ER, For Real

Paul R. Linde is Clinical Professor of Psychiatry at the University of California, San Francisco. He’s also worked in a psychiatric emergency room. He tells of his time in the ER in his new book Danger to Self: On the Front Line With an ER Psychiatrist. The San Francisco Chronicle said, “Linde’s fast-paced but well-detailed accounts supply the wild, loud, chaotic, smelly and dangerous but also mostly moving ‘scripts’ that could easily be a TV show.”

Here’s an excerpt from the first chapter of Danger to Self: On the Front Line With an ER Psychiatrist:

My first night at work is an unseasonably warm evening in the summer of 1992. The customary layer of fog has not yet descended on the city. The psych emergency room is stuffy, the ventilation poor, the ceiling’s air vents clogged with lint and dust. A faint whiff of fresh feces and old urine, ineffectively masked by a cloying cinnamon-scented spray, hangs about the place. It is then that I understand why state hospital psychiatrists smoke cigarettes on the job–to cut the stench.

Though I had worked there for a week as a fourth-year resident just a few months earlier, this is my initial performance as an authority figure in psych emergency. At this point, I haven’t worked a shift yet. I had just returned, lean and refreshed, from a month’s holiday spent traveling with my wife in a 1984 Volkswagen camper van through the Pacific Northwest and the Rockies. I had enjoyed an invigorating taste of freedom on this trip, and now I was beginning my career on a lockdown. Though I was getting paid for my time and had chosen this vocational path, I was still working in a place for which a key was required to get out.

Suddenly, a rather large, unkempt man, a scowl on his face, stumbles out of one of the four seclusion rooms and ambles to the desk.

“What do you want, George?” asks Christina.

“I need to take a piss.”

“Get back in that room, or we’ll have to tie your ass up and give you a shot.”

“But I need to go real bad.”

“Get back in there. I’ll bring you a urinal.”

“I want to pee in a fuckin’ toilet, not a fuckin’ bottle.”

“Get back in there, George. Now.”

“Fuck you, you slanty-eyed bitch,” he says as he comes half-lurching, half-lunging toward the desk.

“Staff!” yell the nurses.

“For that,” Bo says, “he’s going into points.” The shorthand points is emergency room slang for the four points at which a patient’s extremities are attached via restraints to a bed bolted to the floor of a seclusion room. I’m not sure, when Bo says “that,” whether he’s referring to the menacing stance or the racially charged barb or the whole package.

Since I am not officially on duty and am new to the place and generally inexperienced, I step back. Three staff members rush to the scene and grab George by the hands and around the waist and escort him roughly to his seclusion room, where he lies down on the bed without a struggle. “Do we need to call IP?” asks one. At the time, the hospital was staffed by bona fide San Francisco institutional police officers, whose station was next door. We called them often.

“Nah,” said Christina as she deftly encircles one of George’s wrists with the belt loop of a leather restraint. All four of George’s extremities are now strapped by restraints. Seemingly accustomed to this routine, George lies passively, his body supine on a clean white sheet.

“George, why did you have to go and do this?” asks a psych tech. “You’re gonna get a shot now, too.”

“Yeah, but I’m allergic to Haldol.”

“Sure, George, sure.”

A nameless, faceless doctor wrote the order for restraints and Haldol. Or maybe he just signed an order that the nurse had written herself on an order sheet. That was standard operating procedure in those days. Sitting in the staff room would be some MD who was happy to sign whatever order was placed in front of him. Technically the restraints could not be applied, and an injection could not be given, without a doctor’s order. But who was really calling the shots?

This process was bluntly dubbed “shoot first and ask questions later” or simply “tie ‘em up and shoot ‘em up.” It was also called “let ‘em prove to us that they’re okay to come out of restraints.” The burden of proof lay with the patient. It might seem like a pathological need on the part of both nurse and doctor to control things, but the process of restraining and medicating a psychotic patient becomes a necessary and therapeutic step in the patient’s treatment. Giving truly ill patients sedatives and antipsychotic medications allows them a chance to regain a piece of sanity–to tamp down anxiety, hallucinations, and paranoia.

George receives a large injection, the solubilized medications mixed into a single syringe and delivered via an eighteen-gauge needle into the upper outer quadrant of his left buttock, where the thick muscle can soak up all those good tranquilizers and get them on their way to his brain. Venous capillaries absorb the drug, the blood then transports it via circulatory branches to the inferior vena cava, upward to the right atrium of the heart, down to the right ventricle, then to the lungs to pick up oxygen, back to the left atrium, and then down to the left ventricle, which ejects the blood carrying the drug into the ascending aorta and carotids into the brain.

George’s brain, with its dopamine, histamine, benzodiazepine, and GABA (gamma-aminobutryric acid) receptors receiving the signals, decelerates to a resting pace. Not down for the count, mind you, but it descends to a mild snooze. The blockade of the dopamine receptors in the limbic system begins to dissolve the man’s psychotic symptoms. Biologically, it’s complex. Phenomenologically, it’s a cakewalk: man goes to sleep crazy; man wakes up calmer, if not saner.

As I was soon to discover, the medication process was perpetuated because Christina and a few of her peers had become pretty talented mental health clinicians by dint of their experience. And, of course, she was someone to be, if not feared, then at least approached with some caution. By then, several of my physician colleagues were streaming past me toward the meeting room. “Thanks for the doughnut,” I say. “You know, Bo, this place reminds me of a bitter and twisted summer camp, and we’re like the counselors.”

“Oh, yes, honey, you are so right,” he says.

“Or maybe something like a twenty-four-seven casino, and we’re just like the blackjack dealers or the floorwalkers.”

“It is kind of like that,” says Bo. “And much, much more. You just wait and see, girl.”

When I leave the meeting an hour and a half later, I see George the patient careening around in front of the triage desk, none the worse for wear. He has slept off his injection, and I’m sure a psych tech helped him pee into a urinal while he was in restraints. (They wouldn’t let him piss himself in points. They weren’t that mean.) And, frankly, it seems that George has woken up from the shot much less irritable and at least a bit less crazy. It did him no harm.

Dr Paul Linde will be Sunday, February 21, at 4:00pm. Details are here.–David E