My phone rings. I stop walking. The sudden change in velocity causes the gravel under my feet to let out a slow grinding noise.
I often walk the gravel roads on the edge of town when things are slow, even at night. Maybe especially at night. Getting away from the few lights allows the full grandeur of the night sky of envelop me.
It is an expanse I rarely get to appreciate in the city where the smog and light pollution only let a few key stars shine through.
Of course, I am always within 20 minutes of the ED, but at my walking speed, that could be over a mile away. I answer the phone.
“Hey Doc, the police are bringing in a guy who has been acting strange and his mother called a safety check on him. So, they are bringing him in for evaluation.”
“I’ll be there shortly.” I turn and head back to the hospital at a slightly faster pace than before.
The Rural Mental Health Crisis Team
I walk through the doors into the ED. The standard mental health crisis is now assembled: Two small town police officers, an ED nurse, and myself. God help this poor soul, because we probably won’t. At least, not in any way which changes the trajectory of his illness.
“Hi,” Char, my nurse cohort for tonight begins. “So, this is Tim, his mom called the cops because he has been acting strange the last few days. He is talking all the time, wouldn’t let his mom into his room in the house. He has had a lot of problems with meth, so, y’know…”
I acknowledge Char’s statement, but also mentally try to put it on a back shelf.
One of the double edged swords of small town doctoring is everyone knowing everyone. On the one hand, it is quite a bit easier to get a detailed and relevant social history on people. On the other, people often have their story made up in their mind about who a person is and what is going on.
Could Tim be on meth? Sure. Does the fact that he’s done meth before mean he is one meth now? Not necessarily. I have developed a technique of trying to mentally disprove the suggested theory while also proceeding as if it an equally likely possibility. It seems to help me find balance in diagnosis.
If You Get Hurt on this Rotation, You Fail.
We did our emergency psych rotation in medical school in the ED of the county hospital, a level 4 trauma center in the middle of downtown. It was the quintessential urban ED. On orientation day, safety was the first and last thing addressed.
The attending psychiatrist, a tall, thin man who projected both bookishness and a tempered, pulled bowstring kind of hardness, listed some maxims:
- Do your first cursory exam from the door
- Never let a patient get between you and the door
- Try to project calmness
- If you feel unsafe, leave
He finished his talk with this warning: “If you get injured on this rotation, you will fail this rotation.”
Honestly, this was the scariest threat he could have made to a room full of medical students.
Whenever I find myself back in this situation, I stop at the door and do my initial exam. I look Tim over. He sitting in the bed, his hands flailing over his head in somewhat rhythmic circles. If he’d had glow sticks, he would have fit right in at a rave.
“Tim, what’s going on?”
“Just keeping everything together.” He spat out in between his rave routine.
“Are you feeling okay?”
“Oh yeah, I feel great. I just got to keep everything moving.”
“Have you been doing any drugs?”
“Do you know where you are?”
“Yes, the hospital.”
“Do you think anyone is out to get you? Do feel in danger?”
“No, but people have been watching me, talking about me.”
I review the chart. His heart rate is quite elevated and his blood pressure his very high. It could be meth, but he also seems to have some paranoia and something else going on.
Of course, true psychosis and meth intoxication are not mutually exclusive diagnoses.
“Give him 4mg of lorazepam IM, if he calms down, start an IV and give him and a liter of normal saline, he’s probably dehydrated and we’ll need some urine.”
I leave and call his mother. She tells me he smokes marijuana still (of course, I think to myself, marijuana is just a vitamin these days). But, she continues, he hasn’t been acting like he used to when he was on meth. He has been saying that he has been talking to his deceased father and repeatedly saying everything would be okay because they would be seeing him soon. He has not been sleeping, eating, or drinking she goes on.
She runs through a disconnected description of the past few days. She is clearly very shaken.
I return to the ED about a half hour after Char gave Tim his sedative. He is out cold. Rousable enough to avoid intubation, but way more sedate than someone psychotic on methamphetamine would be after that much lorazepam. His vital signs have normalized.
His story is starting to sound more and more like true psychosis, possibly a manic episode.
“Okay, Char, I don’t think this is meth, we should get mental health here.”
“They won’t come til we have a U Tox which shows no meth.”
“Of course, well let’s get that urine then.”
We Count the Hours…..
What is understood between us is how long this is going to take. The closest emergent mental health evaluator is 90 minutes away. So, even if we immediately had a magical urine sample at that very moment, we would be 2 hours from someone actually evaluating him (which has to happen before we even discuss placement).
2 hours later, we finally have a urine sample. We call the mental health evaluator. She agrees to come. I go out for another walk.
After Julie, the mental health person has evaluated him, we talk.
“He is psychotic and needs placement? Right?” I prod her.
“Oh yeah. He definitely needs placement. I have already placed him on a mental health hold. I am going to go start making calls looking for placement.”
“I love you already, Julie.” She smiles back.
This is music to my ears. I hate placing people on holds. It is a huge legal move to restrict their rights and comes with a lot of paperwork. I love it when someone else does it. And placing them on a hold pales in comparison to the work of finding a mental health facility to take him, which she is already starting.
Seriously, I love Julie right now.
I stand up and turn to Katie, the nurse who has replaced Char. This has already gone on so long shift change has already come and went for the nurses. I am here for 48 hours, so no such luck for me.
“Call me when you have paperwork for me to sign, I am going to go to sleep. He can have more ativan if he gets agitated again, I wrote for it already.” I think about ordering him an antipsychotic, but since he is compliant enough on the ativan, I would rather the psychiatrist get to see him in his full psychotic glory rather than already partially treated.
I trudge off to the sleep room.
A New Day Dawns
I wake up to the phone ringing again.
“Hello,” my voice comes out a froggy moan.
“Hey Doc.” It is Char again, shift change has already happened again. He has now been here for 18 hours. “Need you to come out and sign Tim’s transfer paperwork, we have placement and transport is on their way.”
“Okay, I’ll be right there.”
I scribble the legal necessities on the paper work and finish my half typed note from the night before. Honestly, I am pretty pleased at how relatively seamless this was. It took a long time. I feel like it went well.
Cynicism Creeps Back In
However, my cheerfulness quickly fades as I am honest with myself about the situation. Sure, we did what we were “supposed” to do. Theoretically, the ramshackle network of mental health on the High Plains worked.
If I am honest with myself, all it succeeded at was passing the buck.
I know from experience how this will play out in the end. He’ll get stabilized on medications in an inpatient setting, then he will be sent back to the High Plains to the care of his elderly mother, where the closest psychiatrist is 2 hours away. Even then, the psychiatrist is only available 2 days a week.
No one will have the power or will to make sure he stays on his medications. One day, he’ll stop them, because self-medicating with marijuana feels better than antipsychotics, and eventually the cycle will repeat.
Who knows if he or anyone else will get hurt next time.
Dividing the Care of the Person
This is how we make ourselves feel better so our souls don’t rip in half. We break down the tasks involved in caring for human beings into such small parts so we can all feel like we’ve “done a good job,” All the while, for the person, nothing really changes.
This is our “system” of mental health in this country. A revolving door of failure.
Sadly, I shouldn’t even complain. I was thrilled to find out such services even existed. In large parts of rural America, the same patient would have been placed in the local jail. In many towns, the jail is the only secure location in town for these people until placement can be found. At least Tim avoided that fate.
I played my part in this farce brilliantly. We efficiently and effectively “placed” Tim. Who could find fault with my actions?
Of course, it is not my fault we have such a failure of a mental health system and my participation does not mean I own all of its sins. Nonetheless, it is just one more of the millions of tiny cuts physicians endure to our souls while working in our healthcare system.
The history of mental healthcare is filled with terrible and inhumane practices. Will we look back on today the same way? We might not be lobotomizing people anymore or cutting into their heads looking for the “stone of madness,” but we should not delude ourselves.
Repeatedly sending ill people into a world their brains cannot process to self-medicate with drugs and endure repetitive trauma through physical and sexual abuse at the hands of each other is not a more humane choice.
At least the old quacks cutting the stone were actually trying to cure something.
Featured Image: Cutting the Stone, Hieronymus Bosch, 1494 or later.