It had been an extraordinarily busy night. Case after case. But then, it was Saturday night, what should I have expected?
In the midst of working with a suicidal woman and an adolescent who had had the mother of all panic attacks, one of the nurses told me about a new case. A man in his late fifties was brought in by his daughter with psychotic symptoms that began only a month ago. Seems he and his wife were in town visiting their daughter and family and a decision was made to stop in for a look-see.
I was looking forward to talking with the patient, his case fascinated me. I mean, why would a man his age with no mental health history suddenly experience psychotic symptoms? Sounded like a medical situation to me, and apparently his E.R. attending that so as well because he ordered a CT scan. That meant I’d have to hold off for about a half-hour before talking with him; however, it gave me plenty of time to talk privately with his daughter. I wanted to learn more.
While the man was having his head scanned, his daughter and I talked in his room. According to this upset, but poised, young woman, the family was concerned with her father’s sudden change in personality. Indeed, some thirty days ago her father began making frequent references to the Bible, something he’d never done before. And the man was telling family members his long-deceased mother was talking to him. And if that wasn’t enough, he reported hearing other voices, but told his family not to worry because they were happy. Needless to say, the family was justifiably frightened.
After about fifteen minutes, in rolled a gurney carrying the subject of everyone’s concern. Having a look at him, the man was tall and his tan lined face gave the appearance he performed manual labor most of his life. He had very kind eyes and what seemed to be an engaging personality. Well, the first thing I had to deal with was a language barrier because he spoke no English. But that wasn’t a biggie as his daughter served as our translator. Funny – after being introduced and shaking hands, the first thing out of his mouth was a request for his pants. I had to tell him to hang on a bit on that one.
On to the interview. The first order of business was to assess the man’s mental status. So, after explaining I meant no disrespect by asking such things, I asked him if he knew his name, what day it was, where he was, and why he was here. Well, he did alright, with the exception of believing he was at another hospital. That was a concern, as he’s been at this hospital before. And, though he knew why he was in the E.R., he didn’t agree with the reasoning because he didn’t perceive anything unusual about with his recent behavior. According to him, his family members had it all wrong.
I’d secured all the information I needed to help us determine what we were going to do for the man from a psych point of view. So, I ended the assessment, telling him and his daughter I’d be back to talk shortly. The first thing I did was ask his nurse if they’d gotten the results of the CT scan. They had, and the man had what’s called a subarachnoid cyst on his brain. Now, it’s likely he’s had this cyst for many years, maybe from birth, and though it could certainly account for his current symptoms, it wasn’t a slam-dunk cause.
So what do we do now? Do we offer a psychiatric admit? If so, on what grounds? I mean, okay, the man is presenting with psychotic symptoms, but he certainly poses no immediate threat to his safety or anyone else’s. And an inability to care for himself isn’t an issue. The sum of these factors says he can’t be admitted involuntarily. I was content in having him go home with his family, as he and his wife were leaving for Mexico in four days. Well, as is protocol, I called the on-call psychiatrist and we swirled the case around, agreeing on having him go home.
Knowing the medical staff would review the details of the cyst with the man and his daughter and provide referrals, I chose to take the daughter aside and discuss the situation. I brought up the cyst and the fact that it could be involved with her father’s symptoms, but that wasn’t a certainty. I shared with her my recommendations for neurological assessment for her father and she assured me it would get handled.
So, now it was time to say good-bye to her father. I returned to his room and thanked him for being so patient and cooperative, and told him he could put his pants on in short order. That brought a smile. As I was leaving his room I grabbed him by the foot and said, “Vaya con dios (‘Go with God’).” How sweet it was to see that smile broaden as he lit up like a Christmas tree. Seems he deeply appreciated the sentiment. Nice way to end the case.
Ah, but no time to waste. It was time to work on getting the suicidal woman a psychiatric bed.
