Why Psychiatrists Are Physicians First: Country Calm Before the Storm

October 16, 2013

Most New Yorkers were afraid to venture outdoors after the Twin Towers toppled, so a short term, part-time locums post opened upstate, an escape from the decaying metropolis and retreat to the country. What could go wrong in such an idyllic setting?

The air was cool. The apples were ripe and ready for picking. Leaves were falling, carpeting the thinning green grass with red-gold specks. It was a fine fall day, a perfect day for the country.

To someone who never read the news reports, there was no reason to think that anything was amiss. Those who fled lower Manhattan on 9/11 knew that a lot was wrong that autumn.

Downtown New York was closed below 14th Street. Next to no one arrived at the city’s overstaffed emergency departments (EDs), except for extra staff. It was the medical examiner’s office that was busy. Apart from “first responders,” most New Yorkers were afraid to venture outdoors after the Towers toppled. Stores were shuttered. The stench was suffocating.

So I devised a plan to escape the decaying metropolis and retreat to the country, at least for a while. A short-term, part-time locums post opened upstate when a “regular” doc needed time off to tend to “family affairs”-and I needed work until my office reopened.

That’s how I came to spend a few weeks working at a picture-perfect country hospital-and unlearning storybook assumptions about rural practice. Grant Woods’s images appeared in my imagination. In my (naïve) mind, the country was pure, pristine, a place where nothing bad happened. Fresh air and open space solved psychiatric distress-at least according to Wordsworth-inspired “nature cures.”

I headed to the country. Yellow wildflowers lingered, even in autumn. Multi-colored mums exploded like popcorn, topping wide wooden barrels that lined dirt road driveways. No fancy florist bouquets for this country place-just the simple stuff.

How could anything go wrong in such an idyllic setting? At worst, I was told, people who didn’t need inpatient stays spent extra days on the wards, waiting for appointments at clinics with long waiting lists. They said that this was “easy work,” compared with the city.

It was my second day on this short-term job, time to start the “real work.” The first day was spent in walk-throughs and brief meetings with staff and patients-with the exception of one, who was out on a pass.

Right after rounds, the charge nurse approached me, chart in hand, and asked me to sign off on discharge orders. Sign off? That was new vocabulary for me. It’s not like I was accepting a UPS package.

I asked for clarification. She said that Jim (the missing patient) did well on pass. He was ready to return home, high in the hills. His grandma needed him to lift grandpa, who was bedbound since his stroke. Besides, the managed care company wouldn’t pay for another day if Jim was well enough for passes. According to the nurse, all he needed were orders on the chart and a few months of prescriptions to hold him until his clinic appointment.

I did not know anything more about Jim, but that did not matter, because I was not about to sign off on a patient I had never seen. I assured her that I would take care of matters, as soon as I completed my own evaluation and added it to the chart.

Jim was willing to talk. He headed to the interview room. Wearing overalls, with knees patched from wear-and-tear, and not because Soho billboards featured torn jeans that season, Jim sat down slowly. He did not look too happy about going home. But that wasn’t the issue. When he pulled his chair closer to mine, caddy corner, his eyes were in clear view. So was his nystagmus. His irises slid from side to side.

Eyes are almost as important to psychiatrists as they are to ophthalmologists. When recording mental status, we note if “pt avoids eye contact” or “makes good eye contact.” We look at pupils, and their size, and guess about drug use or withdrawal, even before the toxicology screens return. We instinctively look at sclera, to see if they are injected or jaundiced (which is admittedly a tough call). Eye twitches are also important, because they may be tics (secondary to stimulants), extrapyramidal symptoms, or Tourette syndrome. Physicians instinctively make these observations during casual conversation, even without formal neurological examinations.

During neurology rotations, we learn to look for nystagmus and its variations. Some research psychiatrists who study schizophrenia focus on saccadic eye movements. Me, I could never forget my med school elective, where we chanted the words “nystagmus, ataxia” at every epilepsy clinic. Then we marched down the hall in formation, as if on a military drill.

Those were the days when phenytoin and phenobarbital were the mainstays of anti-seizure medications. We learned to identify physical signs of toxicity immediately, lest worse harm happen before lab results returned (if they returned at all). The department chair prided himself in his ability to differentiate barbiturate toxicity from phenytoin toxicity, by looking at eyes and gait alone. I suspect he also prided himself in his ability to torment medical students who were slow to learn those same skills.

Sometimes, nystagmus is a benign condition that appears at birth. However, this patient had spent weeks in a psychiatric ward, at a time when most hospital stays lasted hours to days. No one notated nystagmus before. I was about to ask Jim about his eyes-and his hospital stay-when he asked me about the time.

“What time is it?” he queried. I presumed that he wanted to know when he would be released.

There was a clock on the wall, so I pointed to it, hoping to shortcut the mental status exam by asking him about the day, time, and year right then. Then he asked me a stranger question. As I gestured at the clock, he asked, “Which one?”

“Huh?”

 “Yes, there are three.”

Was Jim using recreational drugs that made him hallucinate or affected eyesight? Was his triple vision related to his nystagmus? I asked about the usual fare for country boys his age, knowing that “shrooms” grew wild in the woods. He matter-of-factly stated that he took grandpa’s meds when home on pass.

I went into hyper alert upon hearing that. It was the same sort of hyper alert state that occurred upon hearing radio news reports on 9/11-after seeing smoke and flames shooting skyward.

Trying to keep calm, I asked for the names of the meds. He didn’t know. That didn’t matter. I knew that his grandfather had a cerebrovascular accident, which meant that he probably had heart problems and high blood pressure, and was probably anti-coagulated. The thought of digitalis toxicity flashed through my mind. My own heart sunk. With anti-coagulants, he could be bleeding to death. What if he downed diuretics or potassium pills? It was equally dire. Strangely enough, hallucinogens would have been safer.

I dashed into the hall, to find the nurse to rush him to the main hospital. She frowned and reminded me that they never returned patients to the hospital after discharge. After I explained my reasoning, she reluctantly summoned an ambulance to transport him to the main medical campus. He went from ED to ICU. His kidneys were failing. Dialysis was started. Word trickled down-they said he would survive. If lucky enough, he would survive without lifelong dialysis.

I think back about how I wanted to talk to Jim about his grandpa, if he resented him, maybe unconsciously wanted to kill him, but tried to take his own life instead. A psychosocial approach was equally compelling. I wondered if Jim feared another snowed-in winter in impassable mountains, crammed into his grandparents’ cabin, with chickens and roosters, but no girlfriend, no job, no GED, not even a car to earn an extra $20 for dump runs. In time, I learned that real life in the mountains above the Hudson Valley was hardly as idyllic as Hudson River School landscape paintings implied.

The psychodynamics behind Jim’s decision to overdose were intriguing-but without noticing his nystagmus, and acting on it, there would be no chance to explore them.

When I think about proposals for “prescriptive privileges,” I shudder. How easy it would have been to write discharge orders and sign his scripts. Do cram courses on psychotropics teach about “medical” medications, and instill instantaneous association about strokes, cardiac meds, and lethal consequences? Unlikely. Because that information was drilled into my head in medical school, I reacted reflexively.

We could not predict the events of 9/11 that led me to the country, but we can predict the consequences of forgetting the value of medical training, and thinking of psychiatry as “medication management” only. Let’s hope that doesn’t happen.