02 July 2011

We are holding you here

Danger to self, Danger to others, Grave disability

For the past month, my patients have either been dying or seriously troubled. Or both.
These might be different sorts of dying.

This may be an introduction for stories to follow. There were more patient moments of transcendence, on palliative care. That’s next – what it means to be able to imagine a life for someone when you’ve never really met them before almost-death. There are the hours and hours and hours of stories, now. The Mental Status Exam – there’s another piece. Will be. But for now, by way of segue, and because the writing for the evening is meant to be five closely hand-written pages on my patient’s background, the factors that have contributed to her current situation, and an assessment and plan of what, in the hospital, we can do.

Cameroun, primate reserve/rehab near Yaounde

Now, I’m on psychiatry at the county hospital. This is exactly the sort of hospital where I want to work – underinsured, uninsured, every problem is more complex than medicine and medications. It’s not about thinking you’re saving anyone, at all – it’s math. There aren’t enough doctors working with these patients. Patients with more insurance, patients with more money, patients with fancy papers and jobs and luck at some level – they have doctors. Math. Simple.

So this is where I’ll be. I’m learning, everyday, what it means to be a doctor. What it will mean. And there are the practical issues like having to clear the pages from my pager, sometimes several times in a day. (Disbelief, the first day that happened. That’s what happens to residents) . Being first call for a patient – this is what that means. Any issues, I get called. By everyone.

It’s about teams – trite, maybe, but true. At the university, tertiary care hospital where I was for palliative care and pediatrics – teams might be like the Congestive Heart Failure Team, the Liver Transplant Team, the Restrictive Lung Diseases team. I had no idea how deeply you could specialize. Patients may have multiple failing organs plus a rare rheumatologic disease and a mitochondrial disease and something neurologic going on. Presenting with an endocrine problem. (For one of my patients in pediatrics, the team coordination I had to do literally consisted of pediatrics, child neurology, child endocrinology, molecular genetics, and then psychiatry) . Not uncommon.

Here? One team consists of ENT (ear-nose-throat) surgeons + psychiatry + social work + nutrition + pain management + social work + nursing. + psych-consult nursing (separate from the psychiatric consult service I’m on, for some reason) . The patient needed surgery, complicated surgery, for the second time. And soon the fifth and sixth and seventh. There’s the CT, the MRI, the X-ray, the lab value version of what happened to him. And there’s the homelessness, alcohol, other drugs, history of child abuse (to the patient), family estrangement, language and cultural issues and differences, a country that isn’t recognized as a country, everywhere, and doesn’t want him back. . .

That’s a team. The surgery note, every day, says “appreciate psych input.” And I end up calling the resident every day, for some issue/discussion about Our Patient.
Our Patient.

This is what I say when I call outpatient providers: “calling about our mutual patient. . .”

The people in the hospital I’ve developed working relationships with in my short time here? (aka, those who recognize my pager number. And voice) . That surgeon. An emergency department social worker. A psychiatric social worker. The charge nurse on the geriatric floor. The residents for my patients (more obvious) . A patient’s therapist. A patient’s psychiatrist. A patient’s social worker. Patient families.

A friend once asked me if doctors think about their patients, outside of the office.

I’m in the hospital. I see the patient at her most acute. My patients, right now, are there for suicide attempts, suicidality, drug overdoses (intentional or not?), altered mental status from alcohol or drugs, assault related to homelessness, dementia related to HIV, dementia not helped by alcohol, everything related to social situation, to past factors, to family history, to childhood, to marginal housing and relationships and proximity to their birthdays. . . everything.

I’m in the hospital, and with permission, I call the out-patient providers.
Every single one has been glad I called – many, relieved in a sense, to know their patient is being taken care of, and that it’s by someone who cares enough to call them to let them know about it. And to get more history. We call that collateral.
I call many times. Maybe we need more information, we need clarification – I’m seeing the patient at her most acute. They may have known her for years. And I promise to call back with our plans. We coordinate.

That’s not billed time. It’s after hours, between patients, during lunch. From home.
I don’t think medicare or insurance companies count that.

And these aren’t short conversations. There are the half hour conversations (almost an hour, with one patient’s husband) . And then we call each other back. And back. I give updates. They ask me.
Nothing is static here.

And the license I have, the incredible, humbling license to call my patients’ medical and psychiatric care providers, to learn more about their relationships with these providers, to know my patient a little bit better pre-hospital and to figure out what I might be able to do. Maybe.

Many of my patients are on holds. The first one is 72 hours - held. In the hospital. Danger to self, danger to others, or grave disability – inability to find food, shelter, clothing, medical care (essentially. And homelessness doesn’t count – technically, if they know about and can access shelters) . There have been holds for danger to self – the ones with suicidal intent/overdose  – and for grave disability – the ones with dementia. Yesterday was the first time I saw what happened when a patient on a hold tried to leave – security came. She was restrained – soft restraints. Is it safer for her? Arguably, right now. Maybe. Can we do something for her? Maybe. The problem larger than the current overdose, though (which she says she’ll repeat – and better) is the living situation. Money, drugs, and how to get that money. Other people on the street. Everything that’s happened up until now and before and after. And this patient spends hours at the library, online, reading about the pharmacology of various drugs. The particular enzymes.

Then there are the 14 day holds. And the hearings – the patient presents his case to the judge. Accepted – patient free to leave. Denied – patient stays until we say go, within fourteen days. Law, medicine, minds.

The new interns have started. These are the people who are a year ahead of me in school – weeks ago, they were medical students (as I’d always known them) . Now, the IDs say “, MD” and the ones in psychiatry have license (with supervision?) to hold people in the hospital. Danger to self, danger to others, grave disability.

Grave disability. Inability to provide food, shelter, for oneself. But “homeless” doesn’t count, as long as you have enough wits/facilities to find shelters, to find food kitchens, to know where freer things are.

Four years of school and we get to pronounce death (time of. . .and the certificate that must be signed). We get to pronounce life (time of. . . and the certificate that must be signed) .
And we get to decide who can’t take care of themselves or their own lives, right now.

"Death" is easy to pronounce. "Danger." "Grave."


Cameroun, primate preserve/rehab near Yaounde

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