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Unofficial Prognosis

Unofficial Prognosis


Perceptions and prescriptions of a medical student
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Taking sides

The views expressed are those of the author and are not necessarily those of Scientific American.


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The page comes from the psychiatry intern on call. “There’s a situation with patient RB on the unit. Please advise.”

We gather in the hall outside the patient’s room. There are already three – no, four – security guards standing several feet away with their arms folded. Backup. Ready. Ready for what? We whisper in hushed tones as the intern explains what happened.

He was “acting out.” He was running through the halls yelling obscene words. He was disturbing the other patients. Then he took his clothes off. He managed to punch a wall before being physically restrained. Now, the intern wonders, what about chemical restraints? We discuss medication options.

Our conversation is interrupted by new noises emanating from RB’s room: he is burping the alphabet. He wants attention, we whisper outside his door. Security stands quietly but ready, looking to the doctors for a sign, an order to spring into action. I don’t feel particularly comforted.

We enter.

You again!

The 30-year-old patient is sprawled on the bed, arms and legs outstretched. Hands are tied down; ankles strapped to the foot of the bed. The room has an odor of someone who has not bathed recently. He wears only boxers. I instinctively look away – a pitiful, moot attempt to protect what’s left of his modesty. He jerks in anger when he sees us, tugging on restraints that do not budge – then, tethered and helpless, resigns.

In the days before, he smashed the bathroom mirror, looking for hidden cameras. People on the radio have been sending him messages, he explained. One day I found him standing at the intersection of two halls staring up at the corner mirror. Did you know if I stand exactly here I can see anyone who might be coming?

You think this is funny?

I most certainly do not.

Chemical restraints are decided: an antipsychotic medication administered by intramuscular injection. I step back as two nurses roll him on his side. I step back: back from the messiness of it all, back from the line of fire, from his protests and verbal cuts as his boxers, his last line of defense, are rolled down and a needle is jammed into his rear.

You – get – the – f*** – away – from – me

There’s movie psychiatry, and then there’s real psychiatry. There’s One Flew Over the Cuckoo’s Nest, and then there’s mental health institutions with compassionate caregivers devoted to patient well-being. The movies give us a bad name.

Here is where you’re supposed to get better, not worse. But for a patient who was paranoid, we were trapped in a loop: the more paranoid he became, the more we needed to monitor him. The more we monitored him the more paranoid he became. It was a downward spiral.

I think how clearly the sides appear to be drawn. We stand; he lies horizontal. We are clothed; he is exposed. We move our arms and legs freely; he is bound. We make decisions. He is literally helpless.

He can’t say no to needles in his rear because he is deemed incompetent at the moment – it’s best for him, he doesn’t know what’s best, he is a danger to himself. In medicine we talk a lot about the patient-doctor relationship. It’s supposed to be an alliance: two individuals working toward a common goal of one’s health. In reality it’s an alliance until it’s not.

Nurses inject medications.

Security guards hover.

Doctors try to talk him down.

Around us, the unit goes on. The mother with depression peeks at the commotion and then retreats into her room. The college student who cuts herself makes an exasperated comment to the musician with his first break of schizophrenia.

If this were a movie, I think, we’d be meant to be on his side, rooting for him against the doctors who restrain him in almost every possible way. If this were a movie, I’d be one of the bad guys.

But there are no sides here. There’s only safety.

This is not funny. This is not funny.

This is not funny.

 

(Certain details of this story have been modified slightly to protect privacy)

 

Ilana Yurkiewicz About the Author: Ilana Yurkiewicz is a fourth-year student at Harvard Medical School who graduated from Yale University with a B.S. in biology. She was an AAAS Mass Media Fellow, and her work has appeared in the New England Journal of Medicine, Aeon Magazine, Science Progress, The News & Observer, and The Best Science Writing Online 2013. She has an academic interest in bioethics, currently conducting ethics research at Harvard after previously interning at the Presidential Commission for the Study of Bioethical Issues. She is also interested in general internal medicine and quality and systems improvement. Follow on Twitter @ilanayurkiewicz.

The views expressed are those of the author and are not necessarily those of Scientific American.





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