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By sugar spun (Thu Jan 29, 2009 at 09:55:59 AM EST) (all tags)
In which fatality is contagious.

We have a new inpatient. She's in her late 30s, about 5 feet 8 or 9 inches tall, and weighs 37kg. I think it's a new low, even for us.

I've not looked in her chart. I don't, with the ED patients. They're not part of my research profile, and their charts tend to all look the same. This one, however, is fairly advanced in years for someone so acute, which suggests unusual disease progression. Based on the therapists looking after her, trauma's a safe bet, and there's only a very, very small set of things likely to have turned this woman into a human anatomy class, all of them downright horrific.

The problem has so many faces. She needs inpatient care, and can't be left unsupervised. So she's with us. But, since she's with us, other patients can see her, and they're impressed by the fact that you can see the shape of her organs through her skin. She's incredibly far gone, and the overwhelming likelihood is that she'll die in our care. The first problem is that she'll take others with her. There's already a mood of unrest associated with mealtimes, and it's only going to get worse. Bread rolls are frequent casualties, and there are little crumb-covered scuff marks on the walls of the staircase today, and a lingering smell of yoghurt. The flying food is only the start, I suspect: bathrooms will go into lockdown in the next day or so if they haven't already.

One alternative would be to isolate her, which we can't do because she can't be left unsupervised and we can't spare a constant monitor. The other would be to place her in the secure inpatients unit, where there's either a 1:1 or 1:2 staff-patient ratio depending on the time of day. But we can't: the stress of that ward would send her into cardiac arrest faster than a bread roll flies down stairs.

So we're keeping her, attempting to do the best we can while seeing the futility in every handful of hair she sheds, in every tortured step. This woman is going to die, and her life is measured in hours rather than days. What's most troubling is how cyclical the whole thing is. Someone did this to her. Like I said, I haven't seen the chart, but this isn't spontaneous and it isn't long standing. Someone is responsible for having caused her to kill herself slowly, painfully and hideously. And her current skeletal appearance is spurring other patients on to emulate her. Others might die because she will. Others certainly will become sicker from contact with her, because she's the face of success.

The only thing saving us from packing our shit and lemming-ing ourselves into the river en masse is another patient, not ED, not inpatient, not acute. This is a lady in her late 70s, who was working for a man twenty years younger for thirty years or so. He recently retired and closed his office, and she suddenly realised she was in love with him. We're helping her cope with the depression of not seeing him any more. She's baking him cookies every couple of days, then remembering that she won't see him and donating his cookies to the department.

If we could get our problematic inpatient to eat them, the end could turn out to be happier ever after. As it is, the sugar's a small comfort. But we take it wherever we find it. How else ought we to live?
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Tales From The Hospital | 10 comments (10 topical, 0 hidden) | Trackback
I think you answered your own question by Phage (2.00 / 0) #1 Thu Jan 29, 2009 at 10:59:14 AM EST
<psych>Why are you asking ?</psych>

That's my job. by sugar spun (2.00 / 0) #5 Thu Jan 29, 2009 at 11:52:02 PM EST
I take care of the ethics side, only sometimes the answers don't seem sufficient.

"We do the best we can and then we go home and thank whatever we believe in that we're allowed to leave" sometimes feels callous. It often feels callous, but therapists who can't detach are only a prescription or two away from getting a seat on the couch. A lot of the ways we talk about patients out of their hearing is downright heartless, but it's how we cope, and the trick is making sure the patient doesn't hear it.

[ Parent ]
Horribly sad. by Herring (4.00 / 2) #2 Thu Jan 29, 2009 at 01:13:08 PM EST
I, like most sane people who can see how hideous the world is, have thought of offing myself from time to time (less so since the Small Boy era). But the midset that the only thing you can control, the only thing you have power over is to starve yourself to death .... that's beyond my comprehension.

Stepdaughter used to cut herself a bit for a very brief period. I think that's because it was trendy though. She does have an eating disorder - she wont eat tasty, tasty dead animals.

You can't inspire people with facts
- Small Gods

I cut myself once by sugar spun (4.00 / 1) #6 Thu Jan 29, 2009 at 11:56:18 PM EST
when it was fashionable. I did a really, really useless job of it. It hurt. I gave up after about half a centimetre's worth of cutting. A friend of mine tried to carve his girlfriend's name into his arm to show her how much he loved her. He stopped at her initial because it was too painful. I think we were incredibly lucky to notice how stupid it was, especially now I'm in contact with people who didn't figure it out.

But then, I don't eat a lot of dead animals either. I would, if they were more fun to eat. I just don't like their texture.

[ Parent ]
Wow by Gedvondur (4.00 / 4) #3 Thu Jan 29, 2009 at 01:18:38 PM EST
I admire your dedication and commitment.  The world needs people like you.

I would last exactly one-half day at a job like yours.  Then I would go home, weep, follow it up by drinking heavily and getting a job in a coffee shop for the rest of my life.

I simply don't have the strength to observe human misery like that.  I don't envy you, but I do admire you.


"I love my brain. It's the only organ I can afford to lose." --frijolito
Drinking's out at the moment. by sugar spun (4.00 / 1) #7 Fri Jan 30, 2009 at 12:00:09 AM EST
I tend to turn the shower up to "mildly scalding" and let the water run till I feel better.

Coffee shops are bastions of human misery themselves. We get it distilled and focussed; jobs where you deal with the public have crazy spraying all over the place unchecked and wanton. It's almost easier knowing exactly what you're getting yourself into with each individual: surprises are minimal but useful when they turn up. And at least my office has a door that locks and a "bitte nicht stören" sign.

[ Parent ]
I suspected ED from the intro. by ambrosen (2.00 / 0) #4 Thu Jan 29, 2009 at 01:42:45 PM EST
I think I need to shadow a little inpatient work before I get too much further in my plan to become a psychiatrist. Adult eating disorders sound a whole lot worse than adolescent ones, if a whole lot rarer.

I wrote some musings after this, but I didn't feel they were appropriate. I feel for you and them, that is all.

Are there any clinically viable options for forced intervention? Presumably in Germany the state's wary of intervening.

Ironically, our trust's weekly internal newsletter was congratulating the local Adult Services inpatient unit on their anti-obesity day today. Guess they're not in the same situation.

Psychiatry by sugar spun (2.00 / 0) #8 Fri Jan 30, 2009 at 12:06:53 AM EST
is incredibly rewarding, but among the least easy options available. The balance between being human so a patient will talk to you, but detached so you don't drown in their pain, is something that seems to take a long time and a lot of pain to find. Successful ones do it, but there's a reason the suicide and other attrition rate is so high. Shadowing is very weird in psychiatry: you can end up feeling like a literal shadow as people completely forget you're there.

At this stage and for this patient, standing up puts her at risk of cardiac arrest. If we introduce anything traumatic like a feeding tube, we could accidentally kill her. The high-calorie drinks seem to be keeping her going (further reason I'm so suspicious; old hands recognise them and won't drink them) and if she gets any stronger there might be more options. I doubt it though. She has the look about her.

[ Parent ]
While I commend you for dealing with by debacle (2.00 / 0) #9 Fri Jan 30, 2009 at 06:24:12 AM EST
This sort of terrible thing every day, it must dig at you to know that you're pushing sand up a steep slope with nothing but your hands. What's the recovery rate for your average case?

I know a woman in her early fifties that suffered through an eating disorder when she was in her teens and twenties. She has still never really recovered, I think you'll always be able to see the effect that the ED had on her. The most frustrating thing, as a man, is that so many girls suffering from ED would be so incredibly beautiful if it weren't for the fact that they can't down a saltine without feeling fat.


Variable recovery dependent on so many factors. by sugar spun (4.00 / 1) #10 Fri Jan 30, 2009 at 07:03:06 AM EST
I think any ED patient will always have some sort of tendency in that direction, even if they're not active. It's the same sort of thing as alcoholism: only an incredibly small number of former alcoholics can have any normal relationship with alcohol. Generally we send them back into the community a bit heavier and a lot more self-aware. Some of them we see again; more of them we don't.

We do what we can. Psychotherapy isn't perfect, but it's getting better and the whole of my job involves making sure it continues in that direction. We won't save this one. We might save others. It's enough.

[ Parent ]
Tales From The Hospital | 10 comments (10 topical, 0 hidden) | Trackback