Louisville Medicine Volume 65, Issue 2 | Page 20

ON THE COVER PHYSICIAN-IN-TRAINING/STUDENT CATEGORY Winner What Drives You Crazy: A STORY Natalie Spiller 4 :32 pm, you’ve been in the emer- gency room since 5 am. This is day seven of seven days in a row before your vacation. Today alone, your team has treated seven chest pains, five abdominal pains, two motor ve- hicles accidents, three drunks, two suicidal patients, a pregnant teen, a broken arm, an allergic reaction and pneumonia. Your shift ends with check-out in 28 minutes and you see one last patient pop up on your screen, a 56-year-old white female with “altered mental status.” Scanning a past medical history you see a common slew of comorbidities: “depression,” “bipolar,” “schizophrenia,” and “substance-abuse disorder.” You order a tox screen and a pregnancy test before you even see the patient, as you’ve done a hundred times this year. this happen? You have seen the same case hundreds of times. You were thorough and clear with your hand-off. What happened to the patient and how is any of this your fault? The interview only solidifies your assumption. The patient can’t follow your conversation, her speech is disorganized and she keeps mumbling something to the effect of “it’s the end, God is coming for me.” She looks disheveled no doubt from the drugs and has no one with her. She was found slumped over on a storefront by a by- stander and her only possessions are the clothes she is wearing. You read through the rest of her chart: previous admission for “bizarre behavior” and no outpatient care or aid. You go ahead and order a CBC and EKG just for completeness’ sake and prep her for admis- sion to the psych floor. 5:00 pm hits, you check out your patients and head home for a nice relaxing few days off. This is neither a totally absurd diagnosis nor the first stroke this ED physician has likely seen. Were the signs of stroke actively ig- nored? One would hope not, but the truth is more often than not, psychiatry patients are undertreated for their medical conditions. It is known that schizophrenic patients in particular live 15 years on average shorter life expectancy. It is not believed to be from the pathophysiology of the disease, but from lack of medical care for the common killers primary care providers set out to prevent. Likewise, depression added on to any disease will decrease life expectancy via the same means. 8:30 am, the buzzing of your cell phone rouses you. You don’t recognize the number but decide to answer anyway; you have the time. An eerily chipper voice alerts you to something a doctor never wants to hear, “You are being sued for the wrongful death of Patient XYZ.” Mumble, mumble, mumble, click, silence. How did 18 LOUISVILLE MEDICINE Unfortunately, this case is not the first and won’t be the last of the under-treatment and over-stigmatization of psych patients. Far too often do physicians see the diagnosis “substance-abuse disorder” or “schizophrenia” and either balk entirely at the idea of treating them or assume all their problems are explainable by their mental issues. In this case, the latter ended up killing a patient. Our patient suffered a stroke, which mimicked a psychotic episode. Until last year, she was a functioning schizophrenic. She ended up off both her psych and anti-clotting meds, but without a support system around to rein her back in. Flash forward a few months and her past IV cocaine use comes back to haunt her as a tricuspid valve calcification breaks off and blocks supply to her brain. If we know this, why is it such a problem? As a third year medical student with a significant personal and family history of psychiatric disorders, what drives me crazy is to see the stark discrepancies in medical care of psychiatric patients. I can’t tell you how many times I have heard a fellow student say something along the lines of “it’s another crazy” or “she’s high and just wants pain meds.” While our