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.

6 thoughts on “Ya’ll Come Back Now, Ya Hear?

  1. You remind me of my years training at a state psychiatric hospital in NC when I was getting my Ph.D. I mostly did psych assessments but did some other stuff, too. One of the social workers asked me to take on Doris, a 58 year-old frequent flier who had been admitted again. It was her 30th admission in 30 years. My background was working with teens and children so I was a bit dubious about what I would do to help her. But I took a developmental approach and decided an appropriate goal for her would be to interact with other adults without taking her clothes off or asking repeatedly if she was dying. So, I would bring a deck of cards, a hot pot, and two tea cups down to her ward twice a week. It got so that she could make conversation again. That was back in the days when people could stay in the hospital for awhile to stabilize. As is true now, there were no transitional living options for discharge. I can’t imagine working in an emergency room with psychiatric patients but I am so glad that someone as kind as yourself is doing so.

  2. Greg.

    Hey, even Paul in his letter to the Romans battled that one. “I do not understand what I do. For what I want to do I do not do, but what I hate, I do.” That recidivism seems to be an innate issue for us all:/

    And Sisyphus may have had more trouble with his huge stone, but I bet the ones we were discussing earlier hurt more!! ;)

    M

  3. That is such a great story, full of the kind of humility and resourcefulness that I’m afraid a lot of present day clinicians are lacking. Bravo.
    You are the one who is kind. Thanks for that thoughtful comment.

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