Sometimes I daydream about a hospital in itself being a myriad of organ systems; a patient micromanaged by an overwhelming power (administration) in terms of providing life support (funds, employees) and this delivered through transporter proteins (Medical Teams), which release transcellular messages (investigations, management plans) with paracrine function to other local cells (Healthcare Professionals). Through this extensive, complex process, one reaches cells that are dysfunctional (Patients) and aim to reverse or control the damage (Disease) in the hope of restoring their function in the role of the whole (Community).
It is not uncommon for medical professionals to go about their everyday work and yet feel detached. Both as a subconscious coping mechanism and as a way of minimising their workload. And through these barriers, we set up not only thick skin resistant to the everyday tragedies we encounter, but also distort our senses: re-setting the "normal" range such that certain news that was considered significant (example 1: you need your gallbladder removed), life-altering (example 2: we need to remove your breast and most of your armpit to catch this cancer) and terrifying (example 3: there's only one solution: we remove your rectum, anus, vagina and bladder. It's the only way to increase your life expectancy) have now become benign, mild and moderate.
And the process is progressive; continuous such that the normality is continuously re-set as clinical experience lengthens and our insight deepens. This brings me to the situation that provoked these thoughts within me.
Matthew, a 28-year-old gentleman, was brought into the Emergency Department by Police under Section 22 (i.e. as an involuntary patient because he was considered mentally disordered). The reason he was brought in with his wrists clamped together with cold steel was a high-speed chase. We weren't told why Matthew was running, or what preceded the hot pursuit. But we did know we needed to see whether the police were correct about his mental state.
That's about all I knew about Matthew just before the nurse mumbled Bipolar Disorder at handover. The clinical picture was a little clearer now; he must've been manic. At that point, it was time to meet him with the Psychiatry registrar.
He was very agitated about being in the mental health ward. I'm being held against my will. Why can't you understand this place is not the best location for my recovery? Why can't you understand? What's your problem? Why are you looking at my hands? You keep getting distracted!
It escalated for a short time and I was sure that Matthew was going to get up and start throwing chairs around the ward, but luckily he didn't; another patient not too far away already volunteered his attempt at sharing a psychotic breakdown and successfully did with four security personnel and a nurse. After a few weeks in this ward, such events seemed not-so-dramatic.
I couldn't help it... I had to ask the registrar. Why did you keep looking at his hands?
"Because I was afraid he was going to get physical. Also, he had complained about upper limb weakness and paraesthesia earlier today. I was grossly assessing his movements. Seemed quite normal to me. What do you think?"
Uh.. I don't know.
The registrar decided to see Matthew a few hours later with the consultant, along with his family. I could sense that he was very restless and agitated, but not in a 'mentally disordered' way. He seemed rational and as the Psychiatrists say, "no formal thought disorder".
Matthew's parents and younger sister attended the meeting to discuss the issues around his admission into the mental health team. Apparently for the past few weeks, Matthew had been demanding his family sit and listen to his teachings about computer specifications, why they should purchase electronic goods with highly specific and elaborate criteria. It got to the point of happening every day, for at least several hours.
What do people do when they get home from work? They walk through the front door, take their shoes and socks off, get into their comfort zone and chill. Well, Matthew's family wasn't allowed to do any of that. They had to walk through the door and listen to his teachings. Luckily he had a job as a night-filler at the local supermarket and the family had some hours of peace late at night, which they used happily to rest and recover.
They wanted Matthew to continue staying in the mental health ward involuntarily until his agitation and from what we understood clinically, his mania, subsided. Dr. BB agreed and we asked Matthew to join us to discuss what we thought. The tricky part was to ensure Dr. BB made clear it was his decision to keep Matthew in the ward, not his family's.
Dr. BB - I don't think it is safe for you to leave just yet, Matthew.
Matthew - Why? I don't see any reason for me to stay. This place is destructive. You're holding me against my will. How could you possibly believe this place is doing anybody any good? You can't smoke, you can't socialise with the other people. There's nothing to read, no access to the internet or phone.
Dr. BB - What would you like to do?
Matthew - I would like to go home where I can smoke, spend time with my dogs and cook some dinner for my family. I want to be able to do the things I normally do to lower my stress. But you can't do that here.
Dr. BB - What can't you do?
Matthew - You can't smoke, for starters.
Dr. BB - We have nicotine patches. I would be happy to organise them for you during your stay here.
Matthew - Mate you know better than me... There are twenty addictive substances in a cigarette. Nicotine patches replace nicotine, but what about the other nineteen addictive chemicals? Do you have patches for them too?
*Silence*
Matthew - This is damaging to me. I don't want to be here. I'm being held against my will. How do you think this environment is healing? There's nothing healing about it. The people are really unwell, the nurses don't give a shit and it takes half a day to see a doctor about anything. It's no different than incarceration.
Dr. BB - I understand. There's nothing I would want more for you than to let you go and enjoy everything you normally do. But -
Matthew - What about my job? I just signed a contract obliging me to work full-time for next twelve months. How can I call my boss? How can I keep this job if I just got this contract and I'm asking for leave? Would they let you do that here?
*Silence*
Dr. BB - I think it is important you stay here for the rest of the week and then we can review you. Once I'm convinced that you're better and your agitation has settled, we can think about granting you some leave.
At this point tears started trickling down Matthew's face. He got up and stormed out of the room.
I couldn't help but feel sorry for him. Although he was mentally disordered to some extent according to the team, he had arguments that were hard to disagree with. How can cigarette addicts control their mood, agitation and attitude well without their regular consumption of smokes? Is it not true that being confined to an environment crowded with people who are also mentally disordered is detrimental? How can one argue with his points? The consultant certainly couldn't.
Matthew's family agreed to his stay at the mental health ward at least until the end of the working week. It didn't seem he had blamed them, but he sure wasn't happy and I think that's appropriate. Nobody would want to be detained against their will - it is a violation of the basic principles of freedom.
It was a dilemma. Did he have good insight into his illness? He seemed to be aware of what had happened and he was able to describe his arguments meticulously. I didn't want to let this go... I promised myself I would bring it up with Dr. BB and when the time came, I did.
Me - Matthew was actually quite reasonable, wasn't he?
Dr. BB - How so?
Me - Well, I don't think this ward is very healing. He is right in being upset about not having the right to smoke, not having access to the things that usually calming him down. Do you really expect him to get better?
Dr. BB - I do think with time he will settle, particularly with medication.
Me - What about the nature of his recovery?
Dr. BB - Yes, I see your point. What can I do about it? I don't think he is safe to be discharged.
**Silence**
Dr. BB - I agree with you. This is not the best place for his recovery, but until he settles down, I don't have much else I can do. And I also think the family needs some time off.
For all I know, Matthew was intact. His reasoning and rationale were convincing and it was hard for me to contain myself listening to him because the tragedy, for both Dr. BB and him, was that he was right.
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