On the inpatient psychiatry ward, a new code governs

“By the way,” my chief resident told me on the first day of my inpatient psychiatry rotation, “don’t lick your lips in front of him.”

“Wait, what happens if–”

I fell silent as the patient walked into the interview room.  The resident wanted to discuss his paranoid delusions; the patient wanted to discuss his discharge.

The patient wasn’t ready to leave because the medications that made the demons stay away were also making his muscles twitch involuntarily.  More drugs would have to be added to his already potent cocktail to counteract the side effects.  The upside was that this week at least there was no poison in the water.  The military was still lurking in the background, though, and they probably would be no matter what dose of drug we overwhelmed his synapses with.

He raised his voice in frustration, his tone becoming more urgent, his speech rapid as he described the soldiers who were stalking him.  ”They’re so smart, they’ve got you convinced you that they’re a delusion.”  He leaned forward.  ”Everyone can hear them, but I’m the only one who can admit the truth.

“And I am getting pissed off.”

I didn’t utter a word, but I had never been so aware of my tongue in my life.

Three days earlier, I had finished my surgery rotation.  Suddenly the rules and culture I had absorbed for the previous 12 weeks fell away.  On the inpatient psychiatry ward, a new code governed not human anatomy but human behavior.

Although the outside door was locked, patients here wandered freely from room to room.  Upon entering, I brushed past the security guard outside the door of the isolation room, past a few small rooms with games and crafts, past the large main room where a flat-screen television hung on the wall and where meals were served.  I wandered into a spacious conference room that sometimes doubled as a group therapy room.

I peeked into the “Oasis Room,” a smaller room where each patient was interviewed daily by physicians and social workers.  It had no windows, but it was lit by an overhead light with clouds on it.  The walls and overstuffed chairs were a soft green.  A painting of trees covered an entire wall.  This was the official interface between doctor and patient.  It was designed to be comfortable and non-threatening.  Most importantly, it was designed to optimize treatment.

I thought of the surgeon’s “Oasis Room”–the operating room.  It too was comfortable and non-threatening, but only for the unconscious patient.  An awake patient, while sedated and being wheeled in, was warned, “Okay, bright lights and cold room.”  Before falling asleep, a patient once commented on the dozens of sharp tools that rested on a table near her barely draped body.  Sterile and sensible, though, it optimized treatment.

And there was the patient.  Anesthesia gave ultimate behavioral compliance.  Chaos in the operating room meant a nicked major artery.  An abdomen full of feces.  A heart that beat wildly out of rhythm.  These things were scary because they were unplanned, difficult to control, and physically dangerous.

But on my first day of my psychiatry rotation, without any of these risks, I was scared.  Patients with minds very different from my own roamed throughout the unit.  Sometimes they interacted with me.  Meanwhile, I struggled to look like the “Oasis Room”–comfortable and non-threatening.  I now worked in a world where licking my lips could mean nicking a major artery.

After I interviewed a patient, my attending gave me feedback.  ”Patients, especially the paranoid ones, watch your every move.  They are afraid of being judged.”  Though my words were appropriate, my body language could have been construed as suspicious.  I had jiggled my leg.  I had rubbed my boots repeatedly.  I had scribbled down too many notes.

On my first day on surgery, I accidentally brushed the sterile sleeve of my gown against an unsterile instrument.  The nurse had hurried to find me a sterile sleeve to slip over my contaminated attire.

On psychiatry there is a whole new set of ways to contaminate your environment.  Situations can escalate and human behavior, like the heart, can beat wildly out of rhythm.

There are new ways to interact with your patients.  You peer inside them, but it’s no longer literal.  You trace boundaries, but around their insight and judgment and not their vessels and ducts.  You try very hard not to sever anything crucial.  If you do, you pray that you can reverse it.

Instead of anesthesia, we have motivational interviewing and mood stabilizers.  We do not wear gowns or gloves or even white coats.  There is only one item that designates our role: “Without your ID, you are a patient,” my chief resident told me.

The rooms have changed.  The rules have changed.  The relationships have changed.

I am ready to change.

Note: Certain patient details have been changed to preserve anonymity.

Shara Yurkiewicz is a medical student who blogs at This May Hurt a Bit.

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