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The psychiatric emergency room, a fast-paced combat zone with pressure to match, thrusts its medical providers into the outland of human experience where they must respond rapidly and decisively in spite of uncertainty and, very often, danger. In this lively first-person narrative, Paul R. Linde takes readers behind the scenes at an urban psychiatric emergency room, with all its chaos and pathos, where we witness mental health professionals doing their best to alleviate suffering and repair shattered lives. As he and his colleagues encounter patients who are hallucinating, drunk, catatonic, aggressive, suicidal, high on drugs, paranoid, and physically sick, Linde examines the many ethical, legal, moral, and medical issues that confront today's psychiatric providers. He describes a profession under siege from the outside - health insurance companies, the pharmaceutical industry, government regulators, and even "patients' rights" advocates - and from the inside - biomedical and academic psychiatrists who have forgotten to care for the patient and have instead become checklist-marking pill-peddlers. While lifting the veil on a crucial area of psychiatry that is as real as it gets, Danger to Self also injects a healthy dose of compassion into the practice of medicine and psychiatry.
THE ER DOC
Who's Calling the Shots?
The activist psychiatrist R. D. Laing has this to say about the potentially coercive power invested in psychiatrists by society: "We should not blame psychiatrists because we give them such depth of power, especially when, to be exercised as expected, it must be exercised routinely."
I guess we shouldn't blame psychiatric nurses, either. When I first started working as an attending psychiatrist at PES, I discovered that my most complicated workplace relationships were with many of the experienced nurses who worked there. They were the power players, and my education began even before I had worked a shift.
Throughout this book, it may seem as if psychiatric nurses and emergency psychiatrists are mentioned interchangeably. And that is no coincidence. In the psychiatric emergency setting, nurses and doctors work very closely, side by side, with each other. There is an egalitarian feel to the place. While it is the physician who has the final say and ultimate responsibility from a practical and a medicolegal perspective, it is a foolish emergency psychiatrist who does not collaborate with his or her knowledgeable and experienced psychiatric nurse colleagues in making clinical decisions.
I had my reasons for choosing to work in psych emergency—some of them logical, others psychological, and many still to be discovered. My first paying gig was low-stress—a doctors' staff meeting convened by PES's medical director. Though he had hired me, the medical director would never be my role model. The son of a diplomat, he carried himself stiffly, a jacket-and-tie kind of guy, the product of boarding schools. He did not manifest the roll-up-your-sleeves style that I imagined an effective emergency psychiatrist should possess.
* * *
My first night at work is an unseasonably warm evening in the summer of 1992. The customary layer of fog has not yet descended on the city. The psych emergency room is stuffy, the ventilation poor, the ceiling's air vents clogged with lint and dust. A faint whiff of fresh feces and old urine, ineffectively masked by a cloying cinnamon-scented spray, hangs about the place. It is then that I understand why state hospital psychiatrists smoke cigarettes on the job—to cut the stench. Though I had worked there for a week as a fourth-year resident just a few months earlier, this is my initial performance as an authority figure in psych emergency. At this point, I haven't worked a shift yet. I had just returned, lean and refreshed, from a month's holiday spent traveling with my wife in a 1984 Volkswagen camper van through the Pacific Northwest and the Rockies. I had enjoyed an invigorating taste of freedom on this trip, and now I was beginning my career on a lockdown. Though I was getting paid for my time and had chosen this vocational path, I was still working in a place for which a key was required to get out.
Uncharacteristically, I arrive about ten minutes early. Two nurses, a man and a woman, sit behind the triage desk, a crescent-shaped structure about four feet high and twelve feet long facing four seclusion rooms, each with a heavy metal locking door, and each containing a steel bed equipped with four leather belt restraints (these days the belts are made of washable polyester and Velcro), one per extremity. The lights are dimmed.
To the right of the desk is the triage area, accessible by passage through double locked doors. This is where the police and paramedics enter to bring in patients from the streets. To the left is the sprawling dayroom, really a twenty-four-seven room, in which patients sit and sleep on pull-out chairs. Behind the desk, separated by a wall with two doors, is the cramped staff room. Sitting at the desk, the two nurses look like commanders of a starship, which in fact they are, as many of the ward's denizens are in some sort of orbit, psychiatric or otherwise. Christina, the shift's charge nurse, invites me over for a chat and a chocolate-frosted doughnut, which I enthusiastically accept. I sit down and begin eating. "Well, Paul," she says, "what do you think of this cray-zee place?"
"I like it here," I say, dropping crumbs on my shirt. "I like the chaos." I already knew Christina from my weeklong rotation. She had worked there since the old days, starting in the late 1970s or early 1980s. It takes me only a few minutes to surmise that she has a knack for getting her way, does not suffer fools gladly, and is not to be trifled with.
"That's good," says the man sitting beside her, the shift's triage nurse, "because I'm sure you'll soon find out that the staff is near-lee as cray-zee as the patients." Bo, short for Beauregard, son of the South, giggles and sniffs twice before grooming his salt-and-pepper beard and adjusting his glasses in what seems like a single motion. "But I'm sure you can handle it."
"Oh, yeah," I say.
Just then the medical director walks by. I'm not sure if it's my imagination, but I think the director, normally flat and imperturbable, rolls his eyes and exhales ever so slightly when he sees me sitting next to the two nurses behind the desk. "Paul, the meeting starts in three minutes, so please join us," he says.
"Sure," I say, continuing to sit there. Once he is out of range, Christina turns to me and asks softly, "What do you think of that one?"
"Well, uh," I say, pausing, trying to think of something tactful.
"He's clueless," she says, not missing a beat. "A deforester. He's only good at creating new paperwork. He doesn't know a thing about what really goes on around here."
"Oh, that one," Bo says in a high-pitched Southern accent. "What a waste of training. If he'd just leave us alone, we'd be okay."
"Yeah, our last medical director was great," adds Christina. "He really knew his stuff. The patients loved him. But, Paul," she says, leaning closer, her voice dropping to a whisper, "they killed him off because he always took our side."
"Who are they?" I ask.
"They ... are the administration," she says conspiratorially. "Especially the nursing leadership. They need to be in charge. Even though they don't know shit about what we do or what goes on down here." I had arrived during an era in which employee-management relationships in health care seemed particularly precarious. The animosity ran both ways and contributed to the rising level of tension already inherent in a place like psych emergency.
"Well," says Bo, "our last medical director also left us because his wife was expecting and he could double his salary in Wisconsin. But they did kill him off."
I nod. "I see."
Suddenly, a rather large, unkempt man, a scowl on his face, stumbles out of one of the four seclusion rooms and ambles to the desk.
"What do you want, George?" asks Christina.
"I need to take a piss."
"Get back in that room, or we'll have to tie your ass up and give you a shot."
"But I need to go real bad."
"Get back in there. I'll bring you a urinal."
"I want to pee in a fuckin' toilet, not a fuckin' bottle."
"Get back in there, George. Now."
"Fuck you, you slanty-eyed bitch," he says as he comes half-lurching, half-lunging toward the desk.
"Staff!" yell the nurses.
"For that," Bo says, "he's going into points." The shorthand points is emergency room slang for the four points at which a patient's extremities are attached via restraints to a bed bolted to the floor of a seclusion room. I'm not sure, when Bo says "that," whether he's referring to the menacing stance or the racially charged barb or the whole package.
Since I am not officially on duty and am new to the place and generally inexperienced, I step back. Three staff members rush to the scene and grab George by the hands and around the waist and escort him roughly to his seclusion room, where he lies down on the bed without a struggle. "Do we need to call IP?" asks one. At the time, the hospital was staffed by bona fide San Francisco institutional police officers, whose station was next door. We called them often.
"Nah," says Christina as she deftly encircles one of George's wrists with the belt loop of a leather restraint. All four of George's extremities are now strapped by restraints. Seemingly accustomed to this routine, George lies passively, his body supine on a clean white sheet.
"George, why did you have to go and do this?" asks a psych tech. "You're gonna get a shot now, too."
"Yeah, but I'm allergic to Haldol."
"Sure, George, sure."
A nameless, faceless doctor wrote the order for restraints and Haldol. Or maybe he just signed an order that the nurse had written herself on an order sheet. That was standard operating procedure in those days. Sitting in the staff room would be some MD who was happy to sign whatever order was placed in front of him. Technically the restraints could not be applied, and an injection could not be given, without a doctor's order. But who was really calling the shots?
This process was bluntly dubbed "shoot first and ask questions later" or simply "tie 'em up and shoot 'em up." It was also called "let 'em prove to us that they're okay to come out of restraints." The burden of proof lay with the patient. It might seem like a pathological need on the part of both nurse and doctor to control things, but the process of restraining and medicating a psychotic patient becomes a necessary and therapeutic step in the patient's treatment. Giving truly ill patients sedatives and antipsychotic medications allows them a chance to regain a piece of sanity—to tamp down anxiety, hallucinations, and paranoia.
George receives a large injection, the solubilized medications mixed into a single syringe and delivered via an eighteen-gauge needle into the upper outer quadrant of his left buttock, where the thick muscle can soak up all those good tranquilizers and get them on their way to his brain. Venous capillaries absorb the drug, the blood then transports it via circulatory branches to the inferior vena cava, upward to the right atrium of the heart, down to the right ventricle, then to the lungs to pick up oxygen, back to the left atrium, and then down to the left ventricle, which ejects the blood carrying the drug into the ascending aorta and carotids into the brain.
George's brain, with its dopamine, histamine, benzodiazepine, and GABA (gamma-aminobutryric acid) receptors receiving the signals, decelerates to a resting pace. Not down for the count, mind you, but it descends to a mild snooze. The blockade of the dopamine receptors in the limbic system begins to dissolve the man's psychotic symptoms. Biologically, it's complex. Phenomenologically, it's a cakewalk: man goes to sleep crazy; man wakes up calmer, if not saner.
As I was soon to discover, the medication process was perpetuated because Christina and a few of her peers had become pretty talented mental health clinicians by dint of their experience. And, of course, she was someone to be, if not feared, then at least approached with some caution. By then, several of my physician colleagues were streaming past me toward the meeting room. "Thanks for the doughnut," I say. "You know, Bo, this place reminds me of a bitter and twisted summer camp, and we're like the counselors."
"Oh, yes, honey, you are so right," he says.
"Or maybe something like a twenty-four-seven casino, and we're just like the blackjack dealers or the floorwalkers."
"It is kind of like that," says Bo. "And much, much more. You just wait and see, girl."
When I leave the meeting an hour and a half later, I see George the patient careening around in front of the triage desk, none the worse for wear. He has slept off his injection, and I'm sure a psych tech helped him pee into a urinal while he was in restraints. (They wouldn't let him piss himself in points. They weren't that mean.) And, frankly, it seems that George has woken up from the shot much less irritable and at least a bit less crazy. It did him no harm.
But does the end justify the means?
* * *
Just a few weeks later, I find myself in a minor power struggle with Christina over medicating a patient. For ten minutes, a young woman in a locked seclusion room, supposedly manic but maybe also high on something, yells nonstop, her volume escalating, and now and again screams at the top of her lungs: "Fuck you, you motherfuckers, why the fuck did you lock me up in here? I want a lawyer, I want to use the phone, I want a shower, you guys had no right to lock me up in this fucking room!"
Her caterwauling grabs the attention of Christina, the shift's charge nurse. "Paul, can't you do something about her yelling?" she asks me.
"Well, she is behind a locked door, and she's not going to be able to hurt anyone." I know that the legal standard for emergent involuntary medication circa 1992 (and today, in fact) is that of imminent danger.
The patient howls in a pitch reminiscent of an injured dog or a coyote. The content is similarly disturbing: "What are you guys? You are sadistic motherfuckers. Let me the fuck out of here right now. I mean it. I'm going to sue all of you motherfuckers when I get out of here!"
"Lovely, isn't it?" Christina says to me tartly.
"Do you think she eats with that mouth?" I say. "But she is exercising her freedom of speech."
The woman's soliloquy is now punctuated by bloodcurdling screams, the type that hearkens back to the days of true bedlam—the era of wet blanket wraps, straitjackets, and hydrotherapy—before psychotropic medications arrived at the state asylums. You can almost see Frances Farmer if you close your eyes.
"Paul, it's time to give her a shot," Christina says.
"Now I know why I had to get a hearing test before I started this job," I joke. I'm stalling a bit. I don't like the screaming, but I don't really want to medicate the patient. It's not as if she's going to break the door down and come out and club us to death.
"But Paul, we shouldn't have to listen to this kind of abuse."
"I can tune it out," I say, "if I try to."
"Well, I can't," she says. "You can't be serious. Can't you see her jacking up the other patients?"
I look around me and, no, I really can't see that, but I do want to listen to what she has to say, since she's worked in psychiatry at this hospital for more than ten years. I can see how all the yelling might have an agitating effect on the other patients, but all in all, the clinic is reasonably under control right now. In fact, no one is in points, and only one other patient is in seclusion.
"We should put her ass down," says Christina. "She's been refusing meds."
"Hey, I'd rather not give her a shot," I say. "She isn't hurting anyone. Yes, it is annoying, but she can't scream forever. She's just sitting on her bed; she hasn't even pounded on the door."
"But Paul, she's also as psychotic as the day is long. She's not going to get better with tincture of time."
Sooner rather than later, the young woman gets up off the bed and starts banging on the door, progressively louder and louder. Even I can now see that she might at least hurt herself with this thumping. "Okay, okay," I say. "Let's do it. Call IP, and we'll give her the old-fashioned—droperidol five, Benadryl fifty. I'll write the order."
Things go smoothly as we get the hospital police to help us put her in restraints and give her the injection. After we leave the room, taking off our rubber gloves, the med nurse safely disposing of the needle, the patient's screeching continues unabated for another four minutes. Then, finally, silence descends on the room. I look through the little judas window and see the woman sleeping peacefully on her back. The snarl and grimaces have melted away after the delivery of the sedatives. Within ten minutes, since she is deeply asleep, we untie her four-point restraints. We leave her door unlocked. She crashes for another two hours and then is able to come out, take a shower, eat dinner, and use the phone. Though still a bit cranky and suspicious, the woman is able to cooperate with staff and navigate the complex peer relationships of the dayroom.
Excerpted from Danger To Self by Paul R. Linde. Copyright © 2010 Paul R. Linde. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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Acknowledgments Preface. Nowhere to Hide
1. The ER Doc: Who's Calling the Shots?
2. The Rookie: Bruno's Man Down
3. The Scrambler: How to Prevent a Murder
4. The Psychodynamo: Learning to Listen with a Professional Ear
5. The Jailer: If You Want to Go, You Have to Stay
6. The Jury: Playing the Suicide Card
7. The Clairvoyant: Whose Life Is It Anyway?
8. The Speed Cop: Talking to Tina
9. The Witness: Trauma Underlies the Pain
10. The Judge: Playing God from a Psychiatric Standpoint
Epilogue. Straight from the Heart Notes References
This book is in the top five books I've read in the past year.
This is not quite an entertainment, so those who look for "hot stories about crazy people" will probably be a little disappointed. The author does not display people in distress like the human circus; he tells their stories in a calm and compassionate manner with respect for who they are and where they come from.
Psych ER is a highly stressful environment with insanity pushed to its limits; patients represent a danger to self, or others, and to keep oneself not just calm and professional but respectful and sensitive to others' pain is a gift.
I like how Dr. Linde places main focus on his patients and the hospital/city environment, not himself; this allows seeing unfolding dramatic stories in a context of a bigger picture of current medical/urban reality. At the same time there is a strong author's presence in this book, and his personality gradually reveals itself through little phrases, observations, and humor.
I enjoyed every story and I highly recommend this book to those who are in the process of becoming mental health professionals or just curious what it is like to be a psych doctor in ER.
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Posted September 15, 2010
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