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Clinical Case 085: the trouble with Phineas

Imagine this scenario.

You turn up to work your day shift and see you have been assigned to the Obs ward for the morning.  It is your task to see the dozen or so patients sleeping off the evils of the night before in the small ward out back of the ED.  You know the drill – a few minor tox cases, a Psych sedation, maybe an old guy with a bump to the head etc….

As you look at the list of patients under your care – you have a heart-sink moment as you recognise Phineas’ moniker.

Phineas.  Well Phineas is a well known individual.  He is about 50, and you have seen him many times over your tenure in this ED.

Phineas was a successful independent builder, running his own small company and living in a well-healed suburb with his wife and 3 kids until he had his accident.

About ten years ago Phineas had a few too many drinks and drove into a wall.  He suffered a nasty frontal brain injury and spent a month in ICU, a craniotomy and a prolonged rehab saw him back to full physical function. But…. his brain injury left him with seizures and “Phineas Gage” persona.  Phineas became impulsive, disinhibited, drank to excess and had trouble organizing his life.  His marriage had disintegrated over a few years and he couldn’t hold any sort of job.  Phineas doesn’t have a diagnosable primary mental illness and he has seen a number of Psychiatrists who have all agreed – he does not need their help.

Over the last few years he has been living in a series of supported housing units, but he tends to get into a lot of fights and never stays anywhere longer than a few months.  However, the ED is one of the few permanent fixtures in Phineas’ life.  He frequently presents via ambulance after experiencing secondarily generalised seizures in public.  He is prescribed phenytoin but whenever he gets a level done in ED it is close to ZERO.

You read through the chart from the night before – same old story.  He was drinking in a local park, when he had a convulsion.  A passerby called 000 and the Ambos brought him in.  He was GCS 14/15 on arrival and blew 0.09 on the BAL analyser.  All his obs and examination were “normal for Phineas”.  He received an IV load of phenytoin 1000 mg over an hour, some thiamine and a hot meal.  He required a few doses of diazepam after this for “twitches”.

The resident decided to admit him for “Neuro obs and  Neurologist review in the AM”  This brings a momentary smile to your face!  This is Phineas’ 23rd admission in 3 years.

You wander into his cubicle, and he greets you with a knowing smile.  “Gday Doc!  I’m glad it is you on today.  That young guy last night seemed very serious!”  Phineas is his usual, jovial self.  

After you check him out and talk about the footy for a while Phineas is keen to leave.  He tells you he is staying in a nice flat with a few other “mental defectives” and plans to head back there for a rest and to make sure they have not knocked off his stash of Bundy rum.

So here we are.  The point of the exercise today is to explore a few issues that this sort of patient can present to us, Emergency Physicians who are sometimes by default the primary carers for some patients.  SO have a ponder on these questions;

Q1:  Would you load Phineas with phenytoin each time he presents “post-ictal”?  If so, would you give him IV phenytoin, or something else?

Here is a post from Dr Bryan Hayes of the Academic life in EM blog on oral Phenytoin loading in ED

Q2:  Clearly compliance is a problem. You are an ED doc.  How far do you go to try and get Phineas to take the meds he needs?  Do you give him a prescription?  Hand him a bottle of pills with instructions?  Get a blister pack made up.  Get a Social worker / community health worker involved?  Do you go round to his flat and check on him?  OR is it ethical to accept that Phineas will not take anything you give him and not bother with the meds?

Q3:  Is this a competence question?  That is – is this man competent to make his own health decisions?  Given the facts:   he has clearly and repeatedly put himself in harms way, has a brain injury yet seems insightful enough when you talk to him.  How do we go about deciding on competence in this situation?

OK.  Enough clinical and ethical food for thought there.  Hit me on the comments page or twitter @broomedocs with your thoughts.

Casey

PS: in a modern version of the Phineas Gage story – here is one from Brazil (thanks Dr Tim for sending it in.)  A lucky man indeed.

Comments

  1. David Berger says:

    1. He has underlying epilepsy, he doesn’t take his tablets and he drinks excess alcohol. The last one of these I had in my short stay in Broome pulled his cannula out halfway through being loaded and buzzed off. I guess you have to give the guy the benefit of the doubt and if he says he’ll take the tablets I would probably give him an oral loading dose, as per the recent post on Academic Life in EM, which is as effective anyway and is less invasive than IV loading.

    2. I think you have to ask him what he wants to do each time. If he says he’ll take the tablets you give them to him in as convenient a form as possible and do what you can to help him comply. If he says he won’t, you document it and don’t give him any. Simple, because the decision is not actually ours to make — it’s the patient’s.

    3. Whether he is competent or not, in UK law anyway, is irrelevant, and I suspect it is the same in Australia. You can’t administer non-psychiatric drugs under a treatment order. Where would you stop? Would you send someone round to his house to give him his ramipril if he wasn’t taking it? Anyway, I suspect he is competent, just cussed and, to our eyes, stupid and self-destructive, but this would go for very many alcoholics. We have a right to be stupid and cussed in our society, it is a hard won right to be cherished and we shouldn’t give it away easily by over-paternalism, however well intentioned it may be.

    • Thanks Dave
      Added a link to that post. Certainly I have been in discussion with local Pharm about this.
      There is currently an Aust wide shortage of IV phenytoin -- so good to know
      Casey

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