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Eli Josefson: The Case

Problem Based Learning Year 2 Case 4

HPI:

Eli Josefson is a 15-year-old male who was brought to the ER by EMS after being found unresponsive by his parents in his bedroom at 10:30 pm. The last time he had been seen acting normally was at 7 pm when the family ate dinner together. 

His physical exam in the ER showed: T 101.1 HR 118 BP 85/45, dilated but reactive pupils, flushed sweaty skin, dry mucus membranes, and hyperreflexia in all four extremities with occasional jerks of an arm or leg. He is unconscious with a positive gag reflex and withdraws to pain but does not respond to verbal stimuli. He was intubated in the ER for airway protection.

An ingestion was suspected with unknown substances, and so in the ER so was given activated charcoal and Golytely as well as bolused with normal saline and initial diagnostic studies were sent as further history was obtained from the parents.

Additional history:

Eli is the youngest of five children and his parents describe him as “very difficult to live with.” He has been in counseling through their church for disruptive behavior at school and decreased grades/absenteeism as well as sneaking out of the house. He ran away 2 years prior to this ER visit and was found trying to get on a bus to Atlanta by the police and then returned home to his parents. His primary care physician has prescribed various medications and recommended cognitive-behavioral counseling as well as psychiatric care, but since free pastoral counseling is available through the large church the family attends, Eli has been getting counseling via that route instead. The parents refused psychiatric referral due to concerns about Eli potentially “being locked up and drugged.”

The medications he has been prescribed include quietapine, fluoxetine, paroxetine, and risperidone. He has frequently threatened to kill himself before when fighting with his parents about discipline or their requirement that he attend church and continue to the go to the school associated with the church.

The parents believe that Eli has trouble at school because of bullying but also are very frustrated because in their view “he brings it on himself.” When asked to give further information about that statement, they relate that he “acts like a girl”—Eli dresses differently than the other kids by dyeing his hair different colors or wearing weird shoes (that they don’t even know how he gets the money to buy), has had earring piercings performed several times despite being forbidden to wear body jewelry, and does not play sports or attend church-sponsored social events. They feel that if Eli made more of an effort, he would be able to “fit in” better and would not be a target of bullies in the school.

The initial toxicology screen is negative for cocaine, benzodiazepines, opiates, methamphetamine, aspirin, and Tylenol. A CT head is negative for edema or bleed, and an LP is performed with normal CSF cell count, protein, and glucose. A chest X-ray is normal, and CSF, urine, and blood cultures are sent. ER physician admits Eli to the PICU on minimal ventilator settings, still intubated and on IV fluids as well as broad spectrum antibiotics. In the PICU Eli’s vital signs slowly normalize, he wakes up slowly and is extubated when he can follow commands. He refuses to answer any questions about whether he overdosed on medications or which drugs he took. He is transferred out to the pediatric floor the next morning. The accepting resident and attending consult the Peds Psychiatry service for additional help in assessing Eli’s mental status, mood, and risk for future harm.

Peds Psych History:

The psychiatrist talks to Eli with his parents in the room and does not initially get much cooperation, either. She then interviews Eli’s parents separately and also calls the school and church and talks to Eli’s pastor and his teacher and guidance counselor to gain additional history.

Eli’s teacher and guidance counselor are concerned about the bullying Eli has experienced in school but feel stymied by their ability to stop what is happening under the radar. They try to get Eli to tell them what is happening, but he refuses and sometimes tries to fight back on his own which leads to worsening bullying. They say that Eli has attended the same school since kindergarten, as has most of his peers, and that Eli became a target of bullies early on because he preferred to play with the girls in his class rather than the boys. His counselor says that he hear Eli even asked for a Disney Princess birthday party in kindergarten, and that Eli gets teased about that to this day. The bullying has worsened since middle school, including a recent episode when an ambulance had to be called because a group of boys beat Eli up in the bathroom and held his head in a toilet of water and feces and he was having trouble breathing.

When the pastor is interviewed, he describes Eli as “confused,” saying that Eli’s parents brought him in for the disruptive behavior as well as concern that they found YouTube vides and Tumblr pages on his computer search history that they don’t approve of. He explains that their church and the counseling he provides is based on a very specific understanding of right and wrong, that most members of the church really only interact with other families in the church due to their belief that many aspects of modern society threaten the family and lead people astray from what’s right. This family and this church community have really been at a loss for how to deal constructively with Eli despite the pastor meeting with the family and Eli at least once a week and the teachers and guidance counselor being included in conversation so that they could help Eli get back on track. The pastor is also concerned that Eli has no interest in girls, and that he may need to refer him to another pastor who performs reparative therapy.

With this information in mind, the psychiatrist returns and asks Eli’s parents to leave so she can interview him privately. She assures Eli that anything he discloses will not be discussed with his parents or pastor without his written or verbal consent, and expresses an observation that Eli seems very alone in his struggles at school and home and must have felt very desperate to take an overdose. She gently expresses that many teens feel “different” and are bullied as a result, and that the bullies are wrong, not Eli.

With continued gentle questioning, Eli discloses that he has felt a romantic attraction to other boys and that he is ashamed of those feelings and has been trying to get rid of them. He explains that he used to have a best friend who was male in elementary school that he disclosed those feelings to, and that since then that friend has refused to have anything to do with him, and has told the other boys at the school that Eli is a “f**got” which has led to the increased bullying. This is what motivated Eli to try to run away a couple of years ago—he couldn’t tell his parents why he wanted to go to another school because they wouldn’t understand and would hate him, so he tried to run away to another city.

He has made contact with a group of older males in internet chat rooms who were “out” and expressed support for him and had even taken the bus to meet them a couple of times in an apartment downtown but “chickened out” and didn’t actually go in the building. He has tried marijuana and a couple of unknown pills he got from a known drug dealer at his school but nothing else, except he does smoke cigarettes when he can get them and hide them from his mom because he thinks it makes him look older and less like a target when he is out by himself.

He expresses feeling very alone and afraid to go to school every day, as well as afraid his family will reject him if he talks about his feelings or fears with them. When he gets into trouble at school, his dad hits him with a belt and takes away his phone and his laptop, which eliminates his ability to talk to others on the internet, which is his major form of support for these problems. He says “I just hate every day. I just don’t want to even get out of bed and face the day because I am the problem and I am not getting any better. I don’t have anyone real who will talk to me that I can trust, and I try not to be this way, but its not working.”

He is terrified that any of this information will be disclosed to his family and repeatedly makes the psychiatrist promise not to tell what he is sharing. 

Follow-up:

Eli’s family refused inpatient treatment and stabilization and thus he is discharged home once he is medically stable. Information about his interview with the psychiatrist was not shared based on his request for confidentiality and fear of disclosure. Outpatient counseling and follow-up was offered but refused by the family as they wished to continue to pursue their current counseling plan through their church.

Three months later, Eli was found dead hanging by the neck from his closet rod in his room.

Your librarian is

Michel Atlas
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