I had two cases today: the first was an elderly gentleman, mildly mentally retarded, with a speech impediment and a history of sudden violent impulses. Like the time seventeen years ago when he killed his girlfriend with a shotgun because "She was only using me for my money". But he seemed so sweet.
The second turned out to be a man hooked on Xanax, but he made me overtly nervous - so much so that I couldn't ask his ex-wife to leave the room to interview him. That was my mistake - he didn't talk until his ex-wife was gone. He doesn't want help. He just wants his family back.
All two of my cases were overshadowed by the gentleman who forced us to invoke duty to warn. This is an obligation by medical or counselling personnel to breach confidentiality where there is clear evidence of danger to the client or another person, and to warn both that person and those who can protect the person. It stems from the 1974 Supreme Court appeal in Tarasoff v. Regents of the University of California, in which a therapist notified the police but not the party threatened, and Ms. Tarasoff was subsequently murdered.
This time, the gentleman informed us that he intended to kill a judge and a prosecutor. He described the circumstances under which he had been slighted by these two persons quite exactly, but refused to name his targets. Perhaps he thought that would protect him. We called the prosecutor's office and described the situation. Email went out. The prosecutor in question remembered the man; he'd come to see her several times since. She called us, and we gave her and the judge their warning. Then we called the police and filed a report with them. This was all very exciting, and much buzzing went on between the medical students.
He was to be admitted to inpatient. That requires a physical. Dr. K looked at me. "Let me talk to him, and I'll see if we should defer the physical." I didn't want to do it. Fortunately, he refused to have one done.
That makes two physical exams now that I have dreaded. The first, O Best Beloved, was on a manic patient in the psychiatric ER. I approached him for a physical exam out in the middle of the main room, something I rarely do, but I had been warned and I knew he would be difficult, and I will not put myself in a situation in which I do not feel safe unless I have good reason to do so. Doing a perfunctory physical exam is not a good reason. "Hi," I introduced myself. "I'm Nykki, one of the medical students on psychiatry. And my job is to do a quick physical exam to make sure you don't have any major medical problems."
Hi, Nykki, he said to me, and grinned in a way that sent verifiable chills down my spine. You wanna go back to my room and get me naked, then?
I had been braced for something to be said. I didn't flinch, just shook my head. "I'd prefer not to, sir."
That's good, 'cause I don't really want to either, he answered in a high-speed "I'm just teasing" voice. So tell me, what's this? And he rucked up his gown, flashing tighty-whities that I didn't want to see, and showed me a scar on his chest. By this point I was creeped out but standing my ground in the middle of the room, confident in my company. "An old surgery scar..." He'd had pyloric stenosis, had to tell me about it. So, what do you need to do to me, Doc? he asks, getting playful again.
I did lungs and heart ascultation with a minimum of contact, not wanting to further encourage him. And that was it. We decided to put "patient declined physical" on the paper, as there were no male medical students to do the work, and nobody would willingly put one of us through that experience.
Today was an interesting day; I didn't go to the psychiatric ER once, and I sort of missed it. It's always ludicrously zany there; there's usually a manic patient storming and swearing as Security brings them in. It's always the same complaints, too - "I'm an American, I have my rights, I've done nothing wrong." Someday they'll see what rights really are.
The interesting day was begun, and nicely too, by the presence of my uploaded Skills Logger on the secure website. A little row of green checkboxes confirmed that yes indeed, I had gotten my two NG tubes and my Vent Management signed off on. That stupid Level II competency in Clinical Skills is complete, uploaded, and no longer my problem. I took off early, got my birth control pills picked up in the morning, was chipper with the pharmacist, and lounged around talking until the day got crazy at noon. And now I'm lounging, thinking about an early bedtime because of my headache, thinking about doing some questions to study, thinking about a lot of things, and I think I'm going to just bum around and be lazy for the night.
Be well, O Best Beloved.