It was the early morning hours and the morning report where a case from the previous nights admissions was presented and discussed had just ended. I was making my way to the floor to see my patients when I got a page from the emergency room. There was a psych patient waiting to be admitted.
Lord, if this is the start of the call, how is it going to end. I made my way down thinking about the delay in rounds on the floor and walked in to the ER. The nurse at the station pointed towards one of the patient rooms and said, “There is your patient. He has a history of schizophrenia and came in psychotic. I have already called the floor and they have a bed available.”
Thanking her, I took the chart and looked at it. No labs, heart rate a little high in the 90’s and the BP low as well. I glanced at his medications and saw Lithium, and a couple of other meds including an anti psychotic medication as well. I asked about a lithium level and the reply was that he is too psychotic right now for any lab to be drawn.
I walked into the patient bay and saw him laying on a stretcher, looking at the ceiling and mumbling inaudibly. “Hello Sir, my name is Dr. Abbas and I am here to ask you a few questions.” I noticed he was a bit hyper vigilant and was staring around the room. He was able to tell me his name, his address and the date as well as where we were. His orientation was pretty good but something didn't seem right. I touched his forehead and he was burning up. I then took his pulse which was rapid but weak. The patient seemed to go in and out of consciousness and was not actively psychotic.
This seemed a medical issue and my suspicion was now that he was delirious due to a medical cause, most likely an infection or lithium toxicity. His physical examination showed that he was ‘dry’ meaning he was dehydrated. We got immediate IV access, started fluids and had a urine catheter inserted to help him urinate and monitor his fluid output. His bladder was almost empty which was a worrisome sign pointing towards kidney issues as well.
I also ordered a stat Lithium level along with other labs and informed the ICU service to be ready for a possible admission their way. I had a gut feeling that this patient was in severe lithium toxicity with his kidneys shutting down and if he was not given proper treatment immediately, the rest of his organs will follow suit. His lithium level came back at almost 3, for reference the upper limit of normal is 1.2. As we were getting ready to admit him, the ER physician told me that the patient had a primary care physician who should be admitting him, so I decided to call him myself.
The PCP refused to admit him, saying that this patient is a ‘crazy’ psych patient who probably wasn’t taking his medications and that I should not have disturbed him. I was already angry at the patient laying in the ER for a few hours with no one doing anything and now this. My anger got the better of me and I let the PCP know a few choice curse words and slammed the phone down. Yes we had phones that we could slam down with satisfaction in those days.
The patient was admitted to the ICU. He coded (read almost died) three times and had to be revived as he also ended up getting a heart attack on top of everything else. It took a few weeks for him to stabilize and then sent over in better health thankfully to a nursing home where he could have more care.
What happened to that patient, occurs on a daily basis all over the US. Psychiatric patients are brought to the emergency rooms or make their way there, only to be shunned or made to feel like they are wasting everyones time. They are human beings like everyone else. They have medical issues, in fact at higher rates than the average population. The way they are treated is pathetic.
I became sensitive to this early on in my life seeing my mother struggle with depression and severe fibromyalgia which no doctor took seriously. The way she dealt with those problems bravely, left a lasting impression on me and probably played a big part in me choosing to go into internal medicine and psychiatry both.
Over and over again, to this day, I see how patients with psychiatric disorders are mismanaged and poorly treated in clinics and hospitals. Doctors and nurses need to be trained properly so that they can be more sensitive to their patients needs. One would think that this is already being done and maybe it is to a certain extent, but not the way it should be. So many patients fall through the cracks as community supports that used to be in place to help them have all but disappeared because of cuts by successive administrations and the pandemic compounded this. I wonder, how many psychiatric patients must have died during this pandemic because of COVID-19, but equally importantly, how many died because there was no one who took them seriously, or they didn’t have anyone to check on them.
These are the most vulnerable amongst us. We cannot call ourselves a civilized people, unless we treat all our citizens equally. I hope that this story will help the reader to realize this, and maybe reach out to anyone in their neighborhood who might be suffering from severe mental illness, but have no one to turn to.