This is Part 2 of a 2 part series where Dr. Tetwiler shares his story from the bowel of the Psych ED. Here is the link to part one of the story .
An attending smiled at me as I entered the workroom. “Hey, there,” he said. “We've got a new patient I think you know. Why don't you go see her with the medical student?”
I smiled at the medical student, a short, soft-spoken fourth-year in her final months before graduation. She had been working in the psych ED for a few days, and we had bonded over talking about vacations at the end of medical school, her near future, and my recent past. I had never had a medical student under my supervision before. The tradition of medicine as a science and an art passed down through generations has always appealed to me, and I had always looked forward to helping train future doctors.
We pulled up the chart of the new patient. I was not entirely surprised to learn I had seen her only a few days before. She was developmentally disabled, a middle-aged woman with a long history of aggressive outbursts.
She weighed more than 250 pounds, and she spoke in single guttural words or short, halting sentences. Her first visit had occurred after her caregiver had had trouble waking her. She had responded to this rather poorly, running up and down her street threatening and throwing punches at everyone she encountered. By the time I saw her in the psych ED, she was more hungry than anything else, and I spent most of my time making sure she received food and calling her home to convince them to take her back.
Her triage note this time told almost the same story, except she had punched a car, leaving a large dent. Perfectly in line with the medical proverb of see one, do one, teach one, I turned to the medical student, and tried to channel every professor and medical attending who had guided me during my education.
“OK, we will examine the patient together. Since I saw her recently, I will ask a few questions, but let you do the majority of the history and physical. Take your time; we aren't in a rush. We can chat about developing a plan, go over the presentation, and then come back to present to the attending. Any questions?”
The medical student smiled, energetically nodded her head, and bounced up to grab her short white coat. I asked the nurse to let us into the patient's room, so he grabbed his ring of keys and led us to a locked room. He opened the heavy door and then headed back to the workroom. I looked at the medical student and gave my best supportive smile and stepped into the room.
The patient was standing in a corner, clearly still upset. I could see that her jaw was clenched, and she was breathing heavily. “Good morning. I was the doctor you spoke with a few days ago. How are you feeling?”
“Angry,” came the exhaled growl from beneath her furrowed brow.
As I stepped forward, I heard the heavy door slam behind me.
My heart sank. My breath left me. Everything slowed.
I turned to look, and the medical student smiled at me. With every ounce of patience I had, with no time to sandwich the constructive criticism, I whispered firmly, “We normally leave the door open when we see patients.”
Her eyes widened, and she realized what had happened. I was now behind a locked door in a small room with a padded bed, an angry and aggressive woman, and a small, soft-spoken medical student.
Moving as smoothly as I could, I slowly made several adjustments. I channeled my middle school basketball coach who taught me how to play defense: I locked eyes on the patient, assumed a slight crouch, and rotated my shoulders to keep my right arm toward the patient and my left toward the medical student. With my heart pounding, I took a slow step backwards, keeping them both in my view, and I kept talking.
“Can you tell me what was going on this morning?”
I took another step back. The patient shook her head angrily.
“Is this similar to what happened the other day?”
Another step, I was at the door. Without looking, I began knocking at the door with loud, slow, persistent thuds.
“I read that you may have run into a car. Are you OK?”
The patient took a quick step forward. I could feel the medical student stiffen as my heart leapt into my throat. Then the patient turned around with an exasperated huff, and I realized she was ignoring me. I turned to peer out the window of the locked door, hoping that help had come.
Outside was another patient, a sweet, elderly grandmother with a fixed delusion pulling on the other side of the locked door. She was trying to save us.
In any other moment, I would have been deeply touched that she had come to our rescue, but I looked at her and pointed frantically to the workroom. She went. I continued my loud, slow, persistent thuds. Over the next few moments, my mind raced. The danger of this environment had become real in a way that it never had before. I had made an assumption about a junior's knowledge, and I had placed a member of my team and myself in danger.
My thoughts on sedation, free will in the context of flawed, restrictive social institutions, and my ability to control a situation disappeared as I realized I was no longer in control. Something had been safe and easy, but everything had changed in a single second. I was afraid of being unable to control or reason with the patient, of being trapped without options, that someone might not come to help in time.
It wasn't lost on me that my feelings were similar to the fear my patient's mother must have felt. The fear that the family of the sweet grandmother felt. The fear that my patient must feel when she spiraled out of control or worried that she might spiral again.
I took a breath, and prepared to distract the patient. Then the door opened.
The medical student darted out, and I slinked out behind her. There stood the nurse with his ring of keys, the attending, and the sweet grandmother. I looked at my attending and felt my face turn redder than it already was. I was beyond thankful to have them there, lights in the darkness to ease my fears. I saw the attending's concerned look relax when he saw we were all right and the start of a slight grin as he looked me directly in the eye. “We normally leave the door open when we see the patients,” he said.
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Keep Scrolling down for Dr. Tetweiler’s Bio
Michael Tetwiler, MD
Michael Tetwiler grew up in a small town in Kansas. After completing his undergraduate studies in English Literature, he pursued his medical degree at the University of Kansas. During medical school, he was awarded a Fulbright Research grant that analyzed clean water initiatives in the Peruvian Amazon. His work in his medical school's free clinic led him to pursue an MPH in Health Management at the Harvard T. H. Chan School of Public Health. These experiences led him to a residency in Emergency Medicine at Harbor UCLA where his work focuses on helping underserved spanish speaking communities and initiatives for resident wellness.
