One thing about saving articles to post about later, it is easy to see them get lost in the shuffle. Well, I found this article from the Washington Post about a week ago, then left it in my email inbox til now, so, hope it is worth the read for readers:
Reminded me of a few experiences I have had in asking to see patients who were not just “psych patients” but people who had psychiatric symptoms from medical illnesses. Which is one reason why I just abhor, just detest this push from psychologists who want to get prescribing habits without full medical training and miss things like the above story relates, or, how about these vignettes below?
1. Asked to see a man in his early 30s one night in the ER, while in my residency, who came in floridly psychotic as he was threatening his wife. He was restrained to a medical stretcher as he complained of a severe headache and his vitals were elevated, so as I tried to interview him, I noticed a right hand tremor and the wife noted to me he had new onset of right sided complaints of weakness and some sensory discomforts at the time he started acting delusional in the past several weeks. After some coaxing of both the patient to be cooperative and the ER to allow him out of the area with sedation, we got a CT scan of his head. Yes, the 2 cm left sided temporal meningioma was overtly apparent, and he agreed to surgery which was done the next day. Symptoms completely gone 24 hours post op. Guess sending him to psych would have been a bit of a wasted hospitalization, eh?
2. 50 some year old african american man came in to same ER the same year of residency on a Saturday night complaining of severe abdominal pain, but, since he was on lithium, they felt it best to wake me at 2AM, one of the few Saturday nights I had a quiet call night mind you (!) to interview him because, hey, he was on lithium, and that infers his abdominal complaints. As I am meeting with him in the psych office space in the ER, he is obviously in pain and hard to talk with, so I lay him down on the examining table in the office and just simply palpate his abdomen, and when I checked for referred pain by pushing down and let go quickly, the howl of pain had 2 security officers in the room before he could breathe in again. The ER attending comes in to admonish me for “playing doctor”, then, the labs were reviewed again and the debate about a 22,000 white cell count with bands could NOT be attributed to a “left shift” seen with Lithium alone, so surgery met with him. Taken up to the OR an hour later and his abscessed appendix removed.
Oh, the epilogue here? The surgery resident hunted me down in the cafeteria the next morning to tell me the patient’s appendix ruptured as the surgeons had his abdomen opened, and the patient was in the ICU for safe keeping for the rest of the weekend. The resident went on to tell me that the ER was planning to discharge him if I cleared him for psych issues, so, the patient would have died if he was sent home. Gee, makes you wonder when you hear TODAY how somatic providers shut down when the word “psychiatry” is mentioned in a patient’s history. read this to see my point: https://www.ena.org/practice-research/research/Documents/WhitePaperCareofPsych.pdf
3. This last story still makes me angry, so keep this in mind as you read further. While working at a CMHC on the Eastern Shore about 15 years ago, I had a 50 some year old woman referred from her PCP for her persistent Upper GI problems seen as just complicated anxiety symptoms. She noted she was struggling with anxiety, but the NEW ONSET of the GI problems with continued nausea and vomiting only made her more concerned and worried. Umm, a little tip to those naive to anxiety symptoms, it is RARE for people to have repetitive vomiting from pure anxiety causes, without an iatrogenic or self induced cause. The daughter with her in the appointments with me felt the patient had real GI issues, and I agreed, but, her PCP kept uttering to the patient, and me in TWO separate calls to him, that “she is just too anxious and making herself physically ill, she needs to be on psych meds, maybe even psychiatrically hospitalized”.
Well, here is the angry part. I get a call from the daughter about a week after the last appointment with me asking to come in urgently. Not for the mom, the daughter. You see, the patient (mom) went to the ER 3 days earlier for severe abdominal pain with repetitive vomiting, and when they got her into the ER, she became unresponsive and CPR was initiated, but they could not save her. The patient had an autopsy at the hospital, and the daughter had just been told a couple hours earlier before calling me that her mother had a small bowel obstruction, something I was advising the PCP try to rule out before pushing for more psych care, so she died from it. It was difficult to redirect the daughter to not want to confront the PCP at his office, I had to call the daughter’s husband from his job to come get her and keep her, and the PCP, safe. The daughter did not act out, fortunately, but I heard through the grapevine weeks later that legal matters were being pursued. Just because the patient was anxious, she wasn’t evaluated fully.
So, the point here is simply this, for people as patients, providers, and invested observers, you gotta rule out medical factors to psychiatric symptoms when the presentation has physical symptoms as well. Look at almost every DSM disorder and it says very clearly in there, “…are not due to the direct physiological effects of a substance or a general medical condition.” And yet why do too many people forget this in the diagnostic evaluation process?
That is why psychiatry has a place in the treatment process. You think all those PCPs and other nonpsychiatric providers out there are going to be able to replace us once PPACA enforces the extinction of superfluous psychiatric services? Think about it.
For you see, exceptions may be few and far between, until, you are the exception?!