Wednesday, 12 May 2010

A plan

Today I was asked to see one of my patients by a Government official who had just interviewed her. The message was that she was “suicidal, and had a plan”.

Now I am all in favour of Government officials being given training in dealing with potentially suicidal people. And it is true that if someone tells you that they have thought out how they are going to kill themselves then you need to take that very seriously, particularly if they have already taken steps to put their plan into action. But I suspect that “having a plan” will soon enter the popular consciousness as being an integral part of feeling suicidal. Just as all flu is now “man flu” (in men, at least) and all vomiting is projectile, so suicidal feeling will be totally unimpressive without a plan in tow.

“Projectile” vomiting used to be a term applied by doctors only to young babies with pyloric stenosis. In this condition the baby will drink a bottle of milk happily (nay ravenously) but then project the milk an astoundingly long way across the room, in the manner of Regan in The Exorcist. That is what a doctor means by “projectile vomiting”. But over many years parents have been trained by keen young paediatricians asking them whether their baby's vomiting was projectile, so that now there is a general understanding that doctors are interested in the projectility of vomit. Since patients so often want to please their doctors they will proudly announce that their vomiting is projectile. And let's face it, you're a bit of a wimp if it isn't.

A long time ago I worked for a commercial out-of-hours service and spent many happy antisocial hours driving around the less salubrious areas of town seeing a series of snotty children and coughing adults. Or occasionally the other way around. When the call details were passed through a very high proportion of the patients were said to have “difficulty in breathing”, but when I arrived their respiration was almost always normal, or at least unlaboured. The reason was that the call handlers always asked the stock question “do you/they have difficulty in breathing?” The customers, perhaps thinking that a doctor would be impressed by such difficulty and might turn up earlier, or fearing that he might not turn up without it, would answer “yes”. This has entered the local folk memory, and even now patients will report difficulty in breathing as a way of seeking my favour.

So I rang my patient who said she was fine, that the official had misunderstood, and she was perfectly happy. Just then her friend grabbed the phone and said “no she's not, she's suicidal”. “No, I'm fine” came a voice in the background. It reminded me of the “bring out your dead scene” in Monty Python and the Holy Grail. (“I'm not dead, I'm getting better!”) I was not convinced that my patient wished to die immediately, particularly when she discussed some of her (non-suicidal) plans for the future, and I made some practical suggestions to give her some hope that things might improve. Which, ultimately, is all you can do for people who see no future for themselves.


Nikita said...

I am sure that you are as aware as I am that the common cold is now eradicated as a presenting condition. Every sniffle, runny beak, cough or spike in temp is now a symptom of 'flu. My nursing colleagues report it in handovers and a GP visit is recommended.

I have learned through observation, intuition, vital signs and basic common sense to differentiate between a panic attack and a possible MI. Some of my colleagues haven't.

Yes, being the wrong kind of nurse, I will call out a GP or locum if I am not sure of a presenting physical condition; but only then.

I can understand why GPs get a bit 'pissed off' with all and sundry requesting their input, but in your cited case - the guy did good. He showed concern and this is a rare commodity in this day and age.

Nikita said...

Hello again!,

Until today I had never delved back in to you previous posts. I have 'had you' on Post Atom for some while and look forward to your intemittent offerings which are always kindly.

I could be wrong here and I think it was last year; but following an article in HealthcareRepublik, I left a comment praising docs who owned up to mental health issues.

I must admit to always wondering about "All illnesses are psychosomatic" and wondered whether it was a psychians view that all illnesses were indeed 'all of the mind!' and that all patients were near as damn it - idiots!

Tomorrow Dear Doctor - I will read all your past posts. I admire you immensely. I think patients, colleagues and all and sundry tend to forget that doctors are human too.

I know that in my work place that due to the high male resident population - not your average EMI home - situations are often confrontational, territorial and verging on if not spilling over into violence - that mental health issues are often misunderstood.

Mental ill-health is stigmatised in our society and is a source of embarrasment. Even if working in mental health, this is a condition that is best left swept under the carpet. I will stop rambling now Dear Doctor - but you have my utmost admiration. I am pleased that your comments are moderated as otherwise I would not have written this.

Kind regards,

Mags. xxx

steph said...

Your wealth of experience shines through in this post.

Great to see you back!

Transcription Service said...

Good an very interesting Plan

Dr Andrew Brown said...

Thank you, Mags and Steph, for your kind comments. Life can be difficult, and we must do the best we can under unpropitious circumstances.