In which my fingers smell like keys.
And just like that, another block is over. I spent a month and a half in the locked psychiatry unit at a nearby hospital, during which I had more donuts and decaf than I’ve had over the last year combined.
The psych unit is like no other service. There are no blood pressure cuffs or IV bags in rooms; the units have common areas for patients to hang out, and to look for a patient, one has to scout around instead of reporting to the proper room.
The precautions are different, too. All the doors to the unit are locked, and terribly heavy. Ties and stethoscopes are disallowed (strangling hazard); patients aren’t given anything sharper than a crayon. No shoelaces on the unit. No coat hooks on the walls (patients could hang themselves). Staff were identifiable by the jingle of keys as they walked. And unlike any other service, the stories swapped by the attendings and residents were out of this world.
Some stories stick out, but not the wacky ones (though I do have those).
I remember a few months ago, during my psychiatry course, I told a faculty member after class on internal bias that I had internal bias against perpetrators of domestic violence and rape. “I just don’t think I can empathize with these kinds of people. If they’re my patient, what if I don’t give them the proper or full treatment because I don’t like who or what they are?”
My professor replied, “It’s good that you realize you have bias. That’s a good first step. We’re professionals, and part of that is giving our best, regardless of whom we treat. If you feel you can’t treat someone properly, it’s best that you find a colleague who can.”
A few months later, I found myself volunteering to take the patients with violent histories. I got a few guys who were in and out of prison for multiple violent assaults, robberies, etc., a guy brought in by police for beating his girlfriend, an intimidating bruiser-type with history of physical outbursts detoxing from drugs.
The nurse manager in the morning would rattle off the new patients to interview each morning and a brief summary of their reasons for admission: “patient A has alcohol abuse, B has suicidal thoughts, C attacked another person without provocation .” We medical students looked at each other and divvied up the patients. “I’ll take C,” I said. “C? Why would you want C?” My classmate asked. She had had a really difficult interview the day before that left her in tears, and today was taking A, who seemed to be an easy interview. I shrugged and smiled. “It’ll be a learning experience.”
As it turned out, A was not an easy interview. He was sullen, belligerent, and impatient. My classmate just couldn’t catch a break.
My interview of C was interesting. I had hoped to learn through all my patients how to see the human side underneath the violence. It was hard to like C, though. The way he told his story, he had bullied and fought his way through life. It was his normal to lash out physically when he was irked. But what concerned him this time was that his heart, weakened by a string of heart attacks, was no longer strong enough to match his aggression. He was scared, scared for his life, and that’s what brought him into the hospital. I asked him if he was worried for the people he attacked. He wasn’t. “I want to live,” he said.
I had a hard time getting over my feelings about that kind of selfishness and victim mentality. But in my interview, I had to be on his side. “That must have been so scary, to feel your heart rate go up and not be able to control it, and worry about another heart attack.” He emphatically agreed. “You have no idea.” “Well, I’m glad you’re here. This is where we can try to help you.” Was I glad he was here?
Patient C, and really all of my patients, taught me that I like to like my patients. But that could be a real problem if my preferences it affected my care for them — how timely it was, how thorough I was. I learned how to give every patient equal time. Especially the ones I liked to hang out with, or the ones I really didn’t like to see at all.
Patient C taught me something else, too. In a session discussing safety plans outside of the hospital, he began to tell me about his struggle with alcohol. After one of his heart attacks, he was in the hospital and realized that he couldn’t remember bringing his daughter to buy her prom dress. He knew he had been there, but for the life of him he couldn’t remember a single thing about where they went, what it looked like, or even the prom itself. Then he thought some more. He realized that because of his alcohol problem, he could barely remember the details of his three children growing up, playing with them, their graduations, or holidays. He was racked with regret for missing basically their whole lives. He did remember what alcohol made him do to them: beatings, destroying the house, breaking things. C looked at me at the end of his reverie. “No more. I’ll never go back. That’s why I’m in an alcohol program now. ‘Cause I have a one year old grandson, my oldest daughter’s baby, and I ain’t gonna miss any of his life. I want to live.” Finally, the words I misunderstood in his initial interview made sense. I was reeling from how much I suddenly cared for this patient. Some missing piece had finally slid into place. I was finally seeing the person under the mental illness of addiction, and it took a wife-beating, child-beating, desperately broken man, the kind of man I never thought I’d understand, to show that to me. He then started, saying, “Sorry, I’ve been ramblin’ up your time, miss A — . We were supposed to be talking about something else, right?” We turned back to our worksheet. “Right. What are some ways you can make your environment safe?”
At the end of the session, I thanked Mr. C. “There are things we really just can’t learn from textbooks. I learned a lot talking to you today.” He smiled. “It’s nothing, thanks for lettin’ me talk.” I don’t think he knew what a difference he made for me. I was really glad he came to the unit.
I was sitting typing out a patient note, and a classmate came in and sat in a free chair in the room. He was saying to himself, “Oh, I’m sorry to hear that. That must be really hard. I’m sorry about that.”
“What’s up?” I asked him.
“Nothing. The attending told me my interview was good, but I needed to be more empathic. But no matter how I say it, it sounds fake. I mean, it is fake. I don’t really feel sorry.” He continued rehearsing, a bit frustratedly. He was right, the validating statements sounded pretty hollow.
“Good thing you didn’t go into acting, Brandon.”
He laughed, but then grew serious. “We don’t get any practice at this kind of acting. How can we be good at pretending to care?”
“In a way, don’t you practice with all your friends? They’ll tell you about something happening, then you commiserate and agree with them. You’re not fake when you do that, because you do care. Right? Maybe that’ll help with your patients.”
“Hmm. I guess so. I never thought about it that way. So I just pretend the patients are my friends venting?”
“If that helps! It helps me to listen to them like a friend. If this stuff happened to my friend, I’d be sad and sorry and concerned. And these things could happen to any of us, too.”
“Yeah, I guess so.” He was silent for a bit. Then he went back to practicing. “I’m sorry to hear that. That must have been horrible…”
Bonus mini-story I forgot to tell from neurology service. In certain types of strokes, blood supply to the language center of the brain is lost, so the patient either can’t understand anything (Wernicke’s aphasia), can’t say anything (Broca’s aphasia), or both (global aphasia). What is preserved in Broca’s aphasia are some words linked to the limbic system, a more primal part of the brain involved with emotions. The most common example is the stroke patient who can’t say anything except curse words — because somehow those words aren’t stored in the same language areas as everything else.
One old lady came into the emergency department as code BAT — a stroke. She had the terrible syndrome of losing all her words, Broca’s aphasia. On neurological exam, she showed the classic symptoms: a right sided facial droop and right sided weakness, and wide open, comprehending, terrified eyes. But as she calmed down, I was tasked with assessing her speech. She couldn’t say her name, she couldn’t repeat a phrase after me. She couldn’t make a sound. But after a few more assays, she looked me in the eye and said, “Praise the Lord.” Loud and clear, that was the only phrase her brain had left to give. She repeated it again and again. “Praise the Lord! Praise the Lord!” I smiled at her and repeated it back to her. Later, my neurologist referred to her as the praise-the-Lord patient.
I hope that even if I lose my faculty of speech, even the deepest part of my brain, where most people only harbor profanities, would know only to praise the Lord, too.
