On psychosis and the truth (or the beginning of Inpatient Psychiatry)

The first week down: survived without much fuss. Had a good patient load with a few admissions, a few discharges, and lots of practice developing a treatment plan with the attending. Felt good to participate with this added level of responsibility.

I do not have the bustling and soul-draining schedule common to many other PGY1s. My residency program is quite humane and allows me time to decompress from challenging patient encounters and to enjoy evenings playing with my son. I’m incredibly thankful for this, as I have the mental slack to pursue professional and personal projects.

I could be spending 12+hrs in the hospital for six or seven days in a row. I could be asked to run night shifts on the floor or I could be pulled into the hospital every weekend. Instead, I have a stable 8-5 where I am paid relatively well and I have a reasonable patient load where I can learn clinical lessons from each case. I am not drowning and thus I can swim to farther shores.

And what have I learned so far?


On Wednesday, I wrapped up an interview with the newest admission, “Mister Green.”

A young fellow, profoundly psychotic (meaning he suffered from severe hallucinations and delusions) with concurrent PTSD (which developed after combat deployments with the US military). He had been picked up by municipal police for bizarre behavior. Upon interview, I referred to him as Mister Green instead of his first name because I thought it would be a good hearkening back to his military days when most individuals are referred by their last names.

Mister Green believed that he reported directly to ‘Donald J Trump’ for an undercover assignment with the Secret Service. He had an intense stare and demanded specific medications which would only increase his agitation and mood lability given his current psychotic state. I finished the interview with explanations that I needed to confirm with his outpatient psychiatrist regarding the medication and that in the meantime we would begin with antipsychotics.

While in the resident lounge and beginning to write-up the H&P, I received a call from nursing. Mister Green had been shouting and causing quite a stir in his demands for that med, disrupting the rest of the floor. I made my way down and the nurse promised to call security for back-up.

When I arrived to the locked unit, Mister Green was leaning into the nurse’s station and aggressively explaining his need for the med with a raised voice and tense affect. I didn’t think he seemed immediately violent, but definitely autonomically activated like a caged animal or traumatized human.

I approached Mister Green with a greeting and he turned to me. His pupils were dilated and he demanded that I prescribe him the medication. I told him that I could not do that, but I could prescribe other medicines that would help calm him down. He refused.

I offered to walk him back into his room, since we were causing such a scene in the hallway: all the other patients had scattered to their own rooms. He agreed and marched into the nearby double room.

He began to aggressively pace. He pointed at his sleeping roommate and told me that he couldn’t stay in this room, “this guy is giving me a weird vibe. I can’t relax around him!” With the nurse’s suggestion, we transitioned from his double to the quiet seclusion room in the center of the unit.

As I entered the quiet room, so did security.

Three large fellows in uniform entered the vestibule and one stood next to me in the stark white seclusion room while I talked to Mister Green. He began discussing his assignment to Donald Trump when he turned to the security guard and pointed.

“See? ‘Sergeant Smith’ knows me. He knows what I’ve seen. Right?”

The security officer nodded slowly. Playing along, I thought a good strategy to keep the situation calm and the patient engaged. Then, the subject switched to the horrors of war that he witnessed while deployed overseas.

After a few tense minutes in the room, I realize that I am unable to talk the patient down from his activated state. I make my way to leave and ask the officer if he is good; he nods to me as well.

Outside the room, I text my attending the current happenings and he says that we need a second opinion to force medications on the patient: either oral antipsychotic or an intramuscular injection.

Over the next few minutes, I consult an attending that I’ve worked with extensively as a medical student. He makes his way down to the floor and into the seclusion room to assess the next for forced medications in this patient. He agrees, and I quickly enter the orders for PO or IM zyprexa in the EMR. I tell the nurse to give him the option for the liquid med, if he doesn’t take it then we have to stick him with the needle.

The consulting attending finishes documenting the encounter in the nursing station while I stand outside the vestibule of the seclusion room with the security officers. The nurse walks out and says, with a smile on her face, that he accepted the liquid medication.

Everyone begins to relax a bit, knowing that the situation is beginning to deescalate.

The security officers leave the patient alone in the quiet room. I thank them for their assistance. The officer in the room with me nods to me and says, “He has changed a lot since I last saw him.”

“… What?”

“I served with him.”

“Wait, so you are actually Sergeant Smith? That wasn’t a delusion?”

“Correct. Tough to see him like this.”

At this point, one of the fellow security officers perks up and copies my stunned face.

Sergeant Smith looks over and tell him, “Yeah, he was in Alpha Company.”

The fellow officer transitions from stunned to amazed; apparently they all served together at some point in the not too distant past.


So far, I learned that a psychotic patient can tell the truth.

My patients tell the truth and I need to be astute and present as a clinician in order to hear that truth.

Because I told this story to the nursing staff. And the next time “Mr. Green” develops severe agitation, the nurses can specifically request “Sergeant Smith” to the floor. Maybe his familiar face will prevent the situation from escalating.

Maybe.


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