The Medications Worked

32 Comments

A grandfather brings in his 14 year old grandson because the boy hurt his wrist … for the second time in two days. The first time he was  brought to the emergency department, x-rayed, and was diagnosed with a Salter Harris Type I fracture. He was put in a splint and sent home.

This time, he was wearing the splint, fell while walking, and had more pain in his wrist. There wasn’t really any point tenderness or deformity on his exam, so I explained that we weren’t going to change the management and we didn’t need to repeat an x-ray because even if there was a small fracture, he was already in a splint.
The grandfather argued with me for several minutes because he felt the patient needed an x-ray to make sure there was no fracture. I finally got fed up trying to reason with him realized that my diagnostic skills leave something to be desired and just ordered an x-ray.
The patient and grandfather had to wait another hour to get through the line waiting for x-rays.
After the x-ray came back as normal … like I was saying, he’s already in a splint, so we aren’t going to change the management. Continue taking the ibuprofen and see the orthopedist for follow up.

“He wants a cast on his arm,” remarked Grandpa.
“I beg your pardon …”
“You need to put a cast on his arm. He wants a cast.”
“No. Sorry. We don’t put casts on in the emergency department. He has a splint to protect his wrist from injury. You need to see the orthopedist for follow up and he’ll decide whether he wants to put on a cast. That’s not something we do here.”
Then the patient chimes in.
“I want a cast NOW!”
“We don’t put casts on in the emergency department. Your arm will be protected until you see the orthopedist. The nurse has your discharge papers.”
“I’m not leaving without a cast!”
“Why do you want a cast?”
“I just DO. I want a cast NOW!”
“I’m not going to argue with you. We don’t put casts on in the emergency department and you aren’t going to get a cast put on today. It’s time for you go home now. Have a nice day.”

I left and went to see another patient, hoping that the patient would be gone by the time I was done.
Ten minutes later, I walked out of the other patient’s room to see that this kid had backed himself into a corner by the exit door, was holding onto a wheelchair, and was loudly stating “I … want … a CAAAAST!”

We called security.
Several security guards then lifted the patient onto the wheelchair and wheeled the patient out to the front of the hospital. The grandfather went to pull the car up to the door.
Then the patient jumped out of the wheelchair and started running down the street.
Grandpa pulled up in the car, rolled down his window and said “I’m not dealing with him when he’s like this. He gets out of control. You’re going to have to call the police and transfer him to a psychiatric hospital.”

The police had already been called and apprehended the patient a block away. He punched one of the officers, was put in handcuffs, and tried to bite another officer. Guess where he ended up.

Back in the emergency department – psych room.

There, the patient threatened to kill himself and everyone else in the room. He was dropping F-bombs left and right and was trying to hit and bite the staff. It didn’t take long for the patient to be put in four point restraints, and then to receive 5mg Haldol and 2mg Ativan. Funny that he didn’t complain of his wrist hurting any more.

Six hours later, we still weren’t able to find a psychiatric hospital willing to accept a violent child. Either they only took adults or they didn’t accept violent patients. The grandfather wanted to leave, but was told that he needed to stay with the patient since he was a minor.

During one of the times I went in and re-examined the patient, the grandfather looked at me and sneered “None of this would have happened if you just put on the cast like he wanted.”

I just smiled. After all, Grandpa would soon be receiving a survey to rate my clinical competence in the care of his grandchild and I do want to receive all “excellent” scores, you know.

Saddest part of the whole encounter was that one of the phlebotomists used to babysit the patient when he was younger. She said that the patient was normal until he started being put on psychiatric medications for attention deficit disorder. Now he was on four psychiatric medications and had been in and out of psychiatric hospitals for emotional outbursts such as this one.

But at least he was able to focus his attention.

32 Comments

  1. I work with foster care kids that have severe behavioral issues, in other words…kids just like the one you described. We have incidents like you described…only we don’t get to give them haldol…darn it.

    It is interesting to note though that a high percentage of our out of control kids share something else in common with your patient…psychiatrict meds. Interesting…

    And don’t even get me started about the psych hospitals that won’t take them…we have that problem all the time. I’m sure I need a raise! or maybe I shoudl get a job in a psych hospital…more money and apparently less stress.

  2. Add this story to the long and growing list of reasons why psych meds will be the last thing I turn to to treat my child’s “disorders.”

  3. The ADHD mismanagement problem isn’t just a problem for medicine, its also an education problem. If John Dewey would take a tour of representative schools today he would probably roll over in his grave.

  4. I was thinking about a patient I pissed off on Monday. He was one of the I would rather talk than listen to reason type of patients. During the encounter I began to think how stellar my satisfaction survey results are going to be this month. Then I read your blog. I have a feeling as bad as mine are going to be, yours will be worse. Thanks for all you do. Serentity Now.

  5. That is sad, but I have a nagging question.

    What kind of doctor would be used to diagnose ADHD either in kids or adults? I lean toward a psychiatrist, but I am guessing that there are other practitioners who do the same? Just curious.

    • I believe a psychiatrist would be the standard answer, preferably one with a pediatric specialty for children. With a bullheaded enough parent or a sufficiently apathetic doctor a standard pediatrician might do it. Seeing as most ADHD medications are schedule II’s though an adult wouldn’t likely get a diagnosis from anyone but a psychiatrist. Even then it would probably be unlikely or difficult for an adult to get an ADHD diagnosis rather than something else.

      I’m not a doctor though. I’m an educator. Hopefully someone can offer a more polished and informed take on this.

      • Aaron-
        I tend to agree with you. I have heard of pediatric docs doing it and it makes my hackles go up. As for adults, I would also say that a “fizzykeyatrist” (in the words of Ricky Ricardo) is the best for adults.

        I have known internal med docs to diagnose adults and I disagree with some of them. I also don’t believe that they follow-up with some of the potential issues that can be seen like the anger, or explosiveness that has been mentioned by patients.

        A friend of mine’s kid is on 6 different meds!! What right-minded doc would use six meds to treat depression, ADD? To me, that is just overdone and the mood swinging is absolutely horrid for the kid. He is zombie-like and seems like he cannot help but sleep if he is not otherwise engaged. I never liked the ADHD dx, and I still don’t. I think there are other ways to handle it and meds should be used in extreme cases if behavior modification doesn’t work- and alas as others have noted…work? (where’s the RX pad?)

      • That’s great in theory. Now find me a child psychiatrist within 100 miles who has openings within the next 6 months and I’ll be glad to refer all my ADHD kids there. Child psychiatrists are very rare and are too busy dealing with the truly psychotic patients to have time to take care of ‘routine’ ADHD.

  6. ADD is just becoming a convenient label for people who don’t want to deal with kids who just have ants in their pants. Except the kids suffer the consequence of these intense psyhcotropics. sad.

    • Well, kids also suffer a lot of social and academic disability when they can’t concentrate or follow instructions in school.

  7. Midwest woman…ITA. I know that there are plenty of seriously damaged children out there, who come home from the NICU (because they were preemies and had positive tox screens) to be propped in front of a TV in a crowded and dirty subsidized apartment and ignored (except for verbal and physical abuse) for four years until they become the “school’s problem” These kids pretty much never have chance.

    But this is the other end of the spectrum. Sounds like a kid who was born normal and got medicated into pysche illness. God never meant for four year old boys to sit still and concentrate for six hours at a time. The natural habitat of a healthy young boy is outside building forts and running and yelling and tumbling around with other little boys like a pack of puppies. But in the last few decades this behavior had become pathological?? We expect these kids to act like mini-adults while their parents get to act like children???

    • And God meant 4 year old girls to sit still and concentrate for 6 hours at a time? Just because more girls learn to concentrate earlier doesn’t mean it doesn’t hurt them too.

      • Come to think of it, I’ve never known of any girls on medications for ADHD. It must happen ..but again wasn’t prevalent when I was younger, but didn’t see much of it with son’s friends either. They are in their 20s now though.

        *** Is this diagnosis more widespread than in the 60s through 90s or was there another name for it?

        Or …is the actual disorder on the increase? And if it is ..do they know why?

  8. I think child psychiatry should be made illegal, as there is no physical disease for a pharmaceutical drug to affect.

    • I think the problem here is more along the lines of there simply not being many child psychiatists out there and normal pediatricians handling parental requests for these treatments in kids who don’t often need them.

      • No. I mean illegal. http://books.google.ca/books?id=2pduB22E43oC&lpg=PA68&ots=ENsWRcTe_I&dq=szasz%20child%20psychiatry&pg=PA68#v=onepage&q=szasz%20child%20psychiatry&f=false
        “Adults have physical and political power over children. This is why sexual relations between adults and children are outlawed and the act is called “statutory rape.”

        For the same reason, we ought to outlaw psychiatric relations between adults and children, and call child psychiatry by its correct name, “psychiatric rape.”

        Child psychiatry — like all of psychiatric slavery — cannot be reformed. It must be abolished.” Szasz

      • Markps2,

        While I respect your right to follow a “religion” founded essentially as a bet between a notable science fiction author and a far lesser writer (soon to be “prophet”) whose first religious tomes were published in the magazine “Astounding Science Fiction”, I doubt you will find a willing audience here. I would invite you or members of your “church” to tour your local emergency psychiatric intake center and then explain to us how those patients without enough money to invest in Scientology to learn of Xenu and the trauma he has caused us all (to the non-scientologists in the group, google it – you seriously can’t make this stuff up – but L. Ron Hubbard can!) should be helped.

        Szasz is akin to Arthur Butz – a great example of the tenure system run amok.

      • I think it might be worth pointing out that some imaging studies do show correlations between differing levels of activity in regions of the brain and SOME disorders. Contemporary psychiatry is no better or worse than contemporary oncology when both are practiced well.

        Comparing the entirety of child psychiatry to statutory rape presents a false dichotomy. If a child is has temporal lobe epilepsy and meets the DSM criteria for bipolar disorder, should it be criminal if the treatment for epilepsy relieves the bipolar symptoms.

  9. Here’s my favorite parenting recipe (simmer for 18 years stirring every so often):

    1) Dump your kid in daycare during the day and babysitters during the nights.
    2) Wait for an outburst of out-of-control-ness.
    3) Get some ADD meds prescribed for 2).
    4) Use the time that you saved in not raising your kid to do something else.

    In this case…it looks like the kid’s parents were step 4) otherwise they would have been the ones there and not the grandpa.

  10. Hey. Sorry, this is rather off topic, but could someone please alert ER Stories that the blog will not load. Neither bookmarks nor google searching worked.

  11. A few years ago, my psychiatrist sent me to a neuropsychiatrist for various tests and interviews to rule out/dx ADD. Prior auths are “necessary” because I’m well over 12 years old. When I was 12 nobody was dx’d ADD!

  12. It is sad. Also disturbing that meds are prescribed that way for anyone ..never mind children.

    Older son did have friends (twin brothers) that were ALWAYS getting into trouble and hard to handle in school or anywhere. Their reputation preceded them. They had an older sister who was sweet and just like any other good student. I knew and liked their mother. She did her best. the father was abusive and they eventually got away from him. (Stomped on his wife’s stomach when she was 5 months pregnant with them and he was over 6 ft and she was tiny.) Anyway ..by 4th grade they were both diagnosed with attention deficit/hyperactivity and put on meds. She said it was a night and day difference for the better.

    But now I wonder ..did they really need it or were they reacting to the abuse they experienced in their young lives and the meds toned them down?

    I know of another family where the son was doing horrible things when he was 12 and his threats would scare the daylights out of me if he were my child. Mom is a teacher. Turns out she and her 2 children were diagnosed as bipolar and on meds and life is normal with the boy. I never noticed anything unusual with mom or daughter tho.

    Maybe these people did need the medications ..but reading these comments is alarming. So many people must be walking around over or wrongfully medicated and it is especially scary if it could cause violent episodes.

    I don’t remember ever hearing of any of these things when I was a child or teenager in the 60s and 70s. I don’t remember kids behaving dangerously/psychologically compromised. or were they kept hidden away?

  13. Oh, come on. It was all about a thing between you and the grandfather where he wanted a cast for his child, not unreasonable, and you being able to deny it. It shines in your post; you loved being in that position.

    And a patient is in the hospital because of it.

    I’m a (old) MD. Common sense still works today, you know.

    • You and I have a different view of what is and is not “reasonable”.
      Splints provide adequate immobilization, are less expensive than casts, and are easier to put on in a emergency department.
      So in this case, I’m supposed to throw away the perfectly appropriate splint that the child already had, then apply a cast because a 12 year old “wants it”? I suppose that if the 12 year old child doesn’t like the color when I’m done, I’ll have to cut that one off and special order colored fiberglass for him because he “wants it”.
      Then when the orthopedist who evaluates the injury in a couple of days examines the child, he can cut the third cast off and put on another one when he’s done. Let’s spare no expense when 12 year old children “want” things.
      We can make more money by having to cut off the cast the following day when the cast gets too tight due to swelling from the injury, too. Our malpractice insurance doesn’t cover circumferential casts put on in the emergency department for just that reason, but who cares about getting sued. Most lawsuits are resolved in favor of the physician, anyway, right?
      In retrospect, after learning about the patient’s history from the phlebotomist, I can’t help wondering whether or not the child is on so many psych meds because he always got what he “wants.”
      You “old” MDs give antibiotics to people with the sniffles and repeat prescriptions for Percocet to patients whose “dogs chewed up their prescriptions” – just because patients “want them”? Free pregnancy and HIV tests from your office to people that “want” them?
      Where do you draw the line at what’s “reasonable”, doc?

  14. I’m an adult, 26 year old female, who has had ADD symptoms for probably 20+ years. I was formally diagnosed with ADD in October of 2009. Started on Adderall and it saved my job. Being on the medication enables me to do my job normally and feeling more “normal” gives me the patience I usually don’t have to deal with patients. I’m a pharmacy tech in a retail location.

    Until I fully realized issues I have on a daily basis, and have always dealt with as being normal for me, are ADD, I didn’t really believe in the diagnosis. It’s way overdiagnosed and I hate seeing little bitty kids on higher doses of stimulants than even I take. But for some…it’s necessary. Sure I coped for 26 years without it, but I lost a job because of it and was literally a day away from being written up again at my current job when I had a heart to heart with my boss and let him know I was seeing my doc.

    But anyway…I was diagnosed and am treated by my family doc.

  15. I work at a pediatrician’s office where the MD regularly diagnoses kids with ADHD and prescribes medications such as concerta and ritalin. He is extremely conscientious in this practice and I haven’t seen any deleterious effects yet. For the parents and the children the medication is a godsend. If there seems to be a larger problem we refer out to the local MHMR. Not all children who are diagnosed with ADHD and given meds are zombies and major psych cases.

  16. We didn’t have ADHD when we were kids because we got enough physical activity to use up our youthful energy.
    We had recess in the morning and afternoon so we could run and play, then we sat still and paid attention in class, or else.
    We behaved in school because we didn’t want our parents to hear that we had MISbehaved in school.
    There would have been consequences.
    Today it’s much easier for parents, because they can just get a pill to make the kid “quiet.”
    Unfortunately, kids are noisy, and the noise is going to come out somewhere. And the nail that sticks up is going to get hammered down.

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