First Night on Call in Emergency Psychiatry

It is evening in early winter as I pull into the parking lot of McLean Hospital to begin my first night on call as a medical student in psychiatry. McLean, the country’s top psychiatric hospital, is situated on 200 acres of woodlands in a suburb on the outskirts of Boston. Gusts of wind scoop up handfuls of fallen leaves, tossing them against the luminescent sky and creating a glitter of black particles against the yellow-gray light. I step from my rusting Honda onto the ice-glazed tarmac. Crows splotch the barren trees like a Rorschach test—a fitting image, I muse, for a psychiatric institute. This acclaimed institute counts among its alumni the likes of Anne Sexton and Robert Lowell. I cross the parking lot and head towards the brick emergency building. I sweep through the double glass doors of the entrance, through a waiting area filled with commotion, and make my way towards the front desk. The senior resident I have been assigned to work with sits at the desk in pale green scrubs, her dark brown locks of hair tumbling like seaweed over her shoulders. She peers up at me through large horn-rim glasses. She reminds me of a koala bear clinging to a shaky tree, staring into the dangerous world beyond. I can sense she has spotted me but she pretends nonetheless not to notice. She is letting me know she is my superior. I need to acknowledge her seniority. These are the rules of the game. Crossing them could cost your evaluation with consequences for residency applications. A previous resident had told me: “You piss off a resident, and you’re dead!” I approach the ‘senior’ slowly, respectfully. She does not look up but continues to flip through the chart, reading under her breath as if memorizing. I clear my throat: “I’m the…” I begin. “…med student. Got it!” she irately interjects, announcing my name for emphasis. Without introducing herself, she rattles off the cases under our charge. For each, she has efficiently summarized the pertinent data into one or two bullet points which she has committed to memory. A solid memory was the truest sign of a ‘strong’ resident. Months earlier, I had expressed to a clerkship director my concerns about the potential safety hazards of memorizing the chart. He responded tartly by asking: “Wouldn’t you like your doctor to have memorized all your medical information?” The resident suddenly stands up from her chair, and we dart towards the patient exam ‘room’—a cramped cubicle. On a side table, the nurse has laid out the patient charts, but they remain closed through the evening. The resident has apparently memorized them. The nurse ushers in the first patient: a highly distressed young woman talking nonstop (‘echolalia,’ I think), accompanied by her parents. She has miscarried again. The last time she miscarried, her husband beat her blue and threatened to leave if she “did it again.” She “did it again,” and he is now leaving her. She is frantic. The resident decides to admit her. We admit a patient who attempted suicide, then another who is psychotic—this one a ‘regular’ brought in by police for disturbing the peace in downtown Boston. The waiting room continues to fill like a rising tide. We are falling behind. The charts remain unopened on the side table. Across the room, I spot an attractive teenager of about sixteen sitting by herself in a corner. She watches me. Our eyes lock for a second. She has light brown mousey hair that falls lightly on her shoulders then curls up like a fresh tendril, a small snub nose and otherwise regular features. She appears calm and centered—a lighthouse in the stormy seas around her. Only her soft gray eyes betray her—rainy gray eyes, like a cloudbank shielding out a scorching sun. I had come to recognize these eyes in patients who had suffered. We see three more patients before this teenager is ushered in. Her name is Tracey. I spot her chart on the side table and am tempted to flip through it but decide against it for fear of antagonizing my resident. The resident is curt with her, tells her to have a seat, and then fires the standard opening question: ‘So what brings you here today?” There is an uncomfortable pause. The resident looks up, raising her voice. “What seems to be the problem?” “I need a refill of my meds—the blue ones,” Tracey says softly. “I don’t have insurance. I live by myself. I feel bad.” “What is the problem?” the resident presses. “I don’t feel good, and my boyfriend left me.” “What happened? Why did he leave?” “I’m not sure, although I don’t blame him.” She falls quiet. The resident pushes her, but Tracey is giving away little. The resident launches into the medical review of systems. Tracey cooperates sullenly with a series of impatient “Yes…No…I dunnos.” The resident proceeds undeterred. “Bowel movements?” she asks. “Are you having regular bowel movements?” Complete silence follows. “Bowel movements?” she repeats. “Are you having regular bowel movements?” Tracey hesitates. I sense frustration as she stares at the agitated resident in disbelief. Then she mumbles matter-of-factly, eyes downcast, “I don’t shit.” “Bowel movements! You must have bowel movements. When did you last go to the bathroom?” the resident presses. “I don’t shit!” Tracey repeats with rising anger, darting a wide-eyed look at me. “What do you mean ‘You don’t shit’? Everybody shits!” the resident insists. “I DO NOT SHIT!” Tracey screams back. “I have no arsehole! Got it?! No a-n-u-s!” No hole to shit from! Ever seen that?!” “What do you mean ‘no anus’? Everyone has an anus!” the resident retorts. They glare at each other. Then Tracey rips off her sweater and tee shirt. She has no bra. Her breasts fall out. We look, expecting breast pathology, but she is pointing to her side. “See that?” she says. Then we see it. A small plastic bag fastened to her side with traces of greenish liquid inside—a colostomy bag. “That’s where I shit! No anus! Want to see that too?!” Before we can stop her, she drops her jeans and panties to the floor, bends over and splays her buttocks. She has no anus. In its place, just soft skin, like an eyelid covering a blind eye. In place of what should have been the sphincter of her anus is pale scar tissue—a soft pearl on the sea floor between the two waves of her buttocks. Her anus has been surgically closed. She pulls up her pants, replaces her top, stares at us in soft defiance. Her eyes fill with tears. “Crohn’s disease,” she whispers. “It’s all in there,” she says, pointing to the unopened chart on the side desk before she raises her voice: ”Don’t you ever read it?”