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The Hard Case

Revisionist history mars a patient’s return

The New Physician April 2010
There were so many emotions when I saw you today, laughing with the nurses. As an attractive man, you caught my eye and my gaze lingered. I must know you from somewhere. The nurse recalled that I participated in your care. “Do you remember the psychiatrist that came to see you in the hospital?” she asked you. You did not remember me and apologized for that, shaking my hand and allowing me to reintroduce myself. I was shocked to see you so healthy. You wanted to know every detail of what happened, so the nurses and I filled you in.

You came in as a trauma case: While riding your bicycle, you were hit by a car and suffered a severe brain injury. You had alcohol and a crack pipe on you. Levels of each were found in your blood. Emergency neurosurgery was performed, but your mental status remained deteriorated. You were paralyzed on one side and confused. Psychiatry was called to manage your confusion and behavior.

It was disheartening to see you back then. It looked pretty hopeless. Young guy, sad case. I told the other staff there was hope. You had subdural hematomas accounting for much of the damage, which led to the paralysis and mental status changes. It was possible that the hematomas could reabsorb and your condition would improve concomitantly. Even as I recited these facts, I didn’t believe it myself.

You were in the hospital for seven weeks. We had to see you every day. It drained me. I was glad for the days that I wasn’t rounding on you.

You were a behavioral nightmare, leaving the nurses and other staff in a tizzy: spitting at everyone, trying to hit them, constantly demanding something they had just given to you. They would turn to me and demand that I do something. I felt helpless. I wanted to give up but couldn’t. We started you on psychiatric medications to use on a prn basis for behavioral problems. My heart wasn’t in it so I relied on my brain. You had a frontal lobe injury and were displaying the typical signs: impulsivity and decreased frustration tolerance. I knew that Depakote was useful in these cases and so I used it and kept increasing it until it showed some effect.

Daily, we titrated other medications to treat the behavior so that the staff could take care of you and provide for your needs. You became increasingly tolerable. They warned me not to talk to you because I would be spit on but I didn’t have a choice.

I was so worn out, and then your mother got involved. The nurses complained that she wouldn’t stop calling, telling them how to do their jobs. And why couldn’t she come in and help them if she knew so much? Then your mother started saying that the psychiatric medicines were the reason you were a behavioral nightmare. That in fact all of your problems were not because of your extensive head injury and neurosurgical procedures, but because of the psychiatric medications you were receiving.

I wanted to scream. Where was she before I started giving you medications? One of the first things we do in the detective work of this job is to look at what medication changes were made in relation to when various symptoms start. It seems so obvious, but I’m amazed that other people don’t think like that. In your case, the psychiatric medication allowed you to cooperate with the medical care you needed.

Today, I felt goose bumps form all over as I listened to you talk. I swelled with pride that, though I sometimes resent the regulations that force me to treat hostile patients, we hadn’t given up. I started to feel a surge of inspiration that could carry me through the rest of the hopeless cases! You talked of how the accident had been a blessing in that you had given up drugs, alcohol and cigarettes. You were putting your life back together. You were in the process of declaring bankruptcy so that you wouldn’t have to pay us for the work we had done for you. I could understand. You had no insurance, and it was a lot of money to pay. Never mind that it wasn’t our fault you chose to get high and go out into traffic, and that we probably deserved something for what we did for you.

Because you didn’t have insurance, there had been a huge issue with where to send you. No one would take you. Your mother was breathing down everyone’s neck, and I was tired of spending so much time and energy on your case and hearing her blame the medications I was working so hard to adjust.

“Send him home with the mother,” I had snapped. “Let her take care of him.” I don’t know why that hadn’t been considered. She balked at first, but within a day or two, you were gone. I was glad to see you go. Relieved to think you were just another sad case that would be disabled for the rest of your life and I would never see you again. But you came back for your records. Such an intense moment, seeing you and hearing you talk. Glad that you couldn’t remember the tragedy of your condition, amazed that you had healed and were doing fine.

Then it all came crashing down. As the nurses praised your amazing recovery and stated forgiveness of your horrible behavior, “Yes, it was the psychiatric medication that made me like that,” you explained to the nurses praising your amazing recovery. “As soon as I got off the psychiatric medication, I was fine.” Luckily, the constraints of professionalism prevented my desired response. All that time, energy and pain to get you stable enough to receive the treatment you needed! It felt like it was all for nothing. I found myself wishing I never would have met you and that you were strapped to a bed in a nursing home somewhere with no one to attend to you because you wouldn’t stop spitting.

The better part of me is glad that you have healed. I know that you’re enjoying the improvement attained through reabsorption of the hematoma, and I’m glad that you no longer require medications. I should be happy with the satisfaction of knowing I helped to make you better, even as you blame me for causing your problems. I should be, but I was awakened multiple times last night on call and I’m tired, and sometimes I wish I had the career I’d imagined instead of having to defend myself even as I try to help you. Sometimes it’s so much easier not to care.

Dr. Alicia Ruelaz is an assistant professor at the David Geffen School of Medicine, UCLA. Direct comments about this topic to