Posts Tagged ‘tangential associations’

Learning to say no, but still saying yes.

June 4, 2011

My maturity is starting to show

I tell you I’m learning but slow

     If the patient’s deranged

     Their mind can’t be changed

But I’m starting now to say no.


Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and just finished working a four-week assignment in Waikari, less than an hour from quake-stricken Christchurch, in New Zealand’s South Island. 

I worked this last month so the regular doctor could go back to the UK to get married; I wanted to leave an orderly desk so I arrived early.

The office staff booked me light for my last day.

In midmorning a patient came in for the first time since November requesting prescription refills.    When a person has press of speech, flight of ideas, over-detailing, and tangential associations, the differential diagnosis (the list of possible diseases) narrows down to mania, hyperthyroidism, and abuse of drugs like speed.  I told the patient my concerns, politely declined to renew his prescriptions, and sent him across the hall to get his blood drawn.

After lunch I stopped at the hospital on the way back to the clinic.  I signed off medications and drew blood.  The charge nurse told me there’d been a glitch in getting a patient transferred from Christchurch, and wouldn’t I be happy to do the admission?

I firmly and politely declined twice, but third and fourth time I said no I quit smiling.  So, she asked, should I phone them and tell them not to send the patient?

I wrestled with that one.  I could have succumbed to the guilt tripping.  But I didn’t.  I nodded.

Even though with the long holiday weekend, the Queen’s Birthday and all, she won’t get here till Tuesday?

I nodded again, and this time I smiled.

The afternoon went well.  I had breaks between patients.  The last person had eye irritation from a phlyctenule (she gave her permission to use this information).   I’ve written before about this rare eye disorder that comes from an infection in another part of the body.  I explained the problem, phoned the ophthalmology resident in Christchurch and wrote a prescription.

I had my computer shut off, my coat on and my hand on the doorknob when the receptionist stopped me with a message from the patient whose refills I’d declined.

I had a bad feeling about the call, but said yes.

His already rapid speech had accelerated; he made his anger clear, and held me responsible for his problems.  I walked across the corridor to the nurse and held the phone up so she could listen to him ramble.  After two minutes of non-stop diatribe, on her advice I said, “If you don’t let me speak I’ll terminate the call.”

Never argue with a crazy person, a drunk, or a woman in labor.  Pointing out logical inconsistencies to a person out of touch with reality does no good.  After interruptions and threats to ring off, I pointed out that he could talk to his regular doctor next week.

By the last minute of the conversation his mood had changed to friendly, he wished me well six or seven times.

I added unstable mood to the list of findings, but it didn’t help me make the diagnosis.