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.

 

 

 

 

Pushmi-pullyu

It’s a common scenario in emergency room telepsychiatry. 

Sixteen year old female comes in after an argument with her boyfriend or her parents (usually fathers, sorry guys). She decides that she is going to get back at the person she fought with, and show them a thing or two. She rifles through the medicine cabinet. The thing that immediately jumps out at her is a big bottle of acetaminophen, the 500 count. It’s cheaper that way you know. She thinks what the hey, it’s Tylenol. How bad could it be if I take a handful or two of it? It’s headache medicine. She proceeds to do just that. Someone finds her, calls 911, gets her to the local ER. Her acetaminophen levels are through the roof, and rising rapidly. Houston, we have a problem. A big problem. Acetaminophen taken in even larger therapeutic doses over a long time can cause liver damage. Overdoses of it can cause liver failure. These ODs kill livers. And sixteen year olds who didn’t really mean to die. 

He’s a stud, a late twenty something with nice tattoos and even nicer pecs who thinks the world is his oyster and the girls will always fall for him. He works hard in construction during the week, but the weekends he considers his to blow out and party like it’s 1999. (RIP, Prince) He starts with marijuana at nine, alcohol at fifteen, cocaine at seventeen, and now and again a little crystal if he can score it. This time, on this Saturday, he goes a little too far. The cocaine, most likely cut and adulterated with God only knows what, treats his heart like crap. He has an arrhythmia that won’t go away. Hearts need to beat regularly. If they don’t, dirt nap. 

He is one of the most genteel and dignified men I’ve ever seen. His silver hair is still thick and full, his skin is ruddy and healthy looking, and he is dressed in nice khakis and a polo shirt. He smells of alcohol, his other vice (expensive cigars). He saw his family doctor the morning before he was admitted to the ER. He is on a small dose of antidepressant and something for sleep. His alcohol use is escalating, he has isolated himself, and he rarely sees his friends any more. He has stopped reading, and he doesn’t care at all this year about another love of his, presidential politics. Oh, and as for love? His partner, his true love, his wife of sixty five years, finally said goodbye to him when she passed away peacefully in her sleep six months ago. He has felt lost, alone, and abandoned ever since. He can’t shake it, and now he’s not even sure he wants to. “Let me die, Doc. Please just let me die.” 

The sixteen year old wakes up, feels a bit better, eats a little. 

“It was just Tylenol, for God’s sake. I was pissed at my dad. I didn’t mean to kill myself. Can I just go home, please?” (Insert grand eye roll and turn away from Doctor, arms crossed)

Her insight is nil. She damn near died. There are real problems at home, not to mention the fact that she has zero coping skills when normal day to day problems arise. She see none of this-yet. 

“It’s a fluttering, Doc. My heart is all a flutter, I guess, you know. The way I affect the ladies. They see me, and boom! They fall for me. It’s a curse.” 

He winks at me, unshaven, hair mussed, but still brash and arrogant and full of the misdirected passion of youth. He has little insight into the fact that he is a heartbeat away from nonresidency. 

“Oh, c’mon, Doc, give a guy a break. I still got some weekend left before seven AM work time on Monday. There’s beer in the fridge at home, buddies are blowing up my phone. I’m good. I’m really good. Let me out of this prison. Please!”

A single tear runs down his handsome tanned face. He looks up at me, telegraphing quite clearly that if he does not get some help, if he is sent home, that he will die. Oh, did I mention that he is an avid hunter and has a safe full of guns at home?

“May I please be discharged now? I’d like to get home to feed my dogs, and take a nap…” He trails off, head hanging down to his chest, hands clasped limply in his lap. He begins to sob, quietly. 

The common threads here are obvious. 

Some patients are at extremely high risk of self harm, even death. Some are young and naive, some are full of the vigor of young adulthood, and some are old and tired and sad. 

The other common thing about all these types of consults is that each patient, without fail, asks to go home. They have almost succeeded in poisoning themselves to death, they are playing Russian roulette with needles instead of guns, and they have given up on any further happiness in life. Somehow, they get to the ER and seek help. Yet, they can’t see the gravity of the situation, the extreme risks, the pain they would cause the ones left behind. They only want what they want, which is not to be in the emergency room. 

What to do?

Well…

You push me…

I pull you…

…with any luck, back into your own life. 

Don’t remember what a pushmi-pullyu was? Watch the video below and it’ll come back to you. 

https://youtu.be/pmp-ITOI0-I

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.

Something I Didn’t Write That You Should Read

Sometimes, someone else says the things that we feel passionately about better than we do. It really is a waste of time to reinvent the wheel, so I’m going to post this link to an article that I’d like all of you to read, if you would be so kind. 

My friend Martha Anne Tudor, who once wrote for the New York Times herself, sent this to me yesterday. 

Juliann Garey writes eloquently in When Doctors Discriminate about how having a mental illness, just having it, sometimes leads to suboptimal medical care. 

“Last year the World Health Organization called the stigma and discrimination endured by people with mental health conditions a hidden human rights emergency.”

Please read this article, think about it, comment on it, and share it with others. 

Have a great Tuesday.