" Consulting a psychiatrist would be a question mark on my spirituality " Said the patient.

Hello everybody

 I hope everybody is safe and healthy. it's been a while that I've been receiving lot of patients in the emergency with mental illness ,thought of sharing an incident of its kind.

Not sure if its the awareness of mental health these days or the pandemic, I am developing keen interest in patients with mental illness .I try to take an extra effort to make them feel comfortable and try to create an insight of what is happening and offer them options of what all can be done. 

Since this it seems like a step towards patient care , I thought I'd share it here as well. This would probably not be the best approach but I welcome any type of constructive criticism , additions or subtraction to my approach because end of the day we are here for best patient care.

A 50 years plus old gentleman ,presented to the emergency with the complaints of chest pain radiating to left arm , breathing difficulty, choking sensation in the throat, inability to open his eyes, pain in his leg for 12 hours now. Similar complaints or about 10 days on and off. There he also says that his blood pressure has been fluctuating quite a lot his routine antihypertensives are not helping him control it. Disturbed sleep for about 2 weeks. Was on polypharmacy for vague symptomatic treatment.He underwent a major surgery about two weeks back after a lot of hesitation for a 3 months old long bone fracture. 

Long story short. he was with us for about 5 to 6 hours after ruling out all major life threatening conditions after having consults with the super specialists in the hospital , we concluded that it was a case of acute stress.

I however wanted the conversation between him and me to be quite comprehensive so if you are in a hurry I'd say come back and read or you can carry on with your routine work but it is going to be a long essay from here.

"Sir, I've been following up with your case and since you appear comfortable now I would want to take some time and discuss something important with regards to your health.Your constant discomfort was very concerning so I made sure to rule out all life threatening emergency medical conditions . Fortunately everything is under control or your bloods your scans everything up here to be within normal limits.So, I would want to discuss in detail again about your symptoms and would want to know if there's something bothering your mind otherwise?"

"Madam ,I don't think it has anything to do with my mental status and I think it's purely a physical illness. I am a mentally very strong person. I have been a trainer myself , I have helped so many people to become best versions of themselves. I am already strong person spiritually. I am single. I have adopted two daughters both of them have graduated. I have seen the worst things in my life and I have been strong throughout. The fracture that I got operated for recently I pulled myself for 3 months without surgery .You know , I'm that strong. I have a 80-year-old mother who I take care of. I am a super strong person and I don't think I need any kind of help with respect to my mind it has to be something with respect to the medical cause."

During the narration , like a typical emergency physician I was calculating the SADPERSONS score in my mind. Sorry not sorry We are trained to be like this.

I excused myself out from there. like every medico here who thinks the other specialties do nothing but miss out essential things ! I thought the treating surgeon has missed out the mental health component and I called him up and discussed about the case all over again. I said , sir , This appears like up your case of acute mental stress.

"Stress? a it's hyper/ super / very stressed." He said

" whatever you call it he's very anxious and stressed and just give him symptomatic treatments and send him home."Yes , it happens in India. Full stop. No questions asked. I understood that he had bothered the treating doctor with his recurrent questions and he obviously understood what was up with the patient.

 "Sir, how about taking a psychiatric review for this case? " I asked.

"Ummmm , let's do it let's take a psychiatrist opinion, Do one thing, talk to him again ask him if he's okay taking a psychiatrist opinion. if he consents , will get it done. " He said.

We usually don't routinely take patient's consent before involving a specialty to facilitate their treatment but the way it was conveyed to me, made me aware of what kind of situation this patient is in.

I went back to the patient and said," Sir , I have discussed about your current condition with your treating physician and we together are of opinion that you are an acute stress and a little help from the psychiatry team would help you come out of it. "

"Oh no doctor, it's not stress. I'm very strong person. such things don't affect me. I'm a very spiritual person too. He pointed at the souvenirs he got from the holy place. Look at this, these 2 weeks I have been praying all throughout. I cry ask for help from God. I know God, He will heal me , he has helped pulled me out of so many situations . He will help me this time too . It's not that I've been lying on the bed doing nothing and looking at the roof. I have been asking for his help continuously I'm a very religious person. Taking a help of a psychiatrist would be a question mark on my spirituality. I would not want to do it." He said.

" I totally agree with the fact that you're absolutely strong fit and fine the results also suggest the same. However the discomfort the sleep disturbance you have ,so let's address that and a psychiatrist can do it better. We can Do a root cause analysis of what is bothering you Take some medicines to calm you down and in about a couple of weeks you'll be normal and be able to do take your decisions by yourself. Being a trainer yourself I hope you understand the importance of seeking help at the right time and how it can help carve your way out of the mess. I would still respect your decision of not seeing a psychiatrist but as a doctor I would recommend you see a psychiatrist as well as a psychotherapist to heal faster." I said.

I excused myself for a couple of for some time to see you another sick patient. 

The patients mother who initially was anxious and was not willing to give her proper history approached me. I spoke in detail about his condition and reassured her that he was fine physically but he needed some help to calm to his mind down and the psychiatrist would be the best person to help him. 

She strongly agreed to my surprise. This is India ! 80-year-old agreeing that his son needs a psychiatrist to help him out came as a surprise.

She later revealed that he has had not eaten anything since morning, he had a huge fight in his family earlier this morning and certain unwelcomed decisions were taken at their household... 

"Beta , you are right he needs a psychiatrist but will he agree. I'm more than willing to take him to the psychiatrist but he should be willing."

I said I have tried from best from my side ,I cannot convince somebody beyond this.

The er got busy , I was handling other sick patients. Sometime in between he called me again and said" Dr, I have been thinking about your words and since I'm a person open mind ,I like to keep keep my ears open so can we have a midway?"

"midway ?what do you mean?" I asked. In India , we bargain about food, careers , clothing and speciality doctors.

"Can I see a general physician or my surgeon ? can they prescribe me medicines to calm my mind down ? The one I am taking is not helping. After you have spoken to me I've realized that my mind is not at a peaceful place so I would want some help with respect to the medication to come my mind down and then probably I'll come over this.

I don't think I'm disturbed enough to see a psychiatrist. 

"You know Il, I have my own medical protocols, I can treat my own self with my own medicines but I would first want to try following the traditional medical system then maybe later I can try my own medicine?"

I gave up! I was glad that I could at least create an insight in his mind to make him realize that it was his mind. I was also glad in this conversation that I was able to help him at least reach to a midway where he thought he needed help to calm his mind down. I referred him back to his treating doctor with a note that he needs to see a psychiatrist and that he is deferred the review. I hope it helps. 

the lack of insight , the traditional stigma towards seeing a psychiatrist or a psychotherapist , loss of rational thinking are major challenges I personally feel and dealing with patients of mental illness. 

how about you? you think anything could be done better? comment down below.

so far so much!