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Sophia Malik, MD-MPH candidate, Family Medicine

“How are you feeling today, Ms. Jackson?”

I clear my throat, realizing my words had been inaudible. “Ms. Jackson! Hello!”

I try again. “I’m Sophia, the medical student taking care of you. Remember we spent some time together yesterday afternoon?”

“Oh yes, Stephanie, hello. Yes, yes, I remember. And you are?” She directs her gaze to the student next to me, who proceeds to introduce himself. This continues until all eight members of the team provide their name and position to Ms. Jackson. My heart, which had surely been beating twice the normal rate at the outset of rounds, is now at risk of exiting straight through my mediastinum and into my hands. Even though I am halfway through my first year on the wards, rounds still make me incredibly nervous. Deep in the gray matter of my cerebrum are precariously stacked blocks of facts waiting to tumble at the slightest provocation. No matter what question I ask, or what I am expected to answer, the blocks must keep their balance.

Satisfied after receiving thorough introductions from the eight white coats that face her, Ms. Jackson pushes aside her breakfast tray, leans back in her dayroom chair, and stretches her hands out behind her head, creating a cozy little nook for her neck.

The ball is back in my court. “Ms. Jackson, I noticed you’re wearing sunglasses today, is there a reason for that?” We are indoors on a locked psychiatric ward, and the few windows dotting the hall provide a view of a truly dreary day.

“Is there any way you could be above ground?” Ms. Jackson responds.

I am most definitely tachycardic by this point. What good are clinical catchphrases or even basic kindergarten conversational skills when speaking to someone from another reality? Five minutes pass and I have not assessed anything of value for my team. Even if there is a secret message hidden in her nonsensical words, this is no time for a game of “Words With Friends.” The basic review for the morning must be completed, and quickly, or else the resident will swoop in and get it done for me. Maybe even the attending, if things get desperate enough.

I prod, more directly this time. “Can you hear or see things that others can’t?”

“See here, these glasses, if you look through them, you can see the pattern. I will show you, take a look.” She hands me her glasses while continuing to explain their experimental effect. I resist at first, and my discomfort shatters my plastered smile. She insists, however, so I take a quick look through the lenses.

“Sorry ma’am, I think my vision must be different.”

“Yes, everyone’s a bit different. That’s quite alright.” Her response comes with a tinge of pity.

As my attending shifts on his feet and checks his watch, I jump to the chase. I ask if she has had any thoughts of harming herself or others. As always with these questions, she seems to momentarily focus in on the seriousness of my world to answer very clearly in the negative. The herd shuffles on to the next patient.

The following morning, my determination is renewed. It’s like being an athlete, I’ve told myself. Visualize success. You will knock any curve ball out of the stadium. I scour the medication record and nurse’s notes from overnight. Despite heavy and frequent doses of lorazepam and olanzapine, Ms. Jackson only slept half an hour. A familiar voice catches my attention. I peer over the chart and spy Ms. Jackson quizzing a nurse.

“Today is the twentieth of March, right? And it’s Wednesday?” As she continues to ask the nurse a few more questions, I realize that she has figured out our pattern for assessing how alert and oriented she is to time and place. Just as I study her chart in preparation to ask her questions, she is predicting and studying the answers she will give me. I smile, knowing that while she may be manic, she is indeed quite clever.

An hour later, we make our merry-go-rounds. This is the geriatric psychiatry ward, and there are slim pickings for conversation. The majority of our patients are in a depression-induced coma-like state, awaiting their next electroconvulsive therapy, the only alarm clock left to awaken them from their stupor. While I silently wait for one of the other medical students to interview his catatonic patient, I see Ms. Jackson on the other side of the dayroom. She is busily working with a uniformed hospital volunteer. She smiles and laughs, gesturing wildly as the magician’s hat that she has chosen to wear today teeters on the side of her head. She tears pictures from magazines, creating a collage with the help of the young volunteer. I have learned from her chart that she was once a talented artist, and she claims to have created a quilt that hangs in our Cancer Hospital. How must she feel, to now be prohibited from using scissors? A life spent manipulating bare metals and fabrics into bright, chameleon-like sculptures and quilts, now reduced to tearing and pasting images from People Magazine.

I look up and scurry quickly, realizing the group has moved on. If I don’t push my way to the front, I’ll miss my chance to initiate the interview with my patient. However, this scuttle proves useless as this morning Ms. Jackson is insisting again that each member of the team introduce him or herself.

“Ms. Jackson,” the resident interrupts her. “Do you not remember us from yesterday? This same group has been visiting you every morning for the last week.”

“Oh, I remember you all. I was asking because I can’t stop my dreaming process. I was horizontal for quite a while, you see.” Her attention shifts to my fellow student. “Now young man, what do you plan to do?”

He is caught off guard by this direct address, but recovers quickly. “I’m not sure, Ms. Jackson. I think I like Internal Medicine, but I want to keep an open mind.”

“Why yes… then I shall call you Dr. Broadhead!”

The student attempts to stifle an uncontrollable laugh, but the attending is unmoved. He will not let this show go on as it did yesterday. “How is your mood today?” he asks sternly.

“It’s rising.” She responds with a flourish, raising her coffee cup. Much of the coffee spills onto her shirt. Without blinking an eye, she stands up and walks toward the wall. She reaches behind the dayroom fridge. We wait with bated breath, unsure what she is going for. She emerges with a yellow “CAUTION, WET FLOOR” sign and folds it out in front of her chair. She rests comfortably back into her seat. “Your next question, sir?”

“Ahem. We heard that you only slept four hours last night,” he continued. How do you feel that you slept?”

“Four hours! Doctor, I slept eight, or nine, or ten hours last night!”

“Well that’s very interesting. How do you think that explains what’s been recorded in the chart?”

She leans in and tips her glasses down her nose. “Your informants, I’m afraid, are not correct. I was playing possum.” She pauses for effect, peering over her frames at each of us. She stays locked in a conversation running parallel to ours for the remainder of the interview, again most lucid while denying any thoughts of harming herself or anyone else.

That afternoon I call Ms. Jackson’s daughter to update her on the plan of care. I explain the use of benzos, antipsychotics, and perhaps most importantly the steady increase in mood-stabilizing lithium. As a team, we had hoped that this would be our trump card. If the current manic episode could be contained, if Ms. Jackson could manage more than four hours of sleep, perhaps she would return to her normal, eccentric yet reality-based self. Her daughter is reassured as our conversation went on, but she eventually shares her true concern.

“You see, before I brought my mother to the hospital, I was terrified. I found her at home, on the floor, asleep in the midst of broken glass. The stove was on, the doors were unlocked. She hadn’t showered or eaten for days. I know when I was younger she used to be ‘ill’ every few years. She would go away for a while, and come back just as if nothing had happened. But this is not the same. I don’t think she can come back and go on as the same person anymore. She can’t be left alone. And I can’t be there to keep an eye on her all the time. What can we do?”

I don’t know how to answer her question. I give a canned statement about how we don’t like to discuss treatment plans with family members when nothing definite is known. I repeat that our current goal is stabilization and that once that occurs we can begin to look forward. As I hang up the phone, I realize that my left hand had been clenched tightly on my chair. I stretch out my fingers and think about what else I could have said. I know that manic patients are only hospitalized when they become a danger to themselves or others. The typical vignette described on our tests is that of a young man riding naked on a motorcycle on a highway at top speeds. The prompts are written to clearly portray something truly bizarre and alarming. I had never thought about what mania looks like in a grandmother who typically spends her time quilting. Rather than bizarre, it feels sad, wobbly. I wonder if her eccentric artistic persona will become progressively fixed in a reality tangential to ours.

I come out of my reverie and run to relay the contents of the phone call to my resident. The last thing a medical student wants to do is look like she is daydreaming. We will discuss discharge plans with the case manager and the patient the following day.

The next morning, Ms. Jackson is notably subdued. Notes from the overnight nurse inform me that the patient did, in fact, sleep seven hours. However, she also fell in the late afternoon. I am reminded how so many of our cures become causes. In our attempts to sedate the patient to keep her safe, we have risked her stability and sacrificed her ability to be confidently mobile. Today she is resting in her room, greeting us kindly as we enter. She has forgotten my name again, but at least has the resident’s name memorized by now.

“Ms. Jackson, we need to speak with you about your plans for when you leave here,” the case manager begins. “We don’t feel that you will be safe if you go back home. Also, we called Red Garden retirement homes for you, the place where you said you would like to stay, but unfortunately their waiting list is at least three months long. We need to figure out where you will go in the meantime.”

The patient shifts slightly in her bed, and for a moment the only sound in the room is that of the pressure monitor in the bed automatically adjusting the mattress. The case manager continues.

“Our best option is Crystal View.” Before the case manager can go any further, Ms. Jackson bolts up. “No! No, I will never go there! I used to volunteer there! I went there with my church group, and let me tell you I saw what goes on. Those are bad, bad people. That is a bad place. I cannot live there.”

We hold our breath. We believe her. She was always an active member of her community, and I am sure that this story is true.

“Okay. Well, we will see what we can do. We’ll continue to discuss this issue over the next few days. Have a good afternoon.” As the team exits the room, we all nod our heads vigorously as if that afforded some form of reassurance to a woman whose life was currently unhinged.

Later that afternoon, I again observe my patient from my post behind the nurse’s station. I watch Ms. Jackson standing alone in her room, rearranging her few personal items in a drawer. She did not wear a magician’s hat or sunglasses today. She did not come out to the dayroom, and I had not seen her collage for a while. Ms. Jackson had presented as an elderly woman living recklessly. Her medical recovery meant that she now appeared no different than the other patients in this gray, quiet, and distant crowd.