THE WESTERN JOURNAL OF MEDICINE * APRIL 1992 *
156 * 4
rabbits have classically been linked to the illness, arthropodborne illness is becoming more common, with ticks being the principal reservoir.2 Rabbits and other mammals represent a source of infection, particularly in the winter months; these animals rarely represent true reservoirs, however, because most infected mammals either become sick and die or recover with loss of the organism.I Although little is known about the actual arthropod infection, it is thought that transovarial transmission occurs. Ticks may live as long as 21 years, with great potential for harboring the organism. 14(pp227,323) The organism has been identified in more than 55 different arthropods. Francis was the first to describe cases of tularemia caused by the deer fly. The disease had popularly been known as "deer fly fever," with a predominance noted in the Western states of Utah and Colorado and an associated peak incidence in the summer months. Typical of arthropod-borne infections, a definite source of infection is often not identified, as in our case. Streptomycin is the drug of choice in tularemia. In vitro it is both bacteriostatic and bactericidal. Patients treated with streptomycin generally defervesce in 48 hours and require
only one 14-day course of therapy. Gentamicin, tetracycline, and erythromycin have been used with only varying success.2 It was of interest that. our patient's fever resolved within 24 hours of the start of therapy with rifampin. Tularemia continues to present a diagnostic challenge to physicians in and around endemic areas. An understanding of its protean manifestations is essential in its recognition and appropriate treatment. In our case, tularemia presented as pleurisy with a pleural effusion. Although isolated pleural effusion with associated pleuritic pain is often self-limited and presumed viral in origin, we suggest that tularemia be considered in those patients whose illness fails to resolve in a timely manner. Serologic tests are diagnostic, and a rapid clinical response can be expected with streptomycin therapy. REFERENCES 1. Francis E: Tularemia. JAMA 1925; 84:1243-1250 2. Evans ME, Gregory DW, Schaffner W, McGee ZA: Tularemia: A 30-year
experience with 88 cases. Medicine (Baltimore) 1985; 64:251-269 3. Overholt EL, Tigertt WD, Kadull PJ, et al: An analysis of forty-two cases of laboratory-acquired tularemia: Treatment with broad-spectrum antibiotics. Am J Med 1961; 30:785-806 4. McCoy GW, Chapin CW: Studies of plague, a plague-like disease and tuberculosis among rodents in California. Public Health Bull 1912; 53:3-11 5. Dennis JM, Boudreau RP: Pleuropulmonary tularemia: Its roentgen manifestations. Radiology 1957; 68:25-30 6. Warring WB, Ruffin JS: A tick-borne epidemic of tularemia. N Engl J Med 1946; 234: 137-140 7. Miller RP, Bates JH: Pleuropulmonary tularemia-A review of 29 patients. Am Rev Respir Dis 1969; 99:31-41 8. Rubin SA: Radiographic spectrum of pleuropulmonary tularemia. AJR 1978;
131:277-281 9. Blackford SD, Casey CJ: Pleuropulmonary tularemia. Arch Intern Med 1941; 67:43-7 1 10. Kennedy JA: Pleuropulmonary tularemia-A discussion of the disease as a clinical entity, with report of three cases. JAMA 1942; 118:781-787 11. Jager BV, Ransmeier JC: Constrictive pericarditis due to bacterium tularenseReport of a case and review of reported cases of pericarditis occurring with tularemia. Bull Johns Hopkins Hosp 1943; 72:166-178 12. Saslaw S, Carhart S: Studies with tularemia vaccine in volunteers challenged with Pasteurella tularensis. Am J Med Sci 1961; 241:689-699 13. Francis E, Evans AC: Agglutination, cross-agglutination and agglutination absorption in tularemia. Public Health Rep 1926; 41:1273-1295 14. James MT, Harwood RF: Herm's Medical Entomology. London, Macmillan, 1969
417
Medicolegal Complications of Postpartum Catatonia GEORGE BACH-Y-RITA, MD ALBERT DE RANIERI, MD San Francisco, Califomia
SINCE PRE-REVOLUTIONARY times and with the adoption from England of the mandate of parens patriae, protecting severely impaired mentally ill persons has been the responsibility of the state. This mandate calls for protecting all citizens or subjects unable to protect themselves, such as minors or the insane. To fulfill its social objectives and to protect the mentally ill from the abandonment and despair common before the development of modern psychiatric institutions, the state charged the medical and psychiatric community with responsibility for the care and treatment of the individual. Concomitantly, the legal community developed laws ensuring guardianship of the insane and incompetent. This partnership of care reached its zenith in the late 1960s with the crafting of laws such as the Lanterman-Petris Short Act of California, which weighed the medical care and the legal protection needs of the mentally ill, in an attempt to balance requirements and rights in a humane fashion. The Lanterman-Petris Short Act of California mandated the formation of an office of patients' rights advocacy. Among the many responsibilities defined under the California Welfare and Institution Code, Section 5500(a), patient advocacy for the mentally ill was "to protect their rights or to secure or upgrade treatment or other services to which they are entitled." An advocate's role in practice occurs in adversarial-type hearings with an attorney sitting in lieu of a judge. In the hearings, a patient's rights advocate protects the patient from the physician, who attempts to retain and treat the patient. The individual rights movement in the 1970s gave rise to a phenomenon that can best be described as distrust of the professional community. The field of psychiatry, which for a number of years had been retreating from ascribing a medical basis to psychiatric illness, was undermined further by prominent psychiatrists who perceived mental illness or psychosis as a myth or adaptation rather than an illness, advancing the perception of medical psychiatry as an instrument of abuse rather than treatment. Fostered by this distrust, a series of legal decisions and laws closely regulated care through the courts, exemplified by legislation restricting the use of electroconvulsive therapy. More recently, the decision in Riese v St Mary's Hospital separated involuntary admission to hospital from involuntary treatment with antipsychotic medications.1 Under this decision, these medications can be given to nonvoluntary patients only after a separate judicial hearing. In the two years since the Riese v St Mary's Hospital decision, we have become aware of its devastating consequences. Report of a Case The patient, a 22-year-old woman with no previous psychiatric history, was admitted to a psychiatric service ten days
(Bach-y-Rita G, DeRanieri A: Medicolegal complications of postpartum catatonia. West J Med 1992 Apr; 156:417-419) Reprint requests to George Bach-y-Rita, MD, 2100 Webster St, Ste 314, San Francisco, CA 94115.
418
after a cesarean section. Her family noticed that shortly after delivery she was fearful, acted bizarre, and had a personality change accompanied by delusional thinking. She began to believe that she was a psychic and was able to read people's minds. This personality change was associated with severe mood swings. She displayed little interest in caring for her newborn child and had difficulty concentrating. On the urging of her family, the patient admitted herself voluntarily to
the psychiatric service. On admission she was floridly psychotic and had a temperature of 38.3°C (101°F). The fever was thought to be from either an upper respiratory tract or a urinary tract infection. She was diagnosed with an affective disorder, and treatment was begun with lithium carbonate and perphenazine. Three days after admission, she became agitated, more labile and delusional, and no longer cooperated with care. The dose of perphenazine was increased, lorazepam was added to the regimen, and almost continuous physical restraints were needed. She required special nursing. To continue treatment, the law required that a judicial hearing be held to determine if the severity of her clinical state permitted the patient to be held against her will, as well as a second and separate Riese hearing to determine if she was being treated against her will. California law permits initial involuntary treatment without a hearing during the first 72 hours of evaluation and hospital stay. While awaiting the hearing, treatment was continued. Five days after admission, a hearing was convened. A hearing officer-lawyer appointed by the court heard the case and deemed the patient "gravely disabled" and thus holdable. The patient was held involuntarily under Section 5250 of the Welfare and Institution Code of California. Immediately after the first hearing, a second hearing was convened to determine if the patient could be treated involuntarily with medicine. A number of professionals were involved in the hearing, including an attorney acting in lieu of a judge (judge pro tem), one appointed by the court to represent the patient, another retained by the hospital, a patients' rights advocate retained by the county, and the psychiatrist presenting the case. The court-appointed attorney requested a brain scan and raised the possibility of a brain hemorrhage at the time of delivery. The judge pro tem denied permission to administer medication involuntarily and ordered that the patient be given medication only when and if she wanted it. As a result of this hearing, the systematic treatment with psychotropic medication was stopped on the sixth day of the patient's hospital stay. From this day onward, unable to treat effectively, physicians were able to maintain hydration only through the use of intravenous fluids and four-point physical restraints. The patient was unwilling to eat and lost weight. Increasingly agitated, she was given fluphenazine hydrochloride, which was administered only when she accepted it. By the tenth day she had a creatine kinase level of 876 units per liter and a pulse rate of 120 beats per minute, which accompanied the unremnitting fever. She remained unresponsive to antipsychotic medication. As a result of concern over the possible development of a neuroleptic malignant syndrome, on the tenth day all psychotropic drugs were stopped. A neurology consulta-
tion
was requested, and an electroencephalogram was normal. The neurologist found no evidence of the neuroleptic malignant syndrome. With no one able to make treatment decisions regarding her health, a petition was prepared requesting the county to appoint a temporary conservator.
ALERTS, NOTICES, AND CASE REPORTS
The patient continued to express paranoid delusions, threatened to harm others, and was increasingly aggressive. The results of a lumbar puncture study were normal. On the 15th day, as a result of her continuing refusal of food and water, increasing agitation and the constant need for fourpoint restraints, and an unabated psychosis unresponsive to medication, she was treated more aggressively with neuroleptic drugs and lorazepam, with little clinical change. By the 21st day of her hospital stay, with continuing hyperthermia and still unresponsive to medication, the patient's creatine kinase level had risen to 1,339 units per liter. All medication was stopped again because of the fear of neuroleptic malignant syndrome. Symptoms of waxy flexibility, excessive posturing, and negativism were also developing. After a ten-day delay, a conservator had been appointed, and, 23 days after admission, the conservator gave permission to do a brain scan. The patient's agitation required that she be given nitrous oxide anesthesia to do the scan. The patient's countyappointed attorney objected to the procedure because he considered the intended use of the nitrous oxide anesthesia to be invasive. He appealed to the county mental health director to overrule the district attorney and block the procedure, demanding that the case be sent to court so that a superior court judge could decide whether the patient would undergo the procedure. It took four days to obtain a court hearing. With no clinical evidence presented to support the objections to the procedure, the judge gave permission to proceed. On the 27th day of her hospital course, the scan was done; it revealed no pertinent information. On the 24th day of her hospital stay, a decision was made to proceed with electroconvulsive treatment. Under California law, this is permitted in a nonvoluntary patient only after all other possible treatment has been tried. The patient's waxy flexibility continued, now accompanied by a scissorslike crossing of the legs and fingers associated with other symptoms, such as auditory and visual hallucinations. The diagnosis of lethal catatonia was made.23 As mandated by law, the treating psychiatrist obtained three psychiatric consultants, adding another two days of delay. Each filled out the necessary affidavits, and permission was requested of the conservator. A fifth psychiatrist, appointed by the county, was now required to review the first four opinions, and this added another day of delay. The case was again referred to the superior court judge for permission to proceed. The court advised that it would take ten days for a hearing. The physicians were concerned that the patient was dying. Consequently, a letter was handdelivered to the court explaining the urgency. Even so, intervention by the hospital attorney was necessary to speed the legal timetable, and a hearing was held on the patient's 32nd day of hospital stay. With no clinical evidence to the contrary, the judge ruled in favor of the requested treatment on a Friday afternoon. On Saturday morning, the 33rd day of her hospital stay, electroconvulsive therapy was done. Within 36 hours, the patient no longer required nasogastric feedings, intravenous fluids, or restraints. Special nursing care was stopped. The patient was sociable and began to feed herself voluntarily. An uneventful course of electroconvulsive treatment followed, and the patient was discharged.
Discussion Legal procedures posed a serious obstacle to caring for this patient and resulted in notable delays in treatment. Al-
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though intended to protect the patient's civil rights, the net effect was just the opposite. Because her physicians had to use physical restraints and extraordinary measures to maintain life, the patient was denied the right to be free of a threat to life and the right to be free of physical restraint. Without the legal obstacles, she could have been treated effectively in 14 days, sparing her weeks of additional involuntary detention and restraint and without her life being in danger. Because of legal obstacles, costs increased. Our patient required 30 days of special 24-hour nursing, 23 days of parenteral hydration, 8 days of nasogastric feeding, and 18 additional hospital days while awaiting the results of legal proceedings. These hearings were directed exclusively at procedural legal matters. At no point was medical evidence introduced to alter the treatment plan. The county bore the cost of a patients' rights officer, a hearing officer, and the fees for the electroconvulsive therapy proceedings. The family paid their own attorney, and the physicians were denied all payment for the care they provided. Most of these expenses were billed to the state mental health budget in California. Our case is an example of how using an adversarial system for making psychiatric care decisions does not help the patient. At the core is the issue of assuming responsibility for a mentally ill patient when that person is incompetent. Although traditionally the family, together with the physician, was trusted to make decisions, the family now is largely excluded. Physicians are still expected to care for and cure, but they are denied the power to make clinical decisions. Bureaucrats and lawyers divide up the clinical decision making, but they are not responsible for their actions, with the exception of the conservator, who also is denied decisionmaking power. This power is left to the crowded courts. Many reforms are necessary, but any changes must fulfill basic principles. No legal procedure should endanger a patient's life, extend the time a patient remains in hospital or in restraints, delay appropriate care, or increase medical costs. Several basic remedies to the present set of procedures are in order. Primarily, the concept of "danger to self, others," and ''gravely disabled" includes a vague set of criteria useful only as a screening tool. These criteria should be abandoned at the time of a hearing. What is of concern is whether or not persons suffer such impaired mental processes that they can no longer act cogently and responsibly on their own behalf. For this they must be sufficiently free of disordered thought and possess the free will and information necessary to make rational decisions. When these are absent or sufficiently impaired so as to render patients incapable of adequately assuming responsibility and representing themselves, the state has an obligation to intervene. Once the state has determined that a patient is impaired, the decision-making function must be assumed by a stateappointed patient conservator or advocate. This advocate must be responsible for the total mandate of Section 5500(a), including "securing or upgrading treatment or other services to which the patient is entitled." One right should not be permitted to overshadow any other rights. For this purpose, the findings of an involuntary hearing and of the Riese hearing must be combined into one. This hearing should occur within 12 hours of notifying the court. The appointed advocate should be responsible to the patient and the family for assuring speedy, humane, and appropriate medical care when indicated under the least restrictive conditions, acting as a highly educated, informed parent or concerned family
419
419
member might act under the doctrine ofparenspatriae. This person should be skilled in medical psychiatry as well as in the legal issues that affect patients' welfare. The budget for legal matters and the costs incurred arising from these must be stripped out of the mental health budget and separately budgeted by the legislature. To include these expenses in the health budget, as is currently done, is to falsely inflate the health budget and subsequently deny medical care to patients. REFERENCES I. Riese v St Mary's Hospital, 209 C3d 1303 (1987) 2. Mann SC, Caroff SN, Bleir HR, Welz WKR, Kling MA, Hayashida M: Lethal catatonia. Am J Psychiatry 1986; 143:1374-1381 3. Lazarus A, Mann SC, Caroff SN: Lethal catatonia, chap 5, In Gold JH (Ed): The Neuroleptic Malignant Syndrome and Related Conditions. Washington, DC, American Psychiatric Press, 1990, pp 169-197
Temperate Zone Pyomyositis PETER BONAFEDE, MD JEFFREY BUTLER, MD Portland, Oregon ROBERT KIMBROUGH, MD Springfield, Missouri MARK LOVELESS, MD
Portland, Oregon
PYOMYOSITIS is a primary bacterial infection occurring in skeletal muscle with no obvious local or adjacent source of infection. It is frequently called tropical myositis because of its high incidence in warm, humid climates. It is responsible for as many as 4% of hospital surgical admissions in East Africa.' The first series was recorded in 1885 by Scriba.2 The first case reported in the United States was in 1904.3 An additional 93 cases have been described in North America, all since 1971. The early cases occurred mostly in healthy children and were reported mainly from hot, low-lying areas. Patients recently reported in the literature have often had an underlying disorder resulting in immune suppression, such as hematologic disease,4-8 human immunodeficiency virus (HIV) infection,9'-3 connective tissue disorders,7. 14-16 and transplantation.17 We report our experience with 14 patients in Oregon over the past ten years. Patients and Methods Patients were identified by a computer search of hospital admission records or by direct review of the records of the infectious disease consulting service from 1979 to 1990. The search terms used were pyomyositis, myositis, muscle infection, and soft tissue infection. About 200 patient records were reviewed. In all the cases included in this study, pyomyositis was (Bonafede P, Butler J, Kimbrough R, Loveless M: Temperate zone pyomyositis. West J Med 1992 Apr; 156:419-423) From the Providence Arthritis Center (Dr Bonafede) and the Divisions of Rheumatology (Dr Butler) and Infectious Diseases (Dr Loveless), Department of Medicine, Oregon Health Sciences University, Portland. Dr Kimbrough is in private practice in Springfield, Missouri. Presented at the American College of Rheumatology Western Regional meeting March 1990. Reprint requests to Peter Bonafede, MD, Providence Arthritis Center, Providence Professional Plaza, Ste 322, 510 NE 49th Ave, Portland, OR 97213.
156 * 4
rabbits have classically been linked to the illness, arthropodborne illness is becoming more common, with ticks being the principal reservoir.2 Rabbits and other mammals represent a source of infection, particularly in the winter months; these animals rarely represent true reservoirs, however, because most infected mammals either become sick and die or recover with loss of the organism.I Although little is known about the actual arthropod infection, it is thought that transovarial transmission occurs. Ticks may live as long as 21 years, with great potential for harboring the organism. 14(pp227,323) The organism has been identified in more than 55 different arthropods. Francis was the first to describe cases of tularemia caused by the deer fly. The disease had popularly been known as "deer fly fever," with a predominance noted in the Western states of Utah and Colorado and an associated peak incidence in the summer months. Typical of arthropod-borne infections, a definite source of infection is often not identified, as in our case. Streptomycin is the drug of choice in tularemia. In vitro it is both bacteriostatic and bactericidal. Patients treated with streptomycin generally defervesce in 48 hours and require
only one 14-day course of therapy. Gentamicin, tetracycline, and erythromycin have been used with only varying success.2 It was of interest that. our patient's fever resolved within 24 hours of the start of therapy with rifampin. Tularemia continues to present a diagnostic challenge to physicians in and around endemic areas. An understanding of its protean manifestations is essential in its recognition and appropriate treatment. In our case, tularemia presented as pleurisy with a pleural effusion. Although isolated pleural effusion with associated pleuritic pain is often self-limited and presumed viral in origin, we suggest that tularemia be considered in those patients whose illness fails to resolve in a timely manner. Serologic tests are diagnostic, and a rapid clinical response can be expected with streptomycin therapy. REFERENCES 1. Francis E: Tularemia. JAMA 1925; 84:1243-1250 2. Evans ME, Gregory DW, Schaffner W, McGee ZA: Tularemia: A 30-year
experience with 88 cases. Medicine (Baltimore) 1985; 64:251-269 3. Overholt EL, Tigertt WD, Kadull PJ, et al: An analysis of forty-two cases of laboratory-acquired tularemia: Treatment with broad-spectrum antibiotics. Am J Med 1961; 30:785-806 4. McCoy GW, Chapin CW: Studies of plague, a plague-like disease and tuberculosis among rodents in California. Public Health Bull 1912; 53:3-11 5. Dennis JM, Boudreau RP: Pleuropulmonary tularemia: Its roentgen manifestations. Radiology 1957; 68:25-30 6. Warring WB, Ruffin JS: A tick-borne epidemic of tularemia. N Engl J Med 1946; 234: 137-140 7. Miller RP, Bates JH: Pleuropulmonary tularemia-A review of 29 patients. Am Rev Respir Dis 1969; 99:31-41 8. Rubin SA: Radiographic spectrum of pleuropulmonary tularemia. AJR 1978;
131:277-281 9. Blackford SD, Casey CJ: Pleuropulmonary tularemia. Arch Intern Med 1941; 67:43-7 1 10. Kennedy JA: Pleuropulmonary tularemia-A discussion of the disease as a clinical entity, with report of three cases. JAMA 1942; 118:781-787 11. Jager BV, Ransmeier JC: Constrictive pericarditis due to bacterium tularenseReport of a case and review of reported cases of pericarditis occurring with tularemia. Bull Johns Hopkins Hosp 1943; 72:166-178 12. Saslaw S, Carhart S: Studies with tularemia vaccine in volunteers challenged with Pasteurella tularensis. Am J Med Sci 1961; 241:689-699 13. Francis E, Evans AC: Agglutination, cross-agglutination and agglutination absorption in tularemia. Public Health Rep 1926; 41:1273-1295 14. James MT, Harwood RF: Herm's Medical Entomology. London, Macmillan, 1969
417
Medicolegal Complications of Postpartum Catatonia GEORGE BACH-Y-RITA, MD ALBERT DE RANIERI, MD San Francisco, Califomia
SINCE PRE-REVOLUTIONARY times and with the adoption from England of the mandate of parens patriae, protecting severely impaired mentally ill persons has been the responsibility of the state. This mandate calls for protecting all citizens or subjects unable to protect themselves, such as minors or the insane. To fulfill its social objectives and to protect the mentally ill from the abandonment and despair common before the development of modern psychiatric institutions, the state charged the medical and psychiatric community with responsibility for the care and treatment of the individual. Concomitantly, the legal community developed laws ensuring guardianship of the insane and incompetent. This partnership of care reached its zenith in the late 1960s with the crafting of laws such as the Lanterman-Petris Short Act of California, which weighed the medical care and the legal protection needs of the mentally ill, in an attempt to balance requirements and rights in a humane fashion. The Lanterman-Petris Short Act of California mandated the formation of an office of patients' rights advocacy. Among the many responsibilities defined under the California Welfare and Institution Code, Section 5500(a), patient advocacy for the mentally ill was "to protect their rights or to secure or upgrade treatment or other services to which they are entitled." An advocate's role in practice occurs in adversarial-type hearings with an attorney sitting in lieu of a judge. In the hearings, a patient's rights advocate protects the patient from the physician, who attempts to retain and treat the patient. The individual rights movement in the 1970s gave rise to a phenomenon that can best be described as distrust of the professional community. The field of psychiatry, which for a number of years had been retreating from ascribing a medical basis to psychiatric illness, was undermined further by prominent psychiatrists who perceived mental illness or psychosis as a myth or adaptation rather than an illness, advancing the perception of medical psychiatry as an instrument of abuse rather than treatment. Fostered by this distrust, a series of legal decisions and laws closely regulated care through the courts, exemplified by legislation restricting the use of electroconvulsive therapy. More recently, the decision in Riese v St Mary's Hospital separated involuntary admission to hospital from involuntary treatment with antipsychotic medications.1 Under this decision, these medications can be given to nonvoluntary patients only after a separate judicial hearing. In the two years since the Riese v St Mary's Hospital decision, we have become aware of its devastating consequences. Report of a Case The patient, a 22-year-old woman with no previous psychiatric history, was admitted to a psychiatric service ten days
(Bach-y-Rita G, DeRanieri A: Medicolegal complications of postpartum catatonia. West J Med 1992 Apr; 156:417-419) Reprint requests to George Bach-y-Rita, MD, 2100 Webster St, Ste 314, San Francisco, CA 94115.
418
after a cesarean section. Her family noticed that shortly after delivery she was fearful, acted bizarre, and had a personality change accompanied by delusional thinking. She began to believe that she was a psychic and was able to read people's minds. This personality change was associated with severe mood swings. She displayed little interest in caring for her newborn child and had difficulty concentrating. On the urging of her family, the patient admitted herself voluntarily to
the psychiatric service. On admission she was floridly psychotic and had a temperature of 38.3°C (101°F). The fever was thought to be from either an upper respiratory tract or a urinary tract infection. She was diagnosed with an affective disorder, and treatment was begun with lithium carbonate and perphenazine. Three days after admission, she became agitated, more labile and delusional, and no longer cooperated with care. The dose of perphenazine was increased, lorazepam was added to the regimen, and almost continuous physical restraints were needed. She required special nursing. To continue treatment, the law required that a judicial hearing be held to determine if the severity of her clinical state permitted the patient to be held against her will, as well as a second and separate Riese hearing to determine if she was being treated against her will. California law permits initial involuntary treatment without a hearing during the first 72 hours of evaluation and hospital stay. While awaiting the hearing, treatment was continued. Five days after admission, a hearing was convened. A hearing officer-lawyer appointed by the court heard the case and deemed the patient "gravely disabled" and thus holdable. The patient was held involuntarily under Section 5250 of the Welfare and Institution Code of California. Immediately after the first hearing, a second hearing was convened to determine if the patient could be treated involuntarily with medicine. A number of professionals were involved in the hearing, including an attorney acting in lieu of a judge (judge pro tem), one appointed by the court to represent the patient, another retained by the hospital, a patients' rights advocate retained by the county, and the psychiatrist presenting the case. The court-appointed attorney requested a brain scan and raised the possibility of a brain hemorrhage at the time of delivery. The judge pro tem denied permission to administer medication involuntarily and ordered that the patient be given medication only when and if she wanted it. As a result of this hearing, the systematic treatment with psychotropic medication was stopped on the sixth day of the patient's hospital stay. From this day onward, unable to treat effectively, physicians were able to maintain hydration only through the use of intravenous fluids and four-point physical restraints. The patient was unwilling to eat and lost weight. Increasingly agitated, she was given fluphenazine hydrochloride, which was administered only when she accepted it. By the tenth day she had a creatine kinase level of 876 units per liter and a pulse rate of 120 beats per minute, which accompanied the unremnitting fever. She remained unresponsive to antipsychotic medication. As a result of concern over the possible development of a neuroleptic malignant syndrome, on the tenth day all psychotropic drugs were stopped. A neurology consulta-
tion
was requested, and an electroencephalogram was normal. The neurologist found no evidence of the neuroleptic malignant syndrome. With no one able to make treatment decisions regarding her health, a petition was prepared requesting the county to appoint a temporary conservator.
ALERTS, NOTICES, AND CASE REPORTS
The patient continued to express paranoid delusions, threatened to harm others, and was increasingly aggressive. The results of a lumbar puncture study were normal. On the 15th day, as a result of her continuing refusal of food and water, increasing agitation and the constant need for fourpoint restraints, and an unabated psychosis unresponsive to medication, she was treated more aggressively with neuroleptic drugs and lorazepam, with little clinical change. By the 21st day of her hospital stay, with continuing hyperthermia and still unresponsive to medication, the patient's creatine kinase level had risen to 1,339 units per liter. All medication was stopped again because of the fear of neuroleptic malignant syndrome. Symptoms of waxy flexibility, excessive posturing, and negativism were also developing. After a ten-day delay, a conservator had been appointed, and, 23 days after admission, the conservator gave permission to do a brain scan. The patient's agitation required that she be given nitrous oxide anesthesia to do the scan. The patient's countyappointed attorney objected to the procedure because he considered the intended use of the nitrous oxide anesthesia to be invasive. He appealed to the county mental health director to overrule the district attorney and block the procedure, demanding that the case be sent to court so that a superior court judge could decide whether the patient would undergo the procedure. It took four days to obtain a court hearing. With no clinical evidence presented to support the objections to the procedure, the judge gave permission to proceed. On the 27th day of her hospital course, the scan was done; it revealed no pertinent information. On the 24th day of her hospital stay, a decision was made to proceed with electroconvulsive treatment. Under California law, this is permitted in a nonvoluntary patient only after all other possible treatment has been tried. The patient's waxy flexibility continued, now accompanied by a scissorslike crossing of the legs and fingers associated with other symptoms, such as auditory and visual hallucinations. The diagnosis of lethal catatonia was made.23 As mandated by law, the treating psychiatrist obtained three psychiatric consultants, adding another two days of delay. Each filled out the necessary affidavits, and permission was requested of the conservator. A fifth psychiatrist, appointed by the county, was now required to review the first four opinions, and this added another day of delay. The case was again referred to the superior court judge for permission to proceed. The court advised that it would take ten days for a hearing. The physicians were concerned that the patient was dying. Consequently, a letter was handdelivered to the court explaining the urgency. Even so, intervention by the hospital attorney was necessary to speed the legal timetable, and a hearing was held on the patient's 32nd day of hospital stay. With no clinical evidence to the contrary, the judge ruled in favor of the requested treatment on a Friday afternoon. On Saturday morning, the 33rd day of her hospital stay, electroconvulsive therapy was done. Within 36 hours, the patient no longer required nasogastric feedings, intravenous fluids, or restraints. Special nursing care was stopped. The patient was sociable and began to feed herself voluntarily. An uneventful course of electroconvulsive treatment followed, and the patient was discharged.
Discussion Legal procedures posed a serious obstacle to caring for this patient and resulted in notable delays in treatment. Al-
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though intended to protect the patient's civil rights, the net effect was just the opposite. Because her physicians had to use physical restraints and extraordinary measures to maintain life, the patient was denied the right to be free of a threat to life and the right to be free of physical restraint. Without the legal obstacles, she could have been treated effectively in 14 days, sparing her weeks of additional involuntary detention and restraint and without her life being in danger. Because of legal obstacles, costs increased. Our patient required 30 days of special 24-hour nursing, 23 days of parenteral hydration, 8 days of nasogastric feeding, and 18 additional hospital days while awaiting the results of legal proceedings. These hearings were directed exclusively at procedural legal matters. At no point was medical evidence introduced to alter the treatment plan. The county bore the cost of a patients' rights officer, a hearing officer, and the fees for the electroconvulsive therapy proceedings. The family paid their own attorney, and the physicians were denied all payment for the care they provided. Most of these expenses were billed to the state mental health budget in California. Our case is an example of how using an adversarial system for making psychiatric care decisions does not help the patient. At the core is the issue of assuming responsibility for a mentally ill patient when that person is incompetent. Although traditionally the family, together with the physician, was trusted to make decisions, the family now is largely excluded. Physicians are still expected to care for and cure, but they are denied the power to make clinical decisions. Bureaucrats and lawyers divide up the clinical decision making, but they are not responsible for their actions, with the exception of the conservator, who also is denied decisionmaking power. This power is left to the crowded courts. Many reforms are necessary, but any changes must fulfill basic principles. No legal procedure should endanger a patient's life, extend the time a patient remains in hospital or in restraints, delay appropriate care, or increase medical costs. Several basic remedies to the present set of procedures are in order. Primarily, the concept of "danger to self, others," and ''gravely disabled" includes a vague set of criteria useful only as a screening tool. These criteria should be abandoned at the time of a hearing. What is of concern is whether or not persons suffer such impaired mental processes that they can no longer act cogently and responsibly on their own behalf. For this they must be sufficiently free of disordered thought and possess the free will and information necessary to make rational decisions. When these are absent or sufficiently impaired so as to render patients incapable of adequately assuming responsibility and representing themselves, the state has an obligation to intervene. Once the state has determined that a patient is impaired, the decision-making function must be assumed by a stateappointed patient conservator or advocate. This advocate must be responsible for the total mandate of Section 5500(a), including "securing or upgrading treatment or other services to which the patient is entitled." One right should not be permitted to overshadow any other rights. For this purpose, the findings of an involuntary hearing and of the Riese hearing must be combined into one. This hearing should occur within 12 hours of notifying the court. The appointed advocate should be responsible to the patient and the family for assuring speedy, humane, and appropriate medical care when indicated under the least restrictive conditions, acting as a highly educated, informed parent or concerned family
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member might act under the doctrine ofparenspatriae. This person should be skilled in medical psychiatry as well as in the legal issues that affect patients' welfare. The budget for legal matters and the costs incurred arising from these must be stripped out of the mental health budget and separately budgeted by the legislature. To include these expenses in the health budget, as is currently done, is to falsely inflate the health budget and subsequently deny medical care to patients. REFERENCES I. Riese v St Mary's Hospital, 209 C3d 1303 (1987) 2. Mann SC, Caroff SN, Bleir HR, Welz WKR, Kling MA, Hayashida M: Lethal catatonia. Am J Psychiatry 1986; 143:1374-1381 3. Lazarus A, Mann SC, Caroff SN: Lethal catatonia, chap 5, In Gold JH (Ed): The Neuroleptic Malignant Syndrome and Related Conditions. Washington, DC, American Psychiatric Press, 1990, pp 169-197
Temperate Zone Pyomyositis PETER BONAFEDE, MD JEFFREY BUTLER, MD Portland, Oregon ROBERT KIMBROUGH, MD Springfield, Missouri MARK LOVELESS, MD
Portland, Oregon
PYOMYOSITIS is a primary bacterial infection occurring in skeletal muscle with no obvious local or adjacent source of infection. It is frequently called tropical myositis because of its high incidence in warm, humid climates. It is responsible for as many as 4% of hospital surgical admissions in East Africa.' The first series was recorded in 1885 by Scriba.2 The first case reported in the United States was in 1904.3 An additional 93 cases have been described in North America, all since 1971. The early cases occurred mostly in healthy children and were reported mainly from hot, low-lying areas. Patients recently reported in the literature have often had an underlying disorder resulting in immune suppression, such as hematologic disease,4-8 human immunodeficiency virus (HIV) infection,9'-3 connective tissue disorders,7. 14-16 and transplantation.17 We report our experience with 14 patients in Oregon over the past ten years. Patients and Methods Patients were identified by a computer search of hospital admission records or by direct review of the records of the infectious disease consulting service from 1979 to 1990. The search terms used were pyomyositis, myositis, muscle infection, and soft tissue infection. About 200 patient records were reviewed. In all the cases included in this study, pyomyositis was (Bonafede P, Butler J, Kimbrough R, Loveless M: Temperate zone pyomyositis. West J Med 1992 Apr; 156:419-423) From the Providence Arthritis Center (Dr Bonafede) and the Divisions of Rheumatology (Dr Butler) and Infectious Diseases (Dr Loveless), Department of Medicine, Oregon Health Sciences University, Portland. Dr Kimbrough is in private practice in Springfield, Missouri. Presented at the American College of Rheumatology Western Regional meeting March 1990. Reprint requests to Peter Bonafede, MD, Providence Arthritis Center, Providence Professional Plaza, Ste 322, 510 NE 49th Ave, Portland, OR 97213.
