1. Vaez, Kelly DNP, APN, FNP-BC


An NP ponders the vulnerability of the seriously mentally ill.


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I can't seem to teach this week. I need to produce a recorded lecture on primary care for the patient with a serious mental illness. I'm remembering the phone call six years ago, a Tuesday morning at 4 AM: my 33-year-old sister Doris was in the hospital on a norepinephrine drip, her blood pressure dropping. I needed to get on the next available flight. I hadn't answered a call from Doris just 12 hours before-I was busy seeing my own patients-and then I didn't return the call because I was late to pick up my son from day care.

Figure. Illustration... - Click to enlarge in new windowFigure. Illustration by Eugene Smith

I'd spent my career as a family NP (FNP) providing primary care for patients with serious mental illness, mostly schizophrenia. I loved my job. I knew that my patients were once without mental illness, just like my little sister Doris had been before her diagnosis 10 years before, and I always tried to picture them like that, each their own best version of themselves. These patients needed close follow-up. We didn't just prescribe a medication, we called the patient to see if they picked it up, and we arranged a follow-up visit just to see if they'd started it.


Doris didn't like the FNP in her new assisted living facility. I caught sight of her once while walking down the hallway with my kids on a visit. She had a scowl on her face and didn't raise her eyes to meet mine. On that visit, we checked out the newborn kittens of Doris's across-the-hall neighbor and chatted with residents who'd become Doris's new friends. Since moving into this facility, Doris had blossomed. At the direction of her psychiatric mental health NP (who she loved), she went from four antipsychotics down to one. As the side effects diminished, Doris lost 30 lbs., went vegetarian, and took a daily two-mile walk. The angelic chef at the facility would make a special meal for Doris, the youngest patient and the only vegetarian, and Doris in turn took the little money she had and bought earrings at the Dollar Store for the chef.


Then Doris went to a dentist, who told her she should have her wisdom teeth removed and unnecessarily prescribed her 20 days of clindamycin. Doris became septic with Clostridium difficile and died a week later. Her medical list showed that someone-my memory has for years told me it was the scowling FNP, but memory can be tricky-had prescribed loperamide for the diarrhea. Yet she was on clindamycin, the highest-risk antibiotic for C. diff. And the nurses said she was sick in bed for three days with diarrhea and a fever. No one put the pieces together.


Years later, the clinic where I worked lost its relationship with the social organization for the patients with serious mental illness, and suddenly we had a great change in our patient population. Our patient population went from 85% with schizophrenia to 15% with schizophrenia. This was a great loss to many who worked there, and most employees left, including Ann, our superstar nurse, who was born to do that job. I meandered for a few semesters, working at the clinic one day per week while simultaneously finishing my doctoral degree and teaching classes. The change in patient population felt personal, as it was my last connection to my sister Doris.


So now I am tasked with recording a lecture about what kind of special considerations people with serious mental illness need in a primary care setting. I picture my sister, who, just prior to her unsuccessful surgery to have her septic colon removed, said to me, "You flew all the way here just for me? You shouldn't have." Then she was rolled down the hallway toward the surgical suite on her bed, IV pressors and fluids running into her veins to try to save her. She held her arm straight up and waved her fingers so that we could see her all the way down the hall, until the swinging doors shut.


What could I say in this lecture to portray how easily we can lose these patients? How they can slip through the cracks of the system in an instant. No room for error or poor communication-these people are the epitome of vulnerable. Instead, another year goes by where I simply assign readings on this topic. Another year where I cannot find words to express what I lost.