Sunday, February 14, 2016
A Real Case Of Psychosis And What Can Happen
Public radio continues to be a rich source of information when it comes to real life psychiatric problems. In this case the NY Times was also involved. Considering the date the story was filed the usual critics have not chimed in yet. They may not be able to since no psychiatrist or psychiatric medication was involved in the care of this patient - and it shows. There is no more compelling story that psychiatric disorders exist, are severe, and for various reasons can end catastrophically. I won't belabor the point that I have treated hundreds of people with very similar problems. For 22 years, I treated people with severe psychiatric disorders and most of them had psychotic disorders. The episode of psychosis described in this story is the kind of psychosis that psychiatrists treat, not the vague symptoms described in a recent paper that suggested that some symptoms of psychosis are a normal experience.
Before I get into a brief discussion of the scenario, I would like to acknowledge the patient Alan Pean for sharing his story. I heard his story on This American Life and the host Ira Glass was explicit that Mr. Pean had signed a release of information so that the hospital records and a 50 page report of the incident could be used to construct what had happened. His family members were also available for the interview. In this age where health care companies view patient information as proprietary corporate information I applaud Mr. Pean's decision to make this very personal private information public. There are numerous lessons to be learned from this incident that I hope to make explicit at the end of this post.
For anyone interested in listening to the audio version of this story go to the This American Life web site and look up episode 579 My Damn Mind. This amazing story begins after Mr. Pean has been shot in the chest and is bleeding to death on the floor of his hospital room. There is blood everywhere on the floor and people entering the room have to put on shoe covers. Later in the story we learn that he lost about 1/3 of his total blood volume. A trauma surgeon is demanding that the police take the handcuffs of Mr. Pean because even though he is shot and immobile, he is handcuffed lying on the floor. According to the Centers For Medicaid and Medicare (CMS) report he was trying to get up after he was shot and saying that he was "Superman". From there, Ira Glass starts to interview Mr. Pean about the 20 hours prior to this incident. He describes being anxious and at times panicky. He was sleeping 4 hours per night and recognized he was manic from his past experiences in 2008 and 2009. He was diagnosed with possible bipolar disorder treated with medication and had no further episodes in 6 years. He was trying to unwind by playing a video game online with his friends. He started to think that the video game controller had been reprogrammed by the enemy and was switching on a processor inside of him. He could not logon to the game because he knew that drones would triangulate on him if he did and destroy his apartment. He called his brother for advice. His brother told him to lay down and put cold water on his face. He concluded that his circuits were overheating like a robot and his brother knew this. At one point he knew he had to escape from his third floor apartment balcony because snipers were closing in on him. As he looked down he thought remember your training - you are trained for this. At that point Ira Glass jokes with him about that point and they both laugh. He of course had no training and it was apparent to me that Glass had not talked with many delusional people. Pean executes a perfect drop to the second floor balcony and grabs the railing. From there he notices two air conditioning units on the ground swings past then and jumps. He hits the ground running for his car because he has called in a drone strike in his apartment building using Google Maps. He jumps in his car and heads out of the parking lot. When the gate doesn't open he rams it until it opens. At this point he is thinking that his rendezvous point is the hospital. In a moment of clarity he also realizes that he needs Geodon, the medication that he takes for psychosis. He feels like he is a bionic person or a cyborg driving the car at a high rate of speed toward the hospital. As he approaches, he loses control and hits several autos and the hospital building totaling out his car. An EMT sees the crash. puts him on a gurney and wheels him into the Emergency Department.
This entire sequence of events was driven by delusions. In the narrative Pean described an intense fear for his life and the fact that his "adrenaline was pumping" at times. That combination of emotion, especially high anxiety and delusional thinking can lead to impulsive behavior and a lack of typically rational decision-making. It is an example of "dangerousness" or the emergency criteria that governs whether a patient with psychiatric problems is offered inpatient treatment or not. The problem is that Pean's actions are all internally consistent with his delusional state. He talks with his brother on the phone and does not mention that he thinks he is delusional. In this state of mind, it is very likely that anyone assessing him for "dangerousness" would seriously underestimate what he was capable of. A lot of his acts are also environmentally determined. His delusional biases interpret the information as he sees it. When he was speeding toward the hospital, he was convinced that some of the buildings he was passing were going to explode at any minute. Despite the non-psychiatric interview, I think the emotion driving the delusionally based decisions is apparent. Ira Glass points out that the narrative though irrational is internally consistent like a movie and not what he expected.
Pean is eventually admitted to the trauma surgery service for further observation of injuries from the car crash. There was ample information that he had a significant psychiatric disorder including direct statements from his father who is a physician. He is noted to be disoriented and believes that it is 1989. His speech at time is incoherent, but the staff observe him to be lucid at times. Immediately prior to the incident, several staff report the patient coming out of his room into the hallway either nude or partially clothed. He had to be redirected back into his room and asked to put a gown back on. He was dancing and in some cases danced away from staff trying to help him into the gown. With his history (and assuming that brain trauma has been ruled out) these can all be features of a severe psychosis. His parents are concerned that they plan to discharge him without psychiatric consultation. The hospital they are in does not have an acute inpatient psychiatric unit and he has not seen a psychiatric consultant. They leave at some point to rent a car so that they can drive him to psychiatric facility if necessary. While they are gone he becomes extremely agitated. He is tasered several times and ultimately shot in the chest just 40 minutes later.
The New York Times article goes into detail about the issue of armed security in hospitals. It reviews the number of people with mental illness who were shot or tasered and killed. I have pointed out some of the problems with firearms in psychiatric hospitals in an article about visitors carrying firearms into Texas state psychiatric hospitals. The same issues apply in this case. Firearms are not a deterrent when confronting a person who is agitated and psychotic. In this case the patient recalls that he was some kind of cyborg secret agent. In that frame of mind he is likely to interpret any efforts to contain his agitation and aggression as potentially dangerous to him and it would provoke extreme behaviors to counter that aggression. In every security setting where I have worked, security and law enforcement lock up their weapons and do not take them into patient care areas even if a patient is highly aggressive and out of control. It takes well trained staff and security to be able to do this and recognize why this is the best approach. It also involves a contingency plan to physically restrain the patient in a safe manner as quickly as possible if the patient does not respond to verbal deescalation.
The CMS document discloses several important pieces of information that are not in the media. The first eye opener is that the hospital administration said the security officer was justified in shooting the patient because he had assaulted them. That statement grates on any inpatient psychiatrist or nurse who recognizes that is not the appropriate frame of reference for this incident. This is not a street fight. This is a vulnerable patient in a hospital whose rights and standard of care needs to be recognized. One of the implicit assumptions in most hospitals is that psychiatrists and psychiatric staff are supposed to view aggression as an occupational hazard. A unidentified staff member speaks to that in the radio piece and is very explicit about the amount of aggressive behavior that he sees in the hospital and the fact that he gets hit. That is not the case in other parts of the hospital where aggressive behavior is more frequently seen as criminal behavior. Early statements from the hospital administration suggested that the law enforcement officers here were justified in shooting Alan Pean, but they were subsequently modifying their position. He was also charged with 2 counts of aggravated assault on both of the law enforcement officers who entered his room. Clearly this is a psychiatric problem and the patient needs protection. As I read through the 50 page document from CMS, the suggested solution varied from being vague to solutions that many hospitals already have such and an emergency response team for behavioral emergencies. They suggest that armed law enforcement officers should be only in the ED, not be involved in the behavioral emergencies until all other resources have been exhausted and intervene only in the case of life-threatening or criminal activity.
One of the primary conclusions of the This American Life piece is that is could have been prevented if the patient had received a psychiatric evaluation. A hospital staff person pointed out that this was standard procedure and also that any number of staff used to encountering aggressive patients could have contained the patient without firearms. There is apparently an inpatient psychiatric unit at this medical center where he could have been transferred. Alan Pean responds to Ira Glass's question about how it is that he went to the hospital with mania and psychosis and ended up getting shot in the hospital instead. One of his conclusions is that he is a young black man and he does not think that it would happen if he was white. He remains understandably traumatized by his near death experience.
The only logical conclusion here is one that I have already reached many times in many posts on this blog. Violence and aggression are treatable problems when they are associated with psychiatric illnesses. There needs to be psychiatric and psychiatric nursing expertise in major hospitals at several levels. One of the unusual parts of this story was all of the information available suggesting that the patient in this case had a significant mental illness. That was made even clearer when his physician father made the statement, requested the psychiatric evaluation, and was told that the patient was being discharged instead. The CMS report does not address staffing levels in the hospital and whether there are adequate staff to address the problem. In my experience, a nurse and another staff person going to address a situation where there is potential aggression by a young manic patient is not enough staff. I have personally found myself in many situations when I walked in a room and there were four highly trained nursing assistants out in the hallway, ready to intervene if necessary. In every case our goal was to protect the patient from injury.
The lesson in this case is that if you go to a hospital with aggressive behavior due to a psychiatric disorder somebody on the receiving end needs to know what to do to keep you safe. Only a fraction of American hospitals are set up to do this and provide the necessary psychiatric care to resolve the crisis. Some hospitals will never be equipped to deal with this problem and the practical solution in most communities is to triage violent and aggressive people to more appropriate facilities. Even though the New York Times article points out that there has been a 40% increase in hospital violence, many of the people with that problem never make it there. There needs to be enough capacity to treat people so that people with violent and aggressive behavior from a psychiatric illness can go to a hospital knowing that their problem will be diagnosed and treated and that their safety will be assured.
Nobody should ever have to experience what Alan Pean went through.
George Dawson, MD, DLFAPA
1: This American Life. 579: My Damn Mind. February 12, 2016.
2: Elisabeth Rosenthal. When The Hospital Fired The bullet. New York Times February 12, 2016.
3: Department of Health and Human Services Centers for Medicare and Medicaid Services. Statement of Deficiencies and Plan of Correction. St. Joseph Medical Center; 1401 St. Joseph Parkway, Houston Texas 77002.
In the report by This American Life, it was apparent that at least some authorities were looking for evidence that the patient had aggressive tendencies outside of the episodes of mania and psychosis. They did this by asking his family if he had any criminal convictions. In the original hospitalization he was also noted to have THC in his toxicology. The fact that there were no other drugs present and that THC can persist a long time was emphasized in the This American Life piece. In fact, THC is not a trivial compound in this case. No conclusions can be made based on the existing data and the lack of direct assessment of this patient, but this compound should be avoided by anyone diagnosed with bipolar disorder, especially if there is any doubt about the diagnosis.