Dealing with patients who have acute psychosis can get complicated but it's far more challenging when you mix with it a physical illness of sorts. It then comes close to the type of fictional cases
Dr. House would be looking to solve; are there 2 separate diseases or is the medical illness causing the psychosis? Perhaps there are 3 diagnoses instead of 2, with overlapping symptoms or maybe the patient is in fact forging some symptoms. I'm sure you're beginning to see just how confusing it can get and that's just scratching the surface.
It was such a case that happened to be cast my way one time during call. See, I was a new intern at the time and while I came to later appreciate how less busy call on the wards can get, at the time, it felt like I'd fallen straight into the 7th circle of hell. The Medical Ward is a bizarre world, filled with all manner of cases that suck out your confidence in milliseconds; even in Medical School, I hated Internal Medicine with a vehemence I'd never felt before. So you can imagine the trepidation I was feeling during my first call on the ward.
And true to its malicious nature, fate gave me the worst sort of patient on that rainy night. He was a teenage boy admitted with an acute psychotic episode and some other symptoms that would more or less gross you out so I won't mention them, let alone go into details. Anyway, I'd been called to see him and assess his state that night; after reading his chart, I wondered incredulously what had possessed the nurses to think I could assess him when the physicians themselves didn't know what to do. Dutifully, however, I went to see the lad, praying silently that it would be over soon.
On reaching the room, I greeted and tried to start a little conversation with the young fellow but he ignored me and stared straight ahead. Wanting a closer look before I started examining him, I leaned in and what happened next is the reason I don't touch psychotic patients unless absolutely necessary, anymore. Moving faster that I could think, the kid turned to face me with a feral grin adorning his mischievous face and proceeded to jab me in the chest, hard, with all four of his right hand fingers.
And it felt like an arrow had gone through my sternum.
Shocked and in more than just a little pain, I stumbled back and stared at the kid, trying to figure out whether he knew what he had just done or not. For all I knew, he could have been trying to kill an enemy by attempting to jam his entire hand through the chest or maybe he'd seen a fly on my coat and wanted to take a stab at it (pun not intended.) And yes, it did hit me that I do have boobs on my chest and this was a teenage boy who perhaps wanted to cop a feel but missed and ended up jabbing me straight in the middle of my goddamn chest instead. Yes, I quickly disregarded that theory; this kid knew where he had been aiming and it wasn't in boob territory.
A little more wary now, I asked the mother to talk to him and ask him a few questions so we could assess his orientation but the kid wasn't listening to her either. He started talking insistently , however, saying that he needed to go home because that was where his medicine was and he wouldn't get better in the hospital. We tried to ask him what he was talking about but he just kept repeating over and over again how he needed to go home because that's where his medicine was.
Nobody knew what he was talking about and even his mother looked rather confused. The more I considered it however, the more sense it made.
Perhaps this kid was on drugs and the acute psychosis was as a result of withdrawal of some sort. I didn't have time to further explore my theory because it was at that time that the patient suddenly swung his legs over the edge of the bed and started running towards the windows in the room.
I saw everything happening in slow motion.
He was moving as fast as he could towards the windows and we started after him a second too late. Before we knew it, he jumped out of the window and into the stormy night, from the 3rd floor of the hospital. Rushing towards the window in a panic, we were relieved to find that he'd just ended up on a flat rooftop that was just a foot or so below the window and there he lay, groaning and twisting in the rain.
By that time, the yelling and screaming we'd done had attracted the guards and more nurses and they helped us extract him from the rooftop. He was relatively unhurt but 100% unstable in my mind; this time, I was not going to blunder. I prescribed enough sedatives to keep him silent for the night and agreed with the family that he needed to be in a more secure location.
I walked away from the scenario more irritated than anything else. Stabbing pains were still running through my chest and the physician I'd called to report the situation to just laughed me off the phone.
On the brighter side of things, they discovered that my hunch was right and shipped the guy off to a rehabilitation center. Perhaps they'd enroll him in a martial arts center thereafter; he'd suddenly be impressive if the 2 week long ache in my sternum was anything to go by.
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