Mental health workers deal with the sometimes odd behaviors our patients exhibit every day so we are not always bothered by it. Psych patients do have medical problems, though and sometimes we end up calling consults from often unprepared medical specialists. Sometimes their responses to our patients is quite hysterical.
Sometimes the reason for the consult is tragic and one learns something new. As a resident, we were brought a patient who was transferred from another facility after trying to pluck her eyes out and was left with nothing but the ability to see a little bit of light. There is nothing funny about this case and it is terrible to see a horribly psychotic patient who slowly starts to come out of her delusional state and realizes what she has done. In a failed attempt to change from a very effective medication with terrible side effects to a newer one with fewer side effects, she fell apart and became religiously preoccupied. This is a very common theme in psychotic patients' presentation. The voices took over and told her "If thine eyes offend you, pluck them out" and that is what she did. The irony is that the patient is an atheist.
The ophthomologist, a quite respected and experienced one, was consulted to see her and provide whatever treatment that he could. He told us that this was the eighth case in his career where he had treated a psychiatric patient who had tried (or succeeded) at plucking his/her eyes out. It is sad to know that this is not an exclusive case. I have never seen this happen again, and hope never to, but I know something to look out for now.
Usually these encounters are not so tragic. Just a basic medical issue that needs addressed and a sometimes humorous result. For those who do not know, psychiatrists are medical doctors, and our training in medical school is no different than any other physician's. The difference is we chose to specialize in psychiatry rather than say, family practice or surgery. To do this, we complete a residency after medical school in that area specifically, just as other doctors complete residencies in their own fields. We are able to treat minor issues, mild hypertension, bladder infections, reflux, but when the patient shows up with uncontrolled diabetes, we are going to need to call a consult. Some consulting physicians handle these situations well, some do not.
We had one patient who was quite insistent that he did not hear voices that tended to carry on conversations to himself all the time. We knew he was hearing voices and did not even bother to ask because it would just get him riled up. He did not tolerate a lot of stimuli and stayed in a quiet area isolated from other patients much of the time. When his diabetes spiraled out of control (this is a common problem in psychiatric patients) we called an endocrinologist to see him. He did make the mistake of asking the patient about hallucinations, and got a very terse response that, no he did not. He would have better to stick with blood sugars but for some reason, asked. Our consultant walked out of the quiet room and stated "You know, when I was walking out Tim (not his real name) turned to the air and said 'Did you hear that? He thinks we're hearing voices!'" Our amusement was more with the doctor's reaction than the patient's. My response was a simple "Yeah, he does that." He seemed bothered that we were not more concerned, but there was nothing to that could be done about the situation. We were just glad that he was not throwing chairs across the room or assaulting security officers, which he has been know to do. If he wants to talk to an invisible man, let him.
Sometimes people are just too intimidated by the patient's behavior to know how to approach it. We had a patient who tended to stand at the end of the hall and walk down it in a series of lunges that reminded me of the "Ministry of Funny Walks" sketch in Monty Python's Flying Circus, for those who know the show. For those who do not, just know that it was a rather strange exhibition. Most psychiatric units at some time or another have nursing students doing rotations and we had some around the time of his stay. Some of them seemed bothered by this behavior and came to me about it, wanting to know why he did this. I gave them a very simple response- "Have you asked him why he does that?" Of course they had not, and seemed rather shocked at the whole idea. "I could never do that, he might get angry at me" was one response I got. I reminded them that he must not mind answering the question that much or he would not be behaving that way in a public setting. I already knew his response because I did ask him, but tortured them by not telling them. They needed to learn on their own. Part of treating a patient is asking questions. If the patient says he hurts, you ask where. If a patient acts strange, you ask why.
He told me he walked like that because he liked to walk that way. And he did not get angry when I asked. Fair enough.
Sometimes the issue is dealing with patients who tend to be rather disinhibited. The manic patient who started propositioning the public defender before a committal hearing will always remain in my mind. Everyone who was to be at the hearing was there to witness this interaction, also. He turned all kinds of shades of red, but still fought like hell to argue that she did not need inpatient psychiatric treatment. He did not win, which is probably good or he might have had an unwanted paramour stalking him if he did. I do not get along with this particular PD anyways.
The best encounters I have seen are with non psychiatric residents, solely because of the fact that their inexperienced nature can result in such shocked expressions when they hear comments they do not expect to hear. We had a very sexually preoccupied patient fall and split her eyebrow open and had to consult family practice to come and suture her back together. I am not sure what crime against humanity the poor intern they sent up had committed for him to get chosen for this detail but the poor kid was as green as the rain forest during the rainy season. He had been given no warning that he might hear something odd or out of the ordinary. He was probably expecting the typical patient who comes in with their face cut open, pretty nervous and not saying a whole lot. Instead, he was treated to her nonsensical ramblings about being a model and a porn star (she was in her late 50's, a heavy smoker and looked much older than her age) with added mumbles, which is her baseline behavior. He was really startled when she asked him "Can I still have intercourse with these in?" The expression he had on his face was priceless. The advice to the intern: just ignore that and keep suturing. He survived to continue his internship and eventually complete his training, but not quite as naive as he once was, and perhaps a bit wiser.
No comments:
Post a Comment