This is your brain on drugs

(A cautionary note: this post is not G-rated)

Friday night I was in the Psychiatric Emergency Room when I looked up at the patient list and saw that one of my former patients was waiting on the medicine side of the ER. The attending physician and I went to see him, and found him strapped to a stretcher in the hallway, talking to somebody who was not there. When he saw me coming, I heard him say incredulously with bug eyes, "Is that Ed Norton?". When I introduced myself, he told me I was in that Fight Club movie and addressed me as Ed Norton. Instead of answering our questions, he rambled non-sensically about "trying to kill the terrorists" and said he saw Satan. He would yell incoherently, then lower his voice and speak in very serious tones about the "international allegionary network". He was constantly moving. While we were trying to assess his mental status ("do you know where you are?", "do you have any thoughts of hurting yourself?", etc.), another man was lying on a stretcher restrained about 10 feet down the hall. He was actively lurching against his restraints, shaking the stretcher and yelling incoherently when when suddenly heard him shout, "somebody better put my dick in restraints!" I hid my laughter behind my clipboard, but our patient didn't care; he was talking to an unseen figure down the hall.

The problem with patients like these is you don't know if they are psychotic because of mental illness, because they are drunk and/or high, or both. Interviewing a patient, there's no way to tell. The truth is, in the setting of acute psychosis like this one, it doesn't really matter because you do the same thing. Ideally, erratic patients are put in restraints, sedated with medication, and have their urine sampled. In reality, they don't get sedated and thrash around in their restraints, left alone with their hallucinations. This is because the county has certified professionals who are authorized to involuntarily admit someone to the hospital, and if you treat the symptoms for which a patient would be committed (like homicidal behavior) then there's no basis for admission. In our patient's case, I brought him as much water as he would drink and eventually we got a urine sample, which was positive for numerous drugs. That'll do it. Does he also have schizophrenia? Quite possibly. After some antipsychotic medication, he was eventually dicharged to the street.