Note that Schultz wasn’t concerned that she enjoyed the mimicry, only that bystanders might observe her laughter.
Failure to die implies that the patient’s continued existence is utterly futile. Medical futility is a very hot topic in hospital corridors these days. Faced with an aging population and ballooning health-care costs, more and more doctors wonder whether they can continue to take on all comers in need of life-saving treatment.
The concept behind medical futility is a simple one: no treatment will put things right with the patient. The problem is that there are no universally accepted criteria for futility in the corridors of medicine. That’s the maddening part of this discussion. When it comes to cracking the genetic code of a disease or coming up with ultra-precise clinical criteria for giving a stroke patient clot-busting drugs, physicians are models of exactitude. But when it comes to medical futility, doctors and nurses can only say they know it when they see it. All too often, medical futility is a judgment made by a health professional based on what he or she—not the patient—would want.
“For me, I think, ‘Oh, my God, I would not want to live like that,’” says Gray. “I tell my children about once a year to pull the plug on me if I get to that sort of state. They have no illusions about that. But that’s me, not everyone. Some people view life as sacred even if it’s not meaningful anymore. And some people say even though their grandpa’s completely demented, if they put a spoon of Jell-O in his mouth, he eats it. So that means that he has some satisfaction in life, and so we’d like to keep going with all possible treatments.”
I have a personal stake in what Gray is talking about. My mother has advanced Alzheimer’s disease. For many years, she has been unable to speak and unable to tell us her wishes. My late father, my sister and I were forced to guess on a number of occasions. For the past three years, she has been unable to feed herself, and so the three of us, plus a growing list of hired caregivers, took turns feeding her. On some level, we supposed she got some pleasure from the taste of food on her tongue. A while back, my mother was admitted to hospital with dehydration. The internist on call gently chided us for calling an ambulance instead of letting her die. “Perhaps you should consider not doing that next time,” he said.
As a family, we have decided not to “keep going with all possible treatments,” as Gray put it.
I’ve never been convinced that front-line doctors and nurses care all that much about medical futility per se. After all, futility doesn’t come out of their pocketbooks. Publicly funded health care, private, or a mixture of the two—it doesn’t matter. Futile or not, we get paid to care for patients with dementia.
Put that way, FTD and futility are in the same ballpark as cheeching and flogging in that all of them mean serving up treatments when you know they won’t bring the patient back. The only difference is that cheeching is initiated by doctors; it’s called futility when it’s requested by patients or their families.
Either way, it’s not good for the person who is often forgotten: the patient.
* * *
The slang we doctors use to describe older patients is an expression of frustration with everything from what’s wrong with them to their very existence. But it doesn’t explain why we’re so frustrated.
One obvious reason is that we mirror the ageism in society at large. In the past few years alone, researchers have documented that ageism affects the treatments seniors receive in heart disease, diabetes and cancer care, to name just three conditions. Sadly, much of the blame goes to the fact that medical students receive little education in gerontology and spend little time with good role models.
This may shock you, but today’s doctors are astonishingly ignorant about how to take care of older patients. We don’t know what we’re doing. And when that happens, we get frustrated.
Ignorance would be forgivable if we resolved to do something about it. But that’s not the case. A 2012 report by the Rand Corporation documented a critical shortage of geriatricians in the U.S.
The trouble is, very few young doctors want to become geriatricians.
“I was told that I was wasting my talents, that I was too smart to be doing something like that. And how could I pick a specialty where I wasn’t actually helping people?” Nathan Stall, who has chosen geriatrics, told me.
Instead of smart and enlightened care, the growing numbers of seniors get a dollop of disdain laced with slang.
6. Swallowers
If you have pneumonia, I can put you on the antibiotic azithromycin and you’ll be feeling better in three or four days. If you come into the ER with a near-lethal level of potassium in your bloodstream, I can order up a cocktail of treatments to bring the level down fast. Show up with a pneumothorax—an expanding pocket of air between the inside of your chest wall and your lung—and I can puncture your chest wall with a tube or a pigtail catheter, evacuate the air pocket and you’ll be breathing better in three or four minutes.
But if you come to the ER with schizoaffective disorder, psychotic break or borderline personality disorder, I—and most of my colleagues—could talk to you for three or four years and not have a clue as to what makes you tick, let alone how to help you. But that doesn’t mean we don’t practise medicine on emotionally afflicted patients. Far from it.
A patient I’ll call Rhonda (a composite of many such patients) has been coming to various ERs for years. She’s been diagnosed with severe borderline personality disorder (BPD), a chronic, largely incurable psychiatric condition marked by extreme depth and variety of moods, unstable interpersonal relationships and a fragile sense of self. People with BPD—mostly women—go through periods in their lives when they try to harm themselves. The most severely affected may commit suicide.
Rhonda is one of the most practised swallowers I have ever met. To call her the Super Elite of frequent flyers, patients who visit the hospital over and over again, is to trivialize her accomplishment. Think of her as if she’d joined the fictitious American Airlines 10 Million Mile Club—as actor George Clooney did in the 2009 film Up in the Air. Rhonda swallows pins of all kinds, kitchen knives, spoons, forks, house keys and the occasional USB flash drive.
Once or twice a year, Rhonda visits an ER to have the large number of objects she’s swallowed removed. It’s become a ritual that is as mindless for the doctors and nurses who look after her as it apparently is for her. As soon as she arrives, the doctor on duty orders an X-ray of Rhonda’s abdomen to locate the things she’s swallowed. Then the gastroenterologist is called to insert a gastroscope and remove the offending bits. It’s done under a light general anesthetic, often administered by an ER physician like me.
I have spent as much as an hour or longer administering vast quantities of the anesthetic drug propofol to keep patients like Rhonda sedated long enough for the GI fellow to snare the various objects.
Professional sword swallowers are probably the only people in the world with any useful insight into this bizarre practice. In 2006, Brian Witcombe and Dan Meyer did a survey of sword swallowers that was published in the venerable British Medical Journal. According to their survey of some fifty English-speaking sword swallowers, most spent hours a day for months, even years, perfecting their craft. The swallowers said they learned to suppress the gag reflex by repeatedly putting fingers down their throats. They then learned to swallow spoons, paint brushes, knitting needles and plastic tubes before progressing to bent wire coat hangers. Then, it was on to swords.
When a pro or determined amateur swallows a sharp object, the principal danger is that it will pierce or perforate the esophagus or stomach. Mortality from perforation can be as high as 30 percent, but few accidental deaths of professional sword swallowers are reported.
When patients like Rhonda come to the ER, most of the time the GI specialist is able to fish out the objects they have swallowed and we send them home. Although such patients have a psychiatric disorder, rarely if ev
er do we ask a psychiatrist to see them. Rhonda’s personality disorder is so intractable to therapy that a consultation with a psychiatrist is generally considered pointless. The cumulative cost in health-care dollars of this recurring exercise would probably run close to $1 million, virtually all of it paid for by publicly funded health care.
As harsh as this may seem, few doctors and nurses would shed a tear if the Rhondas of the world perforated a vital organ and died as a result. The sense I get from ER personnel is that anyone who would do what Rhonda does, and waste ER time and facilities in the process, merits contempt. Even her name is irrelevant. Instead, we use slang to reduce what she does to herself to a stereotype. She isn’t Rhonda; she’s a swallower.
Rhonda’s a subtype of a much larger group of patients who frequent the health-care system and baffle us endlessly. Doctors and nurses label them psych patients.
One guy who has picked up on the lingo is Jason Quinn, a first-year resident in psychiatry who at one point wanted to be an ER physician like me. “‘Psych patient’ is code for annoying, a bother, a time sink and somebody who’s not going to get better and is damaged and wasting the space in my emergency department or on my floor,” says Quinn.
Quinn recalls enjoying his rotation in emergency medicine and especially the excitement of being the first person to lay eyes on a patient. But, unlike ER physicians who recoil at psych patients, Quinn was drawn to them—the sicker the better. He remembers one ER physician whom Quinn regarded as an otherwise excellent teacher who confronted Quinn about his interest in patients with mental health problems.
“Why do you want to see the psych patients?” Quinn recalls the ER physician asking him. “They’re not going to get better. Why don’t you just let one of the senior residents deal with them and then psychiatry will see them?”
Quinn was disturbed by the way the ER physician dismissed not just the patients but Quinn’s interest in them: “To me, that said something about the attitudes that are held throughout the rest of medicine about psychiatry and psychiatric patients.”
Turns out the attitude Quinn encountered from his ER mentor—along with some very pejorative language—has been prevalent in the halls of medicine for a long, long time.
* * *
Pejorative terms for the mentally ill have existed in non-medical literature for centuries. Mad as a March hare dates back to Chaucer’s The Friar’s Tale, most likely written in the 1380s, and in Shakespeare’s King Lear, written about 1605, Edgar disguises himself as the beggar known as Mad Tom. More than 250 years later came one of the most popular references to madness, in Lewis Carroll’s Alice’s Adventures in Wonderland, published in 1865. Lost in a forest, Alice asks the Cheshire Cat for guidance. Many of you will remember his famous advice: “‘In that direction,’ the Cat said, waving its right paw, ‘lives a Hatter: and in that direction,’ waving the other paw, ‘lives a March Hare. Visit either you like: they’re both mad.’”
As mentioned earlier, in his 1973 catalogue of nursing slang, Philip C. Kolin wrote that nurses called patients with manic depression (now called bipolar affective disorder) “manics” and those with schizophrenia “schizzes,” and they described patients agitated by psychiatric disorders as “bouncing off the walls.” Modern medicine is rife with such psychiatric slang. Not surprisingly, many of the terms are invented and used by health professionals who do not specialize in psychiatry.
As a veteran psychiatric emergency nurse, Sarah Reynolds has been observing her ER colleagues for years. “We all have slang, and I think it’s especially prevalent in the emergency room just because of the turnover,” says Reynolds. She admires the ability of ER nurses and doctors to see and treat a wide variety of patients—urgent and otherwise. But toss an agitated and unpredictable psychiatric patient into the mix, and medical staff seem to have a particularly hard time.
“Psychiatric patients are seen to be overdoing it and taking up an awful lot of time,” she says. “If patients are disruptive, intoxicated or manic, they take time and resources. They often frighten people. They have to be restrained. They’re a burden on the resources and frighten the other patients.”
And make no mistake: psychiatric patients are disruptive—especially the ones having a psychotic episode.
An ER nurse told me about a psychotic patient who was hearing impaired. “We wrote out our questions to him. He read them and then answered in this very loud voice. He wanted me to help him make a phone call to his friend. I dialled the friend and gave the phone to him. He told his friend that a spirit had made it necessary for him to enter the hospital.”
Suddenly, the patient screamed that he was in grave danger. “He’s bellowing this, and I’m looking around, and all of these little old ladies are looking at him.” The patient had to be restrained.
Reynolds says it’s hardly surprising patients like that generate some colourful ER slang. “Crazy is used often,” says Reynolds. “Or bat-shit crazy. Nuts is used very often. So are wing nut, wacko and psycho.”
Dr. Grumpy, a pseudonym for a neurologist who blogs about his experiences, says he uses similar slang. “You occasionally see the phrase JPN for ‘just plain nuts,’” he says. “I think I’ve used that one here and there. It’s usually in conversations with other doctors at the hospital.”
Like swallower, such slang words indicate that some health professionals find psychiatric patients mysterious, unfathomable and more than a little frightening. Reynolds has tried to get inside the heads of those who use them—beginning with crazy, which is used in different ways.
“It can mean anything from ‘I think this patient is anxious and might require a chat’ to ‘Shut this person up. They’re driving me nuts and they’re upsetting everybody else,’” says Reynolds. “I think sometimes it is unkind and it diminishes the patients’ needs and treats them as a nuisance.”
I suspect the label says more about the health-care provider than it does about the patient. Like the triage nurse, when I say a patient is crazy, I mean that the patient is making me crazy.
Interestingly, Reynolds says her psychiatric colleagues use crazy as a form of code to indicate to the ER staff it would be better if mental health professionals took over. But as first responders, my ER colleagues and I usually end up having to manage patients in the throes of a psychotic break without immediate assistance from experts in psychiatry. When that happens, the patients are not only a danger to themselves but to ER personnel and bystanders. If we can’t calm such patients by soothing them with words, we sedate them with injections of drugs such as haloperidol and Lorazepam.
“We call the drugs ‘vitamins,’” says one veteran ER physician. “There’s vitamin L for Lorazepam and vitamin H for Haldol.”
These drugs most assuredly are not vitamins. Turning a treatment into slang by calling it a vitamin is a favourite trope of ER physicians. I think it detaches us emotionally from what we’re doing to agitated patients in severe emotional distress. Like a vitamin, it makes us feel more powerful.
As Sarah Reynolds suggests, despite their outward bravado, ER personnel harbour deep insecurity about dealing with agitated patients. We don’t feel particularly competent in assessing and treating them. The slang calms us, just as the sedating drugs calm our patients.
* * *
The world of psychiatry has its myriad diagnoses, labels and slang. Often, it can be difficult to know where one ends and the other begins. The bona fide diagnoses come largely from one source, the Diagnostic and Statistical Manual of Mental Disorders (DSM). Often described as psychiatry’s bible, in terms of the Secret Language of Doctors it might also be described as its thesaurus. The volume is meant as a tool to help psychiatrists diagnose patients, providing them with definitions and criteria patients must meet before they can officially be labelled with such illnesses as depression, psychosis or autism spectrum disorder.
The American Psychiatric Association (APA) published
the first edition of the DSM in 1952. It listed 106 mental disorders. The DSM was born in part out of a need for a common language; practitioners across the country needed to understand each other. “There was great confusion and variability in diagnoses of mental disorders because diagnostic systems were about as varied as the institutions and individuals that created them,” wrote James Sanders, author of A Distinct Language and a Historic Pendulum, an article about the evolution of the DSM.
The creation of the DSM was also an attempt to order an unorderly division of medicine. “To be sure, psychiatrists were aware of their inability to demonstrate meaningful relationships between casual elements and the presence of particular behavioral signs or symptoms,” wrote Gerald Grob, author of the article DSM-I: A Study in Appearance and Reality. “Yet social and cultural roles of medicine required that all physicians—psychiatrists and others—provide some explanation of disease processes.”
It’s more than fifty years later and scientific explanations for psychiatric illness remain elusive, and that leads to a well-entrenched dichotomy in the world of medicine.
“There’s already this ingrained idea that psychiatrists are dealing with non-organic problems,” says Jason Quinn, the first-year psychiatry resident. “Not real things. Not real medicine.”
The words organic and non-organic have legitimate meaning in the world of medicine. However, doctors most often use them as pieces of medical slang.
What Quinn calls “real medicine” refers to treating diseases found in living tissue as opposed to the mind. Think conditions such as diabetes and kidney failure, organic problems for which a definite pathophysiology exists in patients’ bodies. Non-organic medicine, on the other hand, implies that the disease is not a part of patients’ bodies but is in their minds. It is often used as slang for psychiatry.
The Secret Language of Doctors Page 11