part0057

I first met 73-year-old Derek when he was an inpatient on the geriatric psychiatry unit. I was the family physician who provided medical care for the psychiatric patients while they were hospitalized and was new to my role on the unit. The experienced nurses and psychiatrists were kindly guiding me in my care of their anxious and depressed elderly patients, and I was learning how to manage their multiple somatic complaints. There were many subtleties involved in distinguishing the need for reassurance versus the need to investigate. It was a challenging balance.

When Derek was readmitted to the unit, he learned very quickly that I was the new family doctor on staff. He found me at the nursing station and implored, “You’re the new doctor! I have this terrible pain. I need your help. Please, can you do something for me?„ Derek was redirected by one of the nurses to return to his room and reassured that I would come to see him shortly.

The head nurse, Mary, turned to me and stated in a matter-of-fact tone, “That’s Derek. He has been in here many times. We know him very well. He’s depressed and anxious and very somatic. He often complains of abdominal pain.„ As I rose to commence my rounds, I decided to go and see Derek first. After all, his anxiety was contagious.

When I entered his dark room, Derek was lying on the bed. In a strained voice, his litany of complaints began, “Doctor, I have these terrible cramps. I’m so constipated. I can’t go to the washroom. And I’m having such a hard time going pee. It doesn’t seem to matter how much water I drink, I can’t pee. Please help me. All the nurses do is give me Tylenol and tell me to lie down.„

I conducted a systematic review of his complaints. Nothing added up. Derek felt like a collection of riddles that I could not unravel. He was constipated, but he had had a BM just yesterday. He couldn’t pee, but sometimes he was peeing too much. The abdominal pain didn’t fit any pattern. I was unable to come up with an easy answer. He was obviously quite somatically preoccupied. I wondered if I should do a few tests just to make sure I wasn’t missing anything and maybe reassure him too. I offered, “Maybe we should do a few tests just to check things out.„

Derek quickly retorted, “I’ve had lots of tests. I just want something for the pain.„

Then Derek went through the long list of treatments that hadn’t worked. There didn’t seem to be much left that we could do. “Well, let me think about what I can do for you, Derek. I’ll see you again later this week,„ I stated as I headed for the door.

“But I need something for the pain, now!„ cried Derek.

All I could say was, “Let me see what I can do.„ It was a struggle to extract myself from the room.

After seeing my other patients, I returned to the nursing station. Derek was there again. “Please, doctor, give me something for the pain,„ he begged. Derek was redirected by one of the nurses, and I tried to shrink down out of view.

As I started to write a few orders for Derek, Mary, the head nurse, peered over my shoulder and said, “He’s had an abdominal ultrasound last admission, you know. His urine test was clear last week.„

“Oh,„ I said. “We’re trying not to reward his behavior with attention. He needs to be redirected,„ Mary concluded, walking away. So I thought to myself, “ What am I supposed to do? „ I felt a little helpless.

Then his psychiatrist came on the ward. “Hey Mark,„ I said, “I met Derek today.„

“Mmm,„ said Mark. Mark knew Derek very well over the course of his many admissions and provided some background. Derek had suffered intractable depression for over four years. He had overdosed several times. He had been tried on numerous psychotropic medications and even ECT. Small gains were made, but Derek’s depression never fully went into remission.

Derek’s past history revealed that he had been brought up in a home with an unavailable father and a somatically preoccupied and anxious mother. Despite this, he experienced many successes as an athlete and later as a lawyer. However, relationships had always been a challenge. Derek had been married three times. His first wife, with whom he had three children, had divorced him. His second wife had died of cancer. He then met his third and current wife, Joan. She continued to stand by him, but the relationship was strained.

I asked Mark, “So all his somatic complaints have been investigated?„ With a heavy sigh, Mark replied, “Oh yes, he’s had loads of tests and done the rounds with the specialists. Everything has come back looking fine.„

There really didn’t seem to be much that I could do. Twice a week I did rounds on the unit, and each time, Derek was waiting for me. If I didn’t visit him first he would follow me into another patient’s room with his complaints. If I did see him first, he would seek me out again and again at the nursing station with the same litany of complaints and pleas for help. Other patients would also seek me out and have numerous somatic complaints. However, for them, there were things to investigate, symptomatic treatments to try, reassurance to give and hope that their depression would improve. There wasn’t any of that for Derek.

And at times I would reach my limit of patience. I felt angry, and as my sense of impotence escalated, I thought, “ He’s sucking me dry! It’s all about him! Leave me alone! „ There were days when it was all I could do to muster a civil attempt at reassurance and depart. I had tried to help Derek to understand that his physical pain was a reflection of his emotional pain. But it didn’t work.

Then Derek was discharged. His wife couldn’t cope with him at home, but he was too stable to remain in the hospital. Arrangements were made for him to go into a nursing home. I felt a huge sense of relief, but a pang of remorse remained.

A few weeks later, Derek was readmitted to the hospital. He had walked out of the nursing home into the middle of a busy street, stating he wanted to kill himself. No harm had come to him, but the nursing home refused to take him back. Derek’s suicide attempt jarred me out of my frustration with him. He had obviously been in a great deal of emotional pain to contemplate suicide. My empathy returned.

When I asked Derek if he would try again, he said firmly, “I’d never try to throw myself in front of a car again. I’d feel too bad for the person that hit me. What if they got injured? How would they feel knowing they had killed someone?„ It was comforting to hear that Derek could think about someone other than himself. For the first time I wondered what Derek had been like before he’d become ill.

So I made it my objective to discover if I could find more glimpses of the Derek that was buried under the depression. It was very hard to get him to talk about anything other than his bodily functions. Every now and then I’d find a clue in his conversation. Sometimes if I enquired further he would expand.

“These cramps are killing me. Is there anything you can do? Look at this belly. I’m gaining too much weight. I think it is the medication they have me on. I used to be so fit,„ Derek rambled.

“How did you used to keep fit?„ I asked tentatively, hoping this might be a fruitful avenue to learn more about Derek’s strengths.

“Tennis,„ Derek answered flatly. “I used to play a lot.„

And then the litany of complaints would begin again. Slowly though, I started to get an image of who Derek was, who he had been. But I was still frustrated. There was little I could do, but seeing Derek as a person rather than a patient made it easier to empathize and care for him .

Derek underwent another round of ECT. He was a little less anxious and agitated but still somatically preoccupied. His suicidal ideation stabilized. Then I got the news. He was being transferred to another nursing home, the one I worked at. He was going to be on my floor. He was going to be under my care, my patient – indefinitely. He was only 73, young for a nursing home. He was in relatively good physical health. He could be there for a long time. I have to admit I was trying not to despair.