Saturday, May 12, 2007


I know this is becoming a theme, but bowdlerised bad language and grue follow.

Been thinking about doctors crossing boundaries (as opposed to doctors crossing borders, although sometimes one can lead to another).

Part of this came up from following the Kerouac saga (executive summary: George Bush appoints a loony who believes contraception is demeaning to women to run the government department responsible for providing contraception to women but is forced to back down, which presumably means more demeaning for more women in the long term) and part of it from a number of recent things I have seen or heard in the ICU or the Drug and Alcohol Service.

I think I see these things because the two fields I work in have two almost completely opposite ways of looking at things. Emerge and ICU want people to be cured. They deal with medically unstable people, people often so unwell or so unknown that the medical procedures the doctors carry out to diagnose or treat these people are invasive and dangerous and expensive. Additionally, particularly in the ED, space and time and staff and emotional energy are limited resources. Because of this ICU and ED doctors and nurses want rapid, quantifiable progress.

Because of the emphasis on vital signs and quantifiable results, psychiatric or behavioural disturbances don't work well in the ED or ICU. This includes the patient whose behaviour either got him/her in there or is stopping him/her getting out. There is limited patience with, say, the man who has smoked his way into airways disease, or the woman who has drunk herself into liver failure. To the ICU or ED doctor, the worst patients of all are the non-compliant psych patients.

Drug and Alcohol services patients don't think so much in terms of cures. The whole idea of a cure for alcohol dependence, say, is disputed. Truly successful treatment is often measured by lifelong abstinence - although I suspect there is a requirement here that moral flaws require moral punishments. I don't know - it's hard to tease out the correct term for this: are reformed (there's that moral element again) alcoholics* cured? Or are they still sick? Or are they in remission?

Anyway - longer term stuff. Subtle improvements. Non-invasive measurements of progress - urines that probably show up a tenth of the substance use in our client population. Requiring a different set of clinical skills, helping a large number of people, satisfying in a different way.

The thing is, drugs and alcohol don't handle medically sick patients very well**, and ICU don't handle psych/drug and alcohol patients well.

Case in point was Mr Sweet, a man who had been brought in to the ED thirteen times in the last two years near (very near) death, with a total cost to the commuity of over seventy thousand dollars.

Mr Sweet has type one diabetes, the type where things can go spectacularly wrong if you don't take you insulin - blindness, impotence, kidney failure by the early thirties, as I have seen. He had stopped dosing Friday and two Mondays ago was found by his girlfriend (semi-conscious in the traditional pool of his own vomit) and brought in. His blood sugar was seventy - the highest I have seen, the highest reading most of the people to whom I've spoken have heard. A blood sugar of seven is high, this man had treacle in his blood.

He was brought in, dragged back from the brink and once he regained consciousness and the tube was removed, he began abusing staff.

We were all [genitals]. We could all [have sexual intercourse and leave]. The nurse could [perform yet another sexual act] if she reckoned he would stay here. The whole place could [be the passive recipient of an act of sexual intercourse].

After he had reduced one of the nurses to tears I went in and talked to him. He was insiting on leaving against medical advice. It is difficult to do any kind of psych interview with someone who is non-compliant with the interview process, and has recently been pumped full of mind-altering chemicals, but I ended up detaining him, and ringing the psych reg and saying this was the crappest detention I had ever done, but I couldn't be sure if he had a treatable mental illness, but he wasn't taking his antidepressants, hadn't seen a psychiatrist in five years, kept interspersing his obscenities with assertions that he didn't care if he lived or died, and I reckoned that was where the smart money was.

Two weeks later he is still detained, which is comforting.

Anyway, after I had told him about the detention and after I had explained to him that no-one in the hospital could get him out ("Not the nurse, not me, not my boss, not the director of the hospital, no-one before nine o'clock at the earliest when the psych consultant comes around..."), he and my boss had a discussion.

"I don't want to be here" said the sick man.

"We don't want you here either" said my boss, Dr Angle. I winced. "There are sick people, really sick people who need your bed".

"Well, why don't you [go home and have sexual intercourse***] and I'll get out of this [odoriferous latrine/ odoriferous end of digestive tract] and ..."

"Do you have some kind of problem with authority figures?" said my boss, the authority figure, taking a step towards the bed and leaning down. By now I was contemplating what to do if someone took a swing at someone.

"[Most certainly]"


"Because you're a dickhead" sneered the man whose life had recently been saved.

"Well, you're the biggest [intercoursing] dickhead I've ever met in my life!" bellowed Dr Angle, BSc BM BS, visiting consultant intensivist and Fellow of the Royal Australasian College of Anaesthetists.

"Dr Angle, Dr Angle" I squeaked. "PLease come out and have a look at this (completely normal) ECG!"

Anyway. The mentally ill don't only get sick too, they get sick more often and have poorer compliance and have more co-morbidities and so on and so on. And they tend to be poor, so they are more and more a part of public medicine. We are slowly, I hope, learning to deal with it.

Anyway, thanks for listening.

*I probably shouldn't be using this term, it's more correctly "alcohol dependent person". In my defence, I will point out that I'm fat, not overweight, and I've been crazy, as much as unwell, and if I ever lose my leg, I want to be called a cripple.

** When I was at Shipton someone died in the psych ward. A code was called and all hell broke out. No-one knew where anything was, no-one knew how to use it, once they got the oxygen on someone tripped over it and yanked it out - it was hideous.

*** Weird term of abuse, isn't it? Sounds much more pleasant than finishing your shift.


Anonymous ozma said...

I was reading...somewhere very recently that psych patients have much, much shorter life expectancies. Diabetes, weight gain from medication and other things play a big role apparently.

There is nothing more tragic than psychiatric illness, I think--the self is compromised. To be sick is bad, to be in mental solitary confinement like that man is unspeakably bad. But for many people, it is the illness that doesn't really count as an illness. And of course, the people who have it count even less sometimes.

2:39 PM  
Blogger Bronze John said...

This is true. I think the most distressing study I ever read suggested that clozapine - the strongest antipsychotic there is - is the only antyi-psychotic that actually prolongs life by preventing suicide. However, because of the diabetes/obesity etc it causes, you have to be careful to whom you give it - people on average live just a little bit longer on clozapine than without it. But if your schizophrenia isn't that bad and you have a family history of ealry deaths from heart disease - it's a difficult decision.

Who makes that difficult decision is, of course, the next question.


5:09 PM  
Blogger Bronze John said...

Of course, there's the old antipsychotics which don't make you as fat - but they don't have really good coffee mugs either.


6:36 AM  
Blogger jenblanck said...

Yes, let's not forget the coffee mug.

I would make a good psych nurse. I think I'd be the one tripping over the oxygen. You know, we all have our strengths. It's good to know your own.

5:14 AM  
Blogger jenblanck said...

(JenBlanck, the former Juanita Sanchez, before New Blogger changed her identity for her. Oh well, who needs anonymity?)

5:16 AM  
Blogger Midwife with a Knife said...

The coffee mugs are critical.

Anyway, Bronze John, I just wanted to let you know that I've tagged you with the "8 random things about me" meme.

6:55 PM  

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