Complications

I know I just finished a blog a couple of days ago but something happened that shook me to the core.  I had a patient my first month as an intern that was incredibly difficult to work with. He was a guy in his 30's who abused IV drugs, was HIV positive, and didn't care if he spread it. His entire persona screamed psychiatric problems to me. One night when he didn't get his way, he threatened suicide. The next morning, he said if I called psych in to see him, he'd leave AMA (against medical advice) and throw water on whoever came into his room. He said he had no plans of hurting himself and he wanted to live. We treated his abscess, talked about staying clean, and acted like we had made a difference. Then last night happened. He came back to the hospital really sick.  He was being treated when he suddenly started getting more and more sick.  The initial thought was that he had a complication of diabetes. They were treating him appropriately and he initially got better.  Then he got sick.  When things didn't add up, people started asking questions. He told the team who admitted him that he had binged on meth for days and missed all of his medications. He didn't want to get sick so he took all his medications at once after the binge.  He wasn't sure what he took but he said he took 60 pills. As he continued to get worse, they moved him to the ICU where he later refused all care and he died.

Now what's so strange to me is how guilty I feel. I had so much animosity towards him before. He had done all of this to himself. He would complain about everything, he abused drugs to the point of nearly killing himself, and worst of all, he knowingly spread HIV. But now, in hindsight...Now...I feel somehow, somewhat responsible. Why didn't I insist on a more thorough psychiatric eval? I know that he would have likely died from full blown AIDS a short time later anyway, but what if all of this was not him doing to himself? Rather, what if this was a psychiatric disease doing this TO him? I know this guilt isn't a burden I have to carry, I am trying my best to take it more as a reminder. I can't ever be too busy. I can't overlook these details that seem too minuscule as compared to their whole medical picture. Psych was a worry I had, but with how sick he was before, it just didn't seem like that big of an issue. His reassurances sufficed for me at the time. But in hindsight? Man, in hindsight I just can't help but wonder...

~vaya con dios