By Kelly OBrien, MD, FACP, CCHP
Posted on October 5, 2010 – Seems the Rolling Stones aren’t the only ones denied satisfaction. We’ve had a tough month here at the secure in-patient unit at our county hospital. Now, you know I’m not making these things up because I don’t need to.
Mr. Sweeney is 58 years old. Initially accused of being on a hunger strike, he pointed out he had nothing to protest. He’s not afraid of jail, and he was too darn wrung out. Chart review revealed an 80 pound weight loss, and a work-up revealed the World’s Most Amazing Achalasia. No cancer, but he needs tube feedings to improve his nutritional status before surgery. As he begins to feel better, he gets feisty. It takes an EGD tube to help the dobhoff tube fit through the minute opening that used to be his esophageal sphincter. A newfound energy awakens a newfound appetite. He wants ice cream; he wants soup; he wants milkshakes. He only gets popsicles, so he wants many. We’re possibly the only correctional unit raiding the pediatric refrigerator. I finally have to write an order for a formal limit on his popsicle consumption.
Next door, Mr. Vrain has perfected an old technique for medical attention. He’s taken seizure activity to a new level, and really, it’s impressive. He’s willing to hit his head on the floor, to vomit, to pee on himself, to shake and gyrate and he can go non-stop for 40 minutes. This does not go over well in a jail unit, so he’s sent to us. Initially it’s very alarming and you get a new sympathy for the jail staff. He doesn’t, however, have the sophistication to change his brain waves (nor the savvy to not have an episode while being monitored on the EEG). No seizure focus is found and we begin the delicate conversation about pseudoseizures. He’s shocked, of course, and then offended. We settle on the word atypical and inform him that, from now on, we will leave him alone and let him work through these seizures by himself. So much tender care, out the window, just like that.
Around the corner, Mr. Hartz has not been getting satisfaction on a whole different level. He’s admitted for chest pain (Really, this should be a new DRG: Chest Pain at Arrest, With or Without Cocaine.) and is very depressed and hopeless about his situation. After several days of meds, the Psych service feels he can return to jail. When told to dress out, he pours water on the floor and puts his bed cord in his mouth *BAM* flies across the room. He had peeled the plastic coating off the cord. A temporary loss of consciousness and a burned mouth are the only physical consequences, but needless to say, his discharge is canceled. He’s in a paper gown and a mattress on the floor, and the meds are increased. Gradually he sees a future, goes to court, talks to his wife (who was not impressed with his McGyveresque plan) and discharges to jail after demonstrating proper cord behavior.
Popsicles. Attention. Death. The job of the medical staff is to sort each patient’s needs from wants. We’re expected to recognize and satisfy the former while not wasting resources on the latter. There are guidelines, but no firm rules as to which is which. Sometimes this is harder than it looks.
Dr. O’Brien is an SCP member and Acting Chief, Division of Correctional Care at the Denver Health Medical Center. Readers may contact her at kelly.obrien@dhha.org.
