Trapped

The pattern in the brown wooden floor is quite ironic. A small square is encompassed by another larger square, which is surrounded by another square. The pattern screams entrapment. It's an odd design choice for an inpatient psychiatric unit. Perhaps, it's just a mind game.

When I started my psychiatric rotation over three weeks ago, I instantly noted this pattern on the floor. I'm not sure why it called my attention. One of my colleagues elegantly pointed to a reason, drawing on Freudian themes.

"Perhaps, the pattern in the floor reflects you own internal preoccupation/conflict with being trapped on the unit," he said.

Quite an insightful comment not to far from the truth. Sometimes, you can feel trapped, even when you know you can leave.

***
The Seventh floor inpatient psychiatric unit at SF General Hospital is an interesting place. I'm situated in what used to be a themed women's unit. However, the themed units have disappeared due to budget cuts and the need to place acute patients in inpatient beds for stabilization.

The unit is set-up much like a traditional inpatient psychiatric hospital. There are individual units on the seventh floor with a central patio area. A key is required to enter and exit the unit to prevent any patients from AWOLing. A common room set up with chairs, tables, a TV and a piano, is located right next to the entrance. The Nurse station sits in the middle of two long pink hallways; one hallway for the male rooms and the other hallway for the female rooms. The charting room, where the physicians, nurses, and social workers congregate is just across the Nurse's station. The charting room door remains open during the day and patients pass by, sometimes demanding to see their physician or asking to be discharged, other times requesting for Ativan or food, or stopping to stare at you.



My experience on the unit has been a unique experience with it's share of ups and downs. In many ways, it's been a whirlwind learning experience that has made me reevaluate my emotional boundaries.
***

With inpatient psych, you bear witness to some of the most difficult patient situations you will see in medicine. You will see patients at the lowest points in their lives. You see the entire spectrum, everything from suicidal patients that attempted to jump off the Golden Gate Bridge to manic patients who in a fit of rage threatened to hurt others to psychotic patients who believe they are emperors of the world to violent patients with personality disorders to psychotic patients who hear the voice of God telling them to hurt others to delusional patients who believe they have HIV despite negative testing.

While on the unit, I've had patients yell at me, flirt with me, lie to me, cry in front of me, refuse to speak with me, talk only to me, write notes to me, or stare at me.

Many of our patients are admitted from the Psychiatric Emergency Services, where they are initially evaluated. Typically, patients can self-present, be transferred from the medical emergency ER, or brought in by the police or other providers. In the process, some patients are placed on a 5150 legal hold for either danger to self, danger to others, or grave disability.

The stories of our patients are heart-wrenching; you see the frailty of the human mind due to mental illness. You also see the darkest shades of human nature and behavior. Common themes thread through many of their stories-- histories of substance dependence, violence, abuse, neglect, lower socioeconomic status, marginal housing--just a few of the common themes that pervade the lives of our patients.

Mental illness deteriorates the lives of our patients. Some patients are just driven by basic instincts to survive, while other patients are completely out of touch with reality. Sadly, many of our patients with debilitating mental illnesses crumble in society; the hospital becomes a revolving door and their only security net. We become responsible for these patients.

Amidst the emotional turmoil, you (the provider) must take a history and determine the next steps. You are called to "stabilize" these patients and develop an appropriate discharge plan. For patients placed on a hold, we are given a 72-hour window to act (unless we obtain a 5250 hold, which extends th hold to 14 days). At any point, a patient can contest their hold in front a judge. Until the patient demonstrates insight into their condition, you make decisions on their behalf, quite a responsibility.

At times, you find yourself getting devoured by patients who seek your undivided attention so they can yell at you for hospitalizing them.

Other times, you struggle to process the gravity of your patient's words, trying to assess if they actually plan to hurt others, or if they are truly that ruthless. You find yourself losing your patience, having to remember to monitor your countertransference.

At times, you are simply overwhelmed by a patient's history of abuse and the tragedy of their life that you find yourself searching for the empathetic words to say (those PEARLS we were taught in first year), knowing well that what you say can not change or offset the damage. You remain silent, as your patient cries.

You either become skeptical and jaded, or you become emotionally overwhelmed and confused as you process the unimaginable. The constant exposure chips away at you, testing your boundaries and patience. Despite the challenges, you must find a way to remain dedicated to helping your patients.

All day long, you hear similar strokes of the same song. Through it all, you try not to let your own voice be silenced by the noises of the unit, so you can find your escape.