Acute Haldol Deficiency

27 01 2013

My first shift in the emergency department took place over the weekend, and I was a little surprised by how the night went—it was not so different from TV.  Minus all of the staff sleeping with each other and being assaulted by the patients.

The biggest surprise was that all of my patients had legitimate concerns (crazy, right?).  The intern told me that this was not normal—in fact, he was complaining that there were so many ‘sick’ people that he hadn’t had the time to dictate proper notes on all of them.  According to him, the ratio of people who don’t need medical attention to those who do is around 3-4 to 1.

The E.D. is the gateway to hospital admission, and after the paramedics and other first-responders, they see people at their worst.  This weekend, so did I.  Two patients in particular spent almost my entire shift (10 hours) in their rooms sleeping off the massive amounts of booze they’d ingested, because social work would not speak with them until their alcohol levels were under 100.

The first, an 18-year-old with very strong borderline personality traits, drank half a handle of vodka beginning that morning, and tried to ‘kill herself.’  She came in stark naked and talking to a giant teddy bear that she’d brought with her.  While suicide attempts are never, ever funny, it’s usually easy to tell the bona fide attempts from the cries for attention.  This young lady had made almost 20 very superficial cuts in her forearm (not over her wrist) with a butter knife before her mother called the ambulance.  The attempt before that involved taking 3 pills (Seroquel, an antipsychotic) and texting a friend immediately afterwards.  While no perceived suicide attempt should ever be brushed off, it’s already become difficult for me to treat the type this girl carried out with the same urgency as the true attempts that come through the door.  The three I’ve seen professionally have had the clear intention of ending a life; one, a man who had gone a mile off the path in a national park and cut his jugular with a razor blade; the others, massive overdoses where the individuals had left notes and not informed anyone of what they had done.

The second was a woman in her early 30s with a habit of guzzling an entire case of beer each day.  She had taken double her usual dose of Trazodone and enough alcohol to bring her blood level into the mid-300s, and she was barely responsive enough to answer questions even with sternal rub (which hurts).  In an unexpected plot twist, her pregnancy test came back positive.  We tried to check whether the baby was still alive, but she wasn’t far enough along to see well on abdominal ultrasound.

Shortly after her arrival, another young-ish woman arrived screaming nonsensically, and it was later deduced from her history and behavior that she was having a manic psychotic break—also referred to by the E.D. staff as an Acute Haldol Deficiency.  She went to the special padded rooms with several security guards to await treatment, and after calming down a bit they allowed her to walk around in the halls.  It didn’t take very long for her to lose it again, and she began to fight the officers and sing at the top of her lungs:

“WE ALL GO MARCHING ONE BY ONE, BY ONE, BY ONE, WE ALL GO MARCHING ONE BY ONE, BY ONE, BY ONE, WE ALL FALL DOWN.”  Over and over and over again.  All of the patients and family members that were able started closing the glass doors to their rooms, then poked their heads around the curtains to see what was going on.  Unfortunately, the 18-year-old who’d cut her forearm did not want to move; as a result, her door stayed open and the other patient, still fighting the security guards, flung herself into the room, her torso splayed across the foot of the bed.

The 18-year-old lost it.  She started screaming and crying, curled up into the fetal position, and refused to speak to anyone for the next 3 hours.  The other woman was still sing-screaming (by now reined in by the security guards) and continued her repetitive song for the next 20 minutes, the sound barely muffled by the padded room.

Those patients, along with several others who were ill, but less exciting, were my intro into emergency medicine.  I will say this much: for the bad rap that emergency docs get from just about every other physician group in the medical community, they handle a lot, and I am enjoying my experience so far.





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