The Crazy Shift

Psychosis is never pretty, especially in the morning. Depression, anxiety and addiction fare a little better, but not much. Like it or not, these are the types of things routinely encountered here, morning, noon and night. And as I glance around at the patients before me, today is likely to be no different.

Emergency Psychiatric Center (EPC) is a mental health crisis facility at a major metropolitan hospital. The center was established in 1972 to help serve the emergency mental health needs of this major U.S. city, which has a population of approximately one and a half million. It's basically a psychiatric emergency room, open 24 hours a day, and it sees everything in the book, from medication refills to lethal suicide attempts.

It is 8 a.m., and nine patients are waiting to be assessed. And so begins another day at EPC.

8:00 a.m.

Time for shift change at the command center, the hub where all clinicians except nurses are based. It's been a long night for the social worker, two psychiatric nurses and on-call psychiatrist. The incoming day shift is larger, comprising an intake worker, two psych nurses, a therapeutic patient worker (TPW), two social work therapists (including me) and an attending psychiatrist. Report sheets listing the patients are passed out. The primary day shift therapist, Pete, calls out the first name for review.

"Nathalie L." (All names in this article have been changed.) One of the psych nurses from the night shift starts. "Natalie is a 16-year-old white female brought to EPC at 2 a.m. today by police after she told a friend she was going to kill herself. Patient's boyfriend recently dumped her. For a cheerleader, I think."

"Figures," snorts the TPW.

Pete continues. "Next case, Chad S." A groan goes up from the crowd of clinicians. Chad is what we call a "frequent 'flyer," someone who is repeatedly in crisis. These people are often manipulative, and usually "personality disordered"; they are a major physical, emotional and financial drain on the mental health community.

"Chad S.," says the other night nurse, "is a 24-year-old single white male brought in by police after he reportedly threatened It) stab a neighbor's dog. Story is, a neighbor heard something in his backyard and found Mr. S. there with a knife, yelling at his dog. Chad was pretty cooperative when he first came in, but as soon as the police took the cuffs off, he began to get agitated. We locked him in Seclusion Room One and that's when he destroyed the bed in there, tore one of the rails off. We put him in four-point restraints and gave him a cocktail of Ativan [a sedative] and Haldol [an antipsychotic] IM [an injection given intramuscularly]. He calmed down and has pretty much been asleep ever since." She pauses, and adds, "Good luck."

"Sandra P.," Pete barks out.

"Sandra P. is a 39-year-old married African-American female brought in by squad for overdose. Husband came home from work, found her lying on the couch, groggy but coherent. There was an empty bottle of Trazadone [antidepressant with a sedative effect] near her; he called 911. Patient claims she took about 15 of them. Also had been drinking--undetermined amount. She was sent to ACS [Acute Care Side--the medical emergency room of the hospital], medically cleared, and transferred over here for psych eval. She's in bed three."

"How about Helen R.?"

The night social worker takes this one. "Helen a cutter"--that is, someone who chronically cuts him/herself. "She's a 42-year-old white female who came here via ambulance after she called 911 saying she had cut herself with a steak knife. Claims voices told her to do it. She acts like she's responding to internal stimuli. Multi cuts on left arm--no sutures. She's been here before. Patient has been medically cleared and is in SR 4."

"Michelle F."

"Michelle F. is a 44-year-old single black female with complaints of depression."

"Arnold K."

"Mr. K. is a 54-year old divorced white male self-referred to EPC seeking detox from alcohol. Mr. K.'s BAC [blood alcohol count] was .277 upon arrival--it's now. 154. His pulse, temp and BP were up, so we gave him one milligram of Ativan in case he's withdrawing. He's been calm and cooperative. He's in bed two."

"Okay," says Pete. "Stephanie A."

"Stephanie A. is a 25-year-old married black female here for a med refill. Needs two weeks of psych meds until she can meet with her new doctor. History of bipolar. No psychosis detected. A little manic, maybe, but that's all. She's in the lobby."

"Okay, last but not least, Cathy W.."

The night nurse takes a deep breath and begins. "Cathy is our problem child. She is a 44-year-old single white female who was brought in by police after it was reported she was screaming and spitting at neighbors in front of her apartment building. Cathy has a long history of bipolar and borderline personality disorder. Multiple psych hospitalizations. Usually not med compliant. Case managed by Community Mental Health. CM [case manager] has not called back yet. Cathy has been nothing short of a nightmare. She's as manic as they come. She hasn't shut up for 30 seconds; she's up at the desk every two minutes asking if her case manager has called back; she practically started a riot in the back yelling that her rights were being violated; she's called me everything in the book and then some; and she's urinated on herself twice now, necessitating two showers. She's in bed five; actually, she's everywhere back there." The nurse abruptly stops, looking somewhat like a deflated beach ball. "That's it I'm going home."

Report is over. Night shift forces smiles while saying good-byes and good-lucks. Day shift tries to respond in kind.

8:30a. m.

Pete and I huddle to decide who's going to start which cases.

"I'll do Chad. I know him from Northern Heights," I say. "You take the 16-year-old. That's a fair match." Juvenile cases are often quite involved, more so than usual, because of the minors' status and legal implications. Pete nods and we scuttle to the counter to set up shop for the day. I grab Chad's chart on the way; its thickness and heft are physical reminders of his lengthy psychiatric history. Although Chad has managed to compile 25 to 30 psych presentations to EPC in the last two years, I can't find any documentation of actual suicide attempts or violence. He does talk a lot about it, though. Chad is forever threatening to kill himself by electrocution or overdose or gunshot or hanging or jumping off a skyscraper. On good days he's really creative--a corkscrew into the heart, a chopstick through the ear. Sometimes he just says he feels like he needs to be in the hospital. When asked why, he replies, "Trust me on this one."

The behavior manifested the night before with the bed seems unusual for him, and it concerns me. I wonder if Chad has graduated from talking a big game to acting it out. I sincerely hope not. I have long felt that Chad is a powder keg ready to blow, filled to the brim with explosive rage, hurt and fear. Chad has consistently carried a diagnosis of schizoaffective disorder (a combination thought and mood disorder) and borderline personality disorder (defined partly by extreme behaviors, mood instability, interpersonal difficulty and manipulation). His childhood was far from ideal. After his drug-addict mother--herself schizoaffective--abandoned him at age 4, Chad was raised by an alcoholic grandfather who reportedly beat him. It is an all too familiar story, the passing of the mental illness torch down family lines.

8:37 a.m.

I find Chad S. in Seclusion Room One, sleeping noisily on a hospital cot, left ankle and right wrist strapped down with leather restraints. After several unsuccessful attempts to wake him verbally, I cautiously shake his leg. Chad slowly opens his eyes, looks at me and grins, muttering, "What's up, dude? Can you get these off me, dude?" lifting the restraints.

"Can you control yourself?." I answer. "I heard you destroyed a bed last night."

Chad yawns and at tempts to stretch. "Yeah, I had to, dude. But I'm cool now."

"You sure?" I ask, not fully convinced. Chad nods his head, and stretches again.

"Okay, I'll talk to the nurses." I go and check with Tom, one of the day nurses, who agrees it is probably safe to let Chad loose now. It is hospital policy to restrain a patient only if necessary, and only at the minimum level required. Once freed, Chad rubs his wrist, slips off the cot and plods my way. He has a tall, lanky frame with a budding pot belly. His face bears two wild eyes under stringy brown hair. He looks menacing.

Actually, I like Chad. I'm not here to be his friend, though. I'm here to get him help. He steps out of the bathroom and lumbers my way. I lead him to one of the interview rooms and we begin.

"Listen, man," he starts, "I was only protecting myself."

"What do you mean?"

"The dogs in the neighborhood are after me, plotting to kill me." He sits there looking at me, completely serious.

"Uh, why do you think that?" (I mean, how do you reply to that one?)

"I got eyes, man, I can see what they're up to." His eyes set into a steely stare.

"So, why were you in your neighbor's backyard with a knife?"

"Lettin' 'em know who I was. Lettin' 'em know they can't get away with it."

"Get away with what?"

Chad looks at me like I'm the stupidest person on earth. "Get away with murdering me, fool."

"Have you been smoking any marijuana lately, Chad? Doin' any drugs?"

"No, I haven't been smokin' any weed or doin' any drags and even if I was, it's my own damn business isn't it?" His voice is starting to rise and his eyes are dark. He's getting angry. I change the subject.

"Chad, how have things been going lately?" Chad lives alone in an apartment in a high crime-rate area, is psychiatrically disabled, on Social Security, and has far too much time on his hands.

"Oh, you know. I got it going and it goes around and around." Sometimes I have no idea what he's talking about. But at least he's grinning now.

"Have you been taking your medication regularly?" He kind of nods and shrugs, a halfhearted yes that tells me no.

"Have you been depressed lately?"

"No, I haven't been depressed. I've been feeling mad." His eyes flare for a moment. I don't like what I'm hearing and seeing.'

"What's this about tearing up the bed last night?" I inquire.

"What about it? They shouldn't have pissed me off. Everybody pisses me off. It's the law, brother." He slams his fist into his hand, half-grinning. There's something about that grin, and those eyes, that lurks deep within him, something that I don't want to get very close to. We finish and I lead him back to the containment area.

9-15 a.m.

In the command center I look up Chad's case manager's number and dial it. As usual, the CM isn't available, so I leave a message for her to call me as soon as possible. I begin the tedious process of writing up the report.

9:35a. m.

I get lucky; it's the CM. I fill her in on Chad's latest presentation. She tells me that he's had many psychiatric hospitalizations (not exactly news to me) and that, when last asked, he wouldn't talk about his medication compliance (not good). She says he has been worsening over the last month (uh-oh). Apparently, he recently destroyed his room, and has a history of trashing places (I hadn't known that). The only violence toward a person she knows of was an episode a while back when he attacked his grandfather. She thinks Chad needs psychiatric hospitalization.

There isn't anyone else to call for more information. Chad and his mother are estranged; the grandfather is deceased. He has no other family in town, no roommate, no spouse, no girlfriend that I know of. I'm not sure if he has any friends, much less how to contact them, or how reliable they would be. I look around to see if the officer of the day (OD)--the psychiatrist on shift--is in sight so I can present the case. No such luck. I continue to write up the report.

9:40 a.m.

Soon, I notice the police bringing in a handcuffed, shirtless, barefoot man. He has a shock of black hair and streaks of dirt running down his arms and chest. He is quiet, head hanging down, as the two police officers lead him to the nursing desk. The larger of the two police officers removes the handcuffs and the nurse reaches to seat the patient for the admittance procedures. As soon as the nurse touches the man's arm, he goes berserk. He jumps two feet in the air, screeching at the top of his lungs, arms flailing. He begins running around the nursing island in circles, yelling strings of nonsense. The surprised nurse makes an attempt to capture the now out-of-control patient but can't hang on. At the next pass both police officers and the nurse grab him and attempt to carry him to a hospital cot. The man, however, is like a fish out of water, squirming and writhing. By now, someone has called security and five hospital guards burst in, pulling on latex gloves. It takes all eight of them to wrestle the patient onto the cot, strap him down and inject him with a sedative. The man screams, fights, cusses and spits the entire time. They wheel him into an empty seclusion room and shut the door. After a while the screams soften and then dissipate. I approach the nursing desk as the "takedown" team is washing up.

"What's the deal?" I ask an officer.

"We found this guy standing in the middle of traffic snarling at cars and waving a brick. Think he's been crackin'. We've picked him up before for drugs. I think he had one hit too many." I grunt, spying Dr. Arness, the OD. I make a beeline for him.

Dr. Arness looks up from his report, smiles, and sticks a finger in the air. I nod and return to my spot, putting some finishing touches on Chad's writeup.

9:55 a.m.

Dr. Arness walks over. I tell him about Chad's history, his behavior at the hospital, and what Chad's CM has told me.

"John," I say, "I've known Chad for a while, and at best his baseline is not good, but I've never seen him like this. Usually he's suicidal, with a little paranoia and delusional beliefs. Now he's delusional to the max, paranoid and threatening, with a knife to boot." I recommend hospitalization. "Let me talk to him--you're probably right," says Dr. Arness. "Go on and check bed status."

10:05 a.m.

Dr. Arness returns. "Yep, let's get him in."

10:35 a.m.

My next case is Michelle E, the 44-year-old African-American female who's been feeling depressed. She's not sleeping well, has lost 14 pounds, doesn't feel like doing anything and can't concentrate. There don't seem to be any major causes. She just loathes her body, her life, her job and her apartment, and she's tired of feeling like this. From across the table, waves of sadness are palpable. No, she's not suicidal. No, she's not hearing or seeing things. She just wants some pills. Ms. E gets a diagnosis of major depression and a referral to a local mental health agency for psychotherapy and possible medication. I try to emphasize how important it is for her to take an active role in her own recovery--how no magic pill will cure her. Medication can help, but it is only one of many tools a person uses to fight depression. We talk about some of those tools.

12:30p.m.

Somehow, between cases, I escape to the hospital cafeteria for food and cram it into my mouth as fast as I can. We call this lunch.

12:55p.m.

Time for Helen R. The middle-aged cutter listlessly shuffles into the interview room. Her arms are scarred so badly she looks like a burn victim. Arms are a main target for cutters, although some use the abdomen. The cuts are almost always superficial.

"Helen, when you cut yourself, did you want to die?" She shrugs, staring with dull eyes through greasy hair at the floor. Cutters are characterized by lifelessness; they truly resemble the walking dead. This is not without reason. Many were horribly abused physically, verbally, sexually, emotionally and in just about any way you can imagine.

"I don't know what I want," she mutters in a low monotone, her head hanging as if in eternal shame. Not once does she make eye contact with me. The self-esteem of a cutter is subzero. Cutters hate themselves. This is one reason they wound themselves. Some say the cutting is a way for sufferers to release pain; others believe their feelings are so deadened that they cut to feel something, anything. Cutters often carry a diagnosis of borderline personality disorder and are the most isolated people I know.

"Are you still hearing voices?"

A long pause. "Yeah."

"What are they saying?" Another pause.

"They're telling me to cut myself."

"Why?"

"I don't know." Cutters usually don't know why they hurt themselves. They only know they have to keep doing it. Cutters are very difficult to treat. I know, however, that I can't let her leave depressed, psychotic and inflicting harm on herself. After the mental checkup, I arrange for her to be hospitalized.

2:30p.m.

My last case of the day is Arena K., the 54-year-old seeking alcohol treatment. Arena has been drinking since he was 13 years old and has been in treatment more than 15 times. He looks terrible. I ask him if he is suicidal. Not today, he replies. Arena says he's tried Alcoholics Anonymous in the past but doesn't put much stock in it. I tell him maybe he wasn't ready then, but might be now. He shrugs but agrees to go to First Steps, a local drug and alcohol inpatient drug treatment center. After a brief talk with Arena, Dr. Arness agrees to the plan.

I watch Arena leave in a cab. Whether his cab will actually make it to First Steps, I can't say for certain.

3:50 p.m.

It is now almost time for shift change and report. In the eight hours our team has been on, we have evaluated and disposition eight cases. During that same time, seven new cases have come in. Emergency Psychiatric Center evaluates approximately 10,000 cases a year. It is estimated that one out of four people will suffer a major mental illness in their lifetime. One out of four.

Have I accomplished anything today? Eight out, seven in. Ten thousand a year. Sometimes the faces start to blur a bit, and the details overlap. But for every face there's a person and a life--I have to keep remembering that. The reality is, some days it's hard to remember that. They just keep coming. Either way, I'll be back tomorrow. And so will they.

PHOTO (COLOR): The Crazy Shift

PHOTO (COLOR): Some patients are chronically in crisis. They are usually personality disordered, often manipulative, and always a drain on the mental health system.

PHOTO (COLOR): The emergency psychiatric ward sees everything in the book, from mild anxiety to lethal suicide attempts and severe dementia.

Adapted by MSW, LSW

Daniel Watson, MSW, LSW, is an emergency psychiatric therapist. He currently resides in northern Kentucky.