Falling Through the Cracks

During my first trip to the hospital for my bipolar mania, I don’t recall the psychiatrist ever saying anything about bipolar, much less anything about the dangers of it.  Maybe I didn’t want to hear such talk. I think I was still manic such that I missed details like that.  But there it was in the medical records, as I would read later: a diagnosis of bipolar I.  The doctor gave me olanzapine (Zyprexa), I thought it was to help me sleep.  And I don’t recall any talk of outpatient follow up.  I know now that Zyprexa is used to treat bipolar disorder.  And it does actually have a sedating effect.

I’ve since then seen my medical records from that hospital stay.  The notes contain this observation:

"The patient was compliant and willing to take medications.  He was initially given Zyprexa 10mg at bedtime his first night on the unit. The following morning, he was much clearer and able to give a coherent history.  Per the patient’s report and his sister’s report, it appears that he had been struggling      with insomnia for at least the past two months with periods of irritability, agitation, increase in goal-directed activity, distractability [sic], flight of ideas,and with pressured speech."

There was a note that I had two relatives who had suffered from bipolar. We know that bipolar illness can be hereditary.  It can be difficult to trace it back through the family tree, because reporting was less common and diagnosing less accurate.  People didn’t talk about mental illness in previous generations.  Today’s statistics indicate a 15 to 30 percent chance of getting it if one parent has it, 50 to 75 percent if both parents have it.  The risk to the general population is under three percent.

The failure of the Zyprexa regimen was that the hospital stay was too short.  It takes between a week and six weeks for the medicine to start working.  The weekend I was held for was not enough to convince me to adhere to the prescription. I wanted to leave for sure, but I now know it was medical malpractice for them to release me so soon without any plan for follow up.

Our overcrowded and overburdened system does that all the time.  Psychiatric malpractice is tough to prove.  Failing to monitor medications properly is malpractice, but it’s not as obvious as a plastic surgeon horribly disfiguring a patient.  Many psychiatric patients don’t have the wherewithal or the resources to sue. Lawyers will take on the plastic surgery case on a contingency fee basis. But not for psychiatric malpractice.

Two kinds of psychiatric malpractice cases are abuse and negligence.  What was common treatment decades ago would be considered abuse today.

Negligence has four elements: there must be a doctor-patient relationship, the doctor failed to provide reasonable care, there were harms, and finally the harms were caused directly by the lack of care.  The question must be asked: what would a reasonable doctor have done?

My current provider regularly orders up blood tests to make sure my medicine is at therapeutic levels — enough to be working, but not so much to be damaging my liver.  To not do so would be malpractice.  

The problem in our system is when some doctor on call at a hospital catches some indigent patient.  The doctor doesn’t really consider that patient to be his/hers. I wasn’t told, but I found out by accident that withdrawal from the benzodiazepine I was on causes seizures. And it's deadly with the use of opiates. And it's addictive. And it has long term negative effects. However, it's not the doctor's concern about what the benzodiazepine causes after the indigent's hospital visit.

That would be called “falling through the cracks” rather than malpractice.  There’s too much falling through the cracks.