Code Grey

** Names and details have been changed to protect patient confidentiality, privacy, and dignity **  

What drives a patient to violence and agitation? Are there any factors, or "warning signs" to predict an impending explosion? Textbooks list "prior behavior and agitation" as risk factors, but I believe iatrogenic factors may be even more significant. Consider the following situation:

Rodney was admitted to our psych ward for detox from cocaine use. He was a "frequent flier", having many prior admissions, but otherwise healthy. My resident and I met with Rodney several days after his admission. He appeared anxious, and voiced a need for discharge in 2 days in order to appropriate his check before his roommate did. The resident agreed that discharge was plausible by that time, and the interview ended amicably. 

The next day, Rodney again voiced his concerns about leaving, because staff had not given him any information regarding discharge. He reported that he was "feeling better", and his withdrawal symptoms had subsided. The resident stated again that discharge was scheduled. Later that day, our attending physician interviewed Rodney. When asked if he had any suicidal ideations, Rodney responded that he would be "a dead man" if he didn't get out by the time scheduled for discharge, because he would lose his check and thus, his housing. The attending took his remark as a suicidal threat, and decided to commit him involuntarily. 

During pre-rounds the next morning, I was asked by a nurse to aid in a "show of force" for a "Code Grey".  Rodney was pacing the floors, glaring at the terrified staff who had barricaded themselves behind the nursing station. He was cursing, yelling, and kicking around a plastic chair, accusing the staff of lying to him. More and more staff began to gather, until the mass of 20+ people began to corner him. The nurses prepared a needle of Haldol and approached him. Three of the larger male staff members grabbed his arms, and escorted him to the seclusion room.

The following day, Rodney seemed calm and apathetic. I talked to him alone, and passed along some numbers for inpatient rehab facilities. He relayed that since yesterday, he had been ignored, scolded and forced to take medication, but no one had offered to help him with his problem. At the court appearance, the resident testified that he had been non-compliant with medications, and had voiced suicidal and homicidal threats. This resident had never interacted with Rodney; he had only read medical records written by staff and social workers. Rodney was not receiving any medication ― how could he be non-compliant? The judge decided that Rodney would be committed for an additional 2 weeks. Rodney cursed under his breath as he was excused from the courtroom.

Like the Bob Dylan epic "Who Killed Davey Moore", one must ask where the responsibility lies in a situation like this. Was it the patient, who has a limited repertoire to express himself besides acting out and becoming hostile? Was it the resident, who lied to the patient, and dismissed his concerns? Was it the attending, who possibly misinterpreted a remark and missed the opportunity to educate the patient? Was it the staff, who escalated a situation instead of diminishing it? In medical school, we are taught to value patient concerns, and delve into underlying issues that may affect patient behavior and overall health. Rodney's anger seemed to be triggered by his worry about his finances; instead of helping him with this issue, we committed him and further removed him from a solution to his problem. 

Did we fail this patient? Is this incident just an insignificant speed bump in Rodney's life, destined to recur during his subsequent hospitalizations until he succumbs to his addiction? Are we saving him from himself? Would Rodney have reacted differently if we handled the situation in a calmer, more straightforward manner? I suppose we have to wait until the next Code Grey. 

Pained

** Names and details have been changed to protect patient confidentiality, privacy, and dignity **

Last night was my first night on call. Halfway through the night, we got a call from the ED to admit Tom, a 25 year old man complaining of chest pain. As I made my way to his room, I was already envisioning his presentation and thinking of labs to order and supportive measures to keep him comfortable. What I found in the room was not a cardiac case. 

Tom was diaphoretic, hypercapnic, and writhing in pain. He attempted to sputter out a history, but kept pleading for a Percocet. He didn't complain of any chest pain; in fact, his pain couldn't be localized to any specific location. His skeletal body was folded into a fetal position. Tears were in his eyes as he begged me to do something for his pain. He vomited on the floor at my feet. I have never witnessed such anguish.

I reported the findings to my resident. She requested a stat drug screen, which was positive for opiates. He reported daily consumption of a smorgasbord of prescription narcotics. We started him on anti-nausea medication and tried to extract details about where he got the pain medicine from. He promptly had a grand mal seizure. 

After he recovered, we questioned his plans upon discharge. Was he interested in rehab? Was he going to wean himself off opioid pain medications? He again emphasized his need for Percocet due to a degenerative joint disease. The suggestions of physical therapy, NSAID therapy, and alternative treatments were all rebuffed. Tom was indignant that he needed these pain medications to ever feel better. No other solution was feasible in his eyes. 

I have never witnessed a severe drug withdrawal of this nature. Tom was in unrelenting pain. As we filled out order forms and wrote progress notes, I wondered how many Toms are created every day. Some may be created out of malpractice and negligence by overzealous practitioners. Others may have good intentions, but may inadvertently create opiate addictions in patients who could have been managed in other ways.

Pain management has always been a "hot topic" in medicine, due to the variable response to treatments, risk of addiction, and of publicized celebrity prescription abuse. Recent emphasis has been placed on the treatment of chronic pain, to reduce associated physical and mental comorbidities. In 2006, the American Board of Medical Specialties added palliative care to their list, perhaps signifying the need to further investigate and improve the treatment of chronic pain without creating dependency.

So, what will happen to Tom? He is ensnared in a vicious cycle of addiction and withdrawal. He needs pain medication to avoid withdrawal, but the medication heightens his tolerance. When he runs out of pain medication, he will delve into withdrawal, requiring higher and higher doses to prevent seizures and excruciating pain. During rounds, as we left Tom in his room knees-to-chest, wailing in pain for his Percocets, our attending commented, "The doctors who prescribed his medications need to visit their creation."

On the Edge

I was deeply affected by a blog I recently read, written by Dr. Elizabeth Breuer, for KevinMD (here), regarding a comment made to her by an attending on a stressful night. It must have been a difficult experience for her, struggling to effectively care for her patients, while the negative label adhered to her psyche like a name tag. It's very unfortunate that the attending didn't catch herself...had she forgotten what it was like to be a stressed yet diligent resident? What if Dr. Breuer didn't have a support system or a blog to provide an outlet?

Dr. Breuer's experience is not limited to night float obstetrics. How many times have you been affected by a fleeting, yet hurtful remark? The "sticks and stones" adage may be a nice sentiment, but is unrealistic. As social creatures, humans are affected by what is said to us. We thrive on feedback, and it penetrates into the soul. When that soul is tired, grieving, stressed, wounded, or weak, words may be the fatal bullet. 


You never know what may be going on in someone's life. The grocery store checker may have just lost her mother. The doctor may have a special needs child. The student may be the victim of domestic abuse. The police officer may have just received a cancer diagnosis. When people appear to be competent and put together, we may trust the facade, and lash out nonchalantly. We may scan briefly for signs of trouble, and proceed with snide comments.

The problem? People in crisis often conceal their pain. Tears have a stigma of weakness, a manipulation, a "secret weapon" to garner favors. To protect ourselves, we don suits of armor, put on our best poker faces, and hide the crumbling foundation within. We overcompensate with strength…and it works, until that one final push. 

It could be a flippant remark from a co-worker. It could be a "dressing down" by a superior. It could be an angry tirade from a parent. It may even be a less personal action- closing the elevator in someones face, cutting them off, stealing a cab, etc. Cyberbullying suicides rarely occur after 1 incident. It takes repeated harassment, with the constant suppression of emotion, to nudge a victim to consider escape, until that final step. Will your poorly chosen words push someone over the edge?

Please, be kind. You just never know.

Identity

My first hospital job was in an OR recovery room. I was more of a switchboard operator than anything else...communicating with the OR and hospital floors- finding beds for patients, coordinating with ambulatory care for discharges, and keeping staff abreast of OR scheduling status. The calls would come in from the OR in the morning: "there's a hip coming in at 800am, after that we've got a lap chole". I envisioned a disembodied knee crawling down the hallway, followed by a hopping gallbladder. How would patients feel, knowing their hospital existence was reduced to their conditions? Or...maybe it's self-inflicted....

There have been plenty of JAMA and NEJM articles regarding the depersonalization of patients, the reduction of humans into disease conditions, but I have yet to read an article detailing how self-labeling impacts health. It always amuses me when a man introduces himself to me, and right away discloses that he has "ADHD". I usually retort, "Does that mean you can't take me to dinner?"

I hold the firm belief that everyone has or will have some medical issue, be it mental, physical, social, or otherwise. Does a disease define the person? Does the person define the course of disease? Does identifying oneself as a sufferer of a disease hinder the recovery, because that becomes their sole identity? Would a cure or remission deprive one of their identity? Would you be the same person if you were in complete health and free of disease?

I am not the panic disorder. I do not hug the brain injured in the morning, go to school with the depressed,  meet for lunch with the diabetic, and work out with the bowel disease. I do not call the stenotic valve and the prostate cancer on holidays, and send a gift to the preemie. The disease shouldn't define us...it should simply be an aspect, a facet to the many sides of a complex personality and a lifetime of memories. It should add richness to life, a chance to learn, teach, and be a catalyst for others' learning. I was told that Navajo weavers are sure to include a tiny defect in their rugs, acknowledging the imperfections and mistakes in life, and recognizing the beauty despite it, and within it. The mistake is not the totality of the rug, nor is it diminished into obscurity. It is celebrated for what it is. 

Memoratus in Aeternum

Mid-October has been a special time for me, since 2002. I am currently on the verge of sitting for my first "Step" in licensure, and felt it prudent to reflect upon how I arrived at a career in medicine. 

The year 2002 started off normally for my family, a close-knit group of 4-mother, child, and grandparents. Of these, my grandfather seemed the healthiest, save for a few bouts of gout every year. He led a healthy lifestyle, getting frequent exercise with his shepherd/husky mix, chopping trees, shoveling snow and visiting neighbors. He would fatigue quickly, so made a habit of taking daily naps. In late January, my astute mother noticed his ankles were edematous, and made an appointment with his PCP. The PCP prescribed diuretics and advised to follow up.  Shortly thereafter, my grandfather mentioned a nagging pain in his left side. My mother asked for a CBC, which was never completed. My grandfather was tested for heart failure, diabetes mellitus, and various other common ailments. Trips were made back and forth from the doctor; finally a CBC/peripheral blood smear was done, and a diagnosis was made- Chronic Myelomonocytic Leukemia; an extremely rare leukemia with no cure, and no detectability until the "crisis" stage, though commonly associated with chronic gout and splenomegaly.

My grandfather was referred to an oncologist, and began getting blood transfusions. He was put on a few blood-boosting medications and full-time oxygen. He tried to lead life as normal, continuing to cut branches and untangling the dog from the snarls of the oxygen tubing. When he felt well enough, he attended my dance performances, and we even went to see Mel Gibson's "Signs", although he was embarrassed to tote the heavy oxygen canister though the theater. I accompanied him to his blood transfusions, taking careful mental notes of the nurses too busy with birthday celebrations to notice that his oxygen canister was empty and rattling, or too engrossed in watching "The Price is Right" to remove his automatic blood pressure cuff after discontinuing his IV. I watched my strong, 6'3", 230lb grandfather slowly waste away, while trying to maintain normalcy in our lives.

The entire family worked hard to help him heal. In an effort to limit his fluid retention, we cooked low-sodium, low-fat foods, which were labeled and charted to ensure he was getting enough nutrition without harm. My mother purchased a CraftMatic bed for him, so he would be more comfortable and wouldn't use his precious energy trying to sit up in bed. He listened to self-hypnosis tapes and meditated daily, to focus his energy on healing and controlling proliferation. His oncologist seemed to be uncomfortable discussing his prognosis, and advised against splenectomy, due to my grandfather's insurance and age.

By the end of September, and with little encouragement from the oncologist, he decided that treatment was futile. "Save the blood for someone else," he said. "Someone who really needs it".  The oncologist offered to refer for splenectomy, but he was weary and resigned by this point. We discontinued the sodium and fat controlled foods, and made his favorites- lobster tail, hot dogs, shrimp. He passed away in his CraftMatic bed on Oct 17, 2002, missing his birthday by 6 days.

Every patient knows a story like this, either experienced personally or heard from others. Every doctor knows a hundred of these stories, shared in medical journals or by colleagues. Did a medical error occur? Patients and families may emphatically agree; Physicians may not feel the same. My point in writing is not to place blame, gripe about the state of healthcare, or lament that not enough was done to save my grandfather.  Perhaps the disease was caused by years of exposure to benzene from working in a pharmacy laboratory. Perhaps the cause was due to inhaled cigarette toxins, and he hadn't quit in time to prevent damage. Perhaps there is no attributable cause. Whatever the case may be, I believe that a plan is set out by the Most High, and for whatever reason, I needed to experience this loss, this suffering, in order to become a more observant, empathetic physician. I am so grateful for the time I spent with my grandfather, especially while he was most vulnerable. I am grateful for the lessons I learned through this process. When I approach the computer on Wednesday, I am confident that the spirit of my beloved grandfather will be with me. 

I love you and miss you, GVS. 

Take Your Time, Do It Right...

After watching the final moments of the Chilean mine rescue last night, I was impressed by the amount of patience exhibited by all involved with the ordeal. It took 69 long days to evaluate the situation, assess the most dire needs, and formulate a plan to keep the victims alive until the point of rescue. Once commenced, the rescue would have to be done slowly and safely, despite the anticipation of the crowds and media. What would have happened if the mine was exploded in a brazen effort to dig up the miners? Most certainly, the miners would have been buried forever. What would have happened if the rescue tube was yanked up expeditiously? The cable would snap, and the tube would plummet almost a half-mile back into the depths of the earth. Though not the quickest, last night's rescue will be remembered as the safest and most miraculous in history. 

What about patient rescues? Should all patient encounters be performed as quickly as an ER trauma or  life-flighted victim in shock?  As medical students, we are trained to perform physical exams in 15 minutes or less, pressured to elicit a detailed history in rapid-fire. A novice desperately auscultating for an ejection click or a bruit is unlikely to find it in the 3 minutes set aside for cardiac examination out of those 15. Patients are conveyor-belted through vital signs, insurance forms, physical exams, and deposited outside with a prescription in hand. Is this medicine? Or is it crowd control? 

I fear for the future of healthcare. I believe that Obama's healthcare changes will put more emphasis on efficiency rather than quality care. The shortage of healthcare professionals will be pressured to see more patients with less resources available, possibly missing crucial signs and symptoms. Can we still save lives with so little time to work? I can hardly imagine Hippocrates keeping an eye on a sundial as he examined a patient, or Osler advising his rounding medical students to speed up the patient's history because there were simply too many patients to visit. Physicians need time to process the data received, to think through the pathophysiology of the disease presentation. Occam's razor may apply in the majority of cases, but lives may be cost adhering strictly to it, and discounting other possibilities because the history is too long-winded, or because the diagnostic tests are too expensive. The speeding healthcare train must be slowed before it runs out of track. There should be no consequence for taking time to perform one's job properly.