by Robert Lanz, LCSW
Panic attacks are one of the most common presentations to the ER and sometimes the most vexing. I suggest that every social worker in that setting make a point to have a really good pitch because it will be thrown often. Being able to use your relationship with the docs to get the patient medicated when appropriate and get some aftercare meds, too, is as essential as your referral to the appropriate follow-ups, whether that be yoga, biofeedback, insight counseling or whatever else. Your “pitch” should convince the patient that you are highly competent in this diagnosis and that your observations should be followed ASAP for the requisite relief. Of course, the panic attacks may be part of a whole host of other problems including depression, generalized anxiety disorder, recent stress, unresolved grief, etc. Those issues are too time-consuming to address fully in the ER, but your ability to finally address them successfully leads to your air of competency on the subject, and that leads to a more likely follow-up by the patient.
A lot of patients come to the ER suffering from panic attacks. Some of them even come in saying they are having a panic attack because they have had them before. Some come in and think they are having a panic attack because they know someone or read something about panic attacks, realized they were under a lot of stress and that stress was often the cause of a panic attack. Then there are those “others” who come in believing that they are having a heart attack, pulmonary embolism or some other type of total meltdown. Thanks to the ER docs recognizing the commonness of the presentation, there is general agreement that there is no need for anyone to suffer the debilitating effects of a panic attack. Patients are often given immediate relief with a shot of Ativan or some other medicine like it.
The panic attack patients — and there are many of them — usually get referred to the social worker because the SW is the mental health professional in the ER and because panic attacks can be very, very insidious. It is important that they get treated quickly in the out-patient world, just as it is important to receive quick treatment in the ER. Otherwise, the literature seems to indicate there is a good chance the attacks will happen again. (I guess ‘bad chance’ may be a more appropriate choice of words: there’s nothing good about a panic attack except that it may be a somatic epiphany of some sort.)
Anyway, my job was to help the patients identify any recent stress that may have been a contributing factor to their panic attack. Here, I do have to add that a lot of people are clueless when they are under stress and sometimes questioning has to get pretty specific. I might ask the patients if they have been under any undue-stress lately and follow that up by asking what they usually do to de-stress themselves. Then we can discuss some appropriate follow-ups like psychotherapy, stress management, yoga, tai chi, biofeedback — you get the picture. Well, I hope you do. Many patients don’t. That’s when I have to get specific.
“So have you been under any stress recently?”
“No, not really.”
“How’s it going at work?”
“Oh, I lost my job a couple of weeks ago.”
“How long did you work there?”
“About 26 years or so.”
“And how’s it been going at home?”
“Well, since I started drinking again, not too good.”
“You mean your wife’s angry with you?”
“No, she left.”
“Yeah, she went to stay at my mother’s.”
“Well, maybe that will be temporary.”
“I don’t know. My mom’s been feeling bad lately. My dad died about two months ago and it’s been affecting her.”
“Anything else? You didn’t get arrested or anything?”
“Just a DUI”.
“Sometimes it’s hard to say exactly what causes people to have panic attacks but it seems like you may be experiencing a lot of changes lately. Change can be stressful”.
Conversations like this are what caused me to develop calluses on my tongue. There are so many great lines I could give back to someone under these circumstances, but since I am the mental health professional it would be in bad taste to say what I am thinking. I just stay with the standard pitch, which I won’t bore you with now.
So let’s get back to the woman in room 7. She’s pretty average. Has a decent job. Looks a little younger than her age. Kind of cute. Very relaxed by the time I got in to see her. She had been so anxious when she came in that the charge nurse moved her out of the group room she was in and put her in a private one. A private room and a shot of Ativan make it so much easier for me to interview the patient.
This should be pretty routine, I thought. Yeah I know: it’s foolish to think anything will be routine in the ER. The only thing routine in the ER is that nothing is routine. ‘No routine’ is the routine. It’s a Zen thing.
Tonight, two non-routine things happened almost immediately. The patient’s mother comes in at a critical juncture in the interview. The patient is about to tell me she broke up with her boyfriend of seven years because he wants to have kids and she has some disorder that her doctor said would make it impossible for her to get pregnant. At that very moment, the nurse walks in and tells the patient she has a positive pregnancy test. Of course, the woman speaks-up and says there must be some mistake. “I can’t get pregnant and why would the doctor order a pregnancy test if I’m only having an anxiety attack,” she wonders out loud. The nurse beats it out of the room and comes back 20 seconds later. We are still in recovery mode so not much has been said.
The nurse says to the patient, “Did you give me some pee?”
And the patient says she did. And the nurse explains that the doctor had ordered the test on the woman who had been moved out of the private room and into the hall and it was the current patient’s urine that was tested — and the pregnancy test did in fact, come back positive. She offered to do another one to be sure but the patient declined. Probably too stunned or too stoned to think that one through.
The patient’s mother was ecstatic. Her daughter had finally gotten pregnant. The patient was confused — how could she get pregnant? Then there was the issue of the breakup over no pregnancy that led to the stress that caused the panic attack that brought the patient to the ER. Ativan is a pretty safe drug, so we wouldn’t get sued for giving it to a pregnant woman. It was one of those honest mistakes that happen in a busy ER. Sorry folks, but that is reality.
So here we are, the patient very “relaxed” but about to start talking about the breakup and Mom starts getting all pumped up because she thinks her daughter will finally get married to the boyfriend who she really likes, and I’m sort of an afterthought by now.
But all these issues? They aren’t ER issues. ER issues are about why you are here right now.
We fixed that with the shot and reality reared its ugly head again with the pee mistake that lead to the positive pregnancy test in a woman who thought she could never get pregnant and to the true delight of the mother. But that doesn’t mean it rises to the level of an ER issue.
“It would be a safe guess to say that the panic attack you had today was related to stress in your life.” Then the mother broke in, saying “But now she’s pregnant and everything will be OK”.
Maybe it will. I don’t know. I went on ahead with my basic pitch about the nature and treatment of panic attacks, referred her to a local counseling center where they had clinical social workers and marriage counselors. I also thought she would benefit from biofeedback and gave her the number to a psychologist who does that across the street from the hospital. And then I left.
I don’t know if the patient ever told her mother what had really happened. I wondered if she would tell her boyfriend now that she had broken up with him. I don’t imagine she would have gotten an abortion because she was very close to her mother and wouldn’t want her to know. There were so many things I was curious about but few I really needed to know. I had done my job. I had made my pitch
And I was out of there. Next…