug abuse just does not cut it. Never. 

I don’t care if you have run out of rooms. I don’t care if it’s change of shift. I don’t care if you’re itching to get this patient out of your hair because she might be a little more demanding and vocal than you’re used to. 

That’s not my problem.

Give these patients who present with mental health issues the same respect and attention and care that you would give your own mother if she came in having a heart attack. They deserve no less.

Oh, by the way.

Ten minutes later, the hospital called back and my patient was sitting in a room, door closed, camera ready. 

We proceeded without further problems.

The halls of medicine should remain just that.

Hallways.

Not exam rooms.