Madness: Part 1
This is Part 1 of a 2 part series where Dr. Tetwiler shares his story from the bowel of the Psych ED.
All of the doors in the Psychiatric Emergency Department lock automatically when they are closed. They have to. I pressed the buzzer at the entrance of the Psych ED, drowsily stated, “Hi, this is the Emergency Medicine intern that’s been rotating this month. Good Morning” and took a deep breath, waiting for the nurse and his ring of keys to open the door so that I could start my day
As the nurse opened the door, my eyes opened widely as I stepped through. Directly in front of the entrance was a man seated in handcuffs, although I smelled him before I saw him. I gave a weary smile to the nurse and entered the Psych ED, immediately immersed in the pungent aroma of wet urine. As I stepped forward, I heard the heavy door slam shut behind me. The seated man darted a glance at me, then darted a glance at the guards, then the resident speaking to him, to me, the door, the guard, and all the while rapidly explaining to the resident interviewing him why he had been living at the airport for the past month and why she had no right to keep him here.
A loud, slow, persistent thud echoed in the hallway. I walked past the handcuffed man, past the wall of locked doors, towards the doctor’s workroom. Each of the locked doors contained a rectangular window, which contained within it a small room with a padded bed, a patient, and nothing else. The thuds were coming from one of the locked doors. As I passed the thuds, I looked to see a young woman staring out the window of her door. Despite the slow, hard pounding of her fist against her locked door, her face was intense but expressionless, and she stared blankly without blinking. Her hair pointed in every direction, and she had pulled her hospital gown down to expose her right breast. She said nothing, only continued her blank stare outward and her rhythmic thuds against her locked door. She had been my patient the day before, and her mother told me that stress and marijuana use caused her symptoms to reappear. Before coming in she hadn’t slept in several days, had started to talk about wide ranging religious conspiracies, and had at one point thrown the family television down the stairs while screaming at her family. When the EMTs had brought her in she had still been screaming. She was in her twenties, and had been studying for her finals. As I walked past, her unblinking eyes followed me, and the thuds continued
In the workroom, my senior resident was on the phone with a board and care facility. In my short time in the Psych ED I had learned that these facilities were housing units for the chronically mental ill, developmentally disabled, and substance abusers. The facilities provided lodging, food, and from what I had come to realize was a broad, vague spectrum of something like supervised care. The senior resident was firmly, yet politely, stating that a patient had been cleared by the psychiatrist, and was no longer aggressive, a danger to themselves or others, or actively psychotic. My senior was politely explaining to the facility that they were responsible for the patient, and that they were also responsible for picking the patient up now that the workup was done. I had no doubt that the person on the other side of the line thoroughly knew this, because during the past week I had already rationalized, discussed, and pleaded through the same arguments a dozen times with the voice on the other side.
“I don’t think you understand, there is something wrong. Shouldn’t you keep them longer?”
“Have you increased their medication enough?”
“What happens if it happens again?”
While the senior spoke into the phone, the attending doctor gave me a good morning head nod, a warm smile, and a salutation with his coffee cup. I flipped on the computer and booted up the electronic medical record, waiting as it loaded to see who my patients for the day would be. I thought about her. When the EMTs had brought her in shouting yesterday, I had known before I spoke with her that we would sedate her. Yet when I had conducted my interview and history, I had glanced away from the nurse’s expectant eyes. Even when her voice rose to the level of a near scream while telling her disorganized story with tears that didn’t match her voice streaming down her face, I hadn’t given the order. I had spoken with her softly, as patiently as I could. The interview went longer than it should have. Long enough that I suddenly became aware of the Attending doctor at my side. He had whispered warmly, “Well hello, may I trouble you for a moment” and nodded to the nurse. The nurse promptly went to get a dose of Haldol, a sedating medication that would put her to sleep. His voice was patient and he sandwiched his critique between compliments about my work ethic and bedside manner.
“You need to give the sedatives earlier.”
Even as I had bristled a bit at the instruction, I had understood his reasoning. The risk of an acutely psychotic or aggressive patient is that they aren’t in control of themselves, and until sedated put the doctors, the nurses, and the patient themselves at risk of harm. I don’t know whether my hesitancy was out of a naïve hubris that I could calm the patient down myself, a hope for the humanity trapped within the madness to reassert itself, or a fear of having to accept how easy stripping a way a person’s liberty and locking them in a room could be. The truth was that this was not the first time I had delayed sedating a patient, but it wasn’t that I had an argument against the standard of care in the Psych ED necessarily. Even in my most cynical moments I appreciated the necessity of a place that could offer the brief respite of a deep chemical sleep to return a tenuous equanimity to the broken. My true resentment was against the lack of systemic support that could have helped these people before they needed chemical sedation. That, and as a teenager I had spent the night with my grandfather in the hospital. He had become altered in the middle of the night, and I wrestled with him as he tried to pull out his IVs. The nursing staff sedated him, and he was never fully awake again. Regardless of the reason, I don’t like sedating people.
I realized the workroom had emptied while I stared at the computer screen. The day had started. I glanced quickly at the note about my new patient and headed to the holding room. Besides the hallway of locked doors in the Psych ED, there are two large open rooms without doors filled with recliners, a couch, and a television. One room for each gender, each generally filled with around five of the more stable psych patients. The patients in these rooms were generally easier to talk to despite the lack of privacy, and the interviews went more quickly than with the patients in the individual rooms since I didn’t need to grab the nurse and his ring of keys to open the locked door.
I entered the still, dark female holding room and tiptoed past a woman sleeping in the recliner, whose face tattoos I could see just above the blanket she had curled herself in. I found my patient in the corner of the room. She was awake and sitting on the edge of the couch, hands folded, as far as she could be from the tattooed woman snoring loudly in the recliner. The patient was a sweet, elderly Vietnamese grandma who answered all my questions politely and reasonably. Having scanned the triage note describing a patient with a fixed delusion I began to worry I had spoken to the wrong patient. When the sweet, elderly grandmother began to tell me how her landlord had been murdering and eating her neighbors for the past five years I felt reassured that I was in the right place. The note had mentioned that the patient’s family hadn’t understood what was going on, and were afraid that she might hurt herself. I smiled at the sweet, elderly grandmother as my mind processed the fact that she had a fixed, paranoid delusion and would need to be connected to care. Cynical or not, I was also happy to realize that this patient had a clear disposition, and would be gone from my workload soon. To be continued…
This concludes part one of a two-part series where Dr. Tetwiler shares his experiences while rotating in the Psychiatric Emergency Department. Part two will be posted next month’s edition of the Physician Grind Narratives.
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Keep Scrolling down for Dr. Tetweiler’s Bio
Michael Tetwiler, MD
Michael Tetwiler grew up in a small town in Kansas. After completing his undergraduate studies in English Literature, he pursued his medical degree at the University of Kansas. During medical school, he was awarded a Fulbright Research grant that analyzed clean water initiatives in the Peruvian Amazon. His work in his medical school's free clinic led him to pursue an MPH in Health Management at the Harvard T. H. Chan School of Public Health. These experiences led him to a residency in Emergency Medicine at Harbor UCLA where his work focuses on helping underserved spanish speaking communities and initiatives for resident wellness.