One night during my first year as a psychiatry resident, I was a half hour into a short-call shift when I was paged for a new consult: “Patient requesting to leave AMA (against medical advice). Please consult for capacity . . . and agitation.” The patient was middle-aged and had a history of psychiatric hospitalizations but no formal diagnosis. He had presented to the emergency department (ED) requesting to speak with a counselor, but results of routine laboratory tests showed acute kidney injury; further tests revealed his creatine kinase levels to be profoundly elevated. The presumed diagnosis was rhabdomyolysis. Leaving the hospital without proper care was potentially fatal. A brief review of his chart revealed a past history of agitation with attempts to leave the ED on multiple occasions, requiring chemical restraints in a rather short period of time between incidents. I quickly reviewed the pillars of capacity necessary to make a medical decision and headed toward the patient’s room.
I feared this would not be an easy case, and I entered the room with some degree of trepidation. The patient, for one, was an imposing physical presence, at about 6 feet 3 inches in height and weighing over 300 pounds. Secondly, he was clearly upset and impatient. Reminding myself that patients respond to a provider’s affect, I tried to keep my naturally wide eyes and expressive face calm. I sat down, greeted the patient, and asked what was going on. The conversation proceeded haltingly; I found myself rushing to acquire the necessary information, and consistently reassuring the patient I had his best interests in mind. He was growing more frustrated, but I plowed through, trying to cover all my bases. Do you understand the risks and benefits of treatment? What could happen if you left the hospital untreated? My heart beat a little faster as he fidgeted, and I sensed he didn’t think I would allow him to leave the hospital. He stood up, and I told him I needed to discuss the case with my attending and excused myself.
I sat down at the nursing station computer to page the attending on call. While I was on the phone, the patient came out of his room. My heart beat faster still. In the blink of an eye, he was in front of me, shoving the computer terminal toward me. I withdrew my hand just in time to keep it from getting smashed. He moved 3 feet down the counter, reached out, and grabbed a glass vase, which he subsequently threw (directed downward) into a group of nurses. Security had already been called, and they escorted the patient back to his room, where he was placed in restraints.
The guards and nurses looked at me expectantly. Again, a challenge: He had already received a significant amount of medication to which he wasn’t responding. Ultimately, we recommended an antipsychotic and antianxiety medication and encouraged the team to let him out of physical restraints, as we so often find this to be more irritating to patients. However, given what had transpired, the hospital elected to keep the patient in restraints throughout most of the evening.
As for me, my training required me to document carefully what had occurred. I processed the events with my senior resident and my attending, who prescribed me a glass of red wine for the evening. I trembled as I walked home, and I reflected on how the situation could have been better handled. In retrospect, I should have offered medications much earlier and certainly should have had security nearby throughout the ordeal. I had not intentionally misled the patient to believe he might be discharged, but perhaps I had conveyed this to him; thus, the interview could have been abbreviated. And finally, as soon as I sensed we weren’t getting anywhere in the interview and likely my decision was made . . . as soon as I felt a little on edge, my heart rate hastened, and I backed out of the room . . . I should have been more aggressive in summoning security and medicating the patient.
Alas, in residency, we have ample opportunities to put our learned skills into practice. The next day on the inpatient unit, I read through the chart of another new patient. He had a history of being easily agitated. I forced myself to take several deep breaths and then interviewed him from just inside the door. When he provided terse responses to my questions and sat up somewhat threateningly, I quickly backed out of the room and told him I would come back later. Lesson learned, onto the next challenge.
Dr McGuire is a third-year Resident in the department of psychiatry at Northwestern University in Chicago.