Category: Iowa

My Two Cents on the Involuntary Treatment of Tuberculosis and Psychiatric Illness

By now many of us have seen the news headline about the person in Washington state who was arrested and sent to jail for noncompliance with a court order for treatment of tuberculosis. This led to my searching the literature about the connection between court-ordered treatment for psychiatric illness and court-ordered treatment for tuberculosis in Iowa. I’m not assuming that the person who is the subject of the news story has psychiatric illness.

I’m a retired consultation-liaison psychiatrist and the issue of how to respond to patients who refuse treatment for tuberculosis arose maybe once in my career. When the Covid-19 pandemic began a few years ago, I thought of the Iowa code regarding involuntary quarantine of patients infected with Covid-19 infection. I thought it was a situation similar to that of persons infected with tuberculosis. That was an issue for the hospital critical incident management team to deal with.

I found an article relevant to both internal medicine and psychiatry. It is entitled “Can Psychiatry Learn from Tuberculosis Treatment?” It was written by E. Fuller Torrey, MD and Judy Miller, BA and published in Psychiatric Services in 1999. The authors point to the directly observed therapy (DOT) programs in place in several states, including Iowa. Such programs can include positive reinforcement incentives such as fast-food vouchers and food supplements, movie passes and more. They credit the New York experience using DOT with reducing the tuberculosis rate by 55%.

Torrey and Miller point out that many psychiatric treatment programs didn’t offer as many incentives as DOT programs for treatment of tuberculosis. They also say that a “credible threat of involuntary treatment, essential for the success of DOT” often is absent from psychiatric programs.

I was puzzled by their view because of what I saw from our own integrated multidisciplinary program of assertive community treatment (IMPACT) at The University of Iowa Hospitals & Clinics, which started well before they wrote the article. My impression is that it has been very successful. The Iowa Code covers the role of involuntary psychiatric hospitalization in the event of noncompliance as a result of uncontrolled psychiatric symptoms leading to danger to self or others or inability to provide for basic self-care needs.

On the other hand, because of my background in consultation-liaison psychiatry, I wondered about how we might treat someone with both tuberculosis and severe psychiatric illness, the latter of which could make treatment of the former difficult or even impossible.

We can use long-acting injectable antipsychotics to treat those with chronic schizophrenia. They’re not uniformly effective, but they play an important role in acute and maintenance therapy.

But I also forgot about how tuberculosis treatment could be administered to those unwilling to take it voluntarily. I rediscovered that tuberculosis treatment can be given by injection, if necessary, although it’s usually intended for treatment-resistant disease. On the other hand, scientists created a long-acting injectable drug for tuberculosis which was effective in animal studies and which could be a delivery system for non-adherent patients.

And I thought about who would be the responsible authority for administering tuberculosis medications on an involuntary basis. It’s not psychiatrists. It turns out that in most states, including Iowa, the local public health officer is in charge. The CDC has a web page outlining suggested provisions for state tuberculosis prevention and treatment.

Patients with tuberculosis who refuse treatment can be confined to a facility, although it’s not always clear what that facility ought to be. Certainly, I would be concerned about whether a jail would be the best choice.

I don’t have a clear answer for an alternative to incarceration. Would a hospital be better? General hospitals are not secure and there would not be an ideal way to prevent the patient from simply walking away from a general hospital ward. If the patient has a comorbid severe psychiatric illness that interferes with the ability to cooperate with tuberculosis treatment, then maybe a locked combined medical-psychiatric unit (MPU) would be the better choice. Arguably, while an MPU might not be the best use of this scare resource, it’s probably more likely to have a negative pressure isolation room for a patient with both tuberculosis and psychiatric illness. I co-attended with internal medicine staff on The University of Iowa Hospital’s MPU for many years. There are rigorous criteria for establishing such units. The best expert in integrated health care systems I know of would be a former teacher and colleague of mine, Roger Kathol, MD. He is currently the head of Cartesian Solutions.

I’m aware that just because someone refuses treatment for tuberculosis doesn’t necessarily mean a psychiatric illness is present. The critical issue then could become whether or not the patient has the decisional capacity to refuse medical treatment. The usual procedure for checking that would include assessing understanding, appreciation, reasoning, and the ability to make a choice. You don’t necessarily need a psychiatrist to do that. Further, there are nuances and recent changes in the decisional capacity assessment that can make the process more complicated. The New York Times article published in early May of this year, entitled, “A Story of Dementia: The Mother Who Changed,” makes that point based on a real-life case in Iowa, involving psychiatrists at The University of Iowa.

It occurs to me, though, that just because a person is able to pass a decisional capacity assessment doesn’t necessarily make a decision to refuse tuberculosis treatment OK. Letting someone expose others to infection when effective treatment is available doesn’t sound reasonable or safe.

That’s my two cents.

Quenard F, Fournier PE, Drancourt M, Brouqui P. Role of second-line injectable antituberculosis drugs in the treatment of MDR/XDR tuberculosis. Int J Antimicrob Agents. 2017 Aug;50(2):252-254. doi: 10.1016/j.ijantimicag.2017.01.042. Epub 2017 Jun 5. PMID: 28595939.

The Gray Catbird Rusty Rump Mystery

I looked into the mystery of the gray catbird’s rusty rump. I mentioned the rusty colored feathers under its tail feathers in yesterday’s post. For some reason the underside of its tail feathers looks a little messy. I was able to get more video evidence about what might be the cause.

The catbird looks fastidious. That may be misleading. Scientific observation reveals what is really going on.

This is probably also the origin of an old saying. I think it was Plato who said, “Never stand under a bird.”

The Elusive Gray Catbird

We hear the gray catbird more often than we see it. When we do see this beautiful gray bird, it’s only a fleeting glimpse. We more often hear it mewing like a cat. It imitates the songs of other birds as well.

I have caught sight of it in our back yard trees. It streaks back and forth from the trees to somewhere else, most likely a nest.

I finally got a short video yesterday morning from which I gleaned a few pictures. It seemed to show off its feathers, even the rust-colored ones you can see only when it lifts its fan-like tail. It has a handsome black cap.

We have a bird book we consult for help identifying birds. The title is Birds of Iowa: Field Guide, written by Stan Tekiela. I first bought the book many years ago. It was published in 2000. I’m pretty sure I bought it at the Iowa Book store on Clinton Street in downtown Iowa City. It was still for sale at the store as recently as last year.

The book makes it easier to identify birds by color. The sections have titles like “Birds that are mostly gray.” Every page has a tab color making it easier to thumb through the book looking for the birds you saw and want to know more about.

The short descriptions are packed with useful descriptions of things like the behavior, migratory patterns, as well as appearance. Tekiela’s description of the gray catbird includes remarks about its color, saying it is “A handsome slate gray bird with black crown…” and “Often seen with tail lifted, exposing chestnut-colored patch under tail.”

Tekiela also would give some pithy and educational stories about birds. According to him, it’s “A secretive bird that the Chippewa Indians named Bird That Cries With Grief due to its raspy call.” Often it mews like a cat, which is how it got its common name.

You’re very lucky to see it.

Acting Up on Scott Boulevard

We took a walk on Scott Boulevard used my smartphone for the first time to take selfies with the Sitting Man. Can you believe it? I’ve had that phone for over 7 years and never took a selfie with Sena until then.

It was a sunny day and we walked clear out to the intersection of Scott Boulevard and Rochester Avenue. When we did this last February, we saw a sculpture by Iowa City artist, Eugene Anderson. It’s a striking white abstract called “Family.”

Except it wasn’t there anymore. There was a lot of heavy construction equipment and large excavation holes with construction stakes all pretty close to the concrete pedestal where the sculpture had been mounted.

But it was gone. We remembered talking with the developer not so long ago about the new development planned for the area. He mentioned something about a plan for moving the piece somewhere. I sent him a message asking about it.

The President of the Harvest Preserve Board, Douglas Paul himself, got back to me about the sculpture. This is the same Douglas Paul who created the Sitting Man sculpture. Eugene Anderson’s sculpture is in the shop getting needed repairs. Doug Paul is doing the work on it. The plan for now is to move it to the western entrance of Harvest Preserve. It’ll be near the gate, visible from Scott Boulevard.

Doug Paul told me about his book, Go Figure. You might be interested; I know I am.

Juggling and The Wings of Change!

The other day we were at Terry Trueblood Recreation Area mainly to see how juggling goes outdoors for me. We filmed the event for posterity.

It turns out that “wings” had a lot to do with it. I juggled next to Hilde DeBruyn’s sculpture “Winds of Change.” It’s my favorite sculpture, although the winds of change are dictating that the Iowa City Parks Dept. is again going to accept new sculptures for this year which will replace all of those currently on display.

Wings figured in a different way and you can tell by how I react to the bugs flying around. We picked a nice spring day when all the winged insects were buzzing around in my face.

The level of juggling difficulty goes way up when gnats are zipping up my nose, my ears, my mouth, etc.

Resident Physicians on Strike at Elmhurst Hospital in New York City

I read the news story about resident physicians at Elmhurst Hospital Center in New York City who went on strike this past Monday about low pay. The story doesn’t mention whether psychiatry residents joined the strike. The story did mention how difficult it was to work there during the Covid-19 pandemic in 2020.

I looked up the report from the consultation-liaison psychiatry department at Elmhurst during that time. Their report and many others were submitted to the Academy of Consultation-Liaison Psychiatry (ACLP).

The Elmhurst report was submitted April 1, 2020 by Dr. Shruti Tiwari, MD, Professor Consultation-Liaison, Icahn School of Medicine at Elmhurst Hospital Center, Queens, NY.

I read the report in order to figure out what I and my colleagues at University of Iowa Hospitals & Clinics needed to do in order to respond to psychiatry consultation requests in the setting of the Covid-19 pandemic. In general, we followed the Elmhurst suggestions.

I remember how difficult it was to operationalize the consultation protocol in light of the need to control spread of the Covid-19 infection. We worked with our IT department to use iPad devices with video hookups to evaluate patients in the emergency room. Early on, incredible as it may seem, there was limited supply of PPE for emergency room physicians.

We could do curbside consultations sometimes. Often, when I was on service, I found it difficult to use the iPad because of glitches in the device. In order to reduce the number of consultation team members huddling together, residents and I saw patients separately. Often, delirium with agitation demanded we evaluate the patient in person. There was an adequate supply of PPE with some limitations. Psychiatric consultants didn’t have access to N95 masks because of the shortage of them at the time. We wore surgical masks and face shields as well as gowns and gloves. We were not to see patients in the ICUs other than by video assisted means.

I couldn’t tell from the news story when the residents formed a union. One them was interviewed for the story and said that their immigrant status made working conditions more difficult as well as insufficient pay. The story also mentions that the last time doctors went on strike in Manhattan was in 1990.

It would have been difficult for physicians (including psychiatrists) to go on strike during the pandemic, probably impossible. I’ve written about physician strikes before and have given my opinion about that. I hope things work out for the Elmhurst resident physicians and the patients.

Terry Trueblood Birds Show Off in the Spring

Just about any time of year is a great opportunity to walk the Terry Trueblood Recreation Area. The birds are busy competing for mates and nesting spaces.

The nest boxes for the tree swallows are up. Already, vacancies are few. Their iridescent feathers are dazzling.

The music in the first part of the video is a piece called “There Are Chirping Birdies In My Soul” by Reed Mathis.

In the second part of the video, we let the birds themselves make the music. The birds don’t just show off; they sound off. All the birds are singing—except for the one killdeer for some reason. I managed to save a few clips of them singing their songs. They are in the last minute or so of the YouTube video. The first is the tree swallow. The next is the red-wing blackbird. Last is the song sparrow.

You’ll need to crank the volume to hear them. The tree swallows have a subtle trilling chirp. The male red-winged blackbirds have a distinctive call that probably sounds very familiar to most of us. We also saw and heard a song sparrow, a first for us.

Familiar Backyard Birds and One Sort of Familiar

We were bird watching the other day and saw a few birds we definitely recognized. One of them we puzzled about but finally decided was a sparrow.

The Red-Bellied Woodpecker is familiar. We think it was a male. The Blue Jay is still interesting because when it’s not in the sunlight it looks like what it really is—a blackbird. When we first saw it, the bird looked sort of grayish black. Finally, it turned just right and its feather bent the light into the familiar blue color. The Northern Cardinal is instantly recognizable, especially the male. They like to sit a long time, which is great for getting pictures.

The last bird looks like a sparrow but the tail seems longer and the bill is narrower. The breast is not streaked. It has head feathers which stick up. It resembles a female house sparrow, but it seems a bit larger than that. We looked around the web to try and identify the sparrow-like bird we saw.

We wonder if it might be a Cassin’s Sparrow. Although it would be out of its range since it’s found mostly in the southwest United States, Cassin’s Sparrow has been known to wander.

On the other hand, it’s not listed on the websites we saw featuring sparrow species seen in Iowa.

I think the reason it had a greenish breast was because it was reflecting the surrounding tree leaves. We’re calling it a Cassin’s Sparrow for now, but if you know better, shout it out.

Can anybody help us identify this mystery bird?