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Danger to Self

Danger to Self: On the Front Line with an ER Psychiatrist

Copyright Date: 2010
Edition: 1
Pages: 280
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  • Book Info
    Danger to Self
    Book Description:

    The psychiatric emergency room, a fast-paced combat zone with pressure to match, thrusts its medical providers into the outland of human experience where they must respond rapidly and decisively in spite of uncertainty and, very often, danger. In this lively first-person narrative, Paul R. Linde takes readers behind the scenes at an urban psychiatric emergency room, with all its chaos and pathos, where we witness mental health professionals doing their best to alleviate suffering and repair shattered lives. As he and his colleagues encounter patients who are hallucinating, drunk, catatonic, aggressive, suicidal, high on drugs, paranoid, and physically sick, Linde examines the many ethical, legal, moral, and medical issues that confront today's psychiatric providers. He describes a profession under siege from the outside-health insurance companies, the pharmaceutical industry, government regulators, and even "patients' rights" advocates-and from the inside-biomedical and academic psychiatrists who have forgotten to care for the patient and have instead become checklist-marking pill-peddlers. While lifting the veil on a crucial area of psychiatry that is as real as it gets,Danger to Selfalso injects a healthy dose of compassion into the practice of medicine and psychiatry.

    eISBN: 978-0-520-94455-8
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-viii)
  2. Table of Contents
    (pp. ix-x)
    (pp. xi-xii)
    (pp. xiii-xxiv)
  5. ONE THE ER DOC: Who’s Calling the Shots?
    (pp. 1-17)

    The activist psychiatrist R. D. Laing has this to say about the potentially coercive power invested in psychiatrists by society: “We should not blame psychiatrists because we give them such depth of power, especially when, to be exercised as expected, itmustbe exercisedroutinely.”¹

    I guess we shouldn’t blame psychiatric nurses, either. When I first started working as an attending psychiatrist at PES, I discovered that my most complicated workplace relationships were with many of the experienced nurses who worked there. They were the power players, and my education began even before I had worked a shift.

    Throughout this...

  6. TWO THE ROOKIE: Bruno’s Man Down
    (pp. 18-40)

    In the rear of a single cell, deep in the worst tier of a dilapidated county jail, a young man is found hanging. Within minutes, he’s been transformed from a living, breathing man into 140 pounds of near lifelessness suspended nine feet above a concrete floor, his Nike-sneakered feet dangling. A knotted, jail-issued sheet stretches from a water pipe to the young man’s puffy neck, the contours of his face obscured by swelling.

    Once the hanging victim is found, the response is swift. Two burly officers hoist the inmate while a more nimble deputy works the edge of the linen...

  7. THREE THE SCRAMBLER: How to Prevent a Murder
    (pp. 41-59)

    When I was a third-year resident in psychiatry, Sal Pauletti was referred to me for an evaluation by his primary care doctor, who wrote, “Mr. P. is a 50-year-old Vietnam War veteran with PTSD [post-traumatic stress disorder], possible psychotic disorder and a history of migraine headaches with no ongoing psych treatment. Married with a stable occupation. He complains of conflicts with his boss. He reports violent tendencies, troubles with impulse control.”

    Prior to seeing the patient, I call his internist, Dr. Jesus Ramirez, a brand-new attending physician and the source of the referral. I run the gauntlet of receptionist, nurse,...

  8. FOUR THE PSYCHODYNAMO: Learning to Listen with a Professional Ear
    (pp. 60-87)

    For all its headaches, psychiatric training is made rich by one’s interaction with supervisors. In looking for my own psychotherapy mentor, I searched for an approachable, practical, user-friendly psychiatrist—one whom, in an ideal world, I could model myself after.

    The late Dr. David Viscott writes in his classicThe Making of a Psychiatrist, “You can tell a bastard from a nice guy in a moment if you have any sense at all.”¹ I knew I had discovered one of the good ones when I met my first psychotherapy supervisor, a psychiatrist named Chesley Herbert. Ches, who had already been...

  9. FIVE THE JAILER: If You Want to Go, You Have to Stay
    (pp. 88-112)

    They are not the most violent patients. Neither are they the flashiest or the loudest. But they certainly are the smelliest. These are the patients carted against their will into psych emergency grumbling and muttering, preferring a dingy alley to the bright lights of the hospital. These are the ones you might see zonked out on the sidewalk, the ones you need to step over and around if you are to successfully navigate certain neighborhoods in San Francisco.

    These are not the guys who aggressively “spare-change” you. No, these individuals are the ones who quietly sit in front of their...

  10. SIX THE JURY: Playing the Suicide Card
    (pp. 113-139)

    Rick Demerit stands in front of me, swaying, glassy-eyed, smelling of cheap vodka, the hardcore alcoholic’s favorite drink next to Steel Reserve. He occasionally mumbles and laughs to himself as he stands at a sort of attention in front of the triage desk, which is located just inside the front door of psych emergency.

    The ambient lights are turned down low, seeing as how it’s only 7:45 a.m. and many of the patients are just waking up, asking for breakfast. He’s been brought in by the SFPD for threatening to kill himself after the police were called to check out...

  11. SEVEN THE CLAIRVOYANT: Whose Life Is It Anyway?
    (pp. 140-164)

    “That was a profoundly decent thing to do,” said my psychiatrist. I had just finished telling him about my meeting with the father of a young man, a one-visit patient now deceased, whom I had discharged from psych emergency only to have him commit suicide three days later by hanging.

    I thought I detected soft tears in his eyes as he said this, but I couldn’t be sure. Sometimes decency is all anyone has to offer to a grieving person. Yes, I could give myself credit for that. But one cannot undo what’s been done—a man, a father like...

  12. EIGHT THE SPEED COP: Talking to Tina
    (pp. 165-186)

    In psych emergency, sometimes it seems like everyone is on speed. It’s like this: A guy comes in all wild-eyed and crazy. Often he’s been violent in the community and sometimes in the hospital. He steadfastly denies using crystal methamphetamine. Maybe he suffers from bipolar disorder, also called manic-depressive illness, and he’s gotten manic since he stopped taking his lithium. Maybe, but it sure looks like meth behavior, and frankly, much of the psychotic and violent behavior around these parts is assumed to be driven by meth intoxication until proven otherwise. Meth or mania, mania or meth. It’s easy to...

  13. NINE THE WITNESS: Trauma Underlies the Pain
    (pp. 187-205)

    Mary Hughlett is a twenty-two-year-old fourth-year junior at San Francisco State University. She works part-time as a café waitress in addition to taking three classes as an upper-division English major.

    I see her on the day shift, the reevaluation shift. She is one of eleven patients assigned to me that morning.

    “Ah, a high-functioning patient,” I say to no one in particular, knowing that my interview will necessarily take anywhere from thirty minutes to an hour, which, as I’ve mentioned before, is an eternity in my neck of the woods. Why so long? For starters, you’ve got a patient who...

  14. TEN THE JUDGE: Playing God from a Psychiatric Standpoint
    (pp. 206-232)

    I’m working on the psychiatric consult service when I get a stat page. “This is Dr. Sokol,” the voice says. It belongs to none other than the division chief of hepatology and medical director of the liver transplant service at a private hospital where I worked for two years.

    I return the call as soon as I can. “Hi, Bob, this is Paul. You rang? I wasn’t expecting to hear straight from the boss.”

    “Well, it’s my day on service. We really need your help on this one.”

    “What’s up?”

    “The patient’s name is Melissa Peters. She’s a twenty-four-year-old woman...

    (pp. 233-236)

    As an emergency psychiatrist working on the front line, I have the task of putting a human face on the system, on the institution, of mitigating the legal, financial, political, and bureaucratic constraints that we, both patient and professional, find ourselves in. To accomplish this, I must work with not my bestfaceforward, but my bestheartforward. How does one do this?

    Now that I’ve offered seventy thousand or so words in this book as a psychiatrist and a writer, with as much or more left on the cutting-room floor, I am wondering about the wisdom of trying...

  16. NOTES
    (pp. 237-248)
    (pp. 249-253)
  18. Back Matter
    (pp. 254-254)