When I left the hospital today, black storm clouds framed the Minneapolis skyline, perfect running weather. Early this week when I went running with similarly threatening skies, the rumbling thunder gave way to sheets of rain and marble sized hail. It made for an exhilarating return trip and a meditation on the power of nature. Today the weather held, so instead of meditating on life and death, I thought back on an incident that happened one week before.
Last Saturday afternoon was gorgeous, I hit the jackpot and got an early admit, so I was walking out of the hospital at 3 pm, at least 2 hours before I expected to. I snapped my pannier to my bike, rolled up my scrubs, and kicked off downhill towards the hospital entrance. As my bike lazily rolled towards the street, I heard yelling on my left and turned my head to see what was going on. Four security guards were standing around a young black woman who was crying and staggering towards the street, catching herself intermittently on the brick wall of the hospital or the concrete pillars holding up the parking garage. She was wearing shorts, a grey t-shirt, and hospital socks. She had spittle running down her shirt and foam in her mouth. She looked unwell.
So I turned my handlebars and pedaled up towards the scene, leaning my bike up against the hospital wall and slipping on on my t-shirt shirt as I walked towards security. The girl was now sitting on the ground with her back to a post, crying and banging her head against the concrete. I could hear one of the guards angrily telling her that she needed to leave the premises as the others stood next to him and watched. As I approached he turned to me and aggressively told me that I needed to “walk away.”
Now I’m a white man in scrubs, and I shamelessly used that social capital, ignoring his command, and continued to walk toward them. I said that I was a student doctor who worked at the hospital, and asked what was going on. One of the other guards quickly stepped between us and told me that the girl was admitted for a seizure disorder, but that her ED workup was negative. He said she tried to leave the hospital on her own, and was eventually discharged AMA (against medical advice). He then handed me a plastic bag full of her medications, grateful for the chance to be relieved of responsibility. I took the bag and sat down on the sidewalk in front of the girl as the four guards walked away.
The girl didn’t like me. She didn’t like the fact that I was sitting with her. She didn’t like the fact that I put my hand between her skull and the concrete. She didn’t want to be in the hospital. She didn’t want me to call a cab to take her home. She didn’t know why her boyfriend wasn’t there. Every few minutes she stood up and staggered a couple feet only to sink back to the ground, sometimes spilling onto her back, shaking and spitting, her eyes rolling to the back of her head. These spells only lasted a few seconds, during which I tried to keep her from biting her tongue. She would then sit back up and start crying again, unable to articulate much beyond her emotions.
After 20 minutes or so of cyclical conversation and behavior, I was only able to elicit her name, her age, that she was close to her family but that they were on a camping trip, and that she just graduated from high school. When I started to feel like I wanted to pull out my own hair, I knew I had to check myself, so I sat back on my heels as she cried in front of me and ran through what I knew:
The patient was harming herself
She was vulnerable (18 year old girl, alone, no wallet, shoes, ID or phone)
She was either having seizures or some sort of conversation disorder
She was not behaving like a competent adult
She has family she’s close to
I did not have the skills, words, or knowledge base to resolve the situation on my own
She had stopped banging her head, and she didn’t look like she was going to be moving anywhere quickly, so I walked into the ED and asked the admitting nurse what was going on. She told me the same story I heard from the security guard, and when I said that I thought the girl was unsafe and should be readmitted, she asked me if I’d like to talk to the ER Doctor. I said yes, and he came out a few moments later with an irritated look on his face. When he asked me what I wanted, I told him that I was a medical student working at the hospital and that I became concerned when I saw the recently discharged patient outside the ED. As I began to tell him what I saw, he interrupted me.
He told me I had “no idea” about the patient or her history, and that what I was seeing was nothing more than an attention-seeking behavior problem. Stifling my reaction to the heavily race-coded phrase “behavioral problem,” I replied that I agreed with him that I didn’t know anything about the patient’s history and that he likely had a much better idea of the patient than I did. That being said, I followed, there’s a girl outside with no ID, no phone, no shoes, foaming at the mouth and harming herself by banging her head against the wall. “Stay away from her and get out of my face,” he snarled and walked back into the ED.
I think I might have stood for 10 seconds in disbelief with my hands pressed down against the admission desk. As I turned to leave, another bearded young white man, either a scribe or nursing assistant, I couldn’t tell by his scrubs, turned to me and said “we see these people all the time.” I let my frustration get ahold of me as I angrily asked what he meant by that and whether she would have been treated the same if she were white. His eyes immediately widened as he said “You can’t say that. You shouldn’t be saying that,” but I was already walking toward the door, trying to figure out where to go from there.
The girl was still sitting on the ground with her back against the wall. I squatted down in front of her trying to collect my thoughts when two other nurses, both men, came outside beside me. One of them sat down beside her and restrained her from banging her head against the wall, which she had started doing again as they walked up. The other had a wheelchair and spun it around so that it was in front of the girl. I asked them if they would take her back inside, and the one holding onto her head nodded. He said that was why they came outside, and that he thought she wasn’t safe and needed to be re-admitted. She initially struggled when they tried to get her up, but seemed to collapse into the chair once she was in it. As they wheeled her into the ED, I walked back inside to talk to the senior resident on call. The resident was going over notes with another medical student in the lounge when I walked in. I quickly explained what had happened, including what I thought went wrong.
I understand that dealing with patients who are that difficult must be frustrating, because they are the people who require the most complicated physical, mental, and emotional care. I am also aware that I knew less about the patient’s story than the ER Doctor did, and I can imagine how frustrating it is to deal with a complicated patient and then have a 3rd year medical student question your decisions.
However, what I saw was a scared, sick, 18 year old girl 2 months out of graduating from high school. She was harming herself, unable to articulate her needs, and extremely vulnerable. There are always options if we take the time to figure them out, even though this kind of problem solving isn’t as sexy as diagnosing something rare like Pheochromocytoma. We could contact social work and psychiatry, bringing them in to to lay eyes on the patient and lend a different perspective. We could send an aid or sitter outside with the patient to make sure she didn’t hurt herself. We could place the patient on a hold in order to do a further workup and contact her family. Or at the very least we could tell security that it is their job to make sure the patient stays safe and has a ride home.
I also know that there’s a good chance that the ED team went over all of those options and maybe more. However, I refuse to believe that with all of the options and brain power available, that there was nothing more that we could have done. Maybe I’m naive but I still think hospitals should strive to be a place of healing and caring for the whole person, not just their lab numbers. And I know I’m still learning, but from what I can tell, the line between mental health and behavioral decision-making is a fine one and probably not a line at all.
I spent a lot of time reflecting on this incident, and am still not sure whether or not writing about it is a good thing, because it’s hard not to make the story about ‘me,’ when the story really should be from the perspective of those who suffer the most. Because I’m so lucky, I biked home, went swimming, got drinks and dinner on a patio, woke up to a feast of a breakfast made for me because I had a long day, just in time to drive over so we could watch my mom win her age group in yet another triathlon.
I knew I wanted to write though, because I spent the following afternoon eating good food by the creek in my family’s backyard, holding my cousins new babies, and playing with their toddlers. This afternoon reminded me that my generation has an obligation to fight to make their world into a better one. I want them, as well as my future children, to grow up in a society that does all it can to hold up those in need. And I guess the first step for me is rattling the cage when I have the opportunity to, and taking on the responsibility of my profession by working to contextualize and humanize every person I work with, striving to serve my community, and staying hungry for change.