Chief Resident, Psychiatric Emergency Room, Jacobi Hospital, Bronx, NY
The patient is painfully thin, filthy, and jittery. I keep my manner gentle, my voice low, my movements slow. He settles a bit, and tentatively makes eye contact. He’s homeless. An IV crank addict so savagely consumed by the addiction, he shoots in his neck. Very depressed. Can’t sleep. Can’t eat. Continuing with the routine interview, I ask if he is hearing voices.
Twisting behind himself, he pulls out a huge, cheap kitchen knife, lifting it up high. He stabs it down, screeching, “They tell me to kill! To kill!”
Instantly, I am on my feet, moving toward the door. I can’t get out without passing directly within reach of the knife. Everything stops.
How had it come to this?
Becoming Chief Resident in the fourth year of residency is an honor and an acknowledgment by the senior attendings of broad skill, teaching and leadership ability. You can put in the request, but in the end, you are chosen. I wanted the out-patient clinic. Instead, I was offered the psych ER.
I was surprised. Proud. Nervous. But not panicked. Since accepting the reality that I couldn’t know everything in advance, unpredictable clinical situations had become opportunities to stretch myself.
So far, no one had died on my watch. It did not occur to me I might be the one at risk. I accepted the position.
I supervised the first year residents rotating through during the day, and the third years on call at night. I loved the psych ER for many reasons. The pathology was dramatic, the interventions straightforward, and I loved Richie, the night clerk.
Richie was a burly black man in his 30’s, divorced, with two kids to support (“Don’t have kids if you want any money for yourself.”). He worked another full time job during the day, in addition to this gig full time overnight. I had no idea when he slept, but he was always alert and present.
Most important, he always had my back. “You’re confident. You know when to ask for help.” Me? Confident? And, how did that tie together with knowing when to ask for help? I respected Richie. Never look a gift horse in the mouth.
Richie had just started his shift. The chart of the next patient up had Danger! Danger! Danger! stamped all over it. Not for a newbie.
The psych ER was a big square. Two attendings and two first-years sat at the center island desk doing chart work. In addition to the two interview rooms, there was a holding tank in the back for unpredictable patients suffering active psychosis or coming off a bad drug high. Hospital and city police posted there checked these patients for weapons and other contraband.
I alerted Richie I was going in to interview Mr. Danger! Danger! Danger! Excessive stimulant use, especially if chronically injected, can cause extreme paranoia. I had been taught paranoid patients should sit next to the door. Access to the exit might ease the fear.
Accordingly, when the security guard escorted the patient in to the exam room, I offered him the seat by the door. I sat down across him, started the interview--
And now found myself on my feet, all the little hairs on my body standing up electrified, a psychotic, knife-wielding man between me and the door.
What to do? I can’t think. I can’t move.
Freezing proves the right thing. In a moment of clarity, the patient slides the knife across the floor to me, “Take it! Take it!” I resume breathing. With a nod, I pick it up by the blade tip, with my left hand.
He is on my right, by the door. The moment is a bad one when I pass within his reach. But nothing happens. I exit, closing the door behind me.
Where are the cops? Why hadn’t they frisked him? No one but Richie has looked up. We lock eyes. I lift up the knife, letting the blade swing a little, as if I were holding a dead rat by the tail. He raises his eyebrows: Oh boy.
Looking around, I say loudly, “Look at this.” The two attendings look, and as one, stand up from the desk and exit through the door to the medical ER.
I look at Richie: What the hell? He shrugs, and slides off his stool to walk toward me.
Two cops rush by, shoving me aside to get into the exam room. “Wait!” I call out. “Medicine first!” Too late.
“Watch,” says Richie. “Someone will get hurt.” Sure enough, the patient and one of the officers end up on the medical side.
What did I learn?
- Never assume the experts know anything. Let a paranoid patient sit by the exit, thus putting myself at risk? The genius that came up with that must have been interviewing patients in an ivory tower.
- Never assume people are doing their jobs. With the patient’s chart stamped Danger! Danger! Danger! I should have double-checked the cops had searched him. A corollary specific to cops: Never assume cops are team players. Though the immediate danger was past, and the first order of business was to offer the patient some medication, they leapt without looking. Which resulted in unnecessary injury to the patient and themselves.
- Never assume leaders will lead. Both attendings abandoned ship.
- Notice everyone, and get to know everyone in the field of battle. You can never predict who will be an ally. It may be a Richie, someone untitled and unacknowledged by the powers that be, blending into the background. It is a rare and beautiful thing to have someone at your back.
I got it: No one has The Answer(s). Because there are none. To be an adult is to muck about, muddle through and figure it out for yourself. I was on my own, and must trust to my best judgement.
Photo credit: www.flickr.com/photos/shannonkringen/5410191098/