Two attendants held the patient on his side, pants drawn down, while she gave him the injection. The graveyard shift would be coming on shortly, and they had work to finish before they could go off. Marlowe observed the familiar ritual in silence, studying his patient’s reactions.
“Just make sure his blood pressure doesn’t drop out,” he told them. “I’ll write out orders for another 100 IM PRN q 4 hours, if this doesn’t do it. I’ll finish my examination once he’s quiet.”
“Thank you, Doctor.”
Marlowe’s beeper summoned him while he was writing orders. “That’s North Unit. Could you dial that for me, please?” He took the phone from the attendant and wedged it under his chin; one hand holding a Styrofoam coffee cup, the other scribbling an admission note.
“Dr Marlowe, we have an unauthorized absence from North Unit. The patient is Billy Wilson. He is an involuntary admission.” Marlowe sipped his coffee. “Chronic schiz from Jefferson County? I’ve had him on my service a couple times. Better call the family and local sheriff. He usually hitches a ride home and tells people he’s on the run from the CIA.”
“We also have a voluntary admission here to see you.”
“What’s his problem?”
“He says he’s depressed.”
“I’ll get over to see him when I can.”
Marlowe finished his coffee and the conversation, placed cup and receiver in appropriate niches. His beeper wondered if he might phone the ARU. Marlowe thought he might.
“Dr Marlowe, we have three unauthorized absences.”
“These are…?”
“Two voluntary, one involuntary. Jimmy Roberts and Willy Wilbertson from Adams County are voluntary; Freddie Lambert from Tarpon is involuntary.”
“Those first two always check back in together as soon as they’ve gone through their Social Security checks. Lambert usually winds up under a bridge with a gallon of skull-rot; better notify family and sheriff on him.”
He finished his admission notes, looked in on Stallings.The new admission was still raging against his restraints; shrill obscenities penetrated the seclusion room door. “Another 100 mgm Thorazine IM stat, I think,” Marlowe decided. “I’d like a quiet night.”
It was past midnight when Marlowe made it back to North Unit to interview the voluntary admission. As he sought to leave the nurse’s aide on South Unit had delayed him with a question about Dr Kapoor’s medication orders; the Pakistani resident had been eight weeks in the US and six weeks on South Unit, and still hadn’t discovered the distinction between q.i.d., q.d., and q.o.d. when writing medication orders. Marlowe made hasty corrections, ordered stat lithium levels on one patient, and swore a little.
The graveyard shift came on at eleven, and no one knew anything about his voluntary on North. The same, seated beside a flight bag in the office area, regarded Marlowe with politely contained anger.
He wore Nike running shoes, Levi jeans, and an Izod knit shirt, all of it just starting to slide past the comfortably well-worn stage. His beard had reached that scraggly sort of seediness that usually breaks the resolve of its wearer and brings the razor back out of the medicine cabinet. The black hairline was beginning to recede, but there were no flecks of grey. He had a complex digital watch toward which he pointedly glanced. The eyes behind the designer frames were red-rimmed and puffy, despite the effort of the tinted lenses to mask them. Marlowe guessed him to be a grad student or junior faculty from the state university campus at Franklin, some thirty miles to the north, and he wondered why the patient had not availed himself of the posh psychiatric unit at the medical school there.
“Hello, I’m Dr Marlowe. Sorry to keep you waiting.”
“Frank Carnell.” The handshake was accepted, but weak. “Would you care to step into my office, Mr Carnell?”
Each unit included an interview room for the on-call physician; however, as North Unit’s attending, Marlowe had an office of his own on the unit. He ushered his patient into the cheap vinyl-upholstered chair beside his desk and eased himself into the often treacherous swivel chair behind the expanse of pea-grey enameled metal littered with manila chart folders. The office furnishings were state-purchase, some of them going back to Graceland’s army camp days. A filing cabinet and a pair of unlovely metal bookcases of brownish-grey enamel housed a disarray of books, journals and drug company handouts. There was also a couch of cracked brown Naugahyde, a coffee table, two folding chairs, and a spindly rubber tree leaning against the Venetian blinds. Overhead fluorescent lamps hummed behind acoustic ceiling tiles and made all too evident the yellow wax-stains on the uncarpeted floor of worn asbestos tile. One wall boasted a plastic-framed imitation oil of a mountain landscape that might have been discarded by a Holiday Inn, but Carnell was devoting his attention to the framed diplomas and certificates that completed the room’s decoration.
“Impressive credentials, Dr Marlowe. I had the impression that our state hospitals were staffed entirely by foreign medical school graduates.”
“An exaggeration. I’m not the only American-educated psychiatrist here at Graceland.” There were, in fact, two others.
“From what I’ve seen, it makes me wonder what a psychiatrist of your training is doing here at Graceland State?”
“I think the question more properly, Mr Carnell,” said Marlowe evenly, “is why are you here?”
Carnell’s eyes, behind the tinted glasses, shifted to his chewed fingernails. He fidgeted with the flight bag on his lap. “I suppose you could say I’m depressed.”
“Depressed?”
“I haven’t been sleeping well. Can’t fall asleep until the late late show and half a bottle of vodka; sometimes I need pills. I wake up before dawn, just lie awake thinking about things that keep running through my mind. Tired all the time. No appetite. No energy. Used to jog to my classes; now I just cut them and lie about the apartment. Haven’t been able to study in weeks.” Carnell spoke slowly, and Marlowe sensed tears.
“When did all this begin?”
“This spring. I’m in journalism at State, trying to complete work on my doctorate before the funds all dry up. My wife said she’d had enough of floating around the secretarial pool to pay the bills while I played the eternal student. She’s shacked up with her old boss from central accounting, and the divorce is pending. I haven’t been able to adjust to that. My performance has been on the skids — I’m supposed to teach a class during summer session, but I’ve missed so many my students don’t bother either. I’ve been called on the carpet by the department twice. I’m broke, in debt, and now my fellowship has been canceled. It’s just that no matter how hard I try, it just keeps getting worse.”
Marlowe waited while Carnell worked to control his voice. “Mr Carnell, I certainly understand that you have good reason to be undergoing a great deal of anxiety and depression. However, since this appears directly related to your present life situation, I feel confident that this disturbance is a transient one. This is a painful crisis in your life, and I appreciate the profound distress you are experiencing. Under the circumstances, I definitely agree that you need professional counseling; however, I believe you would far better benefit from outpatient counseling rather than hospitalization at this time.”
Carnell fumbled with his flight bag. “Am I to understand that you are refusing me psychiatric care?”
“Not at all!” Marlowe had seen patients produce knives and an occasional handgun from unscreened personal belongings, but he doubted that Carnell was likely to turn violent. “I very strongly urge you to accept professional counseling. In my opinion you will derive considerably greater benefits through outpatient therapy than as a hospitalized patient here at Graceland.”