The Man with a Microphone in his Ear takes you inside the mind of a very inexperienced, psychiatric resident. On his 2nd day of residency, he is assigned to treat a violent, psychotic man. Overcoming his own fear was just the first step…
On July 1, 1969, I entered Philadelphia General Hospital (PGH), an ancient medical fortress located at 34th and Spruce Street, to begin the first day of my three-year psychiatric residency. Residents from Drexel University School of Medicine (back then it was called Hahnemann Medical School), Jefferson Medical College, and The University of Pennsylvania School of Medicine shared the responsibility for treating thousands of inner city, mentally ill patients.
I got off the elevator at the third floor, walked down the dimly lit hallway, and stood frozen staring at the ten-foot-high metal door that led to the locked psychiatric ward. Four years of medical school and a year of medical internship did not prepare me for this moment. Nothing could have prepared me for this moment. Finally, I pushed the entry button.
“Who is it?” a scratchy voice asked through the speaker above my head.
“Art Smukler, one of the new first year psych residents. There’s an eight a.m. meeting.” What if when she buzzed open the door, I simply turned around and left? I’d find a phone on the first floor and explain my grave mistake to the chief of psychiatry. A friend had mentioned that there might even be an opening in Internal Medicine right here at PGH.
“Okay. Come in and close the door immediately behind you.” The door clicked. I sighed and stepped inside.
What struck me first was the gloom; a grayness hung in the air and obfuscated any attempt for color to inject life into the wide hallway lined with offices on both sides. The only visible window was way down at the other end of the hall, maybe a hundred feet away. Were those bars across it? Dust particles swirled and danced in the muted light, little molecules that I was inhaling. Was Schizophrenia contagious? Of course not. Nevertheless, I held my breath for an extra few seconds. My next breath was tinged with the odor of urine.
A skinny, gray-haired man, six feet tall, bald with a week’s worth of facial stubble, shuffled towards me — tiny steps, jerky and lacking any fluidity. His washed-out Temple University sweatshirt was three-sizes too large and his baggy jeans were wet in the crotch. His face was fixed-and-rigid and dribble oozed down one side of his mouth. As he shuffled, his thumb and forefinger on both hands rolled rhythmically against each other. I turned sideways and let the man pass. What was I thinking when I decided to become a psychiatrist?
A tall, stately, latte-colored woman wearing a beige sweater and a knee-length brown skirt, holding a metal chart, stepped out of a doorway and literally blocked my way. Not so hard since I was half plastered against the wall.
“You’re Doctor Smukler, Doctor Arthur Smukler,” she said with authority. Her hair was pulled back in a tight bun, each strand fully captive.
“Yeah. That’s me.”
“Fourth office on your right.”
“The meeting room?”
“Who are you?” I asked.
She stared me square in the eyes and didn’t break eye contact. I didn’t either. Finally the woman answered, “Lena, the head nurse.”
I unplastered myself from the wall and extended my hand. “Pleased to meet you, Lena.”
After a few long seconds, Lena gave me a quizzical look and her hand grasped mine, a warm, firm grasp.
“Is something wrong?” I asked. “Something I’m missing?”
She sighed and pointed down the hall. “Room 304, Doc.”
“…Thanks,” I said, and had the distinct feeling she wanted to add something, but thought better of it. Was there a secret to all this madness?
As Lena disappeared into the nursing station, an elderly woman with waist-length, disheveled, blond hair with graying roots, approached. She fluttered her eyes provocatively and hissed like a wild cat. Frozen, I nodded hello, and forced myself to keep walking. A few feet further down the hall, a middle-aged man, black-hair greasy and matted, stood against the wall. His arms were folded tightly across his stained, gray T-shirt, his eyes frozen in place, staring at nothing.
As the hair on the back of my neck stood at attention, I walked straight ahead. The schedule called for a full day of orientation before we would take over our new duties.
I entered Room 304. There were two men and a woman already seated around an empty mahogany table.
“Hi,” I said.
“I’m Wayne,” a man in his late twenties answered. He smoothed down his full beard and held out his hand. “One of the first year residents.”
“Art.” I shook his hand.
“Hey, Man,” the other guy said, smiling hello. His name was Barry. He was clean-shaven, and wore a multicolored shirt and bell-bottom trousers. “This place looks like it never left the nineteenth century. You think they unchain the inmates when the new residents start their rotation?”
“I’m Cathy,” the woman said, meeting my eyes and immediately glancing away. Cathy was at least seventy pounds overweight and wore a black turtleneck sweater and a black skirt.
At that moment, the door opened. A man, medium height, about forty, clean-shaven, boyish features, horn-rimmed glasses, and wearing a brown-tweed sport jacket and brown slacks, sauntered in and sat down at the head of the table.
“Hello,” he said, opening his briefcase. “I’m Doctor Richard Newman, call me Rich. I’m the Director of the Inpatient unit.”
We all shook hands and introduced ourselves. Rich’s smile was warm and assured. There was no evidence of anxiety or misgivings. This place didn’t seem to scare him at all.
“Obviously this unit needs some major interior decorating, like a stick of dynamite,” he said, causing all of us to chuckle and relax a bit, except Cathy. Eyes frozen on her notebook, she jotted something down.
“Unfortunately the funds to make any cosmetic changes won’t be available for at least six months, and by then you’ll all be back at the Med School’s main campus on the seventeenth floor. Which, by the way, is state-of-the-art and very attractive. Not withstanding, I guarantee that you’ll learn more here at PGH in the next six months than you ever thought possible. This is a remarkable facility and a wonderful opportunity to see as much interesting psychopathology as can be found anywhere in the world.”
No one said a word.
“Ah, my psychoanalytic intuition senses that you doubt me.”
We three men laughed again. Cathy’s frozen expression never changed as she scribbled something on her pad.
Rich smiled. “The unit here is unique in that it is set up as a patient government unit. The patients actually vote on whether they get passes or other changes in their status. Even discharge.”
“How can that be?” Barry asked. “Aren’t these people psychotic? I mean, how can they be expected to know what’s best for them if they’re–”
“Crazy?” Rich asked.
Wayne and I nodded in unison. Cathy sat writing, her jaw tightly clenched. She looked scared to death. Maybe she was the only sane one in the room?
Rich said, “We try to encourage the healthy part of our patient’s mind, the part that can make sensible, healthy decisions. Even when someone is ready to be discharged.”
We all nodded.
Rich continued. “To me psychosis is fascinating. In schizophrenia, manic-depression, and paranoia, patients often experience auditory hallucinations and beliefs that are not shared by other members of the human race. They hear voices that communicate with them and think they are being followed by aliens. A schizophrenic woman actually believed that she was the Queen of England, and no amount of logical discussion could shake that idea. However, interestingly, no-matter how crazy she was, her sensorium was intact. She paradoxically knew that even though she was the Queen of England she was also Juanita Espinosa. Parts of her mind were perfectly logical and sensible. She knew that she was in a hospital, and she knew the correct date and time. She also knew she lived four blocks from the hospital and that her phone was disconnected because she couldn’t pay the bill. It was my job to make the healthy parts of her mind work better; so she could leave here and rebuild her life.”
Rich loosened his tie, hung his jacket on the back of his chair and smiled. “We try to make everything here as comfortable and non-medical looking as possible so that patients aren’t threatened or intimidated. To that end we don’t wear white jackets, but dress somewhat casually, yet professionally.”
For the next two and a half hours, Rich described the types of patients we would be treating and the medications that were used to treat them – anti-psychotics, antidepressants, tranquilizers, and a new drug called Lithium Carbonate. He hoped that we’d get approval to use it sometime before December, in less than four months.
Hmm. In one morning, I learned more about the mind than I did in four years of medical school. Dr. Newman’s explanations helped me see a rhythm to things, a sense that all wasn’t chaos and craziness. Having someone confident and articulate to guide us, made me feel that my instincts to become a psychiatrist might have been right.
After lunch, Stanley Gerber, a second year psychiatric resident who was scheduled to show us how patient charting worked, burst into the conference room.
“Jerome, a paranoid schizophrenic, is out of control,” he said, standing in the doorway, his eyes darting first at us, then back towards the ward, then back at us again. Stanley’s blond hair was disheveled and his blue eyes couldn’t find a place to rest. “He was admitted last week after refusing to eat, shower, or leave the house. Before that happened he was walking around with a hunting knife and saying that people were trying to get him. He thinks we’re all out to get him and hears voices that curse and call him names. He’s on large doses of Thorazine, an anti-psychotic tranquilizer that we use a lot of up here. I need your help.” With that last statement, Stanley motioned for us to follow him.
We followed our new leader down the hallway, past the offices (each one dark and small, maybe eight feet by six feet and furnished with a metal desk and two chairs), past the cafeteria (a washed-out green room with eight wooden tables that seated six-to-a-table), and stopped in front of the dayroom. A woman wearing a gray blouse and a long black skirt with red stains on the front, squeezing an orange so hard that the juice squirted all over the floor, smiled and squeezed more juice on the floor. A skinny man with a scraggly beard moved out of our way muttering, “Bullshit, bullshit, bullshit.”
The dayroom was a twenty by twenty-foot room, painted the same green color as the cafeteria. It was furnished with two, worn-fabric couches, a dozen assorted wooden chairs, a battered, brown piano, and a TV console on the far wall. An afternoon soap was on with the sound turned off. Stanley took a syringe out of his sports jacket pocket and removed the plastic needle guard.
Wayne shook his head and mumbled a not so quiet, “Jesus.” Cathy was nowhere to be seen. “This syringe contains two-hundred milligrams of Thorazine,” Stanley said, trying to educate us in a pseudo-brave tone. “If we all approach Jerome together, he’s less likely to lose control.” This strength in numbers didn’t seem all that logical to me, but what did I know…
“Why can’t the nurse give him a shot?” Barry said, his voice an octave higher.
“Where’s Dr. Newman?” Wayne asked.
I was thinking exactly the same thing.
“He’s not here,” Stanley said. “Believe me, it’s really not a big deal. A few months on the unit and you’ll understand exactly what I’m doing. It’s right out of Psych 101.”
We took a few more steps into the dayroom. Jerome, a tall, stocky, black man, was standing in front of the piano glaring at us. He wore a pale-blue work-shirt and beige, corduroy pants. Beads of sweat dripped down his forehead. The room was empty except for Jerome and Stanley’s merry band of idiots. A dozen patients stood in the hallway watching us through the glass window. Holding the syringe behind his back, Stanley approached Jerome.
“Jerome. It’s me, Doctor Gerber,” Stanley said, inching closer and closer to Jerome — fifteen feet, ten feet, three feet. Stanley moved his hand from behind his back.
“You’re not goin’ to shove that thing up my ass!” Jerome bellowed, his eyes narrowing. In one smooth motion, he picked up the piano stool and smashed it against the top of the piano. The stool slid halfway across the room leaving him holding two of the legs high above his head.
“Jerome, calm down,” Stanley said, quickly backing away, knocking into Wayne, who tripped and almost fell down. “I’m your doctor, Doctor Gerber,” Stanley croaked as he kept backing up. Jerome, body covered in sweat, swung the piano legs like propellers over his head. I lowered my head and moved backwards.
“Lying fuck! You’re no doctor. Gerber, fuckin’ Gerber peas or beans or baby shit or whatever the fuck Gerbers are or whoever the fuck you are. None a you is anything but a lying fuck!” Jerome ran towards us, swinging the piano legs like clubs.
We all scattered, Stanley and Wayne ran into the nursing station, Barry and I ran down the hall towards the patients. Jerome stood in the middle of the dayroom violently swinging the wooden legs, screaming, “Leave me alone. I hear you. I hear what you’re trying to do. No Gerber’s going to fuck me up the ass!” Standing next to me, the woman who had squeezed orange juice all over the floor stood frozen in place, her eyes shut.
The man who I had seen shuffling down the hall when I first entered the unit stood very still, except for the pill-rolling movements of his thumb and index finger on both hands. His face looked like it was carved in wax.
Three security men dressed in khaki shirts and pants, nightsticks strapped to their belts, strode into the dayroom and surrounded Jerome.
“Fuck you, assholes!” Jerome screamed, staring at the three men, swinging the piano legs faster and faster. “Fuck you! Fuck you! Not me! Fuck you, you pieces of Gerber-shit!” Spit flying, he charged the security man closest to him, who backed away outside the reach of the piano legs. The other two men approached Jerome from his back. Jerome spun around. Before he could cock the piano legs, the first man tackled him, and the other two men grabbed his arms and legs. Jerome screamed like a bull elephant. “No! No! Fuck you! Fuck you!”
At that moment Lena, like a powerful lioness, bounded out of the nursing station holding a syringe. She knelt and injected Jerome in his thigh. They all continued to hold Jerome down on the ground until two aides rolled a gurney into the room and lowered it. The guards and the aides moved Jerome onto the gurney, strapped down his arms and legs, and put another strap across his waist. They raised the gurney and rolled him away.
Minutes later it was as if nothing out of the ordinary had happened. The patients wandered back into the dayroom, some sitting down on the sofas and staring at the television, a few just sitting and staring into space. One picked up a magazine, holding it upside down, and staring fixedly at the pages… Just another average day on the patient government psych unit where every patient has a vote.
If this intrigued you, check back for the next episode. There are four.
Art Smukler MD is also the author of Chasing Backwards, a psychological murder mystery and Skin Dance, a mystery. They are available as paperbacks and eBooks.