Sometimes it just doesn't work

Sometimes the health care system just does not work. 

I had seen him one week earlier on a Friday afternoon, accompanied by his estranged wife. They were there because of concern about increased depression. He told me that he had stopped taking his lithium and paroxetine (Paxil) several months earlier because he felt they weren’t working. He also readily admitted to having returned to the habit of drinking one or two six-packs daily and more on weekends several months before the medications stopped working.

As the story evolved, I learned that he had stopped going to work and then was fired. He had no energy or ambition. He was not sleeping either well or regularly. This visit had been precipitated because he had gotten angry with a neighbor and tried choking him. When I asked him if he had had other times when he considered doing things that might harm others, he said that he had been driving around with his loaded gun, feeling very angry and wondering if he would feel better if he shot somebody, and whether it would be better to shoot somebody he knew or a stranger.

We talked briefly about the fact that his medicines might have stopped working because of the alcohol, but that he was now dangerously depressed, and that the options were to go directly to the crisis unit for admission or, if he refused, I would call the police. He readily agreed to admission. “That’s why I’m here doc. I need help before it’s too late.”

His wife drove him straight to Crisis in the hospital across town, where he was evaluated. They called and told me the decision had been made to admit him.

I was now seeing him in follow-up. The story he told me was unbelievable - but was confirmed by his paperwork and a phone call to the hospital emergency department.

He had indeed been seen and evaluated by the nurse practitioner on call, and was felt to be seriously depressed and ‘at major risk for harming himself or others.’ Because it was late in the day, there was no open bed at that moment on the psych floor, and the psychiatrist had already left for home, he was kept overnight in the emergency room for admission in the morning. During that time, he underwent the standard and appropriate metabolic screening and a physical exam  by the emergency room physician whose note confirmed the patient’s description of events.

Early Saturday morning he was visited in the ED by an intake worker. She reviewed the chart and spoke to someone on the psych floor, after which she explained to him that he did not need inpatient care. He was discharged home with (written) instructions to see his primary care physician so he could be restarted on his medications. He was also told to call for an outpatient counseling appointment after the weekend.

When he called, he was told that the counseling sessions were currently full but that he would be put on a waiting list, and that if he felt he needed services sooner, he should contact his primary care physician or return to the Crisis Unit in the ED.

We contacted a friend to make sure he no longer had a gun. We restarted him on his medication, which he agreed to take. Five days later he was brought back to the ED by the police who had been called by a friend. He was intoxicated and threatening to drive his car into the river. He was kept over night and then transferred to a psychiatry floor in a neighboring community for a two week stay followed by intensive outpatient therapy.

He’s doing much better. 



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