The emergency department is fast-paced. Full of chaos. Incredible suffering. Frustration. Disappointment. Screams, tears, smiles. Reassurance. Good news. Bad news. Diagnoses. Failure to find a diagnosis. Getting a last-minute cardiac arrest coming in at 650 a.m., ten minutes before the end of your 12-hour, overnight shift – you have the energy and wherewithal to do the task, but to process the life that was lost? To truly realize the dead body upon which you performed futile efforts to resuscitate? Needless to say, it’s challenging at times. A few tears often escape my eyes after the chaos has calmed. A quiet reminder that I am not immune to others’ suffering. And recently, those tears struck again. A floridly psychotic patient came into my area of the ED. I interviewed another patient but was distracted by this woman sitting, standing, sitting, standing, and pacing. Talking to herself. Talking to us while I was trying to assess my patient. Talking so fast, so pressured, so incomprehensible. The loosest of associations. Next, I sign up for the said patient. I go talk to triage. Was she this psychotic when she checked in? Should we place her on a one-to-one observation? I look at her chart. Polysubstance abuse. Bipolar. Antipsychotic meds. A long history of visits to the psych ED. I try to assess her. She is complaining of mouth pain. But her speech is so fast and so tangential that I can’t follow. She quickly switches from talking about her mouth to talking about gunshot wounds. She pulls down her pants to show me her upper thigh. I see some old scars. She’s in the middle of the waiting room with her pants down around her knees. I am eager to have her pull them up – would she be this willing to be so exposed in public when her mind has calmed and the illness abated? She is too frenetic that I can’t get close enough to actually evaluate her. She sits in a chair and aggressively kicks in my direction. “Bam!” Now she’s up again. Friendly. Talking about friends, parents, crack cocaine, the Bronx. Impossible to follow. She threatens me. She isn’t redirectable. I can’t get a word in. She vacillates between being pleasant and friendly to explosively angry. It’s clear we have to call the psychiatric ED. But they want us to medically clear her first. How can we possibly do that? She’s too unstable and not safe to get near. We call security and the knot in my stomach tightens. Clearly, she will see this as a provocation. It is, isn’t it? They do their best to reason with her. Try to get her to calm down. But it’s not possible. The chemical dysregulation in her brain won’t allow for it. You can’t reason with someone who has lost their grip on reality. Now she’s threatening security. Swinging and kicking at them. This escalation was inevitable, wasn’t it? They hold her limbs in as safe a way as possible. As they’ve been trained. I put in the orders. 5 and 2. Five of Haldol, an antipsychotic, and two of Ativan, a sedative. Both are able to be injected IM. Intramuscular. Perfect for this scenario when the situation is too volatile; when all you can do is hold someone down and jab a needle into their limb. We did it. It wasn’t pretty. There was thrashing. Shouts. You could see the burden on the nurse’s shoulders. No one goes into medicine wanting to force medication onto a person against their will. Immediately afterward, the patient relaxes. She’s accepted defeat. Not because the drugs work that fast. But because she knows the drill. Despite her very tenuous grasp on reality at the moment, this song and dance breaks through the cloud. She knows what comes next. Temporarily, she seems to accept it. But then the violence returns. The kicks. The swings. A security guard gets hit. We call for another 5 and 2 as other patients look on. After the second dose, we get a stretcher. And four-point restraints. The patient screams about being claustrophobic. Begs to not be tied down. Then quickly transitions back to violence and verbal assaults. One leg. The second leg. The right arm. The left arm. Leather restraints on every limb. Holding her to the bed, arms above her head. Keeping her and our staff safe as we wait for the drugs to take full effect. Tears well up in my eyes. I think about those in my life who have struggled with severe mental illness. I think about the people I know who have probably had something similar happen to them. I think of my own abject fear of my bodily autonomy being taken away. It makes me sick to my stomach to imagine my own limbs being tied down in such a way. It would make me break. What is this woman like? Is her life so wrecked by mental illness and drug abuse (exacerbating the mental illness) that she has no periods of anything resembling normalcy? Or is she simply manic/psychotic/intoxicated right now, whereas at baseline, between episodes, she is relatively functional? How many times has this happened to her? What type of life is this? To continually end up in the hospital, being held down against your will, drugged and restrained because you are truly a danger to yourself and others. I shudder. Does she have a family she is connected to? Or have they abandoned her because of her struggles? Does she have anyone in her life rooting her on? I think about all the similar patients I worked with in my prior career, especially when I had that research job working with patients struggling with addiction, homelessness, and psychosis. I think about reading the charts of that one patient who was also floridly psychotic. The charts were filled with delusions about killing gay people. And here I was, a gay man, who would be meeting with this patient every month. Then I remember his other, grotesque delusions that consumed him. He believed he was ejaculated out of his dad fully formed, albeit small and Thumbelina-like. Literally writing his mom out of his creation story. His belief that he had dismembered nurses with a large samurai sword; the details equal parts monstrous and elaborate. And then there was that period when I visited him in the psychiatric hospital. He was off meth and on the proper psychiatric meds. He was an entirely different person. Seemingly undisturbed. A gentle soul. A guy who, when I escorted him out of the hospital and on a walk throughout the city, would hold open the door for anyone and everyone. Someone who offered to use the small amount of money I just paid him for the research interview to buy me snacks. He gave some of it away to someone else we encountered who was clearly dealing with homelessness. Then my last visit with him. Back on the streets. Off his meds. Using meth again. Once again wracked by his disturbing delusions. Maybe this was his true baseline. If you can focus just on the things that a floridly psychotic patient says, it’s incredible. To see where their train of thought goes. How they connect one idea to another. And when they aren’t even having full thoughts, how they string words together. Clanging is when they just spew words that sound similar, without meaning. Fling. Bling. Sing. Ding. Or word salad. Where there is no sentence structure, and the words have literally no relation to the word preceding them. The human mind is incredible. Terrifying. And yet, it’s hard to reflect. To focus too much on the horrifying power of the mind. Because at some point, I get distracted by those “deer caught in the headlights” eyes. I get pulled out of my reflection by my patient’s screams of anguish. I switch focus back onto the body and life in front of me, the one so ravaged by mental illness. By a disease that far too often elicits revulsion, judgment, and punishment instead of the open-minded curiosity, compassion, and understanding that it deserves. The author is an anonymous emergency medicine resident. Source
