Category: Medicine

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Consult-Liaison Education Medicine Reading

DSM-5: Delirium.

This post is the most recent addition to my DSM-5 e-mail list. I include it here only because I apparently have a fondness for delirium; it was one of my favorite teaching topics when working with medical students. If you’d like to read my other DSM-5 summaries, let me know.

(724 words = 5 min read)

How rarely, particularly outside of hospital settings, do we remember to think of delirium!

DSM-5 lists five criteria for delirium:

A. There is a disturbance in attention and awareness.

Because people who are delirious have problems with focus and sustaining attention, this means you might find yourself asking the same questions over and over. The delirious patient may end up providing the same answer over and over, even though you’re asking a different question.

Furthermore, if patients have severe inattention, they might not be able to have a conversation with you at all.

B. Delirium develops over a short period of time, typically hours to days. There is a change in baseline attention and awareness. It fluctuates throughout the day.

Attention and awareness often worsen at night (sometimes referred to as “sundowning“).

C. There is also another disturbance in cognition, such as in memory, orientation, language, and perception.

Delirious patients might think that a pair of socks is an opossum (illusion), the nurse is trying to sell his blood (misinterpretation/delusion), or that he can hear the conversations that are happening in the cafeteria (hallucinations/delusions).

D. The disturbances in (A.) and (C.) are not better explained by another pre-existing, established, or evolving neurocognitive disorder. (Having a neurocognitive disorder, however, increases the risk of the development of delirium.)

You also can’t diagnose delirium is someone is comatose. Essential to the diagnosis of delirium is that the patient can respond to “verbal stimulation”.

E. There must also be evidence that the delirium is due to a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies.

This means that delirium always has a cause. Your job is to find that cause (or work with someone who can help you find that cause).

There are many specifiers for delirium (which clarify the cause):

(1) substance intoxication delirium
(2) substance withdrawal delirium
(3) medication-induced delirium
(4) delirium due to another medical condition
(5) delirium due to multiple etiologies
(6) acute
(7) persistent (how terrible!)
(8) hyperactive (more frequently recognized, because these are the people who are shouting that they are on a boat and think that the IVs are snakes)
(9) hypoactive (this is often missed because these are the people who seem to be the most “compliant” patients ever)
(10) mixed level of activity

DSM-5 spends a fair amount of time discussing the recording procedures. If you are a consult-liaison psychiatrist, you should look those over.

DSM-5 states that, in hospital settings, delirium usually lasts about one week. Some symptoms, though, persist even after individuals are discharged from the hospital.

Delirium is considered a “great imitator” amongst psychiatrists. People who are delirious can look psychotic, depressed, manic, anxious, or a combination of all four. Delirium also messes with sleep-wake cycles and may manifest more at night because there is less environmental stimulation present.

DSM-5 provides some prevalence numbers:
(1) people in the community: 1-2% (that number ideally should be 0%)
(2) hospitalized people: 6% to 56% (this is not a comforting range)
(3) people who just had surgery: 15% to 53%
(4) people in ICUs: 70% to 87%
(5) people in nursing homes: 60% (yikes!)
(6) people who are at “end of life”: 83%

Thankfully, the majority of people with delirium experience a full recovery, though delirium is a harbinger of death: About 40% of people who are diagnosed with delirium in the hospital are dead within a year. Delirium also increases the likelihood of “institutional placement” and “functional decline”.

In addition to neurocognitive disorders, other risks for delirium include extremes of age, drug use, polypharmacy, a history of falls, and functional impairment.

Delirium is a clinical diagnosis (there is no test for it), though EEGs might show “generalized slowing”.

I have never thought about the differential for delirium, as that is what I always consider first (but that may be due to my past work as a consult-liaison psychiatrist). DSM-5 includes psychotic disorders, acute stress disorder, malingering, factitious disorder, and other neurocognitive disorders in the differential for delirium. Rarely, though, do those conditions have the “waxing and waning” in level of consciousness and attention that is seen in delirium.

I’ll resume sending [DSM-5] posts out after January 1st. May you all recall fond memories from 2013. May 2014 bring you good health, mirth, and ongoing learning.

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Consult-Liaison Medicine Observations Policy Systems

Ever Seen a Hospital Orientation?

Perhaps more important than the actual “rules” of hospitals is how these “rules” are communicated to patients.

Medical students spend two years training in a hospital before they work as physicians. It often took me over a week on a specific service (e.g., surgery) to understand its routines and rhythms. While it is true that patients and hospital staff have different roles in the hospital, how can we expect patients to understand their roles upon admission?

Those of you who work in hospitals might be thinking, “But patients don’t have roles in the hospital. They’re there to receive care.” Of course patients have roles in the hospital. When patients deviate from the roles you think they should play, that’s when you start calling them “difficult” and then consult psychiatry.

In general, hospitals have not honed their skills in orienting patients to their roles in the hospital. Rarely does anyone tell you what to do or what to expect when you go to the hospital. This orientation may happen on an individual level (thank you, nurses!), but it is an uncommon institutional practice.

Consider all the places you visit that are not “yours”, though you might be labelled the “customer”. How about fast food joints? They often have signs that tell you where you order your food and where to pick it up. The cash registers tell you where you pay. Shallow corrals tell you where to line up. Those are small details, but they help define your role and shape your behaviors while you are in the fast food restaurant.

Hospitals would do well to adopt the practices of airlines. Have you been on an airplane? Remember how you paid attention to the safety announcements before your first flight? The flight attendants tell you how your seatbelt works, point out the exits to you, tell you about the flotation device that is disguised as a seat cushion, and how to work the oxygen masks that will appear if the cabin pressure drops. It only takes a few minutes. And, in case you want to review the information on your own, they include all of that information “on the card in the seat back pocket in front of you“. Have you ever looked at that card? There are few words on it: It aims to be universally understood.

Why not include a small booklet—comic book?—in each hospital room that provides similar orientation?

Consider hotels. Not only do hotels have written material in each room about hotel operations, but some of them also have a television channel dedicated to hotel features and operations!

Most hospital rooms have a television bolted to the ceiling or to the wall. Why not develop a “hospital channel” that offers similar information about hospital operations and features?

A skim through Google shows me that some children’s hospitals (in Cincinnati and Chapel Hill) have created YouTube videos that offer hospital orientation to kids. Why do we not do the same for adults?

When I have worked in hospitals, I often felt like there wasn’t enough time for me to do everything I needed and wanted to do. When I sat in my mother’s hospital room, I was surprised with how much waiting we did. That time could be used to teach patients and their family members what to expect during the hospitalization, like when the doctors typically round (and what “rounding” even means) or what to do when the IV starts to beep.

If you work as a hospital CEO or at a similar paygrade, I encourage you to work on easy-to-understand materials that orient patients to their roles in the hospital. Realize that patients want their hospital stays to go smoothly. They want to know what to expect. The vast majority of patients don’t want to “bother” hospital staff. They want to help hospital staff so that the medical staff can help them. Patients don’t want to stay at the hospital longer than they have to.

Understand that hospital orientation is like building rapport on an organizational level. Data shows that effective communication between physicians and patients leads to better patient health outcomes. If the outcomes are better on an individual level, why couldn’t outcomes improve on an institutional level?

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Education Medicine Nonfiction Observations Systems

Who Works at a Hospital?

Who works at a hospital? (Again, just indulge me for now.)

Doctors. If you’re a patient at a teaching hospital, this includes medical students (people in school to become doctors), interns and residents (people who have earned the title of “doctor”, but who are still learning their craft), and attendings (people who have completed their formal training as physicians). If you’re not at a teaching hospital, it’s less likely you’ll see medical students and other trainees (the army of white coats tromping through the hallways). Instead, you’ll see lone attending physicians.

Nurses. Nurses play vital roles in patient care; without them, hospitals simply would not work. Nurses arguably spend the most time with patients. They monitor and observe patients around the clock. As a result, they’re often the first to realize that something has changed and thus have the responsibility to do something about it.

There are different kinds of nurses, such as registered nurses, licensed practical nurses, and certified nursing assistants. Their roles differ in terms of their training, skill sets, and responsibilities, but they all serve to observe and monitor patients and their conditions.

Therapists. Not the talky kind. There are respiratory therapists, speech therapists, physical therapists, and occupational therapists. They focus on skills and function: How can we help this patient walk? How can we help this patient talk with less difficulty? How can we retrain the muscles in this patient’s hand so he can write again?

Technicians. Radiology technicians, pharmacy technicians, surgical technicians, electroencephalogram technicians, patient care technicians… the list is long. They assist other professionals in the hospital in their duties and may have more contact with patients that the professionals themselves.

Consider an ultrasound technician. A physician may order the ultrasound, but it is the technician who will explain to the patient what an ultrasound is and perform the procedure. A radiologist will interpret the results.

A special note about patient care technicians (PCTs): These individuals often spend the most time with patients and are often a treasure trove of data for nurses and physicians. If you are a physician working in a hospital, make a point of talking with the PCTs. They’re the ones who will know if the patient slept, went to a procedure, has a change in mental status, etc.

Janitorial staff. These individuals have one of the most important jobs in the hospital: They help with hospital-wide infection control. They help prevent people from getting more sick. If you work in a hospital, thank a janitor today for what they do.

Clerical staff. This includes the clerks who serve as receptionists for the hospital units (not an easy job: imagine juggling phone calls from patients, managing the anxiety of family members of patients, paging physicians multiple times because they don’t call back…), hospital operators, all the people working in medical records, and the staff who work with the hospital administrators. Hospitals generate a lot of data. Someone has to help manage and organize all that data.

Information technology staff. Electronic health records now hold patient information. The networks fails. The mouse doesn’t work. There aren’t enough terminals. Someone can’t remember their password. The radiology images aren’t showing up. The orders didn’t go through. The IT department gets a lot of pressure to get it all right.

Food services staff. There are all the people who cook hospital meals, transport and deliver the meals to each patient, and wash the leftover dishes. These people also prepare the food in the hospital cafeteria, which feeds the rest of us who are well enough to get it on our own.

People want to eat and they want to eat food that tastes good. In the hospital it is hard to please all of the people all of the time.

Environmental services staff. These are the plumbers, electricians, HVAC experts, etc. who make sure that the electricity stays on, that there are backup generators available, that the water temperatures are satisfactory, that the ambient temperatures are within a certain range, that the windows seal tight, etc. If the building doesn’t “work”, then the hospital doesn’t work.

Pharmacy staff. I don’t know how many thousands of medications are available, but the pharmacy takes care of all of them. Whether they are amazing antibiotics that will drip through an IV or cartons of chicken soup (yes, doctors can order chicken soup), the pharmacy takes all of those orders and fills them. They ensure that medications are available in every single hospital unit and prepare medications for patients to take with them when they leave the hospital. And they have to make sure that they fill the right drug at the right dose at the right time for the right person.

There are many more people who work in hospitals; I do not omit them willfully. We often take for granted all the people who make a hospital work.

If you are a patient (or someone visiting a patient) in a hospital, I encourage you to thank all the people who have helped you. Hospital staff appreciate hearing that and want to know that their actions made a difference.

If you work in a hospital (especially physicians), I encourage you to thank your colleagues, particularly those who have a completely different job from yours. They are doing something to help you do your work. Let them know that you appreciate it.

Next time: The “rules” of the hospital.

Categories
Education Medicine Observations Systems

What is a Hospital?

So what is a hospital? (Just work with me here.)

Hospitals are physical structures. They are buildings that have rooms and beds. People, who become “patients”, are “admitted” into a hospital and assigned a bed. Because patients receive a bed, there is an assumption that they will be in the hospital for at least one night. This is called an “inpatient” admission, because the patient is “in” the hospital. (Contrast this to a visit to a clinic, which is called an “outpatient” encounter.)

Hospitals provide acute health care. “Acute” can mean “intense” (like cutting someone open to remove an organ or the delivery of a baby in a mother who has major medical problems) or “fast” (like giving a patient antibiotics through a vein to fight an infection or using a machine to help filter blood when a patient’s kidneys suddenly stop working).

Because most hospitals offer services from nearly every medical specialty, patients can experience “one stop shopping” for acute health care issues. Patients might see four different kinds of doctors, have numerous tubes of blood drawn, undergo five imaging studies, receive education from dieticians, undergo strength training with physical therapists, and talk with pharmacists about their medications.

Hospitals permit around-the-clock observation of patients. This is directly related to the previous point and is arguably the primary reason why people are in hospitals. If someone does not require frequent and regular observation, then she doesn’t need to be in the hospital. All that staffing and equipment in the hospital serve to monitor patients and their health (heart function, breathing, infection, etc.). If medical staff observe an acute change, they can then deliver an acute intervention.

Hospitals are businesses. Hospitals, like hotels, want a low vacancy rate, as this is how they make money. Sometimes patients are ushered out of the hospital sooner than expected because other patients are waiting for open beds. (I’ve worked in hospitals where, in the morning, the operators announced over the intercom a “code” about bed status. This was a discreet message to hospital staff about the census. If the census was high, then we were to try to discharge patients if we could.) Sometimes patients are welcome to stay in the hospital for another night because the census is low. This is not actually a good thing. (The longer someone stays in the hospital, he is at higher risk of developing an infection from the hospital. This is bad because infections that originate in the hospital are often resistant to available antibiotics. Furthermore, patients often get “deconditioned” because they aren’t moving around as they usually do. As muscles, stamina, and endurance weaken, that can cause problems with mobility and function.)

Hospitals are not places of rest. While it is true that people can recover in hospitals, that doesn’t mean that people recover in peace. Hospitals are often noisy places with frequent, unexpected intrusions because of all the observation, testing, and services that occur there.

Now that we have a general sense of what hospitals are, we’ll talk next about all the people who work in hospitals.

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Education Lessons Medicine Nonfiction Observations Reflection

Cancer.

As a fourth year medical student I did my “sub-internship” in oncology. I hoped that this rotation would help me choose what specialty to pursue: internal medicine or psychiatry.

One of “my” patients was a woman with breast cancer that had spread to her liver and lungs. Fluffy brown hair fell to her shoulders. Wrinkles surrounded her puffy eyes that held jade green irises. Though she was in pain, she was patient and kind.

On the evening of her second day in the hospital, I came to her room and asked if there was anything else we could help with that day. Her pale, thin lips stretched into a sad smile.

“No, thank you,” she answered. “Have a good night.”

“I’ll see you tomorrow,” I said.

She was sleeping when I saw her the next morning, though awoke without a startle when I said her name. She kept her eyes closed as I placed the cool, metal diaphragm of the stethoscope on her chest and back. She murmured her thanks before I left her room.

As the attending oncologist, resident, intern, nurse, fellow medical student, and I approached her room later for formal rounds, she called to us.

“I can’t see!” she gasped. “I can’t see!”

We surrounded her bed and the attending began to ask her questions. He waved fingers in front of her face. He directed the beam from his penlight into her eyes.

“I can’t see! No, I can’t see!”

“But you could see yesterday, right?” he asked. She turned her head as if she was looking around at us, but her gaze was over our heads.

“Yes… but I can’t see now. Does this mean that I will never see my husband and daughters again? Is this permanent?”

I tried not to cry. The other medical student and the intern also looked away, their eyes welling with tears.

We learned later that the cancer had metastasized to her occipital lobe, the part of the brain that controls vision. Though her eyes were in good working order, the part of her brain that interpreted the electrochemical signals from her optic nerves was not. The cancer had stolen her sight.

You learn a lot of things in medical school: anatomy, physiology, pharmacology, and other concrete facts about human function. You also learn about human relations, communicating with people with different agendas, the system of health care, and other topics that fall under the “informal curriculum“.

You also learn how tenuous life is. You see women give birth to dead babies. You see children succumbing to cancer. Healthy adults get hit by stray bullets and drunk drivers. Heart attacks and strokes steal time and life away without making a sound.

You begin to recognize the blessings that you previously overlooked: I can eat all the cookies I want and I don’t have to take insulin. I don’t need a walker to get around. My fingertips and toes can feel the soft fur of a cat, the hot water coming out of the shower, and the zing of static electricity. I can breathe without difficulty and without having to lug an oxygen tank around. My arms and legs move when I want them to. My balance is intact.

You also realize, with some dread, that all of that can change in an instant. So you better enjoy the blessings while you got ’em.

My mother was sent to the hospital with urgency the day I returned to California to visit my parents. She was subsequently diagnosed with metastatic lung cancer.

I am grateful that I could advocate for my mother while she was in the hospital. I am also thankful that I could translate what was happening—not just from English to Chinese, but also from medical jargon to plain English—to my parents.

I was struck by the degree of confusion and uncertainty throughout her hospitalization. Things that I knew as a physician were not at all obvious to my parents. Things that I knew as a concerned family member were not at all obvious to the physicians.

I was and remain humbled.

As a consequence of this, upcoming posts will focus on how health care in hospitals work, what hospitals can do differently to help patients understand what is happening, and things that both medical staff and patients can do to make the hospital experience better for everyone.