F You

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This is a reposting, with slight modifications, of a piece I did not quite four months ago after a tornado touched down just miles from my boyhood home in Georgia. With all the angst surrounding cancer and the destruction of prophylactic treatment, plus the devastating news of the deaths of more children in a monster tornado strike in Moore, Oklahoma, yesterday, I felt the need to repost it. Please bear with me. We’ll get back to the emergency department shortly. For now, let’s support those who labor in the hospitals of Oklahoma, saving lives, comforting families and putting a community back together one stitch at a time. Godspeed, Moore, Oklahoma. 

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F4.
Incredibly strong tornado.
207-260 mph.
Strong frame houses lifted off foundations and carried considerable distances to disintegrate; automobile sized missiles fly through the air in excess of 100 meters; trees debarked; steel re-inforced concrete structures badly damaged.

Devastating damage.

We had a strong storm front come through the midwestern United States yesterday. In the center of the ragged slash of weather on a weather app was the hard, bright-red mark of destruction. Pretty on the screen, destructive on the ground.

Destroyer of worlds.

Reports began to trickle in from a small town in Oklahoma of a monster twister that had descended from the blackness of the cloud bank, a mile-wide kiss on the the ground, crossing the landscape and leveling buildings like they were made of children’s wooden blocks. Not quite an F-4, but terrifying nonetheless. Reports of multiple deaths began to trickle in. Many of the dead were children. Veteran reporters cried giving the details on the ground. It was an emotional nightmare for all.

When I see such destruction I think of my friends, family and aquaintences who struggle with cancer. My aunt who succumbed to ovarian cancer. My mother, who is a breast cancer survivor. My friend, who is more than five years past a diagnosis of testicular cancer. Another friend who lives with metastatic breast cancer. Like an F-4 monster, the disease drops unexpectedly from the sky. Pretty colored X-rays and scans reveal the destructive power underneath. Sirens go off. The mind screams take cover, take cover! The body sometimes is only grazed, shrapnel cutting but not killing. Other times, the impact is devastating. Nothing looks as it did before the storm. The landscape is flattened and only rubble is left.

Is there anything good about F-4s and cancer?

What an odd question, you think.

Not really.

These scourges, while leaving city blocks and body parts in absolute ruin, are often surgical in their devastation. That is, a few hundred yards away, or a few inches outside the margins, the sun is shining, the tissue is healthy and life goes on. Friends rush to help. Prayers go up. Communities, wonderful communities form. Support is not only offered but insisted upon. Rebuilding begins-immediately-in the aftermath of the siren’s wail and the surgeon’s knife.

When the horror and the shock and the denial and the anger and the tears and all of it subsides, victims become empowered survivors.

Strong!

The chorus goes up.

F you, tornadoes. We will rebuild.

F you, cancer. I am scarred, but alive.

We’re still here.

F you.

Ya’ll Come Back Now, Ya Hear?

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“I can stop drinking any time I want to, Doc. I’ve done it a hundred times!”

”I don’t need my lithium any more. I have the strength of ten men. I’m smarter than anybody in my family. Why would I need to take medication?”

“God told me to stop getting the injections. He talks to me every day. Don’t you, God?” (looking over toward the empty exam room chair in the corner)

Recidivism.

The scourge of the ED. The scourge of medicine in general.

Why do we ALL (and I sheepishly but with full disclosure include myself in this camp) continue to do the things that we know give us problems, make us sick, and land us back in the doctor’s office, the exam room, the ED, or a hospital bed?

Why? It makes no sense.

Psychiatric patients are sometimes unceremoniously called “frequent fliers” in the business (as are, of course, other medical patients who visit the ED with greater than expected regularity). This is not derogatory in my personal opinion, but it is damn sure descriptive. How many? Hundreds, thousands. In and out of treatment. In and out of acute care hospital beds, which are now scarcer than hens’ teeth. On medications, then off medications, Therapeutic blood levels of medications this week, then a level of zero next week. (Noncompliance is now a non-PC word, but there you have it. Call it whatever you like.) Repeated blood alcohol levels of 200, 300, 400.

I saw a patient recently who was sitting up, reasonably lucid, talking to me and was pissed as hell that I would not order strong narcotics for his thirty-year-old back and hip pain. His blood alcohol level? 479. For reference, at 100, you’re drunk.

You can’t go home again.

Well, of course, you can, if your home is the ED of a local hospital or a publicly funded clinic that has little choice but to take you back, muttering soto voce about it but doing it nonetheless. You know it, and they know it.

Why are there repeat offenders (against themselves and their own health) in the medical world?

Chronic illness is just that. It’s chronic. Unrelenting. Painful. Hard to live with. Sometimes we want to give up. I was diagnosed with polymyalgia rheumatica a few years back. It’s under good control now, but some days I wake up feeling like I slept under a Sherman Tank. I’m stiff. I hurt. My body says “no” and I say “but I have to get to work by eight if I want to eat”. I go back to the doctor when I have to. When I need to. When I need some help. Not often, but I go.

Mental illness is a little different. Are you catching that drift from me as we go through this exercise together, you and I? Mental illness takes away our ability to process things normally, to make good decisions and to do things that are in our own best interest. We stop taking medications, we drink more and more, we drop out of service at the clinic, and we take a few more pills each day to keep us going. Pills off the street. Illegal drugs. “Legal drugs” like spice that don’t show up as THC in a random urine drug screen but that I’ve seen make pretty normal people bat shit crazy in an emergency department.

Which kinds of mental health problems show up most often in the ED for evaluation? If you look at my log of consults done, something I keep at the end of each shift, every day that I work, you would see a long column of reasons. Danger to self outshines them all. Intoxication is well represented. Danger to others pops up. Unable to care for self has its moments. Yes, there are patterns.

It has astounded me, truly astounded me, how big a part substance abuse plays in the presentation to the ED for mental health evaluation. I may as well go ahead and check off “marijuana” on your forms before I even talk to you because eighty per cent of the time I know you smoke it. And, please, don’t even try to go there with me. We can argue until the cows come home about whether the drug should be legalized or not, whether it’s just like alcohol or not, whether it’s a gateway drug or not, whether it calms your nerves better than Xanax or not, ad infinitum. In SC, using marijuana is illegal. If you get a random screen pulled and you “piss positive”, you get fired. Deal with it. I’m not going to argue with you about it at midnight in the ED when your blood alcohol level is also 300. Move to Colorado.

Mi dispiace. Got carried away there. (Sitting up straight and straightening tie, if I still wore one, which I usually don’t).

Is it ever safe to just say, “no more”? To say to the patient, “Look, you don’t want treatment, that’s obvious, so why don’t we call it even? I’ll discharge you if you promise to never come back to my ED ever again. Deal?”

That’s a struggle for any of us who took the Hippocratic Oath (yes, we really did) and basically had it beaten into us as medical students and residents that we HELP people. We TREAT people. Sick people. People who don’t think clearly and who do not make good decisions. That’s what we do. Yeah, but to the point of personal abuse?

I think I need to come back to this, what do you think? This is important stuff, but I’m at a thousand words already and your eyes are glazing over.

Tough issue, this one.

So we muddle through.

You come in. You’re sick.

We patch you up, send you out.

You come back in. You’re sick. Same sickness.

We patch you up, send you out.

I seem to remember something from Greek mythology about a guy named Sisyphus.

Hmm.

Let’s shift gears next time and talk about some special populations that I see in the ED for mental health evaluation nowadays. Sound good to you?

Deal.

See you back here soon.

Would you give me a hand with this rock? Thanks.

The Waiting Game

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So there was the time I was hugging a trashcan in the lobby of the community hospital ED just a few blocks from my house. Not because I have a molded plastic fetish or because I like the smell of trash, mind you. I had an itinerant renal calculus, otherwise known as a kidney stone that was moving through my urinary system.

It. Hurt. Like. Hell.

I. Wanted. To. Die.

I was throwing up blood. I was so sick I just wanted someone to kill me so the pain would go away. (Remind me that I need to come back to that re: pain that is so bad that one wants to commit suicide to escape it. There’s a good post there that needs to be written.)

But wait.

My peripatetic pain particle is not the point of this morning’s post. I was sick, yes. I was in terrible pain, yes. I was in the ED because I was seeking help, yes. But that was not the main problem at that instant.

I was made to wait.

In the waiting room.

Waiting for help.

Waiting for relief.

Waiting.

Mental health patients come to the EDs in my state and they want many things. Sympathy. Drugs. Medications. (They’re not the same sometimes, are they?) Counseling. Escape from abuse. Understanding. Housing. Hospital admission.

The common denominator across chief complaints and emergency departments?

Waiting.

These patients usually have to wait.

They come to the ED to get put back on medications that they injudiciously stopped on their own three months before, leading to a serious resurgence in symptoms. They come for detox from heroin. They come for admission to a psychiatric unit because their family wants them to be “put somewhere”.

The problem is, the ED system is a careful, methodical, slow moving glacier of health care provision for these folks, and others too I guess. Now isn’t that strange? You think of all the ED shows you see on television and the action is fast and furious, the pace frenetic, situation after situation life and death. On the brink, hanging on by a thread. Real life in the ED is like that only a fraction of the time. The rest of the time is broken bones, earaches, and anxiety attacks.

Mental  health patients are usually put in isolated rooms or corners of the ED. They are seen briefly and then they wait. In my state, this might mean waiting anywhere from two hours to twenty four hours for a telepsych consult, depending on how backed up we are. Sometimes we have only two consults in the work queue waiting to be seen, but on rare occasions we have had thirty consults, thirty, lined up to be seen. It takes from thirty minutes to two hours to do a telepsych consult. There is always one doctor on shift, and most of the time there are two working together. Do the math.

The patient is told that the telepsych doctor will see them and then make the decision about their going home or not. This is not true. We consult, but we do not discharge or retain directly. That is left up to the attending physician in the ED. Patients get angry when I tell them this. They feel that they have been lied to, especially when they have just smiled at me for thirty minutes and put their best foot forward to get released after a serious suicide attempt that in my mind has just punched their ticket for a hospital admission.

Sometimes they are physically or chemically restrained, a practice that we would like to think went out the door with Cuckoo’s Nest, but is still very much with us today. This process warps their sense of passing time even more, making the waiting that much harder to bear.

Sometimes it is days or weeks before a psychiatric hospital bed opens up. This is complicated by the fact that some patients have insurance to pay for services, some have Medicaid or Medicare, and some are truly indigent and have nothing. More waiting. Finally, the patient becomes so frustrated and upset about waiting in the tiny pale green room with the harsh fluorescent lighting and no stimulation at all they become more depressed, desperate, demanding and agitated, leading to staff pushing for an early discharge that might not be indicated at all.

The waiting truly is the hardest part.

When you’re dancing with a trashcan and throwing up blood.

Or when you’re hallucinating, depressed, and thinking of the easiest way to kill yourself.

Don’t Bug Me!

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Now, where was I?

Yes. Assessment.

The one-size-fits-all assessment found in most EDs today does not work for mental health patients. At least, not entirely. Yes, a perusal of this completed and often quite lengthy form will fill me in on blood pressure, pulse and temperature. It will let me know about medications taken at home. It will list previous medical diagnoses and oftentimes who is treating those illnesses. It will talk about elimination patterns and intake. It will assure me that the bedrails are in the proper position to prevent falls. All important items to address in an environment that is geared towards rapid global assessment in a safe environment.

We joked, again, in a teleconferenced staff meeting yesterday afternoon about the fact that these assessments will let me know what the patient’s TB testing status is for the last ten years, but will sometimes give me absolutely no clue as to the number of previous serious suicide attempts, even though the consult sent my way asks for an assessment of suicide risk.

Forms follow function.

Now some ED staff members, especially those wonderful, insightful ED nurses who are my lifeline to what’s really going on with the patient I am about to interview, ask probing and spot-on questions that get to the core reason the person arrived at the hospital. That’s great. Others, stressed to the max, covering too many really sick patients, and pulling their fifth long shift in a row, just don’t have the wherewithal to dig deep for some of the things I’d like to be told or made aware of as a matter of course. I’m not blaming them. It’s just a fact.

I’ll give you an example. A few weeks ago, I was going to see a young man who had supposedly made threats to kill himself and was very paranoid about family members at home. Pretty straight forward, right? I reviewed the records, called the nurse working with this man, asked her how he had been doing in the ED so far, and what her personal assessment of his current symptoms and status was.

She told me that he had been very quiet (spoiler alert-this is usually not good given the history I started you off with just now), a model patient, and had given them no trouble at all. No, she had not heard anything from him about delusions (she had not asked), did not think he had a plan to kill himself, and felt that he would probably be safe to discharge home (one of the primary, if oft-unspoken goals of an emergency room consult, truth be told).

I thanked her for her insights, got the patient on the screen and asked what brought him to the hospital. My first clue was his assertion that the federal government had placed a bug in the back of his head that was tracking his every move, that there were helicopters outside his house, and that he had made very detailed plans that he felt would lead to a successful suicide attempt when he got home. Oh, yes, he had indeed been very quiet and no trouble at all in the ED. He was not acting out, had not required IM medications or restraints, and was not taking up too many of the ED’s resources. The problem? He was very quietly psychotic as hell. I recommended admision for his safety and to treat his “obvious” symptoms. Obvious only if you took the time to really look for them and assess them.

Lastly, all that glitters is not gold. All that hallucinates is not schizophrenia. All that looks sad and flat is not depression. This is a real pet peeve of mine. One of the reasons doctors with medical school and residency training make good psychiatrists is that they know what else to look for. This is  not a cookbook specialty (Oh yeah. DSM-5. My copy has shipped this week and should be here soon. Please don’t get me started. That’s another series of posts for another day, you can be sure of that) and things don’t usually line up neatly as they should. As a matter of fact, in the ED they almost never do. You have to be curious, ask the right questions, dig a little, and when you hear hoofbeats sometimes look for zebras and not the conventional horses as you were taught in medical school.

I have seen hypothyroidism show up to the party as “major depression”, an undiagnosed brain tunor cause “schizophrenia”, and “panic attacks” that were due to hypoxia. One of the most challenging and fun things about psychiatry for me, and ED telepsychiatry is certainly part of it, is that my patients don’t always read the book. Granted, they read it more these days than they used to, but they don’t often read beyond the outlines or the first few paragraphs.

Diagnosis is a challenge. Assessment done right, and thoroughly, is a huge part of that.

What shall we talk about next? Hmm. Maybe what Tom Petty and the Heartbreakers allude to in their song. You know the one I’m talking about.

The Waiting (is the hardest part).

Enjoy. I’ll be back soon.

If the Dog Bites, If the Bee Stings, If I’m Feeling Sad

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The ED is a hectic place. 

Sore throats. Heart attacks. Dog bites. Broken bones. Strokes. Major trauma. If you work in an ED, you see it all. And then some. 

Is it any wonder then, with the potential for literally thousands of medical and surgical problems to stumble through the doors of an ED, that hospitals and the bodies that accredit them demand strict, regimented, standard, reproducible emergency assessments and the forms that document them? Of course not. This insures that all the basic questions are asked, that decision trees are followed, that diagnostic criteria are carefully applied, that correct diagnoses are made, and that treatment decisions are made based on evidenced based standards of care, both local and national. 

There are (at least) two wild cards in this process. Health care providers and patients.

Oh, yeah, those. Real people. Stressed people. Tired people. Hurting people. People who are throwing up and having chest pain and screaming and threatening to sue. People who are seeing their hundredth patient at the end of a double shift while trying to focus their eyes on the paperwork in front of them at the same time. Exhausted, sick, frightened, smart, superstitious, trusting, paranoid people. 

Mental health patients are people. Surprised by that, are you? Yeah. They’re people, just like you and me. They just happen to pull out guns to shoot themselves when they get really depressed, or take their clothes off and get hyper-sexual when they’re manic, or put black sheets and duct tape over the windows in their houses when they think the FBI has helicopters hovering outside their house. Other than those little details, they’re pretty normal people just like you and me. 

These normal people with not so normal chief complaints (“I think the federal government has put a metal bug inside my brain, right back here at the base of my skull, look Doc.”) come into the ED in all sorts of ways as we’ve already discussed here. Here’s the rub. These folks don’t fit the usual medical mold. Not surprised at that either, are you? Good. You shouldn’t be. Why is this a problem?

  1. A one-size-fits-all assessment in the ED does not usually address psychiatric and mental health needs fully.
  2. Substandard psychiatric histories by health care providers unfamiliar with mental health presentations often lead to the report that “the patient has been fine” and lead to inadequate assessment, diagnosis and treatment. 
  3. All that hallucinates is schizophrenia and all that is agitated is bipolar disorder. The problem with that level of reductionism? Hallucinations can come from drugs, brain tumors and iatrogenic medication interactions. Agitation can come from hypoxia, angina, and impending pulmonary embolism. 
  4. Patients who hit the ED doors with previously diagnosed psychiatric illness may not get the same attention when they have somatic complaints.  My “live patient” for my psychiatric boards was a middle aged man with schizophrenia who was complaining of atypical chest pain. My examiners expected that I knew schizophrenia backwards and forwards (I did). They wanted to see if I would adequately address these potentially life threatening symptoms in a previously diagnosed psychiatric patient. If I had ignored these issues and focused only on his (relatively stable) delusions and hallucinations, they would have sent me packing. I passed the boards. 

The ED is  often the place that mental health patients, especially if they are indigent, come for both mental health and physical assessment and treatment. Both must be addressed. 

More about this in the next post in this series.

 

Do You Care?

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Two of my blogging friends wrote excellent posts yesterday thay made me think. Of course, that’s what good writing does.

 The first post, from @jordangrumet was titled “Caring 2.0:#HCSM And The Rise Of The Empathic Physician”. Jordan makes several good points, including the fact that nowadays doctors, nurses, pharmacists, patients and advocates can reach not hundreds or thousands but even millions of people online, getting the word out about diseases and treatment and sharing knowledge. He says that knowledge is limited, but maybe caring is not. He says that it’s time to not only tell people what we know, but who were are. 

 He challenges us to move to a Caring 2.0 mindset, a process that involves us showing patients that we are human, that we suffer too, and that we have a lot to offer because of our own life experiences that we will share with them in the collaboration between the patient and the healer. 

 I am rethinking my own blog at gregsmithmd.com. I want to not only share my knowledge and  understanding of mental health, forged in the fires of twenty six years of clinical experience in the field, but to show that I live, love, and suffer too and that these life experiences make me better able to serve my patients. In doing this, I want to become “the doctor my patient really needs”, as Jordan so nicely sums it up.

 Another friend made these feelings manifest in words and pictures in a blog post titled “Let them eat…garbage?” that can be found here. @knotellin speaks of the Jewish tradition and custom of putting out leftover bread in public, sometimes tying it up in plastic bags on the metal outcroppings of rubbish bins so that it may easily be found and harvested by the poor who search for the leavings of those more fortunate than them for daily subsistence. In so doing, the writer goes on to say, “not only is the poor person who has to feed himself or his family debased, but so is the giver. There is no dignity in this transaction for anyone”. 

 My comment to @knotellin about this post was the following:

“I can’t “like” this post, but it certainly makes me think. I am struggling with the same issues in my own field of medicine, psychiatry, in that the medical care that is provided for these “throwaway patients” is often substandard, inferior, and “hung from the metal projections” of the medical hierarchy. What indeed does it say about us as humans that we often provide the neediest among us with the leavings of the richest of us, thinking that we have done out part and washing our hands of any more responsibility than that?”

Thank you, @jordangrumet and @knotellin, for really making me think yesterday. You showed me that we need to move forward to be more transparent in our dealing with our patients as people, and that judicious use of life experience shared makes the therapeutic process richer and the act of healing deeper.

 You also showed me that this sharing can and should occur in a way that is not demeaning to patient or exhalting to clinician, but in a way that lets mutual respect forge a strong partnership that is based on trust, not solely on paternalism and charity.

 Thank you for your writing, your teaching and for touching me in a profound way yesterday.

 

(In)Dignity and in Health

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We doctors who specialize in psychiatry have a sacred trust. We are given the opportunity to talk to people who are hurting every day, people who trust that we will listen to them, try to understand them, not laugh at them, and not think that they are stupid, crazy, or horrible. A tall order, granted, given that we hear stories that sometimes border on the unimaginable, bizarre and otherworldly. This is a privilege. I believe that with all my heart, even on the days that I am the most busy and bone-tired and wondering why I chose to do what I do. My interaction with my patients, that sacred emotional bond between the hurting and the helping, is paramount. If we forfeit that, what do we really have to offer?

That being said, there is a horrendous breakdown in this trust between the hurting and the healing in the emergency departments where many mental health patients are forced by default to go for acute and  chronic care. We make jokes about the TSA and the indignity of passing through the obligatory minefield of airports large and small since 9-11, but the same indignities are being visited on the mentally ill of America every day.

When a person is picked up by the local sheriff’s department executing a probate court order for transport for mental health evaluation, one of the first things that often happens is that the patient is handcuffed. Keep in mind that this person has not been arrested or charged with any crime. They are simply being transported for a medical evaluation. I have heard patients with trauma histories talk about how they are triggered to the point of hysteria by this practice, as some of them have been bound, assaulted, even tortured in the past.

Can you imagine? You are scared, maybe strung out on drugs, already paranoid, and the police come to your front porch, seize you bodily, handcuff you, and put you in the back of a cruiser. This very first step, the very first contact with a system designed to help the mentally ill, scares some of these patients so badly that they never go back for treatment again.

This is only the beginning. When patients arrive at the ED, they are stripped of all personal possessions, clothing, jewelry, money, everything. No keeping an iPod that might be playing the very music that calms you and makes the voices fade into the background just enough to make them manageable. No keeping a Timex that might help you stay oriented during the next few days when you will be held in a nondescript room with no windows or clocks to help you know what time of day it is.

In some hospital EDs, personal health information is gathered and discussed in open cubicles or behind flimsy curtains that do little to address HIPAA regulations. The person next to you is having belly pain and is likely to have an appendectomy presently. You are hearing voices that tell you to kill yourself. Now everybody knows about both of you.

Security guards are used as sitters outside your door once you are committed for treatment. You can’t take walk down the hall to stretch your legs. You can only take a shower when allowed, and no razors are given to shave beards or legs. You can’t smoke, something that may not be in your best interest but that has strong implications among psychiatric patients. As my patient said last week, “this feels worse than prison, Doc”.

We talk about treating people with mental illnesses with compassion and gentleness. We talk about people being more than a diagnosis, more than a diagnostic code. More than just another case or “the bipolar in Bed 2”.

It’s time we start doing instead of talking. It’s time we start treating people who come to the emergency department for help with mental illness with dignity.

 

Next: treatment issues.