Sunday, February 20, 2011

The Invincible Ironman

Have you ever seen the patient who will not die? He who cannot be killed, despite every self-inflicted effort to do so? In the medicine ER, they may be called Gomers. Here is the story of the ultimate psych gomer, who I have christened Ironman.

Ironman has been coming to my hospital since my first year of residency. It started out as suicidal ideation. It progressed to overdosing on psych meds. He would get hospitalized on a med floor, transferred to psych, then sent to a nursing home/group home/state hospital. Rinse and repeat, multiple times. Then he started overdosing on a certain medication. A lot of it. I won't say the name, because I don't want to give anyone ideas. But they were real overdoses, with really high levels, that would have killed some people and given end-organ damage to lots more. He has done this multiple times, and the above sequence kept repeating itself again.

More recently, he started swallowing things. Non-food things. Batteries, pins, pens, paper clips. Even a tree branch. Again, any one of these could have been bad, but somehow he survives. The thing is, he IS NOT trying to kill himself! He really just wants to be institutionalized for the rest of his life. Lots of people have the same wish (believe that), but they usually lie to doctors and sometimes succeed. Ironman doesn't lie (at least about his "suicide" attempts), but despite his serious attempts, he continues to thrive.

What I have told you so far covers only his visits to my hospital. I know he has been to every other hospital in town several times. A few weeks ago, this text exchange happened.

ER Doc: You know a guy named Ironman? Says he was discharged from your hospital and overdosed on (that bad med discussed above).

Psych Doc: I'm surprised u never saw him before. Whatever he said, he prolly did it.

ER Doc: He looks pretty bad.

Then last week:

ER Doc: Ironman is back. Swallowed a tab off a coke can.

Unfortunately, I don't think my literary skills have relayed the scope of this guy's pathology. Oh, wait, here are some more examples.

1. He has ripped out IVs. Lots of them. Not because of agitation or delirium, but because he was mad at me for not admitting him to the psych unit.

2. Yes...we are getting burnt out on consulting this guy. Surgery consults all the time for swallowed foreign body, and my attendings won't even go assess for suicidality.

3. If he finds a new med student or doctor he's never met, he will claim that some psych med gives him priapism. I used to punish med students by having them check that one out for me. The best report I ever received from a med student was "half-mast, at best".

4. Once, he was particularly upset on our inpatient unit. He was trying to fight somebody, so he was placed in a seclusion room. He then started eating his own feces. I guess he thought it hurt us more than it hurt him. Cops were called in to help restrain him, and he grabbed onto an officer's apple bag so hard, he had to go home sick. Then Ironman was discharged to jail. At least I didn't have to see him for 3 months.

This is the story of the worst case of a personality disorder I have ever seen.

This is narcissism, borderline, antisocial, dependent rolled into one hot mess.

This is the man who will survive the apocalypse.

This is the legend of Ironman.

-Psych Doc


Anonymous said...

This is the legend of ironman.....greatness

SerenityNow said...

He really doesn't want to die. He loves being the patient. He is the easiest overdose to take care of b/c he is so compliant. He will drink whatever antidote you give him. Just says "ok." Then he will tell the nurse "er doc says i just have to drink this then i will get to go to the psych hospital again."

When I first saw him, he was literally discharged from psych docs hospital that day. As soon as he got to his new group home, he found a stash of meds and tried to kill himself, legitimately. he just calls 911 right after the attempt. truly is iron man

Anonymous said...

Eating your own feces just to piss off someone else takes some goddamn willpower. I'm impressed.

Anonymous said...

So why not admit him permanently and be done with it?

SerenityNow said...

Because, the government does not permanently institutionalize people like it did 50 years ago.

-psych doc

SerenityNowHospital said...

Admit him permanently where? And who's gonna pay. Yes ghat makes sense and seems the cheapest in the long run, but someone has to be willing to take him and the bill....

ER Doc

Anonymous said...

Does the community mental health center there not have a permanent housing /supported housing block grant? Why is he not in assisted living, at a minimum? Damn, I live in the sticks, and even here we can get these guys in a group home.

SerenityNow said...

Hes in group homes all the time He doesnt like group homes. That where he ODs. He likes hospitals/psych facilities

ER Doc

Anonymous said...

I once had a patient beg to not be discharged because he "couldn't make it out there". He was right, too. He was going to be sent to an adult home, and he already had brain damage and other injuries from being raised by schizophrenic parents.One day he pulled a tooth and put it in his penis so he had to stay longer. We did have longer term beds, but even with that he was going to be discharged. Next step? He stabbed an employee in the neck with a pen. He got what he wanted. He'll be spending a long time in a forensic psychiatric hospital. Community placement just doesn't work for some people.

SerenityNow said...

"Does the community mental health center there not have a permanent housing /supported housing block grant?"

Hahahahahaha. What state is that?

"Why is he not in assisted living, at a minimum? Damn, I live in the sticks, and even here we can get these guys in a group home."

Trust me, he's probably been kicked out of more group homes than even exist in your state. Nursing homes too.

-Psych Doc

ERP said...

"ER superuser" if ever there was one.

Crazed Nitwit said...

Wow. It's almost but not quite insane. Another story for the bizarro files.

Crazed Nitwit said...

Oh, I work in assisted living and we do not have the staff to monitor someone like this. I have enough residents with personality disorders, major psych issues (psychotic hyperchondrosis {yup made that dx up but it fits}, drug seekers, and non compliant CHFers to deal with. Many times it's me and a med tech/caregiver for 89 residents.

ERRN4U said...

Yes. It is sad and each year more and more funds for Mental Health are slashed. I live in Texas and our legislature is getting ready to make big cuts to MH programs that are already struggling and they are cutting to the bone, group home assistance, closing state schools etc. It's the same everywhere.

I often wonder if it wouldn't be cheaper to institutionalize folks that need it rather than have the merry-go-round approach.

No easy answers.

Holly said...

wow.....just wow.

Anonymous said...

I know a good veterinarian who can help you with this guy....

Mark p.s.2 said...

Who created Frankenstein's monster?
You want the mentally ill to be smart, then you F up their brain with poisons, so they can not be smart. There is no psychosis molecule for an anti-psychotic to effect.

Street Spirit: Your research also shows that there is a real increase in people who have a severe mental disorder. Now, this seems counterintuitive, but is it true that you believe much of this increase is caused by the overuse of some of the new generations of psychiatric drugs?

Robert Whitaker: Yes, exactly. I looked at the number of the so-called severely disabled mentally ill—people who aren’t working or who are somehow dysfunctional because of mental illness. So I wanted to chart through history the percentage of the population who are considered the disabled mentally ill.

Now, by 1903, we see that roughly 1 out of every 500 people in the United States is hospitalized for mental illness. By 1955, at the start of the modern era of psychiatric drugs, roughly one out of every 300 people was disabled by mental illness. Now, let’s go to 1987, the end of the first generation of antipsychotic drugs; and from 1987 forward we get the modern psychiatric drugs. From 1955 to 1987, during this first era of psychiatric drugs—the antipsychotic drugs Thorazine and Haldol and the tricyclic antidepressants (such as Elavil and Anafranil)—we saw the number of disabled mentally ill increase four-fold, to the point where roughly one out of every 75 persons are deemed disabled mentally ill.(1987)
One in every 50 Americans disabled by mental illness today. And it’s still increasing.(2005)

Jules said...

Mark, what the hell are you going on about? Looks like you forgot to take your meds.

SerenityNow said...

"There is no psychosis molecule for an anti-psychotic to effect."

True. But there is dopamine and serotonin.

There is no hypertension molecule for an anti-hypertensive to effect.

But there are Calcium channels, noradrenergic receptors, angiontensin-converting enzymes, and angiotensin receptors.

There is no diabetes molecule for an blood-sugar lowering medicine to effect.

But there is insulin, beta cells, DPP4 molecules, etc.

There may be a stupid molecule, and if ER Doc and I keep this blog going long enough, we're gonna find it and patent the shit out of it.

-Psych Doc

Mark p.s.2 said...

re "Mark, what the hell are you going on about?"
The rate of mental illness per person is increasing, not decreasing.
The religious belief in antipsychotics for psychosis is not working.
"Combined spending on antipsychotic drugs and antidepressants jumped from around $500 million in 1986 to nearly $20 billion in 2004. So we raise the question: Is the use of these drugs somehow actually fueling this increase in the number of the disabled mentally ill?" Robert Whitaker.

Psychiatry has made the problem of psychosis in its patients worse and can not admit to the error, not admitting it is making a second error.

Psychiatrists say that if you were REALLY crazy you wouldn’t know it.

Question for psychiatrists: Is psychiatry crazy?