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…
Following my fellow first-year residents, I walked back into the consultation room and sat down. We looked at each other and started laughing hysterically.
Minutes later Stanley opened the door, looked at us and shrugged.
“Psych 101?” I said, as we all continued to laugh. Gerber joined in. With Jerome locked away, we could afford to laugh as long as we wanted.
”Gerber, what was that all about?” Barry asked.
“Honest, that never happened before,” Gerber said. “I swear. Over the last six months no one ever threatened us, or threatened me. It’s the truth.”
“Explain again the purpose of all of us following you,” I said.
“Containment. Honest, I’m not a death-seeking masochist. Often with paranoid patients, if they know there are limits, it helps them keep their internal controls more in check. When a patient is psychotic and out of touch with reality, having a few visible staff members to set limits can be very helpful. In spite of what just happened, and the fact that Jerome saw us as a threat rather than a calming force, this meltdown is the exception rather than the rule. The ward is really a fine place to learn. An amazing place.”
Stanley stretched his neck to the right, then to the left. “We don’t have much time, because tomorrow I start my rotation back at the medical center; so let’s go over writing orders and charting, both of which are very straightforward.” Twenty minutes into Stanley’s explanation, it registered in my over-stimulated mind that Cathy was gone. She never did return, at least to our program.
When that first day ended I was hooked. I was exhausted and overwhelmed, but psychiatry was beyond anything I ever imagined. Voices, delusions, the madness that drove people over the edge into insanity were absolutely fascinating. I wanted to be around when we got to discover how to help these people.
* * *
The next day Jerome was assigned to my caseload and all my misgivings resurfaced.
In the nursing station, I read Stanley Gerber’s notes about Jerome Cotton.
He was a fifty-year-old man who worked full-time as a cook for the Philadelphia School District, married twenty-seven years to the same woman, and he had a sixteen-year-old son and a twenty-year-old daughter. There were no serious illnesses, no history of prior psychiatric treatment, and no family history of mental illness except for a brother who drank too much.
Lena walked into the nursing station, hair still in a tight bun, and dressed in a black sweater and a gray skirt. She replaced a dozen metal charts on the rack. I smiled hello and a brief flicker of a smile crossed her lips. Lena was a bit odd, but there was something about her that appealed to me. I turned back to the chart.
One week ago Jerome’s wife, Victoria, a first grade school teacher, called the police because for five days Jerome had refused to eat, shower or leave the house. He talked about people trying to get him and walked around with an old hunting knife strapped to his belt. She said Jerome had never, in the twenty years she had known him, been violent or acted this way. She thought the problem might have started four months ago when their son Clyde was picked up for using marijuana and cutting school. Jerome became preoccupied, less communicative, and would sit for long periods of time in their den with the lights off. Victoria begged him to get medical help, but he refused. On one occasion, Jerome screamed at his son, threatening to knock his head off. Victoria reported that that kind of behavior was definitely out of character, because Jerome was always a kind and gentle man.
Mute and paranoid, Jerome was brought to the hospital in an ambulance. He allowed the Emergency Room doctor to do a physical exam and to conduct an extensive workup. The physical exam, blood tests, chest film, skull x-rays, and EEG were all within normal limits. When Stanley first evaluated Jerome, Jerome glared at him with obvious mistrust, mumbling curses under his breath. Stanley’s presumptive diagnosis was Schizophrenia, paranoid type.
My supervision session with Dr. Newman wasn’t scheduled for two more days. I guess I could call him, but hesitated. Running to Daddy didn’t seem appropriate. Remembering how confident Lena had been when Jerome went berserk, I took a deep breath, walked over to where she sat writing in a chart, and sat down next to her.
“Lena, any suggestions about Jerome? I guess I drew the short straw.”
“The short straw, huh?” She smiled and then laughed.
“What’s so funny?”
“I’ll tell you sometime. Maybe when I get to know you better.” She took a sip of her tea. “There’s always fresh coffee brewing and hot water for tea. Feel free to help yourself. We all pitch in a buck every week.”
“Thanks, count me in.” I put a dollar in a small metal box and poured myself a cup of coffee.
Lena said, “Chances are Jerome was cheeking his meds.”
“Not swallowing the pills. Paranoid patients are like chipmunks or squirrels. They hold the pills in their cheeks, swallow the water, and as soon as the nurse leaves, they spit the pills out. Paranoid patients don’t trust anyone. Jerome probably thought we were trying to poison him and incorporated us into his delusion. It’ll take a few days of intramuscular injections of Thorazine for him to come around. I’d recommend giving him lots of space until the meds start to work. Yesterday, Doctor Gerber did exactly what he shouldn’t have done.”
“You mean when we all cornered him?”
Lena nodded. “He was already too far gone. You corner anyone that paranoid you need a way to keep him from hurting anyone or hurting himself.”
“What would you have done?”
“Tried to gently talk him into getting a shot to take away the fear in his heart, and if that failed I would have called security.” Lena chuckled. “You boys were a sight to see.”
I laughed. “The thought that went through my mind was the Four Stooges. Thank you.”
Lena smiled. I picked up the chart, left the nursing station and walked over to Jerome’s room. Part of me was petrified, while the other part was immeasurably intrigued.
Dressed in a white hospital gown, Jerome lay face up on his bed, ankles and wrists bound in leather restraints. He hadn’t shaved for days and stared straight up at the ceiling. When he saw me he pulled hard against the leather straps, groaning with exertion. A sheen of sweat covered his dark forehead. His eyes held a mixture of pain, fear, and something very primitive.
How was I possibly ever going to treat this man? What do I say?
As I stared into his eyes, my thoughts drifted back to what Lena said about trying to take away the fear in his heart. Jerome scared me, and at the same time he looked so vulnerable.
An old memory drifted into my mind. I was four years old and in a car driving with my parents. It was early in the morning and I remember sitting in the back seat and asking them where we were going. They said we were going to a store to buy electric trains. I wondered why we were going when it was dark and why I was still wearing my pajamas. My father parked the car and we walked to a one-story building and went inside. We entered a large room that had chairs lining two walls. My parents spoke to a woman behind a desk and I played on the floor, a cold linoleum floor — black and white squares — pretending I had a train engine in my hand and choo-chooing the train from one end of the floor to the other. When are we getting the trains? I asked. My mother told me that we’d see them in a little while, but didn’t look at me.
Sometime later, the door next to the desk where the woman sat opened and two men dressed in white walked towards me. I looked up at my parents. “Where are the trains?” The men grabbed me and wrapped me in a sheet. “Where are the trains?” I screamed, looking for my parents. They weren’t there. I was alone, screaming, wrapped in a sheet. I couldn’t move. There were no trains. Only the two men. As I screamed, they carried me into a very cold room and tied me to a table. Another man wearing a green mask put something over my face. I couldn’t breathe! The man was trying to suffocate me.
The next thing I remembered was waking up, my throat on fire, and a nurse telling me what a brave boy I had been and that I had beautiful eyes. What did beautiful eyes have to do with any of this? Who cared! My mother came in the room and fed me some ice cream. She said how lucky I was to be in such a special hospital and that I could have all the ice cream I wanted. Later I learned that a doctor had taken out my tonsils, whatever tonsils were.
My parents had lied to me and abandoned me. Without explaining a thing, they let the men wrap me in a sheet and tie me to a table. If I were bigger and stronger and older, it wouldn’t have happened. There would have been a war!
I looked down at Jerome and for the first time really understood. The poor guy was staring at the ceiling; sweat beading on his forehead. Was being psychotic any different than being little and confused? In both of those states, there were things that were beyond understanding.
“Hello, Mister Cotton,” I said, standing at the foot of the bed, holding the metal chart under my arm. “I’m Doctor Smukler. Doctor Gerber was transferred to another hospital and I’m taking over for him. I’m your new psychiatrist.” Slowly, I walked towards the head of the bed and stood next to him.
Jerome glanced briefly at me, struggled against the restraints, finally gave up and stared again at the ceiling.
I put my hand on his shoulder for a moment. Yesterday he scared the hell out of me. Now, at this moment, I was still scared, but more than fear was a sense of empathy. “Mister Cotton, I was hoping you could tell me why you’re here; so I can try and help you.”
Just silence. He continued to look at the ceiling as if I didn’t exist.
I pointed to the chart. “Doctor Gerber wrote that you hadn’t been doing well for a number of months, something related to your son using drugs and not attending school. Your wife said that his behavior upset you very much. A short time later you started thinking that people were trying to hurt you.”
There was no response.
“No one will hurt you here. This is a hospital and I’m a doctor. It’s my job to help people.”
Jerome’s unblinking eyes continued riveted to the ceiling. I looked up. He was staring at a heat register.
“Mr. Cotton, I think you’re looking at a heat register, but since it’s July the heat isn’t on. This hospital is so old they don’t have air conditioning. It was built a long time before either of us were born… Are you hearing voices? Maybe voices coming out of the duct?”
Jerome’s eyes flickered but stayed focused on the register. Voices were definitely a lot more interesting than my amateurish monologue.
“Mister Cotton, hopefully the medication will start to work and you’ll feel better, not so frightened. The medicine, Thorazine, is to help with the voices you might be hearing and the thoughts that everyone is trying to hurt you. Yesterday you were so frightened you became violent. When you feel better, I can take you out of the restraints. That’ll help I’m sure. Being tied up can’t be easy.”
Jerome just stared at the heat register, my words as impressionable as the summer breeze hitting the side of the building. I left his room, went back to the nursing station, and noted on the chart what had transpired.
* * *
The next morning when I walked into Jerome’s room, he still lay face-up in bed in full restraints. The restraints would stay on until I wrote the order to have them removed.
“Good morning, Mister Cotton. It’s Doctor Smukler, your psychiatrist,” (the guy who has no idea what to do next and is afraid he’ll never have the guts to take off your restraints). “Remember? I saw you yesterday morning.”
“Why do you have me tied up?” Jerome said, moving his body, trying to pull his arms and legs out of the restraints. The tone of his voice was more confused than angry. Whoever invented Thorazine was a genius.
“Three days ago you became violent. You smashed up a piano stool and came running after the staff with the legs. You’re in restraints to protect yourself and any other people you might attack. You scared everybody. You’re a big guy and in great shape. We had to have three guards come up to the unit and hold you down.”
“I don’t do things to hurt people. You can ask my wife, Victoria. She’ll tell you.”
I nodded. “She said before all this started, you were a very gentle man. She said that nothing like this has ever happened before. Not in all the years she’s known you.”
“Mister Cotton, do you know where you are?”
He looked at me and stretched his head so he could see outside his door. Only the hallway was visible. The ward, a large room with two lines of ten beds was twenty feet further down the hallway. When Jerome became violent he was transferred to this sparse room with only a bed. The theory was that less was better because it was safer. No objects to throw or to use to harm oneself. “It looks like a hospital, an old hospital. Why am I in a hospital?”
“Why do you think?”
“You said I tried to hurt people?”
“How about before that. Do you remember anything regarding why you’re here?”
“An ambulance. I remember that.”
“Do you know why the ambulance came and took you here?”
He shook his head. “Where am I? What hospital?”
“I’ll tell you, but first can you tell me the date and who you are?”
“The date? July. I know it’s July. The summer of 1969.”
“Good. That’s right. How about who you are?”
I nodded and smiled. “You’re in PGH psychiatric ward, Philadelphia General Hospital. Your wife became concerned because you weren’t eating or showering and you thought people were trying to get you.”
“They are doctor. There’s no way I can forget that.” He struggled against the restraints. “They’re still tryin’ to get me. Do I have to stay tied up? I’m no criminal. My arms and hands feel numb.”
“I can’t let you out until I’m sure you won’t hurt anyone.”
“I never hurt anyone, Doc. I don’t do that.”
“You don’t remember when you smashed the piano stool and were swinging the legs over your head running after us?”
Jerome looked up at the heat vent, then back at me, and shook his head.
“Mister Cotton, the way you’re acting, it seems like you’re hearing voices.
Jerome just kept staring.
“What are they saying?”
Jerome took a deep breath and licked his lips. “They’re goin’ to get you. Watch out. They’re goin’ to get you.”
A shiver went up my spine. “Who’s saying these things?”
“Do you know this man?”
Jerome shook his head.
“What does he look like?”
“Like a man.”
“Can you describe him?”
Jerome shook his head.
“Not at all?”
“Just a man.”
“Does the man say you should hurt people?”
“What if he tells you to hurt people like he did three days ago? Then what?”
“What do you mean?”
“I mean what will you do?”
“I don’t hurt people. I don’t do that.” He looked back up at the ceiling. Did I dare release him? Would he go berserk again? Yet, leaving him tied up seemed so inhumane.
“Mister Cotton, you have to help me. I can only untie you if I’m perfectly sure you won’t hurt anyone or hurt yourself. That makes sense, doesn’t it? The rule is that we have to do everything to keep you safe and keep every other patient in the hospital safe. I don’t want anyone to hurt you, and I don’t want you to hurt anyone. Including me. I don’t want you or me hurt.”
“Doc, I won’t hurt anyone.”
“Is that a promise?”
“Yes, Doc.” Jerome looked me square in the face. “I promise.”
“What if the voices tell you to do something destructive?”
“Doc, I gave you my promise.”
“We still need to give you medicine. Do you promise to cooperate with the staff and not give them a hard time?”
He nodded again.
“Okay, Jerome. Here’s what I think. I’ll untie you and we’ll take a walk. Then we’ll see how you do and whether I need to put the restraints back on. Okay?”
Jerome just kept looking at me, his eyes wide and pleading.
I walked around the bed and unbuckled the first ankle restraint. He moved his leg and I almost jumped backward. Then I unbuckled the second ankle restraint. For a moment I hesitated, my hands lingering above the left wrist restraint. Jerome was fifty pounds heavier than I and was strong, very strong. Shouldn’t I get someone from nursing to help me out? Maybe I should call Doctor Newman? I leaned across the bed and unbuckled the left wrist restraint. Jerome flexed his hand and stretched his fingers. Finally, I unbuckled his right wrist and stepped back from the bed.
“Mister Cotton, sit up slowly, and give it a minute before you stand up. You’ve been flat on your back for three days, and I don’t want you to faint from low blood pressure.”
Jerome rubbed his wrists; then rubbed his left arm and his right arm. Slowly, he swung his feet off the side of the bed and sat up. Bracing his hands on the mattress, he put his feet on the polished cement floor, waited, and stood up. Even though he was only a few inches taller than me, he was very broad. Jerome would have made a formidable linebacker. Maybe he played football in high school? Slowly, the two of us walked out of the room and headed down the hallway.
Check back for episode 3.
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.