Often, we are presented with patients who have a mental status that is frequently described as “altered.” Mental status can be altered for a myriad of reasons, but the point remains the same. They can’t help it.
Patients with mental disease, schizophrenia for example, have a chemical imbalance in their brain. Their brain does not work like it should. These patients will take medications in an effort to correct, or control theses imbalances, which can help them function better in society. Oftentimes, the schizophrenic patient will take their medications, and feel better, and mistakenly stop taking their medications, thinking they have been ‘cured,’ but the underlying problem of a chemical imbalance is still there. They can’t help it.
Patients with dementia, or Alzheimer’s have a different problem. These patients lose functional brain capacity, or their cognitive ability They actually lose brain matter. These patients are, for the most part, pleasantly confused in my experience. Medications can be administered to these patients that can slow the progression of the disease, but it can’t be reversed. Dementia will eventually progress to the point that the patient is essentially an infant again, requiring everything to be done for him or her. Sometimes, patients with dementia can be aggressive, or combative. Mostly because they are unaware of their surroundings, and unable to process events like you and I. They can’t help it.
Intoxicated patients can be under the influence of any sort of drug. Alcohol being the one most of us think about when we hear the word “intoxicated.” Alcohol impairs cognitive function in the brain, and lowers inhibitions, which probably has a large part to do with it’s popularity on college campuses. While the amount of alcohol consumed may be largely the responsibility of the patient, the patient, at some point, is not in control of themselves. They can’t help it.
Patients who present with hypoglycemia, whether diabetic or not, may at times appear intoxicated. We have easy diagnostic tools to detect hypoglycemia though. Hypoglycemic patients have a low serum blood sugar, which is the ‘fuel’ needed by the brain to function correctly. If the brain doesn’t get enough fuel, it stops working correctly. These patients can present with all sorts of mental status changes, from the incredibly physically strong, to the classic ‘white out’ symptoms, and everything in between. We can fix this problem relatively easy. We start an IV and give some dextrose, or squeeze some oral glucose between their gums and cheek if they have a gag reflex, or we stab them in a large muscle and inject some glucagon. I’ve never met a hypoglycemic patient that wasn’t apologetic for ‘getting that way.’ But it’s okay, I tell them. They can’t help it.
Addicts also have chemical, and maybe structural, changes in the brain. The urge to ‘get that fix’ may override the basic need for food, shelter, water, or any other necessity. Addicts will, and do, use any means necessary to procure their drug of choice. Rats have been known to choose heroin or cocaine over food, to the point of starving themselves to death. People have been known to get so high on drugs, that they kill themselves through exertion. Addicts are wired differently in their brain. They can’t help it.
When we are called to these patients, for whatever reason, our duty to the patient does not change just because they have an altered mentation. Sometimes, we have to strongly coerce patients towards an ambulance, or transport to the hospital. Sometimes, we are forced to physically restrain patients to protect not only ourselves, but bystanders, and even the patients themselves. When we have to restrain a patient, for whatever reason, it’s important to remember why we are restraining, and to make sure we do it safely. After all, we can help it.
These patients don’t mean to fight. They would be horrified to see their behavior on video when their mental status was altered. We have to remember that they can’t help it.
Arguing with patients is pointless, especially when you aren’t arguing with someone who has all of their faculties. Yelling at a patient means you are losing control of a situation. Threatening a patient with an altered mental status means you have lost control of the situation, as well as your emotions. Someone else should probably take over at that point.
You can control yourself, and your actions. The patient can’t. They can’t help it.
The patient relies on you to help them.
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While controlling yourself and your actions on ANY call is a must, I disagree with your point on alcohol and drugs. They can help it by making the choice to NOT do it in the first place. If my patient put themselves in this position by choosing to drink that extra drink, or chose to get their next “high”, then its their fault for being in that position. Yes, while in the majority of cases the use of these substances are related to deeper issues, ranging from depression to a history of addiction and beyond, they had the chance at some point to be able to help themselves help it and chose not to. Once again, out of professionalism and pride for my job, we still treat them the same as anyone else and do our best to help them, but I have much less sympathy for them and choose to believe that at some point, they could help it.
1. When you invest in something, it will eventually pay off, or at least you hope that it will if you’re looking for positive things.
2. There are such things as heredity and the mystery of many disease processes whose causes and origins are not known that confound the first statement.
Apart from those confounding factors, we know, for instance, that if you are overweight for a long period of time, especially if the weight gain continues to bariatric levels, that it may lead to high blood pressure and diabetes and that in turn will lead to chronic kidney disease and eventually to failure, dialysis and death.
The American Heart Association has long said that cigarette smoking, hypertension, hypercholesteremia were the top three causes of heart disease, and the fourth following close behind is lack of exercise. So if a person ends up with heart disease and has not watched his diet, exercise, blood pressure and avoided smoking cigarettes, his investment has produced a payoff. Do we treat this person, are we professionals?
Yes, of course. I have a friend who ballooned to almost 400 lbs before having “the band” put in, after which he dropped in the next few months by over 100 lbs and looking to lose about 80 more. But he leveled off and then began to rise again and has stabilized in the area of 310-320. Why? You have to watch him eat and watch what he orders at a restaurant and you will see. He’s fortunate his overall health is not worse than it is.
If you invest in the consumption of alcohol and drugs (and cigarette smoking), eventually you will receive a payoff. It may well not be a good one. It’s sad, but it is the result of investment.
If a person is mentally ill, you can invest in your mental health by remaining medication compliant. If you don’t there will be a payoff. You can’t help the mental illness, you can control your compliance. I speak from personal experience of having serious mental illness in my close family. The comment of the person involved. “I guess I’m going to have to take my therapy and my medications seriously.” Since that time, quite a few years ago, there have been no serious problems. The investment produced the desired results.
I think I’ve made my point without extending this discussion further. There are some things that, as CCC has said, cannot be helped. You do not cause them, you do not contribute to them. There are other things that you don’t cause but don’t treat properly. The results are your fault. There are other things – certain lifestyle choices as they say – that are investments that produce results. Those can be helped and in many cases treated and reversed. Those are your fault.
We don’t treat people differently because of lifestyle choices, diseases, mental health issues, or alcoholism and drug abuse. Or because they’re illegal aliens or not. Or whatever.
Steve Jobs made a choice, and investment, in his health when he was diagnosed with cancer. He decided against the medically accepted and proven possibly curative solution and opted for a different kind of approach with no science behind it. His investment produced results. It wasn’t his fault that he got cancer but he deprived himself of the possibility of extending his life by his health care choices.