(I originally posted this in May of 2006. The back story to this back story is as follows: There is a type of competition in lindy hop called “Jack and Jill“, which focuses on the abilities of dancers to dance well together in a social context—that is, their talents to adopt to and improvise with each other. This is in contrast to the performance of a choreographed routine. The clinical material is a toxic amalgamation of patients we have all seen in the emergency room.)
Jack and Jill went up the hill to fetch a pail of water. Jack fell down and broke his crown and Jill came tumbling after.
Jack had consumed about a fifth of gin about an hour prior to this incident. Due to this inebriation, he was unable to ambulate safely and subsequently could not coordinate his motor activity. It is unclear if he lost consciousness when his head hit the ground (he was yelling obscenities at the ambulance service and continued to scream expletives upon arrival at the emergency room; he was not directable and was ultimately placed in four point restraints due to his attempts to assault staff). However, he was moving all of his extremities and he clearly had a GCS of 15 at presentation. His blood alcohol level was near 400.
Jack was obviously unable to provide any pertinent history as to why he and Jill went up the hill to fetch a pail of water. Witnesses at the scene stated that Jack actually pulled Jill down the hill and that she actually did not go “tumbling after” him. Police records indicated that Jill had called 911 at least four times in the past year due to concerns that Jack was going to kill her; she stated that Jack “flew into rages” when he was intoxicated with alcohol or methamphetamine, another substance he frequently used. Jack was incarcerated for about nine months last year due to domestic violence charges; it is unclear at this time if these were solely directed against Jill.
As a result of the fall, Jill sustained several contusions and abrasions, mostly on her left arm and left leg. Radiographs revealed a comminuted fracture of her left humerus. She reported that she clearly recalled all the events surrounding this incident, but the physicians ordered a head CT scan due to fears of litigation in the event that she did sustain a head injury.
Jack’s urine toxicology screen was positive only for marijuana. Jill’’s urine toxicology screen revealed marijuana and opiates. Her past records indicated potential misuse of prescription narcotics; she was hospitalized about three years prior after sustaining a fall from a fourth-floor balcony. The history surrounding that incident was also unclear; there was some suspicion that Jack had pushed her off of the balcony into Quite Contrary Mary’s garden. Both Jack and Jill denied any foul play; she stated that like Humpty Dumpty, she was sitting on the edge of the balcony and simply had a great fall.
Jack’s physical exam and radiographs did not reveal any acute pathology, but due to his alcohol intoxication and assaultive behavior, he was admitted to the neurology service with an admission diagnosis of “alcohol intoxication”. The neurology service consulted the psychiatry service for assistance with his withdrawal symptoms. Jack later also began to articulate desires to kill Jill’s mother due to her constant intrusions into the relationship Jack had with her daughter. He also mentioned his intentions to kill the witnesses who reported that he pulled Jill down the hill. “They’re lying, all of them!” he yelled. “She tumbled after me! That gold-digging whore—once my crown broke, she wanted nothing more to do with me! Money, that’s all that skank wants!”
Although Jill sustained relatively little injury, she was ultimately admitted to the hospital to the general surgery service. While in the emergency room, she developed abdominal pain. A CT scan of her abdomen revealed some vague stranding around her pancreas and spleen; her physical exam, however, did not reveal any significant tenderness, rebound, or guarding. The surgeons elected to watch her overnight and perform serial exams and labs on her in the event that her pancreas or spleen were indeed injured.
(My apologies to Mother Goose.)
25 Apr 2007 | 1 comment.
Powerless.
“How many people do you find dead in the alleys?” he demanded, wiping the tears from his eyes. “How many people die because you won’t hospitalize them?”
I felt my heart thumping against my chest. I said nothing.
“I know this isn’t your fault,” he recanted, wiping his nose on his sleeve, “but this is like losing my son.”
“I understand your frustration—”
“—no, I don’t think you understand,” he coldly interrupted. “He isn’t your son.”
I took a deep breath. “Let me rephrase that,” I replied. “You’re right—I don’t completely understand, but I’ve had to speak with many other families about situations that are very similar to this one.”
He looked away, the tears continuing to trickle down his face.
“He’s not going to accept any help—he thinks that the secret messages from the textbooks will save him. How much worse does he have to get before he’ll get care? He can’t go home tonight—I don’t know what he’s going to do. The law in this state grants too much freedom to people; it’s gone too far.”
My heart continued to thump in my chest.
His son was reclining on a gurney a mere two rooms away, his fingers intertwined with each other and serving as a humble pillow for his head. His right ankle was crossed over his left and his light brown eyes peered at the ceiling tiles. The hunter green polo shirt, overlaying a thin, white tee-shirt, complemented his smooth, cocoa skin. His jeans, purposely tattered at the heels, barely hinted at the shape of his lean legs. A metal watch with a large, orange face adorned his left wrist and a single ring of silver was on his right thumb.
“I know it sounds weird when I say it,” the son said, a self-conscious smile appearing on his face. He was handsome; his smile radiated warmth and playfulness. He ran his right hand through his shaggy brown hair, the thumb ring glinting from the overhead lights. “The case law not only provides information about how society has organized itself in the past, but also contains the collective wisdom of all the people who have lived before us. We cannot change the future if we do not understand the past. There’s the content of the papers; then there’s the actual messages contained within. Everyone can read the messages, but few people pay attention.”
It was his first year of law school. He had stopped attending classes a few weeks prior because he believed that he needed time to recollect himself. He was receiving too much information.
“The messages are everywhere—it’s almost like I need to assemble the information to make it coherent. This responsibility is daunting—but I’m learning so much about the genesis of morality. There are other ways of living; ancient peoples had codes of conduct that were superior to our current way of living. This information is accessible; it leaps out of the books in a different print—it’s like it’s between the lines, or the words really mean something else, or it’s a code. I don’t know why I have been selected by these past societies to transmit this information to the present time, but we could benefit so much from learning about this untainted information. It is a boon to our culture.”
He had borrowed over four hundred books from the law library; about half of them were overdue. They were stacked throughout the space of his loft, creating small towers of knowledge upon which rested numerous sheets of notebook paper, each covered with sentences that contained few commas and even less periods.
“I choose not to use the computer anymore,” the law student continued. “The radiation from the electromagnetic fields of the television and computer interfere with the messages sent from the past. I find that if I focus my mind on texts only, the messages travel with greater ease from the collective consciousness into my brain. Everything else is just noise, a distraction—and I can’t waste time. There are still probably close to a thousand books that I need to read to complete my edification of correct morality. Once I can capture all of these ideas and transform them into a succinct paper, then I can disseminate it to the public to resolve the world’s problems.”
Security officers had to escort him out of the library four times the previous week and police officers found him loitering outside of the city’s public library at dawn, forehead pressed against the glass, eyes closed, and kneeling in quiet repose, on three consecutive mornings.
“I can’t tell my dad about all of this; when I say ‘collective consciousness’ and talk about the interfering radiation, he thinks I’m messed up in the head. That’s not what I actually mean,” the son said, flashing that beautiful smile while coyly looking away. “It’s just a different way of communicating.”
“He’s psychotic,” I murmured to my colleague. “He’s totally psychotic and it’s probably going to get worse unless he receives treatment. He’s bright, though, and has enough cognitive reserve to pull it together. He’s declining inpatient hospitalization, or outpatient care, or any mental health intervention, really—he says he just wants to go home and read more tonight before going to bed, so he’s at least sharing a reasonable, safe plan—and we have absolutely nothing to offer the mental health professionals to get him detained. His dad is understandably freaking out.”
“Don’t worry,” the law student said, sitting up on the gurney, twisting his thumb ring. “I’m just trying to figure all of this stuff out; I’m not going to hurt myself or anyone else. I’m just trying to help humanity.”
“He’s telling me that he doesn’t need to eat as much anymore because knowledge is his primary sustenance now!” his father bitterly said. “He started yelling in the car about the absence of morality in my soul and hoped that the collective consciousness would blot my mind out because I am not facilitating the transfer of messages from the past to the present! My son—my son!—thinks that when he dies, the collection of knowledge that he has accumulated in his brain from these ’studies’ will spread throughout the world through the sixty-fourth dimension! This is not my son! And you’re telling me that he can’t get hospitalized?!”
I took a deep breath—I knew he was not going to like what I was about to say.
“In the state of Washington,” I began, “psychiatrists—physicians—do not have the power to involuntarily detain people for mental health reasons due to concerns about civil liberties. The only people who have that power are individuals known as “mental health professionals“, who are agents of the county. There are only two states in America that use this system. The reason why this system was put in place was that physicians could unjustly violate the rights of others—for example, if I didn’t like someone, I could get him detained for illegitimate reasons. This dual agency is problematic, right? Thus, a third party—a mental health professional—is called in to assess the situation and order detention, if he deems it appropriate. Mental health professionals, or ‘MHPs’, are generally social workers and psychologists who are familiar with both psychiatric conditions and the law.”
The father nodded.
“MHPs will only detain people if two broad conditions are met: The patient has to be an ‘imminent’ danger to himself, an ‘imminent’ danger to others, or gravely disabled—that is, unable to care for one’s own safety and health. These prior conditions must be due to a mental condition. These are the criteria that the MHPs look for when interviewing patients.”
I swallowed.
“MHPs need evidence that the patient is a danger to self or others or is gravely disabled. ‘Evidence’ means reports from witnesses who heard the patient make threats, police reports, things like that. This evidence is submitted to court in the form of an affidavit and the person who wrote the affidavit may have to testify.”
I took another deep breath.
“Your son would benefit from inpatient hospitalization to prevent further worsening of his symptoms. However, he is unwilling to be hospitalized at this point and we don’t have any evidence that he is trying to hurt himself or someone else… and he’s clearly still taking care of himself right now. Thus, it is highly unlikely that the MHPs would detain him.”
“So you’re saying that he has to get worse before he could get treatment?” the father sputtered. “What kind of law is that? I understand the concerns about freedom and whatnot, but this is my son and I don’t know what’s going to happen to him if he keeps on doing this stuff! What if someone assaults him outside of the library? What if someone beats him up because he’s going on and on about ‘the genesis of morality’ and ‘transmission from the past’ and ‘the collective consciousness’? I can’t take him home this evening—he doesn’t trust me—and he needs help. He’s not going to follow up at that appointment you’ve scheduled for him—he thinks that only the textbooks can save him—and so he’s just going to get worse?”
I felt my heart thumping against my chest. I said nothing.
His father put his hands over his face and began bawling, his hoarse voice breaking into sobs.
His son was kneeling on the floor in quiet repose, eyes closed, forehead pressed against the folded sheets of paper that were on the floor.
22 Apr 2007 | 16 comments.
How I Got Into Lindy Hop.
I was eighteen years old. My social dancing experience up to that point was limited to
- the Egyptian (second grade)
- clogging (third grade)
- square dancing (fifth grade)
- the running man, kid ‘n play, the Robocop, the Roger Rabbit, and the snake (sixth grade)
- the electric slide and the macarena (high school)
(Dubbing the last two as “social dancing” is overly generous.)
In the high school jazz band, I was required to wear a necktie that featured the keys of a piano to reflect the instrument I played, though I preferred to wear one that illustrated four different facial expressions of Mickey Mouse: laughing, smiling, frowning, and pondering. In boredom, the drummer and I would often annoy the band director by breaking out into songs like Beck’s “Where It’s At”. The director did not appreciate our abilities to spontaneously improvise and entertain.
It was in this jazz band that I first became acquainted with big band music. We bobbed through Mongo Santamaria’s “Watermelon Man”, leisurely strolled through “On the Sunny Side of the Street”, located the beat in Glenn Miller’s “(I’ve Got a Gal in) Kalamazoo”, and sang with our instruments in Benny Goodman’s “Sing, Sing, Sing (with a Swing)”.
An unknown band called Big Bad Voodoo Daddy was slated to perform in one of the auditoriums at UCLA. The Office of Residential Life informed the dormitory residents that FREE swing dancing lessons would be offered prior to their performance.
Never before had I thought that rock step, step, step, rock step could be so glorious! Social dancing suddenly took on new, heightened meaning. The arm-flapping, butt-shaking, shoulder-raising, and leg-kicking associated with club dancing now seemed uncoordinated and goofy. This, I decided, is dancing.
Thus began the era of two-toned shoes, downloading of big band music (under shady circumstances—certainly not on the sunny side of the street), trips to The Derby, and admiration of zoot suits.
We never learned how to lindy hop. We watched the lindy hoppers, all dressed up in period clothing, take command of the dance floor—”how do they do that?”—but we allowed our academic pursuits to interfere with our dancing development.
A variety of factors then terminated my engagement with swing dancing: Medical school. Lack of awareness of a local swing dancing scene. Absence of my dancing partner. Academic guilt. Shyness.
Years passed. Though unpracticed, I still knew how to rock step, step, step, rock step. The music in my soul (sole?), though quiet, had not completely faded.
Having successfully completed my internship, I suddenly realized that I did not have a life outside of work. After some internal waffling, I enrolled in lindy hop classes in an effort to extricate myself from the mire of medicine—
—and I was then kindly introduced to the fantastic world of step, step, triple step, step, step, triple step. Lindy hop, along with its great uncle, the Charleston, made me smile and laugh. It still does.
I still occasionally do The Sprinkler while lindy hopping, though. I’m not above looking uncoordinated and goofy.
20 Apr 2007 | 2 comments.
Consult-Liaison.
“He’s a 34 year old guy who jumped off of a high bridge, sustained a pelvic fracture, shattered his left femur, cracked a few of his left ribs, and fractured his left ulna. Can you see him for this suicide attempt?” the orthopedic surgeon asks.
“The ambulance service brought this 82 year old woman in because the nursing home was concerned about her behavior. She was apparently wandering the halls at night, eating toothpaste, and disrobing in front of the other residents. We’re working up her altered mental status; so far, we’ve found a urinary tract infection and a few ulcers on her rear end. She was up all last night, screaming at the nurses; she also won’t stop pulling at her IV and Foley catheter. Can you help us manage her agitation?” the internist asks.
“He’s a 54 year old guy—totally nice—who was diagnosed with acute myelogenous leukemia within the past few weeks; he’s here getting his bone marrow transplant. He’s upset and crying; can you give recommendations about how to treat his depression?” the oncologist asks.
“He’s a 49 year old man with hypertension and COPD (chronic obstructive pulmonary disease); no other major medical problems. I’ve been seeing him for about five years now and recently, he was telling me about people poisoning his coffee and cars following him. He’s otherwise pleasant. Can you tell me if he’s got schizophrenia?” the family practice doctor asks.
“She’s a 26 year old, G3P1 (three pregnancies, one delivery) woman who delivered yesterday; her birth was uncomplicated. She’s freaking out now, though; she refuses to let anyone else touch the baby. In fact, she won’t even let go of the baby—and she’s constantly screaming at the nurses to go away when they check in. Can you help us figure out what is going on?” the obstetrician asks.
“She’s a 37 year old woman with well-controlled diabetes and a history of kidney stones. She’s telling me that she’s been feeling depressed and unmotivated. She doesn’t want to kill herself and she’s still working, but she’s not feeling quite like herself. She just came into my practice about a year ago. Can you assess her depression and recommend a medication?” the internist asks.
“He’s a 32 year old man with HIV; we admitted him to work up his complaints of a severe headache. He’s causing problems for staff, though; he won’t stop insulting the night nurses, but he’s just fine with the day nurses. Hardly any of the night nurses are willing to work with him—and now the nurses are also starting to argue with each other. Can you help us?” the neurologist asks.
Consult-liaison psychiatry (also known as psychosomatic medicine) works at the interface of psychiatry and the rest of medicine. The above examples describe the “consultant” role of the consult-liaison (CL) psychiatrist; the “liaison” component is often less recognized, though can be more important. Although CL psychiatrists are frequently considered liaisons only between psychiatry and other medicine and surgical services for patients, they commonly provide liaison services for everyone else involved with the patient: Doctors. Nurses. Families. Other patients. Regardless if the belief is accurate, psychiatrists are considered the artisans of the interview and thus, skilled in diplomacy and managing difficult interpersonal interactions.
Because of frequent encounters with a diverse population, CL psychiatrists frequently engage in education. Not only can they teach patients about diagnoses (or lack thereof), medication options, and coping skills, they can also educate medical staff about the same topics—including how to appropriately manage their patients independently (e.g. how to exercise more care in diagnosing depression, versus prescribing a medication simply because the patient cries during the office visit). They can provide information about mental health and facilitate further engagement, if necessary, with psychiatric services. Knowledge of various medical conditions that may (or may not) adversely affect mental status falls under the purview of psychosomatic medicine. Other services can use this information to provide optimized care for patients, as not all psychotic behavior is schizophrenia: It could be a pneumonia, a urinary tract infection, overmedication with narcotics, a brain tumor, alcohol withdrawal….
The complexity that arises from the intertwining of medical and psychiatric conditions results in intellectual stimulation, creative problem solving, and flexible application of psychotherapy skills (though not the psychoanalytic kind—can you imagine a psychiatrist pushing a couch around the hospital?). The clinical experiences offer breadth and depth: The CL psychiatrist may see all of the above scenarios in the same day (though, admittedly, most patients that CL psychiatrists are asked to see are delirious—see example #2 above).
In the inpatient setting, CL psychiatrists also get to walk around a lot. This is a bonus for those of us who don’t like sitting down all day, every day (in contrast with private practice “talk” therapists).
Two of the major deficits of CL psychiatry (from my perspective) are (1) the absence of “continuity of care” and (2) the lack of longer-term psychotherapy. Behavior change does not occur overnight—nor necessarily in one week, one month, or one year. Helping people shift their thoughts and behaviors to result in improved moods and greater successes in reaching goals through psychotherapy is… fun.
Consult-liaison psychiatry is my fellowship interest. (I hope this exposition is sufficient for the inquisitive, persistent, and self-described intueri “devotee” Catherine.)
19 Apr 2007 | 6 comments.
Thirty.
Mrs. Lefferdink was my first grade teacher. Her teaching assistant, a portly woman with big hair whose name I cannot remember (all names pale in comparison to “Lefferdink”), had a small glass jar filled with jelly beans. Upon completion of our work, Big Hair would offer us two to four jelly beans as a reward. She discouraged us from taking the yellow jelly beans, as those were her favorite.
Mrs. Lefferdink gave me a B+ for one of my coloring assignments. Apparently, I didn’t color in the Care Bear quite right.
There were about thirty of us in that class.
The drum major’s uniform was white with predominantly blue trim. Brass-colored buttons marched down the front of the coat and the royal blue cummerbund supported a royal blue sash that rested over the left thigh.
The instructors at the drum major camp advised us to keep our fingers together when conducting the band from the top of the ladder. Closed fingers create a greater surface area upon which band members can fix their gazes. The human eye is drawn to the color white, which is why drum majors usually wear white gloves.
I waved my arms and hands, with fingers closed, at about thirty people on various football fields while standing atop an aluminum ladder.
Thirty people comprised one-third of my graduating medical school class.
The general medical ward is shaped like a rectangle. The nurses’ station, along with the chart racks, dumb waiter system, and charting rooms, are located in the center. The clean utility closet, containing sterile gloves, gauze pads, unused urinal containers, Foley kits, lumbar puncture kits, central line kits, band-aids, hair brushes, toothbrushes, socks, TED hose, petroleum jelly packets, and vacuum tubes, among other items, is also in the center. Next door is the soiled utility closet, which houses bright red biohazard bins, a large toilet without a lid that doubles as a sink, basins holding traces of vomit, an old microscope, non-latex gloves, and fecal occult blood test kits.
A bright red code cart silently sits in the hallway separating the clean and soiled utility closets. The lumbering EKG machine rests next to the cart.
The patient rooms line the periphery of the rectangle.
Most of the rooms hold two patients. There are at least two single rooms, usually reserved for people who (1) lack an effective immune system (due to HIV, leukemia, etc.) or (2) have an infectious disease (tuberculosis, C. difficile, etc.).
The board that lists the names of all the patients on the ward hangs above the charge nurse’s desk.
The ward can accommodate a little over thirty patients.
Sometimes, up to thirty American soldiers die in Iraq over the course of three days.
On my way to work this morning, NPR told me that one person was dead from a shooting at Virginia Tech. My eyebrows furrowed in displeased surprise. Didn’t something like this happen recently in Seattle?
While dashing to my supervisor’s office at lunch, NPR told me that thirty people were dead from a double shooting at Virginia Tech.
My mouth fell open in shock.
“What? Thirty people?” I exclaimed to myself. “Why, thirty people is equal to….”
16 Apr 2007 | 7 comments.