This review would appear to document that attention by addiction treatment team members to the baseline and periodic vital signs, including but not limited to computerized documentation of the pulse rate, blood pressure and temperature respiratory rate as well as attention to the baseline and periodic bedside physical diagnosis (Modai and Rabinowitz, 1993), including but not limited to the level of consciousness and the general appearance of the patient, ensures a high probability of definitive and timely identification and treatment of the medical and/or surgical issues found on an inpatient psychiatry service.
While it is generally appreciated that our chemically dependent patients may well be afflicted with chronic disorders, my focus in this paper is to address the issue of the diagnosis and treatment of the acute and potentially life-threatening disorders of these patients. Coordination of care may be best achieved by recognizing that:
- Chemically dependent patients may well be medically as well as psychiatrically ill.
- As with any patient admitted and hospitalized on a medical and/or surgical unit, chemically dependent patients require a reasonably complete history and physical examination.
- Chemically dependent patients must be viewed as whole patients rather than simply labeled with tunnel vision as "just an addict" or "just a drunk."
- Last, and perhaps most important, counterphobia, when and if it occurs in health care providers, needs to be confronted and addressed.
Decades ago, "alcoholics" and "addicts" were provided with just halfway houses. Then, for a period of several decades, we provided residential inpatient chemical dependency units. Now, with the closing of our residential inpatient units and our return to just halfway houses (or in some instances, three-quarter travel-under-escort housing), we may have come full circle. This is just the time to approach our chemically dependent patients with renewed enthusiasm and intensity of purpose, to focus our history and physical examinations in order to identify both acute conditions and chronic conditions.
Our addiction treatment team meetings provide us with an opportunity to share our provider learning experiences with each other. Lessons we have learned include:
- The value of our search for underlying medical issues.
- The value of consultation with our fellow surgical providers.
- The value of consultation with our fellow critical care providers.
- The value of our ongoing search for curable malignancy.
- The value of our endeavors to refocus our efforts on the medical needs of our patients.
The two core principles in the diagnosis, treatment and care of our chemically dependent patients would appear to be logic and humility. Decades ago, as an undergraduate at Johns Hopkins University, I learned to avoid the fallacy of "Post hoc, ergo propter hoc." Logic empowers me to search for any and all underlying, treatable, curable causes. Appropriate humility leads me to the realization that curable malignancy may well be discovered incidentally and that it may not be the initial primary focus of the patient, and my humility mandates my sitting down personally with every patient from whom and for whom we need to obtain written, witnessed operative procedure consent. After any surgical procedures my patients are encouraged to follow-up with me. This includes calling and writing to inform me of how they are doing. My patients know that I am concerned about them as people as well as patients. My patients and I also know that the best laboratory test is the second office visit. I recall the words of a dean spoken to the graduating class of a respected medical school in the South, "All you need to know after medical school is to remember to say, 'I don't know how to do thisåPlease help me!'"
With the realization that our chemically dependent patients deserve the very best of our knowledge and experience, we can make all due reasonable efforts and attempts to "keep the medicine in psychiatry."