Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis - Hardcover

(AUTHOR’S NOTE)

The names of all patients and certain details of their stories have been changed in order to preserve confidentiality. For the same reason, the names of some of my colleagues have also been changed.

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(PROLOGUE)

Bedlam

Canst thou not minister to a mind diseased?

—Shakespeare, Macbeth

In early January, Charles Harold Wrigley, a twenty-two-year-old gas engineer, was brought by his family to the psychiatric hospital. “The patient is extremely depressed,” the evaluating physician wrote. “He sat with his hand on his forehead as if in pain during my interview. He says everything he does is wrong and that he is very miserable.” A second doctor’s note adds, “I am informed . . . that the patient has suicidal tendencies and since he has been [at] this hospital has attempted to strangle himself.” Notes like these are familiar to me. As a psychiatrist, I have seen countless patients in emergency rooms, inpatient units, and outpatient offices whom I might have described in nearly identical terms. This patient’s symptoms are not striking; however, the familiarity of the description is, considering that Charles Harold Wrigley was evaluated and treated at England’s Bethlem Royal Hospital in 1890.

Before I became a doctor, I had more faith in medicine. I thought that medical school and residency would teach me the body’s intricacies, its capacities to heal and to falter, and all of our various methods of intervening. Once I mastered these, I thought, I would really know something. That has turned out to be partially true. I know many more things about the body—its wonders and its failings—than I could ever have imagined. But as a doctor, I have emerged from my training with a shaken faith. If I hold my trust in medicine up to the light, I see that it is full of cracks and seams. In some places it is luminous. In others it is opaque. And yet I practice.

At times this doubt is disillusioning. More often, however, I’ve come to view the questions that arise as a vital component of the work of medicine. My faith in medical knowledge has shifted into a faith that the effort—the practice—of medicine is worthwhile. I cannot always say with certainty whether the course of treatment I prescribe will heal; I cannot always locate with precision the source of my patients’ symptoms and suffering. Still, I believe that trying—to heal my patients and to dwell amid the many questions that their illnesses generate—is a worthwhile pursuit.

I have found that one of the gifts of medicine is that it allows those who practice it to participate in the purest and most vulnerable moments of human life. As doctors we share in the utter joy of birth, the irrepressible relief of a normal scan or a benign biopsy. We deliver earth-shattering diagnoses. We accompany people to their deaths. In these moments there is not much room for the protective or insulating layers that people—all of us—put upon ourselves in our daily lives. Joy is joy, and grief is grief, and fear is fear; and in the context of medicine, those emotions are often at their most primitive and raw. As an inpatient psychiatrist, I treat people who are in moments of profound crisis. The majority of them are hospitalized because they might not be safe otherwise. I do not lose sight of the fact that my patients come to me in these precarious states.

I am a few years into my psychiatric practice. Relatively speaking, I am new to the job. Every day that I go to work on the inpatient psychiatry wards, I encounter people who are despondent, or terrified, or raving mad. I see people whose lives have been ruined by addiction. I hear unfathomable things that people have done to others, from familial betrayals to brutal attacks. I talk with people who, more than they have ever wanted anything, want to die. It is not a dull job.

This book was written over the course of my residency in psychiatry and in my first years as an attending psychiatrist. As a resident, I worked in many different psychiatric settings, from prisons to outpatient offices to medical and psychiatric hospitals. These days I work as an inpatient psychiatrist on the locked wards of a freestanding psychiatric hospital. I wrote the book not as a sequential exploration of patients I have encountered over these years but rather as a visiting and revisiting of hard questions that emerged for me about patients, and medicine, and the mind. Questions that stayed with and gnawed at me. This book arose from psychiatry’s mysteries and my own misgivings, from patients whose struggles I could not make sense of, from the doubts and queries that haunted me and kept me from sleep at night.

·   ·   ·

It was in my current job working weekends on the wards of the psychiatric hospital that I met Joseph. On the weekends I cover an entire adult unit in the hospital, which means that on Saturday mornings I will have eighteen to twenty patients to see. Before I see them, I will have had a brief Friday sign-out on each patient from the weekday doctor. Sometimes this will be a conversation that spans a few minutes. Sometimes it is a phrase written beside a name: “resolving paranoia,” for example, or “manic, assaultive.” The nurse in charge of the unit meets me when I arrive and gives me pertinent information from the last twenty-four hours: vital signs, the degree to which a patient is participating in the unit therapy and activity groups, whether a patient is eating and taking her medications, whether a patient appears to be withdrawing from alcohol or from drugs. The nurse will also pass along anything the staff has noticed, either worrisome or reassuring. It is in this early-morning session that I hear about who wandered out of whose room naked and confused, who has gone two days now without talking to himself, who remains suspicious about whether her medications are poisoned, who was caught with cigarettes.

If a patient has been admitted overnight on Friday, then I will have the record of his emergency-room evaluation, but I will be the first treating psychiatrist to see him. It will be up to me to learn how the patient ended up in the hospital and how his treatment on the unit should begin.

This was the case for Joseph. When I walked onto the unit and saw his name listed as a new patient, I pulled his chart from the rack and flipped to the ER assessment: “42-year-old man with a history of depression who was referred by his caseworker after becoming increasingly depressed, not eating or drinking, not leaving his house, etc. Patient engages minimally with interview. States he wishes he were dead, but denies plan or intent to kill himself. Patient has been on antidepressants for many years, but recent compliance is questionable.”

Because of Joseph’s “minimal engagement,” there wasn’t much additional information in the evaluation. Our records showed that he had been hospitalized here five times before, but his most recent prior hospitalization had been seven years earlier. That was before the hospital had adopted computerized records, which meant that Joseph’s records were entirely contained in paper charts, and those were archived. They could be requested, but it would require several days to obtain them. I needed to begin treating him now.

From the nursing report, I learned that Joseph had arrived on the unit and gone straight to bed, where he had been asleep for the last six hours. When the report had concluded, I made my way to his room to see him. I knocked on his door, and no one answered. I pushed the door open gently and called, “Joseph? I’m Dr. Montross. Okay with you if I come in?” The room was dark; the curtains were drawn. I took a step in and immediately noticed the smell of a person who had not bathed in some time. As my eyes adjusted to the darkness, I could hear Joseph snoring loudly. It wasn’t unusual for me to find my patients asleep. I started rounding early. Some patients, like Joseph, would have come to the hospital or would have been transferred from another ER in the middle of the night. Not infrequently, at some point in the admission process, patients received medication that had the potential to sedate them. I tried again.

“Joseph?” The snores continued. I turned and left the room. I’d give him some time to rest while I saw the other patients. If he hadn’t woken up by the time I came back, I’d have to awaken him. For now I’d let him sleep.

I made my way around the unit, stopping into rooms to talk with the patients. I jotted down notes as to how they felt they were doing. I made myself a list of orders to write: medication changes for certain patients, additional privileges—like outdoor walks or permission to use their own razors—for others. I had met with about half the patients when Henry, an experienced nurse, pulled me aside, looking concerned.

“Hey, Doc,” Henry said. “We’ve been trying to get Joseph up for his vitals. He’s not responding at all. I even gave him a sternal rub, and nothing. Can you come over and examine him?”

I work with Henry frequently. He is easygoing and typically unflappable. Patients like him, I think in part because his demeanor is so even. Their worlds might feel chaotic, but Henry radiates calm. At this moment, however, he was talking quickly, and his tone was businesslike—a departure from his usual slow, unruffled jocularity. I took note immediately and followed him back across the unit toward Joseph’s room. As we walked, Henry anticipated all my questions.

“I brought in the pulse ox and the manual cuff. His vitals are fine: one-eighteen over seventy-six, pulse of sixty-four. Oxygen saturation is ninety-eight percent on room air. But he’s totally unresponsive. I checked the admission paperwork,” he continued. So had I. “He blew a zero on the Breathalyzer when he came in, and he got no meds at all in the ER. He’s been with us eight or nine hours now, and he was at least with it enough to register and get oriented to the unit on the night shift without them worrying he had a heavy dose of anything on board.” We got to the door, and Henry paused. “I really dug my knuckles into his sternum, Doc.”

Sternal rubs are a seemingly vicious part of a neurological examination. People respond to different stimuli at different levels of consciousness. When afraid and alone in a quiet house, a person might be aware of the tiniest sounds or movements: the freezer’s hum, the click of a thermostat, or the whisper of a single leaf fluttering outside a window. Adrenaline hones our senses and renders them keener. In contrast, in the depths of sleep I may not notice my partner’s leg brushing up against my own. She may hear our daughter’s single cough; I may not. There is a range of awareness. And yet the body’s response to pain is preserved in these depths, for reasons that are evolutionarily obvious. Even in the deepest dream, a burning ember on your skin would wake you.

A sternal rub consists of making your hand into a fist and grinding your knuckles into a person’s sternum, or breastbone. Try it on yourself; it doesn’t take much pressure until you want the feeling to stop. With patients who are sound asleep, or sedated, or feigning unconsciousness, doctors and nurses first try less painful means of rousing them. If the gentler methods yield no response, so-called painful stimuli like the sternal rub may be employed. When someone truly does not respond to painful stimuli, there may be real cause for medical concern.

Most of us, as patients, are not entirely forthcoming with our doctors. We overestimate our exercise and round down on our junk-food consumption when we talk with our primary-care doctors. I generally tell my dentist that I floss more regularly than I do. The crass conventional wisdom in the emergency room is to use a formula when calculating the “true” amount of alcohol a person drinks: Ask patients how many drinks they have in a typical week. Then, if the patient is female, multiply the number by two. For men, triple it. For veterans, multiply the number by five.

The true state of the psychiatric patients I treat may be obfuscated by a range of factors. Drugs—of both prescription and street varieties—are far more likely to be involved with my patients than with nonpsychiatric patients. Mentally ill people may be less able to accurately recount the symptoms they are experiencing or the drugs or medicines they have taken. They may be paranoid or angry and, as a result, refuse to disclose information that is important for me to know about their care. They may also—as in the case of suicidal patients who have intentionally overdosed—be less inclined to be forthcoming about what may have brought about changes in their condition or mental state. A pediatrician friend once joked that treating babies and young children can be like practicing veterinary medicine, since the patients cannot fully communicate with you. Sometimes psychiatry is similar; my colleagues and I must attempt to deduce what is going on when patients’ explanations do not—or cannot—help.

I knew so little about Joseph that I had to keep a broad range of possibilities in mind. And if a patient was not responding, emergent causes needed to be ruled out first. It was reassuring that Henry had reported normal vital signs. Patients who overdose on opiates or sedatives have suppressed respiratory rates—they take fewer breaths per minute than a nonsedated person would, and their oxygenation levels drop accordingly. Joseph’s breathing rate was normal, and so was the level of oxygen in his blood. But other medical emergencies could cause an acute change in someone’s ability to respond. A neurological exam—including response to painful stimuli—could help determine whether there was a physical cause in his brain. I needed to know whether Joseph could be having a stroke, for example, or an otherwise undetectable seizure.

“Joseph?” I called loudly as I stood by his bedside. He remained motionless in the bed. I took hold of his shoulder and shook it. “Joseph, I need you to wake up now,” I said. There was no response. Not even the snoring I had heard from him earlier in the morning. “Okay, I’m going to examine you, Joseph,” I said as I lifted his limbs one by one from the bed. His reflexes were normal. I lifted his eyelids and shined a light in his eyes; his pupils were the same size, and they shrank in diameter when the light struck them. All reassuring signs. I began thinking that maybe Joseph was ignoring me, simply refusing to engage. Then I remembered Henry’s sternal rub. I took Joseph’s hand in mine and held my pen crosswise against his thumbnail. Then I pushed down on it, first gingerly and then, when there was no response from Joseph, as hard as I could. He didn’t even flinch. The sensation of hard plastic pressing against a nail bed is unpleasant at best, excruciating at worst. Before a clinical-skills exam in medical school, I practiced it on my partner, Deborah, right after assessing her cranial nerves and position sense. Not having expected what was coming, she almost punched me. Joseph’s lack of response was meaningful. It made me nervous. I started to leave the room, resolved that I would send Joseph out to a medical emergency room,...