It was my receptionist, who alerted me to the fact that James was in my waiting room. She called me on the intercom and explained that she thought he was a drug seeking patient. Walking out to greet him, I was taken by his agitated appearance. Quietly, I whispered that I was not prepared to prescribe tranquillisers or opioids under any circumstances. He acknowledged my message and walked into my consulting room. Across my desk, I noticed that his pupils were pinned consistent with recent opioid use. As his story unfolded I discovered that he had been referred to me by someone in the street who knew me and that he had spent a total of 19 years of his 45 year life in jail. He acknowledged he was now dependent on heroin again and that his life was spiralling out of control. I was alarmed when he said that he had been communicating with his long dead sister, but that now he felt she was slipping away and he could no longer talk to her. The impetus to see somebody had come when he tried to introduce his friend to his dead sister. She was so taken aback by this that she had advised him to seek medical help. When I asked James if he had received any mental health treatment in the past, especially in jail, he said no that he was too embarrassed to talk about it with anybody.
It transpired that James sister had died in a motor vehicle accident when James was 11 and his sister was 7. The car had been driven by their alcohol dependent father. James acknowledged that he was not sleeping and had suicidal ideas but no active plan.
Reaching for a sample of an antipsychotic medication, I explained to James that I thought he needed to be assessed by a crisis team but in the meantime the medication would help him sleep. I then phoned the local acute care team and then my day proceeded to deteriorate. First, I was told, that no one was available to speak to me and my name would be placed on board. Somebody would call me back in the afternoon. When I explained that James lived a few kilometres away in a different area I was told I would have to phone another acute care team, as he was out of area. My irritation was evident to the triage nurse on the phone when I explained that the patient was in front of me and a call later in the afternoon was not a satisfactory response. She commiserated but said that all of the mental health team personnel were at a meeting and nobody could speak to me now. Armed with a number of adjacent team I rang them immediately and discovered that again my patient was not in their catchment area. Another number was provided and I rang that one. By now James was pacing up and down in my office. Again, the team was unavailable but a nurse would call me back.
Forty five minutes had gone by and I was no closer to a resolution of James's acute problem. Finally the call came in the nurse asked me if I thought James was suicidal. Yes I said he had had suicidal ideation. Then she asked if he had an active plan with intent. No, I responded. " Are there are drug and alcohol issues associated with this patient?"
“Yes, he uses heroin. Perhaps you'd be better off calling the drug and alcohol service at your local hospital.”
“He doesn't like hospitals and refuses to attend. He has spent a long period incarcerated and this is major issue I countered.
“Well then” she said exasperated “perhaps you'd better call the police as I don't think our team would attend under these circumstances.”
By now, my hallucinating patient had had enough. James headed for the door. I encouraged him to return the next day and to take the medication I'd provided him. He has returned daily and with medication, has become more stable. But my experience with acute care teams has been illuminating. I have discovered a systemic desire to exclude patients that fall into the ‘too hard basket’ and staff that is adversarial and largely unhelpful. Perhaps this is due to the poor funding of this vital service or to the fact that psychiatric hospitals are full to overflowing.
The reality in 2010 is that GPs have no central phone number which is dedicated to them and so we must traverse an impenetrable thicket of bureaucracy. No wonder GPs have decided to leave the difficult end of psychiatry to the public system and have opted out.
We are still the best placed to deal with such patients. They trust us and only have to tell their story once.
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