True Story from the Psych Unit

I'm taking psych call this month at a large hospital. Call duties include consults from the ER, consults from the med/surg floors (rare, since they're after hours or on weekends), "behavioral emergencies" throughout the hospital, and covering the inpatient psych unit, which houses 40-50 patients. I would just like to throw in there that my psych calls are nearly as stressful as my medicine float shifts--psych call is not easy.

A couple of weeks ago, my urology elective experience suddenly and unexpectedly came in handy.

(If you're squeamish, stop here.)

I had just returned a page from the nurse in the emergency room and was hearing about a patient I had to see (the usual "super urgent" med refill type) when I received 2 pages in about 1 minute from the floor. GODDAMN, dude, I'm on the phone with the emergency room! I'm sorry, but people need to learn some pager etiquette!

Ahem.

I returned the page with a slightly snarky "Did someone page Dr. TS TWICE? Can I help you?"

A slightly panicked male nurse answered "Yes, doctor, patient so-and-so has gotten his, ah, his penis caught in his zipper."

WTF???

"Uh, is it, uh, is it still stuck? Is it bleeding?" (I was stuttering and nearly speechless)

He assured me that it was not bleeding, but was still stuck. Holy Christ! I called the ER and told them I had a medical emergency to deal with on the floor (at which point I was "reminded" that there's a policy to see ER patients within 20 minutes of arrival--Eff You, guidelines! The nurse actually asked me why the floor nurses couldn't just "deal with it" themselves. Um, it's not YOUR junk caught in a zipper, but if it were I doubt you could wait an hour while I deal with Ms. "I didn't know how to operate the automatic refill telephone number"). I raced upstairs.

The patient was lying on his bed so calmly I didn't realize it was the right man, until I saw his fly hanging open. It seemed to be an accidental injury (although I'm sure weirder things have happened). I donned gloves and did a quick inspection--whoo-ee, that skin was really wrapped in the zipper. (I warned you about the squeamish thing!) I left the room and paged urology.

"Um, hi, this is the psych intern. I have a patient with his penis caught in his zipper. What do I do?"

Uro: "You pull."

WTF??? ARE YOU KIDDING ME???

He wasn't kidding. I went in and attempted to pull on the zipper, but the patient freaked out (naturally) and wasn't going to tolerate it. I paged urology back and explained the situation.

Uro: "I can come up there if you want, but I'm just going to pull harder."

WTF???????????????

The nurse on duty wouldn't let me take the patient down to the emergency room, since "this is a hospital up here, there's no reason a patient can't get treatment up here just like anywhere else." I had no choice. I asked for a bottle of lidocaine, a syringe, and some wound dressing materials. We got the patient into the treatment room, I did a little local anesthesia, gave him a Vicodin, donned my gloves again, and PULLED.

It didn't budge (but at least this time the patient didn't feel a thing).

We found a suture removal kit with a pair of forceps, which I used to try to get a grip on the zipper. This time when I pulled, it moved a teensy bit. I had the male nurse try to pull, I tried to pull, but we made almost no headway. I carry trauma shears in my pocket (you never know when these bad boys will come in handy) so we tried cutting the zipper off the pants and then cutting the zipper in half. Now, we were left with even worse leverage. I was beginning to freak out, thinking OMG WTF I JUST RUINED THIS MAN'S PENIS!

The patient started talking to us at that point. He said he'd had this problem before (WTF???) and had seen a doctor with similar complaints before. He then reached down, grabbed hold of the zipper, PULLED, and the zipper broke in half; he PULLED again and it came off his skin. I nearly fell over with shock, amazement, relief, and nausea; the male nurse had turned around and was unable to watch.

True, he had several lacerations that I cleaned with iodine and dressed with ointment. I put him on some antibiotics (his hygiene wasn't so great, and god only knows what was on that zipper), and we found him some sweatpants and some briefs. I also lectured the patient on a) wearing underwear and b) tucking it back while zipping up his pants. Honest to god, this was a grown man. I actually told him "Dude, you only have one of these, TAKE BETTER CARE OF IT."

One of the highlights of the evening: I wrote an order in the chart to this effect: "Patient to wear briefs and non-zippered pants while injury heals."

Not exactly what I had in mind when I signed up for this (but certainly a great story!)

He's Fantastic (As Usual)

If you have a few minutes and want to read about the history of nationalized medicine in England, France, and Switzerland, as well as the history of how the American health care system came to be, and even the American telephone system(?!), go read this article by Atul Gawande in The New Yorker. Go, now.

I found the link at Kevin, MD. Congrats on Best Medical Blog of the Year!

Evidence-Based Medicine

I've long admired the attendings who really know EBM. I have aspirations to be one someday: have an office filled with articles to print out for residents, know which trial said what, who conducted the important trials, be able to read articles critically and pick up on subtle clues that the research was or wasn't great.

I initially said "always" instead of "long" in that first sentence, but I changed it. My first experiences with EBM were pretty pointless. In our first year of med school, we took a mini-class in statistics, where we had to memorize the "ABCD" tables and what sensitivity/specificity meant. It didn't make much sense to any of us, and everyone groused through the course. That summer, I had to do a project for my preceptorship that involved "PICO" questions. They're ridiculously easy to write, so I couldn't figure out why I had to do so many. I was told that I needed to learn how to search Pubmed properly, so I had to have a good question. Later, I had more lectures on how to search Pubmed well. Seriously, people, most med students now are pretty familiar with Google or other search engines and know how to conduct a quick internet-based search to get what they want. Sitting through stifling lectures about "boolean operators" and learning the difference between searching with AND and with OR... Shoot me.

I think med students may get turned off by the statistics and the uselessness of learning how to search the internet and lose sight of why EBM overall actually matters. It has very little to do with PICO questions, after all.

The way I see it, EBM has several points. First, doctors should know how to critically appraise an article, so when the drug rep hands you the article about linezolid vs vancomycin you aren't blindsided by the pretty graphics. Second, doctors should know how to search the literature to find answers to clinical questions--this is where PICO comes in, but it isn't always necessary to go through that whole process. Still, if you want to read the actual study that UpToDate based their guidelines on, you should have an idea of where to find it. Third, all of this critical appraisal *should* lead to evidence-based guidelines for treatment. I know many doctors get upset at the idea of "cookbook medicine", but I'm all for some standardization (with final discretion always with the doctor and the patient, of course). If the literature said Drug X is very good in diabetes, but not Drug Y, then I think a doctor who wants to prescribe Drug Y to a diabetic should have a really good reason for doing so.

So what are the downsides to EBM? Why isn't everyone doing it? I think there are several potential problems:

First, while the randomized controlled trial is the gold standard for testing therapies (new drugs, new imaging, new surgical techniques & devices, etc), not everything can feasibly have an RCT. Pregnant women and children are often overlooked for studies, because who wants to have their fetus or small child experimented upon? The elderly are often excluded from studies, as are the really ill patients. Thus, RCT's often ignore whole populations that may need a treatment, so then we have to try to extrapolate the results to an untested population (or, if you're a purist, just say "there's no evidence for X in pregnant women" and don't treat). Diseases with very small numbers of patients may be studied in fantastic trials that can't reach statistical significance due to lack of power. And sometimes, you just can't randomize people to have a certain condition--see the satirical "Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials" from the BMJ.

Second, there's often a disconnect between study data and clinical practice guidelines. You don't usually base guidelines on the results of one study, but sometimes that happens--see the WHI hoopla. A treatment may become standard of care based on one study (like using steroids for spinal cord injury) and then even when later studies debunk it you can't change the standard of care (defensive medicine, anyone?). Other times, it takes years and multiple studies to "prove" something works or doesn't work, meaning at any given time the guideliness available are many years behind the evidence. Also, guidelines are written by "panels of experts", so sometimes it's difficult to tell what's truly EBM and what's "expert opinion".

Which brings me to my third problem: we in medicine haven't done a good job of selling the public on EBM. Patients don't really know about sensitivity and specificity, false positives and false negatives, statistical likelihood of disease, number needed to treat, etc. How many people would take Lipitor if they knew that between 100-250 people have to take it to prevent one MI? How many people would clamor for increased HIV testing in the ER if they were the patient with the false positive who had to go through the extra testing and fear of having HIV? Even worse, one may still be sued successfully for following EBM practices when it results in a poor outcome.

Fourth, there's a wide disparity of practices between patients with money and good insurance and patients who do not, or even between geographic areas. In a rural area, if you have stable angina, you're likely to get nitro; in an urban area, you're likely to get a cath. Do people in urban areas live longer? (I don't know, but I haven't seen the evidence). I feel like one goal of EBM *should* be to reduce some of these types of disparities, but it hasn't really happened. The growth of medical technology outpaces the body of literature.

Finally, what do we do when there is no evidence? Many of us are not comfortable doing nothing, and many patients are not comfortable doing nothing. For example, when a patient has viral bronchitis, we know the evidence says DO NOT GIVE ANTIBIOTICS. Yet, patients still come to the doctor with cough and runny nose. There's no evidence for giving cough syrup or inhalers, yet I think many of us do so, simply for the sake of doing something (and to get the patient off our backs about the freaking antibiotics, the answer was NO).

So why do I heart EBM? I feel that it's the best system out there for keeping abreast of the unbelievable amount of medical knowledge available. Sure, it's got flaws, and perhaps in the future a new system will come along and wipe EBM off the map, but until then we should use what we have.

You can wake up now, I'm done.

Another New DSM-V Diagnosis

Pager PTSD

Criteria for diagnosis:

1) Exposure to a constantly blaring pager; correlation has been found between an increased number of re-pages within 3 minutes (because the person wearing the pager was in a hallway with no phones, so the person paging felt the need to "try again") and severity of symptoms

2) Persistent reexperience; patient may have illusions of the pager going off or nightmares of missing pages

3) Persistent avoidance of stimuli associated with the pager trauma, ie, turning the pager off when not on call

4) Persistent symptoms of increased arousal, ie, sleeping with the call room light on so as not to sleep through a page, anger and cursing when the pager goes off, constant checking and rechecking of the pager when it is NOT going off to be sure the battery is intact

5) Duration of symptoms lasts longer than the exposure to the pager; patient may experience resurgence in anxiety when other people's pagers go off or may fumble for an imaginary pager when hearing the sound of another's pager

6) Significant impairment in occupational functioning such as cursing in front of patients when the pager goes off, snapping at auxiliary staff for paging incessantly, crying at work

Often comorbid with or must be differentiated from the following potential new DSM-V diagnoses:

1) Pager phobia--avoidance of pagers with increase in anxiety when the patient sees or hears a pager, reluctance to touch or wear a pager, patient must know symptoms are excessive

2) Pager OCD--compulsions of constant checking and rechecking of the battery; patient may even test-page him or herself to rest assured that the pager is working; obsessive thoughts of the pager not working or of beating it to a pulp Office Space style

3) Generalized call anxiety--anxiety and worries not just about the pager, but about the 40+ patients the intern on call is responsible for, interferes with sleep and appetite on call, patient may experience fatigue and muscle tension associated with call room bed and overweighted white coat pockets

Loaded Statement

This dude gave a quote for a smoking-related article on CNN that I think is a) dumb and b) illustrates a point about paying for healthcare.

Retired radio broadcaster and iReporter Gerald Dimmitt, 65, has smoked since he was 14.

"I've always smoked a pipe," he said. "I have successfully quit about 40 times." But, he says, he always restarted, because "it calms me down."

Dimmitt has even more incentive to quit now, since developing lesions and irritation in his mouth. After speaking to his doctor, he received a prescription for Chantix, a pill to aid with smoking cessation. But when he went to pick up his prescription at the pharmacy, he was charged $139 (because it's not generic) for two weeks worth. Outraged, he left the Chantix behind.

"If smoking is so dangerous ... why then do they want to charge $139 to make me stop? There is something very wrong with that. I guess they would rather pay to take care of lung cancer," he said.

So, $139 is too much to pay to quit smoking (when apparently everything else this guy has tried has failed)--fine. But to imply that "they" would rather pay for lung cancer... when the treatment would involve some combination of surgery, radiation, and/or chemotherapy, along with hospital stays, and medication, and would cost THOUSANDS of dollars, that makes $139 seem more like a bargain. Essentially, this guy is saying that $139 out of his pocket is intolerable, so he'd rather make his insurance/Medicare/Medicaid (or whatever health coverage he has) pay for lung cancer instead--because clearly, if $139 is too much for this guy, then thousands is beyond his reach.

I'm largely a supporter of some form of universal health care (although not single-payer), but I'm still torn on some issues, and this is one of them. This guy is going to deliberately forego a treatment that could help him stop smoking and save himself and his health insurance (or Medicare/Medicaid, I don't know what he has) thousands of dollars because he doesn't want to pay out of pocket. Essentially, his insurer is now going to pay for his poor judgment that he's acknowledging publicly on CNN.com.

Now, is the answer to subsidize anti-smoking therapy? Maybe that's not a bad idea, if we're going to suggest banning smoking on federal property and such--use penalties on one side and rewards on the other, give a little extra incentive. Is the answer to penalize such people who are deliberately NOT trying treatment which may be effective in quitting who are deliberately placing an extra burden on the health care system? Maybe--in the private insurance world, these people may already pay a higher deductible, and I'm okay with that. I think that even with a universal health plan, people should be required to pay for part of their health care. ER visits should cost money. Prescriptions should cost money, especially brand-new brand-name meds like Chantix (although I'll admit, $139 for 2 weeks does seem steep).

I just hope his insurer read his little "comment". I guess it's less "dumb" than I initially thought, because if his insurer will pay for his lung cancer why should he pay to quit smoking? Oh, I don't know, unless he'd like to LIVE without CANCER. Because lung cancer kills you. People (myself included) need to take some freaking responsibility with their own health.

Now I'm all riled up to start my Monday. Grrr.

You Need to Be in the Hospital

I'm learning the ropes in psychiatry, and one issue that comes up is "commitment". Why is it that you can "commit" a patient to the hospital for their schizophrenia, but not for their myocardial infarction? What is the difference? How are the procedures different for each? What if the patient wants to leave AMA? I think there's a lot of fear and misinformation surrounding this topic, so I'd like to delve briefly into how a medical hospital stay is similar to and different from a psychiatric hospital stay.

If Mr. X walks into the emergency room with chief complaint of "chest pain", he gets triaged to the medical ER. Likely within a few minutes he'll have an EKG and cardiac enzymes done. If the EKG shows massive ST elevation and the troponin is elevated, the doctor will say "Mr. X, you are having a heart attack. You need to come stay in the hospital to have treatment."

Mr. X has two options at that point: say "sure doc" or "no way". If he says yes, he signs the consent form and is off to the cath lab. If he says "no way", it's a little more complicated. Is he delirious? Is he drunk? In other words, is he in his right mind and able to make this decision? Is he unconscious without family around--if so, you treat emergently and let the consent work itself out later. If he is not delirious, you assess him for capacity to refuse treatment: does he know what a heart attack is, does he know what the treatment is, does he know he could die without treatment, does he know he could live with the treatment? If he meets capacity and says "doc, I know I could die if I leave, but I do not want treatment" then he signs a paper stating that he is leaving Against Medical Advice (AMA) and walks out the door. The procedure is the same if he's already on the floor and decides to leave.

What if Mr. X is delirious? What if his brain is deoxygenated and he's agitated and trying to leave, but only yesterday he told his wife "absolutely treat me if I have a heart attack?" In this situation, you can obtain consent from his wife (or next of kin) for treatment and pursue treatment. If you document that the patient does not have the capacity to refuse, and you feel that the benefits of treatment likely outweigh the risks, and that they are "not themselves" (disoriented, delirious, etc), then you now have the ability to use restraints against this patient if you need to do so. Ever see the patients tied down in the ICU so they won't pull out the vent tube? A patient who is septic, hypotensive, and delirious may try to pull out a tube--they're uncomfortable--and clearly doesn't know that what they're doing can kill them. That patient is at that moment being held and treated against their will, so this is not something you take lightly. Restraints usually have to be assessed every few hours by a doctor, and patients may need to be sedated so they don't a) have discomfort that led them to try to pull the tube out in the first place and b) fight against the restraints so hard they have rhabdomyolysis.

Therefore, not everyone in the medical hospital is there with their consent. An adult with capacity may consent to or refuse treatment and this should be honored. An adult without capacity to consent to or refuse life-saving treatment may be restrained in certain situations. The family may provide consent for treatment if the patient is incapacitated (which is how we end up with so many demented patients in the ICU--another issue altogether).

So how is it different in psychiatry?

If Mr. Y walks into the same emergency room with chief complaint of "I want to kill myself", he gets triaged to the psychiatric ER. Shortly thereafter a doctor or "mental health professional" (maybe social worker or PA) will assess the patient and perform a mental status exam. If the patient is very depressed, still says he will kill himself, and states that he keeps a loaded gun at home just for this purpose, the doctor will say "Mr. Y, I'm concerned for your safety. You need to come stay in the hospital to have treatment."

Mr. Y has two options at that point: say "sure doc" or "no way". If he says "sure doc" then he signs a consent for mental health treatment and is admitted to the psych unit (after some basic labs to be sure there's nothing major medically wrong at that moment). If he says "no way", then it gets tougher. If his risk of committing suicide seems very high, as in he is an elderly Caucasian male, feels hopeless, has no family, lives alone, has a firm plan for death, is in dire financial straits, and it's the anniversary of his wife's death, then you may make the argument that he is in imminent danger of harming himself and should be admitted to the hospital. (If his risk is low, he's a "frequent flyer" in the ER who uses this line to get a warm bed because the shelter was full and his check is spent, etc, then "Sayonara!") You may also argue that the patient's severe depression is preventing him from making rational decisions or having full capacity to refuse treatment.

For psychiatry, instead of having the family sign the patient in when they refuse but lack capacity, you file paperwork with the court--legal "commitment". This varies from state to state, but usually involves some manner of stating that the patient is in imminent danger of harming himself or others, lacks capacity to refuse due to mental illness, and will acutely decompensate and/or likely kill himself if allowed to leave without treatment. The patient will be brought to a locked psych unit and will remain until treatment is completed. Patients who are on "involuntary" status don't necessarily stay longer than "voluntary" patients; it simply means that they must stay until a physician releases them or the court determines that they may be released.

Now, if Mr. Y signs himself in voluntarily, but 4 hours later decides he wants to leave, what do you do? On the medical floor, the patient asks to sign out AMA. In the psych unit, they ask for essentially the same thing. Different states have a different procedure for doing this, but the patient must ask for a document stating that they want to leave (essentially AMA). A doctor must come examine them within a certain period of time to determine whether the patient has capacity to leave. Mr. Y in our example above told us 4 hours ago he wanted to kill himself and has a gun. If the doctor examines him and he says "doc, I want to leave so I can go kill myself", then the doctor is going to have to file paperwork to commit him to the hospital--after he's already there. If the patient is stable, and doesn't meet criteria for legal commitment, then you must let them leave AMA after they request it.

We often err on the side of having patients sign in voluntarily so that the patient isn't forced to be committed legally, but sometimes that leads to a double standard (in my opinion)--we're saying the patient has capacity to accept treatment (which we want), but not to refuse (which we don't want). I think one reason we do this is because we want to use the commitment process as infrequently as possible. Once a patient has been committed, this becomes a matter of public record with the court, where if they sign in voluntarily this is covered by HIPAA.

Legally, it's all very complicated. Due to some abuse of commitment in the past (in this country and others) a very complicated set of rules must be followed. The patient must meet criteria for admission (usually reserved for acutely suicidal, acutely psychotic, acutely manic, etc) and be either about to commit suicide, about to hurt someone, or be completely unable to take care of themselves (the manic patient wearing their undies in the snow to preach the gospel in the middle of the street, for example) to the point that they cannot practice basic safety. Once you file paperwork with the court stating that you've examined them and they should be committed, they'll be assigned a court date. After around 72 hours, a second exam must continue to document that patient still requires involuntary hospitalization. The case will go before a judge at some point who will either confirm the commitment until a doctor says they may be released or will deny the commitment and order the release of the patient.

You can also order emergency medication. After his heart attack, Mr. X became hypotensive and was acutely bleeding, and was unconscious so he couldn't sign the consent for blood products; he will still be transfused. After his admission, Mr. Y became acutely psychotic and agitated, tried to throw tables at the staff, tried to punch through a glass window, and refused to take his meds; if he refused to take an oral med, he would likely get a shot of something sedating (usually haldol 5 mg + Ativan 2 mg) to calm him down. If Mr. Y continues to refuse to take his meds, continues to be agitated and dangerous, you can petition the court to order medication.

Some people would argue that the two aren't the same at all. After all, the patient with the MI who is bleeding is going to die; as my med student put it yesterday "well, psych stuff isn't life-threatening." It depends. Even patients in locked psych units can commit suicide if they're determined enough; they can commit homicide, they can attack other patients or staff. A condition called "agitated delirium" or "excited delirium" can actually cause a patient who is so overstimulated by their psychosis (and often by drugs) to suddenly drop dead. Maybe it's not as clear cut as the MI situation, but psychiatric patients can die from their disorders or related complications. Speaking for myself and the people I work with, we wouldn't put someone in the hospital against their will and medicate them against their will if it didn't seem vitally important to that patient's ability to survive.

Legal commitment remains controversial; just look at the wikipedia page. Obviously, there is some overlap with this and medical treatment, but some striking differences as well. I think we should continue to work very hard only to use involuntary hospitalization and forced medication when absolutely necessary. Judicial oversight helps keep the process honest, but I'm sure mistakes are made. It does help to compare it to what happens in the regular hospital; if you're out of your right mind and lack capacity you're not leaving, whether it's post-MI or the aliens infiltrating the TV set. If you need emergency IV fluids or emergency sedation, it's an emergency, period. This is a rather awesome power doctors wield, and I'm kinda glad there's a judge looking over this process.

First Post of the New Year

And it's a lame one. I've been busy, blah blah blah, vacation/work/learning psych call. All the same old excuses, and largely the same ones I use when I don't go to the gym. Hmm, methinks I need some new excuses! (Or I need to get my fat butt to the gym--I gained at least 5lb on that cruise, but at least the food was amazing!)

Happy New Year to you and yours!

And for the love of god, if it's not too late, try not to take your first disability check of the year and go celebrate by snorting/shooting up/smoking >$100 of cocaine. Try to pace yourself, or you're going to end up in a psych ER seeing and hearing Satan telling you to kill yourself, and that's just not pleasant.