Monday, October 5, 2009

Random Reflections from Grady Wards: The Karate Kid

*names, details changed but story written with permission of the patient.

"Wax on. Wax off."

-Mr. Miyagi in "The Karate Kid"
Sometimes there are patients admitted to the hospital who don't have a clear clinical picture. Is this belly pain because of appendicitis? Or is it just a nonsurgical bowel issue such as diverticulitis? By no fault of the patient, these instances can be pretty frustrating. Most of these clinical situations involve my service (Internal Medicine) and another service (i.e. Surgery, Psychiatry, etc.) And it's not just those times when there is a medical conundrum that makes things tricky. If someone comes in specifically for say, a broken leg, but they also have a side of HIV and uncontrolled diabetes, they generally don't get admitted to the Ortho service. They instead go to the ultimate destination for patients with multiple issues: Medicine.

The truth is that I'm okay with this to a certain degree. I'm happy to care for a lady with complicated medical issues while my surgical colleagues do their part, and I'm glad to manage a critically ill gentleman with active psychiatric issues. But sometimes the problem is purely nonmedical. Okay, maybe it starts out kind of questionable, but eventually time and lab tests allow us to remove all doubt. That's when it becomes pret-ty darn annoying. And this isn't unique to Grady Hospital at all. It happens everywhere. Medical doctors responsible for the primary care of hospitalized patients with nonmedical problems--a national epidemic. Somebody needs to call Michael Moore, for real.

*(Non-doctors: When I say "nonmedical," I am referring to issues that do not warrant the involvement of internists like me. . .issues that are, say surgical or psychiatric in origin. Get my drift?)

Okay. . . .so today I am reflecting on this twenty-something year old fellow admitted to my Grady inpatient team for "altered mental status." Someone in his neighborhood had called 911 after finding him "acting weird" outside of his Midtown apartment. When he was assessed in the emergency department, he vacillated between being completely nonverbal with staring and blinking to being full-on aggressive and combative.

No one was around to give a history or background on him, and the only thing found on his person was his driver's license. His urine drug screen was negative. His blood alcohol level, tylenol and salicylate (aspirin) levels were undetectable. He even had the extended toxicology screen looking for all sorts of cool things that only come up on that TV show "House"-- and that was negative, too. A CT of his head showed no signs of trauma, and even a lumbar puncture yielded no clues of a cause related to his spinal fluid. No open pill bottles anywhere or evidence of self-mutilation. Just a blinking, staring, catatonic Latino gentleman. . . .with a negative workup.

ER admitting diagnosis: Young guy with no past medical history and negative tox screen who is acting real odd. Maybe schizophrenia?
ER ad
mitting plan: You can't go home, but you got to get the heck up outta this emergency department. (Translation: Admit to Medicine)

This is where I got involved. We were asked to "exclude medical causes" of his altered mentation. Like I said, I am all for assisting with the care of a patient. I am happy to explore and data mine for any potential medical etiology, too--especially when it is a real possibility. For the next 72 hours, we did just that. We examined him from head to toe. We asked him questions (most of which he never answered.) We asked each other questions and stood around pontificating about what this could be. We called the social worker to search for clues about him from his environment, but no real leads. Just the same blinking and staring, occasionally interrupted by thrashing limbs against wrist restraints and angry protests in what sounded like Spanish.

The nurses kept asking me why was he on the medical floor, and I had no answers for them. My service was busy--with over twenty patients at the time--and I was tired. Too tired to keep wrestling over a question that did not seem to be mine to ask. From the very start, it looked like a call for the "mind police"--and I really hoped Psychiatry could provide us with the insight (and care) we needed to better serve this patient.

Enter the Psychiatry Consult Team

"This looks like some kind of catatonic state. It could certainly be a catatonic form of schizophrenia," said the Psych attending physician with gentle authority. His soft voice was as soothing as a lullaby. "He says a few words in Spanish, but according to my resident who is fluent, it makes no sense." (The bilingual resident stood beside him firmly nodding her confirmation of this detail.) Dr. Smoothvoice rubbed is chin and added," You know. . .This could also be severe depression with psychotic features, but it just isn't clear. Catatonia is seen frequently with mood disorders, so that has to be considered. It's all very interesting. We'll continue to follow him with you."

Interesting? FOLLOW him with me? Dude! This patient has not said more than 10 words to us in three days! Uggghh.

"I appreciate your insight," I replied carefully to hide what I was really thinking. I contemplated my next words for a moment before speaking. "So. . . .since catatonic schizophrenia is not really my expertise. . .did y'all consider assuming care of this gentleman on the Psychiatry service? I mean, since the differential diagnosis seems to be mostly psychiatric causes?"

Come on, buddy. Tell me something good. See how collegial and professional I am being here? (Insert rosy, pleasant smile here.)

"Well, I'm not sure that we've completely excluded all medical causes," he answered quicker than I would have liked. Officially killing me. Softly with his soft voice.

The all-star Spanish speaking resident chimed in. "We also have no male beds on psych right now, so we couldn't transfer him even if we wanted to. Please call us with any questions, okay?"
Arrrrggghhh!! Booo! Hisssss!

"I certainly will." I deliberately grinned to keep from scowling as I watched the psychiatry team head down the corridor and off the ward. I was two seconds away from raising up my arms and one leg in full "Karate Kid" stance to emphasize my feelings. Then I glanced over my shoulder, and remembered the two medical students that I'd taken on rounds with me that morning. (I figured I'd save my "Karate Kid" warrior pose for a more private setting.) They stood there quietly, as if waiting for me to say something deep. I had nothing.

Finally, I shrugged and said matter-of-factly, "Oh well. Let's go and see how he's doing today. You never know, we might have an epiphany while we are in there."

In we walked, frustrated me with two bright-eyed, bushy-tailed third year medical students in tow. We had already pored through his chart one more time, hoping to find the missing piece. Now, I just stood there scanning the patient, the room for anything that might provide a clue.

"I was reading about schizophrenia, and doesn't it usually present when patients are in their twenties?" one student asked earnestly.

"Yes, you are absolutely right. But twenty seven would be a little on the later side for a first time presentation," I answered while continuing to study the patient.

"Maybe this is a recurrence in someone who already has schizophrenia," suggested the other student.

"Good thinking. . . . definitely a possibility. . . . .hmmmm," I spoke while pulling back the sheet and inspecting my patient's toes. I shifted my attention back to his face and then back to his feet. "Hmm."

I grabbed the patient's hand and said to the students,"Look at his hands and feet. He is meticulously groomed. Perfectly manicured and pedicured. And look at his face--especially his eyebrows. My goodness, I have never seen brows so perfectly shaped." Turning my head sideways and squinting, I let out an audible sigh while still holding his restrained hand. "Sir, whatever is going on with you. . . .you were okay as as recently as a few days ago. Those brows are no more than three days old. Just a few days ago, you were well enough to sit in a salon somewhere. Unless you know something I don't."

The students shifted glances toward one another, not sure if I was joking or serious.
"I'm serious," I replied firmly, "Look at him. This is not a disheveled guy who hasn't been taking care of himself. This kind of grooming takes time and energy."

The other funny thing I noticed is how the patient looked at me as I spoke. He in no way gave me the puzzled stare of a person who is unfamiliar with the English language. It almost seemed like he fully understood me, and as if part of his nonverbal state was voluntary. I wondered how a non-English speaking, schizophrenic guy could manage to know exactly the best place for an impeccable mani-pedi and pristine eyebrow arching. It just didn't add up.

After a thorough exam (again), I was out of ideas.

"Sir, we are working closely with the Psychiatry doctors to help you feel better. They recommended some medications for you which we started on yesterday, and will see if it helps you. I will return with our Spanish interpreter to tell you this." I make a point of always talking to people as if they understand me, whether they are comatose, demented, or even catatonic. I guess a part of me never knows what the person is getting.

Before we left the room, I playfully leaned over the patient and added, "Mr. Jimenez. . .the minute you start talking to me--do you know the first thing I am going to ask you? Who does your brows, and are they waxed, plucked or threaded!"

Without any warning, he rolled his eyes, batted his lashes, and snapped his finger on the restrained right hand for "yes, girlfriend!" emphasis, and then--I KID YOU NOT--he stated in the most born-and-raised-in-the-United-States-and-not-even-nonEnglish-speaking voice,

"Oh, sweetheart, I only thread!"

I jumped back and nearly fell over the edge of the chair sitting at the bedside. It was like one of those moments on "America's Funniest Home Videos" when someone pretends to be sleeping on the couch and then leaps up, scaring the poor passerby to death. Funny and predictable on TV, but this time, not so much. I widened my eyes and shook my head in disbelief. He added a neck roll and glared into my incredulous eyes.

Now that I thought of it, he kind of favored Ralph Macchio from "The Karate Kid."
The students looked at me and then at each other. No one could believe what they had just heard. Wait, did he really just say what I think he said? I had to make sure I wasn't crazy.

"Where do you get your brows threaded?" (I really did want to know.)

"A girl can't tell all her secrets," he replied with a devilish grin. His voice was decidedly feminine and delicate.

I shook my head and laughed out loud nervously. "I can't believe you are talking to me, Mr. Jimenez. I can't believe it! Why haven't you said anything until now?"

He chuckled, curled his lips and answered,"No one asked me anything I felt like answering 'til now." Awesome.

And so, from then on, the seal was broken. He told me of his devastating breakup with a long term boyfriend the week prior to his admission. "He wasn't 'out' yet," he explained to me about his former love. "I helped him get the courage to be his true self, and do you know he came out and then got him somebody else? It was awful, Dr. Mannings. And someone I knew, that asshole!"

I still couldn't get over the fact that he a.) was talking, b.) in English, and c.) without as much as hint of a Latin accent. It had to be, hands down, one of my greatest Grady moments of all time. I listened to the rest of his story, and learned that my Psychiatry colleague was indeed correct. This seemed to be a case of severe depression with catatonia. And the medication appeared to be helping.

It took a while to convince my Psychiatry colleagues that he was actually talking to us in perfect English, but once I did, they immediately returned and were quite helpful with the rest of his management. He walked out of the hospital behaving in a completely appropriate manner, and promised to come see me as an overbook in the clinic one week later.

I was delighted to hear that he was at the front desk asking for me that following Monday in the Green Pod clinic. He was taking his antidepressants and had already been set up with a psychiatry appointment. The jovial, confident gentleman that sat across from me was light years away from the odd, blinking, staring mystery man I'd seen just 7 days before. Amazing.

We chatted about how things were going, and how much better he was feeling. "Dr. Mannings," he said with a bright smile (his pronunciation of the "Dr. Mannings" was the only time I detected his South American roots), "I have something for you." His words were warm and genuine. "Thank you for taking so much time with me. And for talking to me like a real person. This is for you. . . .It's not much, but I know you will appreciate it."

A wave of uneasiness came over me. I always feel a little funny when a patient gives me some kind of gift. I hate the thought of a person spending limited money to show appreciation. He reached into his pocket and handed a card to me. He saw the puzzled look on my face and clarified with a wink,"This is where I get my brows threaded, girl!" We both threw our heads back and laughed. I was glad to see him feeling better. Oh, and yes girl, he was still groomed to a 't' and you better believe those brows were fierce.

The actual card given to me by Mr. Jimenez. (still in my wallet!)

So, the honest to goodness truth: I go to that very shop to the very person he suggested (who is AMAZING, by the way) to have my eyebrows shaped-- to this very day. Don't believe me? Look below (just saw her last Wednesday.) Of course, back then when she asked me who referred me, I just told her, "It's a looooong story."

The moral of the story: Paying attention to the little things really pays off. You get the right diagnosis, and if you're lucky, you get the right person to do your brows, which if you ask me is win-win. Thanks to my patient Mr. J., I no longer wax my brows. From now on, "sweetheart, I only thread!"

Someone getting their eyebrows "threaded"

Me and my brows thanks to my patient, Mr. Jimenez, and my amazing threader at Hair Images!
Wax off, baby!


  1. You always were a very entertaining and excellent writer. I'm sooooo proud of you! I got in touch with your sisters on FB. Hope you remember me Laura (Jimenez) Salinas.

  2. Absolutely CLASSIC!!! I love this one!

  3. I always went to Hair Images when I lived in Atlanta. They have a cult you probably are aware from the long lines on most days of the week!


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