Friday, February 17, 2012

The End of the Stories: Patient B

Thank you to everybody who commented on my hypothetical jail patient scenarios in my post Send Them Away. Here is what happened to Patient B:

Patient B was sent out to the emergency room where he took a swing at the ER doc examining him and later another one at the consulting psychiatrist there (the police grudgingly uncuffed Patient B so the nurse could take vital signs. The police warned them not to.) They started a detox protocol which sedated him but he remained disoriented. The ER doc called the consulting psychiatrist back (who was waiting for Patient B to sober up so he could do an evaluation). The ER doc insisted that the consulting psychiatrist admit the patient to the psychiatry service as soon as possible for detox. The psychiatrist explained that he could not assess the need for admission, if any, until the patient sobered up. The ER doc walked away muttering something quietly under his breath. Several hours later the patient was no longer combative, but he was also no longer responsive. The psychiatrist came by to see if Patient B was sober yet and found him obtunded with a single dilated pupil. Patient B was rushed to radiology for an MRI. His intracranial bleed was caught just in time. After an extended stay on the neurosurgery service he was discharged to a rehabilitation facility.

Meanwhile, the local state's attorney had an attempted murder on his hands. The victim, a local used car dealer, narrowly survived a knife attack when Patient B walked into his girlfriend's apartment and found the car dealer...um...checking the oil. The girlfriend was unharmed but told the police that Patient B was there in violation of a protective order she had taken out against him two weeks before. Given the serious nature of the charge and the political implications of domestic violence in general, the prosecutor refused to drop the charges even though he knew that Patient B was in the hospital. They held the bail review hearing at the patient's bedside. Patient B was held with a no bail status and a correctional officer was posted at the patient's bedside. Leg irons bound the patient to the bed as he recovered from his neurosurgery. His ex-girlfriend, learning that Patient B had been near death, had an immediate change of heart and got into a fight with the attending officer when she insisted she needed to be at the bedside as well. Hospital security was called when she refused to leave, and she was ultimately taken into custody for disorderly conduct.

Ultimately Patient B was seen by the psychiatry consult liaison service. He was found to have moderately severe short term memory impairments, abstraction problems with difficulty reasoning, expressive aphasia and profound apathy. And he could only walk with assistance. His public defender took one look at Patient B sitting in the wheelchair in court and he knew he would have to request a competency assessment. He also knew Patient B would be found incompetent to stand trial, but not dangerous due to his physical impairments.

Patient B dropped into legal purgatory. He was incompetent to stand trial but could not be admitted to a psychiatric hospital for restoration because he was not dangerous. Even the neurosurgeons couldn't predict how much, if any, of his mental faculties would be regained over the longterm. The state's attorney's office refused to drop the charges because of the seriousness of the offense. When the statutory limit of incompetence was reached, the judge threw out the charges but the state's attorney immediately reindicted the defendant, thus restarting the clock. The case was appealed to the highest court in the state and a final opinion is pending.

Meanwhile, many many years later Patient B spends a few minutes every morning sipping coffee on the front porch of the assisted living facility the nursing home released him to. He hasn't heard from his girlfriend in many years although he has vague fond memories of motorcycle road trips with her hugging him from behind. His housemates---a demented elderly professor of economics and a frail former teacher---see him on the porch and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person.

8 comments:

Dinah said...

It took 20 years but I've finally turned you into a novelist! Perhaps the Waren Wilson influence helped....

Anon Anon said...

So could his combative behaviour have been the result of the intracranial bleed or the intracranial bleed the result of alcohol or detox or was there no relation?

Doc Brainstem said...

Just another day at the office...

Liz said...

ugh-- scary... what would have clued you in to send him to the er rather than keep him in the "observation room"? would there be signs of a bleed like this before the situation became critical?

jesse said...

Until now I did not realize the extent that Forensic Psychiatry can be involved in the treatment of a difficult, underserved, and in-need population. It is community psychiatry in purest form. Resources are sorely lacking and a high percentage of patients must be unable to get satisfactory long term treatment, particularly considering that these are people with limited means and chaotic lives.

These vignettes also make clear that the alternative to forced psychiatric treatment in a hospital might often be that the patient is arrested, and care is delivered within the prison system. Would that all health care providers were as thoughtful and caring as Clink.

Anonymous said...

Jesse can you please clarify what you meant when you wrote:These vignettes also make clear that the alternative to forced psychiatric treatment in a hospital might often be that the patient is arrested, and care is delivered within the prison system.

I cannot tell if you would propose that jail might be an alternative to be looked at in general or if you just mean that it is often the place people end up when the cops don't realize they ought to have taken the person to hospital as was the case with patient C. I know the latter is true and am hoping you don't mean more people who need treatment be taken to jail for it although in some cases the hospital and jail
have an awful lot in common, esp when talking forced treatment.

jesse said...

@Anon, I meant that jail, very very unfortunately, is what the police often do when in fact they should take the patient to a hospital.

I once was treating a man who one day became belligerent in a store and slammed the door. The owner called the police. When they arrived my patient was lying down in the middle of the street, looking up at the louds. Amazing he hadn't been killed. So where did the police take him? An emergency room? No, to the jail. No Clink, no treatment. A few years ago I saw, from my car, a homeless man who might have been he.

It was very sad.

Anonymous said...

Jesse,

Thanks for clarifying . One day, I was listening to the louds and the cops came to take me away. They brought me to a hospital. Eventually the louds quieted down a bit. They never really go away 100 per cent but for everyone else's purposes I function pretty well.I know you meant to write clouds but louds is such a fitting word for what I experience so please forgive me.
I am not a robot. I just can't read the word verifications anymore.