Pysch-Aide
By Ryan Gossen
There is a nurses’ station in a ward in a hexagon of buildings in a sprawling medical campus near downtown. Nurses sit in the nurse’s station, a plexiglass enclosure from which they dispense pills in little white paper cups. Doctors are in another building somewhere. I never knew where. Nurse’s aides are out with the patients.
It’s our job to control the space, to be there with them, watch them, talk with them, clean up messes, and do whatever the nurses say needs doing.
Much of the time that was enjoying fresh air, chatting, and letting folks know when it was mealtime, but sometimes what needed doing was holding someone down with one person on their legs and one on their torso while a nurse yanked down their pants and administered an intra-muscular (IM) injection. This was sometimes done when medication had been ordered and the patient repeatedly “cheeked” their pills, or when the situation required the medication to enter the bloodstream against the patient’s will and immediately. The term “chemical restraint” was sometimes used.
Aaron was a twenty-something white kid who came in from a detention center. There is a lot of overlap between the criminal and the insane, and there was much traffic between prisons and our hospital. Most people in prison would rather be here, but it's hard to pull off. “Malingering” is a word that means avoiding work or military duty, and it also means faking illness. In the hospital, it's the technical term for a sane person pretending to be insane. Isn't pretending to be mentally insane itself a symptom of mental illness?
You can have some pretty interesting arguments about the true disposition of a malingerer, but it's really a few specific disorders that interested us in the Acute Psychiatric Ward. Schizophrenia and its flavors, bipolar variations, depression. Type-2 personality disorders were diagnosed for people who were a special pain in the ass. Borderline, antisocial, narcissistic. Psychopathy was out of favor at the time and sociopathy was in, though rarely diagnosed. The DSM (Diagnostic and Statistical Manual of Mental Disorders) is a big thick book, but we used very little of it.
Most aides didn't read files, it was our job to be standing and aware of our surroundings, but I liked to read them and sometimes I wrote entries. Aaron’s file was sparse, it was clear the admitting nurse didn't know what to make of him. He came in reporting having spoken with aliens. He had a little “schwa” tattoo that seemed to corroborate this interest. He was charming, a good conversationalist, and eager to improve his situation, though he seemed uncertain how to do so. He was anxious to understand this new place and to know its angles.
He described a stint at Gary Job Corps, where he lived in a bunkhouse with other young men sent to work in a semi-penal, judge-mediated arrangement. He missed those guys, they were real people to him, his true friends, but the place he described was hostile and dangerous. I didn't understand.
“We weren't friends at first. When I first got in there, they put me in this top bunk and everyone was mean-mugging me and this one guy kept calling me a white pussy. He goes, ‘Anytime you want to get froggy, you just jump, little froggy.’ He kept on calling me froggy and I finally just jumped on him. I was like on the top bunk and I just WHAPHAA!”
“What happened?”
“They all jumped on me. Kicked the shit out of me. Then we were cool.”
Aaron was well-liked and made a lot of friends. He was good at sucking up to staff, he had a subtle way of presenting himself as an ally, subservient and harmless. Every aide gets charmed by the occasional patient, even the veterans. It was common wisdom among the aides that having a favorite was unavoidable, and it was pointed out to me that Aaron was mine. I wasn't comfortable with it. I was a member of a ruling caste, and now I had a “favorite.”
If I related to patients as people, we were separated by caste into people with keys and badges and people without keys or badges. Some aides clearly saw patients as a different, objectified unit which was their job to manage, and this allowed them to focus on their job, or at least to not care too much about what happened. These two states flickered back and forth in me, and confused me when I was with a patient I related to, like Aaron. We would be talking in the yard, and I would look down at my keys and feel dizzy with the awareness of the gap between us.
I found a kind of resolution in the words of Renaldo, an older guy who had been an aide for a very long time. He said, “You can never be cool.”
When a load of donated clothes came in, Aaron swapped the wide-cuffed rave jeans he had arrived in for a pair of khakis and a collared rugby shirt. There were no belts. Suddenly, he was basic and preppy.
He complained of nightmares and fear, panic attacks centered around an encounter with aliens. He suggested specific drugs that had helped him in the past but they weren't antipsychotics. Aaron wanted Ativan, Xanax, benzodiazepines. This was an amateur move. Aides have no say about meds. All we can do is report med-seeking behavior, which is the surest way to never get the meds you want again. Even Mrs. Harmerster, who wore a rosary and nursed a filthy teddy bear, eyed him with suspicion.
Then Denis arrived.
I came in for the 3:00 to 10:00 shift and he was sitting there in the dayroom, chatting up Alecia, a pretty, vulnerable-looking depressive. He was shuffling a deck of cards and I couldn't hear what he was saying in the nurses’ station, but the powerful edge of his voice cut through the plexiglass during the handoff meeting between our shifts.
I had heard of Denis, he was a legend among old-timers. There was the time he beat up a nurse then got naked and covered himself with vaseline, broke a leg off the day table, and waited in the hall for the reinforcements to be sent in, holding the leg. There was the time he ate a belt buckle. His was a thick file and one of the only times I read the word “psychopathy,” written more than a decade before. Sociopathy followed years later, followed recently by the less specific “antisocial,” served with a side of “psychotic features.”
I wondered whether the increasing vagueness of Denis’ diagnoses was a good thing or a bad thing from a clinical perspective, but Denis was clearly the same guy. The hospital was a stop on a circuit that included prison, halfway houses, and “the streets.” He had been traveling this circuit for a very long time and this ward was a familiar place to him. He knew its secret places, probably even how to escape if he wanted. At 43, he was of average height with a strong physique.
He terrified me.
Denis took an immediate interest in Aaron as the only potential rival on the ward, and they became “friends.” Aaron was young, male, and looked sometimes like he might be strong. Other times Aaron looked like a little boy, and it was hard to tell if he could control this flip.
Denis was reasonable and compliant for about a week. His pattern was to come in and get on his meds, then stop taking them and decompensate. He was known to be an expert cheeker. Things would get bad, something would go down, and he would have to be restrained, medicated, and sent somewhere that took more violent cases.
As he approached his violent phase, he became paranoid. It was a relief to me. This was not Hannibal Lecter, but a man who saw things that were not there. He accused me of stealing his underwear and reported me to Client Services. The next day I was interviewed by a tired-looking man in a button-down shirt who had to, by law, ask me if I had in fact stolen Denis’ underwear. Denis was just pulling whatever levers he could reach, but I think he came to believe I had done it. I’m not a frightening or even memorable person, but I came to occupy the role of one of his demons.
Over time, Denis became more and more agitated, and everyone could see the arc. Oscar saw it like the approaching exit on a freeway and made careful notes in Denis’ file indicating increasing perseveration and the old chestnut, “responding to internal stimuli.” The goal was to make this transition as safe as possible for everyone. Usually, Oscar would get a standing PRN order for Haldol, Benadryl, and/or whatever for when the inevitable occurred, but there was a new doc who thought that maybe we should see how this all played out before prescribing more meds.
Doctors obediently doing what the nurses tell them is the norm for a reason. Doctors sometimes like to think for themselves though, even if only to prove they can, especially the new ones. I started to grind my teeth each time I stepped out of the nurses’ station. I had already learned to stand with my back to the wall, but I was nervous if I didn't know where Denis was.
Aaron and Denis started to chafe. One day when I started my shift, there was tension. Denis was assuming the alpha role, throwing his weight around where he could, telling people where to be, and asking for favors, all while navigating his hallucinations and blanketing the dayroom with that voice. There are times when the dayroom is pleasant, when it feels safe, like somewhere a person could crash and be ok for a while, perhaps after experiencing a life-changing tragedy or something that went wrong with their mind.
When the staff is working well, when the only threats are in one’s mind, it's not a bad place to land. Other times, patients must navigate internal and external danger at the same time. Perhaps it's safer than being homeless. Perhaps being held here gives protection to family members. But failure to supply physical safety felt, to me, like a massive institutional failure of which I was a part. It took its toll on me as well. Eight hours of constant vigilance could be brutal, and from time to time, we could be conscripted without notice to work the night shift, which was its own world with its own reality.
I developed a sleep disorder. I cherished happy hours when nurses and aides could drink and vent. It was a cult and I was building a sense of who I was there and what I was trying to accomplish. When I started waking up screaming, my girlfriend began to insist that this was a bad job.
After what felt like an unnecessary week of fear and stress, a new doc approved the PRN order for Denis’ meds. He was full of energy and his delusions were interspersed with predatory games he played with people in the real world. He seemed to be grooming Alecia, who now tolerated sitting next to him on the couch and even followed him around a little bit. It wasn’t like it was easy to rape someone here, there were no private spaces unless there was a staffing shortage, in which case, there was the occasional unlocked, unmonitored hallway. And sometimes you could find a private moment in one of the common dorm rooms.
We had levels: Level 1, the dorm, bathroom, and courtyard doors were unlocked and people could browse around. Level 2, The courtyard was locked and each ward took turns on the yard. Level 3, lockdown. The doors to the dorm were locked unless it was bedtime, no yard access, all aides and all patients were in the dayroom except for carefully choreographed migrations to the cafeteria. Patients had to ask staff to get access to the bathroom and some felt this was less convenient than peeing in the corner. Without access to the yard, smoking could not happen, which was a very big problem.
Our ward was at Level 3, with the exception of one or two people who were allowed to go outside with another ward’s yard time. This had to be negotiated by telephone between aides across wards.
“Hey, Claire, I want to send Frankie out on your break.”
“Yeah, he’s fine.”
“Thank you. Get you back next time.”
Movie time was announced to break things up a little. Popcorn was popped in the microwave and poured into a plastic bowl. Denis took Alecia’s hand and led her to the sofa. Heavy, steel-framed, vinyl-upholstered chairs were dragged from the day table and people made themselves more or less comfortable as the opening dogfight of Top Gun began, and Kenny Loggins introduced us to the concept of a highway to the “Danger Zone.”
Denis had requests. Could we turn the lights off? No. He went to his room and came back with a blanket, which he spread over his and Alecia’s laps. She looked poker-faced at the movie. Over the past week, Alecia had been taken aside many times by staff and asked if she was ok. If she felt danger or if she wanted to be kept separate from Denis. She always responded that she was fine and that no intervention was necessary, nevertheless, the request had been put in to transfer her to another ward. This was seen as a sacrifice on the part of staff, because Alecia was an easy patient, and sending her away would mean we would roll the dice on getting a more difficult case. Something should open up in the next day or two, but a lot of things could change by then.
The ideal situation was for Denis to do something violent enough to get him transferred out of this population, but not so violent that anyone got hurt.
I felt that when I went to take the blanket away it would set him off. So we planned it carefully: Greg, Harlon, and Alice, the other three aides on staff tonight were old hands, they knew Denis and how situations like this worked. On the desk in the nurses’ station, Oscar had Benadryl and Haldol in syringes in front of him as he watched behind the glass. I took point because I was the new guy.
Maverick was really getting chewed out by the captain for doing a fly-by as the tension on the ward began its terminal climb. Mrs. Harmerster stood up with her teddy bear baby and walked into her room. Dale, though disoriented and depressed, moved to the card table on the other side of the dayroom. I felt nauseous. Every hair on every neck was raised as Greg and Harlon took positions at opposite sides of the room and I paused the movie and stood a few steps away from the sofa.
“Denis, I need that blanket.”
Alecia continued to look at the frozen image of Tom Cruise, moving deeper into whatever coping mode she had been in when she sat down.
“FUCK you, Ryan. I know you stole my underwear!!!”
Greg and Harlon approached as I repeated myself a couple of times. I was no longer nauseous, things were flowing now. “Ok, I’m just going to pick it up…”
I picked up the blanket by a corner that was out of arm’s reach to Denis, but he grabbed it back and stood up.
No one had been paying attention to Aaron. I think we assumed he had accepted a beta role and would keep his head down as we addressed Denis. He came in from the far wall when it looked like Denis was about to take a shot at me and got in his face. Following a brief exchange of fuck you’s, Aaron swung a haymaker across the coffee table, landing on the side of Denis’ face. Denis dove across the table and the two formed a tight knot on the airport-carpeted floor. All of the staff in the room jumped into the dogpile.
Denis was a known biter, so the first thing was to disentangle and keep everyone away from his teeth. He screamed and thrashed with the pent-up rage of the most recent cycle of streets-jail-hospital that led to this moment. Aaron detached immediately and allowed himself to be led to an isolation room by Alice while the rest of us addressed Denis. I was on his back with my heels hooked around his thighs and a good grip on one arm. Greg had the other arm and Harlan had his legs. Oscar brought a coffin-sized board fitted with five-point restraints and set it on the ground next to us. The veterans had a sequence for getting him strapped in while he was still struggling and they walked me through it. Once he was strapped down, we took him into the second isolation room and Oscar gave him the injections. It was finally over.
For his troubles, Aaron got an injection of Ativan, which was like a vacation, and soon after that, he left the ward. I was not privy to the next phase of his cycle. Perhaps they found a way to send him back to prison, or maybe they contracted with a private hospital that took forensic cases. I decided that being a nurse’s aide in a psychiatric hospital was one of those jobs that was a true vocation and a sacred calling deserving of one’s full strength and purpose, but I wasn't willing to get night terrors for below minimum wage.
It was time to look for another job.
Ryan Gossen is a writer living in Austin, Texas, where he also pursues dance, Brazilian Jiu-Jitsu, and climbing, and is an active member of Texas Search and Rescue. He has had many vocations, including user experience (UX) designer, experimental psychologist, construction worker, arborist, and ski bum. He writes mostly about man’s interaction with nature. More of his writing can be found on his website.
