Mania

I'm back in Portland after 5 weeks of a psychiatry rotation in central Oregon, and am reflecting on the types of patients I saw and helped to treat. For every rotation we have a list of patient objectives that we have to fill out and return to the Dean's office, to prove that the medical school is doing it's job in getting us access to patients. For psych, this was a checklist that included patients with schizophrenia, substance abuse withdrawal and/or intoxication, depression disorders, anxiety disorders - including obsessive compulsion disorder, post traumatic stress disorder, and generalized anxiety disorder, as well as bipolar disorders (someone who has episodes of depression and/or mania). I did see patients in every category, but did not really comprehend the meaning of a manic episode until the last two days of my rotation.

The first "contact" I had with this patient came in the form of the intake coordinator coming to the psychiatric ER office and telling us about a mentally ill patient who was out in the community causing havoc, but was unable to be brought in by the police. I saw this happen many times - a patient who was psychotic, schizophrenic, or manic, would be causing some kind of trouble, but was not willing to come in to be seen. In this case, nothing can be done until the person presents as a danger to themselves or others - then they can be brought in against their will, put on a two-MD hold for up to 5 days, until they could then be treated or released, or brought to a judge for consideration of a longer term commitment.

The intake coordinator rushed into our room, needing to vent her frustration that the police were unwilling to bring in a young 18 year old who was clearing having a manic episode. They had spent over day chasing this guy, with the last attempt occurring at a porsch dealership in town where he was trying to buy a car. (This behavior meets one of the criteria for a manic episodes - a period of high impulsivity, in this case shopping). The coordinators distress was mostly due to the fact that he had threatened a medical provider the previous day, making death threats targeted against the provider and his family. This I guess, isn't even enough to get the cops involved, and so we listened to the coordinator vent.

It was only an hour later that we learned the patient was on his way, as the cops caught him trying to hot wire a car (which he hurt himself in the process, since he really did not know what he was doing - another criteria for mania - grandiosity - the belief that you are capable of things that you aren't). We cleared a path for him, and a whole gang of police and security brought him in, handcuffed behind his back, to a room where we removed everything but the mattress. The social worker and I went into his room to see if we could get some information from him about what had led up to this, and if there was any prior history of mental illness.

Trying to have a conversation with a manic patient is like trying take a breath while there is a fire hose blasting your way. He talked so fast, non-stop (called pressured speech in psych lingo), that it was impossible to get a word in edgewise. He moved rapidly from one topic to the next (distractible, flight of ideas - more lingo), and had grandiose beliefs. He could easily be a doctor (he had a stethoscope at home), and would soon learn how to fly helicopters. He was sure that if we just called his buddy Dr. So and So, he would be out of here lickity split. He had been up for 50 hours (decreased need for sleep, another criteria for mania), and was encouraging us to hurry up and do our urine and blood tests, as he had places to go and things to do. (increased goal directed activity).

I left the room thinking, textbook case mania, happy at having seen so many of the signs and symptoms of mania, satisfied that I could now easily check off the little box on my patient log that indicated I had evaluated a manic patient. How nonchalantly I initially viewed this patient's mental illness, and how quickly I would soon witness the ugliest part of mental health treatment. We went back to our safe little room, where we have video monitors for all 5 of the rooms with patients. While we waited for the lab results to come back, to do all the admitting paperwork, and to talk to the psychiatrist on call who would make decisions about how to treat this young man, we watched him in his full-blown mania in his locked room. First, he just did countless numbers of push-ups and sit-ups, then he moved onto running fast tight little laps in his painfully small room. I was like watching a struggling bug swirl around and around a bathtub drain; he moved all his limbs, running faster and faster, as if there was a hurricane inside him that he could not control. When the running was not enough, he put the mattress up against the wall, would run a few laps, and then launch himself up against the mattress covered wall. Soon this was also not enough to contain the bomb going off inside him, so he resorted to pounding his fists up against the window in his door.

As he was moving more and more closer to actually hurting himself with his agitation and physical activity, the doctor had been contacted and it was decided to give him a shot of drugs that would calm him down (haldol and ativan - an anti-psychotic combined with a benzodiazepine/sedative). To do this we had to call a "Dr. Strong" which is a well known code in all hospitals that means, "there is an uncontrollable patient, that needs to be controlled and/or contained). Health care workers are trained in how to do a Dr. Strong intervention, including how to approach and/or hold the patient in a way that will minimize risk or injury to both the patient and the health care workers. So I stood aside as 6 strong men came to the unit, and one nurse who drew up the two shots to be given once the men had the patient controlled. I stood aside to watch.

We opened to locked door to the room, and immediately upon seeing the 6 men, the young man backed up into the corner like a caged animal. He asked what was happening, and was told by the nurse that he was being given a shot of haldol and ativan to help him calm down and maybe sleep some. The look in this man's eyes was complete and utter terror. What happened next was such a blur, and over in seconds.

Instead of taking a swing at the nearest "strong man," which I understood later was a quite common occurrence, he instead launched himself head first over the bed, right in between the 6 strong men, and right towards me, standing in the doorway. Thankfully one of the nurses had caught his leg, and they were able to pull him back away from the door (and useless me), flipped him onto the bed, pulled down his scrubs, and one, two, shots were given in his buttocks. Each strong man let go of his limbs one by one, and slowly backed out the door, while the biggest nurse told him that if he got off the bed, they would use restraints to tie him to the bed. They all backed out of the room, his door was locked, and we retreated to our safe little office, where the events were needlessly recounted over and over by a group of men that were all reveed up, hearts pumping, adrenaline surging, much like the patient we had just forced two shots into.

There was nothing more tragic to me on this rotation than those events and the ones that were to follow on the following two days. This patients mania was barely touched by the medications that were given to him. He would sleep for a few hours, but then be back up running around, pounding on the windows, screaming out demands and profanity, scaring the other patients on the floor. The first night he actually escaped from his room when being given his tray of food, and immediately tore up the hallway, and one of the unoccupied patient rooms. He was like a bear in captivity, scared, enraged, and totally not able to be reasoned with. He attacked a security guard that night with a chair, had to be "Dr Stronged" for the second time in one day, and was this time strapped to his bed. I was supposed to learn the indications for the use of restraints as part of my objectives, but I can't say at all that I was happy this time to have checked off that box.

What I felt while watching this tragedy unfold, which just got even more tragic when the dad came to visit, not understanding the nature of his son's illness, screaming at us to let his son out, was a profound sense of shame. I was ashamed that we had to plummet to the means of physical restraint and forcing medications, all in the name of "protecting the patient" from hurting himself and others. I was mortified with how the men on the Dr. Strong team recounted the events, laughing when recalling the patient started crying after being slammed into a door on the second Dr. Strong. I thought to myself, is this just male machisimo? Or have these nurses and security guards been so desensitized to the suffering of others in all their years working in the psych wards. I never did answer this question, and I was happy to leave that place, to not have to sit by and watch the dehumanization that sometimes occurs within the practice of medicine.