Who Knows?

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.

The mid-50’s guy with a scraggly grey beard and a big old paunch that stretches out his faded, once white T-shirt sits in a slouchy, sprawly way next to his prim and proper wife. She wears a light-blue hospital mask over her nose and mouth, her beautiful brown eyes peering over the top of the mask. She has long chestnut hair and shortish bangs over her forehead that complete the frame of her visible face.

We are sitting about two feet away from each other, our knees almost touching, in a cramped examining room. I’m balancing a clipboard on my lap, stuffed with notes, a police report and forms of all kinds that will need to be filled out at some point tonight.

Outside the room and down the hall in the admissions areas, a woman in her mid to late 70’s is screaming ear-splitting profanities directed at a middle-aged man, perhaps her son, who in turn is looking at the admissions nurse with a wide-eyed expression on his face that seems to say, “See what I mean?”

“Well, maybe I do yell…I’ve been told that I yell,” drawls the slouchy guy. His wife looks down at her hands which are interlaced and locked so tightly, I can see her whitened knuckles. She glances furtively at him and then slowly turns toward me. Not being able to see the entirety of her face behind the hospital mask, I am surprised at how much I got from just her eyes.

“Based on what I just talked about with your son, it seems like yelling was at least part of it,” I say in a neutral tone, hoping to encourage the slouchy guy to be a little more forthcoming. His face breaks into an incongruous half-smile and he emits a deep throated chuckle and a snort, like something funny just occurred to him. 

“I had to use duct tape because he was getting out of control,” he says, continuing to snort. 

About twenty minutes ago, I had started evaluating my fifth patient of the night in this very same room, located in the heart of this dingy old psychiatric hospital. The patient, a 13 year old boy with jet black hair that had been treated with some kind of goo or gel that allowed his 8 inch long hair to stand up in big, undulating waves high above his head, had been brought in by his parents because he was, “out of control.” I was marveling at this boy’s rather extraordinary hairstyle, when I caught him looking intently at my balding head. Inwardly, I smiled. Here I was studying his thick shock of hair that could do tricks, while mine had been reduced to one trick: turn gray and fall out. Oh, well.

As the kid and I talk, it becomes apparent that the boy had poked, or possibly stabbed his father in the gut with a metal guitar stand at home during a heated argument earlier in the evening. The boy then went after his Dad with the actual guitar itself. Dad had cuffed the boy down to the floor, sat on the kid’s legs and then proceeded to duct tape the kid’s arms tight to his body. Somehow, at this point, the kid got loose and ran out of the house, down the street and through the neighborhood, and finally managed to get a neighbor to call 911. The police showed up and escorted the kid, Mom and Dad here to the emergency unit of this psychiatric hospital.

Okay, sure.

The kid has a stock answer to the first handful of questions I ask him, “I don’t know.” In spite of his curt answers, he looks somewhat earnest and hopeful. His eye contact is pretty steady. His face has that fawn-like or changeling appearance, not quite a boy and not quite yet a man. 

He doesn’t know it, yet, but he will likely be staying the night against his will in this old psychiatric hospital. Unaware of this, with less guise than he imagines, I can tell that he is working it, working his plan to get me on his side and get him released.

Back in the room with the parents, the scraggly bearded Dad tells me that the boy has once again broken probation and over the past few weeks has been skipping school and failing classes.

Earlier in the year, the boy had been caught stealing some pricey property from a home in the neighborhood. He had also vandalized some other things a few days before that. The boy had been sent to ‘some kind of juvenile law breaker place,’ according to Dad, and the boy was placed on probation, not for the first time. Shortly after beginning probation, the boy was caught with something he shouldn’t have had, (Dad was vague about this), and things went from bad to worse. The Dad says, “Me and the wife are at our wits end.”

The emerging story was that over the past few years, medications hadn’t been helping. Setting limits had been unenforceable. The legal system wasn’t making any difference. Brute force, apparently, was the only thing that was being used at home, and its efficacy could be measured in our meeting here tonight.

Slouchy Dad hitches up his trouser leg, his legs spread out wide from his chair, and says, “I know it’s probably his testosterone and wanting to be the alpha dog, but we just can’t keep going on like this.”

Over the hospital mask, Mom’s eyes have a beseeching expression tinged with fear. I assure them that a lot of kids go through an adjustment phase during adolescence. I also go on to say that not all kids have this kind of conduct and end up in a psychiatric hospital. As I’m talking with them, my mind is meandering through categories of conduct disorder, oppositional defiant disorder, intermittent explosive disorder, substance abuse, trying to find something that will give a sense about how to move forward with a treatment plan.

I look at the parents and I’m impacted by their despair and confusion. For a brief moment, I imagine them in their younger days. Youthful and in love, wanting to start a family. I know from our earlier conversation that they have three kids. I imagine their first two kids, daughters, separated by two years, bringing smiles to their faces. The daughters go on to do well. Good students, both of them destined for college. Eight years after the daughters are born, a baby boy arrives. I imagine the wriggly, cute baby boy brought home from the hospital. The parents are delighted with him, enjoy playing with him, getting used to the distinctly different energy that comes with a boy compared to the girls. At what point did it start falling apart? Were there signs along the way that the boy would grow up to have problems?

Or did I have it all wrong in my fantasy about this family? Is the Dad some kind of rough character, an overpowering force that browbeats the family, and the only option the boy had was to rebel? I look at the wife, at her fearful eyes. She looks away. Slouchy guy scratches his beard and shifts in his chair.

Out of the corner of my eye, I see that the elderly woman, who has been cursing at the top of her lungs the whole time, has taken a big, lunging swipe at the middle-aged man, whom I am assuming is her son. Something will have to be done soon to get her calmed down before she is transferred to the ward. The admissions nurse is giving me a meaningful look.

Sitting knee to knee with the parents of the once duct taped boy with big hair, I realize that I am not likely to learn the truth tonight about what has really happened that got them here, both from years gone by or from earlier tonight.

I take in sharp breath, suddenly aware that I really hadn’t been breathing. I launch into the professional wind-it-up mode, and tell the parents that I will be admitting their son. I explain that in the morning, the primary team will meet with their son, and later in the day, the social worker will call the parents with a summary of the treatment plan, including length of stay. The parents nod dully at me. No, they say, they don’t have any other questions for me.

The screaming elderly woman is now pounding desperately on the plexiglass of the nurses station and looking suddenly unsteady on her feet. The admissions nurse is now waving at me. Time to make my move.

I stand up and thank the parents for their time and input. Behind her hospital mask, the woman with the beautiful and fearful eyes stares down at her tightly wringing hands. The scraggly bearded man’s half smile appears again. Who knows what is going on here?

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