External threats allow a brief, but happy, truce in the ongoing battles between management and healthcare staff.
By JP Sutherland
“The boss wants to see you,” said Colleen, charge nurse for the day, and smiling as she said it.
“Uh-oh. What have I done now?” I replied, still managing a chuckle, though my day was busy enough that I could do without any administrative headaches. Healthcare managers come and go, but I had already sparred a few times with Marina, the latest occupant of this unpopular job.
“It’s your new admission. Shelley.”
“Ah yes, I can see how that might be an issue.”
“She hasn’t arrived on the ward yet, so you better brief me on what to expect. I remember her from last time and she was pretty wild when she was psychotic. But I notice that you haven’t asked for one of the seclusion rooms for her.”
“Actually, she’s doing well, at least by her standards, and she can share a room on the main ward.”
Shelley was well known to all the inpatient staff, because of her turbulent history of schizophrenia, whose relapses were fuelled by her unstable semi-homeless life, poor compliance with her medications, and occasional drug use. She was a large and loud lady, whose presence dominated the ward even when recovered, and who had to be treated in the locked off area when ill so as to spare everyone else from her delusional rages. But she hadn’t been admitted for almost a year now, and I was delighted at her new stability in the community, even as I knew it might collapse at any time.
Colleen looked curious.
“If she’s doing so well, why are you admitting her?”
“For gynaecology.” I said with a smile.
“What?” She answered, eyebrows raised. “Oh, Marina’s going to love this.”
Healthcare administration is a demanding job, and I know I should be respectful of the managers, not least because I am sure that I would be truly awful at doing their job myself. They have to balance the needs of many different arms of the healthcare system, without sufficient resources to satisfy everyone, or even anyone. And some of the groups they deal with, such as doctors, are used to high levels of autonomy and can react badly when being limited in some way, especially when the manager in question is younger and less educated than them. I know all of this, and have seen some of my colleagues treat managers very poorly, and so I try to remain polite and professional with anyone from administration.
However.
The problem for me is that I seem to have been cursed by being sent all the worst managers that the health system has at its disposal. I have occasionally worked with dedicated and intelligent youngsters who have skilfully juggled all the conflicting demands placed on them, so I know that they exist. But I usually end up having to deal with someone like Marina.
I opened the door to her office to be greeted with a curt “You can’t go ahead with this admission.”
“Good morning, Marina. How are you.” I replied.
“No direct admissions are allowed.” She went on, ignoring all courtesies. “We’re in a bed crisis.”
“Actually, no. I’ve spoken with the psychiatrist-on-call and they have no current patients in the ER awaiting admission for once, so they gave permission for me to admit Shelley direct from home.”
“But she’s not even mentally ill.” She went on, with no acknowledgement of having been in the wrong. You’ve written ‘cone biopsy of the cervix’ as the reason for admission. So send them to the gynae ward.”
“Actually they suffer from schizophrenia, and we’ll have to work quite hard to get her to the colposcopy clinic.”
She glared at me silently.
“Would you like me to explain the background to this. I know it’s highly unusual, and it’s actually pretty complicated.”
“I don’t have time for this now. But if you go ahead, then don’t expect that you’ve heard the last of it. I’ll have to take it to the director.”
“As you will.” I said, gratefully taking this as my cue to leave. I knew Marina’s director better, and felt confident of a more sympathetic hearing, should it ever actually come to that, which I doubted.
I relish my place as a generalist in mental illness, accepting all those rejected by other clinics’ exclusion criteria, even if that means occasional battles with those who guard the gates to ring-fencing, such as Marina.
The story behind Shelley’s admission, that Marina hadn’t wanted to hear, was complex enough to make it a unique experience in my career. Shelley was in her thirties, and had recently arrived at a more settled pattern of life, though this was only in comparison to her highly disturbed younger years. Now she managed to hold down rental accommodation for a few months at time, before becoming homeless again. She knew the homeless shelters well, and didn’t seem to mind a temporary return to them, but the disability pension I had enabled meant that she always managed to find a room of her own again before long.
It was her repeated relapses into psychosis that lost her housing in the past, either because she ran away from a property where she believed the CIA were spying on her, or else because the landlord had to evict her due to the nights when she screamed abuse at her hallucinatory persecutors. Now that she and I had brought these psychotic symptoms under control, her homeless periods seemed to originate in an argument with a friend, or sometimes because she had spent her rent money on something else, or even occasionally just on a whim.
This ongoing unpredictability meant that she didn’t always arrive for her follow-up appointments with me, but was at least now attending most of them. And recently she brought a question with her.
“What is Sinny?”
“Sinny?” I replied, unsure of what I had heard.
“Sinny.” She repeated, bringing out a crumpled and food-stained letter. “Here, take a look. I don’t understand it.”
“CIN III.” I read. “Shelley, this is a letter from the colposcopy clinic.”
“The what?”
“Ah yes, colposcopy. Did you recently have a Pap smear from a family doctor?”
“I saw a doc at the homeless shelter recently and she gave me a check up.”
“Did that include a vaginal exam?”
“Yes.”
“So the swabs she sent off have come back and show CIN III. That’s some changes they’ve found at your cervix.”
“What’s that?”
“That’s the neck of your womb. Do you get to see that doctor again, Shelley?” I asked, thinking that the results of her Pap smear would be best discussed with her family doctor, rather than with an old man whose gynaecology knowledge was buried deeply under many years of practising as a psychiatrist, and who hadn’t done a Pap smear in decades.
“No. It’s always someone different, and mostly there’s no doctors.”
“You could connect with a family doctor. We have a list of those taking new patients.”
“Nah. Too much trouble. You’ll do. You can tell me.”
And so, sighing internally at the unusual demands of trying to provide holistic healthcare, I did. Pap smears are a screening test for cervical cancer, and Shelley’s result showed the highest level of change, short of actually having cancer. CIN III results are presumed to proceed to cancer unless they are surgically removed, and the letter was inviting her to attend the clinic for the simple procedure required.
“You said cancer.” Said Shelley, looking worried, after I had finished.
“Not yet. And likely not ever. But you need to have this procedure to avoid developing cancer.”
“Does it hurt?”
“I think there’s a bit of discomfort, Shelley, but I really don’t remember this stuff any more. The clinic will tell you details when you go there.”
“I’ll think about it.”
I caught her ambivalent tone, and so spent a little longer trying to persuade her of the importance of getting this seen to, but all I got in return was a warning that I was losing my hard-won rapport. So I changed tack, helped her with her issues of the day, and then drew the appointment to a close.
During my career medicine has become increasingly specialised, and then subspecialised, and this has some obvious advantages. A good example would be the care of people who have suffered from the debilitating effects of a stroke. If this isn’t urgently addressed with clot-busting medications (that can be quite dangerous in the wrong hands) then the patient’s speech, or movement, or vision are impaired long-term. Yet after the brief window of medical intervention has passed, rehabilitation teams offer the opportunity for significant reduction of the disabilities, even if a full recovery is no longer expected. Studies have shown that each of these interventions, acute and longer-term, are best carried out by dedicated teams, and the outcome of patients on a specialised stroke unit is better on average than those cared for on more general units.
However, such specialisation also has a downside. In order to focus solely on their area of concern, teams draw up exclusion criteria which prevent them from seeing (or being distracted by) patients who fall outside their area of expertise. Some of this is obvious, and no one expects a dedicated stroke unit to accept a patient who hasn’t had a stroke. The problem emerges when patients turn out to be the complicated humans they are, daring to present themselves at hospital not with a single easily categorised condition, but with a number of comorbidities.
In psychiatry we see this problem frequently. A specialist service for the treatment of those with an early onset psychosis will likely show improved results over a generalist’s care, yet they may refuse to accept a referral of someone suffering from both the psychosis, but also alcohol dependence. Their letter declining the referral will helpfully suggest a redirection to the addiction team, until they in turn decline the referral because of the co-existing psychosis. As medicine has developed into these little villages of subspecialist care, ring-fenced with exclusion criteria, there is a risk that patients such as Shelley get lost in a no man’s land between them. She should obviously have been seen at the colposcopy clinic, but her mental illness and behavioural difficulties prevented that from occurring routinely, thus needing the combined efforts of the gynaecology clinic and our psychiatry ward.
The need for generalist services that will accept whatever complicated situation walks through the door will never disappear, yet our numbers diminish with each year of newly developed specialty clinics that attract new graduates. I know that I will never be a subspecialist in anything, yet I relish my place as a generalist in mental illness, accepting all those rejected by other clinics’ exclusion criteria, even if that means occasional battles with those who guard the gates to ring-fencing, such as Marina.
At Shelley’s next visit I made sure to ask again about the colposcopy clinic. She dodged the question, but left me in no doubt that she hadn’t contacted them. However, she had no trouble telling me what she didn’t like about the issue, starting with the fear of surgery that anyone might have. I explained how this was minor surgery from a physician’s perspective, while keeping to myself the old aphorism that minor surgery is a term that only applies to other people, and never to oneself. Beyond that she was put off by the highly personal bodily location of the operation, and the rest of her opposition seemed to be a carry over from the general difficulties of engaging her reliably into anything.
Hearing people out about their concerns, and providing reassuring answers to some of them, often results in a patient ultimately accepting a medical suggestion. But not this time.
“The bottom line,” I eventually said, needing to make things explicit, “is that without this operation you will almost certainly get the cancer, and if you leave that untreated then it will kill you.”
“I know! I know!” She wailed at me. “But I can’t decide!”
“OK.” I said, backing off. “Why don’t we leave it for today. But would it be OK for me to call the colposcopy clinic, and talk it over with them.”
“Sure.” She said, obviously relieved at my retreat, and shortly heading for the door.
The colposcopy clinic was certainly surprised to get a phone call from a psychiatrist – ‘this is a first’ said Abigail, the nurse in charge, when I was put through to her – but after that it all went well. They had flagged Shelley as a worry, and had made repeated attempts to contact her, but she had moved on from the address they had, and being Shelley she hadn’t thought to let them know.
“I’ve been encouraging her to come and see you,” I said, “but she’s really ambivalent, and a bit scared.”
“And we’re a little uncertain of her too. It says schizophrenia on her chart. What’s that going to look like?”
“Oh, she’s doing well at present. You’ll find her a little eccentric maybe, but there are no delusions or hallucinations at the moment. If there were I’d probably admit her.”
“If only she were sicker, then you could admit her and then we could do the procedure while she was hospitalised. You know we’re only two floors down from the psych wards?”
There was a pause on the phone line while we both thought through what she had said, and in this way was born the idea to admit her to our ward for purely gynaecological reasons.
“You could always form her under the Mental Health Act,” said Abigail, “that would make sure she stays put.”
“Sadly no. I can only use the Act for mental illness. But I will offer her the inpatient route to get to you.”
Shelley seemed relieved at the offer when we next met, but with the bed crisis that Marina mentioned (and which was an all-too-common state of affairs for us) it looked like being a long wait until we had open beds that I could use. I worried that when the stars aligned to open a space, I would be unable to find Shelley, or persuade her to come in, but she arrived promptly when asked. She walked on to the unit looking no more hesitant than anyone facing either a psychiatric hospitalisation, or a gynaecologic operation, or both, and was relieved to see that Jean was nursing that day.
“Shelley! It’s good to see you.” Said this seasoned old nurse, who had been with Shelley during many past relapses.
“Jean! Will you be my prime nurse again? I’ve got to have this operation and I’m scared.”
“I’ll see if I can come with you on the day. Would that help?”
Shelley smiled her assent, and the pair of them disappeared to get her set up in her room.
“First you take a bed for someone who isn’t ill, and now you want me to sanction an extra nursing shift so someone from psych can accompany her to the operation.” Marina had sought me out on the unit, and wasn’t sounding any more friendly.
“Jean is willing to go with her, and might make all the difference about whether Shelley goes through with it. Shelley trusts her.”
Marina frowned, and shook her head in exasperation, but didn’t actually say ‘no’.
“Think of it like this,” I added, “the sooner she’s had the operation then the sooner she leaves and frees up a bed. If she backs out at the last minute then we’ll probably keep her longer and try again.”
I hadn’t thought Marina’s eyebrows could rise any higher, but the thought of Shelley needing a longer stay seemed to achieve that. Then I sealed the arrangement with one final comment.
“You know, this is not just about making the unit run efficiently. It’s Shelley’s life on the line here.”
And with that Marina was gone, Jean was engaged for another shift, and she and Shelley were booked for the operation first thing in the morning.
“That was nothing!” She bellowed on returning to our unit just as all our patients were settling down to lunch.
Jean lagged behind her, smiling, but encouraging Shelley to keep her voice down. Which had the same success as usual.
“You should all do it!” she continued to shout to the mixed crowd of men and women, young and old, increasingly inappropriately until Jean managed to persuade her back to her room for a rest.
Then we kept her for twenty-four hours of follow-up, before discharging her back to her peripatetic life. The gynaecology report said that all the precancerous cells had been removed, Marina went quiet, and Jean and Colleen and I shared a moment of quiet satisfaction at a difficult job that had eventually been well managed.
_ _ _
“First it was gynaecology, now it’s orthopaedics. Why is it always you causing these problems?”
Marina hadn’t stayed quiet for long, but I had no idea what she was talking about, and my face must have indicated that since she went on to explain.
“Ortho wants a patient of yours transferred here. Are you telling me you don’t know about this?”
“I’ve been in an awkward family meeting for the last hour, and I’m just going to answer my calls now.” I said, looking down at my pager, which did indeed ask me to call the orthopaedics resident.
Using that as an excuse to sidestep any more antagonism from my nemesis, I stepped into my office and picked up the phone.
“Dr Sutherland? Thanks for calling. I’m Mike Stavely, the orthopaedic resident. You taught me psychiatry in med school.”
“Ah yes, Mike!” I said, as enthusiastically as I could. His name rang a vague bell, but with over a hundred students coming through the psychiatry course every year I had long ago given up on trying to remember them all.
“We’ve got your patient Roger Thompson here after knee surgery, and we’re hoping that we can transfer him to your ward.”
“Oh dear, has he had a relapse in his schizophrenia?”
“Not exactly. But we’re finding it hard to manage him here. If you could come over then you’ll see what I mean.”
“Sure.” I said. “Is that someone shouting in the background? It doesn’t sound like Roger.”
“Er, that’s my boss Dr Hardcastle, who is, um, encouraging us to resolve this quickly.”
Since what I had heard in the background sounded like someone complaining about psychiatry being so damned slow, I got the message.
“I’m on my way.” I said, putting down the phone. Brushing past Marina on the way out I could see that I was going to be caught between an orthopedic colleague who wanted us to take Roger, and a manager who didn’t. But, I thought as I hurried to the other side of the hospital, it wasn’t so much me as my patient who struggled to find a home where he was wanted.
“Dr Sutherland!” Said the tall, dishevelled man, surrounded by healthcare staff. “They won’t let me stand up, come and help me!”
“Hello Roger.” I said from a distance. “Just let me catch up with your doctors and I’ll be with you.”
“Actually,” said Mike, emerging from the scrum of bodies, “maybe you can first tell him to get back to bed. He has to be non-weight-bearing for the next two weeks or he’ll wreck the surgery.”
“Okay.” I said, joining the action and opening a path to stand next to Roger, who was being held in place in a wheelchair. “Did you hear that? They need you to be in bed for a couple of weeks.”
“Right-oh Dr Sutherland, I’ll do anything you say.” He replied, and then immediately attempted to stand again, only just being held back by his nurses.
“OK.” I said to Mike. “Can we wheel him back to his bed. I’m coming too.”
Once there Roger seemed to settle, but as soon as I stood to leave and get the medical handover he was swinging his legs over the side again.
“No!” Shouted the staff, and intervened again to stop any weight-bearing.
Realising that I had better stay with him for a while, I then got the details about his situation at his bedside. I heard that he had slipped on the ice, and needed an operation on his knee. His right leg was heavily covered in a cast, but Mike explained that the cast alone couldn’t stabilise everything, and that if Roger put his weight on that leg then it would likely undo all the surgical benefit, and might lead to permanent disability. Mike suggested that there didn’t appear to have been problems so far, despite Roger’s non-compliance, but that it would only a matter of time before disaster caught up with him.
“So Roger,” I said, turning to him after hearing the story. “Why won’t you stay off that leg?”
“Oh, I will Dr Sutherland, you can rely on me.”
“But they say that you’ve been walking around.”
“Well, yes.” He said, briefly looking down, before resuming eye contact with me and flashing his best smile. “But I promise it won’t happen again.”
Everyone seemed to be looking at me, and raising their eyebrows every time Roger made another empty promise. And knowing what I did about him, I needed a moment to think.
This is the historical image of mental health units at their worst.
Roger was now in his forties, but had been a decade younger when he first came under my care. Even at that time he had a long history of schizophrenic relapses and hospitalisations, but had been blessed with some stability by being able to live with his long-suffering parents. They had died a few months before I met him, and he had drifted, psychotic and hallucinating, into the harsh world of homelessness. A few weeks on the inpatient unit, and one or two adjustments to his medications, had allowed him to return to his new baseline. He no longer heard voices or believed that he was being persecuted, but he was severely disabled by the other features of schizophrenia.
Psychiatrists are relatively successful at treating the hallucinations and delusions of this most severe mental illness, but it is the negative symptoms (‘negative’ because they imply deficits) that lead to disability in a majority of those with the diagnosis. We commonly see reductions in patient’s emotional expression, and their speech, and their involvement with life, but with more severe cases of schizophrenia there is also an erosion of someone’s cognitive abilities. This may show as a problem with memory, or attention, or any number of other domains of thinking.
Roger hadn’t lost his talkativeness or cheerful disposition, but he had lost a lot of cognitive function. Much of his talk consisted of sensible sounding phrases, that in fact were empty and meaningless and repeated over and over again. His loss of function was sufficient to require a guardian to manage his decision making. There were no remaining family members, and so the office of the public guardian took on the responsibility for him.
His first hospitalisation under my care had enabled us to not only treat his psychosis, but also manage a transfer to a supported living facility, thus preventing further homelessness, and the endless hospital readmissions that would inevitably follow. Having a safe place to stay, and staff to keep an eye on him, allowed him to be compliant with treatment and avoid another hospital stay. But although that was a success for the hospital system, he remained a shadow of his previous self, and proved to be a major behavioral challenge for his support staff.
“He won’t stop taking other people’s food.” His carers would complain as they accompanied him to his appointments.
“I promise you it won’t happen again, Dr Sutherland.” He would immediately reply.
“But Roger, that’s what you said last time.”
“Well, this time I mean it. And if you have any comments or concerns, I’d be happy to answer them.”
This last phrase was his stock expression, that I had heard hundreds of times, seemingly engaged and helpful, but in reality nothing more than a remembered sequence of words, signifying nothing.
This patten of appointments had continued for years now. His delusions and hallucinations remained in abeyance, but every visit brought a new behavioural issue for me to address. His staff said that being told to stop things by me had an effect for a while, possibly they thought because I was the only older male figure in his life, but by the time his next appointment came around there would be something else.
“He’s started to urinate in the sink instead of the toilet.”
“I promise it won’t happen again, Dr Sutherland. And if you have comments or concerns…”
Another attempt on Roger’s part to stand up brought me back to the present.
“We can’t manage him here,” said Mike, “but we thought you might be able to physically restrain him on a psychiatry unit.”
“We prefer not to,” I answered, somewhat shocked by the request, “or at least only as a last resort. But chemical restraint is easier. Would you be OK if I ordered an intramuscular injection?”
“Whatever you say. We just have to keep him off that leg for a couple of weeks.”
“Lorazepam four milligrams, please.” I said, and then as their nurse’s jaw dropped I added, “I know it’s a big dose, but we really need to sedate him and buy ourselves some time.”
“A big injection?” Roger interjected. “Will I be OK?”
“Oh yes,” I reassured him. “It will feel very comfortable and you’ll just drift off to sleep. I’ll stay here until it’s done.”
And with that the crisis settled, at least for a few hours, and we could all leave his bedside and decide what to do.
Shelley’s hospitalisation had been a unique example of having to accept someone on our unit without an active psychiatric disorder, and I never again had cause to liaise with gynaecology like that. However, Roger’s situation represented a more common occurrence, when our colleagues elsewhere in the hospital needed our assistance for management of an acute behavioural problem. Sometimes we left the patient in situ, especially when their need for intravenous lines and cardiac monitoring was more than we could manage, and then we visited regularly to assist by trying to calm the patient psychotherapeutically, and likely also with medications. But the orthopaedic surgeons were asking for Roger to be transferred to us, and then they would be the peripatetic physicians, coming to visit him on our ward to check on his post-operative recovery.
I was fine with this request, even though I knew Marina wouldn’t like it (and possibly because she wouldn’t, I had to admit to myself). But then what? Once Roger surfaced from his benzodiazepine induced slumber, would we have to physically restrain him?
Restraining a patient may mean a brief moment of holding them down, as was happening when I arrived to see Roger, but more generally means applying physical restraints, such as belts around their waist and wrists and ankles, that leaves them anchored to a bed. This is the historical image of mental health units at their worst, and although padded leather straps have replaced the ropes and even chains that were used in the past, protestors against psychiatry continue to use our modern restraints as evidence of what they see as barbarism. On the wards where I have worked for a couple of decades we have thirty patients, and physical restraints are used approximately once per week on somebody, so although the practice isn’t common, it’s far from rare.
What justification can we offer for this practice, which would otherwise be seen as an assault on the individual? The easiest answer (though still not enough to convince sceptics) is that without being restrained some people would violently harm themselves or others. This is certainly true, but begs the questions about why we can’t manage the situation without tying someone down. And we do try. Our most benign interventions with a potentially dangerous individual are to try and engage them verbally and de-escalate the situation with a conversation, usually focused on their major concerns. Some staff are wonderfully skilled at this, and even I have felt the great satisfaction that stays with me long after I have successfully talked down someone who might have ended up restrained.
When verbal de-escalation fails, we then have a hierarchy of interventions, that leads only to physical restraint as a last resort. Next, we might place someone in a room whose door we can lock, which effectively secludes them from hurting anyone else. But if that isn’t enough then we proceed to chemical restraint with medications to sedate someone. This may be because they might be hurting themselves, or merely because their level of distress is unbearable, and it is a kindness to send someone to sleep for a few hours’ break from their torment. And then, only if everything else has failed, will we restrain someone physically.
That is the rationale for using restraints, but how are we legally permitted to do this? In the acute setting, when someone may be about to harm themselves or someone else, then no special legal arrangements are required, and common law allows mental health staff (or laypeople coming across such a situation outside hospital) to restrain someone for safety reasons.
Once the urgent need has passed, and if ongoing restraint is needed, then a legal process is required. Most commonly we can declare patients requiring restraint to be non-competent to refuse, since their lack of insight prevents them from seeing that they are not actually about to be killed by unseen delusional persecutors, for example. This step allows us to approach someone else for substitute consent, most commonly the patient’s nearest relative, or occasionally a guardian.
The whole process of physically restraining someone is obviously distasteful, but is it harmful? Usually the restraints are safe, but occasionally someone will struggle so much, or the straps be tightened so much that physical harm results. This damage is most often to muscles, and may result in a scary consequence called rhabdomyolysis, but there are also rare reports of patients strangulating themselves in restraints and dying, though I have never come across a case myself, or even rhabdomyolysis. Having nursing staff in attendance substantially reduces such risks, and is mandated in every hospital where I have worked.
But beyond the risk of physical damage, what of the psychological consequences of being restrained? The worst I can see would be in someone for whom the restraint would echo some past trauma. Physical or sexual abuse in childhood is horrifically prevalent in society, and even more so in the backgrounds of patients that I see. So being tied down to a bed by authority figures will inevitably trigger memories of past assaults, all leading to a worsening of someone’s mental state. But even if someone’s past is free from abuse, the process of restraint has a psychological consequence that is unhelpful for them, and also for me as their psychiatrist.
Most psychiatric disorders carry the potential for recurrence, meaning that after someone has recovered from an acute episode, they and I need to concentrate on preventing another round of illness. We might use psychotherapeutic techniques or medication for this, but the disorders that most likely lead to restraint are psychotic, for which medication is the mainstay of protection against relapse. This means that my psychological skills are focused on engaging a patient into long term follow-up, and having sufficient insight into the need to remain on medication. This can be a challenge in itself, but it is made far harder if at some point I have had to order physical restraints. For why should they trust me in future if I have imposed such primitive control over them in the past? I always explain my reasoning, and I try to appear mild-mannered and understanding, and sometimes a patient does grant me full cooperation in prophylaxis after being restrained. But equally often someone takes their discharge from hospital once recovered, and is then never seen again, in my office or a pharmacy, until the inexorable cycle of relapse brings them back to the emergency room, and maybe even another round of restraint.
Roger’s need for restraint, if that was what we were going to do, was unique in my experience. His mental state was at its calm and pleasant baseline, even if we knew not to trust any of his assurances about the future. We would never usually restrain anyone acting so benignly, yet if we didn’t then his knee would likely come apart under the pressure of weight-bearing, and leave him with a physical disability to add to his chronic schizophrenia. Although I couldn’t see any other way forward, I didn’t feel comfortable about making the order, and so I did what we always do when in doubt.
Dr Gladys Wong was sitting at the charting desk when I got back to our unit (with Roger being wheeled along in a bed behind me, oblivious to the world after his intramuscular shot), so asking for a second opinion was a matter of thirty seconds or so. And even after she agreed with me about restraint, I knew I had an automatic third opinion in this case, since I had to get the consent of Roger’s public guardian.
“I’ve never come across anything like this,” said Editha, Roger’s guardian, when I called her. “I’ll ask around amongst my colleagues, but if the surgeons say he has to stay off his legs to save his knee, then I’m thinking that I’ll need to agree. I know Roger won’t just do as they say. How long have I got to decide?”
“Can I hear back within twenty-four hours?” I said. “The sedation might last that long, or if not I can give him another shot, but it’s not good to keep him comatose for day after day.”
“OK. Talk to you tomorrow.”
And with that she put the phone down, and went off to get her own second opinion from her own colleagues, since she too found herself in uncharted territory.
And with that they went off to see their patient, leaving manager and doctor chuckling together, in a never-to-be-repeated moment of guilty complicity.
“I’m sorry about this, Roger.”
“That’s alright Dr Sutherland,” he said smilingly, before adding, “Sorry about what?”
“About these restraints you’re in.” I said, indicating the thick brown leather straps and buckles that held him, starfish-like, to the corners of his bed, and which Editha had sanctioned.
“They’re fine,” he replied, “but what are they for?”
“To keep you off that leg of yours. It’s vital that you don’t put any weight on it for two weeks.”
“I remember. But you needn’t worry, I won’t stand on it.”
“That’s good.” I answered, keeping my disbelief to myself. “We’ll have to let you sit up to eat, and you’ll be out of restraints when you need to go to the bathroom, but we’ll have to have you in a wheelchair with a nurse nearby.”
“OK.”
“Do you have any questions for me?”
“No. But if you have any comments or concerns…”
His guardian had consented, Marina had silently acquiesced, and Mike had come to visit Roger daily to check things were OK. The x-rays looked good, and so I think we all relaxed.
“I haven’t seen your boss during this process,” I said to Mike one day as he was writing up his charting after a visit, “and I don’t think I’ve met him before.”
“Dr Hardcastle? No, I don’t think he’s come yet. Between you and me I don’t think he feels very comfortable about psychiatry.”
“It happens.”
“Especially amongst surgeons?”
“Ah now, that’s an old, old prejudice. There’s lots of psychologically aware students going into surgical specialties these days. You look pretty comfortable here yourself, I would say.”
“Thanks. I reckon we got a good exposure to psych in our medical school training, and that’s what makes the difference. Anyway, Roger is doing well, and so he should be able to stand up soon. I’ll bring Dr Hardcastle along tomorrow to give the final confirmation, and then we can take him back to our ward. Thanks for being so flexible about having him here.”
“No worries, but I know our manager will be happy to have him back on your unit.”
The following day I was sitting in the room behind the nurses’ station, quietly checking test results, when I heard the shouts.
“Roger!”
“Get back in bed!”
“Don’t stand on that leg!”
Rushing on to the open ward I saw Roger, cheerfully standing in front of his wheelchair with his nurse trying to get him to sit again, but without wrestling him down and causing more damage.
“Help me get him to sit again.” She called.
“Hello Dr Sutherland.” Shouted Roger, waving at me.
“He got away from me as I was opening up the bathroom for him.”
They had quite a group of staff collecting now, so I turned back to the desk in order to allow them space. And that’s when I noticed. Looking down the corridor to the unit’s entrance, I saw the door open, and in walked Mike with a large, white-coated, and uncomfortable-looking man who had to be Dr Hardcastle.
I quickly turned to see how we were doing with Roger, only to find him still on his feet, and still waving to me enthusiastically. Fearing the worst, not only for my patient’s surgical outcome, but also for the furious dressing-down that I saw coming in my direction, I glanced behind me again.
Mike and his boss were coming down the corridor, but apparently deep in conversation, and as yet unaware of the drama still unfolding at our end of the ward. Then I also saw Marina, standing at the desk, and staring our way with an appearance even more hostile than usual. I caught her eye, and pointed to the approaching thunderstorm in the corridor. After that I turned again and joined the crowd getting Roger back into his chair, and then into bed.
As his final restraint straps were being tightened I looked at his leg, which appeared unchanged in its angle, though the plaster cast hid whatever damage might have been sustained. While my eyes were focusing on Roger my memory had been running wildly back to my early days in medicine, when I always felt the discomfort of being on a surgical ward, and being found wanting by the staff. Now this burly orthopaedic surgeon, who didn’t like psychiatry himself, was going to come and explode at our inability to protect his careful surgical handiwork from Roger’s undoing.
However, no one arrived, and eventually I left Roger’s room and went back to the desk. There stood Marina, who beckoned me over, but there was no sign of Mike and his boss.
“They’re in the back, looking at the x-rays.” She said, reading my mind. “I think I distracted them well enough by asking about when they would transfer him back to ortho. Is Roger OK?”
“As far as I can see.” I answered, noting her co-conspirator stance. “Thanks for your help.”
After this the surgeons appeared, and Mike made the introductions. He’d warned me that his boss was uncomfortable around psychiatry, but I wondered if he noticed my awkwardness in return.
“Thanks for having him here.” Said Hardcastle.
“Oh, it’s our pleasure,” lied Marina.
“How much have you been able to keep him off that leg?” Queried Mike.
“Almost completely,” I said, avoiding a lie, though trying to downplay things as much as I could. “We’ve had to restrain him in bed, but when he gets up to the bathroom there is sometimes a moment of weight-bearing till we regain control.”
“Hmm.” Said Hardcastle. “It’s not ideal but I suspect that’s as good as we could expect.”
And with that he and Mike went off to see their patient, leaving manager and doctor chuckling together, in a never-to-be-repeated moment of guilty complicity.
All names and other identifying details have been changed to protect patient confidentiality.
JP Sutherland 