Agraphia Medical Tragicomedy


Water Poisoning

I had the most endearing interaction I think I've ever had today with a patient.  He was an extremely polite schizophrenic man who came in because he was convinced his water supply was being poisoned.

Me: What makes you think your water is being poisoned?

Him: Well, my girlfriend, she told me to drink less water.  She thinks I have too much every day,  so she told me to drink less.  I'm pretty sure she poisoned it.

Me: Why would she want to do that?

Him: To get me to drink less, of course.

The logical explanation lies with his past medical history; he suffers from a condition known as potomania - overactive thirst - which can cause significant electrolyte imbalances in the body with too much water ingestion.  The treatment is to drink less water; his girlfriend was actually looking out for him.

For a moment, I entertained the fallacy of his reasoning.  "Why on earth,"  I thought to myself, "would your girlfriend poison your entire water supply? This is the schizo talking."

Then, I thought back a couple of weeks.  In the middle of a particularly hectic shift I took care of an autistic kid who kept coming up to the physician's desk asking the same question over and over again.  "Can I get my medication refill now?  Please, I want my medication refill now.  Now? Now."  I finally lost my temper and snapped, "Listen, kid.  I'll get to it when I have the time.  Right now I have more important things to do than refill your meds."

I saw the hurt in his eyes and immediately regretted my words.  One of our child life specialists who I deeply respect pulled me aside and admonished me.  "Zac.  He's scared, it's loud in the ER and he needs help.  He's autistic and he's already out of his comfort zone.  I know you're busy, but don't lose your compassion."

Fast forward to today.  "Tell you what, boss," I said, "why don't I do a good physical exam and we'll make sure you didn't get water poisoning?"

"That would be great," he said, "I've been so worried."

I've been reading Cutting For Stone by Abraham Verghese, a physician at Stanford well known for his veneration of the physical exam.  Dr. Verghese gave an incredible TED talk about the powerful bond a careful exam creates between physician and patient.

So, finding myself with a few extra minutes in my day, I examined my schizophrenic patient in minute detail.  I tested for nystagmus, checked Romberg and Babinskis, carefully listened for the slightest of cardiac murmurs, and checked his ears for wax.  And, after a normal exam:

"Good news, I don't think your water was poisoned!"

His response was wonderful. "Doctor, thank you so much.  You've put my mind at rest.  It was going round and round like a carousel and I couldn't seem to get off the ride."

I suppose a physician's touch - even in a busy ER - is still a valuable tool.

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  1. Yeah, but now he’ll go back to over-drinking. If you let him think it might be poisoned, he’d be less likely to indulge his potomania.

  2. Good point, Yero…

  3. This is a beautiful post. For me, one of the most important things about my clinical experiences has been learning how to deal with the things that make patients unique and different from textbook cases (their personal circumstances, their beliefs about medicine and the world, etc.). I think your post illustrates an out of the box approach to dealing with something that was seriously troubling your patient but that would likely have been dismissed by a lot of other doctors. Sure, it might create more of an issue with overdrinking…but I’m not sure that the overdrinking would’ve been any better if the patient had been left with his fear that the water was poisoning him.

  4. It’s wonderful that you took the time with this man, Zach. I’ve also read Cutting for Stone, and I recently watched Dr. Verghese’s TED talk. I’m not a doctor, only a patient, but I loved the book and thought that the doctor’s compassion and wisdom were striking in their sincerity and simplicity. If only all doctors thought that way! I’m glad for you–and for your reassured patient.

  5. Just found you whilst wandering the internet. As a nurse, I can tell you that yes, gentle physical touch creates a connection with every patient – and it is that connection that allows you to probe a bit more, and the patient to trust a bit more, and tell you whatever they have omitted – often the piece that makes the whole puzzle make sense. It doesn’t have to take a lot of time – true attention and presence is very powerful, and communicates a kind of safety that helps you and the patient.

  6. The placebo effect is so strong. I personally have a chronic ailment that took a turn for the worse in the last year. So I was precribed a stronger medication that I did take before, but was off of for a couple years. This medication needs to build up in your body for about half a year before it takes effect. For me, even though I know all about it, it was working from day one.

    • A reassuring voice from a trusted authority can have the same, if not stronger effect, I forgot to add. Even if I suspect, or think to know, the opposite.

  7. Thank you for the TED Talks link, it struck a chord with me!

  8. Thank you so much for posting this. My mother has been diagnosed with paranoid schizophrenia for years and most of the time people don’t understand that with a little time and understanding it is easy to not only calm them down but enable them to get back to a calm existence and a peaceful state of mind.
    It really touched my heart that someone who isn’t related and is extremely busy would take the time to do this.
    Please keep doing what your doing. It means more than you know when you put in an extra 15 minutes with someone in that situation.

  9. Hi! I’ve been reading your posts for a while, and it’s given me a great idea of what medical school is like. I’m a senior in high school, and I’m in a class called Health Science Technology 2. We’ve been doing clinical rotations at a local hospital 4 days a week for about an hour and a half at a time. One of the assignments for our class is to contact 10 people who are successful in whatever profession they are in and ask them if they have any advice for how to be successful. I’m very interested in a career in healthcare, and I would really appreciate any suggestions that you may have. Any reply (no matter how short) would be helpful! Thanks!

  10. Where are you? Miss reading your stuff a lot. I hope all is well.


  11. It is really nice post.I loved it.

    Thanks for more info………….

    Ross Finesmith

  12. You definitely need to take a step back and look at the big picture sometimes and realize that people are just looking for reassurance. It can be hard when your busy to take the extra step but, this is what makes the difference. Good story like the post.

  13. This is what I call serendipity…I just watched Vereghese’s TED talk last week and am now making my way through Cutting for Stone.

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