If it were not for drugs and alcohol, emergency room psychiatrists would be straight up out of a job. When I completed my psychiatry core rotation as a medical student, I was exposed to the most extraordinarily interesting, yet troubled patients. Two out of every three patients that arrived in the psych ER suffered from a wicked drug or alcohol problem.
I saw everything from Cocaine to Phencyclidine (PCP), Ecstasy, Heroin and Marijuana. The most ‘in-my-face’ patient were the speeders, of course. They were not your run of the mill drug abuser; they were the inconceivable addicts, those so distraught that they would jam a needle full of crystal methamphetamine into their veins without thinking twice of the repercussions.
My experiences as a medical student over 3 years ago in the some of the busiest hospital ER’s in the country, where the times in my training that began the process of defining me as a young physician. New York City had patients that seemed to have experienced it all. I was several weeks into my psychiatry rotation, and was on shift in the psych ER when I met my most memorable patient, John Doe, high on PCP.
John, a 40-year-old male for which his true name was never known, was brought to the psych ER at Metropolitan Hospital in New York City by police after he was found naked in a very busy intersection at 5th Avenue and Central Park, directing traffic.
“Another PCPer,” the lead officer said.
I was frightened as I watched as a crew of law enforcement officers held down my patient under the influence of the drug, and thought ‘Dear God help this troubled man’.
Nude, strapped to the stretcher and certainly requiring medications for combativeness, John wasn’t just another run of the mill addict that came through the ER doors on a daily basis, he was the most severe case of overdose that I had ever seen. He seized a few times and his heart raced fast, I knew it was only a matter of time before drugs would end John’s life.
PCP, also known as Angle Dust, wet, rocket fuel or embalming fluid, is a dissociative anesthetic that was developed in the 50’s as a surgical anesthetic, and later discontinued in the 60’s after patient’s often became agitated, delusional and completely irrational. Its sedative effects are trace-like, and at high enough doses can cause hallucinations, seizures, coma and death. Even the tiniest amount (less than a milligram) of the drug is enough to make even a gorilla go insane, and caring for a hallucinating, combative and potentially threatening patient is the side of medicine that no one ever really prepares you for.
John Doe, for which we never were able to discover the true identity of who he was or where he came from, eventually came down from the unpleasant psychological effect of the overdose after several hours. He was later admitted into a longer-term psychiatric institution for his underlying schizophrenia, bipolar disorder, and suicidal and homicidal tendencies, with hopes that a family member would soon turn-up. I feared for my life when I first met John, but I also feared for his.
My experiences as a medical student in the hospital ER of New York City brings me to the hospital ER of Philadelphia, now as a Resident.
On the outskirts of the heart of North Philly’s Badlands, I have been completing my ER rotation in a rough part of town, where crime and drugs rule the street.
This was particularly a busy week in the ED, with more patients in this one-week than I have had all month, the majority under the influence of PCP. It’s the first week of the month, and people just got paid. For one patient, today made for her third visit in 7 days.
I took 4 police officers to bring in Jane and restrain her arms and legs to the stretcher. My experience now is different that as a medical student, now I can make the decisions. When it was safe to approach, the anti-psychotic medication was administered. Within 10 minutes, Jane was fast asleep, only to wake up 4 hours later with no recollection of the serious harm she caused others and herself.
On top of marijuana and other pills, the costs of drugs pile up and several of the patient’s I’ve encountered actually admitted dealing crack to afford their addict lifestyle. This too was true for Jane.
With emergency room visits related to drug overdose at an all time record high, according to the federal government’s Drug Abuse Warning Network (DAWN), a doctors job is only going to become more difficult as a whole new category of hallucinogens and synthetic cannibinoids are being laced with PCP.
Having a patient come through the ER doors in an out-of-body experience is a scary and dangerous ordeal for everyone involved, and as the trend of combining substances continues to rise, doctors face incredible challenge. What my experience with these types of patients have shown me is that in order to protect myself from emotional strain, I’ve had to develop two lines of defense: toughness and humor. Still, I am working on the toughness.
People want to see doctors as machines, but the truth is, we are far from infalliable.
The names of patients and the encounter have been de-identified to protect the privacy/dignity of the patient.