Rites of Spring
(Note: I'm not terribly happy with this commentary, and I apologize for that - I've been sitting on it for the past few days, trying
to re-work it, and all of a sudden, it's Thursday, and I have to write another one tonight. So if this one isn't up to my usual high
standards (such as they are), I apologize.)
A couple of months ago, I attended a lecture by Sir Martin Rees, the astronomer royal, at the University of Victoria. He was
there to speak to the astronomy department about gamma ray bursters, which, if you don't follow the astronomical world, are a
subject of considerable interest to astronomers. This doesn't really have anything to do with medicine, but one of the first things
he said when introducing the topic was that we tend to try to classify unknown phenomenon into our fields of expertise. And
why do I bring this up? Because it applies not only to astronomers, high energy physicists, and hard science geeks, but also to
doctors and medical professionals as a whole. When confronted with a new problem, we like it if we're able to pigeonhole it
into something we understand at an intuitive level.
This was floating through my head as I watched Lucy run from patient to patient in the emergency department, trying to
interview them about their mental state. You'd think that, with her presence in the ED, they were calling psychiatric consults on
every single person who presented that day. Okay, I admit it, we often say that we should be asking for psych consults on
everyone who shows up, but we don't do that. (Of course not. That would mean the psychiatrists would have to actually do
work.) Of particular note was the law student who attacked his car -- I didn't really see any reason to call a psych consult for
him, although in hindsight, it turned out to be the right thing to do. (To be honest, if I felt it were necessary to have a psychiatric
evaluation done, I probably would have done it on an outpatient basis -- there's no need to tie up an ED bed with someone
who isn't acutely ill and isn't a flaming danger to himself or to others.)
(Brief inter-note: did you notice the cardlocked doors in the psychiatric unit? These are standard on secure wards. In one
secure unit out here (I'm not naming names), the doors require cards to open. I like to use my Blockbuster card, personally;
co-workers use things like ATM cards and Air Miles cards. Don't ask. I don't know why I brought this up.)
Lucy was absolutely right about Seth: the kid was way over-medicated. Nobody - not children, not middle-aged men, not the
elderly - should be taking that many prescription drugs at once, and not just because of the effect they have on the body
together. There are very few controlled studies of patients taking three drugs, and none of patients taking four. Drug interactions
multiply with every new agent added until it's impossible to tell what's causing the complaint. One patient I like to talk about
presented to the ED complaining of headaches. During the history, it was discovered she was on 14 different prescription
drugs, and a whole host of OTCs. And you want to know why you're having headaches, huh?
Psychiatry is more guilty of this than most branches of medicine, although in a certain sense, we're all complicit here -- patient
and provider alike. The current thinking is that if you're sick, you go to the doctor and get a drug, and the drug will make you
better. Patients show up and demand prescriptions for all kinds of drugs for all kinds of ailments; doctors don't know how to
say "no" and end up needing refills for their prescription pads more often than they should. The over-usage of antibiotics is,
perhaps, the most serious manifestation of this problem, although there are others just as noteworthy: Prozac, Xanax, Ritalin,
and -- I hate to say it -- Viagra. (Stupid cliches.)
With mental illnesses, it is important to try non-pharmaceutical therapy first, and then move to the drugs if there's no
improvement, particularly with kids. I firmly believe that children newly "diagnosed" with ADD need to be put into therapy
before they're given Ritalin.
Random things:
The conference: I didn't buy it. For starters, there's no way in hell you're going to get a bunch of off-duty emergency physicians
to give up their Saturday afternoon to go sit in a hotel ballroom when they don't have to. Trust me. I also didn't buy Mark's
unwillingness to go -- every self-respecting on-duty physician welcomes the opportunity to go nap attend an educational
conference: it's a habit picked up in residency that carries on into later life. (Walk into a lecture hall full of residents some time.
Half of them will be alseep. Actually, I think this is true for undergraduates of both medical schools and universities, as well as
residents.)
Did Kerry and Peter bribe the people at Annals of Emergency Medicine? That study only wrapped up at most a couple
months ago; those of you who have tried to get academic material published know what sort of hoops you have to jump
through just to get a study ready to submit. There is no way in hell that the AEM editorial board would have made a
publication decision on this study so fast (particularly when in the real world they'd still be doing data analysis). Even if they had,
you'd still have to wait at least a year and a half for publication. If you want to shake the world up with your groundbreaking
results, guys, write to ACEP and get on the schedule for the Scientific Assembly this fall; if you missed that deadline (I'm not
keeping track anymore), get in line for the International Conference on Emergency Medicine in Boston next spring. (There's a
whole whack of other conferences in between now and May of 2000; those are just the first two on my attendance list.)
Come to think about it, this one bugs me a lot more than just about anything else that happened in this episode. I'm not sure
why.
Note to the writes: I'm getting really sick of Carol and babies. Look, we get it already! Furrfu!