Back in early February, I composed a little blog post that never saw the light of day. I'd dragged myself into the Urgent Care one morning after spending five straight days with a fever above 101. Satan had taken up residence in my entire respiratory tract (ever had bronchitis and
a sinus infection?), and my immune system needed help. So I went. And sat. For a long time. (For the record, my PCP, while generally pretty good, is closed Fri-Sun. This was Saturday.)
The post I wrote in my head was called The System Hates You
Yes, I have insurance and was able to get the medications I needed and really only sacrificed half a day being miserable on a hard plastic chair. I know that things could always be worse. But that is hardly a reason to pretend we ain't got problems.
The system really does hate you. And me. And doctors who give a damn. And any other skilled health practitioner who doesn't fit its mold. And a system that hates you will fail you when you need it most.
's current story deals with the rise of bipolar diagnoses in children and the concomitant surge in the use of powerful antipsychotics to treat these kids. [Check KNME
's schedule for repeat broadcasts, or watch online here
.] There's a lot here to talk about, like the fact that children are being diagnosed and treated using guidelines and drugs that were never intended or haven't been tested for use in children. Like the fact that the dramatic increase in childhood psych and behavior problems has directly accompanied a similar surge in the astonishingly unhealthy things kids are exposed to (poisons in food and the environment, nutrition-depleted soil and foodstuffs, violence and overstimulation in television and video games, and so on) but no one is acknowledging the link
. Lots of stuff; lots of ways the system isn't working for kids and their families. But here's where it's intersected with my life, right now:
Last week I ran on a patient who the system failed, when she most needed it to work for her. Bipolar and in the middle of a severe manic episode, she was suicidal and a danger to herself and others. Now, I've got plenty of baggage of my own when it comes to mental health. The patients aren't a population I enjoy dealing with, largely because I don't believe that true, caused-by-chemical-or-structural-brain-defects, psychiatric disorders exist anywhere near as much as they're diagnosed. I've seen too many people whose situation would be better served with therapy or diet changes or more exercise or a combination of all of these. I've seen too many people who really do just need to get over themselves, but prefer to cling to the victim status their bogus diagnosis affords them. And I know a lot of folks disagree with me on this, and that's fine. Just airing my particular biases. But in this case, this woman on this day needed help. Whether her problem was "real" or not was immaterial. She was in crisis mode and would almost certainly hurt, or even kill, herself or someone else.
So I talked to her. It took an enormous amount of energy and time and patience. I could have simply physically restrained her and hauled her off to the hospital, screaming and spitting at me. This would have been perfectly defensible, both legally and medically. Ethically, even--but I wanted a better way for this patient on this day. And so we talked. She screamed and she cried and she sobbed. She was terrified, livid, desolate, apathetic. A half an hour of talking got her into my ambulance, and more talking on the way there kept her on the gurney. No restraints, no drugs, no fighting, no further trauma for her.
And then the system failed her. I learned later she'd been restrained for hours in the ER. Tied down, medicated, left alone in an exam room while her husband of fourteen years sat in the waiting room. I saw her again that same night, when the psychiatric facility where she'd been transferred called for an ambulance. She'd improvised a weapon from part of her bed and cut herself on both wrists and on her neck. I was thankful for having met her on the first call, because without that history the second wouldn't have gone well. Confronted with a violently agitated, blood-covered stranger, I would have restrained her, no question. Instead, we talked some more. For a long time. And she sat on my gurney voluntarily. Back in the ER, I saw the exasperated look of recognition, the oh no not her again
look in the nurses' eyes, and I knew she'd be back in restraints soon enough.
You could say that the system did its job well enough that night--after all, that patient didn't manage to end her life. We "saved" her, you could say. But I wouldn't.
The system hates you because the system needs you to be just like everyone else, and you're not. How could you be? But for maximum efficiency (read: maximum profit), you need to fit into a round hole, regardless of what shape your particular peg might be. I'm by no means an expert, and I know rules is rules, but I really believe things would have gone much differently if my patient had been a person to the system and not a peg. Talk to her
, I told the staff. Let her husband be with her.
But the overworked staff of a modern-day ER doesn't have time for talk, and the rules say no family with "that kind" of patient, because sometimes they cause problems and we don't have the resources to sort out whether this might be one of those times or not.
The system needs you and I and my patient and ill-behaved children to fit its holes, not the other way 'round. The system needs us to accept a
diagnosis, fill a prescription, and stop having symptoms (or accept another pill to treat those symptoms if you don't). The system cannot tolerate those who defy
diagnosis, those whose symptoms don't respond to the standard, cookie-cutter treatment, those who want to explore other options before popping pills. The system hates the square pegs, and the system will fail them, like it did my patient, and like I believe it's doing for millions of kids right now.
And I don't know what the solution is. Most people can't afford to get out of the system, to pay out of pocket to join a physician's practice
or to get regular acupunture or visit a naturopath. And teasing out the good doctors that are still in the system is damn near impossible. Like a lot of other factors of modern life--our food system, our car-centric cities, our bloated-beyond-reason government--it seems that the only way to fix this mess is for it to come crashing down around our ears. Raze it to the ground and start fresh. But what to do in the meantime for my patient, for the sick kids, for folks who barely even have access to the most basic of care
, for all of us? We've got to start figuring this out now, before the collapse, which is surely coming.