Scenes from the Psych ED

The psychiatric emergency department is not where you want to end up. Yes, it’s an essential piece of every big hospital, but it’s not a happy place. mental illness — often silent, minimized, and neglected — can become so severe that it bursts forth conspicuously from their brains and force the people into involuntary incarceration. The Psych ED receives these people and gathers them in one confined space.

Here, let me describe it.

A young healthy dude in his 20s requests to be brought in because he’s been increasingly anxious for the past week. No panic attacks, but the low-grade worry is bothering him. As he walks in, the door swings closed and locks automatically. It has a funny-looking smooth metal self-injury-proof handle on it. The only ones holding keys are the four security guards: giant muscled men averaging 6’2” and 250 pounds each, clad in matching blue uniforms. The only other door out leads into the nursing station, which peers into the hall of patient rooms from behind thick windows. Immediately his senses are assaulted, and he realizes his voluntary entrance into this place was probably misguided.

Three of the security guards are surrounding a man in a folding chair with his hands handcuffed behind him. They’re trying to convince him to change his shirt and pants voluntarily before they force him to “do it the hard way.” The disorganized man flatly chants “No, I don’t want. No. I don’t want.” The guards pin him into four-point restraints and do it the hard way.

Peeking out of the last room, there’s a disheveled man yelling incoherent obscenities in a coarse rattling voice. Instead of papery blue scrubs, dressed in tattered jeans and wool blankets he’d look like that homeless man who yells incoherent obscenities from the street corner at night. Actually, he is that guy.

Another room reeks of feces, urine, and the indescribable stench of dreadful hygiene. There’s a man picking at his butt and painting on the wall with his poop. After all they’re not allowed pens so he had to be creative with his medium of expression. Drool is dripping off his beard onto his blue scrubs, and his pants are moist in other places too. Needless to say, he’s floridly psychotic.

Next door is a manic woman pacing back and forth energetically, badgering the nurse to see the head of the hospital. She insists she knows her rights and that staff is breaching them, that she’s close friends with many famous and influential people, and that we will pay dearly — now much verbal degradation and later with deluges of litigations — for our defiance of her will. No one else can eke in a word to calm her down.

The anxious guy feels his anxiety building alongside other emotions like astonishment, fright, bewilderment, and sympathy. “Uhh… actually, can I leave??” No, sir, you cannot. Sorry. You need to change into blue hospital scrubs. The psychiatrists need to evaluate you, then obtain collateral information from people who know you. These are the rules.

Thankfully, not every patient is so intrusive. One gal’s paranoid that her room is bugged, so she maintains willful silence. One guys’s so psychotic he believes he’s mute. One guy’s so intoxicated that he’s sleeping through a chemically-enhanced slumber despite all the clamor outside.

Meekly hiding in a quiet room is the suicidal college student. On her disturbingly slender arms are fresh bandages from her moment of despair the previous day. In front of her is a tray precisely half-eaten — a banana sliced neatly in half, a yogurt cup peeled back halfway, juice poured into a clear cup to be painstakingly measured.

There’s actually a person who prefers it here. The malingerer, whose face is all too familiar to the staff, has memorized the right phrases to delay his discharge for as long as possible. In truth, no one wants to imagine the horrid conditions of his normal circumstance.

Well, there is one man whose apparent normalcy seems out of place. He is annoyed by his current detention, but in the meanwhile offers tales about his great job on Wall Street. He admits to drinking a little bit too much for the week, but it’s part of the corporate culture, and he’s been clean for 2 years anyway. Then his narcissistic deception is slowly unraveled. Too much means liters of whiskey daily. He’s been in the medical ED for acute alcohol withdrawal and intoxication 7 times in 2 weeks. He was in prison for the last 2 years for assaulting his girlfriend when drunk. Well… at least he was honest about his abstinence?

Finally, the depressed patient, so crippled by their own mind. Lying there exhausted but unable to sleep, lost in thought somehow in an empty mind, long devoid of hope and soon devoid of self. They’re there in the psych ED because they might as well be in the psych ED. Their disposition so heartbreaking and draining because while schizophrenia and psychosis and mania are comfortably foreign, sadness is all too familiar.

That’s a sampling of the most dramatic characters I encountered during three weekend shifts in the Psych ED (fortunately, they weren’t all present simultaneously). No one is detained unnecessarily. The nurses administer dramatic rescue medications, the social workers sort out amenable living conditions on the outside, the psychiatrists sort out inpatient admission plans. Even a lowly medical student like me can contribute to the time-pressed team by interviewing, digging past impaired insight, and employing elementary psychiatry.

Should I say it? Oh, why not.

The Psych ED is a crazy place.