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Kornhauser Health Sciences Library

Eli Josefson: The Case

Problem Based Learning guide for 2nd Year medical students.
The Case

Setting: Emergency Room

HPI

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

Physical Exam

Test Value
T 101.1
HR  118
BP 85/45
RR 26
SpO2 96% on RA

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.

An IV was started and he received a crystalloid fluid bolus for volume resuscitation. He was intubated for airway protection.

An ingestion was suspected with unknown substances, so Eli was given activated charcoal and polyethylene glycol after an orogastric tube was placed. 

While awaiting further diagnostic testing, you consult the critical care team to admit Eli to the intensive care unit. The resident arrives to collect additional information from Eli’s parents.

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, poor grades and increasing absenteeism as well as sneaking out of the house. He ran away a year ago and took a bus to Atlanta, but the police found him later that day and returned him home to his parents. His primary care physician has prescribed fluoxetine and recommended cognitive-behavioral counseling as well as psychiatric care, but since free pastoral counseling is available through their church, 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.”

At home, Eli gets along with his siblings just fine. He argues with his parents frequently about their requirement that he attend church and the school associated with the church. After these fights, he is notably less talkative, eats less and isolates himself. Once, during an argument, he stated the family would be better off without him.


Continuation of discussion with Eli’s parents:

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, wearing earrings and other piercings despite being forbidden to wear body jewelry. He also 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 acetaminophen.

A CT head is negative for edema or bleed.

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.

Eli continues to receive IV fluids and is started on broad-spectrum antibiotics. By morning, his vital signs have normalized, he wakes up 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. She then interviews Eli’s parents separately and calls the school and church to talk to Eli’s pastor, 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. Eli has refused to tell them what is happening, but sometimes tries to fight back which leads to further bullying.

Eli has attended the same school since kindergarten, as have 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 heard 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 up Eli 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 videos 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 social media, disruption of the traditional family framework, and many other 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.


The psychiatrist returns and asks to interview Eli 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.

Eli discloses that he has felt a romantic attraction to 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 year 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 are “out” and expressed support for him. He has 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 but no other drugs, except he does smoke cigarettes when he can get them because he thinks it makes him look older and less like a target when he is out by himself.

He expresses feeling alone and afraid to go to school every day, as well as afraid his family will reject him if he talks about his feelings 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. He says, “I just hate every day. I just do not 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 to talk to that I can trust, and I try not to be this way, but it’s 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 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 in his room. The previous week, he was taunted and beat up by a group of boys at school, badly enough to need stitches and a couple of days to recover from a headache. His parents had planned to send him to church camp to help “kids like Eli.” He left a note apologizing for being a problem child and describing how lonely he felt.

Clinical Librarian

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Ansley Stuart
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Kornhauser Library, Rm 204
502-852-8534

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