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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.


Tuesday, March 18, 2014

On Call-The Mad Crapper


It's been a while since I've posted one of my On Call chapters. For those who missed the ones I have posted, The Feel of Call and Spitback Dose, just know that I wrote these when I was a resident, and they're about my experiences taking call. Also, go to the links and read the other two, because I like them and it will make me happy if you do.

This next one may have been the first one I wrote in full, although not the first one I thought of writing. I used to think it was the funniest one. But some of the funniness has to do with my reading it out loud and doing the appropriate voices. Still, it's kind of outrageous.
Re-reading it now, though, I'm reminded of just how frustrated and angry I felt at the time. It makes me a little uncomfortable, but I decided to share it, anyway.


The Mad Crapper



One of the inpatient psychiatry floors is what’s known as a Dual Diagnosis unit. The “dual” refers to psychiatric illness coupled with substance abuse. Ideally, a dual diagnosis patient would be someone with, for example, a hardcore depression, together with a heavy drinking problem that began demonstratively later in life than the depression.
The reality is never that clear cut.
For one thing, alcohol and other drugs of abuse can independently cause psychiatric symptoms such as depression, paranoia, hallucinations, and mania, among others. There is also a widespread though inaccurate belief that the only reason people abuse drugs is to self-medicate psychiatric illness. So there’s a chicken-and-egg thing going on, and as a psychiatrist, it’s hard to tell if you’re treating a primary psychiatric condition, an addiction disorder, or an egg.
The other complicating factor is that the patients who end up on this ward are often substance abusers with no additional psychiatric problems who have run out of money, have no place to go, and malinger their way into a hospital admission to avoid spending a night on the street. The typical presentation is someone who comes into the ER in the middle of the night and tells the screening resident he needs to be admitted because, “I hear a voice telling me to hurt myself and others”. This catch-phrase is usually uttered while the patient lowers his head, covers his eyes with his hand and shakes his head from side to side to simulate despair, and also to cover up the grin spreading across his face
ER Psych residents know all about this trick- at least, they do after one or two calls. In fact, it’s fairly predictable. People get their social security checks on the first of the month, so this scenario rarely takes place either very early in the month, because there’s still money to spend on drugs, or very late in the month, in anticipation of getting the check and not wanting to be stuck in the hospital when they could be out getting high. It is, therefore, most desirable to take call around these times of the month, because there are fewer ER screens and fewer admissions.
Despite being aware of the malingering, residents are often pressured into admitting these patients due to a weird combination of liability and financial factors. The covering attending may insist on admission because he or she doesn’t want to be responsible for the off chance that a given patient is telling the truth and will go out and kill himself or someone else. Furthermore, the hospital encourages this kind of admission because it gets paid for it, and then the patient usually leaves the next day, having no tolerance for the confinement and rules of an inpatient psychiatric unit, and the absence of cigarettes and other pleasurable activities. This keeps the average length of stay in the hospital low, and the number of discharges high, which makes it look like the hospital is providing efficient care for patients, and hospital administrators and insurance companies like this very much.
The bottom line is that the patient population on a dual diagnosis unit is a tough one. Hardened by life on the streets, often with prison histories, these patients can be demanding, entitled, and will occasionally become threatening and even violent in an attempt to get their way. They usually have no tolerance for delayed gratification, and will often insist on leaving as soon as they realize their demands for drugs or “sleeping pills” are not being met.
The law requires that a patient who has been voluntarily admitted to the hospital, and who requests to be released in writing, be released within 72 hours of this request, provided he is not deemed a danger to himself or others. This written request is called a “72-hour letter”. Some patients can tolerate waiting until morning for the daytime team to make a decision about their release, after they’ve submitted a 72-hour letter at night. Others cannot.
On the dual diagnosis unit, these releases are routine, and happen each morning. When a patient insists on being released after hours, and he can’t be convinced to wait until morning, the resident on call is supposed to page one of the unit attendings at home, and discuss the situation, and get permission to discharge the patient, if it seems appropriate. As a resident, you feel bad about bothering the attendings at home about this kind of garbage, especially in the middle of the night, but they don’t seem to mind-lucky for me.
It was early in my PGY-2 year, and I was taking call on a Saturday. It was evening-not too late-and I was doing a consult on a medical floor, when I got paged to the dual diagnosis unit. When I called back, I got an earful from the heavily accented, hystrionic Phillipino nurse in charge.
Oh, doctor, it is so terrible. Please, doctor, you have to do something, Mr. so and so needs to leave right away, it was so terrible, what he did.”
I said, “Okay, slow down, tell me what happened. Did anyone get hurt?”
Oh, doctor, please you need to help. Mr. so and so is demanding to leave the hospital right now. And doctor, he went around to all the rooms, and he defecated in the doorways, and we had to clean it up, and now he is threatening to do it again if we don’t let him go right away. Please, doctor, you need to call Dr. G right now.” All this spilled out in a rush, without any trace of irony or humor.
I took a deep breath. I thought about the attending, a man who was never seen wearing anything besides his custom-tailored suits and shirts with French cuffs and matching tie/pocket-square/cufflinks. I didn’t relish the idea of calling him at home in his Park Avenue triplex, to ask him if I could let a patient “go” because he “went” all over the unit and was threatening to do it again. Could I really count on his usual good sense of humor in this situation?
And besides, was it really necessary to give in to this threat? If the guy just finished shitting all over the place, he probably wouldn’t be able to do it again for another few hours, at least. Maybe we could just not feed him, and let him leave in the morning. Or maybe we could placate him with some methadone, which he’s probably addicted to anyway, and which would constipate him and prevent any further attempts.
And then I wouldn’t have to bother calling Dr. G.
Okay, F. Calm down. I’ll call him, and then I’ll get back to you. Just give me his number.”
I paged him, and he called me right back. Oh, why couldn’t he have blown off the page?
Uh, hi. Dr. G? This is Psych Practice. I’m sorry to bother you.”
That’s okay. What’s up?”
Well,” Oh, please let him not be in the middle of dinner right now, “You know Mr. so and so?”
Yes?”
Uh, h-he would like to be discharged. Uh, now. The thing is, he’s kind of demanding to be discharged, and it seems he, uh,” say this real fast, “defecated-all-over-the-hallway-and-he-threatened-to-do-it-again-if-we-don’t-let-him-go-right-away.”
I swear, I could hear the wry smile creeping onto his face.
Let him go,” very matter-of-factly. He’s still smiling.
Uh, okay. Thanks, Dr. G. Sorry to have bothered you. Uh, goodbye.”
Should I have told him to have a nice evening? To enjoy his dinner?

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