Night Shift: Reality Testing

7 Comments

“Hey Dr. Plaster, we have a problem in Room 12,” the resident said taking a deep breath while shaking his head.

“What’s up?”


ADVERTISEMENT

“It’s a middle aged guy with a straight forward STEMI.”

“Is he crashing?” I interrupted. “Can you handle it?  What are you doing standing here?”

“No. He’s actually pretty stable.”


ADVERTISEMENT

“Then call the cath team and get him out of here. Pronto!  You know how to handle that. What’s the problem?”

“He doesn’t think he is having a heart attack. He says it’s just a ‘tummy ache’ that he gets every time he rides his bike lately.”

“What?”  He almost had my full attention now. “Show him the EKG and explain to him…”

“He thinks he’s 12-years-old,” the resident said interrupting me giving a pained look.


ADVERTISEMENT

“Wait, wait, wait!  What?  Is he having a psychotic break?”

“I don’t think so,” the resident said with a shrug. “It’s really weird, though. He presented to the Peds ER first complaining of a belly ache. They took one look at him and sent him over here. But he keeps telling everyone he’s just a kid and belongs over there. He even insisted on wearing one of the Peds hospital gowns. You know the ones with dinosaurs on them. He got kind of afraid when they rolled him over here.”

“He’s not a sexually precocious 12-year-old who just looks like a middle aged guy, is he?”  I was starting to get really confused.

“My first husband thought he was a sexually precocious 18-year-old for 25 years of our marriage,” the charge nurse said after overhearing our conversation. “That why I canned his a…”

“Thank you for your non-helpful opinion,” I said cutting her off. “He’s having a psychotic break,” I said turning to the resident. “Does he have a guardian?  If not, get psych down here to certify him and get him to the cath lab before you have a crashing 12-year-old on your hands.”

“Well, that’s what’s strange, Dr. Plaster. He’s here with his wife. They’ve been married for 20 plus years. She claims he is perfectly sane. He’s never seen a psychiatrist. She claims he doesn’t have hallucinations, delusions or suicidal ideation of any kind. Well, he did join the Boy Scouts. But when they found out that he wanted to be a scout and not a scout master, they thought it was kind of creepy and refused to let him join.”

“Well, he’s having delusions now,” I said pedantically, “If he thinks he’s 12-years-old.”

“I… I understand how you feel about this, Dr. Plaster,” said the resident. “But how do I say this without seeming to insult to your age?  It’s a different time now than when you began your practice a few years ago.”  I saw the charge nurse bend over and start walking like she was using a cane.

“Very funny,” I said smirking at her mocking me. “How old is he actually?”

“Fifty-five,” the resident said. “But he really believes that you are only as old as you feel.”

“Oh, come on,” I huffed. “That’s just a slogan to sell vitamins to old geezers.”

The charge just pointed to me as I glared silently at her.

“Dr. Plaster…I talked at length to him about this. He knows his body is 55-years-old.”        “How is that not delusional thinking?” I said. “Isn’t that the very definition of a delusion, thinking something that in reality is not true?  If we don’t have a hard reality to deal with, how is psychiatry supposed to help anyone?  If a patient presents to a psychiatrist thinking that he is the President of the United States, should we convince him otherwise or play ‘Hail to the Chief’?”

“But he feels that “he”, the true person inside of the body, is only 12. It’s his reality. Do you acknowledge that?”

“Ok, I get it, it’s 2021. And I’m an old dog. But this is not a new trick I care to learn. His body, which we are treating, not his feelings, is 55-years-old and has partially obstructed coronary arteries. Now go in there and give him the Boy Scout handshake and tell him that we will give him the First Aid merit badge if he goes to the cath lab. And if he doesn’t he will never make Life Scout, let alone Eagle.”

“Please don’t mock him, Dr. Plaster,” the resident said sympathetically. “These seem to be deeply held beliefs on his part. He deserves your respect as a person, even if you don’t agree with him.”

“I’m…truly sorry,” I said sincerely. “I shouldn’t have said that.”

“He thinks that we should be able to treat his body in a way that would somehow make it more like a 12-year-old that he feels like inside. He thinks he has too many ‘grown man hormones’ and he would be just fine if we treated him with some kind of hormone blocking agents.”

“Let me go talk to him,” I said finally.

“Thanks,” the resident said handing me the chart.

“Hi, Mr. Sanders, I’m Doctor Plaster, the attending physician in charge of the Emergency Department tonight. Dr. Adams, the resident physician, told me you were reluctant to go let us take you to the cath lab for a look at your heart.”  I was surprised to see a heavy man with a thick black beard slumped on the bed looking comical in his children’s hospital gown barely covering his big belly.

“He probably told you he thought I was crazy, too. Am I right?” he said with a look I had a hard time interpreting. He seemed a little intimidated by me, but trying to fight through his fear. He reminded me of how my kids used to look talking back to me when I scolded them.

“No, quite the opposite,” I said sincerely. “Though he was surprised by your perspective on your age, he was quite sympathetic.”

“So you came into be the heavy and brow beat me, huh?”

Actually I had, and he had seen right through me. But now I was intrigued to really know this man.

“Well… I do hope that I can convince you to go to the cath lab. But first I’d like to hear your thoughts about how you see yourself. It just might help us to communicate a little more clearly. What do you think?”

He studied my face for a long moment. Then he seemed to relax and take a deep breath. “When I was a kid I had a great time. I liked my life. I loved my dog. My parents thought I was great. That was the real me.”

“Junior High was really tough on me, too,” I said with a sigh without taking my eyes off his softening face. “I went out for basketball because my brothers had been good athletes and I thought that was how I could keep my father liking me. The coach kept me on the team. But I was the last boy and they didn’t have enough jerseys. So I had to wear a tee shirt and change with one of the other boys in the unlikely event that I ever got in a game. My father was embarrassed and he took it out on me by mocking my gangly appearance.”

It was deeply painful recalling that decades old memory.

Mr. Sanders started to weep. “I know how you feel.”

“I think you do,” I said. “I don’t know what wounded your heart so long ago. But it was real. And it has caused lasting scars. I’m just concerned about another wound that is going on right now. We can prevent this one. But you have to trust us to take you to the cath lab now…before it’s too late. I know you don’t know me. But I know you better now. Will you trust me?”

He studied my face again. Then without breaking eye contact, he reached out and placed his hand on mine resting on the bed rail. “Ok. Will you come talk to me afterwards?”

“Yeah,” I said with a softening smile. “We can share some good memories from Boy Scouts.”

ABOUT THE AUTHOR

FOUNDER/EXECUTIVE EDITOR Dr. Plaster has been an emergency physician for more than 30 years, working exclusively night shifts for the past 20 years in emergency departments across the country. During that period, he joined the U.S. Navy and served two tours in Iraq. Dr. Plaster is the founder and executive editor of Emergency Physicians Monthly and the founder of Plaster Publishing.

7 Comments

  1. I love this! A true testament of taking time out to really connect with patients in the midst of a busy ER. Thank you for your service Dr. Plaster and thank you for displaying a wonderful bedside manner.

    • Mark L Plaster on

      Jamie:
      You do know this is fiction. I wish that I really had that good of a bedside manner. I try. But this is my fantasy alter-ego with a story about the problem of dealing with people who do not see themselves accurately. Many times for very good and understandable reasons. But, nevertheless, they are disconnected with reality.

  2. First of all, affirming a delusion is NOT how to treat it. Any such delusion which puts the patient at risk because it leads to poor decision – making and/or self-destructive behaviors is an inherently BAD thing.

    It is dangerous to have the perspective of:

    “But he feels that “he”, the true person inside of the body, is only 12. It’s his reality. Do you acknowledge that?”

    as if this is actually a valid thing to be acknowledged, given the objective data to the contrary, the acute nature of the problem AND the adverse outcome if the course of decision-making isn’t changed. The resident is misguided as are their instructors for allowing such a patient-endangering perspective to actually prosper and grow in the minds of those being trained!

    Delusional disorders are exactly that – Disorders! They are FALSE, FIXED Beliefs by definition, with no basis in fact. “Acknowledging” that they “feel” that way and allowing that to guide the course of medical treatment in any way that doesn’t allow the patient to see through their delusion OR get past it to make the decision that is in their best interest, is a recipe for folly and an enabler of worse pathological outcomes due to, again, poor decision-making and erroneous thought processes. So what, are the resulting poor outcomes to be promulgated as “normal” because that’s how the patient “felt” and that was their “reality”? Should this outcome also be “acknowledged” as par for the course?

    Gimme a break!

    What about if the patient’s delusion were that he was possessed by a mass murderer and should be allowed to kill everyone in the room before going to the Cath lab? Because his actions would be illegal, do we not “acknowledge” those feelings? They feel that way and “believe it deeply” just as the patient in this case. Who is first in line to act accordingly by presenting their carotids? I think the answer there is overwhelmingly no one. So what, now we pick and choose which delusions are okay to acknowledge and which ones are “bad”?

    We need to stop this foolish, fallacious activity right now before it’s too late.

    Adults with decision-making capacity either come to grips with their delusions and permit us to treat them or make use of the AMA form. Yes, this means a psych consult in the middle of their MI if need be. Document thoroughly. If they lack capacity, then their POA, caretaker, spouse, hospital administrator or even the state can determine the next course of action.

    Time is STILL myocardium. Or do we no longer care about that?

    • ED docs aren’t here to solve the world’s problems. If I can solve one problem per patient I count that as a win. The problem to solve here was getting this patient to the cath lab. His delusion, or whatever you want to call it, was a barrier to that. A hospital administrator, the “state”, a psych consult (for a STEMI in a guy who is conversational and approachable?) isn’t going to break down that barrier for us in a way that actually helps this patient. As ED docs, we may not be experts in surgery, cardiology, neurology, etc. but our ability to make a quick but meaningful connection and do what we need to do to get the job done calmly and without drama is what separates us from other specialties. This patient made it to the cath lab safely and in a timely manner. That was the goal and it was accomplished. The rest can be sorted out later. Kudos to Dr. Plaster for masterfully managing this situation.

      • Mark L Plaster on

        Matt:
        Thanks for the kudos, but this is a fictional story to illustrate the troubled waters we are currently navigating dealing with people who do not live in reality. Read the reply to TiredDoc above and consider the difficulties we face in dealing with other people suffering from a variety of delusional states.

  3. Mark L Plaster on

    Dear Tired:
    As I noted to the reader above, you do know that this is fiction, based on reality, but nevertheless fiction. I happen to agree with you totally, but things are sometimes a lot more complicated than they seem. Substitute “sex” for “age” in the above scenario and we have a political firestorm of our own making. We can still be sympathetic and caring.

  4. Mark,
    You fictionally, but accurately show that a practitioner can be sympathetic and caring without affirming a patient’s obvious misperception of reality.
    Your two vignettes (this one and the anorexic young woman from a past NightShift) point out the discordant approach to different patients who exhibit reality misperceptions.
    How do we explain the discordant approach and treatment to patients, for example, the anorexic who identifies as obese and the 55 yo man who identifies as 12 yo?
    Compassionate appropriate patient-centric care is possible (and indicated) without affirmation…..we have done it for hundreds of years as professionals. We have compassion for the end-stage COPD smoker (still smoking) without affirming them.
    Affirming reality misperceptions ignores three of the four pillars of medical ethics for the sake of autonomy.
    Some of our professional colleagues are trying to sit on a four legged stool having removed three of the legs. In time they are bound to fall….in the meantime how many patients will be permanently injured?

Reply To Mark L Plaster Cancel Reply