Monday, September 24, 2007

I Lack Insight

I had a patient on my pediatrics rotation whom I'll never forget.

She came in the middle of the night in DKA. She'd passed out at home and been brought in by EMS with her worried mother in tow. Fifteen years old, she was disheveled, wearing huge sweatpants and a baggy t-shirt.

The intern said I could do the H&P interview, so we politely asked her mother if we could speak to her daughter alone, the mother left, and we sat down to talk to the girl.

At first, the interview was fairly normal. How long have you felt bad? Have you been taking your insulin? Have you been sick recently? How long have you had diabetes? When was the last time you saw your pediatrician?

She told us she'd recently moved, that she was under a lot of stress from switching schools, that she'd maybe forgotten her insulin once or twice, and she'd been a little tired lately.

In adolescent interviews, there is a series of questions for the "sex, drugs, and rock & roll" topics. Under a mnemonic of HEADSS, you ask questions about Home (who lives there, any conflict?), Education (what grade in school, grades)/Employment, Activities (after school, church, sports, music, etc), Drugs (cigarettes/alcohol/illegals), Sexuality (with what gender, how many, what protection), and Suicide (any thoughts of, feelings of depression, access to firearms, etc).

I'd learned the mnemonic, but I thought it was dumb. What teenager was going to tell me about any of these things? I am the man, after all. I persevered because I had to, basically, but inside I felt retarded.

We started into HEADSS with our patient. Home, it turned out, was hectic; mom was always at work, dad was in jail, older brother was out of the house, money was scarce. School was okay, but most of her friends were at her old school. Some of her friends used marijuana, but she denied all drugs. She'd quit sports. She didn't have a boyfriend and wasn't sexually active.

When I asked her, "Have you ever thought about killing yourself?", she didn't even bat an eye. "Well, yes."

I almost fell off the end of the bed where I was perched.

As we probed deeper, we got a history of months of 20+ lb weight loss without effort (documented in the chart from a prior admission; she didn't even care), feelings of guilt, hopelessness, and worthlessness, excessive sadness, tearfulness, extreme worry about her incarcerated father (he'd been in jail over 2 years), grief over a long-deceased grandmother, poor sleep, poor appetite, fatigue, and a desire to be dead. She'd been "forgetting" (ie, refusing to take) her insulin for a while because, as she put it, "what is the point?"

We asked her if she'd tried to talk to anyone. She said her mother said everyone has problems, deal with it; her school counselor and friends told her to pray about it. She'd reached out to several people for help and received none.

We asked her if she had a plan for committing suicide. She told us she thought some of her friends had guns or could get guns; she felt like she could get one to kill herself.

Her DKA resolved in a few days. We had her transferred to an inpatient psych facility to begin treatment for her depression. I don't think I ever forgot to give the HEADSS screening for the rest of pediatrics.

And yet, I didn't think I'd like psych. =-P


Chris said...

Wow. Heck of a story.

I think a lot of my M1 classmates are getting tired of the lectures on the psychosocials. Yet, at the end of the day, the sometimes I wonder how much we could help people without drugs and just listening and counseling. This is an exaggeration, of course. But if doctor doesn't ask "what's really going on," then who will?

Cool story!

Chris said...

Neat story!

Since I'm a new reader, clue me in: are you going into psych?

Tiny Shrink said...

Yes, I am going into psych. Thanks for reading!

And yes, it can seem dull to ask every patient "whom do you live with? are you working? sex/drugs/rock&roll", etc. In general, when doing a long medicine or pediatrics H&P, a brief social history is appropriate. In a busy clinic setting, it's much more difficult, and on a surgery service, your attendings would probably laugh at you.

I think the take-home message from your lecturers is that sometimes, you pick up on psychosocial stuff that is directly influencing the patient's health.

Chrysalis Angel said...

Well done! Sometimes, it isn't just the questions your taught to ask, it's in the way you ask them.

A, a fourth-year medical student said...

Nice post. I remember the first time I stumbled on depression in an interview, in a very well composed elderly woman there for a pre-op. I still feel funny sometimes screening questions, but it's getting much easier. And wow, does it amaze me how often I find something.

Keep up the good work.