MADMAN - John R. Suler, Ph.D. - copyright 1995
Chapter 3 - Rounds
"Thanks for giving me a poke," I said to her. "I just drifted off for awhile. Fred must think I'm an idiot."
She smiled from ear to ear, as she often did, even when she was nervous or embarrassed. Her glowing white teeth marched along her lips. Small drops of spittle stuck in the corners of her mouth - an unattractive glitch in a woman who had the body of a porno star, but was too innocent to even know it. "Oh, I'm sure he's an understanding person," she answered cheerfully, "although he doesn't always seem that way." She paused to think. "He must be understanding - he's a chief resident in psychiatry."
Talk about naive optimism. I tried to disguise my basically cynical constitution. "Well, let's hope so. We better get going before our empathic leader starts rounds without us."
She followed me out, her corduroy pants ruffling through two steps for each one of mine. For a moment I could not see the group. Then, out of the corners of my eye, I spotted across the unit one of the medical students, at the tail end of the rounds-roundup, being herded into a patient's room. We hurried around the outer perimeter of the unit, slipped through the half-closed door, and came to an abrupt halt at the back of the group. Barb almost collided into me. I suddenly realized I had forgotten to convey Jon's hello to her. No matter. It was just an idle promise, another of those social amenities we all use to smooth out the rough edges of our day-to-day interactions.
Barb listened intently to the Chief, unaware that I was watching her. How strange, I thought, that she was engaged to Jon. The spaced-out, rebellious, intellectual radical and the sweet, naive homebody. There is a great deal of validity to the "odd couple" phenomenon. Opposites attract. They balance, compliment each others' strengths and weaknesses. Take, for example, hysterical women - highly emotional, flighty, impressionable - who marry compulsive, overly intellectualized men. They need each other to feel more whole. Yet beneath the surface of each person, pressed into some forgotten corner, too scary to acknowledge, hide the characteristics of the mate. Perhaps this more than anything else is the source of the attraction between them.
"Well now, Miss Finski, I've heard this is your second visit with us." Fred spoke confidently - maybe too confidently for a chief resident - and with a bit of pedantry. "So what has brought you back to us?"
Rachel sprang up in her bed and slicked back her short, dirty hair. "My water is blocked." Her oddly narrow face was nearly expressionless, but she spoke with urgency.
"Now you see, I don't understand that. Explain what you mean."
"My water is blocked. It cannot flow freely. Water must be able to change from liquid to solid, from solid to liquid. It must be able to sublimate, to create the atmosphere that protects us all. It must be free to flow in me, and through me, and out me, below and above me. The water in the air is the projection of my aura. Your EEG and catscan will show you that. Water is the essence. It doesn't care. Water has no concerns. It just wants to flow."
Scratching his head, Fred donned his impatient, skeptical expression. "Now Rachel, let's forget about the water for a minute. Your outpatient therapist told us there have been some problems in his therapy with you. Tell me about that."
"We got along well at first. He was empathic and supportive, and some of his interpretations were quite accurate. I felt like I could trust him. He was a good object. He studied psychoanalysis at Austin-Riggs, you know. A real top-notch. But then he tried to take me apart, like some kind of car mechanic. He tried to take away my essence by rearranging my braindikes. But the water got blocked. The right hemisphere of my brain flooded. The axons sprang leaks, and he didn't have enough fingers to plug up the holes. He tried switching my anti-psychotic medications, from haldol to thorazine. That just made me worse. My water got so contaminated that it couldn't seep through my neurons. It was like neuroplasmic sludge. My brain short-circuited. I had epileptic seizures. I was afraid the fire in my belly would go out because the water couldn't get to it. I need that fire, you know. Winter is coming. It is the neurochemical energy of my soul. He's trying to take away my essence, but I won't let him."
The medical students' eyes spun in their heads. But Fred was undaunted, "Rachel, let me interrupt you." He placed his index finger against his temple, as if pointing inside. "Now you realize there is no flooding in your head, no leaks, no fire in the belly. These are things you have imagined. After all, it isn't even logical that a fire would go out if water didn't get to it. Water extinguishes fire, now doesn't it?"
Rachel frowned and fell back, frustrated, against her pillow. "This is why I'm not getting better. I'm drowning in fossils. Is there a shaman in this hospital?"
"Rachel, now listen to me carefully. Your outpatient therapist told us that the problem was that you stopped taking your medications. You were beginning to hallucinate again."
"Hallucinate, hell yes! And what a regression, or is it progression, or concession? A vision a day keeps the doctor away, you know."
"Rachel," Fred interjected, shaking his head, "you were beginning to hallucinate again. Your therapist told us you were starting to feel very depressed. He said you started talking about suicide. Now Rachel, are you still thinking about killing yourself?"
"You're the one who's killing me with this reality testing. Can't you see that water can't be created or destroyed? It just changes form. From solid to liquid to gas to spirit."
"Rachel," Fred interjected again, even more insistently. "It's important that you answer my question. Are you still thinking about killing yourself?"
She paused for a second. Her chin dropped. She looked defeated. Softly, she responded, "I thought about it last night, some. I couldn't sleep. They gave me a sleeping pill but it didn't help."
The chief was satisfied with himself. "The nurses told me you were awake most of the night. Were you thinking about suicide the whole time?"
"No ... not all the time. I was worrying about fire and water too because - "
Fred quickly interrupted. He stared right into her eyes. "Did you think of any specific way of hurting or killing yourself?"
"Well ... no," Rachel replied thoughtfully. Then, suddenly remembering, she reached under her pillow and pulled out a book. "I thought maybe I would crumple up these pages and swallow them, one by one, until I choked to death." I looked at the title of the book as she held it out towards Fred. It was Fenichel's Psychoanalytic Theory of Neurosis.
That was a new one. Fred momentarily was caught off guard. "Uh, yeah .... Do you just think about doing this, or will you actually try it, or some other way of hurting yourself?"
"I don't think I'll do it. I'm sure this book tastes awful. I'd probably just get sick and puke it up." She held her stomach with both hands and looked out the window towards the sky. "I still think about it though. It makes me nervous."
"About killing yourself."
"About kicking the big bucket." She continued to gaze outside, her eyes unfocused. "All that water. Where will it flow to?"
Fred peeked at his watch. "You're in good hands here, Rachel. Your primary therapist, Dr. Lawrence, started you on some medications that should help. It's important that you take them and that you talk to your therapist, let him know when you're feeling depressed, or when you're thinking about hurting yourself. O.K.?" Fred grabbed Bob Lawrence by the arm to pull him forward from the group. A thin, fragile, somewhat androgynous guy, Bob almost fell over from the yank. But Rachel didn't move her eyes from the sky.
"Medical students are O.K.," she mumbled through her trance. "They're only half-baked."
"Do you understand me, Rachel?" Fred said.
"Yes, Dr. Cooling."
"Right." Fred did an about-face and marched out the door, the entourage trailing behind like imprinted ducklings. Halfway to the next room he stopped abruptly, folded his arms across his chest, and waited for us to flock around him. We quickly settled into our silent formation. For one dramatic moment, he paused.
"Well now, doctors, what did you observe?"
We all hesitated, except for Ron Peri, the resident who supervised Bob. With his nose slightly elevated, he adjusted his glasses and spoke with confidence that bellowed up from his discrepantly pudgy, short-limbed body. "I think it's clearly a schizophrenic process. There were loose associations and tangential thinking, and obviously paranoid beliefs in the form of her fear that her outpatient therapist was trying to poison her. Also, I believe the ideas about fire and water in her body qualify as somatic delusions. In fact, there was considerable perseveration on those ideas."
I wanted to throw up all over his white lab coat (the only physician on the staff who wore one). If there's one thing I can't stand, it's a know-it-all. If there's one thing that makes me absolutely livid, it's a know-it-all doctor. I wished that all motion in the world, except me, would magically freeze for one minute, so without anyone knowing, I could tie his shoe laces together.
Fred nodded, "That's correct. But let's not forget that there were also signs of depression, as Dr. Lawrence mentioned in morning report - for instance, suicidal ideation and her trouble sleeping last night. So we have to consider the diagnosis of depression superimposed on schizophrenia. Order a DST."
"Yes, definitely a DST," Ron echoed, "to determine whether an endogenous depression is superimposed on the schizophrenia."
A favorite expression of my old high school teacher hissed subvocally through my throat: "Obsequious sycophant" - the most grimy of Brown-Nosers. No doubt Ron hoped the chief resident would join him in mutual preening. But Fred, forever focused on business, was impervious to Ron's toady entreaties, which made Ron even more desperate for attention.
"What else did you observe?" Fred asked as he scanned our faces. Barb hesitantly poked her head between the shoulders of the two residents and started to speak. But Ron interrupted her. "Wouldn't you agree, Dr. Cooling, that the patient's expression 'braindike' is a neologism?"
"Well, I guess it could be considered a neologism in the sense that it's a word you wouldn't find in any dictionary, a word that has a special meaning only to the patient. But neologisms usually are more nonsensical, more gibberish. Usually it's a condensation of two or more words rather than simply the idiosyncratic linking of two words."
Ron looked down and shuffled his feet. Not being exactly right irritated him. I imagined his singed little ego when Dad told him he didn't screw the top of the jelly jar on tight enough.
"I was just thinking that - " Barb paused, realizing she had succeeded in breaking into the conversation. She smiled nervously. "I was just thinking that Rachel seemed to be sad."
"We've already determined that depression is present," Ron answered sharply. "Experience in working with these patients will tell you that they often describe depression as feeling sad, blue, or low. It's in the DSM."
I wanted to wrap my hands around his neck. If he couldn't keep his self-doubts and self-deprecations to himself, if he couldn't contain his attempts to project them into others, I was more than willing to help stop up his mouth.
"Oh, I'm sorry," Barb said. "I've only read part of the diagnostic manual. I guess I didn't mean depression. It was just that Rachel seemed sad, or ... mournful, like she felt she was losing someone, or something."
"Interesting," Fred mused. "No doubt her worry about losing her capacity for intellectual thinking. She seems to know something about psychiatry, which is partly the result of her being in and out of mental hospitals for the past ten years. She's also very bright and she uses her intellectualizations as a defense. But it's starting to give out under the strain of her decompensation. It doesn't work too well as a defense anymore, and she's worried. You could see her struggling to maintain control over her thinking, without too much success. She couldn't cope with my open-ended questions at the beginning of the interview. Her thinking was unfocused and almost nonsensical. But then what did I do to change the interview?"
Everyone looked down into their coffee. I cursed myself again for not having grabbed a cup before morning report.
Fred's patience quickly wore out. "I provided more structure," he continued tenaciously. "I was more direct and asked more specific questions. I helped her reality test by trying to show her that her delusions were false. This is what schizophrenics need: Structure and reality testing. And when I was persistent with this she responded well. She became more logical and coherent."
"But wasn't she also a little incoherent towards the end of the interview?" Bob asked. He quickly became self-conscious about having questioned the chief. After all, he was only a medical student.
"Yes, good!" Fred answered. "Now why was that? What issue did I focus on that made her unravel?"
Bob hesitated.
"Suicide," I mumbled, the word tumbling out so automatically that I did not even have time to worry about possibly being wrong.
"Correct." Fred riveted his eyes to me. "And what was the result of the lethality assessment?" Everyone turned to look at me. Now I was nervous. An image of smashing onto the roof of a car briefly skirted across my mind. "Well, uh, there were some suicidal thoughts, although she didn't seem to have strong intent, and no specific plan, or at least no plan that would be considered really lethal. Unless you consider Fenichel lethal."
No one laughed.
"True," Fred said, "choking on paper isn't exactly a very lethal method of killing yourself. But I'd rather play it safe, at least for today." He turned to Bob, who was listening intently. "Put her on 30 minute checks." Bob nodded obediently.
"Right. Let's move on."
I started after Fred as he strode off to the next patient's room, but someone held my arm. It was Marion.
"You've got a call on 09. It's Mrs. Mobin."
"Who?"
"Mrs. Mobin. Your new patient's mother."
I had completely forgotten about the admission. Rounds pushed forward without me. I stepped into the nursing station and picked up the phone. "Hello, Mrs. Mobin. This is Dr. Holden."
"Hello, Doctor. They told me you'd be takin' care of my son Richard."
"I'll be his primary therapist while he's here on the inpatient unit. Is there something I can do for you?" As she started to answer, I heard the click of another receiver being lifted off the hook.
"I just wanted to know if you was gonna shock him."
"What do you mean?"
"Somebody told me that when people get sent to the sanitarium, you know, when they ain't really actin' right, the doctors give them an electric shock to the brain, to snap them out of it. I don't want my son to get no shock!"
"I don't know exactly what kind of treatment we'll be giving Richard. We have to wait until he gets here to see how he's doing, then we'll decide. From what Dr. Cooling told me - you remember him, you spoke to him on the phone - from what he told me about Richard, it doesn't sound like we'll be giving him any shocks. We only use that as a last resort, and usually only for people who are very depressed."
"I don't want him to get shocked. He's a good boy, you know. He's been into trouble lately, he's been a little wild and actin' funny sometimes, but even if he seems bad on the outside, on the inside he's a good kid, a kind kid. I never used to have any problems with him. It's those other kids on the block. They needle him, just because he's big and a bit slow. They keep doin' it, tryin' to trick him, and they won't let up. He don't really want to hurt nobody. If they would just leave him alone. He can't help bein' different. People just make him out to be bad."
"Has he physically hurt anyone?" I asked.
"He's gotten into some scruffs, but nothin' bad. Are you gonna shock him if he does?"
Before I could answer, I heard a voice ringing loudly in the phone, too loud to be coming from her end of the line. I turned around. On the extension at the opposite end of the nursing station was Ron Peri. "Your son is psychotic, Mrs. Mobin. We need to treat him as soon as possible. I suggest you bring him into the hospital as soon as you can."
"Who's this? Dr. Cooling?"
I tried to wave Ron off the phone, but he ignored me. "No, Mrs. Mobin, that's Dr. Peri on the other extension. He's the - "
"What do you mean my son's psychic? He don't read minds."
"Your son is having a psychotic episode," Ron continued. "That means he's losing contact with - "
"Please let go of the line, Dr. Peri," I interjected.
" - reality. There is a disintegration of his - "
"What? Reality?"
"Mrs. Mobin, I apologize for - "
" - ego."
I amplified my voice to drown out the chatter. "Mrs. Mobin, I apologize for this confusion. I'd like to speak to you in private this afternoon when you bring Richard in. What time do you think you will be here?"
"... I don't know about this."
"It's important that I see Richard so I can help him. What time will you be here?"
She hesitated. "About three o'clock."
"Fine. I'll see you then."
I hung up the phone. Ron was leaving the nursing station. I intercepted him. Oblivious to having committed an incredibly tactless transgression, he jumped with surprise when I grabbed his stumpy arm. I tried to control myself and act rational, but my voice quivered with anger, "Why did you do that?"
"Do what?"
"Interrupt my phone call."
"I didn't interrupt. I picked up the phone when you did. It was important that I talk to the patient's mother."
"But I'm the primary therapist. There's no reason for you to talk to her."
"I was with Fred when he spoke to Mrs. Mobin. He assigned me as medical backup, so I'm responsible for the patient."
Primitive impulses bubbled up from my id, a murderous rage pressurizing my gut. My eyes watered. My stomached tightened. The fight-or-flight response. I tried to steady myself. "I'm the primary therapist. I'm responsible for the patient. When I need your help, when I need medical backup, I'll ask for it. Otherwise, don't interfere with my work."
Ron seemed unruffled, even indifferent. "I'll give him a physical when he comes in. After I talk to Fred I'll decide what meds would be best. I'll make an entry in the chart."
He walked away, leaving me standing there. The white noise of exasperation buzzed through my brain. A block of wood. I just had a conversation with a goddamned block of wood. I wanted to chase after him, confront him, tell him to his face what I really thought of his stupid, small mind.
But I didn't. "Why are you looking so gloom and doom?" Barb was standing next to me, beaming her simpleton smile. "Be happy! Fred was just called down to E.R. The rest of rounds are canceled."