thermodynamicsOne of the first times I walked onto an inpatient psychiatric unit, a nurse with a kind voice and skin like shoe leather pointed to the tie around my neck and told me, “Take it off.”  

I  fiddled with the piece of cloth around my neck, attempting to not tangle my own fingers into the knot.

“Around here, that’s a noose,” she said, staring at me with a tired, knowing gaze that suggested I was not the first rosy-cheeked medical student to make that mistake.  

I took it off, left with nothing to cover the mustard stain that had failed to wash out of my shirt.  Great, I thought.  Nothing says, “Trust me, I’m a doctor,” like evidence that eating is still a learning process for me.  

Hires_No Weapons_Couture

Watercolor and Ink Painting: “No weapons allowed on the unit” by Danielle Couture, MD


Safety is a prime imperative on psychiatric units and I spent the next week learning how everyday objects are turned into deadly weapons.  There is a whole dark science to it.  Shoelaces can cut off the blood and air supply to the brain when wrapped tightly around the neck.  Pens are not for scribbling, but for stabbing the dull point into a jugular.  Pills are not for healing, but poisons to be gobbled by the handful. Chairs, as shown by the WWE, are for flailing through the air toward a skull or spine.  Kitchen utensils, forget about it.  Forks are just tiny elaborate spears.  Knives are well… knives.  A spatula can’t quite become a weapon, but it sure sounds like one. Run! He’s got a spatula!

An entire morbid field of possibility waits beneath the surface where anything can be instantly transfigured into an instrument of pain and death.  An insidious demonic dimension pervades the world and promises to destroy us.  There is a dark underbelly to all things revealed to a mind desperate enough to look.

As a psychiatry resident, I realized the job of inpatient and emergency medical staff is to detect the demonic dimension and keep it at bay, deploying mechanisms of control to disable it.  If Bob in room 674 got the idea to use his bedframe as an awkward battering ram, it was time for him to sleep on a mattress on the floor.  If Sally with the matted hair thought the tiny golf pencils were perfect to stab the demon baby inside of her and shoved them into her vagina, it was time for her to give up her prospects of being the next Ken Kesey.  If demented grandma Edna got the idea to dash for the door at 4AM, and slipped on her own urine, and fell flat on her face, cracking her hip like a Maryland crab, it was time for grippy socks, diapers, and a bed alarm.  

Methods of control are not foolproof.  The staff could not eliminate violence, only reduce its dose from massive boluses at chaotic intervals to a slow, predictable drip.  When Bob had to sleep on a plastic mattress on the floor so he wouldn’t bash someone’s brains in, violence did not disappear, rather, it was diluted.  The locked door changed from a means to preserve privacy to a way to confine.  With the addition of three to four polyester straps, practically any bed can become a tiny, little cage.  

On an overnight shift once, I was called to the floor for an acutely suicidal patient, which is doctor lingo for someone wanting to die, like, right the fuck now.  When I stepped off the elevator onto the low lit linoleum cavern of the inpatient unit, I noticed all the nurses gathered around the fuzzy glow of a security camera monitor.   

“She tried to hang herself with her gown, doc, so we put her in a paper jumpsuit and placed her in seclusion. Now she keeps punching the door,” I was told by a tech as he stroked his beard.

The seclusion room is what people imagine when they think of a psych ward. It’s a small room with padded walls and a padded door for patients whose desperation could turn the innocuous, flat, hard wall into a weapon.  On the screen, I could see the fuzzy silhouette of an overweight young woman with short hair and a wobbly gait, tearing off her clothes and wrapping their strands around her neck.   

I yelled to the girl in the room, “What’s going on? How can I help you? Can you calm down?”  It is very awkward to try to sound concerned and also project your voice across a wall.  She replied eloquently by continuing to bash her limbs and head against the wall. At the time, I had no psychoanalytic training, but interpreted her actions as saying “go fuck yourself.”   

“We gotta do something, doc.  She’s not gonna stop,” said a  soft-spoken nurse as big as a fridge. The girl on the screen punched the door and headbutted the wall.    

“Thorazine 25mg IM,” I said in the deadpan of medical professionalism, though inside I felt like screaming, “HOLY HELL THIS IS SO FUCKED! MOMMY! WHY DIDN’T I GO INTO TECH?”  

Moments later, three imposing figures moved into the padded room –– two techs and a nurse.  The girl put up a fight, but the techs grabbed her limbs and subdued her as she continued to struggle against them.  The conflict was palpable, muscles straining in slow, tense warfare.  As the girl slowed her fight, the nurse uncapped the needle and inserted it into her thigh.  There was a moment’s pause as the medicine coursed through her tissues.  The girl, now on the floor, drew her knees up to her chest and cowered in the corner.  The medical staff left the room.  

It did not end there, however. Moments later, she was up and smashing her fists and head against the walls.  The entire scene above had to be repeated three more times with higher and higher doses of thorazine before she finally slept.

Watching the girl receive shot after shot of sedatives,  I did not feel that I had diminished the demonic dimension.  Instead, I imbibed the darkness and couched it in the terms of the medical system. Demonic energy can never be created nor destroyed, only transmuted.  This was not just medicine or psychiatry, but a dark alchemy converting chaotic, impulsive, spontaneous violence into systematic, orderly, predictable violence, but the conversion is never complete, and residues remain…

Behdad Bozorgnia is a third year psychiatry resident at Penn and co-editor-in-chief of this magazine.

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