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Consult-Liaison Education Lessons Medicine

Red Herring (I).

I sat in the emergency room and flipped through a magazine. I wasn’t actually reading; it was a way of distracting myself from all the noise.

Three hours had passed. No one had seen my patient yet.

The nurses, bless them, were kind to my patient. They brought her food and noticed that she was taking gigantic bites, but not swallowing any of it. The pocket of food in her cheek expanded and desperation stretched across her face.

“You don’t have to swallow it if you don’t want to,” I said, worried that she would inhale the food. “You can spit it out.”

A nurse saw us and grabbed some paper towels. “Here, spit that out. I’ll get you some soup. You look like you’re struggling to eat that.”

My patient obediently spit out the wad of food and looked relieved.

“Can you please document that in your notes?” I asked.

“Of course. I’m sorry that no one has seen her yet. Do you want another magazine?”

“No, I’m okay, thanks,” I said. She nonetheless returned a few minutes later with two magazines from last year.

Three hours earlier, I had shared a clipped account of her history to the triage nurse and she sent us to the medical side of the emergency room. I supported this decision, as I wanted my patient evaluated for medical concerns. That was the chief reason why I went with her. My patient would not be able to describe the problem. She’d say she was fine.

Upon learning that I was a doctor, the unit nurse pulled the emergency room attending physician away from a computer and asked me to talk to her. I immediately launched into my patter, summarizing why we were there.

I saw it happen and almost wanted to laugh: Her features hardened. The muscles that allowed any possible soft expression on her face tensed up. Her face showed nothing but muted anger.

“I don’t even know if I will see her. I’m going to go away now,” she said at me. As she was walking away, I heard her mutter, “Why didn’t she go to psych?”

During my entire time in the emergency room, she never came near us again.


My patient did not want to go to the emergency room.

“But we have to,” I said, trying to sound calm. I wished I didn’t feel as frantic as I did.

“I don’t want to go,” she said, literally hopping from one foot to another. She wrung her thin fingers together and fear overwhelmed her face. Those sunken temples seemed to sink further as she frowned.

“I know you don’t want to go, but we have to,” I said, pointing at the scale. “I said that you would have to go to the emergency room if your weight dropped below 100 pounds. Remember?”

“Yeah.”

“What is your weight today?”

“99 pounds.”

“And what did I say would happen if your weight dropped below 100 pounds?”

“I’d have to go to the hospital.”

“That’s why we’re going to the hospital.”

“But I don’t want to go to the hospital.”

“We’re going to the hospital. I’m coming with you.”

We sat next to each other in the back of the car.

“You’re coming with me, right?” she asked, her eyes looking abnormally large in her head.

“Yes. I am going to be with you until a doctor sees you. I want to talk to the doctors directly, too.”

I had written up a document that summarized pertinent information about her: name, birthdate, diagnoses, medications. I wrote down the details about how her weight had fluctuated over the past year, how she went to a different hospital just six months prior for the same reason. I wrote how she had needed two blood transfusions, how they had dropped a camera down her esophagus to look around for disease. Except for mild inflammation, everything was normal. I wrote that I had reduced her psychiatric medications; she didn’t need to take so many. I wrote that she was fine, that her psychiatric symptoms hadn’t changed in months. I shared my fears that her symptoms were due to medical reasons. I didn’t want the hospital staff to follow the red herring that was her psychiatric diagnosis.

Back in the emergency room, the nurse had asked her to take off only her shirt and put on the hospital gown. My patient peeled everything off with no shame. As she pulled herself onto the gurney, everyone saw her gaunt buttocks through the gown flap.

The hours passed. The emergency room was busy. More gurneys were pushed into the room and people were muttering, screaming, upset.

She looked at me. I smiled with my lips, but not my eyes. We continued to wait.


Part one of an ongoing series. Read more for

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Education Homelessness Informal-curriculum Lessons Medicine NYC Observations Policy PPOH

Supervision and Support.

To conclude a description of my previous job at PPOH in New York, let me tell you about Friday afternoons.

Every Friday afternoon, the staff psychiatrists met as a group for three hours.

Those three hours were important and valuable. During that time, a variety of activities occurred:

Case presentations. Different psychiatrists presented cases to solicit ideas and help. Hearing the thoughts of others provided fresh perspectives and helped us “think outside of the box”. Each psychiatrist had his specific strengths and this forum allowed us to access his expertise.

Example: Someone once presented a case about a woman who was refusing to accept treatment for a major medical problem. The psychiatrist had assessed her decisional capacity and it appeared intact. This meant that we—other doctors, her psychiatrist, other non-medical staff members—had to respect her wishes… and also watch her become more ill and eventually die. The psychiatrist who presented this case wanted to (1) ensure that his assessment of her decisional capacity was thorough, (2) learn how to manage the (often angry and frustrated) reactions of the other physicians and non-medical staff, (3) get ideas about how to coach the other physicians involved in the patient’s care when they wanted to do something and she refused, and (4) vent and get support from us, as managing his own reactions and the reactions of others was taxing.

Sometimes the case presentations were less complicated: How can I encourage this patient to try medication? Is there anything I can do to get this patient to stop asking for medication? Do you have any ideas as to how we can keep this guy out of the hospital?

Grand Rounds. Grand rounds refers to a lecture on a specific medical topic. It is often considered a “big event” (i.e. lots of people are invited or expected to go). In academic medical centers, someone well-known in the subject usually gives the lecture.

PPOH established a Grand Rounds committee[1. The PPOH Grand Rounds committee was comprised of two people: a senior PPOH psychiatrist and me, as we were both interested in medical education. If you would like me to speak at your Grand Rounds or provide other teaching, let me know.] to organize a series related to homelessness and mental health. Speakers with expertise on schizophrenia, common infections in the homeless, harm reduction, housing first, tobacco use and cessation, and other topics shared their knowledge with us.

These lectures were an essential part of continuing medical education. We need and want to learn so we can provide excellent care for our patients, particularly since there is a dearth of literature for this population.

Peer supervision/support. Every job has its challenges. In psychiatry, it is no different. Working with individuals who have significant mental health problems, homeless or not, can be stressful. Sometimes we feel anger towards patients. Sometimes we feel frustration with other psychiatrists or physicians. Sometimes we feel scared that we did something wrong. Sometimes we worry that our patients will die.

Much of psychiatric training uses the apprenticeship model. While in residency, we meet with “supervisors” (attending psychiatrists) on a regular basis. Supervisors provide coaching and guidance to help residents learn psychotherapy and prescribing practices. This is also where the informal curriculum is taught: Supervisors are essential in teaching (demonstrating) professionalism and attitudes. It is during supervision that we also learn to examine our own reactions to clinical encounters… and, oftentimes, our reactions tell us more about ourselves than about our patients.

I was deeply grateful for these weekly three-hour meetings. (I have since realized that this set-up is rare. No money is gained while physicians are meeting for supervision. Neither patients nor insurance companies are billed. From a financial standpoint, it is wasted time. However, I’d like to think that this investment in physicians ultimately provides benefits for patients. I don’t know if there is any data to support this, though I believe it is absolutely true.) The built-in network of peers gave me security: I knew I could trust them to help me become a better doctor.

Many medical students and residents feel embarrassed to ask questions. They might feel ashamed to say “I don’t know”. With time and experience, that shame goes away. It’s okay if you don’t know. What you do next is what matters: If you need help, ask for it. You will (re)learn something, you will take better care of your patients, and you can then help another doctor in the future.


Categories
Lessons Medicine Seattle

Happy Thanksgiving.

Originally written in 2004. Remember all those things and people you are grateful for.


Happy Thanksgiving. You’re holding the slender and sweaty hand of your beautiful girlfriend. Her eyes are halfway closed and her entire body stiffens. Her head slowly turns towards the left. Her pupils are large, oh so large, making her green eyes that much more beautiful.

She’s seizing again.

The heart monitor shows her heart ticking away at 160 beats per minute—no, make that 170. Now 180.

The nurse, the mother, and the physician look at the heart monitor, as if it is some sort of oracle that will exorcise the spirits that have overtaken the body of this beautiful young woman.

Drugs are pushed. Her eyelids flicker, her body slackens a bit. She begins to mumble again. She picks at her sheets. Those green eyes show themselves again and she takes your hand, addressing you as her mother.

You take her hand, feeling that lovely warmth between your fingers. You stroke her hand gently as she continues to babble nonsense through the fog of her encephalitis. She begins to laugh—at what, you’re not sure—and you can’t help but laugh with her.

She’s right there before you, but she doesn’t know who you are. So all you can do is squeeze her hand again.

Happy Thanksgiving. Your sister has a brain tumor that has pushed most of her brain towards the left side of her head. She’s sleepy. She won’t wake up. She can’t move the right side of her body. She, of course, is not aware of this. You are.

Along with your mother, your church, her friends, and other relatives. You have somehow packed fifteen people into the room. There are ten more people outside, peering into the room. You’re crying. You’re trying not to. You’re worried that she’s suffering, that she’s in pain.

You ask questions about morphine—is she in pain? is she choking on her saliva? why is she making that sound? why is she breathing funny? What you really want to ask is When is she going to die? but you can’t because it just isn’t fair. She’s so young. Why does she have to have a brain tumor? Why does this have to happen today?

You ask for morphine—and the doctor knows that it’s not for your sister; it’s for you. You’re suffering for her. You’re suffering because of her. And you want to make it stop.

She’s too young to die.

“Nobody can predict when she is going to die,” the young doctor says with greater confidence than she actually feels. In fact, she is horribly terrified that she is going to say the wrong thing, that she is going to break fifteen hearts simultaneously. But she continues softly: “Just as every individual leads a unique life, each person dies a unique death. And no one knows when or how it will happen. But we will do everything to make her comfortable. And please let us know what we can do to help you.”

You burst into tears. It is that “D” word. That horrible “D” word that is going to steal your sister from you.

You don’t see the young doctor after she leaves the room—she travels through the stairwells, thinking about many of the things that are going through your mind. And you don’t know that this young doctor has never declared a death before[1. The patient in question did die on Thanksgiving. I declared her death. Every Thanksgiving, I think of her.] and may have to do just that, tonight, on Thanksgiving.

Happy Thanksgiving. There is a smorgasbord of Thanksgiving goodies in the hallway, in the nurses stations, in the Tupperware boxes that relatives and friends are bringing to the hospital. Little children are drawing pictures of scraggly turkeys with worn-down crayons. Elderly mothers are cutting turkey breasts into chunks to feed to their sons. Young daughters and sons are laughing with their fathers who are sitting in the ICU, wires and tubes encircling their bodies. Couples stare out the windows, talking softly, watching the light rain drizzle upon the dying trees towering over Seattle.

“Happy Thanksgiving,” I said into the phone. “I just wanted to call and say ‘I love you’, Dad, because, you know, you could be in the hospital today. And you’re not.”

“Happy Thanksgiving, Maria,” he replied. “I love you, too.”


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Blogosphere Medicine

The Last Time.

Dr. Charles solicited entries for a poetry contest a few months ago. The judges have made their decisions. You can read the winning entries here. Congratulations to the poets!

Poetry has never been my thing, though I nonetheless submitted a poem for a chance to win a tomato. You’ll notice the striking resemblance to prose. Enjoy.


The Last Time

This can’t be the last time I see him
He doesn’t look like the man I married
A machine breathes for him
Bags of fluid drain into him
Wires are taped all over him
His eyes are closed, his limbs are swollen.

This shouldn’t be last time I see him
I have yet to see him alone.
Doctors are coming and going
Doctors who don’t know that he
volunteers at the soup kitchen
has hiked most of the Appalachian Trail
bakes a tasty chocolate cake
can make any child laugh.

Will this be the last time I see him?
They’ve pushed me out the door
Someone is injecting something into his arm
Someone is pushing on his chest
Someone is shouting “CLEAR”
Someone glances up and sees me, then looks away.

This can’t be the last time I see him
It was never supposed to be this way
He was supposed to grow old
Die in his sleep, quietly, with no pain
In his own home, where he lived, laughed, and loved.

This is the last time I will see him.
And we never got to say good-bye.