Consult-Liaison Medicine Observations

Chart Notes.

While reviewing old chart notes, I frowned as I learned how distressed the patient had been while he was in the emergency department. Without realizing it I murmured a line from a physician’s note:

Rambling historian, only clear complaint is hunger.

A colleague, who is often hungry, overheard me and responded, “That would be my mental status exam.”

A different chart provided this information:

Patient started getting agitated and threw a bagel at staff.

I couldn’t help but snort with amusement[1. All of us who must write clinical notes often dilute details because they’re often not relevant to clinical care, though these details often add context to what happened. Like the writer of this note, I often include factual details without intending to be funny. Sometimes we laugh because we otherwise would feel overwhelmed with sadness, anger, or helplessness.], though then wondered:

  • Was it a whole bagel?
  • Was it an old, stale, and hard bagel?
  • Did the bagel have cream cheese on it?
  • Was it thrown like a frisbee or like a baseball?
  • Did the bagel actually hit anyone?
  • What happened that led the patient to throw the bagel?
  • Did the patient elect to throw the bagel instead of an open carton of milk? or a single serving of jelly?

Yet another chart included this terse note from a medicine resident in the early hours of the morning:

Interval exam changes. Agitated overnight. Double middle finger to providers. Haldol 5mg IV ordered and given.[2. For those of you who are interested, Haldol 5mg IV equals Haldol 10mg PO (by mouth), which is a standard dose for someone with a diagnosis of schizophrenia. The thing about Haldol 5mg IV is that sometimes doctors order this with the intention of inducing calm in a patient so he doesn’t punch staff, destroy property, hurt himself… but, sometimes, the patient instead becomes sedated and is in a deep sleep for many hours. The goal should be to calm, not snow, the patient.] PRN Ativan.

One would hope that a patient doesn’t receive a sedating antipsychotic medication simply for extending both middle fingers to doctors and nurses!

Homelessness Nonfiction Observations Seattle

Street Scenes.

The woman walking in front of me on the sidewalk was wearing a short skirt and a sleeveless blouse. After stepping out of the street he readjusted the strap of the large duffel bag on his shoulder and began to drift towards her. Uneven stubble covered his face and his hair stuck out in several directions.

“Hi,” he said, smiling with both his eyes and lips. “How are you?”

She swept past him without turning her head. Unfazed, he then saw me.

“OH, COME ON!” he exclaimed, his voice more delighted than annoyed. He clearly recognized me.

As he continued to grin at me, I offered, “Hi.” I know you, too…

“Hi! How are you?” he greeted, his voice warm and his eyes bright.

“Fine, thank you. How are you?” You were one of my patients, but from where…?

“I’m good, thanks. It’s so nice to see you!” Neither one of us stopped walking, though he slowed down just as I began to cross the street.

I waved good-bye to him. He waved back.

Oh! I last saw you in jail! You thought you were a machine! You told me that everyone could read your thoughts! You shouted at the walls of your cell—

—and how much better you look now![1. The moment someone changes out of a hospital gown or a jail uniform into casual clothes he will immediately look more healthy, independent, and dignified.]

My father was telling me a story as we walked past the corner store. I’m not sure if he saw the man approach me.

“Hey, can you spare some change?”

Turning my head with a small smile and looking at his face, I said, “No.”

“Oh, hey now,” the man said, starting to walk next to me. He then reached out and stroked my arm. “I just want to touch you.”

“DON’T TOUCH ME!” I shouted, still walking. The man stopped. My father, taken aback, looked at the man over his shoulder, though remained silent.

“Go on,” I said lightly to my father, who then did. However, I didn’t hear anything he said. Did that actually just happen?[2. In my years of working with people who are homeless it has been rare for anyone to touch me. This includes people who were actively psychotic or acutely intoxicated. Furthermore, when people have touched me, it was within the bounds of social convention: We shook hands, gave high fives, bumped fists. Hence my alarm after this man touched me.]

The yellow sign on the fence reads: “Illegal activities and loitering not permitted.”

Within the confines of the fence are at least ten tents arranged in a half circle. Some are reinforced with several layers of duct tape. Others are covered with blue tarps.

A small barbecue grill, round and uncovered, is in the center of the circle.

A freeway ramp is on the other side of the fence. Trucks with 18 wheels, cars running on electricity alone, clunkers painted different colors, sleek sedans with round logos, and vans carrying kids, groceries, sporting equipment, and DVDs roll past.

The camps have grown this year.

Observations Reflection

Some Thoughts on Equus.

I saw the 1977 film Equus this afternoon at the recommendation of some friends. Some of my reactions:

– Had this scenario—a young man believes that horses are gods, which ultimately drives him to stab out the eyes of six horses—occurred in present day he most certainly would have received antipsychotic medication for a presumed psychotic disorder.

(All of the hugging, acting out, night sessions, etc. also would not occur in present day. At least one would hope not.)

– In a monologue near the end of the film the psychiatrist comments:

Passion, you see, can be destroyed by a doctor. It cannot be created.

Indeed! More than one person has shared with me that, while taking psychotropic medication, they don’t feel like “themselves”, their emotions feel muted, they feel “numb”, etc. Certainly medications are not the only agents that can destroy passion: Consider the potential violence in societal expectations, cultural norms, and other social structures.

Only the gods know where passion comes from. People have tried to thwart the gods for as long as we’ve been around.

– In another monologue the psychiatrist notes:

The Normal is the good smile in a child’s eyes. It’s also the dead stare in a million adults. Both sustains and kills… like a god.

Much of the film focuses on the idea of “normal”. Though most people don’t believe horses are gods and experience sexual ecstasy when riding one, everyone has their own penchants that others will find disturbing or peculiar. Most of us have learned to mask these proclivities from public view.

A few times a year people will ask me, in my professional capacity, if I think they are “normal”. While there are a variety of reasons why people ask me that, what often underlies this inquiry is the belief that I can distinguish between “normal” and “not normal”.

Can I just say—I’m sort of joking, but not really—that psychiatrists shouldn’t be the arbiters of “normal”? As a population, psychiatrists are a weird group of people.[1. You will note that I wrote “As a population, psychiatrists are a weird group of people.” To be clear, I didn’t add “as a population” to suggest that I, as an individual, am three standard deviations less weird than the average psychiatrist. I’m weird, too.] Some of the strangest social interactions I’ve experienced have been with psychiatrists… and we all knew that we were all psychiatrists. On more than one occasion I’ve wanted to exclaim, “Why are we so awkward? Can we please just be actual people right now?”

– There’s a lot of violence in the story. I refer not only to the actual stabbing of the horses’ eyes. I refer to the lies about the “truth serum”, the hypnosis and medication administration that seems to occur without consent, the father’s reaction and shame related to his son’s attendance at the “skin flick”, the dreams the main characters have.

Sometimes what we think is kindness is actually violence.

– There’s a bit of dialogue before the climax of the film that goes like this:

Martin: Where are you now, Alan?

Alan: Cabbages, with the moon on them.

I’m pretty sure that Alan’s response is meant to add a rustic, romantic touch to the scene. What do I do? I laugh out loud.

– I don’t recommend the film, though I’d like to see a theatrical production. The monologues of the psychiatrist are noteworthy, though I couldn’t understand much of them until about halfway through the movie.