Upon reaching the ER, I had to admit that things were far from calm. A medical intern and two residents were working away. In addition, four or five attendings were there seeing their own patients. One of the nurses handed me a chart and said that this fellow had been waiting for some time; they hadn't been able to reach his private physician. I took the chart and headed for the examining room, reading as I went. Chief complaint was "Nervousness; ran out of pills." Christ! I stopped and looked closer at the chart. The private doctor was a psychiatrist; no wonder they couldn't locate him. And the patient, a thirty-one-year-old male, was in the psych room. That was back the other way, to the right. Just my luck, I thought, a psych patient. Why not a simple scalp laceration — something I could fix — instead of an inside-the-head job?
As I walked into the psych room and sat down, I faced a youngish-looking man sitting on the bed. The bed and the straight-backed chair I was in were the only two pieces of furniture in an otherwise plain, white-walled room. Both bed and chair were securely fastened to the floor. It was spotlessly clean in there, and quite bright from a bank of white fluorescent lights built into the ceiling. After glancing at the chart again, I looked at him. He was a reasonably good-looking fellow with brown hair, brown eyes, and neatly combed hair. His hands were clasped in front of him, giving the only hint of his nervousness; they worked against one another as if he were molding clay in the palms of his hands.
"Not feeling well?" I asked.
"No. Or, yes, I'm not feeling too well," he replied, putting his hands on his knees and looking away from me. "I suppose you're an intern. Isn't my doctor coming?"
I looked at him for a few seconds. I had learned that letting them talk was the best thing, but it became apparent he wanted me to answer his questions. "Yes, I'm an intern," I said, a bit defensively. "And no, we can't reach your doctor. However, I believe we can help you now, and you can see your own doctor later, perhaps tomorrow."
"But I need him now," he insisted, taking out a cigarette, which I allowed him to light. Psych patients could smoke if they wanted to; there was no oxygen in this room.
"Why don't you tell me something about what's bothering you, and either I or the psychiatry resident will be able to help." I was certain I couldn't get the psychiatry resident to come in, but I could probably get him on the phone.
"I'm nervous," he said. "I'm nervous all over, my whole body, and I can't sit still. I'm afraid I'm going to do something."
There was a pause. He was looking at me again, steadily. Although he had lit the cigarette, he did not raise it to his mouth, but held it between his second and third fingers, with its trail of smoke snaking up past his face. His eyes, wide open, showed relatively dilated pupils. Moisture glistened at the hairline above his forehead.
"What kind of thing are you afraid you'll do?" I wanted to give him all the rope he'd take. Besides, I didn't really care whether I sat there for a long time or not. The other ER problems, out in the pandemonium, would get solved without me. Served them right for giving me a psych patient.
"I don't know what I might do. That's half the problem. I just know that when I get this way I don't have too much control over what I think… over what I think. Think." He was looking straight ahead at the white wall, staring without blinking. Then he made a sudden grimace, his mouth forming a tight slit.
"How long have you been having this type of problem?" I asked, trying to break the trance, to keep him talking. "How long have you been under the care of a psychiatrist?"
At first he seemed not to hear me at all, and I was about to repeat my question when he turned toward me once more. "About eight years. I have been diagnosed as a schizophrenic, paranoid type, and I've been hospitalized twice. I have been under a psychiatrist's care ever since the first hospitalization, and doing well, especially over the last year or so. But tonight I feel like I did a number of years ago. The only difference is that now I know what is happening. That's why I need more Librium, and why I must see my doctor. I have to stop this before it gets out of control."
His insight surprised me. I surmised that he had been under quite intensive care, maybe even psychoanalysis. He was intelligent, without a doubt. Although I was a novice at this sort of thing, I knew enough to try to keep him talking and communicating. It would have been easy just to give him some more Librium and wait for it to take effect or not. But I was interested now, partly in him and partly in his ability to keep me out of the rest of the ER. In the background I picked up the wail of a screaming child. "What necessitated your hospitalization?" I asked.
He responded eagerly. "I was in college, in New York, and having some mild difficulties with my studies. I was living at home with my mother. My father died when I was a baby. Then, during my second year of college, my mother started having an affair with this man, which bothered me, although at first I didn't know why. He was very gentlemanly, handsome and pleasant and all that. I suppose I should have liked him. But I didn't. I know that now. In fact, I hated him. At first I kept telling myself I liked him. I mean I was attracted to him. I know that now, too."
I was beginning to get the picture — the same one that psychiatry had given him, a framework for his anxieties. Now that I had him started, he kept going.
"And my mother, well, I began to hate her, too, for several reasons. It was hate on an unconscious level, of course. One reason was for starting up with this man and leaving me out in the cold, and the other for keeping him to herself. I think I had latent homosexual tendencies. But I loved my mother. She was the only person I was close to at all. I didn't have many friends — never had — nor did I find much enjoyment in dating. Well, then President Kennedy was killed, and I heard it was some young guy. I was riding in the subway coming home from school at the time, and I could see the newspapers all around me: KENNEDY ASSASSINATED BY YOUNG MAN. I Was nervous, had been for days, and all of a sudden, since I was a young man, I decided, don't ask me how, that I had been the one who killed Kennedy. The next couple of days were just hell, as much as I can remember about them. I didn't go home. I was terrified that everybody was out to get me. What made it worse, people were crying everywhere. I was worried that they would find out about me being the murderer, so I just kept running, for two days, apparently, afraid of every person I saw, and, believe me, it's hard to get away from people in New York. Luckily, I ended up in a hospital. It took me almost a year to calm down, and another year of intensive care to understand what had happened to me. Then things went…"
Suddenly he stopped dead in the middle of the sentence and stared at the wall again. Then he looked at me and asked, "Would you take my blood pressure? I'm worried if s too high."
I didn't mind taking his blood pressure, but the room held no equipment. I went out for a pressure cuff, slightly dazed by the sudden, concise, and overwhelming history of a paranoid schizophrenic. On my way back, a nurse tried to give me another chart, but I waved her off, saying that I wasn't finished with my present patient.
Back in the room, my patient had his sleeve rolled up in anticipation. He was intensely interested as I put the cuff around his arm, and he tried to see the gauge when I pumped it up. His pressure was 142/96. I told him it was slightly elevated, but consistent with his agitation. Actually, I was a little surprised at its height. Then I asked him what had happened after he got out of the hospital.
"Which time?" he asked.
"You were hospitalized more than once?"
'Twice. I told you."