Monday, March 9, 2009


- By William Hay
I was called from my room. A phone rang. I awoke and listened to the succinct description by a very competent nurse. Dressed in minutes I left a beautiful soft skinned woman in my bed. Her hair was tousled. I looked back at her still sleeping as I quietly departed. Minutes later I was on the ward.
“He’s the fellow who killed his relative the last time he was psychotic,”the little dark haired nurse told me. I took the chart she handed me, paging through it speed reading as she spoke. “The police said he was threatening his family again. When they found him he was waving a knife. He said the devil was telling him to kill. They didn’t have any difficulty getting the knife though. He gave it to them. He’s always had respect for the police uniform. “
I read the emergency doctor’s report saying he was disheveled, not speaking but apparently hearing voices. They’d admitted him to psych. It was the emergency nurse who called me.
“We gave him 10 mg of Haldol , 2 mg of Benztropine and 2 mg of Ativan IM and he’s just been sitting in the corner of his room since.”
There wasn’t much more in the chart, blood pressures, pulse, respiratory rates. Nothing that would change the situation from so many before.
“I’ll see him now,” I said.
With the nurse beside me I walked down the hall. Out of the corner of my eyes I saw the stocky male nurse and long haired orderly had joined our group. They’re being protective of us, I thought.
It was always this way. In the out of the way places I’d worked the staff knew that people were most important. They just knew to leave the paperwork for another time and join together to get the real work done. More and more it wasn’t that way in the city. Everyone looking over their shoulder at the paper pushers. I didn’t let my mind go there. This was here and now. I was surrounded by competent people. This was going to go the way it should go, the way it almost always did go.
I looked in the little window on the solid metal door. In the corner a man sat hunched in blue ward pyjamas on the single sheeted mattress the only furniture in the locked room. The only other item was the stainless steel seatless toilet.
The young man’s hair was greasy. I couldn’t see his face. Maybe 6 foot tall. The chart said he was 25 years old. His feet were cut, bruised and scratched. I saw similar abrasions on his hands. He’d been living in the bush. Last anyone had seen of him was three weeks ago. The police notes had said something about a family argument.
He was supposed to be on injectable antipsychotics every two weeks. It looked like he’d missed at least two or more injections. Psychosis didn’t always come back right away. There was usually a grace period. In his case it had been days or maybe weeks.
The little nurse pulled the very big key out of her pocket and inserted it in the door. She opened it a crack and said,
“Joe, the doctor is here to see you,” Joe didn’t look up. He just sat there slumped and despondent. I knew he had heard, though. The nurses did too. We knew things like that after years of working in these environments with patients whose reality was different than ours. A 6th sense. Something one came to rely on.
I walked in past the nurse and stood for a while looking down at Joe. I was hardly inside the room. A classmate had almost died as he was attacked entering a patients room. The two police he’d been with had hardly had time to save him. He’d been scarred physically for life. The emotional scars almost always went deeper. I wonder if he ever talked about that time. Now wasn’t a good time for reflection.
I looked carefully at the young man. His hands were wrapped around his knees. He was on his butt in the corner of the mattress, back to the wall. His feet would not have much purchase. There’d be time, I thought.
I knelt. I felt the nurse moving closer behind me and sensed the other nurse moving into the corner of the room. The orderly was still in the doorway. It was a coordinated effort.
“Joe, I’m Dr. Hay, how are you feeling.”
He didn’t answer me. His breathing changed slightly but he didn’t move.
“I understand you’ve been having a difficult time.”
He shifted slightly.
I felt my knees straining under my weight, wanted to make myself more comfortable, but knew it was too soon.
“Could you tell me what’s been going on?”
I saw his head begin to move. He looked up at my knees. No eye contact. The wall behind him was cement. He leaned back a little. His eyes came up to my chest. His hands relaxed around his knees. He seemed to rock a little.
“Go away,” I thought I heard him say. It was a frightening otherworldly whisper.
I resisted the temptation to move closer, to lean in.
He’d killed a man. The chart had said he’d been violent on other admissions. I was thankful for the foreknowledge but it wouldn’t have changed my procedure. I’d been kicked so hard in the chest, I was bruised for weeks, as a student. A catatonic 70 year old went from catatonic stupor to catatonic frenzy when I’d asked her about her husband. I’d learned later he’d run off with her younger sister after 50 years of marriage. I’d been too close that time and if I could help it I wasn’t going to make that mistake again, ever.
“What did you say, Joe, I couldn’t hear you,” I said louder than need be in that little room.
His hands went to the mattress beside him. I watched his musculature. He was pushing up, just shifting his position. I didn’t stand up and move back. Any quick movement could startle him and backing away now could undermine the relationship I’d need to build.
His head came up and he looked me straight in the eye. Almost feral. “I said, go away. Go away. Go away or he’ll kill you!” He repeated before looking away and turning his head to the wall.
“Alright Joe, the nurse will give you some medication to help you feel more comfortable.”
With that the nurse and orderlies came forward as I nodded and we gave Joe another 5 mg of haldol IM and 1 mg of Ativan. He’d not moved when the nurse pinned him somewhat with her body and injected his right buttock with the needle she’d obviously been carrying with her. The other nurse had moved in beside her and the orderly and stepped around me. I had just stood up when this fluid teamwork took place and we all moved back out of the room keeping our eyes on the patient.
It was a couple of days before the routine changed much. The nurses gave him other injections when I wasn’t there but together we repeated the routine until the third day he agreed to come to my office and talk to me. A nurse stayed behind his chair. Those first days he didn’t say much. More medication. More observation. More firmness and respect. Then one day he talked about the nightmares and the dead bodies haunting him. He said they’d been all around him in the room stopping him from speaking to me there. We moved him to the open area after that. After a few more days he was talking non stop to his primary nurse telling her about the time in the bush.
He told me about the man he killed. I didn’t ask. He just walked through it like he might a shopping list. He told me he’d stopped hearing voices and that he thought the medication was helping.
“I’ll take the injectable medication if it will let me go home,” he said about 10 days after he’d been admitted. I started that then. On the weekend he had an afternoon pass with his mother . When she returned she said he’d done well.
A day pass went just as well and then he was gone for a weekend before I discharged him on injections arranging home visits with the community nurse. He was so pleasant when he left. All the scariness in him that had been there on his admission was gone.
I was laying awake in bed beside my beautiful partner when I told her, “Remember I told you I admitted a violent guy a week or so ago. I discharged him to the community today.”
“So soon?”, she asked.
“Yea,” I said. “He’s back on meds and I think he’s going to be okay” I didn’t say the other reason: lack of beds or resources. In the best of possible worlds I’d have kept him a little longer. Too often I was cutting corners because of the pressure from above.
“Still, “ she said.
I knew what she meant. I’d felt the madness that first day. Now it wasn’t so palpable. Lurking, maybe, but not so overt anymore. I hoped this time he’d stay on his medication. His family were something else. I’d never have been able to sleep in the same house with him when he first came in but they took it in their stride. They’d been caring for him for years, even after the death.
“It’s the illness, doctor. It’s not him. He’s better now” His brother said when he came to take him home. He reminded me of what’s so easy to forget. Especially when afraid.

No comments: