by Judith Lucci
Alex said simply, even though her heart was beating full force, "Thanks, Anthony. I'll take what I can get. Don't let me interrupt. Just continue as if I wasn't here." Alex felt frenzied, uncertain. She turned to Monique, her eyes pleading with her to take up the reins of the group therapy meeting. Monique nodded at the group leader to continue. Alex was definitely out of her comfort zone and she knew the patients on the unit knew it.
The group leader continued the meeting. "Now, group, before we were interrupted, we were sharing our feelings about what happened to Angie. Rose, I believe you were talking."
Alex turned her head towards the patient identified as Rose. She looked to be in her thirties, was waif thin, and had long, stringy brown hair. Alex thought Rose looked afraid of her own shadow. She wondered if she'd been abused at some point in her life. Rose literally seemed to shrink and almost became invisible as the group stared at her.
"I ... I ... feel so awful for Miss Angie." Rose's voice was soft and hesitant. "She was nice to me. We talked last night, just before Jim started that fight in the day room." Rose looked around at the group and saw them staring intently at her. Her voice faltered and she began to cry. Then, she said, "Angie and I could have talked longer, but Jim ruined our conversation." She gulped, her thin shoulders heaving in despair as she burst into sobs.
Anthony's voice was hoarse with anger and resentment. "Why are you crying, Rose? You’re such a little crybaby bitch. Ain't nobody hurt you yet. You're such a cowardly little piece of crap. You're a slut, just like all the women. You remind me of my ..." Anthony's voice had become louder and louder as he screamed at Rose, his face livid with rage. Suddenly, he stood up and lunged towards the frail, pale woman, who seemed to shrink away from him. He was going for her neck.
"Oh, no! No! No," Alex could only exclaim. She was unable to move, paralyzed in her chair.
In a flash, Donna Meade, the nursing manager of the general psychiatry unit, a behavioral health tech, and Dr. Desmonde wrestled 6 foot Anthony to the floor, pinning his arms behind him. Donna Meade left for an instant to ring the "all staff alarm" red button located by the door. The ASA was to psychiatry what a code blue was on general hospital units. It announced a psychiatric emergency and requested that all available staff report immediately to the location. Within seconds, two additional male psych techs and a second RN appeared with the syringe of Haldol, which, after a nod from Dr. Desmonde, was administered into Anthony's upper arm. The two psych techs lead Anthony away to the seclusion room while the rest of the patients stared.
It was then that an acute realization hit Alex. These people, these patients, had their own culture, their own pecking order. They had their own leaders and power structure. Anthony was the power structure. Now that he was down, no one was going to say much or offer any significant help.
Alex felt safe for a brief moment. Then she realized, with a sinking feeling, that she was in a very dangerous situation. Suppose the other patients acted out? Didn't that happen often? She tried to remember from her nursing school days. Didn't one patient incident spark other patients to act out? Like an avalanche? Of course they did. She felt her heart rate pick up quickly and the hair on her arms stood up. She felt chilled. Yes. That is what happens. That's exactly what happened last night in this very place! Alex looked around furtively.
Several patients were agitated, rocking back and forth in their chairs in perfect rhythm. Another patient was plucking invisible particles from the air. Alex felt her heart fill with panic. Just to her left was another large man. He suddenly began screaming and pulling at his hair. Then he stood up and started pitching empty chairs against the window, hollering that he had to get out and save his baby.
Donna Meade looked at the patient, calmly touched his arm, and said in a soft, steady voice, "Jim, stop throwing the chairs. You're okay now. You're in the hospital and nobody's going to hurt you. Please, you're upsetting the other patients." Donna's voice was calm and quiet. She slipped her hand into the crook of Jim's arm just as he was about to toss another chair at the barred windows. He immediately replaced the chair on the floor.
Jim gave Donna a confused look. Then recognition seemed to appear on his face. "Oh, oh, oh! I gotta get outta here. I gotta go. I'm sorry, Donna. I didn't mean to cause no trouble." Jim's eyes were terrified and were full of tears. He looked ashamed of his behavior. The huge man was literally cowering before the staff and the patients.
"I know, Jim. You just couldn't help it. Let's go to the quiet room and rest awhile." Donna continued to hold his arm gently.
Then, to Alex's amazement, the large man allowed the petite Donna Meade to walk him to quiet room.
Donna motioned to Monique that she needed some medication and then said to Jim in a quiet voice, "I want you to rest for a little while. We'll talk about this later."
Alex shifted her eyes from Jim and glued them on Monique. If Monique left her in the community room, there'd be no staff member at all to subdue any patient outbursts. In fact, they had been lucky that Donna had been able to quiet Jim. It would have been impossible for Alex, Donna, and Monique to wrestle the enormous man to the floor.
Several minutes ticked by. It was finally quiet. The only noise in the room was the click, click, click sound of someone clicking their tongue against the roof of their mouth and the squeaking of the two rocking chairs as the patients continued rocking back and forth.
Monique made a decision. She spoke to the patients in a cool, calm voice, glancing at her watch. "Our time is about up. Why don't you all take a break and then report to where you should be at 4 o'clock. Rose, you can go to my office because we have individual therapy at 4:15. The rest of you know your schedules."
The patients left the community room quietly. Only the two rocking patients remained. Alex breathed a sigh of relief. She was impressed with how Monique had handled the situation. Dr. Desmonde's firm tone of voice had waylaid any further patient outbursts. The psychiatrist had taken control of a potentially dangerous scenario by neither acknowledging nor discussing the situation and by redirecting energies of the patient group in a positive manner. Her behavior and poise were highly professional.
Alex glanced around, still uncertain of her surroundings. "Monique, we've gotta talk ..." Alex began.
Monique lifted her index finger to silence her. "Yes, but first I've got to make sure Donna got Jim to the quiet room. Wait for me. I'll send some medicine and a psych tech back here to deal with these two." She gestured at the two remaining patients.
Alex left the community room and walked into the central nursing station, behind a door and glass windows, where she felt much safer. She was relieved to see the patients playing board games and watching the soaps on TV. She wondered to herself just how therapeutic watching soap operas could be, but figured it was better than beating up on each other and the staff. She decided to keep her mouth shut about what she thought was therapeutic. She turned and saw Dr. Desmonde in the medication room and followed her. She watched Monique select a 3 mL syringe from the locked cabinet, snap the top off an ampule of Haldol, and deftly fill the syringe. Monique continued to draw up Ativan for anti-anxiety and Cogentin to combat the side effects of the Haldol.
"Alex?" Monique intoned as she nodded towards the hall.
Alex and Monique walked deliberately down the hall to the quiet room, where they found Donna and Jim talking quietly. Jim had been crying. As they entered the quiet room, he spoke.
"Donna, I don't know what gets into me. These tempers just come. I don't know what to do. I need help. I'm scared. I never know what I'll do next." Jim was so upset, he began to sob, his voice coming out in great gulps.
Donna patted his shoulder reassuringly. "Jim, we're gonna try to help you. We care about you here in the Pavilion, don't we, Dr. Desmonde?" Donna's acknowledgment of the physician's presence drew Jim's attention to Monique.
He looked at Dr. Desmonde sadly and said, "Sorry, Doc. I just need more help. I don't know what's happened to me. Is there somethin
g else you can do to help me? A new pill or something?" Jim's voice was desperate.
"I know, Jim. I know you don't understand your outbursts and, yes, we will continue to help you." Dr. Desmonde looked sad as well. "We'll keep working on it. We've made some headway. I've made you a shot that'll help you rest. Where do you want it?"
"Can I have it in my left arm? Last time it was in my right." Jim pointed towards his left deltoid muscle.
"Well," Monique hesitated, "this needle's a little long. How much muscle do you have in that arm?"
"Doc, I got muscle. I just don't have no brains!" Jim smiled for the first time.
Alex was surprised at how handsome he was. He had a beautiful smile, dark hair, and perfect, brilliant white teeth. She guessed he was in his mid-thirties. He looked to be of Irish descent. The Black Irish, Alex wondered to herself, acknowledging her knowledge of Jim's bad temper. How very sad if he is really one of them.
Dr. Desmonde returned his smile as she injected the needle and said, "You've got plenty of brains, Jim. They're just a little scrambled right now. We'll get them fixed!"
"Thanks, Doc, Donna, and Alex. I'm pretty tired now. I guess I'll sleep awhile. See you soon." Jim turned over in the bed of the quiet room.
Alex was impressed that Jim had remembered her name and said so to Monique and Donna on the way down the hall.
Donna said, "Jim's very bright. I'm not surprised at all. I like him. He wants to get better and I want to help him." Donna's voice was concerned, her interest in helping the patient obvious.
Dr. Desmonde looked narrowly at Donna. "Don't let personal feelings get in the way of professional judgment, Donna. Jim's very ill, psychotic. Don't set Jim and yourself up for disappointment. Don't get too involved in this case." Monique's voice was sharp and a little accusatory.
Donna's face turned red and she replied hotly, "I hope you're not suggesting I have feelings for Jim that are other than professional! There are no boundary issues here for you to be concerned with." Her voice was cold and defensive. "It's just that most of our patients are chronic and we never really help them. Besides, most of 'em don't want help. Many are so manipulative that they can't be trusted. I doubt many of them even want to get well. Jim does. That is the impetus driving my 'involvement' in this case." Donna was enraged and felt attacked.
Monique was quiet for a moment and then spoke. Her voice was repentant and reassuring. She'd accepted Donna's rebuke with grace. She shook her head and said, "I'm sorry, I apologize. I know how you feel, Donna. I have a special place for Jim myself. But, we have to keep it all in perspective. I am sorry if you think I suggested that your involvement is anything other than professional," Dr. Desmonde's voice was pensive and apologetic. She hugged Donna around the shoulders and added, "Nice job in there, gal."
Donna hugged her back. "Thanks Monique. But, you and I both know we've gotta do something about this place and the staffing. That situation could have gotten completely out of hand – the one last night did! My nurses are scared. Several are terrified and are planning to leave the Pavilion." Donna stopped for a minute and then admitted, "I'm scared too, and that's not even factoring in what happened to Angie. The patients are getting sicker and sicker and more and more violent, especially since we started taking the ones from the state hospital that Lester Whitset contracted for. We're not staffed for those types of admissions."
Dr. Desmonde sighed. "Yes, yes. I know, Donna. I'm trying to get more positions allocated, even if they are only muscle positions. I'd be thankful to have strong bodies to help us in emergencies like this one today. Since we've been under this contract management, it's next to impossible. We need more behavioral health techs to help us out when we have these outbursts of violence."
Alex nodded in agreement with Monique and said to Donna, "I'm concerned about your staffing, too. You don't have enough staff to handle such severely ill patients and control these kinds of situations. What's your typical census?"
Donna responded quickly. "We've got 22 general psychiatry beds and average about 18 or 19 patients. Usually, eight or so of them are overtly psychotic and have histories of violence or acting out behavior. The rest are acutely depressed or have organic brain syndrome and/or Alzheimer's disease."
Alex nodded in understanding. "How long have we been mixing the elderly and the adolescents with the others? I thought they used to be separated." Alex asked, looking questioningly at Monique and Donna.
Donna shook her head and answered, "We started mixing them at the time the contract manager started. Whitset cut our staff 20%, making it impossible to run an age differentiated behavioral health unit. He maintains that a therapeutic milieu can occur with all ages together, so everyone can 'learn from each other'! Isn't that some crap? We've even had to eliminate geriatric and adolescent tract therapies. We couldn't staff them!" Donna's voice reflected her dismay.
"How's it working?" Alex asked.
"Not well, not well at all I'm afraid," Donna said. "The patients just don't identify with each other because of their ages. Mrs. Smithson, the elderly patient with the apple cheeks, is appalled when the adolescent female patients talk about their sex lives and how they have to have "it" every day. The way they talk about sex is disgusting to Mrs. Smithson and I know it horrifies her. In fact, her son told Angie last night that he thought she was worse. He said he was gonna transfer her to Ochsner's private geriatric program. I don't blame him. She could get better care there, at least more care directed towards her age group. I'd move my mother over there, as opposed to here, so she could get better care. No question about it." Donna shrugged her shoulders.
"Is Mrs. Smithson the little lady who looks like Mrs. Santa Claus?"
Monique and Donna nodded.
"Why's she here?"
"She's in for a reactive depression. Her husband died in April and her only daughter, her caregiver, has rheumatoid arthritis and breast cancer. It's very sad, but also very typical for people in her age group. Her son is correct when he says we haven't helped her. Older patients need a different kind of care that is more structured to their place in life and their late life losses. Do you think we have been effective with her, Monique?" Donna looked carefully at Dr. Desmonde.
"Perhaps the meds have helped some, but basically we haven't helped her much. You're right, Donna. What we are doing isn't helping. I'm philosophically opposed to mixing these patients, but in view of managed care and reimbursement, we have no choice. I guess some concentrated care is better than none at all. At least we can watch her for suicide attempts – at least, most of the time." Monique looked sheepishly at Alex and Donna.
"What do you mean, most of the time?" Alex asked, her voice anxious.
"Face it, Alex. I usually have two RNs and two psych techs on the day shift. There is even less staff on evenings and nights. We have no security and not a lot of muscle to wrestle these people down if they have outbursts. My RNs have to assess each patient, do paperwork, run groups, give meds, handle emergencies, and participate in community meetings. The psych techs supervise the daily care of the male patients and, together with the RNs, monitor the five-step patient responsibility level." Maybe it will get better when the new health reform act goes into effect. I heard that it may."
"Five step what?" Alex asked.
Donna explained, "Well, it's really not five steps anymore, not since the length of stay decreased to three or four days, sometimes even less. It’s a system of patient responsibility level used as a gauge to grant individual patient privileges. As patients improve, they're given more responsibility and freedom. On level I, patients are restricted to the floor. On level V, they may leave the floor unescorted and take unaccompanied trips off hospital grounds."
Alex's legal mind was racing. Her thoughts scared her. She interrupted Donna. "Are you suggesting that we could have possibly sanctioned an activity where one of the psychotic patients could have left the hospital last night and attacked Angie, with CCMC's blessing?" Her eyes were wide with worry.
/> Dr. Desmonde intervened. "No, we haven't had a patient on level V for several years, mainly because insurance won't pay. They figure if the patient can be off hospital grounds, he can be out of the hospital. Most of our patients reach level III, meaning that they can leave the unit in a group, escorted by a staff member. They go to the coffee shop for meals, the gift shop, and so on. Right, Donna?"
Donna looked pleased. "Good, Monique. Very good. You are the first attending shrink that ever understood the system! I'm proud of you." Donna grinned at Dr. Desmonde.
Alex smiled as the nurse and physician high-fived each other.
"I don't know if admissions will ever return to the pre-HMO days when a psychiatric admission actually changed behavior. According to news reports, mental health services are supposed to get better under the new health care system. Supposedly, 32 million additional mentally ill people will receive psych benefits and the benefits of the 30 million Americans who already have them will improve. I just don't see how that is going to happen, but it surely sounds good," Monique added. "Of course, I am totally clueless on how we are going to care for them. We have no space for more admissions now and I’m pretty sure we have more than our fair share in Louisiana," she added.
"Yes," Alex agreed. "It sounds good in theory, but it's all determined on how states interpret the "rules" set forth by the President. Some states could make as many as 500 drugs available for the mentally ill, while other states may only allow access to 250 drugs. Benefits will occur on a state-by-state basis. The same will be true for inpatient care for the acutely mentally ill and for substance abuse treatment. Some states may allow longer acute care stays or better rehab programs than others. It remains to be seen how all of that will settle out, particularly in Louisiana."
Monique looked at Alex and repeated, "Yes, particularly in Louisiana. I think we already know and shouldn't look for much to improve. There will be no silver linings for us," she added regretfully. "We'll just have many, many more patients with no place to put them. I’m not looking for any great fixes to occur in the next few years."
