Personal view

A hollow victory

Three weeks ago I had reviewed this woman for a parasuicide attempt on the medical ward. At the time I had thought that there was probably not another patient who was as unlucky as she was. She had an extensive medical history with hypopituitarism and related hypothyroidism, hypoadrenalism, and diabetes insipidus. In addition, she suffered from epilepsy and osteoarthritis and was about to be investigated for gastro-enterological problems. She was a habitual overdoser and she had been on long term antidepressant treatment.

In view of all this I asked the casualty officer to ensure that there was no physical cause for her attendance and to check urea and electrolytes. This was met with an incredulous response from the casualty officer and the charge nurse. Subsequently the urea and electrolytes were normal and the patient was referred with the diagnosis of psychosis and a definitive statement by the casualty officer that she did not have a physical problem.

When I eventually saw the patient she did not recognise me. Her behaviour was erratic and disinhibited and there was a complete change in her personality. I attempted to do a physical examination. She complained of heaviness in the occipital region and there was indeed a palpable tender area. I wondered again whether there was really an organic cause for the change in her mental state and the differential diagnosis included an intracerebral cause or an overdose. From my previous experience I knew that before I embarked on any investigations I would need the support of the physicians or the neurologist on call. When I told the medical resident medical officer of my dilemma I was told that I had sufficient medical experience myself, which indeed I had, and that I should go ahead and order a computed tomogram or refer her to the neurosurgeons. I decided in the first instance to ask for an x ray of the skull and tend to my other patients while this was being done.

The patient's behaviour was generally causing problems in the accident and emergency department and the staff were aware that I was trying to exclude a physical cause. We were all working under pressure, but I was aware that suggestions were being made about my own sanity and wisdom in extending such intense physical screening to someone who was so obviously a nut case.

While waiting for the results of the x ray I decided to present my dilemma to the neurosurgeon. After initial surprise at receiving a referral from a psychiatrist he listened carefully and was so helpful that he came to review the patient. He thought that the patient was possibly hysterical and did not have a neurosurgical problem. I remained unconvinced, however, and wondered whether we should arrange a computed tomogram of the head. The skull x rays were normal and it was now left to me to decide what to do next. The staff in the accident and emergency department thought that she had a psychiatric problem, the neurosurgeons thought the same, and the medical resident medical officer suggested I used my experience.

I contacted the radiologist on call and again noted the surprised response on receiving a referral from a psychiatrist. I asked her not to hold this against me and that if she felt it was indicated to arrange a head scan. She asked me if I had asked for a medical or neurosurgical opinion and I told her that they had either been unhelpful or had disagreed with me. After listening to the history she agreed to do a scan as an emergency. When I gave the request card to the sister in the casualty department I was told that I was mad for organising it and that the patient was the same as she had always been.

All this took three hours to arrange while I attended to other patients with psychiatric problems and tried to liaise with other specialties. Then the result came; the patient had a subdural haematoma.

It was a hollow victory and caused much conflict. I was unsure whether to rejoice at my instincts or feel sad that there was yet another addition to the patient's multiple problems. Should I be grateful that I had persevered or angry that I had to face all the discrimination, resistance, and ignorance?

The case highlights several points. Firstly, there are the problems of liaising among the various specialties. This case was not unduly difficult and any complete examination should have attempted to exclude an organic cause. My suspicions were raised quickly and I tried to justify my request for other opinions, help, and investigations. This was met by the proverbial brick wall.

Secondly, in a time of increasing specialisation it is easy to forget that patients may have multiple problems, and in cases of doubt we may require several teams to assess and treat our patients. Specialisation can provide superior care for a specific problem but can sometimes also be a major handicap when we try to address unfamiliar problems.

Finally, I think that this case highlights the real discrimination that is faced by the patient and the staff of the Cinderella specialties. Patients with psychiatric problems do have organic problems and because of their disturbed mental state it may be more difficult to assess these.

The benefit of the doubt should surely be given to the patient and due courtesy to the psychiatric medical staff so that these patients receive the quality of care that is due to them.

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