Lately, however, his depression was worsening, problems at home seemed more severe, and he had begun thinking of alternatives, as he put it.To make things worse, he had a gun at home and was reticent about having his wife lock it up for him -- not a good sign.
We talked about inpatient admission and I walked down to the ER with him to get the evaluation process started. I spoke with the ER director, she agreed with my assessment, and at that point, technically speaking, the decision about hospitalization was out of my hands. I had a funny feeling, though, that gnawed at me all evening.
When faced with hospitalization, patients can experience what's called "flight into health," which means they suddenly feel less distressed and despite having been suicidal hours before, for example, they deny it completely. And, of course, this means they don't meet criteria for inpatient care. The problem is, once released, their "recovery" doesn't last and their behavior can become rapidly lethal.
So, I gave in to the feeling and got on the phone. Sure enough, my patient had a change of heart and the evaluator was contemplating a discharge. A few minutes into our conversation he reversed his thinking and the next morning my patient said he was glad we'd decided not to listen to him after all.
They say you shouldn't take your patients home with you -- metaphorically speaking -- and that's generally true. But if you're going to care about the people for whom you're responsible, sometimes it's going to happen. You'll wake up in the middle of the night, make a call, and go back to bed glad you did. It doesn't happen quite as often as one might think and eventually, experience (and the supportive advice of colleagues) teaches you how to set limits on yourself. Like everything else in medicine, there's a learning curve and all of us are students, no matter how much practice we've had.
(Image by Toni Blay via Flickr -- creative commons licensure)
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Love your persistence Dr Bill!
ReplyDeleteWas he placed on an I.T.O.?
I'd learned the hard way that I couldn't take it for granted that patients I wanted admitted would necessarily BE admitted. Clinical evaluators have their own opinions and sometimes they get "territorial." So, experience taught me that it was wise to follow-up on patients I sent to the ER. I also learned how much more likely it would be that I'd get what I wanted, if I could enlist my ER counterpart as an ally rather than an adversary. That took some practice. :-)
ReplyDeleteIf by I.T.O., you mean an involuntary hold, I think that probably happened. It's been a while since this occurred, but I can't imagine admitting a suicidal patient on a voluntary basis -- as you know, it's too easy for them to sign out AMA.