Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis Read online

  So, standing in the dark of Joseph’s room, my mind returned to young Charles Wrigley, who was described as miserable and holding his hand on his forehead as if in pain. “I just want to be left alone,” Joseph had labored to tell me from his impenetrable stillness when I began to test his gag reflex. “I’m terribly depressed.”

  I sat down beside Joseph to ask him more questions, now that he’d broken his silence. “How long have you been feeling this way?” I asked. His eyes remained closed. He did not respond.

  “Joseph?” I tried again. “I’d like to hear about what you’ve been going through so that I can help.” He did not stir. I sat there beside him, the awkward silence in the wake of my voice hanging between us. I felt a palpable discomfort—my own inability to penetrate Joseph’s misery, the paralysis of his suffering. I found myself thinking of a short-lived flirtation I’d had with Buddhism in graduate school, when I’d sit and reach for the meditative stillness the practice espoused only to find my mind wandering and waylaid, my body stiff or itching. “Joseph?” I said again. “Joseph?” Eventually I stood and left the room.

  Medicine asks its practitioners to confront the messy, unsatisfying, nonconforming human mind. As psychiatrists, we see the mind while it careens and lists, and we are not always sure how—or whether—we can right it. How do we respond when a patient’s suffering breeds unbearable discomfort and unease within our own selves? What do we do when our patients’ symptoms do not relent? When their experiences cannot be accounted for—or helped by—what we know about medicine, or the brain? What then?

  (CHAPTER ONE)

  The Woman Who Needed a Zipper

  Those wounds heal ill that men do give themselves.

  —Shakespeare, Troilus and Cressida

  Lauren’s back again.” The gastroenterology fellow groaned. “Lightbulbs this time.” I was in my second year of residency training and had just started working in a major medical hospital as a psychiatric consultant for medical and surgical inpatients. I had no idea who the fellow was talking about. When I told him so, he began to laugh. “Oh, my God. You’ve never seen Lauren? Every time she comes in, the ER docs call us and we call you guys. We all give our advice on how to treat her, but you know what she really needs?” I didn’t. “A zipper,” he said. “See you in the ER.”

  I was utterly confused. Lightbulbs? A zipper? Sounded more like supplies for a child’s science project than relevant clinical information. My mind was spinning as I walked through the dingy hospital stairwell to the emergency room to meet Lauren. On the wall at the landing hung a faded hospital-benefit poster of a horse-drawn carriage in the snow and some lines from Robert Frost. When I walked by the poster, I was typically working an overnight shift, and so “miles to go before I sleep” had taken on a bleary, fluorescent-lit meaning quite detached from woods, “lovely, dark and deep.” As I swiped my badge to go into the ER, the lines were still running through my head: Between the woods and frozen lake / The darkest evening of the year.

  Lauren was in a room across from the nurses’ station. The ER rooms had three walls; the “fourth wall” was a pink-and-tan curtain that could be drawn for privacy or pulled back to enter or exit. Lauren’s curtain was wide open, and a security guard in a navy uniform sat in a plastic chair at the foot of her bed. I took a look in as I walked by. Given the gastroenterology fellow’s dramatic reaction to her presence, I expected her appearance to be notable. It wasn’t. She was sitting glumly on the bed, upright, in a hospital johnny. She was thin. Her dirty blond hair was a little mussed. She was twenty-five, but she looked slightly older. Otherwise, there was not much about her that was remarkable. I continued walking by; I wanted to take a look at her chart before I went in.

  As I pulled Lauren’s chart from the nurses’ station, one of the nurses seated there glanced at my name tag. CHRISTINE MONTROSS, M.D., it read. PSYCHIATRY.

  “Aha!” The nurse smiled and in a singsong voice added, “I know who you’re here to see.”

  “The woman in 2B?” I asked. “You know her?”

  The nurse nodded and laughed, surprised. “You don’t? I thought everybody knew Lauren. Have fun!” She winked and handed me a folder with the patient’s ER paperwork in it. “Oh, Doc?” she called as I walked away. “Don’t lend her that nice pen of yours.”

  I opened the chart. A sheet of Lauren’s orders was on top. Along with the ticked boxes indicating the conventional laboratory studies for ER patients were a few additional specifications: “Finger food diet only,” read one line. Beneath it: “NO objects to be left in room—SEE BEHAVIORAL CARE PLAN.” I couldn’t be sure how to interpret these orders, but from them I surmised that Lauren must be either suicidal or homicidal. Patients who were relegated to finger-food diets were those who could not be trusted with utensils.

  Beneath the orders page was a sheet of Lauren’s lab values. I quickly scanned it, looking for the typical irregularities of psychiatric patients: elevated blood-alcohol levels, a positive drug test, subtherapeutic medication levels, thyroid abnormalities, infection. With the exception of a toxicology screen that was positive for her having smoked marijuana sometime recently, nothing stood out. Her complete blood count and electrolytes were totally normal. Her pregnancy test was negative. Chest and abdominal X-rays had been taken; the results were pending.

  I flipped through the remainder of the paperwork and found that Lauren was already slated for admission to a bed on the internal-medicine service. The admitting resident had seen her and written a note. I deciphered the scrawled shorthand to read: “This patient is a well-known 25-year-old female with extensive psych history and multiple previous intentional ingestions.” Usually an “intentional ingestion” meant that someone had drunk bleach or eaten rat poison or overdosed on pills as a suicide attempt, but the meaning was different here. Lightbulbs. Suddenly keeping utensils and objects and nice pens out of Lauren’s reach made sense. Nobody wanted her to swallow them.

  I walked past the security guard and into Lauren’s room. Before I could introduce myself, she glared at me and said, “Let me guess, you’re the shrink, right? I can always tell you guys—you’re all nicey-nice handshakes and dipshit smiles.” The security guard, who had doubtless seen a number of ER psych consults, stifled a chuckle and put his fist over his mouth to hide a grin.

  “Sounds like you’ve pegged us,” I answered, reaching out my right hand in a nicey-nice shake. “I’m Dr. Montross.”

  “Yeah,” replied Lauren, glowering at my hand without taking it. “I can read your fuckin’ name tag, Christine, but unless you are going to get me something for this pain, I’m not in the mood for a conversation.”

  I turned to the security guard. “Would you mind letting us talk alone for a minute?” I asked.

  “Whatever you say, Doc.” He shrugged. “I’ll be right outside if you need me.” He stepped out and drew the curtain closed behind him when he left. I slid his chair to the side of Lauren’s bed and sat down.

  Lauren pulled the hospital blanket up to her neck, lay down against her pillow, and rolled onto her side, turning her back to me. “Jesus, you people don’t listen. I wasn’t kidding. Unless you give me something for my pain, I’m not talking.”

  “Since I’m meeting you for the first time, it’s hard for me to know about your pain. If you tell me about it, maybe we can come up with a way I could be of help,” I offered. It was a stretch—she was talking physical pain, and I was going to try to access her psychic pain—but it didn’t feel like a lie. I knew I wasn’t going to write her an order for pain medication—that was the territory of the ER and the medicine teams—but I needed an entrée, and I hoped that asking about her pain would soften her defensive stance. Or at least encourage her to roll over and look at me. “What’s going on that you’ve ended up in the emergency room?”

  “Read. The. Chart,” Lauren intoned, not making a move.

  “I’ve looked at it a bit already,” I sai
d, “but I’d actually rather hear from you—”

  “Well, I’d rather be left alone,” she interrupted.

  “Fair enough,” I said. “Let me just read you what I’ve got here, and you tell me whether that sounds about right, okay?” I opened the chart to the admission note. Lauren was silent. “It says here that you were feeling upset and that you swallowed some pieces of a lightbulb. Is that right?”

  Lauren scoffed, then abruptly turned toward me, angry. “Yeah, ‘upset.’ That’s one way to put it. See? That’s why I don’t talk to you people. I’m in the hospital three days ago, you all decide—you shrinks and the surgeons and the GI docs—you all decide to kick me out even though I’m telling everybody I’m not ready to go home, and then some intern writes that I’m ‘upset.’ Well, fuck yeah, I’m upset. I’m upset because I told you I wasn’t ready to go home and no one listened to me. So pardon me if I don’t really buy that you’re so interested in my side of things.”

  “What happened with the lightbulb?” I asked.

  “Lightbulbs,” she said.

  “Okay, what happened with the lightbulbs?”

  “I was pissed. I crushed them up and swallowed them,” she said matter-of-factly. “Not the metal part, just the glass and wire.” I nodded. There was a moment of quiet between us. Then she spoke. “Now do you believe me that my stomach fucking hurts?”

  I left Lauren and went off to write up my evaluation and recommendations. The surgical team to which she would be assigned consulted the psychiatry service for help in managing her psychiatric medications while she was hospitalized. The team’s larger hope, of course, was that we would be able to provide some sort of intervention that would break the pattern of Lauren’s swallowing, or at least lengthen the periods of time in between her intentional ingestions. To better understand the medications she had been on and the psychiatric treatments she had tried prior to this admission, I pulled her old charts from medical records. She had stacks of them, some of which were more than four years old and so had been archived. I looked up the most recent admissions that had taken place in the last four years; there were twenty-three. Her hospitalizations had been prompted by her ingestion of the following:

  ninety screws

  AA batteries and paper clips

  two knife blades and four fork handles

  four candles

  four metal spoon handles

  the screwdriver from an eyeglass-repair kit

  a knife and six barbecue skewers

  a bedspring

  thirteen pencils

  a knife, a knife handle, and a mercury thermometer

  a box of three-inch galvanized nails

  a screwdriver, a ninja knife, and a knife blade

  a steak knife

  a razor and five pens

  two knives

  scissors, pins, and a nail file

  four four-inch pieces of curtain rod

  scissors, a drill bit, and a pen

  a six-inch piece of curtain rod and a seven-inch knife

  a knife, three spoons, and some copper wire

  two six-inch steak knives

  a pair of scissors

  a four-inch metal blade, three spoon handles, and a nail clipper

  Over and over, Lauren would swallow potentially dangerous objects in the context of stress. She swallowed the screwdriver, the knife blade, and the ninja knife when she learned that her uncle was terminally ill. The two knife blades and four fork handles were a response to learning that her sister had hepatitis. The box of nails was after a fight with a neighbor. Each time she said she felt better after she had swallowed something and then brought herself to the emergency room for treatment. Over and over, doctors performed endoscopies, threading a camera and tools down Lauren’s throat with a tube to try to get the objects out before the things she had swallowed inflicted damage on her esophagus, stomach, or intestines. Only once, after she’d ingested a single spoon handle, was endoscopy deemed unnecessary. “She had some discomfort,” the discharge summary read, “but the spoon passed normally.”

  In contrast, once, when an eight-inch knife blade was too dangerous to pull back up through her esophagus and out of her mouth, Lauren’s abdomen had to be surgically opened and the knife removed. Many times, multiple endoscopic attempts were required to “retrieve” the same object. One endoscopy note read, “Four approximately 4-inch-long sharp pieces of broken curtain rail were found in the gastric fundus. Removal of two was accomplished with a snare. The other two could not be removed. They kept holding up at the gastroesophageal junction despite two hours’ manipulation.” If objects could not be extracted, more experienced doctors were brought in for additional attempts. A senior physician developed a reputation for being able to retrieve items Lauren had swallowed when others had failed to do so. Once, during a hospital meeting that had specifically been convened to discuss Lauren’s care, an administrator asked the gathered group of clinicians for ideas about a systematic approach for treating her during her recurrent admissions. A GI fellow piped up from the back, “If at first you don’t succeed, try, try again. If you still don’t succeed, call in Dr. Friedrichs.”

  Not infrequently, once awake and recovering back on the floor, Lauren would swallow something in her hospital room and require further treatment. Several times she swallowed the handles of spoons from her meal trays. Once a pencil. Once she broke fragments of wood from the frame of her room’s window and ate them. One night in the emergency room, she removed and swallowed a metal piece of the gurney.

  The doctors charged with Lauren’s care had no choice but to treat her when she came to the emergency room. Each time her actions were potentially life-threatening. To deny her care not only would be ethically incomprehensible but could also be medically catastrophic. No one could suggest that doctors should refuse to perform procedures on her, even if the procedures themselves were somehow reinforcing the maladaptive behavior, even if Lauren might swallow something as soon as she awakened from an endoscopy that had narrowly averted disaster. And yet the frustration of the surgical staff, who once during a consultation expressed their shared wish to “let her experience the consequences,” was only partially an emotional response to her flagrant self-injury and misuse of their expertise. It was also a manifestation of the fact that they felt they were contributing to this young woman’s demise. “It doesn’t matter that she’s the one that swallowed the razor,” one surgical resident said to me. “If I have to operate, I’m the one that’s cutting her open, exposing her to the dangers of major surgery, giving her a belly full of scar tissue. . . . I might fix the emergency, but beyond that, none of what I’m doing is going to help her in the long run.”

  Many surgeons differentiate their field of medicine from others by their ability to perform a procedure that fixes what’s wrong with the patient. Surgeons realign the broken hip and remove the cancerous breast; they repair gunshot wounds and replace burned skin. One particularly brazen surgeon with whom I trained as a medical student would routinely wait for his patients to awaken from anesthesia and then come to the bedside, look them in the eye, and announce, “I cured you!” This was all the more disquieting to observe given that some of his patients were terminally ill, and his role—to remove a cancer-ridden lobe of the liver or extricate a tumor-infested loop of bowel—might well have been only palliative in nature.

  In general, the surgeons with whom I work have a great respect and appreciation for the field of psychiatry, but they also feel they’d be particularly ill suited to practice it. Lauren was an unsettling patient for all of us, but psychiatrists often face complex patients and ambiguous diagnoses. Lauren’s condition was particularly irritating for the surgeons who treated her. The chronic, “unfixable” nature of her illness was made plain in her personalized Medical and Behavioral Treatment Plan, the first line of which read, “Approach for this patient should focus on disease m
anagement, not cure.”

  By continuing to ingest objects in the hospital, Lauren was not only putting herself at risk but also putting her doctors and the hospital at risk. A hospital’s job, by definition, is to keep patients safe and healthy. In the treatment of psychiatric patients, this means that reasonable measures must be taken to prevent potentially dangerous patients from having a way to hurt or kill themselves or others. For these very reasons, many psychiatric hospitals have specialty fixtures. Door handles and showerheads flip down when weight is put on them to prevent patients from hanging themselves. Beds and couches are often built into the walls to prevent them from being upended or used to blockade doors. Patients on “suicide precautions” cannot shave with razors, nor are they permitted to have belts on their pants or laces in their shoes.

  With Lauren, everything was theoretically ingestible. To protect her—and themselves—hospital administrators developed a Behavioral Care Plan specific to Lauren, outlining the “Process for admission to [an] inpatient unit”:

  1.Immediate Security Constant Observation with TWO guards

  2.Immediate sweep and removal of any and all objects inside patient room

  3.Objects for removal are not limited to but must include:

  a.controls for blinds

  b.clock and batteries

  c.regular trash barrel and all bags

  d.biohazard container and bag

  e.all pens, pencils, markers, books, thumbtacks

  f.hygiene-related products (soap, toothbrush, toothpaste, mouthwash, powder, and all applicable containers, etc.)

  g.artwork

  h.wall hangings, clips, nails, and signs

  i.nonessential medical-related equipment

  j.any nonessential, non-medical-related items

  k.fan

  l.beverage containers/bottles

  4.Patient is to receive finger foods ONLY.

  a.Meals delivered on a single Styrofoam plate/tray only.