Delusions. If you can't beat them, sometimes you have to join them.

It played out more like a television skit than most television skits. I wouldn’t believe it myself had I not been there.

We were third-year medical students at the University of Rochester, doing 6 week psychiatry rotations.We spent one night a week in the emergency department doing psychiatric exams and mental status evaluations on emergency patients.  Some of these involved patients who had true psychiatric illness and were admitted for psychiatric care, but most involved patients with medical problems and varying degrees of overlying (or underlying) ongoing psychosocial issues. In these patients we were enlisted to get a comprehensive social, functional, and mental status evaluation as part of their admission. Norman and I were taking turns seeing patients that night. Norman is now a psychiatrist, and you’ll soon understand why.

Norman was next up. The charge nurse came to our cubicle, where we were quizzing each other on the intricacies of the DSM. Handing him a clipboard, she said there was a “probable keeper” in the quiet room who needed to be evaluated. Norm set off to see this young man whom the nurse’s triage note described as a 24-year-old disheveled and agitated male with marked paranoid ideation and no known past psychiatric history or drug or alcohol abuse.

A psychiatric interview of a medical patient consisted of a detailed social and psychological history and a psychological review of systems done at the patient’s bedside. The quiet room was reserved for psychiatric patients whose behavior was judged by the triage or charge nurse to be potentially disruptive. Most of the psychiatric patients were discharged with an outpatient care plan, but some required direct admission. These were the most interesting - but also the most frightening. A frantic and disorganized patient in the grip of acute paranoid hallucinations, or a full-blown manic with overpowering energy and unfiltered arrogance and sexuality, are challenge even to a seasoned and well grounded clinician. For the neophyte and incompletely trained medical student still struggling with his or her own transition to the role of clinician, experiencing these patients can be traumatic and leave a lasting negative impression about psychiatry.

Our quiet room was outfitted with a desk and two chairs too heavy to be usable as a weapon, a phone, and not much else. There was nothing breakable, throwable, or detachable. We were advised always to stay between the patient and the door, which did not inspire confidence.

About fifteen minutes after Norman had disappeared into the quiet room with the typical false bravado of a third year medical student, the commotion began. The quiet room door was flung open with enough force to render the doorstop into scrap and dent the wooden wall behind the door. A voice rang out, at football stadium volume: “Help. Help. We need help. Call the FBI. It’s an emergency.”

I looked up from my reading and was surprised to see, not Norman, but a gangly young man with a huge head of tangled red hair and a scruffy beard, shirt untucked,  hands waving, who looked for all the world as if he was flagging a rescue vehicle down for an accident on a busy highway. I jumped up and headed down the hall, both curious and fearing for Norman’s safety. I was joined by a stream of staff led by the charge nurse (who is always the fastest and most competent responder in an emergency room), and followed by several residents (with the youngest competing to get there first), and finally a portly, red-faced security guard at the rear, struggling to keep up.

The security guard and a large surgical resident led the young man down the hall between them, combining verbal reassurances that all would be fine with a firm grip on both upper arms. When we got to the quiet room, we found Norman sitting in his chair with a gun in his hand. The gun was pointed unwaveringly at the back left corner of the room. Norman, his face an unreadable blank, was motionless except his head, as he shifted his gaze slowly back and forth between the open door, the gun in his steady hand, and the empty corner. In a quiet voice he asked: “Is he gone?” When we assured Norman that the young man was gone, he placed the gun down on the table gingerly as if he feared it would explode, and in a slow and distant voice he explained what happened.

Initially, the interview had gone according to script: name, age, some demographic information were confirmed, and some basic medical history reviewed. As Norman had started asking questions about the source of the young man’s distress, the patient became progressively more agitated, pacing around the room, and repeatedly pointing at a corner and asking with increased intensity: “Don’t you see them? See? Look. Stop them. Make them stop.“ The more often Norman suggested he sit down or asked him questions, the more upset the young man became. Abruptly, the patient had pulled a hand gun from his jacket pocket and pointed it at Norman. “You must be one of them. They’re eating my jello. If you can’t stop them, you must be one of them. Don’t let them take my jello.”

Norman paused. “I didn’t know what to do,” he said. “No one ever pulled a gun on me before. It seemed forever, like time stood still. Then, I heard this voice saying, “You’re right. We can’t let them have the jello. Its your jello. You earned it. We have to stop them. Give me the gun. I’ll keep them covered while you go for help.”

 


 

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