Psychosis
"Stop playing around! You need to keep still!" I heard my nurse yelling from the patient's room. He stormed out, visibly angry. "What a drama. She's playing games with us, and I'm not going to get stuck with a needle." Our patient had "fainted" in the waiting room, and per protocol required IV access. We didn't even know her name yet.
She was 25 years old but still lived with her parents, both of whom accompanied her. "What's going on?" I asked (my open-ended question of choice). She looked at me fearfully, but didn't answer. I smiled...."Why did you come here to see us tonight?"
"Tell him about your stomach" her mother prompted.
"Yeah, my stomach hurts" she mumbled, glancing around furtively.
"Well, when did it start hurting?" I smiled again.
"When I was six." she replied.
I looked at her mother for a hint of guidance. "Is that right?"
"No, but she hasn't eaten or slept for the past two days." the mother replied.
The family first noticed something was wrong during church services on Sunday, where she had been singing with unusual passion and volume. She even ran up on stage and grabbed the microphone from the preacher and began giving her own sermon to the congregation. She made quite an impression, apparently.
"I feel better, I want to go home! Let's go, Momma!" my patient said abruptly, as she started to get up. She went from lethargic to agitated in the blink of an eye.
"Ma'am," I said, "You came here to get some help. You fainted in our waiting room. Now I need you to relax and tell me what's the matter." I placed my hand on her arm to re-assure her.
"DON'T TOUCH ME!!!!!!!!" she yelled. She bared her teeth at me like a wild animal, so I took a step back. "I need to go to work!" It was midnight.
"What kind of work do you do?" I asked. She looked away and started to sing to herself.
"She's a teacher at the high school." her mother said.
She didn't look like a druggie, and she didn't look sick. That left psychotic. She didn't know what year it was and couldn't name the president of the US. She thought I was one of the principals at her school.
I looked the patient in the eyes. "Listen to me. You are an educated person. I would expect you to be able to tell me very clearly and concisely what is the matter, and sit still for an evaluation. For some reason, you are not thinking clearly or acting normally. I'd like to try to find out why. We are going to need to draw some blood and I need you to give us a urine sample.
"I'm going to faint" she said, and dramatically flopped her head back on the pillow. Then she sat up immediately and started babbling in a language known only to her.
Everything was normal: CT brain, metabolic and thyroid panel, urinalysis and drug/tox screens. She finally let me examine her abdomen, and it was benign.
"I'm concerned about this change in your personality" I told her. "I'm afraid your judgement is impaired, and you need to be evaluated in the hospital by a psychiatrist." Since this was her first episode ever, it was unclear how bizarre she might get. She agreed to be admitted, and she was accepted by the psychiatric hospital. I was surprised she never required sedation, just a calm approach and the support of her family.
Often these patients turn suddenly aggressive and become more agitated requiring chemical sedation and physical restraints. I have seen similar patients run in a panic out of the ER and across a busy street without regard for their own safety. It is imperative to have someone with them at all times and to frequently re-evaluate them for change in status.
If physical restraints are to be used, it is essential to use chemical sedation as well, and to administer it as soon as possible. The use of multiple personnel to physically hold down an agitated patient, or the use of leather straps without sedating such a patient can lead to irreversible cardiac arrest from asystole. This is especially true if the patient is under the influence of stimulants such as cocaine or amphetamines. Agitated delirium is a truly life-threatening condition, and must be treated appropriately.
She was 25 years old but still lived with her parents, both of whom accompanied her. "What's going on?" I asked (my open-ended question of choice). She looked at me fearfully, but didn't answer. I smiled...."Why did you come here to see us tonight?"
"Tell him about your stomach" her mother prompted.
"Yeah, my stomach hurts" she mumbled, glancing around furtively.
"Well, when did it start hurting?" I smiled again.
"When I was six." she replied.
I looked at her mother for a hint of guidance. "Is that right?"
"No, but she hasn't eaten or slept for the past two days." the mother replied.
The family first noticed something was wrong during church services on Sunday, where she had been singing with unusual passion and volume. She even ran up on stage and grabbed the microphone from the preacher and began giving her own sermon to the congregation. She made quite an impression, apparently.
"I feel better, I want to go home! Let's go, Momma!" my patient said abruptly, as she started to get up. She went from lethargic to agitated in the blink of an eye.
"Ma'am," I said, "You came here to get some help. You fainted in our waiting room. Now I need you to relax and tell me what's the matter." I placed my hand on her arm to re-assure her.
"DON'T TOUCH ME!!!!!!!!" she yelled. She bared her teeth at me like a wild animal, so I took a step back. "I need to go to work!" It was midnight.
"What kind of work do you do?" I asked. She looked away and started to sing to herself.
"She's a teacher at the high school." her mother said.
She didn't look like a druggie, and she didn't look sick. That left psychotic. She didn't know what year it was and couldn't name the president of the US. She thought I was one of the principals at her school.
I looked the patient in the eyes. "Listen to me. You are an educated person. I would expect you to be able to tell me very clearly and concisely what is the matter, and sit still for an evaluation. For some reason, you are not thinking clearly or acting normally. I'd like to try to find out why. We are going to need to draw some blood and I need you to give us a urine sample.
"I'm going to faint" she said, and dramatically flopped her head back on the pillow. Then she sat up immediately and started babbling in a language known only to her.
Everything was normal: CT brain, metabolic and thyroid panel, urinalysis and drug/tox screens. She finally let me examine her abdomen, and it was benign.
"I'm concerned about this change in your personality" I told her. "I'm afraid your judgement is impaired, and you need to be evaluated in the hospital by a psychiatrist." Since this was her first episode ever, it was unclear how bizarre she might get. She agreed to be admitted, and she was accepted by the psychiatric hospital. I was surprised she never required sedation, just a calm approach and the support of her family.
Often these patients turn suddenly aggressive and become more agitated requiring chemical sedation and physical restraints. I have seen similar patients run in a panic out of the ER and across a busy street without regard for their own safety. It is imperative to have someone with them at all times and to frequently re-evaluate them for change in status.
If physical restraints are to be used, it is essential to use chemical sedation as well, and to administer it as soon as possible. The use of multiple personnel to physically hold down an agitated patient, or the use of leather straps without sedating such a patient can lead to irreversible cardiac arrest from asystole. This is especially true if the patient is under the influence of stimulants such as cocaine or amphetamines. Agitated delirium is a truly life-threatening condition, and must be treated appropriately.
Labels: patients
posted by scalpel at 2:59 PM
6 Comments:
Interesting story... No chance it was anticholinergic toxicity, is there? I would assume that usually wouldn't last quite so long, however! I recently wrote a 2-part blog post about my experiences of going through anticholinergic toxicity. If it hadn't been for my best friend James working in the ER the night I came in and then went completely delirious, I probably would have been shipped to the psych ward. It was about 7 hours or so before I "snapped out of it." The first time it happened, it actually lasted for 4 days, but I wasn't completely gone like the 2nd time - I had moments where I was totally with it and then other times where I was out of it, but probably more correlated with when they gave me certain meds. I still list those experiences as some of the worst things I've ever been through!
My mom, in particular, was very afraid that I was "gone for good." While the time this happened in the ER, I had no idea whatsoever what was going on until it began to end, I think it was much harder for my family and best friend who were wondering if the person they knew was ever going to come back. I still shudder to think about it!
Take care!
Carrie :)
Good thought, Carrie. Absolutely, drugs or medications are first on the differential in a situation like that. From what I could gather, she was on no meds whatsoever.
I'm always hesitant to give a patient a psychiatric diagnosis, because I have seen many many patients with medical conditions which are the cause of their "psych" symptoms.
The most humbling perhaps is the dystonic reaction from nausea meds. For such a common side effect, it is amazing how often it is missed. One of my favorite stories concerns a young professional woman who went to see a Neurologist because she couldn't talk. Her speech was distorted to the point she was unintelligible, and she gave the appearance of a brain-injured patient who needed 24 hour care. The Neurologist she saw sent her away, thinking she was just retarded or crazy. Her mother told me that her daughter was an accountant, and it turned out that she had taken a Phenergan suppository a couple of days ago.
After one shot of benadryl, she was completely normal. She insisted that I call the Neurologist who dismissed her so she could chew him out in person. That scene was priceless.
Oh I understand that one, too! For headache, they use a lot of these meds that cause EPS symptoms. I actually am anaphylactically allergic to Haldol, and my tongue swelled up to the size of my mouth...very weird. I tend to get very jittery from a lot of the meds and have increased problems with muscle spasms, in general. Cogentin is my best friend whenever I'm in the hospital because it calms down meds like droperidol, etc. However, apparently cogentin with depacon are what caused the first anticholinergic toxicity reaction...at least I think that's what I remember reading in the transcription report!
There was some ER episode where the patient got anticholinergic toxicity from eating Skittles - I can't remember how that exactly occurred. My mom and I were watching that episode, but I was in my apartment and she was at home. I called her as soon as they said the guy's diagnosis, and we both started laughing (not at the guy's pain, but because my experience was REALLY out there...) - and I remember my mom saying, "Hmm...You, yourself, eat a LOT of Skittles!!" LOL - nice try mom, but that wasn't it! ;)
Take care!
Carrie :)
Oh and if you ever care to read about my 2 anticholinergic reactions, the two blog posts are here:
Mad as a Hatter - Part I
Mad as a Hatter - Part II
Part II has the really wacky incident, but Part I has the whole background! I just had to blog about them, and it is amazing how many people end up at my blog (via sitemeter) from googling the phrase "Red as a beet, dry as a bone, mad as a hatter" or something like it. Also have had a lot of hits from people simply googling anticholinergic toxicity. If writing those two posts helps to educate others about this scary condition, then I'm really glad that I wrote them!
Take care!
Carrie :)
?Porphyria?
GruntDoc
Interesting thought, porphyria. If her belly pain or lab abnormalities had been convincing enough to convince a medical service to take her, that would have been a good thing to work up. Unfortunately, but not unexpectedly, the medical consultant I spoke with wasn't too enthused about pursuing the workup beyond my initial screening, so the patient went to the psych ward instead.
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