The text read: “Stat consult, ED. Risk management involved.”
“What could this be?” I thought. I was just finishing psychiatric consult rounds on a Friday afternoon, looking forward to heading home for the weekend. I called the resident who had initiated the consult.
“Dr. Kersun, this is an unusual situation.”
“Uh huh,” I replied.
“We have a patient down here who is hypercalcemic, secondary to multiple myeloma. He needs to be admitted for hydration, and he’s afraid to get into the elevator.”
“Can you help him walk up the steps?” I asked jokingly.
“Risk Management won’t allow that.”
“Can you give him some Ativan and then see if he’ll get on the elevator?” I inquired.
“We’re worried about giving him a benzo with his multiple myeloma.” He then articulated a nonsensical reason.
“Huh?” I thought. With his explanation, I became irritated and thought this sounded like a stupid consult. I went to the ED to see what was going on. A nurse directed me to the senior resident, who looked befuddled and embarrassed. I glanced at the patient over the medical resident’s shoulder and was bemused at the person who was causing this commotion. The patient was a frail, old man with a stooped posture, his right hand resting on the gurney. His shirt was plaid, his pants striped and stained with urine. His fly was open, and an old leather belt was keeping his pants from falling down. The resident began to present the case, but his words seemed disconnected from the patient. Feeling impatient, I interrupted the resident, “Let me talk to him.”
“Hello, my name is Dr. Kersun. I’m from psychiatry.”
“Psychiatry? I don’t care where you’re from,” he replied.
I smiled. He was going to be a challenge, the kind I enjoyed. “I understand you need to come into the hospital.”
“I don’t need to go anywhere,” he said. He then uttered something confabulatory that caused me to wonder if he was psychotic or cognitively impaired. A brief Mini Mental Status Exam disclosed that he was neither.
I continued, “When was the last time you got on an elevator?”
“1954,” he said boastfully.
“That was a long time ago,” I replied.
“It sure was,” he said.
The residents and students were off in another corner of the room, running their list, discussing what needed to be done for their other patients. They were getting things done, checking off their to-do boxes. “We have a little situation here,” I said to the patient. “You need to come into the hospital to get some fluids. Your room is on the fourth floor. How are we going to get you up there?”
“I don’t know,” he replied.
“Would you be willing to take medicine to help you feel calm, then try to get on the elevator?”
He agreed. He then motioned to me to come close. I leaned in, and he put his hand up between the two of us to whisper something in my ear. What he said didn’t make any sense to me but was clearly intended to be a joke, just for us. I laughed, sincerely laughed. We were now friends. In the span of several minutes, we had connected.
“Give him Xanax 0.5 mg, then wait 20 to 30 minutes and see how he feels. If he’s more relaxed, try the elevator. If not, give him another dose. Okay?”
A nurse and a resident looked up from what they were doing and assented to the seemingly simple request. The tension, palpable in the room, dissipated.
So this “stupid consult” was success fully handled. Curiously, the Internal Medicine team was unable to manage this problem. Why? While the team had done a thorough job evaluating the patient, they did not connect with him. Rather, they became frustrated and irritated. They were having a collective emotional response that made it difficult to effectively communicate and care for the patient. These occurrences are extremely important; they are calls for reflection because they provide information about the doctor–patient relationship. I was able to interact successfully with the patient because I was not distracted by strong emotions. However, as I now reflect, the word stupid indicates I had a strong emotional response too. I was feeling intolerant toward the residents. I was frustrated and irritated with them because I wanted to go home and because they were unable to handle this simple problem. Strong feelings, regardless of their target, are calls for self-reflection. In this case, reflection on how a lonely older man from North Philadelphia who was afraid to get on an elevator could cause such intense emotions in so many doctors.
Jonathan Kersun, MD
J. Kersun is assistant professor, Department of Clinical Psychiatry and Behavioral Science, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; e-mail: email@example.com.