Category: Lessons

I called the emergency department that night. If she was released, I wanted to know. (Did she make it home safely?) If she was admitted, I wanted to know. (Did the staff know her past history? Experience had taught me not to rely on a paper trail alone, especially when the patient was travelling through multiple departments.)

Though nearly ten hours had passed, she was still in the emergency department.

“Were you the one who tied the note to her gown?”

“Yes.”

The ED doctor on the other end of the line laughed. “We got that, thanks.”

He then told me about the evaluation—physical exam, labs, X-rays—and no significant medical problems were apparent.

“She’s going to be admitted to psych to rule out an eating disorder.”

Frowning, I sighed.

“Please give the admitting team my phone number,” I said. “I want to talk with them once she’s upstairs.”

---

Several days had passed. No one from the hospital had called me.

After leaving two messages with the attending psychiatrist, I finally got a phone call from the resident about a week later.

“How is my patient?”

“Your patient is fine… don’t worry….” She sounded bored.

“Did you receive my note with the past history?”

“Yeah… schizophrenia, eating disorder… we’ll take good care of her… she’s fine….”

“She hasn’t demonstrated symptoms of an eating disorder in almost two years. I’m worried about a medical etiology.”

“Uh huh, okay….”

“What is her weight now?”

“How much does she weigh? Um… I don’t know.” She suddenly sounded attentive.

“Can you find out right now, please?”

“Yeah, sure, sure… the nurses check it every day…”

“So what was it today?”

My patient wasn’t gaining weight. In fact, she had lost weight since her admission to the hospital.

“We’re locking her out of the bathroom for an hour after every meal so she can’t vomit. She seems to be doing well with that.”

Frowning, I sighed.

“But her weight is down?”

“Um… yeah.”

“Have you considered calling a medicine consult?”

“The patient was medically cleared in the emergency room. Anyway, we’ll probably discharge her soon and she can follow up with her primary care doctor.”

“Ideally, her discharge weight should be greater than her admission weight.” We both understood that my comment was a warning, rather than an opinion.

She quickly ended the conversation.

---

I visited her a few days later. She was more energetic, though still very thin. The hospital gown hung on her like a sheet on a clothesline.

“Hiya!” she greeted, her smile disproportionately large compared to the size of her face.

After exchanging pleasantries, we sat down on couch covered in dark blue vinyl.

“Have you been throwing up?”

“Yes. Sometimes.”

“You’ve been throwing up…?”

“Yes.”

“They tell me that they keep you out of the bathroom after meals.”

“Uh huh.”

“When do you throw up?”

“At night.”

“Do you make yourself throw up?”

“No.”

“Do you feel sick?”

“I’m fine.”

“Do you hurt anywhere?”

“I’m fine.”

I examined her face, halfway hoping that I could read her mind.

“Are they treating you okay?”

Yes, apparently they were, even though they really were locking her out of the bathroom for an hour after her meals. And, despite this, her weight was still dropping. My efforts to speak with the inpatient psychiatrists were unsuccessful.

I looked at her, unsure of what to say.

“Don’t worry,” she said. “I’m fine.”

---

Less than a week later, hospital staff called The Worker and told him that they were discharging the patient that morning.

“I wish they would give us more notice,” he grumbled.

He escorted the patient from the hospital directly to the office. We asked her to step on the scale. We all frowned as the digital numbers appeared.

“What? What?” the patient asked.

“93 pounds,” The Worker said. “You weighed 99 pounds when you went in.”

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(Part five of an ongoing series.)

In medical parlance my patient was called “a poor historian”. When this phrase appears in the chart, it means that the doctor who was conducting the interview believed that the patient could not communicate effectively. Perhaps the patient made no sense (Doctor: “Where do you hurt?” Patient: “Pain in the lettuce!”) or the patient’s report contained many contradictions (Patient with dementia at minute two: “I always take my blood pressure medicine.” Minute twelve: “I can’t remember the last time I picked up my medicines from the pharmacy.”)

In regards to my patient, she made little sense when she spoke. This, however, was not due to problems with her grammar or vocabulary.

She always said that she was fine.

She, however, was not fine.

She had lost over fifty pounds in the past year. When asked about her weight, she said that it was fine. She was vomiting on a near daily basis for the past few months. When asked about her health, she said that it was fine. When asked specifically about vomiting, she said that was fine. When asked how many times she had vomited in the past day, she said, “Three times.”

When asked to repeat what we had just spoken about, she said, “I’m fine.” Only with additional prodding was she able to parrot back the conversation.

She had huffed toluene in her former life, which destroyed many cells in her brain. We suspected this was the primary reason why she was “a poor historian”. She never seemed like she was fully present. This wasn’t willful behavior. It’s just the way she was.

For all of her problems with communication, though, some things carried over from her past: She was courteous and gracious. Whether waking up from a nap in the busy clubhouse, waiting for her worker at the office, or sitting in the lobby of her building, she’d flash a toothy grin at me and greet, “Hello! How are yoooou?” as if we had known each other for years.

Good manners go a long way.

Someone else had escorted her to the emergency room prior to her first hospitalization. We initially suspected that she had an eating disorder that led to her weight loss. During that hospitalization, however, she received two units of blood. And that doesn’t usually happen to people who vomit to lose weight.

The medical doctors abruptly discharged her from the hospital. No psychiatrist evaluated her while she was there. No follow-up medical appointments were scheduled for her. No one had an explanation for her weight loss.

Her weight only decreased further. Every week, I asked her to step on the scale in the office.

“I want my weight to be 100 pounds,” she said.

“What’s going to happen if your weight goes below 100 pounds?” I sternly asked.

“I have to go to the hospital.”

“Do you want to go to the hospital?”

“No.”

“So how much do you want to weigh?”

“130 pounds.”

She kept vomiting. Even though she continued to order fried chicken and pizza when out and sat down for meals at her residence, she continued to vomit.

“Are you making yourself throw up?”

“No.”

“When does it happen?”

“After I eat.”

“Do you have pain anywhere?”

“No.”

I had no idea how much faith to put into her answers. However, there was no incentive for her to lie, as we used her weight as the benchmark for hospitalization.

“What’s your favorite thing to eat?”

Her face blossomed into a smile.

“Cookies.”

“What kind of cookies?”

She thought about this. “Oreos.”

“I want you to eat at least half a package of Oreo cookies every day.”

She smiled even more. “Every day?”

“Every day.”

“That’s not really healthy, is it?” the patient’s worker asked. He, too, was worried about the patient’s health, though questioned the prudence of my suggestion.

“It’s not, but she needs to eat something. I just want to train her to eat something regularly.”

As far as we know, my patient never did this.

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(Part three of an ongoing series.)

My patient was exhausted. She tried to drink the soup the nurses gave her, but said it tasted bad. She curled up on her right side and her eyelids drooped. I watched her fall asleep.

I wanted to talk with a doctor. Though I knew that it was unlikely she would die at that moment, I nonetheless worried that she would.

At least we were in an emergency room.

In an effort to “do something”, I brought my document to the clerks’ desk. Could you make a copy of this and put it in her medical chart?

“You have to give that to a doctor or a nurse and then they can give it to us.”

“No doctor has seen her yet and I might have to leave before she is seen. Can you please make a copy and put it in her chart? It has a lot of useful information that—”

“Listen, I can’t take that. You have to put the patient’s name and medical record number—”

“I have.” Anger made me speak louder. “I’m her psychiatrist. I have information that I want them to see. Can you please—”

“No. You have to give that to a doctor or a nurse—”

“Fine. Thank you.”

I don’t know why I thanked her. I wanted to yell at her, tell her that I was a doctor and she wasn’t. Didn’t she realize that, as a doctor, I might have some idea what the physicians would want to know? Could she only cling to a policy that made no sense in this situation?

But my condescension wouldn’t have helped my patient. So I bit my tongue and returned to her. She was still sleeping.

A voice announced over the intercom: “To help ensure that patients are seen in a timely fashion, we ask that all family members please leave the emergency room at this time.”

I did not budge. My patient would not be able to explain what had happened. I needed to speak to the doctors directly.

A security guard ambled over.

“Excuse me, miss, I have to ask you to leave.”

“My name is Dr. Yang and I am her doctor. I must speak to her physicians directly. She has not been seen yet.”

“She can talk to the physicians herself.”

“Actually, she can’t. I must speak to her physicians directly.”

“Why can’t she speak to herself? Is she mentally retarded or something?”

“No.” That’s none of your business.

“I’m sorry, but you’re—”

The security guard who saw me come in with the patient hours earlier passed by. I looked at him with hope.

“She’s fine. She can stay.”

“Thank you,” I said. Both guards walked away.

More time passed and no physicians were in sight. I began to think about quality improvement. What if hospitals implemented a system similar to that at the DMV, where you took a number and had some idea where you were in the queue? Why not build that into emergency rooms?

I knew why. Emergencies come in. People are seen out of order. And whenever staff saw the chart for my patient—“Woman with schizophrenia, weight loss in past year”—I knew that they would consider her a low priority.

Because, in many ways, she was. My patient wasn’t actively dying. She would not lose significant weight in the next few hours. Furthermore, she wasn’t making any noise. At this point, she was asleep, unperturbed by the cacophony in the emergency room. To everyone else, she was Not A Problem.

Though I wanted to believe otherwise, experience had taught me that when people saw a diagnosis of schizophrenia, they often did not take the patient’s—or my—concerns seriously.

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(Part two of an ongoing series.)