The door between myself and our psychiatric patients has four layers.

The first is the bottom half of the door, just higher than my waist.  The second is the top half of the door, which has a window made of inch-thick plastic in the center.  There are nine holes drilled in the plastic, about face height, each about a centimeter in diameter.  My patient can talk to me, hear me, and maybe spit on me if I’m dumb enough to stand right in front of the holes, but they can’t get through.

The third is a secondary “top-half,” made of solid wood.  If I close it behind the plastic window, I disappear from view.

And the fourth is the electronic lock.  Without a hospital badge, when any of the other three layers are closed, the door will not open.

I only have the first layer engaged now, listening to my patient.  I am leaning against the half door, my arms resting on the top edge.  She is about my age, and she is as broken as any of my trauma patients.

“I need to call my brother.  I need to make sure our sister doesn’t go to my house.  She’s going to kill my dog, and she’s going to destroy my house.  I know this is happening, and I need to call my brother and make sure she stays away.  I can’t call the police because they’re working with my sister to make sure my dog dies, and then they will probably burn my house down to destroy all the evidence.  Can you write this down for me?  Please, I need to write this down.  My sister’s name is Melinda, she is working with the sheriff to kill my dog and burn my house down.  They’ve been stalking me for weeks, following my car, watching my house with drones — ”

This is easily the fifth or sixth time she has told me this story.  I have been on our small emergency psychiatric unit for 30 minutes.

At the mention of the drones and the stalking, she begins to crumble.  Her psychic distress is so severe that she begins to draw inward physically.  She crosses her arms over her chest, bends her knees, and begins to double over at the waist.  Her face is a mask of agony.

“Nobody believes me.  My brother thinks I’m crazy.  Why are they harassing me?  Why won’t they leave me alone?  They are SCARING THE SHIT OUT OF ME!”

And then she begins to cry, huge, heaving, choking sobs.  There is nothing I can do for her.  She is awaiting a mental health evaluation by a county representative who will eventually detain her involuntarily due to her psychosis.  But until the evaluation is done, I can’t even give her a sedative, nothing that would ‘alter her mentation’ – or that would give her any relief from the incredible distress she’s experiencing.

So I do the only thing I can think of.  I lean out a little further over the door and open my arms.  And she staggers into my embrace and weeps on my favorite work jacket, and I rock her back and forth but I say nothing, because there is nothing I can say.

~ ~ ~

Different ER, different year.  He is homeless and schizophrenic, and the police brought him in this time because he was standing downtown in the middle of a busy street, screaming at the cars that went by.

This ER has a large separate emergency psychiatric ward with its own staff.  All we have to do is perform a “medical clearance,” which entails basic bloodwork and a urine drug screen, and then he can go over to psych.

But first I need to convince him to pee in a cup for me.

“Michael, I need you to pee in this cup, man.  After that we’ll get you set up with a bed for the night.”

Michael is not responding to me, because he is staring intently into the empty doorway just beyond my right shoulder.  He is scowling at something or someone that only he can see, and it is making him very angry.

I try a different approach.  “Hey, Michael, do you want a sandwich?  And maybe some juice?”

The mention of food speaks to a very fundamental human need, one so basic that it temporarily overrides the hallucinations higher up.  He turns his head for a moment, and looks at me.  “Yes.  Yes, please.”

I step out of his room, past the police officer at the door, and head over to the supply room.  I grab a pre-packaged ham sandwich, grateful that we haven’t run out already tonight.  I pour some apple juice in a styrofoam cup.

Back in his room, I place the cup on his bedside table.  He is still staring at the doorway.  Trying to reconnect him with something solid, something real, I reach down and place the plastic-wrapped sandwich in his hands.  He takes it absently.  I step away, and lean back against the wall.

And then Michael explodes.

“YOU SHUT THE FUCK UP YOU DIRTY MOTHERFUCKER, I WILL FUCKING KILL YOU!” he screams, and he pulls his arm back and whips the sandwich through the open doorway.

It hits the wall twenty feet away on the other side of the hall with an audible whump, and then slides down to rest behind the code cart parked there.

Michael seems startled by his outburst, and then is almost immediately startled again by the rush of people into the room.  Techs, nurses, a police officer, all responding to the violent outburst.  I hold up my right hand.  “We’re all right.  I’m fine.  Michael is fine.”

And I was, and he was.  He wasn’t angry at me, and he hadn’t thrown the sandwich at me.  I probably wasn’t even part of his awareness at the time.

Michael’s fury was at the hallucinations that tortured him every moment of every single day.  And without heavy-duty medication, they would torture him forever.  And without stable housing and stable medical care, he could not keep up with his medicine.  And without his medicine, his hallucinations prevented him from managing his own housing or medical care.

The mentally ill in the United States are the modern-day Sisyphus.

Michael was frightened, trapped, and alone, with only his demons for company, just as he probably had been for all of his adult life.

I walk over to the code cart, move it out of the way, and pick up his slightly misshapen sandwich.  I walk back over to his bedside, and hold it out to him.  He reaches out with a violently trembling hand, and takes it back.  He unwraps it slowly, and takes a bite.

“Thank you,” he mumbles.

~ ~ ~

Your average ER nurse does not like psych patients.

We don’t like people who arrive by ambulance after a breakup, and tell us they want to hang themselves, and then get angry when we won’t let them leave.  We don’t like angst-ridden teenagers who tell us they overdosed by taking “four Tylenol and a Benadryl,” and then get upset when we take their backpacks away and search them for more pills.

I can’t speak for my coworkers, but I don’t like the first group because I was there when EMS rushed her in, the ligature marks dark on her neck, her roommate hysterical after finding her hanging in the closet.  I was also there when we shut off the vent and let her go.  She was 23.

Yes, I’m going to take your statement of intent seriously.

And I don’t like the second group because I have stood by the bedside, frantically setting up the NAC drip, triple checking an intensely complicated dosing calculation, listening to the doctor tell his family that we will probably not be able to stop his liver from failing from acetaminophen toxicity, and that if it fails then he will die tonight in the ICU.

Yes, I’m going to take your ‘overdose’ seriously.

But the average ER nurse also doesn’t like the truly psychotic psychiatric patients, either, although I think it’s for different reasons.

We have an instant gratification complex.  This is why we work in the ER.  Got a kidney stone?  I can literally have you lined and pain-free in less than five minutes (thank you, Toradol and Dilaudid).  Did you eat at that sketchy food truck and now you’re puking?  Thanks to Zofran and IV fluids, you will feel amazingly better in about an hour.

I can’t fix psychosis in an hour.  I can sedate it.  I can hit it with dose one of a psychoactive drug.  But I can’t fix it.

No one can.

And your average ER nurse really, really, REALLY likes logic.  We like science, and chemistry, and predictability.  If we give you nitroglycerin, your coronary arteries will dilate and your chest pain will back off, but your blood pressure will drop and you’ll probably get a headache.  We know this, and expect this, and if it doesn’t happen — well, it never doesn’t happen.  Nitro just works the way nitro works.  We like it this way.

Psychosis isn’t logical, or predictable, or rational.  You cannot argue with illogic.  You cannot bargain with irrationality.  You cannot re-orient someone to your world when they live in a world of their own.

I think we don’t like psych patients because they frustrate us.  Because we can’t make it better, and making it better is what we do.

But until we choose to create a healthcare system that comprehensively cares for the mentally ill, and prioritizes them as deserving humane, ethical, and intensive medical treatment, the ER will continue to be frustrated.

Because although some of them come to us of their own free will, many do not.

~ ~ ~

I could tell that his femur was fractured before they even moved him off the ambulance gurney.  His left leg was shorter than his right, the muscles of his left thigh bunched up and contracted without the counter-stretch of an intact femur to lengthen them out.

I could also tell that he was mentally ill.  He was talking over the medics, paranoid, irrational, gesticulating wildly with hands, seemingly oblivious to what must have been excruciating pain.

The medic pulled me aside.  “You know the car that was t-boned a little while ago?”

I nodded.  They’d called the team to the trauma bay, and were still frantically trying to save her life.

He gestured to my patient.  “This is the guy that ran the intersection and hit her.”


He arrived shortly after my twelve-hour shift started, and he stayed the whole night.  The hospital was full yet again, and there were no beds available on the trauma/ortho unit.  We sedated him with haldol and gave him pain medications when the ortho residents arrived to put him into traction.  They drilled holes into his proximal tibia and inserted long, slender metal pins.  When the pins were attached to a weighted bag hanging over the end of the bed, the pull of the weight straightened the broken femur, holding it in place temporarily until he could go to surgery later in the day.

His sister showed up, distraught.  He hadn’t had his meds in months, she said; he’d disappeared and she hadn’t known where he was.  She had been fighting for years to have him declared incompetent, too mentally ill to care for himself.  Only then could she, acting as his medical power of attorney, force him to accept the monthly injections of the psychoactive drug that kept him functional, if not sane.  Her petitions to the court were denied every time.  He was competent, they said, and the court was not willing to revoke the fundamental human rights of a competent man.

The state police showed up, and questioned him for a long time.  He seemed almost startled when told that he had caused a car accident.  He couldn’t give a coherent timeline leading up to the accident.  He kept going off on tangents, paranoid delusions of being followed, of having batteries implanted in his skull that gave him an electric shock, of his food and water being poisoned.

Eventually his sister went home, heartbroken, feeling as though she had failed her only sibling.  And then, in the early hours of the morning, seeing that he was literally pinned and tied to the bed, the police officer guarding him left, too.

Towards the end of my shift the sun began to creep above the horizon and through the window of his room.  My patient had only slept fitfully through the night, but the haldol seemed to be keeping a few of the demons at bay.  He saw me now, and interacted with more purpose.

“I was in a car accident?” he said, as though trying to clarify a distant and hazy memory.

I nodded, hanging a bag of IV antibiotics.

“Gosh,” he said, and was quiet for a moment.  I started the IV pump, and stepped to the foot of the bed.  He looked up at me, and in that moment the hallucinations were gone, and all that was left was the simple human underneath, the person who had laughed and played as a child, loved sports as a teenager, kissed a girl in high school, planned for college, had been his parents pride and joy —

Until the day that everything suddenly changed, and that first voice said, hello.

He looked down at his hands.  “I hope the other person is ok.”

I nodded again and turned away.  I didn’t know what I could legally say, but regardless of the law I hadn’t the heart to tell him that the woman he’d crushed with his car had died an hour after he arrived, that her family had mourned her for hours in the bay, that she was now lying on a cold metal slab in our morgue.

I glanced back at him from the doorway.  He sat there, distant again, listening to a conversation I couldn’t hear, unaware of his body tied to the hospital bed, trapped in a mind from which he could never, never escape.