The following essay is based on an actual encounter I had while I was in residency training. Names and other personal characteristics have been changed to protect the privacy of the patient for whom I provided care late one summer night. As a resident physician, one has the opportunity to begin to practice the skills acquired in residency, which is the four year postgraduate training that follows medical school. As a resident, you know a lot, but the actual practice of medicine in the specialty of psychiatry, in particular, takes a few years before you start to have a true trust in yourself. Moonlighting is the term that is used to refer to working outside of the required daily duties of the residency training program. After a full and demanding day in residency training, one may work an additional five hours late into the night at a different hospital, thus the term, moonlighting.
“Hey, Maggie,” I say quietly as I slowly approach a patient seated in an oversized chair. “I’m Dr Crooks. I can see that you are in the restraint chair…” I pause, waiting for a response. Nothing. “Can you tell me what is going on?”
“I’m hearing voices,” she mumbles thickly.
The patient’s chart indicates that she is my age.
Drooling profusely, with her short, dull grey-haired head bowed, she utters something softly and unintelligibly. She is wearing a stained pink velour top and matching stained pants. She has baby blue hospital socks on her feet.
As I start to look her over, I notice that she has a watch strapped on each wrist. The watch on her left wrist is metallic and on her right, a watch made of plastic. I notice that the hands of each watch indicate different times, neither one of them accurate.
Her shoulders, wrists, abdomen and ankles are strapped down snugly to the chipped red metal restraint chair, held in place by no-nonsense grey nylon straps. In the corner of the small, darkened room where she has been isolated, there is, curiously, a large, standalone heavy-duty punching bag, with a pair of worn-out boxing gloves balanced precariously on top.
Just outside of the room, an imposing African-American man wearing several earrings on one ear watches me silently, leaning back in a lounging position on a beat-up plastic lawn chair. He has a lollipop in his mouth and is holding a worn out paperback book in his hand. He nods politely at me as I turn to him. He is one of the helpful orderlies who are on duty to contain the chaos that can erupt in this ancient psychiatric hospital ward.
I turn back to the restrained patient, and hunker down on my haunches in order to be at her level. I remain alert, having learned the hard way that although a patient may be restrained, they still can spit at me.
“What are the voices telling you?” I ask soothingly, as I check the tautness of the straps to make sure there is no restriction of blood flow to her hands or feet and to confirm that she is able to breathe freely. She has frank abrasions on the knuckles of her right hand and a healing wound on the index finger of her left hand. I assume these are souvenirs of the violent behavior that was noted in the patient’s chart during her admission. I recheck the straps, making sure they are not too tight, but also, not too loose.
“Kill…” she states simply in a wavering voice.
“Kill who? Other people? You?” I ask, trying to engage her attention. She doesn’t answer me. The drool from her mouth is profuse at this point. A thin, white hospital towel has been draped around her her neck, put there to absorb the saliva that courses from her slack mouth. She appears very sedated to me.
“Can you look at me, Maggie?” I ask, trying to judge just how sedated this patient may be. Thirty minutes ago, prior to my arrival on the unit, Maggie had involuntarily been given an intramuscular injection of a strong antipsychotic medication combined with a benzodiazepine, the combination of which can profoundly sedating. She glances up at me briefly. Her sunken eyes are as grey as her hair and as empty as infinity. Her head slumps down again.
Just prior to entering the room to evaluate Maggie, I spoke with the charge nurse who had made the call to put the standing orders into action to have the patient restrained and injected. According to the nurse, the patient had been banging forcefully with her fists on the thick Plexiglass that separates the patients from the staff. Additionally, the patient had been throwing lawn chairs and small tables across the room, threatening staff and scaring the other patients in the common area.
Maggie is not a large woman, but the intensity of her anger is formidable, the nurse tells me. In speaking with the nurse, I am told that whenever the patient is in the restraint chair, (and this has been going several times a day for the past 3 months since she was admitted), the patient will appear very sedated and drool constantly. The nurse tells me that the moment the patient is released from the restraint chair, the patient springs into action, with all previous signs of sedation gone and her drool all dried up, and she will go into a frenzied attack mode.
I gaze at Maggie for a little while. To release or not to release. That is the question that is percolating in my mind.
The patient received some news earlier today that she is going to be transported to a long-term forensics psychiatric hospital later this week. The institution where she is being transported is intended for patients who have committed felony crimes and who have been found not guilty by the courts by reason of insanity. The forensic psychiatric hospital is also the destination of patients from state run hospitals who have been found to be manifestly dangerous. Maggie, apparently, qualifies on both counts.
In review of the initial psychiatric evaluation performed some three months ago when Maggie was admitted, I read that the police had been called to Maggie’s house after a neighbor had observed Maggie out on her front porch, screaming and waving a large knife. According to the officers’ report, Maggie was intent on cutting her wrists and had already taken a few preparatory passes prior to the police arriving.
While the police attempted to de-escalate things, Maggie ran into her house and brought out a gun, threatening to kill herself and to kill the cops. Fortunately, the officers had mental health training and continued to try and calm Maggie down. Nevertheless, there had been a standoff of several hours before the police officers were able to talk Maggie into putting down the gun.
Maggie is my age, and she is strapped in a chair. No amount of medication is going to make this woman regain any quality of life. Her family has long ago given up, burned out by the nonstop chaos that a medical disorder has inflicted upon this woman. We in the hospital are functioning mainly as crowd control in our efforts to divert Maggie’s fury from erupting on herself, on other patients and staff. And me. I feel a vague sense of hopelessness arising in me, and yet, what else is there to do at this late hour?
I stand up slowly. The watches on Maggie’s wrists reflect different times, neither one of them correct. I sigh and wonder what time will hold for Maggie. For the time being, she will remain in restraints.