Thursday, May 11, 1989
Frank paused outside the door to the locked unit and rummaged for his keys. He reflected on how tightly he had held his keys during the first few days on the psychiatry rotation. Perhaps it was not surprising after all: John Umstead Hospital was a strange place, with strange denizens, in a strange small town. Then too, perhaps subconsciously he had worried at first that the keys were the only feature that would distinguish him from the patients and save him from being locked in by accident. Not that he was really worried that he was crazy, of course.
Since then he had gotten to know the patients of Three East, and was much less concerned. These were seriously ill folks. True, there were a few sociopaths and the occasional malingerer, and even a very few indigent patients with good old major depression. But very few North Carolinians visited Butner, N.C., for a holiday, or for that matter for any reason at all. The town was even far enough from I‑85, and close enough to Durham and Raleigh, that almost no one came into town even to fill up a tank. Most out-of-town visitors came in heralded by flashing lights, in an ambulance or a sheriff’s van. Mary Pettit had been in the ER here for his first call night at Butner. The familiar face had been reassuring for his first call on psychiatry, though he’d failed to break his tradition of feeling mentally slow in her presence.
She’d patiently heard his evaluation of an ER patient, and his diagnosis of “major depression, recurrent, moderate severity,” and had shaken her head when he’d had no answer to her follow-up question, “what else does he have?” Then she’d shared this clinical “pearl” which, like most things she taught him, he’d written down in his lab coat pocket book of Stuff to Memorize: “Frank, no one is here at Umstead for just one problem. People are depressed and alcoholic, or schizophrenic and antisocial, or manic and unemployed. Otherwise they’d be at their local community hospital, or Duke or Chapel Hill.”
Myrna Jones might be the exception, though, thought Frank as he walked through Three East toward the nurses’ station. What a fascinating patient. And he might actually make a difference in helping her. Last night he’d called home for the first time this academic year to tell Christine he’d like to stay over on a partial call night rather than leaving for home around midnight. Many students stayed over anyway in Umstead’s rudimentary student call room, either to try to impress a resident with their devotion above and beyond, or because no one really enjoyed the longish, lonely drive back to Durham. But Frank was a fish out of water without Christine, and usually one night away from home was one too many.
Last night he’d been in the hospital library reading up on the new admission when he realized with a shock that it was almost midnight and he had been having a great time reading. That was a first; there had been fun moments studying earlier in 3rd year, but they had been rare and brief. Sitting there still half-disbelieving the time on his watch, an echo of a fondly remembered conversation had tickled his memory: If you’re going to spend decades in a career, you should do something you like. It sounds like what you really like is learning new things and figuring out what makes people tick, so the question is whether medical school prepares you for a career as a perpetual student and people-watcher.
He had sat bolt upright. You’re kidding. Psychiatry? I must be sleep-deprived. But today the thought refused to die, popping up in his mind a few times already.
As he sat down at the nurses’ station and pulled out Mrs. Jones’s chart, Susie Applegate walked by in a flowered sundress, waved and smiled at him. Frank waved back, trying carefully for a neutral, professional gaze, and turned back to the chart. Ms. Applegate was the first patient he’d admitted at JUH, a 38-year-old woman who had been picked up by the highway patrol for walking naked along I‑85. Frank vividly recalled the team conference the next morning when, after reviewing the available history, they had invited her in. She was wearing short shorts and a halter top, with lipstick and eye shadow applied overenthusiastically. She smiled at Frank more than was quite comfortable. He could replay the conversation in his mind like a favorite videotape. Why was she here? The cops had brought her in. Why? There was a simple misunderstanding. They didn’t know she was a priestess and that’s how priestesses dressed. When did she become a priestess? She had been one for months, but she had just realized it that afternoon. How had she been sleeping? Fine. How many hours did she sleep at night over the past week? One and a half. Wow, that’s not much sleep—was she tired? No, she was full of energy. What was her job? She had quit her secretarial position a week and a half ago. How was she going to support herself? She had recently come into some money. Then the most fascinating part: How much money? She asked for a piece of paper and a pen, leaned over the table and carefully wrote: $1,305,723,987.18. (The ridiculous precision amused him, then mystified him as he tried to think like a psychiatrist—did the 18 cents mean something?) Frank had been fascinated to see a textbook description reified. Mania was standing right there in front of him.
The really amazing thing, though, had been her dramatic improvement over the next couple of weeks on lithium. She didn’t like to talk about the I‑85 episode and sounded embarrassed about it. She was sleeping 6 hours a night and had called her boss to apologize for walking out and to ask for medical leave. There was no more talk of being a billionaire. And yet there were moments when Frank wasn’t sure how complete her recovery really was. She said she wasn’t a priestess, but she didn’t actually deny she had been one. Her makeup was no longer smeared but was still prominent. And she still sometimes flirted with Frank. His attending, Dr. Gamble, was trying to finesse Ms. Applegate’s increasingly frequent queries about when she could leave. “Gamble’s rule,” he called it: when you think a manic patient is back to baseline and ready to discharge, wait 5 more days. “The first thing that disappears in early mania is insight,” he reasoned, “and it’s the last thing to come back. If you send bipoles home too soon, they quit taking their meds every time and they’re back a week later.”
Focusing on the chart in front of him, Frank tried to focus again on Mrs. Jones. She was a rare patient brought in directly to Umstead by her family, who lived in Creedmoor, about 5 miles away. She’d been there once before with the same symptoms, and the first time had been a painful 30-hour ordeal for the family that involved two general hospitals, a long overnight in the ER, and a lot of needles and X‑rays. In the end she’d landed in the Umstead ER anyway. This time they figured they’d skip the ordeal in favor of the 10-minute drive.
Mrs. Jones had come in from the hospital entrance on a gurney, face up, eyes open, mouth ajar, unblinking, pointing upwards at a fixed 30-degree angle with her right arm and index finger. She had remained in that posture, mute and unresponsive, until she’d fallen asleep half an hour after 5mg of Haldol i.m. According to the nurses’ notes, she’d only slept 4 hours; the next time the nurse had come by for rounds she was in the same position she’d been in when she’d rolled into the ER, and had lain motionless ever since.
That reminded Frank of his reading the night before, and he flipped to the orders page and wrote for an i.v. with a slow saline drip, subcutaneous heparin every 12 hours, and an order to turn the patient every 2 hours. Before signing off on the orders he checked the vitals section, found the usual blank page, hunted down the rounds clipboard, and found that morning vitals were unremarkable except for a heart rate of 100 beats per minute since admission.
A quick physical showed some of the signs Frank had read about, but no complications. He made a few notes and made it back to the nurse’s station a few minutes before rounds.
Dr. Gamble came into the report room joking with the ward social worker. He sat down at the head of the table, smoothed his coat briefly, and caressed his goatee. “OK, one admission last night? Which resident was on?”
Before his resident could answer, Frank raised his hand and said, “Dr. Petropoulos and I were on last night. I’d be glad to present the case if you like.” Susan Weight, the other student on service at JUH, raised her eyebrows at Frank, who had a reputation among his classmates of never volunteering for clinical work.
Dr. Gamble smiled avuncularly, glanced at the resident for confirmation, and told Frank to go ahead, but warned, “you have 8 minutes.”
For perhaps the first time all year, Frank felt truly ready. He glanced at his written admission note to make sure he got the first few sentences perfect. “Mrs. Jones is a 66-year-old woman who is admitted involuntarily on an urgent basis due to catatonia that developed gradually over the past two weeks. Information comes from the patient’s husband and daughter-in-law, who seem reliable, and from hospital records. Her psychiatric symptoms first began when she was 25. I’ll come back to her recent symptoms in a minute.” He looked up at Dr. Gamble to make sure he was OK with including the past psychiatric history with the HPI (history of present illness). Some psychiatry attendings liked it that way and others didn’t, but Dr. Gamble just nodded absently. “She was hospitalized on her 5th wedding anniversary, two weeks after her father’s funeral, after a psychologically serious suicide attempt. In the hospital she lay in bed for two weeks, nearly mute, refusing all food. She needed an i.v. for hydration. She cried silently at times. Once, the psychiatrist asked her a few questions but after she remained mute, he finally gave up and turned away, only to have her then finally answer the first question correctly. To make a long story short, she had a typical but severe melancholic major depressive episode that lasted for 3 weeks and then resolved after the 4th of 7 bilateral ECT treatments. She then recovered completely.”
Dr. Gamble interrupted. “You mean she was normal for her—normal enough that the family didn’t worry about it—or she was absolutely normal?”
Frank was expecting that question. “She was completely fine. She raised 4 children, volunteered at her church, enjoyed playing bridge with her friends and several other hobbies, and displayed normal affect. Then three decades later, at age 56, she developed a second depressive episode, this time accompanied by delusions of guilt and auditory hallucinations of the devil telling her she would soon die and be under his control because of her terrible sins. Her pastor visited several times and never could figure out what sins she was talking about.
“Again she recovered completely, this time without treatment. Finally, last year at age 65 her family brought her here after she “froze” in an awkward position with her head turned to one side and her neck flexed, with her lower extremities rigid but not twisted. The ER doc here sent her to Duke via Durham County General, where her physical exam, drug screen, head CT, thyroid function tests and routine labs were all normal. She lay in that position for over a week until she again underwent ECT, this time 6 unilateral treatments, followed again by full remission.
“She’s been fine for the past year, until 2 weeks ago. She started repeating her own spoken phrases and crying, supposedly ‘for no reason.’ She started ‘freezing’ for 2 to 15 seconds, with her hands in whatever awkward position they had been in when the freezing spell began. When asked after the fact, she remembered what happened around her during the freezing spells. She stopped baking oatmeal raisin cookies every Saturday for the grandkids, who usually visited on Sundays. One of the older grandchildren stayed overnight two weeks ago, and said she heard grandma up half the night pacing the floor. Yesterday when they came to visit, she handed her son a manila folder with information about a reserved burial plot, but about 75% of the time she was holding an uncomfortable position, like this,” (Frank demonstrated). “She didn’t speak the whole visit except once, when they asked her what she was pointing at, she said, ‘the devil,’ but didn’t answer further questions. Finally they carried her to the car and drove her here. She has never had a manic episode nor had psychotic symptoms when she wasn’t depressed.”
Frank continued with her past medical and surgical history, which was minimal except for a blood clot in her leg that had gone to her lung during her previous psychiatric hospitalization, her medications (warfarin, to prevent future blood clots), and her family history and social history. “On exam last night, vital signs were normal except for a pulse of 104; blood pressure was 95/50 and we did not attempt orthostatic vitals. Neurological exam was limited by cooperation but showed no focal signs. She was lying on her hospital bed with her eyes closed but holding the pointing-finger posture. Her lips looked dry. She was mute throughout the exam, so much of the typical mental status exam was not possible. However, when I told her I wanted to look in her eyes, she squeezed her eyelids shut more tightly. Her eyes were closed tightly with a prominent frown on her face. When I moved her arm to a resting position, it gradually drifted back up. The nurses report that overnight she appeared to sleep for 1 or 2 hours only, and she has not spoken nor eaten or drunk anything since her arrival last night. Serum chemistries, CBC and urine were all normal, except for an elevated BUN. PT and PTT were elevated, consistent with her warfarin history.
“So, to summarize, this is a 66-year-old woman who most of her life has been in good physical and mental health but who has had 3 major depressive episodes, two of them complicated by catatonia and the other by mood-congruent psychotic symptoms. Now she has catatonia, manifesting catalepsy and negativism on exam, in the setting of 2 weeks of crying, apathy or decreased enjoyment, thoughts of death, severe insomnia, psychomotor agitation at home, decreased p.o. intake, and an apparent recurrence of hallucinations and delusions about the devil.”
Dr. Gamble interrupted, “hallucinations?”
“She said she was pointing at the devil, so most likely that was a visual hallucination,” clarified Frank.
“And why did you say psychomotor agitation at home? Usually that’s a sign, not a symptom.”
“The granddaughter said she was pacing most of the night.”
Dr. Gamble nodded. “So, what’s your diagnosis?”
“Well, catatonia can come from numerous neurological or systemic illnesses, but in this case by far the most likely diagnosis is recurrent major depression with psychotic features.”
“OK, let’s say that’s her primary diagnosis. What should we do for treatment?”
“Catatonia generally needs supportive as well as specific treatment. Supportive measures include hydration, prevention of DVT and pulmonary embolism, and feeding if needed. In her case I believe the best direct treatment is ECT—it’s a first-line treatment for catatonia and for psychotic depression, and she responded well to it in the past. She’s not eating, so there’s some measure of urgency, too, and medications don’t work as quickly. Besides, it’s what her family is expecting.”
“Hm.” Dr. Gamble thought for a minute. “So, you’ve covered the most likely diagnosis. What about possible diagnoses that are easily treatable, or that we would hate to miss because they could make her worse if not treated?”
Frank replied, “in her case, given the neuro exam and labs, the most obvious would be severe hypothyroidism. But it doesn’t explain the relapsing-remitting history very well, and last year during a similar episode her thyroid function was normal.”
“Good work! Anyone else have something to add?” Dr. Gamble looked around the room. When no one answered, he asked, “What else might kill her, if complications of not eating don’t do her in?” After another silence, he added, “come on, what is our most common lethal concern for depression?”
“Oh. Suicide,” answered Frank along with a couple of others.
“Right. She’s probably already on suicide precautions, but we’ll want to watch her as she starts to get better. OK, one more for Mr. Kimball. Suppose she gets better with ECT. Do you want to send her out with any other treatment?”
“She’s had more than two episodes of depression,” answered Frank, “and they have all been pretty severe, so she should be on an antidepressant to reduce the risk of another episode. Given her age, I’d like to avoid a tricyclic, so I’d vote for fluoxetine. But we’d have to monitor her labs carefully, since it can interact with warfarin.”
“Alright, we have a plan, but there’s a problem. I’m guessing she’s not able to provide informed consent for ECT. How do you want to address that?”
Frank replied, “Well, in a lot of states, a court can approve ECT, and the family says she was glad it was there for her last time she was sick. But there’s another option that Steve—Dr. Petropoulos—and I were considering. There are a handful of reports using lorazepam i.v. for catatonia. In about half of the cases, there was dramatic improvement, though it didn’t always last. We wanted to propose giving that a try, and if she improves enough, that would allow her to consent to ECT herself.”
“Huh. Well, sounds like it’s worth a shot. Steve, if you do go i.v., I’m sure you’ll be careful with the dosing and monitoring. I’d like to see the papers you looked at. Alright, folks, let’s go take care of sick people.”
A couple of hours later, Frank and the resident were seated by Mrs. Jones watching her closely. “OK, Frank, how long since we finished the first half milligram?”
“Eight minutes.”
“Feels like an hour. Check her respirations for me, OK? I’ll answer this page and be right back.” Frank counted it out. Sixteen per minute, maybe a touch slower, but her finger was still pointing at the top of the wall past her feet, her face still looked anguished, and she had yet to speak. Frank mused on how, even though he was still wanted for his watch and pen, he had begun to feel like a real part of the team. He could appreciate the change in his skills and confidence since his medicine rotation at the beginning of third year.
Frank heard a quiet noise and looked over at Mrs. Jones. She swallowed again and he realized that her hand had drifted downward almost to her lap. She blinked a couple of times. Frank wrote down the time and watched her carefully. Dr. Petropoulos walked back into the room and the patient turned her head slightly and looked to see who had come in. “Oh!” Steve said, eyes wide, and glanced at Frank. Frank leaned forward and asked, “Mrs. Jones?” She blinked twice, swallowed again, and looked like she was about to say something. They waited for another minute, and Frank was about to call her name again when she said roughly, “I’m thirsty.” Then she started crying. Frank ran for a cup of water while Steve patted her shoulder and asked what was on her mind.
“It’s all my fault,” Mrs. Jones said after another pause of at least a minute. Her body had now relaxed into a normal posture, and she had finished her glass of water. Eventually she was able to tell them that her whole family was dead due to her negligence. Frank tried to reassure her that no, her husband and children had been in touch within the past few hours, but she was sure they were just trying to placate her with polite lies.
“Mrs. Jones,” Steve said, “it looks like we don’t agree on your family’s health, but I think we can agree that you have been feeling horrible lately.” He waited, and five or ten seconds later she nodded through her tears. “You have all the features of a severe depression, and our team believes that the best treatment for you is ECT, the same treatment that helped you so much last year. Will you agree to have ECT again?” After another ten-second eternity, she nodded again. “Frank,” Steve said sotto voce, “get me the consent form, now.” As Frank started for the nurses’ station, he heard Steve reminding her about the procedure and its likely good and bad effects.
Half an hour later, back in the resident work room, Frank was still flabbergasted. “That was amazing! I mean, she was 90% better in just a few minutes. The closest thing I’ve seen all year was when a guy on medicine basically passed out in the middle of a sentence and his blood glucose was 25, and he woke up and started talking while the i.v. glucose was still going in. I guess those are the miraculous moments you dream about in medicine.”
“Just remember this moment,” Steve said, “the next time some internist tells you ‘at least we can cure people in medicine.’ And then,” Steve grinned, “you say ‘yeah, like you always fix heart failure.’”
“Actually,” said Frank, “I was just reading how the treatment response rate was slightly higher for the top ten diagnoses in psychiatry than in the top ten diagnoses in general medicine. Not significantly higher, but still. I think people just get some prejudice against psychiatry stuck in their head and it sticks there like bubble gum to the underside of a chair.”
The conversation lost steam as they continued with notes and orders for the patients on their team.
The next morning on rounds, Mrs. Jones, still looking fatigued after pacing the halls most of the night, asked when “they” were going to kill her. She refused consolation for her conviction that she had led to her family’s death. After her husband and daughter visited later that day, Frank sought out Mrs. Jones to see if their visit had cheered her up. Crying, she said, “it isn’t going to work, trying to make me feel better by bringing in those actors.”
“Actors?”
“Those people you brought in made up like my family, trying to make me feel better.”
“What? We would never try to deceive you like that. And anyway, we don’t have a budget to hire actors! This place doesn’t even have the budget to replace these windows with”—he paused before saying “shatterproof glass,” worrying that might give her ideas—“with newer windows,” Frank finished lamely.
She looked over Frank’s shoulders at this point, eyes widening, and her hand drifted up pointing past him. He looked over his shoulder but saw no one there. “He’s coming for me!” she said breathlessly, still pointing.
“Who?” Oh. “The devil?” She did not answer this time, just nodded her head fractionally, still pointing.
Frank spent the next fifteen minutes helping Mrs. Jones sit down, and calling Steve to get her another dose of lorazepam. Frank was thinking it would be hard to wait for ECT to get started. She was already on the schedule for tomorrow morning, but 20 hours seemed like forever given how pitiful Mrs. Jones was feeling.
The next morning, Frank was in the ECT suite, eager to see firsthand this treatment with a reputation somewhere between magic potion and evil tool of the oppressor. The chief resident was there, looking busy, and asked Frank if he’d gotten lost. “No, I’m the med student taking care of Myrna Jones, and I wanted to see her treatment.”
“Yeah. OK, stay out of the way.” But over the next 5 minutes, the chief mellowed enough to quiz Frank a couple of times—why is the blood pressure cuff on her calf? why will people have jaw pain in spite of the neuromuscular blocker?—and seemed at least somewhat less unimpressed with Frank when he actually knew the answers. Mrs. Jones hadn’t yet reverted this morning to keeping her arm in the air, but she seemed awfully tense. It was almost a relief to see her relax when the methohexital went in and her eyes closed. The succinylcholine was next, and anesthesia breathed for her with an Ambu bag a few times. The paddles were placed, there was a buzz for a few seconds, the toe that had had the cuff inflated pointed down vigorously for a few seconds, then twitched up and down for another 20 seconds or so, then relaxed.
“Wait, that was it?” Frank almost asked? After standing in cardiac surgery watching them stop a heart, stitch in the opened chest, and restart the heart, this 30 seconds of almost nothing was completely anticlimactic. Mrs. Jones was already breathing on her own again, though still unconscious. He followed her into the recovery room, and over the next half hour she woke up, asked for a drink of water, and gradually moved from muzzy-headed to fully alert. She actually smiled at him when he brought her the cup of water, and he stopped briefly in surprise at seeing a completely new expression on her face. She tended to be more distractible for a few hours after each ECT session, but memory function was normal by the next day. Over the next week, she passed milepost after milepost: stopped pointing at the devil, stopped believing her family was dead, cried less, started sleeping 5-6 hours every night, started eating at every meal, and eventually joining in occupational therapy activities on the ward.
Over the course of that week, Frank read about involutional melancholia, mood-congruent delusions, psychosis with temporal lobe lesions, and Capgras syndrome—and loved it all. Christine loved it less when he went on and on about these topics with guests over dinner. “But at least,” she relented later that evening, “it’s better than having you ruin our appetites at the dinner table about pathologists and food.” A couple of months ago, Frank had been expounding his theory that pathologists must be hungry because they named everything after food. The conversation had gone downhill after he started listing off examples, like apple green sputum and nutmeg liver.
Now he was telling everyone about Cerletti and Bini, who found out that an abattoir in town was knocking out pigs with electricity before killing them. “They figured, hey, we’ve got distraught people that could use calming down, let’s try it on people. Obviously this was 100 years ago, in the days before human research ethics boards. So they just picked a guy, zapped him with some electricity, . . . but nothing happened. In fact the guy says, ‘not another one, you’ll kill me!’ So of course they tried again with higher charge, and then the guy has a seizure and started to improve.”
Christine responded, “sounds like this was also in the days before decency and common sense.”
Frank strolled along with Dr. Gamble towards the parking lot, the two of them walking alone at this time of the evening. “Well, Frank,” the older physician said, turning briefly to look at him, “you did good work there with Mrs. Jones.”
“Thank you, sir.” Frank had lived in North Carolina long enough to know that “sir” was not a title of nobility but rather a polite necessity.
“I think you have that something special it takes to be a good psychiatrist. You have some feeling for what makes people tick—some psychological-mindedness—to go along with a good foundation in neurobiology and pharmacology. If you decide you’re interested, feel free to call me up for advice, or if you need a reference letter.”
“Thank you! That’s very thoughtful of you. Honestly a few months ago I wasn’t thinking of psychiatry at all, but I’ve really enjoyed this rotation. Thanks for being a good mentor.” After a moment, Frank continued: “I just remembered, I do have one question from rounds today. That guy who had a delusion of being a psychiatrist . . . you said, ‘he must be a frequent flyer.’ You were right, he’s been admitted about 20 times. But how did you get that before you’d heard anything but the warning that he thought he was a psychiatrist?”
Dr. Gamble laughed. “Son, this guy has a delusion of grandeur. He could have believed he was president, tycoon, even God, omnipotent and omniscient. You know how people generally see us head shrinkers—we psychiatrists have the lousiest PR of any profession. Except maybe politicians. Anyway, who else but a long-time psych hospital patient would even entertain the belief that psychiatrists have great power or know everything?” He chuckled and got in his car, leaving Frank to ponder on the intersection of power, prejudice and humor.