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The fifth amendment and the psychiatric interview in civil commitment proceedings
vaginal carriage of enterobacteria in patients compared to similar cultures from women who have never had a u r i n a r y tract infection. (Editor's note: Women who present with recurrent urinary tract infections probably should not be treated in the ED, but referred.) David J. Orban, MD
urinary tract infections
The fifth amendment and the psychiatric interview in civil commitment proceedings, Perry ET, J Leg Med
45-51, (Aug) 1977. In cases of involuntary civil commitment, the psychiatrists recommendation to the court is based upon the psychiatric interview. According to the author, in t h e majority of cases the psychiatric recommendation is the effective d e t e r m i n i n g factor in w h e t h e r a person is committed. The courts apparently fail to ensure t h a t the psychiatrist comply with statutory standards for making recommendations according to the requisite finding of dangerousness. The article argues further t h a t the patient is forced to make a choice between self-accusation, perjury and contempt and t h a t various forms of coercion are used to elicit material used in the interview. The fifth a m e n d m e n t would protect the individual from self-accusation, reinforce his right to freedom from coercion and his r i g h t to privacy. One recent federal court decision held t h a t ¢'statements made to a psychiatrist by the subject of a commitment proceeding, unless voluntarily given after notice of the possible consequences cannot be the basis for a n order of commitment." Other courts have followed with similar decisions. The question is ripe for the Supreme Court. (Editor's note: In this article also, there is an implication that the physician and patient are adversaries. This is a distressing direction which fails to acknowledge the issue o f the patient's
serious illness.) legality, psychiatry, commitment
Anne Salmon, PhD, MD
Tuberculous peritonitis. Cromartie RS, Surg Gynecol
Obstet 144:876-878 (Jun) 1977. The records of 40 patients with tuberculous peritonitis t r e a t e d at Louisiana Charity Hospitals were reviewed. The average age was 36.5 years, 39 patients were black, 24 were male. The most common symptoms were fever, abdominal pain, abdominal swelling, a n d weight loss, which correlated well with the clinical findings of fever, abdominal tenderness, and ascites. The ascitic fluid recovered generally h a d a high protein content (greater t h a n 2.5 gm/100 ml), a varying white blood cell count b u t with a differential predominantly t h a t of lymphocytes, and a glucose low in comparison to the serum glucose. The x-ray film findings were t h a t of a mild ileus, ascites, elevation of the diaphragm, diffuse haziness of the abdomen, and loss of the psoas stripe. Diagnosis was most often made at laparotomy (24 of 40), and t r e a t m e n t consisted of any of a n u m b e r of long t e r m multiple drug regimens. (Editor's note: Tuberculosis in its many guises is still prevalent in the United States.) Geoffrey Korn, MD tuberculosis, peritonitis
Indications for thoracotomy following penetrating thoracic injury. Siemens R, Polk HC, Gray LA, et al, J
Trauma 17:493-500, (Jul) 1977. Although most surgeons agree t h a t closed thoracostomy drainage is t h e initial t r e a t m e n t of choice for p e n e t r a t i n g thoracic injuries, t h e t i m i n g of early thoracotomy and cardiorrhaphy in sucl~ patients remains controversial. The purpose of the study outlined in this paper was to determine which patients with penet~'ating injuries to the chest require immediate thoracotomy o r cardiorrhaphy. Over a two-year period 190 p a t i e n t s p e n e t r a t i n g thoracic injuries were treated. Of 53 patients who required immediate thoracotomy, 31 suffered cardiac wounds. Based on a retrospective analysis of these cases the suggested
,~)
6:12 (Dec) 1977
indications for immediate thoracotomy or cardiorrhaphy are: 1) location of the entrance wound in upper mediastinum; 2) blood pressure on admission < 90 m m Hg; 3) initial thoracostomy blood loss >800 cc; 4) radiographic evidence of retained hemothorax, and 5) clinical evidence of pericardial tamponade. Decisionm a k i n g by emergency physicians may be facilitated in these patients by r e m e m b e r i n g which patients with p e n e t r a t i n g thoracic t r a u m a are most likely to require early surgical intervention, regardless of the patient's clinical status at the time of presentation to the emergency department. (Editor's note: This is the sort o f investigation emergency physicians should be pursuing.)
Robert Hockberger, MD injury, thoracic
The fifth amendment and the psychiatric interview in civil commitment proceedings. Perry ETI J Leg Med
35-39, (Jul) 1977. The author suggests t h a t the fifth a m e n d m e n t privilege against self incrimination be applied to the psychiatric interview when used for civil c o m m i t m e n t . M a n y state s t a t u t e s provide for emergency involuntary admission for any person with an alleged mental illness who needs immediate observation, care and treatment. The article argues t h a t the ~'police power" andparens patriae doctrines rest on untenable assumptions t h a t h u m a n behavior is sufficiently predictable to allow preventive detention of the mentally ill. It is unclear legally whether the state can order a person to accept t r e a t m e n t against his wishes. In most m e n t a l institutions, the patient faces physical abuse, loss of privacy, social stigma and m i n i m a l or no treatment, thus rendering the effect of c o m m i t m e n t s i m i l a r to i m p r i s o n m e n t . The a u t h o r suggests t h a t interest in avoiding civil commitment should be as h i g h as in criminal commitment cases. The fifth a m e n d m e n t would help protect involved individuals. (Editor's note: It is specious to argue that the poor condition of many mental hospitals makes commitment to them similar to imprisonment and therefore commitment should be handled much more rigorously, legally. More important, the facilities to which patients are sent should be better staffed and maintained. We favor thoughtful commitments but for the suicidal or homicidal patient such legal paranoia against physicians can only increase the likelihood o f a patient "dying with his rights on.") Anne Salmon, PhD, MD
legality; psychiatry, commitment
Exertion induced rhabdomyolysis with acute renal failure and disseminated intravascular coagulation in sickle call trait. Koppes GM, Daly JJ, Coltman CA, et al,
Am J Med 63.'313-317 (Aug) 1977. There have been reports in the literature concerning sudden death in black Army recruits with sickle cell trait. This current report concerns acute exertional rhabdomyolysis, r e n a l failure and coagulopathy in blacks with sickle cell t r a i t following rigorous exercise. The four patients reported in this study enjoyed good h e a l t h previously a n d were in somewhat good physical condition. Neither the location nor weather conditions seemed to be contributing factors in the onset of illness. Although the causal relationships of sickle cell anemia in the pathogenesis of the patients' illnesses is open to debate, possible mechanisms secondary to conditions t h a t predispose to rhabdomyolysis include intracellular potassium deficits. Also, if physical activity l e a d i n g to m y o g l o b i n u r i a is a s s o c i a t e d w i t h d e h y d r a t i o n , hypotension and acidosis, acute t u b u l a r necrosis is more likely to occur. Every black patient who presents with evidence of severe illness following vigorous exercise should be evaluated for sickle cell t r a i t and appropriate t r e a t m e n t instituted, primarily directed towards reversing those conditions which predispose to sickling. (Editor's note: Sickle trait, as opposed to sickle cell anemia, often goes undiagnosed until an unusual situation o f oxygen decrease provokes a medical crisis.) Leland Mew, MD
anemia, sickle cell, sudden death; rhabdomyolysis 578/87
urinary tract infections
The fifth amendment and the psychiatric interview in civil commitment proceedings, Perry ET, J Leg Med
45-51, (Aug) 1977. In cases of involuntary civil commitment, the psychiatrists recommendation to the court is based upon the psychiatric interview. According to the author, in t h e majority of cases the psychiatric recommendation is the effective d e t e r m i n i n g factor in w h e t h e r a person is committed. The courts apparently fail to ensure t h a t the psychiatrist comply with statutory standards for making recommendations according to the requisite finding of dangerousness. The article argues further t h a t the patient is forced to make a choice between self-accusation, perjury and contempt and t h a t various forms of coercion are used to elicit material used in the interview. The fifth a m e n d m e n t would protect the individual from self-accusation, reinforce his right to freedom from coercion and his r i g h t to privacy. One recent federal court decision held t h a t ¢'statements made to a psychiatrist by the subject of a commitment proceeding, unless voluntarily given after notice of the possible consequences cannot be the basis for a n order of commitment." Other courts have followed with similar decisions. The question is ripe for the Supreme Court. (Editor's note: In this article also, there is an implication that the physician and patient are adversaries. This is a distressing direction which fails to acknowledge the issue o f the patient's
serious illness.) legality, psychiatry, commitment
Anne Salmon, PhD, MD
Tuberculous peritonitis. Cromartie RS, Surg Gynecol
Obstet 144:876-878 (Jun) 1977. The records of 40 patients with tuberculous peritonitis t r e a t e d at Louisiana Charity Hospitals were reviewed. The average age was 36.5 years, 39 patients were black, 24 were male. The most common symptoms were fever, abdominal pain, abdominal swelling, a n d weight loss, which correlated well with the clinical findings of fever, abdominal tenderness, and ascites. The ascitic fluid recovered generally h a d a high protein content (greater t h a n 2.5 gm/100 ml), a varying white blood cell count b u t with a differential predominantly t h a t of lymphocytes, and a glucose low in comparison to the serum glucose. The x-ray film findings were t h a t of a mild ileus, ascites, elevation of the diaphragm, diffuse haziness of the abdomen, and loss of the psoas stripe. Diagnosis was most often made at laparotomy (24 of 40), and t r e a t m e n t consisted of any of a n u m b e r of long t e r m multiple drug regimens. (Editor's note: Tuberculosis in its many guises is still prevalent in the United States.) Geoffrey Korn, MD tuberculosis, peritonitis
Indications for thoracotomy following penetrating thoracic injury. Siemens R, Polk HC, Gray LA, et al, J
Trauma 17:493-500, (Jul) 1977. Although most surgeons agree t h a t closed thoracostomy drainage is t h e initial t r e a t m e n t of choice for p e n e t r a t i n g thoracic injuries, t h e t i m i n g of early thoracotomy and cardiorrhaphy in sucl~ patients remains controversial. The purpose of the study outlined in this paper was to determine which patients with penet~'ating injuries to the chest require immediate thoracotomy o r cardiorrhaphy. Over a two-year period 190 p a t i e n t s p e n e t r a t i n g thoracic injuries were treated. Of 53 patients who required immediate thoracotomy, 31 suffered cardiac wounds. Based on a retrospective analysis of these cases the suggested
,~)
6:12 (Dec) 1977
indications for immediate thoracotomy or cardiorrhaphy are: 1) location of the entrance wound in upper mediastinum; 2) blood pressure on admission < 90 m m Hg; 3) initial thoracostomy blood loss >800 cc; 4) radiographic evidence of retained hemothorax, and 5) clinical evidence of pericardial tamponade. Decisionm a k i n g by emergency physicians may be facilitated in these patients by r e m e m b e r i n g which patients with p e n e t r a t i n g thoracic t r a u m a are most likely to require early surgical intervention, regardless of the patient's clinical status at the time of presentation to the emergency department. (Editor's note: This is the sort o f investigation emergency physicians should be pursuing.)
Robert Hockberger, MD injury, thoracic
The fifth amendment and the psychiatric interview in civil commitment proceedings. Perry ETI J Leg Med
35-39, (Jul) 1977. The author suggests t h a t the fifth a m e n d m e n t privilege against self incrimination be applied to the psychiatric interview when used for civil c o m m i t m e n t . M a n y state s t a t u t e s provide for emergency involuntary admission for any person with an alleged mental illness who needs immediate observation, care and treatment. The article argues t h a t the ~'police power" andparens patriae doctrines rest on untenable assumptions t h a t h u m a n behavior is sufficiently predictable to allow preventive detention of the mentally ill. It is unclear legally whether the state can order a person to accept t r e a t m e n t against his wishes. In most m e n t a l institutions, the patient faces physical abuse, loss of privacy, social stigma and m i n i m a l or no treatment, thus rendering the effect of c o m m i t m e n t s i m i l a r to i m p r i s o n m e n t . The a u t h o r suggests t h a t interest in avoiding civil commitment should be as h i g h as in criminal commitment cases. The fifth a m e n d m e n t would help protect involved individuals. (Editor's note: It is specious to argue that the poor condition of many mental hospitals makes commitment to them similar to imprisonment and therefore commitment should be handled much more rigorously, legally. More important, the facilities to which patients are sent should be better staffed and maintained. We favor thoughtful commitments but for the suicidal or homicidal patient such legal paranoia against physicians can only increase the likelihood o f a patient "dying with his rights on.") Anne Salmon, PhD, MD
legality; psychiatry, commitment
Exertion induced rhabdomyolysis with acute renal failure and disseminated intravascular coagulation in sickle call trait. Koppes GM, Daly JJ, Coltman CA, et al,
Am J Med 63.'313-317 (Aug) 1977. There have been reports in the literature concerning sudden death in black Army recruits with sickle cell trait. This current report concerns acute exertional rhabdomyolysis, r e n a l failure and coagulopathy in blacks with sickle cell t r a i t following rigorous exercise. The four patients reported in this study enjoyed good h e a l t h previously a n d were in somewhat good physical condition. Neither the location nor weather conditions seemed to be contributing factors in the onset of illness. Although the causal relationships of sickle cell anemia in the pathogenesis of the patients' illnesses is open to debate, possible mechanisms secondary to conditions t h a t predispose to rhabdomyolysis include intracellular potassium deficits. Also, if physical activity l e a d i n g to m y o g l o b i n u r i a is a s s o c i a t e d w i t h d e h y d r a t i o n , hypotension and acidosis, acute t u b u l a r necrosis is more likely to occur. Every black patient who presents with evidence of severe illness following vigorous exercise should be evaluated for sickle cell t r a i t and appropriate t r e a t m e n t instituted, primarily directed towards reversing those conditions which predispose to sickling. (Editor's note: Sickle trait, as opposed to sickle cell anemia, often goes undiagnosed until an unusual situation o f oxygen decrease provokes a medical crisis.) Leland Mew, MD
anemia, sickle cell, sudden death; rhabdomyolysis 578/87