The Imposter (8 page)

Alex
felt safe for a brief moment.  Then she realized, with a sinking feeling, that
she was in a very dangerous situation.  Suppose the other patients acted out? 
Didn't that happen often?  She tried to remember from her nursing school days. 
Didn't one patient incident spark other patients to act out? Like an avalanche?
Of course they did.   She felt her heart rate pick up quickly and the hair on
her arms stood up.   She felt chilled.   Yes.   That is what happens.   That's
exactly what happened last night in this very place! Alex looked around
furtively. 

Several
patients were agitated, rocking back and forth in their chairs in perfect
rhythm.  Another patient was plucking invisible particles from the air.  Alex
felt her heart fill with panic.  Just to her left was another large man.  He
suddenly began screaming and pulling at his hair.  Then he stood up and started
pitching empty chairs against the window, hollering that he had to get out and
save his baby.

Donna
Meade looked at the patient, calmly touched his arm, and said in a soft, steady
voice, "Jim, stop throwing the chairs.  You're okay now.  You're in the
hospital and nobody's going to hurt you.  Please, you're upsetting the other
patients." Donna's voice was calm and quiet.  She slipped her hand into
the crook of Jim's arm just as he was about to toss another chair at the barred
windows.  He immediately replaced the chair on the floor.

Jim
gave Donna a confused look.  Then recognition seemed to appear on his face. 
"Oh, oh, oh!  I gotta get outta here.  I gotta go.  I'm sorry, Donna.  I
didn't mean to cause no trouble." Jim's eyes were terrified and he was
full of tears.  He looked ashamed of his behavior.  The huge man was literally
cowering before the staff and the patients.

"I
know, Jim.  You just couldn't help it.  Let's go to the quiet room and rest
awhile." Donna continued to hold his arm gently.

Then,
to Alex's amazement, the large man allowed the petite Donna Meade to walk him
back to his room.  Donna motioned to Monique that she needed some medication and
then said to Jim in a quiet voice, "I want you to rest for a little
while.  We'll talk about this later."

Alex
shifted her eyes from Jim and glued them on Monique.  If Monique left her in
the community room, there'd be no staff member at all to subdue any patient
outbursts.  In fact, they had been lucky that Donna had been able to quiet
Jim.  It would have been impossible for Alex, Donna, and Monique to wrestle the
enormous man to the floor.

Several
minutes ticked by.   It was finally quiet.  The only noise in the room was the
click, click, click sound of someone clicking their tongue against the roof of
their mouth and the squeaking of the two rocking chairs as the patients
continued rocking back and forth.  Monique made a decision.  She spoke to the patients
in a cool, calm voice, glancing at her watch.

"Our
time is about up.  Why don't you all take a break and then report to where you
should be at 4 o'clock.  Rose, you can go to my office because we have
individual therapy at 4:15.  The rest of you know your schedules."

The
patients left the community room quietly.  Only the two rocking patients
remained.  Alex breathed a sigh of relief.  She was impressed with how Monique
had handled the situation.  Dr.  Desmonde's firm tone of voice had waylaid any further
patient outbursts.  The psychiatrist had taken control of a potentially
dangerous scenario by neither acknowledging nor discussing the situation and by
redirecting energies of the patient group in a positive manner.  Her behavior
and poise were highly professional.

Alex
glanced around, still uncertain of her surroundings.  "Monique, we've
gotta talk …," Alex began.

Monique
lifted her index finger to silence her.  "Yes, but first I've got to make
sure Donna got Jim to the quiet room.  Wait for me.  I'll send some medicine
and a psych tech back here to deal with these two."  She gestured at the
two remaining patients.

Alex
left the community room and walked into the central nursing station, behind a
door and glass windows, where she felt much safer.   She was relieved to see
the patients playing board games and watching the soaps on TV.  She wondered to
herself how therapeutic watching soap operas could be, but figured it was
better than beating up on each other and the staff.   She decided to keep her mouth
shut about what she thought was therapeutic.   She turned and saw Dr.  Desmonde
in the medication room and followed her.  She watched as Monique selected a 3
mL syringe from the locked cabinet, snapped the top off an ampule of Haldol and
deftly filled the syringe.  Monique continued to draw up Ativan for
anti-anxiety and Cogentin to combat the side effects of the Haldol.

"Alex,
come go with me," Monique intoned as she nodded towards the hall.

Alex
and Monique walked deliberately down the hall to the quiet room, where they
found Donna and Jim talking quietly.  Jim had been crying.  As they entered the
quiet room, he was saying, "Donna, I don't know what gets into me.  These
tempers just come.  I don't know what to do.   I need help.  I'm scared.  I
never know what I'll do next." Jim was so upset, he began to sob, his
voice coming out in great gulps.

Donna
patted his shoulder reassuringly.  "Jim, we're gonna try to help you.  We
care about you here in the Pavilion, don't we, Dr.  Desmonde?" Donna's
acknowledgment of the physician's presence drew Jim's attention to Monique. 

He
looked at Dr.  Desmonde sadly and said, "Sorry, Doc.  I just need more
help.  I don't know what's happened to me.   Is there something else you can do
to help me?  A new pill or something?"  Jim's voice was desperate.

"I
know, Jim.  I know you don't understand your outbursts and, yes, we will
continue to help you." Dr.  Desmonde looked sad as well.  "We'll keep
working on it.  We've made some headway.  I've made you a shot that'll help you
rest.  Where do you want it?"

"Can
I have it in my left arm? Last time it was in my right." Jim pointed
towards his left deltoid muscle.

"Well,"
Monique hesitated, "this needle's a little long.  How much muscle do you
have in that arm?"

"Doc,
I got muscle.  I just don't have no brains!" Jim smiled for the first
time.  Alex was surprised at how handsome he was.  He had a beautiful smile,
dark hair, and perfect, brilliant white teeth.  She guessed he was in his
mid-thirties.  He looked to be of Irish descent. 
The Black Irish
, Alex
wondered to herself, acknowledging her knowledge of Jim's bad temper.   How
very sad if he is really one of them.

Dr. 
Desmonde returned his smile as she injected the needle and said, "You've
got plenty of brains, Jim.  They're just a little scrambled right now.  We'll
get them fixed!"

"Thanks,
Doc, Donna, and Alex.  I'm pretty tired now.  I guess I'll sleep awhile.  See
you soon." Jim turned over in the bed of the quiet room.

Alex
was impressed that Jim had remembered her name and said so to Monique and Donna
on the way down the hall.  Donna said, "Jim's very bright.  I'm not
surprised at all.  I like him.  He wants to get better and I want to help
him." Donna's voice was concerned, her interest in helping the patient
obvious.

Dr. 
Desmonde looked narrowly at Donna.  "Don't let personal feelings get in
the way of professional judgment, Donna.   Jim's very ill, psychotic.   Don't
set Jim and yourself up for disappointment.   Don't get too involved in this
case."  Monique's voice was sharp and a little accusatory.

Donna's
face turned red and she replied hotly, "I'm hope you're not suggesting I
have feelings for Jim that are other than professional!  There are no boundary
issues here for you to be concerned with." Her voice was cold and
defensive.  "It's just that most of our patients are chronic and we never
really help them.  Besides, most of 'em don't want help.  Many are so
manipulative, they can't be trusted.  I doubt many of them even want to get
well.  Jim does.  That is the impetus driving my 'involvement' in this
case."  Donna was enraged and felt attacked.

Monique
was quiet for a moment and then spoke.   Her voice was repentant and
reassuring.   She'd accepted Donna's rebuke with grace.  She shook her head and
said, "I'm sorry, I apologize.   I know how you feel, Donna.  I have a
special place for Jim myself.  But, we have to keep it all in perspective.  I
am sorry if you think I suggested that your involvement is anything other than
professional," Dr.  Desmonde's voice was pensive and apologetic.  She
hugged Donna around the shoulders and added, "Nice job in there,
gal."

Donna
hugged her back.  "Thanks Monique.  But, you and I both know we've gotta
do something about this place and the staffing.  That situation could have gotten
completely out of hand -- the one last night did!  My nurses are scared. 
Several are terrified and are planning to leave the Pavilion." Donna
stopped for a minute and then admitted, "I'm scared too, and that's not
even factoring in what happened to Angie.  The patients are getting sicker and
sicker and more and more violent, especially since we started taking the ones
from the state hospital that Lester Whitset contracted for.  We're not staffed
for those types of admissions."

Dr. 
Desmonde sighed. "Yes, yes.  I know, Donna.  I'm trying to get more
positions allocated, even if they are only muscle positions.  I'd be thankful
to have strong bodies to help us in emergencies like this one today.  Since
we've been under this contract management, it's next to impossible.  We need
more behavioral health techs to help us out when we have these outbursts of
violence."

Alex
nodded in agreement with Monique and said to Donna, "I'm concerned about
your staffing, too.  You don't have enough staff to handle such severely ill
patients and control these kinds of situations.  What's your typical
census?"

Donna
responded quickly.  "We've got 22 general psychiatry beds and average
about 18 or 19 patients.  Usually, 8 or so of them are overtly psychotic and
have histories of violence or acting out behavior.  The rest are acutely
depressed or have organic brain syndrome and/or Alzheimer's disease."

Alex
nodded in understanding.  "How long have we been mixing the elderly and
the adolescents with the others?  I thought they used to be separated."
Alex asked, looking questioningly at Monique and Donna.

Donna
shook her head and answered, "We started mixing them at the time the
contract manager started.  Whitset cut our staff 20%, making it impossible to
run an age differentiated behavioral health unit.  He maintains that a
therapeutic milieu can occur with all ages together, so everyone can ‘learn
from each other'!  Isn't that some crap?   We've even had to eliminate
geriatric and adolescent tract therapies.  We couldn't staff them!"
Donna's voice reflected her dismay.

"How's
it working?" Alex asked.

"Not
well, not well at all I'm afraid," Donna said.  "The patients just
don't identify with each other because of their ages.   Mrs. Smithson, the
elderly patient with the apple cheeks, is appalled when the adolescent female
patients talk about their sex lives and how they have to have "it"
every day.  The way they talk about sex is disgusting to Mrs. Smithson and I
know it horrifies her.  In fact, her son told Angie last night that he thought
she was worse.  He said he was gonna transfer her to Ochsner's private
geriatric program.  I don't blame him.   She could get better care there, at
least more care directed towards her age group.   I'd move my mother over
there, as opposed to here, so she could get better care.   No question about
it." Donna shrugged her shoulders.

"Is
Mrs.  Smithson the little lady who looks like Mrs.  Santa Claus?"

Monique
and Donna nodded.

"Why's
she here?"

"She's
in for a reactive depression.  Her husband died in April and her only daughter,
her caregiver, has rheumatoid arthritis and breast cancer.   It's very sad, but
also very typical for people in her age group.  Her son is correct when he says
we haven't helped her.  Older patients need a different kind of care that is
more structured to their place in life and their late life losses.   Do you
think we have been effective with her, Monique?" Donna looked carefully at
Dr.  Desmonde.

"Perhaps
the meds have helped some, but basically we haven't helped her much.  You're
right, Donna.  What we are doing isn't helping.  I'm philosophically opposed to
mixing these patients, but in view of managed care and reimbursement, we have
no choice.  I guess some concentrated care is better than none at all.  At
least we can watch her for suicide attempts -- at least, most of the
time." Monique looked sheepishly at Alex and Donna.

"What
do you mean, most of the time?" Alex asked, her voice anxious.

"Face
it, Alex.  I usually have two RNs and two psych techs on the day shift.  There
is even less staff on evenings and nights.   We have no security and not a lot
of muscle to wrestle these people down if they have outbursts.   My RNs have to
assess each patient, do paperwork, run groups, give meds, handle emergencies,
and participate in community meetings.  The psych techs supervise the daily
care of the male patients and, together with the RNs, monitor the five-step
patient responsibility level."   Maybe it will get better when the new
health reform act goes into effect.   I heard that it may."