Another Dose

"Zyprosamide 10 mg IM stat," I say with equanimity. "And 1 mg of his benzodiazepine with it," I add.

"I have it here in my hand. Pretty sure this was going to happen," Sarah replies. The record had shown our new admission had required physical and chemical restraints prior to his arrival on our unit.

I watch as she readies the needle that will deliver a dose of this powerful antipsychotic medication into the deltoid muscle. Smell of the quick alcohol swipe briefly fills the air as she quickly cleanses a place to inject him. Our patient Jacob continues to thrash wildly against the restraints that bind his hands and wrists. Four points. He yells incoherent gibberish, we call it word salad.

"TV, God, I'm, we're... Not! Changes, I am going, best songs...songs..I don't....Alone, alone, alon......Jacob finishes his current string of nonsensical words that die on his lips as the medication takes hold.

Jacob is court ordered to be admitted to the inpatient psychiatry unit for nonadherence to his medications. He is a new admission today, but not new to us at all. He has had multiple inpatient hospitalizations for psychosis. A state in which the patient is disconnected from reality. Jacob has been diagnosed with schizophrenia. His medications work well when he takes them, but he has protracted periods when he does not.

In dealing with his mental illness for years, his family has been as supportive as they could have been. He is emotionally challenging, at times confrontational, and financially a drain. Today he is dirty, smelling of urine, and rail thin. His hair is unwashed and there is a scruffy beard covering his face. He will need to be checked well for lice when he is quiet enough. He is homeless yet again, not through the fault of his family. He is impossible to control.

This time he was reported by his neighbors. They stated he walked into their home without clothing except socks and was chanting. Police picked him up yet again and brought him in for treatment. This is not a deep read for me, these are common findings.

Following a medical evaluation of standard labs and CT scan of the head it was concluded that there was no medical cause for his current relapse. We all begin again. A revolving door patient is back through the revolving door. Treat, arrange outpatient appointments, scripts to pharmacies, discharge with court ordered follow up, then no shows.

"Jacob's back," I say feeling defeated to Rebecca the charge nurse for the unit. We have worked together for a couple of years, co-dependent and a really good team.

"Yep, I think he was just discharged a couple of months ago," she replies. " I have a list of his home medications but... I'm pretty sure he hasn't been taking any of them."

Important fact. We have to start at lower doses than what he was discharged on and gradually increase them as needed. She has no time to waste on politics and philosophy today. If he is back, it is what it is. She has other priorities.

In the past we have voiced our mutual frustration with a system that cannot keep Jacob and others like him safe. No sense in rehashing it now. But it least he has not engaged in any self-harming activities, no cuts or burns on his body. He has not choked, stabbed or hung himself. He did not threaten others with violence. We are happy for these small blessing. Even if the system is a failure.

"Have the mental health technician check vital signs every 4 hours," I order. A doctor's order here so totally unnecessary as Rebecca and the rest of the staff are already attending to this. She is a seasoned psychiatric professional. She is the charge nurse. Her biggest task is how to stretch the already stressed resources to accommodate for Jacob's needs. His 1:1 observation.

I start reviewing his record from the admission two months ago. Pretty much the same.

There are twenty patients on this locked unit. These are all short stay admissions. This is not One Flew Over the Cuckoo's Nest. They come, get pumped with medication, a few group meetings. In five to ten days they're out. Medicine run by insurance companies. Payments no longer approved. The patients range in diagnoses, but most are depressed, intentional overdoses and other suicide attempts, schizophrenics, bipolar disorder, borderline personality, and substance abuse. They are challenging, demanding, aggressive, apathetic, resistant, attention and drug seekers. And many,many people who practice self harm with cutting and burning.

The unit is quiet for a short while until..... Aaron begins. He was admitted two days ago.

"I don't belong here," he says with conviction in a slightly elevated voice.

I can hear both Rebecca and Sarah, talking softly, but firmly to him. De-escalation. Soft vocal tones, familiar and reassuring using his name frequently. They do it well and I resume my work on Jacob's chart.

Aaron is having none of it.

"I have to leave, now. I am not staying here! I don't need to be here!" in angrier and louder vocal tones. Aaron too is court ordered. Bipolar Disorder type I. There is a difference between Jacob and Aaron. Aaron is a repeater, but like a weapon, Aaron can be dangerous. He has been verbally and physically aggressive. I am now on alert. So are the two large male mental health technicians on the unit. They see the escalation in Aaron's behavior and move in... not quite in time.

Code 22 is called overhead. Three loud buzzes, then "Code 22 adult. Code 22 adult. Code 22 adult," the voice from the overhead intercom says in bland tones. Like the overhead intercom in the grocery store, "Clean up in aisle three." Someone has pushed the panic button.

Staff bang through the locked doors from other units. Not quite as sanguine as the overhead intercom.

Aaron bolts down the hall racing toward the locked doors that prevent elopement from the unit. A bevy of staff follow in pursuit. Me included. Most of us are small women, we are all thankful for the men on the unit.

"Grab his arms!" Time the male tech yells at no one in particular. Aaron is a large man. Over six feet tall carrying extra pounds for a combination of age, diet and medications side effects. Though there are many staff participating in restraining him, it is remarkably quiet. Mostly force exhalations for their exertions. Spit flies from Aarons's mouth where he has six carious teeth remaining causing fetid breath.

Sarah is struck in the face. "Sh.t! Sh.t!" the expletives are out before she has time to think. She steps away from the fray. A fist, arm, head, Aaron is banging his head on the door and flailing against the staff holding him.

Sarah's eye is red. Subconjunctival hemorrhage, a break in a tiny blood vessel in the white of her eye. Ice and time, it will go away. No real harm done.

Another round of medication. His is halindole ordered by his primary psychiatrist. Rebecca runs for it while everyone else holds him. The minutes are counted for the duration of the manual hold. Something that is monitored for quality of patient care.

"Got it, just hold him for a few more. Wait! You're going to have to move so I can get to him," she huffs out of breath. No as slender as she used to be. Everyone jockeys into new positions. Rebecca moves in.

"Shot in." she says.

Aaron is held in place for several more minutes. The head banging stops. He is calmer. The staff start guiding him toward the quiet rooms. Rebecca will have to make calls to get additional staff. No one wants to pull extra duty.

All is quiet again. There are other patients on the unit who were moved to their rooms during the chaos. They are now ablet to mingle in the common areas again. Aaron is moved into seclusion and restraints. Another 1:1 observation patient.

"Code 22, all clear," rings overhead three times. everyone breathes. Chatter about assignments, hold time, documentation of events, details. Everyone talks. Nervous chuckles in relief of the adrenal rush. Sarah needs an occupational medicine visit, incident report to complete. A morass of paperwork for each event. Weights and chains making hard jobs harder.

I am again trying to complete the admission paperwork for Jacob. Then notes for Aaron before our next admission or emergency.

Marie, a young female who was admitted for delusions of being pregnant approaches the workstations. She has been requesting a pregnancy test every day since her admission. No one notices or wants to notice her. We are all busy trying to finish the impossible. Medication orders, medication passes, vital signs, group sessions for the twenty other people on the unit. Tiny Marie with her dark eyes and dark hair wearing institutional pajamas several sizes to big stands waiting.

It is some long moments before any of us looks. Finally, I do. "Mother of....God," I say not even loudly. "Marie, Marie, look at Marie!"

I am starting to move.

Everyone stops. I stop. All eyes on Marie. She is not only delusional she is a cutter. She has scars on her arms and legs. She has lacerations superimposed on scars that are in various stages of healing. And somewhere in the melee with Aaron she had found a paperclip. On a psychiatry unit a simple paperclip is a weapon. She lifts her pajama top. On her abdominal wall still dripping with blood she inscribed, NOT ALONE.

She points weakly at a corner of the hall and urinates on the floor. The smell is strong and wets her pants from her crotch down. Staff are now on the move trying to get to her while she stands wide eyed and helpless.

Jacob is awake. He is chanting, "We are not alone. We are not alone. We are not alone."

I start to say, "Another dose of zyprosamide, now."But something stops me.

It was there in Jacob's current record. The chants in the house he entered prior to his admission. I run back and look once more. There it is. He was chanting, "We are not alone." Over and over like a skipping record was how it was described. I turn back to the record from his prior admission two months ago. There it is again. Patient was nonsensical and psychotic. Stating repeatedly, "We are not alone."

From the seclusion room where Aaron now lies in his restraints is a piercing scream. Then loudly in a voice filled with terror, "I have to get out of here! Let me go! We are NOT ALONE!"

The other patients are gathering and the noise on the unit escalates. The staff stops mid efforts in cleaning and dressing Marie's wounds. The mental health technicians run from the seclusion rooms, fright etched on normally calm faces. Faces who have seen it all and not afraid of what they have seen.

All eyes are on Marie. On tiny, helpless, bleeding Marie and her pointing finger. Following, frozen, frightened.

In their restrained seclusion rooms Jacob chants, Aaron screams. In the hall Marie stands dumbfounded.

The hair on my arms stands on end, my breath catches, my heart beats hard.

I think, "Run!"