Movers and Fakers

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One of the first things I look at when a new consult comes into the queue is the date and time that the request was faxed into the electronic medical record system. The next thing I look for is the date and time that the patient hit the door to the admissions area of the emergency department. Sometimes the difference between the two is as little as five minutes.  How can that be?

Well, you see, the ED is a very busy place. Patients are coming in with chest pain and vomiting and surgical abdomens and broken ankles and all manner of ailments. One of the first jobs of the ED staff is to triage these patients, that is, to decide who has a routine need like a badly scraped and bleeding knee, an urgent need like fever and nausea, or an emergent need like crushing substernal chest pain, an ashen face and radiating pain down the left arm.

Psych patients come into this swiftly flowing stream of humanity and get buffeted from one side of creekbed to the other. It’s almost a given, almost, that if the chief complaint is “I’m seeing little green men”, “Brad Pitt is in love with me and wants me to have his babies” or “The NSA is tracking all my phone calls”, then that patient gets shuffled off to the mental health area of the ED. (Oh, shoot, I meant to edit out that last example. Can’t use that one anymore. Note to self…)

Now, this is all well and good if the patient does indeed have a bonafide mental health problem and nothing else. She gets put through the usual screening process, has her clothes exchanged for luxurious blue paper scrubs, and is asked to take a seat in a hard cold plastic chair until someone can see her.

But what if this patient, who presents with let’s say, acute anxiety and a feeling of impending doom, starts to become ashen-faced, gets more and more short of breath, starts to have chest pain, and then collapses onto the floor in a heap? One then starts to think (really quickly and with feeling) about “real” medical problems like hypoglycemia, pulmonary embolism, and heart attack. Little green men and Brad Pitt be damned, people who have mental health problems also get sick with medical problems, and some of them will die if these are not recognized in time.

This is another special group of patients who come into the ED and have what appear to be anxiety, depression, tremors or even hallucinations, but in fact have an undiagnosed medical condition.

Could you give me an example, please?

Of course I can. Several.

Thyroid disease is one of those pesky problems. Have the thyroid gland rev up too much and a person can present looking as manic and paranoid as RIchard Pryor on crack. Stop it from working, and you have a depressed automaton, Al Gore on the campaign trail.

Anxiety, and a patient that looks jittery, jumpy and psychiatric in triage could come from hypoxia, pulmonary embolism or drug withdrawal.

Of particular interest are the connective tissue diseases and autoimmune diseases, which can take up to a decade to correctly diagnose. Patients come to the ED with funny physical sensations, migratory numbness or even hallucinations with no prodromal history of schizophrenia or any other psychiatric disease. I have heard many of these folks tell me after the fact that they started to believe they were “really crazy” after trying to explain their very real physical symptoms that seemed to have no rational or diagnosable cause to physicians who were skeptical at best.

As I’ve said before, all that glitters is not gold.

All that hallucinates is not schizophrenia.

Sometimes the patient who presents with weird numbness and one sided weakness is not having a conversion reaction but is suffering from a neurological or medical disorder that is diagnosable and treatable, if one will only look for it before the patient goes to ED mental health purgatory.

Are You Ready To Commit?

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One of the hardest things I have to do as a psychiatrist is to commit a patient for involuntary treatment.

As I have told you in many previous posts over the years, I see people who have anxiety attacks and depression and physical complaints and problems sleeping and all manner of relatively common, relatively easily assessed and addressed issues. That is the bread and butter, stock-in-trade life of the psychiatrist, just as treating diabetes and hypertension is old hat for an internist.

Sometimes my clinic work, and especially my emergency department work, require me to see someone, assess dangerousness or inability to care for self, or inability to make good decisions involving one’s own care, and then take a drastic step. I must decide to take away that person’s right to choose, that person’s freedom to get up and walk out of the office or the ED. I must make that decision because not making it might literally mean putting the person’s life in jeopardy.

At first glance, this parens patriae is a huge amount of power over other people, the ability to call the shots and hold you against your will just because I think that needs to be done. Obviously there is room for abuse here, just as there is the possibility of a vindictive family member going down to the local probate court and signing an affidavit stating that someone needs to be committed just because they are having a family dispute over money or land and one member is angry at the other. Not the best use of the system, but it happens.

I take the responsibility very, very seriously. If after listening to you and gathering corroborative information I find that there is reason to believe that you might harm yourself or someone else, or that you are just not able to safely take care of yourself for any number of reasons, I will move to commit you to a secure facility against your will.

“You can’t do that! I’m not going to go. I’m going to walk out of here and you can’t stop me!” says the now frightened patient, who was just threatening to blow his head off with a twelve gauge shotgun.

Well, yes, I can do that, and no, you’re not going anywhere, and yes, I can stop you.

This is a drastic step and one that is obviously taken much more often in the emergency department setting than in the community mental health center.

I have seen patients go from being in my face and hostile and threatening to kill me on the spot to blubbering wrecks when they find that I am done talking and ready to act to protect myself (and them) from their rage.

I have seen mothers weeping uncontrollably as I have recommended involuntary admission for a child whose constant cutting and drug abuse is out of their control.

I have seen alcoholics just this side of death try to argue with me about how they are no longer drunk, no longer going to shoot themselves, and no longer going to beat their wives if I’ll just let this one slide and send them home.

This decision to hold, to commit, to involuntarily detain is a very hard one indeed. I have to balance your right to freedom and to make our own decisions against the countless times I have seen others just like you, with the same stories, come to me and beg to be sent home too.

I have committed some of them, hearing them curse me as they were placed in the back of a police cruiser for transport, gone home and rested well that night, knowing that they would get the assessment and treament they needed in a safe, secure place.

I have let some folks go, only to find out that the next day or the next week or the next year they overdosed or shot themselves in the head or hanged themselves. Their choice, not mine. Doesn’t matter. It kills a little part of me anyway, every time it happens.

Risk assessment is a tedious, hard, nerve-wracking, necessary job.

Recommending the treatment that I believe you really need, in spite of all your lamentations and bargaining and pleading for me to do otherwise, sometimes feels like I’m sending my own mother to jail.