Another psych patient. Could the signs be any clearer?

Another psych patient just fell on me last night. (Not the two other cases I didn’t write about.) We had split the night up and gone to bed – two hours and twenty minutes for each of the three of us on call. Two patients came in on my watch with abdominal pain. One was seriously psychiatrically ill.

He knew none of his medicines except for valium, which also was the only one he brought with him. (I actually can understand this; in an emergency, I’d definitely pick the clonex over just about any other drug.) His pain wasn’t really probably that serious, but his anxiety levels and panic caused him to pace around screaming, “I’m dying! I’m dead!” Fist pounded into wall. “Give me something for the pain!” He had a bed, but didn’t want to stay in it. He was doing the exact thing I described here. The nurses and staff were sick of him, especially since at 3 AM, most of the ER was sleeping and he was disturbing other patients. It would have been easy for me to get annoyed too, but I couldn’t, having written what I wrote just days earlier.

Everything about the story and exam suggested nothing serious. When talking to him calmly, he calmed down considerably. Touching his abdomen, even deeply, caused no obvious discomfort as long as I kept talking to him about something else while doing it. He had taken so much valium at home that I was hesitant to give him a narcotic, even though I did believe that he was in a lot of distress. I explained that to him. I thought that the thing that most would help him would probably be to give him a little more valium, maybe even IV, but I didn’t. I didn’t know how much he took regularly; he said he had taken 40 mg at home. He didn’t seem calm at all, so I figured that was just about maintenance for him.

In the hospital’s infinite wisdom, the psychiatric hospitalization discharge summaries in the computer are blocked. I couldn’t see what he was taking other than that (thinking along the lines of drug ileus), or what much of his problem was. An old medical summary had PTSD in there, but also mentioned a psych evaluation that had included episodes of psychosis under stress, borderline IQ. Whatever. All I wanted to know was what meds he was on.

The thing is, since I was already up, and not really feeling safe about giving him serious pain relief, and the nursing staff was going apeshit, I decided that it was time to try a “non-pharmacological pain control” mechanism, the kind of shit you learn about in the touchy-feely medical lectures, but never actually have time to do, and don’t believe will work anyway. I went over to the bed, stood at the head, put him back into bed, and I actually dropped the head of the bed down to put him below eye level for me. I always tend to walk in and the first thing I do is put the head of the bed UP so people don’t feel so helpless, and because it’s weird to me to talk to someone not on eye level, but this time I wanted the opposite effect.

I decided I was going to try something I’d never done before. I was going to do like the ER docs do. He was still yelling to “do something, I’m dying.” I summoned up my most authoritative “doctor” face and posture (and believe me, that gave me a little internal laugh), and instructed him to lie very still.

I examined his abdomen again very slowly, even though I had done that just 15 minutes before. I told him that nothing had changed, that everything was fine. I kept one hand on his shoulder, firmly, as I spoke. I told him that even when I went to work at the station, he was in a bed very close by, and I was keeping one eye on him to make sure nothing would happen.

To my utter amazement, it worked.

Anxiety and pain are funny, linked phenomena. People regress when they’re scared, need someone to take charge.

Unfortunately, when the morning surgeons came on, they decided that they couldn’t communicate with him well enough to rule out a serious problem without a CT. So he got a heavy dose of radiation. I never would have ordered that, especially given the whole history of the pain.

Damn.

* * *

I guess the lesson of this is for me is that there is a time and place for me to take on the authoritarian role. To speak very certainly, not explain options, just tell the patient that something is fine or not, and what the next step is. “I am now going to send you straight to x-ray,” without explaining why.

Usually when I do a physical exam I talk through it, while I’m doing an abdomen, I say as I move my hands around, “There’s the liver area, look, it’s not tender…and now let’s see about the spleen.” I also note every normal finding as I do it, because a lot of people think the worst. For example, when the doctor listens to your heart, really most of what they check is the valves only. A heart having a heart attack most likely sounds completely normal. It’s my little personal routine, as I move the stethoscope from spot to spot,  to say in between, “Everything sounds good.” This is a fairly meaningless statement, because plenty of hearts with problems sound fine, but still, it seems to me the considerate thing to do. I’ve never had a reaction other than relief or gratitude when I say this.

I also think: after all, it is the patient’s body, not mine. Just because I am trained to know things about it, to extract details about its state of health doesn’t mean that I have the right to know something about it that the patient doesn’t.

Incidentally, I also explain why I ask a weird question when I do, one that might seem irrelevant.

I do this because I remember as a kid, or not even a kid but a college student, the physical exam being so mystifying. What the hell were they doing? What could they tell? Why were they sinking their hands into my stomach? What did they hear in my heart?

But I didn’t do that this time. Instead, I examined very slowly, with a serious face, as doctorly as I could, and then gravely pronounced him “Well.” And…it worked.

* * *

I would like to improve at dealing with angry, challenging patients. Not the ones who come in angry that they are ill, that they had something horrible happen to them, that they had to wait. Those who come in immediately hostile to doctors and to me, often to women in general, and who immediately challenge me on every point, including “Good morning.” They often have very suspicious streaks toward the world in general, or narcissistic ones that mean that no one is a good enough doctor for them, that they aren’t getting the treatment they deserve, no matter what. They also often come from a perspective or worldview that is very violent or power-struggle oriented, in which the way to get something is through a show of threat.

I suck at these patients. One reason is that they are usually men who are physically bigger than me (I’m a teeny thing, even if my presence is larger than life sometimes, ha ha), and it’s always a little scary for me to step alone into an exam room with them. I rarely know these patients beforehand, so I don’t have any gauge of violent potential or what will make them blow.

Furthermore, while I can call security to come stand there, to me that seems like it would just make everything worse. Maybe not, though. Maybe I need to reconsider.

I used to think this was just a situation to deal with, that they were whatever they were for their own reasons, and I just needed to get in and out of there as fast as possible. On some level, I’m probably angry at them for them being able to scare me. I am sure that they see that they intimidate me. Then, they end up pushing me more and more for unnecessary testing, and nothing every satisfies them. A good example would be the father of the girl with no acute problem.

But I’ve noticed that some doctors walk in and manage to defuse the situation, at least partially, very quickly. Lately, I’ve been watching very closely, trying to figure out what they are doing.

I have been dealing with them in the same way that I deal with most patients, explaining everything I am doing and thinking. I think this is where I go wrong. The doctors who manage to deal with them, sometimes even get a “thank you, doctor” from them at the end, don’t do anything like this. They usually walk in very calmly, sit very close to the patient, and are absolutely unruffled by the aggression. Now, to be fair, I’ve seen mostly men who are very gentle by nature do this. And usually they are older than I am, with those few gray hairs that make them look more authoritative, more “like doctors” than I do.

They take a history, explain nothing except what will happen next. Then, at discharge, they say confidently what it is (without admitting to the uncertainty involved in almost any diagnosis), state that the patient will be fine or needs to do x, y or z, and walk out.

I think that what happens is something like this. These patients see everything as a power struggle or hierarchy. This is a primitive kind of thinking, but it is what it is. The doctors who deal with them well, I think, do something like this: they walk in and establish their authority immediately. They use the position of doctor and the socioeconomic gap as leverage; they are not “fellow human beings” in this relationship.

Yet while they do that, they use their calm, gentle demeanor to establish themselves as benevolent authority. When a patient only understands pecking order, he also understands the concept of being in the subordinate position, and can accept that, and is quite happy when the authority is benign and caring. I suspect this is what happens because the “thank you, doctor” they get is often in a very deferential tone. They say things like, “That guy was a great doctor. He knew exactly what he was talking about.”

A position of equality, or maybe of uncertainty as to where they stand, bothers them; they need to know who is in charge. With someone like me, a kid, and a girl, on top of it, all they know how to do is to push and bully. What I see as being respectful and fair and honest is seen to them as an invitation to try to get “on top.” These are the patients who get angry when I offer them treatment options.

My problem with this is as follows: we don’t always know, even most of the time, we don’t know. We can say it is nothing serious with confidence, but God knows we have no explanation for various headaches, stomachaches, joint pain, constipation, etc.

Here is an example. An older man had hernia surgery. The family was very concerned, because a few hours following the surgery, he had one episode of loss of control of urine. After that, he had no problems and the incident did not recur. They were very concerned, which is reasonable enough – after all, there are nerves down there that are definitely in the area operated on. Had he had a stroke? Had he had a seizure?

After that one time, he had no urinary symptoms, no retention, no incontinence. Normal neuro exam. It had been general anesthesia, not anything in the spinal area.

The family kept pressing me for an answer. Now, I don’t think any doctor has any idea why this happened, except that elderly people can lose continence around a medical stress. I was certain that nothing serious had happened. I said, “I don’t know why it happened. It most likely won’t recur, and there is no evidence of any damage.”

They were pretty unhappy with me.

Then a friend of mine came through (at exactly the stage of training I was), and they asked him. He immediately said, with a ridiculous amount of confidence, “It was a reaction to the anesthetic or the muscle relaxant used during the surgery, that caused the muscle to stop working for a little bit.”

Now, what he said was certainly plausible, though it isn’t really a listed complication of anesthesia. Was there any evidence that what he said was actually what happened, other than “it could have been?” No. But the family was overjoyed with this “explanation,” and loved him, while assuming I was a shitty doctor.

Most doctors do this a lot for something minor – come up with some “explanation” that sounds vaguely physiological, something that they could believe themselves. But I always feel dishonest if I do this, if I say, “We know exactly” when we don’t. When doctors discharge someone with non-serious, yet undiagnosable complaints that will probably go away on their own, they usually throw a medical word or two at it: You have “gastritis.” You have “a slipped disc.” Do they actually know the stomach is inflamed, or is the history very suggestive of it? Is there any evidence to suggest that the disc is the cause of the pain?

I have trouble doing that. I feel dishonest. I usually say something like, “You don’t have appendicitis. You don’t have gallstones. You don’t have a perforated ulcer. You don’t have anything dangerous at this moment. Given the symptoms you have and the way they occurred, it is most probably infectious and should go away on its own.” I am always afraid to toss out one of those half-assed diagnoses, because I always think that it is possible that as the natural course of the disease plays out, a different and more clear diagnosis will come through, and I’ll be the idiot who said the wrong thing.

But it seems like people really want that. Ambiguity is, apparently, a tough pill to swallow.

* * *

As for me, I seem to be doing better, as evidenced by the fact that I’m writing about medicine and life, rather than my own personal misery. In fact, I’m not sure I want this blog to take that direction; medicine consumes enough of my life, and this was supposed to be an outlet for other things, for me. My misery blog. I wouldn’t want to gather a readership that is the “medblog” group. This is where I want to be allowed not to be a doctor.

And most misery blogs get boring or abandoned once the writers get well. I mean, I’m happy for them and all, but reading these kinds of blogs, well, we mostly do it to find someone who feels bad too. During my well periods, I usually abandon this blog.

But I’m going ahead with it, at least this time, because it is roughly a continuation of the last post and touches on some psych issues, if not mine.

And knowing me, don’t worry, more misery will be on the heels of this good spell. Just stay tuned.

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7 Comments

  1. Sara, This was another excellent entry. i just loved the description of the way you “took charge” and with g e n t l e authority handled the man…and it worked! i wish i had the knowledge and writing ability to express how much your entries mean to me. Your descriptions of the events make me feel like i am almost there…it sounds like you are interacting so well with the patients…makes me wish (not for the first time!) you were my doctor! i know writing this entry must have taken a great deal of time…thank you so much…from all of us…heh, heh, and no, i don’t mean my personalities 🙂
    ” tootles”, tracy

  2. Nicely done!
    Personally, I would prefer a doctor who was ambiguous and honest. But I’m fairly well educated in anatomy and physiology, so I want the full picture, whereas many people who would go in aren’t necessarily looking for various probabilities, they would rather just hear someone say that they’re going to be okay after all.

    I agree with you 100% about those people who are aggressive with you. They’re obviously sensitive to vulnerability and will take the higher ground if they’re given the opportunity.

    You may be small, but you can be powerful. There are often body language flags that will go off immediately that will queue you in on the possibility of the next patient’s demeanor and likelihood of being aggressive like that. But I’m sure you already know that and are practicing that every day.

    That’s the biggest attraction I have to the healing profession. I love studying people and trying to determine what sort of personality they will show. Being in a position to help them is completely appealing to me.

    Of course, my main focus will be research… but hopefully I’ll have a small practice, as well.

    You rock. I love reading your writing. Thank you.

  3. I hear you in the last part of this post not wanting to have a medblog discussion, which means I’m not sure I want to post the response I was writing in my head! This is a very, very interesting post. I think about this stuff a lot and would be delighted to discuss it if that’s the direction you want to go. Or I might just talk about it on my own blog. There’s an idea.

  4. I am the difficult patient. This entry made me rethink some things. Thank you for your eloquence and passion!

  5. You make an interesting point that most misery blogs get abandoned when the writer gets well… I have to think about that. I don’t consider your blog to be a medblog – I think it just happens to intersect with a lot of different topics about medicine – and you happen to have a very unique perspective when it comes to a lot of things psychiatric.

    Maybe you need to give yourself permission to write about good things (not necessarily about work, but about life?) on your misery blog?

  6. Miss Ash – yes, people are fascinating, but a lot of them, unfortunately, are assholes, no matter how idealistically you go into the situation.

    Rach – I used to never write about medicine here. I think I didn’t even state my profession at first, just that I was a professional something. Writing about good things is usually boring. Or best saved for other forums.

    Part of the reason I’m so miserable is that this job is taking over my life…so that’s part of the reason I don’t want it to take over here as well. I want someplace I can be “me” – not the doctor not the whatever…just me.

  7. Hi,
    Some thought provoking points here. Would you like to exchange links? My address is http://leovineknight.wordpress.com (A Psychiatric Nurse’s Blog).
    Cheers,
    Leo


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