Sunday, October 7, 2012

Moment for life

[Disclaimer: All patients appearing in this are fictitious. Any resemblance to real persons, living or dead, is coincidental.]

No week is ordinary on an inpatient psychiatric ward, but this one stood out.

We received notice of her arrival at morning sign-out from the charge nurse. "Mid-20s female with a history of bipolar disorder with psychotic features, self-reported to the psych ER with suicidal ideation and depressed mood. History of depression, self-reported bipolar-affective disorder, drug abuse." With each of those descriptors I added a mental characterization - unstable, psychotic, jaded, distrustful. Then again, a self-reported history of "the bipolar" in Baltimore frequently means no more than a means to a disability check.

Shantel turned out to fit all those descriptors, yet bore little resemblance to the caricature I had painted.

We sat in the cramped conference room for her initial interview, facing off against her over an unforgiving metal table. Her long, tapered fingers beat a staccato rhythm, a conspicuous, irritable edge to her movements. Faint tear marks tracked down her cheeks, bracketing the false bravado in her tremulous smile. She caved in as we introduced ourselves, folding into the hard chair and desperately trying to keep her pride and personhood from shattering against our white coats.

We asked her questions.
"How have you been?"
"Tell us a little bit about yourself."

She twisted her fingers, played with her hair, wove convoluted sentences - stuffing with nothing holding them together.
"I'm eating like I'm pregnant, but I ain't pregnant."
"They got me, but then I went away and they didn't get me anymore, but I read a book and I knew where to go, until I found some apples."

But ten minutes in, when my resident's patience was thinning and I was leaning down to retrieve my pen, Shantel floored me with a sharp look of tempered fear. Her raspy voice tripped over the words, still pressured but ringing with sincerity. "I committed myself. I gotta be better. For me. For my little girl. For them. Else we all get hurt." She sat a few inches taller than me, but as she spoke, she bent with her words, a sapling valiantly fighting its own youth and fragility.

Her wiry frame quivered with her dreams for the future, simple ones - stay safe, be healthy, raise a family - confined by the boundaries of her paper-thin skin and see-sawing psyche. The confession attenuated her hesitation, but not her paranoia, and the rest of our week was filled with the color of her personality and a litany of complaints, both from our staff and our elusive patient.

Shantel keeps flirting with the young male patients.
They hate me. They're putting stuff in my food. It's yellow!
She started gyrating to Nicki Minaj in the common area this morning.
I'm staying in my room today. They keep glaring at me, I can see the devil in their eyes.

None of the contact numbers she initially gave us worked. One was an anonymous voicemail, one was connected to a construction company, and the last was to a sex hotline - an interesting explanation to human resources…

When I finally tracked down the aunt who had raised her, she had one piece of advice for us. "You keep her locked down, you hear? She runs. That's all she knows to do, and she's damn good at it!"

Shantel's elopement history spoke for itself. She was damn good at it. She had escaped from any number of institutions and programs in a 30-mile radius, sometimes repeatedly - by removing AC units, stealing nurses' keys, scrambling through air vent systems, sneaking out on the food cart.

She acted half her age and looked twice it, no insignificant disparity for a woman in her mid-20s. I could have wrapped my fingers twice around her wrist. Her face was gaunt, her cheeks sunken under the weight of her illness and her struggles.

I checked in on her a few times a day. The first time, she set the tone with a warning, "I have a gift where I can see through what people are saying. I was a crack baby." 

"Hey Shantel, how are things going today?"
"Everything hurts - my legs, my calves, my arms."
"Is anything else hurting you?"
"My feelings."

Her childish innocence repeatedly reared its unforgiving head, as if she was checking whether we were paying attention.

"How are you feeling today?"
"I don't feel the sincerity or the loyalty I should."

"We heard from the staff that you wanted to stay in your room today, is everything okay?"
"They act like they're scared or disgusted. They treat me like I'm strange or different, and I don't like that."

"Do you want to hurt yourself or anyone else?"
"I don't know if I want to live or die."

"What do you like to do?"
"I like to write poems, and collect knives."
"Someone hurt me a lot, when I was little. Beat me up. Had sex with me. The poems help my head, and the knives help my body."

The inherent power imbalance in our relationship, she was well aware of. But she never learned the extent to which we had managed to even the scales of knowledge of her past. What we knew of it, we learned from the one call to her aunt, or from the three-inch stack of past records painstakingly obtained from her array of psychiatric visits to dozens of individuals and institutions, a novel in its own right.

But even though we had thousands of scraps of her timeline, they were constantly overlapping, never lining up. The sad truth about inpatient psychiatry, it is a layover toward a final destination. We never had the chance to walk through her past with her. We would have had just enough time to break down her defenses, with none to spare toward building a safety net for the released demons.

In her case, the destination we sought, and her social worker managed to secure, was a housing program for patients requiring psychiatric support. Given her penchant for running, the social worker even ensured door-to-door service. A representative from the program came to accompany Shantel from the locked entrance of the inpatient unit to the watchful eye of the house caretaker.

Three weeks later, our team's social worker flagged me down from the opposite end of a long hallway. The distance felt interminable, watching her face transform from exaggerated attention-seeking to apologetic and pitying. She rarely flagged me down, and even more rarely for good news. I was not hardened enough yet for the news she was about to hesitatingly deliver to me - news I had unknowingly brought upon myself.

"They IDed a Jane Doe on one of the autopsy tables at the morgue yesterday."

She paused. I wonder what my face gave away. Shock? Grief? Resignation? The last one seared through me, an unforgivable burn. I forced myself to prompt her for the name, fingers crossed behind my back and toes crossed inside my shoes. Perhaps hearing it would be my absolution for so readily losing faith.

"Shantel. She ran away."

Her autopsy results were not due back until after my time on the ward completed. But the superficial cause of death was somewhat irrelevant. Ultimately, the driving force would be irreversibly tangled with her mental illness, her drug habit and her naïve immaturity.

I only felt increasingly powerless as the weeks carried forward. Nothing I wanted to take from this experience was helpful to my patients during their fleeting sojourns with us, or so I felt. I still did not have the time to build a meaningful therapeutic relationship with them, did not have the breadth of resources to hold their hands through a torturous walk down memory lane.

What I did learn, albeit indirectly and over a painful month of second-guessing, was the power of the psych ER and the inpatient ward as a front line of defense. For all that it felt like we were failing our patients, we served another purpose - tracking them to the long-term therapy that would help rehabilitate them. Maybe we gave Shantel a few extra weeks she may not have had otherwise. Maybe in the time she spent with us, we validated her experiences and her sense of self.

Our profession finds mileage in the weightlessness of hope. Perhaps even more so in a field where the damages born are invisible and the wounds take years to scar.