Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Friday, May 17, 2013

On Call

Like Dinah over at ShrinkRap, I'm fed up with DSM-5, CPT. EMRs, RDoC, APA, E-rx, AMA, and NiMH, even if I could find Mrs. Frisby there.

So what to write about?

When I was a resident, I starting writing little vignettes about my experiences taking call. Eventually, I had written enough of them that I thought they would make a nice book, On Call: Stories from a Resident's Night. I never published it, although I may self-publish at some point. But I thought I'd share a chapter.

It was intended for a lay audience, so there're some explanations that people reading this blog probably don't need. But I'm guessing people will relate to the experience.

Spitback Dose

I'm in the ER on a Sunday evening, maybe 7PM. A guy comes in, typical story- suicidal, heroin addict, HIV positive. 
I go through my usual routine of checking the computer system for any previous admissions.
Yup. He’s been here before, but not on psych. He was on the detox unit. 
Aaaaand, he was discharged today. At 3PM. 
You know what? His chart is probably still on the unit. I'm gonna run up there and get it, before the chart fairy spirits it away to medical records, where it will serve its obligatory 5 to 10 months under a pile of disoriented neurology charts.
I head up to the detox unit, and sure enough, it’s there. I start to read.
Admitted 2 days earlier for heroin detox. Administratively discharged. That means they kicked him out.
For giving a spitback dose of methadone to a female patient, in exchange for sexual favors.
What’s a spitback dose?
I have no idea. Or, more accurately, I know exactly what a spitback dose is, and I don’t want to believe it.
I try to imagine the routine on that floor. The guy comes to the nursing station. He’s given his dose of methadone in a little paper cup. He gulps the contents quickly, in front of the nurses, but keeps the liquid in his mouth. Then he shuffles down the hall, past where he can be seen by the staff, and spits the dose back into the cup.
He then hands the cup to a female patient, who downs it, HIV-infused spit and all, and proceeds to blow him in the bathroom.
The thought of the blow-job doesn’t bother me, but I’ve always been kind of grossed out by saliva related substances. I’m grateful I’m not a heroin addict, because the choice between getting my fix, and drinking someone’s spit would be a rough one for me.
I’m not sure how the staff found out about it, but I don’t care. Now I have my ammunition. I can easily convince the ER attendings that this guy needs to go. And I don’t have to admit another lying, conniving, manipulative drug addict to my pristine unit, and get blamed by the attendings for not being sufficiently selective. 
I repeat to myself my ER mantra: “I, am a wall!”
I’m practically skipping when I get back to the ER. I see the head nurse, H, who has worked here for years and who’s seen everything. 
Everything minus one, as it turns out.
I tell her about the spitback dose. She has the same reaction I had, “What’s that?”
I explain. 
She’s incredulous. 
I say, “No, really.”
She says, “Oh my god!”
As I’m walking away, she pulls over one of the other nurses and says to me, “Tell him about the spitback dose!”
She repeats this process 5 or 6 times during the course of the call. I guess she’s also surprised that she hasn’t seen everything. I have my 15 minutes of fame that night, and I repeat another mantra: “You can’t make this stuff up.”

The information I have about this guy, however juicy, does not absolve me of the responsibility of evaluating him for admission. So I call him into the office. I leave the door open. He’s jumpy and scary looking. He obviously needs a place to be, and probably doesn’t have money for more drugs, so if he’s not in a hospital, he’ll have to tough out a cold turkey detox. 
I look at his eyes. The pupils aren’t pinpoint-sized, which means he hasn’t been using. And they’re also not inordinately wide, which means he’s not in any significant withdrawal yet. None of which really means anything. 
Addicts know how to fake withdrawal symptoms, so they can get an extra dose of whatever, to keep them comfortable. If they want to be sweaty, they do some pushups. If they want widened pupils, they go into the bathroom and leave the light off for a few minutes. If they want goose bumps, they douse themselves with cold water until they start to shiver. If they want to vomit, they stick their fingers down their throats.
The detox staff knows all these tricks. In fact, if the patient complains of needing an extra dose of methadone because he’s had diarrhea, he won’t get it unless said diarrhea is still in the toilet, and the nurse has verified it.
It always amazes me how the extremes of pain and mental suffering are so intimately connected with bodily substances.

I ask the guy why he’s here. He says he’s depressed, and he wants to kill himself, and he needs to stop using. It’s the standard FOS line. Unfortunately, it’s also true. But the bottom line is that this man is a survivor. He gets kicked out of a hospital for unacceptable behavior, and 4 hours later he’s back, unabashedly seeking admission again. He probably does want to kill himself. But he’s not going to. He’s too precious to himself. 
Could I be wrong? Yeah. Could this be his end of the line, and I’m just too jaded to see it? Sure.
But I’m probably right. And a hospital is not a hotel. You can’t just check in when you run out of money and drugs, and expect 3 hots and a cot. It’s a place for people who are genuinely ill (which this guy is), AND ready to try to do something about it. I don’t think 4 hours is enough time to become ready.
But there’s another reason I don’t want to admit him. I’m tired of being taken for a sucker. The 4am Xanax runs. The FOS malingerers. This is my turf, and I’m gonna defend it. I am a wall. I don’t let the enemy pass unchallenged.
And this time I’ve got the facts on my side. Even the most conservative ER attending won’t mind kicking this guy out, to say nothing of Dr. C, the hyper little man who once yelled at a malingering patient, “Get out of my ER! My tax dollars are not paying to support your drug habit when you run out of money for food!”

I ask Mr. Spitback a few more questions about his medical and psychiatric history, then I tell him I need to talk to my supervisor. I have not told him I read through the chart from the detox unit. I don’t want to introduce this topic with no one else around. He’s denied having been here recently, so he’s outright lying.
I get the attending, and together, we explain to the man that we know about what happened earlier that day on the detox unit, and that he’ll have to leave. We try to get him to sign the discharge papers, but he refuses. We walk away while he’s gathering his stuff.
As he walks past me, on his way out, he yells, “I hope your husband fucks you real hard up the ass!”
I pray I never see this man again, particularly in a dark alley. At the same time, I realize that in his life scheme, I’m not very significant. He’s been kicked out of places before, and he probably wouldn’t even recognize me if he saw me. 

This vignette was the most difficult one for me to write. At first I thought it was because it was unnerving to experience an attack so infused with fury and hatred. When it happened, I even briefly considered calling security, or the police, to show this guy he can’t treat me this way. And who’re they gonna side with? A female physician, or a male drug addict? They’d probably beat the shit out of him.
But I think it’s more than the fact that it was scary. I’ve had other scary encounters with patients. I’ve even been hit by patients, on two separate occasions.
What bothers me is that this man came seeking help, came to a hospital, a place of healing and comfort. And instead of being helped, he was treated like the enemy. I don’t think the hospital has the resources to deal with his problems. I know I don’t. But this doesn’t imply that he should be demeaned, or viewed as an enemy. 
What hurts is how easy it was for me to lose my sense of compassion in order to protect myself from feeling helpless.

1 comment:

  1. thanks for writing the post

    you describe a very difficult experience