MS3 at a medium-sized city safety net county hospital, medicine rotation. Patient is late 20s, male. Emaciated and bitter about the chronic disease (and shitty home life) that has demeaned him so long and turned him into a piece of meat that needs to be fed through tubes. For 5 days, every interaction with any hospital staff involves screaming, swearing, perseverating in the face of evidence (convinced his vitals and lab values are all wrong), and threats. Refuses cares, splits, flips, refuses treatment then says he'll accept it but is always found to be away from room, outside smoking. Chart review indicates vague previous diagnosis of psychosis but assessment (with affirmation from psych consult) is worse: schizotypal, i.e. "terrifying but just outside of any indication for inpatient psych", i.e. "nothing we can do–maybe outpatient therapy?"
Every profile you've seen of a mass murderer. Thin, white, young male, bitter, put down his whole life, violent verbally and physically. I was the only one there when he called the nurses "f*cking n*****s". First time in my short clinical career when I had to consider how to document the n-word in a note. Hoping there won't be as many more times as I'm starting to realize there will be. I'm going into psych. I love humans, but this one lost my empathy.
Today: "this is why I wish I'd brought a weapon with me here. You're all f*cking idiots, I'm superior to all of you"
I was there with the intern and senior resident when he said this (we had already decided to only see him in a group). During table rounds, I presented as usual–interval events, subjective (disputes validity of overnight temperature reading indicating fever), vitals (feverish overnight, normothermic at this time), lab values, imaging, assessment, plan. Plan is: discharge asap. At the end, the intern asks, "do you want to tell him about the comments?" and I describe the incident. Attendings just switched over and this one hasn't met the guy yet. I say that I am concerned that he could very well show up at the hospital with a machine gun and our team would be his first target. Together we discuss the sincerity of the threat, call psych, I am not on the case anymore, I can have a different patient.
Psych is upping the frequency of their follow, helping us find a place he can go to on discharge that will handle both his medical needs and need to be behind locked doors. I don't think security was called. I looked up red flag laws in my state, efforts are being made to put it in place but it's not here yet. I keep picturing what would happen. I spent the day assessing safety exits and looking up laws in my state. I want to call the police and have them check his house for guns, but the indications aren't met and it doesn't seem HIPAA-compliant. But I'm just a medical student and I only have so much pull.
What can I do?
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