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    Sometimes, tough love is the best care

     

    Sometimes, tough love is the best care

    When her suicidal patient balked at going straight to the psychiatric hospital, the author put her foot down—and was rewarded in more ways than one.

    By Elaine M. Holt, MD
    Internist/Cary, NC

    The nurses and doctors were sitting in the office lunchroom blowing off steam when a staffer brought in a huge flower arrangement. "Dr. Holt, these just came for you," she said. The crowd instantly began shouting out candidates for the sender: "Your husband?" I remembered thinking to myself, they don't know John if they think he'd send me flowers for no reason. "An admirer?"

    The card attached to the spring bouquet read: "Thank you for taking care of me. Love, Ruth."

    Ruth is a patient who'd taken a near-lethal combination of lithium, gabapentin, and trazadone—and at the time was at Holly Hill, a psychiatric hospital. A week earlier, I'd received a call from the local emergency room saying that she had overdosed and was being admitted to the intensive care unit.

    When I arrived, Ruth had a nasogastric tube in place. The excess tubing was taped to her forehead, charcoal lined her mouth like a bad appliqué of lipstick, and her hands were tied to the ER gurney's side rails.

    "Ruth, what happened?" I asked. "You were doing so well."

    "I snapped."

    Ruth, a plump, single woman in her mid-30s, has had bipolar disorder since she was a teen. She'd had a brush with suicide in the past, but had recently been enjoying the rewards of a new secretarial job, a stable home life, devoted parents, and a good therapeutic alliance with her psychiatrist. Her new crisis was sparked by her discovery that a colleague, hired to do a similar job, was getting a higher salary.

    Because she was rushed to a hospital in which I, not her psychiatrist, had privileges, I managed Ruth's emergency. She had ingested 27 grams of lithium, along with other prescription drugs. For 24 hours she was in tenuous shape, with neurological signs and lithium levels that nearly required dialysis. The ICU nurses tirelessly administered charcoal, hooked up IV pumps, and answered calls from me every half-hour. I spent the night getting treatment advice from a poison control center and learning the warning signs of clinical deterioration.

    By the time Ruth stabilized it was 4:45 am, just a half-hour shy of my usual wake-up time. Deciding that it would be fruitless to lie down for such a short while, I showered and changed my clothes.

    Thankfully, Ruth made a speedy turnaround during the next 24 hours, and we arranged for her father to take her to a psychiatric hospital. Ruth and her dad had agreed to all of this the day before discharge, and as far as I was concerned, the transfer was wrapped up with a ribbon. But 45 minutes before her departure time, Ruth grew agitated. She wanted to stop off at her apartment before going to the hospital. That sent warning flags up for me that translated into "I'm feeling better now, so screw the psych hospital."

    I couldn't leave my office patients at the time, so I phoned Ruth in the ICU.

    "Ruth, what's this I hear about you not going straight to Holly Hill?"

    "I want to go to my apartment first," she pleaded.

    "That's not an option," I said sternly.

    Silence.

    "Ruth, you must go straight to Holly Hill with your dad."

    "Why? I want to stop at home first. This isn't fair. I don't see why I can't go."

    I don't know exactly what about this dialogue pushed my buttons—perhaps I was overtired. I raised my voice and said: "Why? Because I don't trust you to go to Holly Hill after you get home. People who recently have taken near-lethal doses of their medications can't be trusted, by definition. Also, I'd like you to stop complaining and start thanking people. On the way out of the hospital, you should thank each and every nurse for saving your life. Heck, you haven't thanked me for staying up all night talking to poison control, trying to reverse your mistake and give you a chance at life. Either you go without complaint, or I'll commit you involuntarily and you'll go in handcuffs—without your dignity."

    And I hung up the phone. My voice had crescendoed so that my nurse appeared at my door with a look that said, "Glad I'm on your good side."

    That hostile conversation, along with an urgent call to Ruth's dad later on, are what earned me the beautiful bouquet.

    Though I've seen Ruth in the office a few times since that episode, I've never gotten up the nerve to question her motive: Did the flowers represent an awareness of her selfishness? Were they an expression of genuine thanks? Or were they a peace offering to a doctor who bullied her? I'm not sure that I'll ever know what inspired the flowers, or whether the phone conversation was entirely professional. It was tough love, tough talk, and a hard line.

    Though I'm sorry I lost my temper, I'm not sorry for what I said, or that I showed Ruth my human side. In fact, at her first office visit after her hospital stay, without a word, she gave me a hug. I don't know whether hugs are entirely professional, but they are human.

     

    Elaine Holt. Sometimes, tough love is the best care. Medical Economics 2000;23:144.

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