Uncharted Medical-Legal Issues

I remember a civilian contractor, who presented for care, having been brought in by his contract company. In the USA, we have clear laws and regulations regarding those who have lost contact with, what is generally considered, reality. There are commitment laws of various types, and ways to pursue involuntary psychiatric hospitalization. Downrange, that is not the case—it is all very murky. The military is less murky since the same regulations apply, essentially the Department of Defense Instructions regarding Mental Health Evaluations. The civilians are set up for health care but the idiosyncrasies of loss of capacity for decision making or refusal due to psychotic illness are not established.

This case was one such example. The man was employed as a contractor, and was becoming increasing disorganized. He did not show up for work and his company decided to check up on him. His Containerized Housing Unit CHU was apparently a chaotic wreck. Not knowing what was going on, they gave him a warning to clean up and show up for work. When he did not, and since he was becoming unintelligible, they brought him to the CSH ER where I saw him.

Not knowing his history, and since psychosis in middle age is quite rare, I made efforts to rule out other processes (such as delirium, CNS infection, or stroke), but unfortunately we did not have a CT scanner, making the medical workup quite difficult. Luckily, he was coherent enough to tell me his mother’s phone number in the USA. I used Skype to call her. I learned that he had a prior break many years before, but it had resolved after a brief psychiatric hospitalization. He had never required psychiatric medication, but he lived alone except for his mother. Essentially, he had these two psychotic blips, but otherwise was mainly schizoid. This history combined with the bizarre quality of the mental status change led me to believe that this was a psychiatric process, and I treated it as such.

I treated several other civilians, including those who weren’t American citizens, not even NATO. Once again, these situations with civilians were cleared for medical care, but the psychiatric manifestations had not been fully considered, including how Behavioral Health conditions might affect executive function and rational decision-making. I reverted to a conventional medical model, in which I just tried to do what seemed best from my perspective.

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