The Worst Night of Your Life

My past two weeks have been another round of night float, this time at Harborview, our county hospital. It's a very different experience from this summer's time at the main UW hospital, partly because it involves being the covering doc for nearly 60 inpatients (as opposed to 14), but also because Harborview has a dedicated psychiatric emergency room. Most of my night is spent hanging out down there in the PES (that's Psychiatric Emergency Services) and trying to help whomever comes in the door. Early in the rotation, one of my attendings said to me "Remember, anyone who comes in here is probably having the worst night of their entire life." I think a lot about the experience from the patient's point of view. I can imagine it being fairly harrowing.

It's midnight on a weekday. Maybe your long-standing depression is getting the better of you, and you've been sitting alone with a bottle of vodka and contemplating a second bottle full of pills. Maybe you have no home, and you've been wandering the streets of Seattle in the drizzling mist, trying to get your thoughts to quiet down. You're miserable, edgy, and you think you'd be hungry if your stomach weren't tied up in knots. You didn't sleep last night, if you've slept well at all in weeks. Maybe you called 911 or the Crisis Line because you feared what you might do. Maybe a cop stopped you and you figured you'd just scream and maybe punch him -- let him just shoot you and get it over with. Maybe you can't remember exactly what happened, or what day it is, or much of anything, because you're too exhausted to remember what's real and what's just the chaotic whispering of voices from your brain. Somehow, you find yourself being wheeled on a gurney into the hospital.

Your first stop is the regular medical ER, surrounded by coughs, the occasional moan, the rambling pleadings or loud snorings of the severely intoxicated, and a constant rush and beep of doctors, nurses, and aides. You get a cursory once-over (usually, if things aren't too busy -- after all, you're a psych patient, so probably there's nothing wrong with you physically, right?) and then it's off to see the shrinks. They put you back on the gurney, fasten a strap around your waist, and wheel you to an unmarked door on a side hallway. A grey television screen hangs next to it, letting those outside be aware of any lurking menace, ongoing emergency, or potential escapee. A swipe of a badge, the beep and click of a magnetic lock, and you're in. A small grey hallway offers enough room for perhaps two of these gurneys side-by-side and several of them end-to-end. A nurse in light blue scrubs unlocks one of ten identical wooden doors, turns on the lights inside, and escorts you in.

Your room is roughly one step up from a prison cell. The only reliable piece of furniture is the gurney/bed on which you sit. If you ask nicely, you can have a blanket or three. The walls are a uniform grey, unmarred by windows, highlighted only by occasional scuffs, scratches, or missing chunks. A metal speaker, set flush into the wall, is your connection to the locked and glassed-in nurses' station. In the ceiling, a closed-circuit camera transmits your grainy image back to a bank of monitors, watching you for signs of violence or self-harm. Until you're seen by a doctor and cleared, the light stays on, no matter the hour. You couldn't adjust it if you wanted to -- the light switch requires a key.

In the next room, someone is shouting and singing at the top of her lungs, sometimes angry, sometimes happy. Across the hall, you see a pair of tattered sneakers protruding out from under a blanket as some unseen person occasionally tosses and turns. Further down the hall, there are moaning wails. Not screams of pain, not calls for help, simply the helpless keening of an infantile brain trapped in a grown man's body. A tall, thin man with a scraggly brown beard paces the hallway, not speaking, not looking at anything, just staring straight ahead. If you look all the way down the hall, at the far end, you can see a fishbowl-office with reinforced glass windows. People in scrubs and professional clothes sit and talk and type on computers and pick up phones. Are they talking about you? Do they know you're even here? Does anyone even know you're here?

And so, sometimes for hours, you sit alone with your thoughts, in this small grey cell with its faint odor of unwashed humanity. You wonder about calling a friend or at least playing some games on your cell phone, but that, along with all your other personal possessions, is now in an orange "patient belongings" bag behind a locked door. If you ask nicely, and it's not been a busy night, you might be able to get some water, or even a small snack. Need to use the restroom? Wait for the nurse to unlock it, and be prepared to give a urine sample. At some point, sometimes even before anyone comes and talks to you, that same nurse comes back in to ask for some blood for our routine screening labs. A pinch, a few seconds of anxious breath-holding, and then it's back to waiting some more.

Of course, you could also choose not to wait. If you've had a few drinks, or something a bit stronger, you might be feeling a bit aggressive or entitled, and thus you might choose to go up to that office and demand to be seen immediately. Or you might get sick of all these other people making noise, and so you might decide to go into their rooms to tell them to shut the heck up. Or you just can't stand the tension, and decide that you need to get out of this semi-prison right this moment. Or maybe it's as basic as your nicotine craving getting the better of your frayed nerves and telling you that you either get outside and smoke this second, or you're really going off the deep end. None of these ideas turns out particularly well for you. You're doing something perfectly reasonable, and suddenly there's three very large people in bright blue "Public Safety" vests around you. You protest, but are met only with "Sir, you need to go back into your room now." There's a clank of chains, a press of bodies, and suddenly you find your bed chained to the wall, and yourself held to that bed by clever padded Velcro wrist and ankle cuffs. Waiting for hours with minimal creature comforts is unpleasant. Doing the same waiting while restrained is doubly so.

Eventually, five minutes or five hours will pass, and a reasonably nicely-dressed person will walk into your room, plunk down a beige plastic lawn chair, and start asking questions about your journey to what now seems like a lesser circle of Hell. Those questions start to get pretty personal, too. Sexuality? Recent stressors? How far did you go in school? Substances of choice? How often? How much? Where's your family now? How do you manage to keep yourself housed/clothed/fed day-to-day? The actual focus on your current, short-term crisis can actually be pretty minimal; we're more interested in knowing how you got here than where "here" actually is. (Unless we know how you got here, it's a lot harder to get you back out.)

Maybe you pour your heart out and answer everything as completely as you can, eager to just give vent to your troubles. Maybe you've had enough of know-it-alls by now, and you grumble out the minimum necessary to get this guy to go away. The outcome is often similar either way, because unfortunately, psychiatry doesn't have much in the way of quick-fixes. It's an inherently slow specialty. Our medications take two weeks or more to kick in. Psychotherapy takes months. Stabilization of a chronic disease might take a year. Whatever's going on tonight, the end result is that after half an hour to 45 minutes of telling your life story, you're most often told than we can't fix it. Unless you're genuinely about to take your own life or harm another person, there's not much benefit to bringing you in to the hospital.

So, instead, after waiting in the prison cell for who-knows how long, you'll get tossed some scraps of short-term stabilization: the number for a community clinic that does sliding-scale work and could maybe see you in a week or two. A prescription for two weeks of meds. Permission to sleep in our ER until morning (if it's late and we're not full) or a bus ticket and a swift boot in the tail (if it's a normal night and there's someone waiting to use your room). A reminder that you have a case manager, what her number is, and a strong suggestion to call her first thing in the AM. If we have some left, a turkey or tuna fish sandwich.

And that's the end. You call a friend to pick you up, or you make your way on your own with a bus ticket and your own two feet, or if you've a long way to go, we might arrange a cab ride. A nurse hands you back that orange plastic sack with your personal effects, you put your shoes back on, and one of us escorts you back through that ominously-locking door. Assuming you didn't get medications (we very rarely give them out, perhaps one person per night), the only thing we've really given you is hope. You've made it through your darkest hour and are still alive, no matter how ragged. You have one more idea to try when the sun comes up, and you can cling to that little strand of hope that someday, things will be better than they are now. It's a far cry from the sutures, antibiotics, and surgical miracles we'd work on you if you came in with a medical problem, but sometimes a little hope is more powerful than any drug.